Education and decision-making autonomy as drivers of HPV screening outcomes in Nepal.

Abstract

e22574 Background: Cervical cancer screening is uncommon in Nepal due to reasons including resource scarcity, lack of cancer screening knowledge, and sociocultural barriers to women’s healthcare decision-making. Scalable, low-resource HPV screening strategies may reduce disparities, but implementation determinants influencing screening knowledge, outcomes, and follow-up remain understudied. Methods: We conducted a pilot, community-based HPV screening study at two health fairs in Janakpur City, Nepal, in 2025. Clinician-collected cervical samples from 274 women were tested for high-risk HPV (HrHPV) using the AmpFire isothermal amplification assay. Participants completed a brief survey assessing age, education, prior cervical cancer screening awareness, source of screening information, and healthcare decision-making autonomy. Associations were evaluated using Pearson’s chi-square and Fisher’s exact tests, with stratified analyses adjusting for age and education. Results: Education level significantly influenced prior awareness of cervical cancer (χ2= 9.85, p = 0.02), though it was not significantly associated with procedural knowledge of vaginal sampling in univariate analysis (χ2= 4.31, p = 0.23). Women reporting their husband as the primary healthcare decision-maker had a higher HrHPV positivity rate compared with women reporting autonomous decision-making, but the difference was not significant (14.3% vs 9.6%; χ2= 0.93, p = 0.33). Among the 32 women testing positive for HrHPV, 62.5% completed follow-up Pap testing, with age group variation: under 30 (45.5%), 30-44 yo (70.6%) and 75.0% in those > 45 yo. Only two women refused follow-up due to spousal decision-making, citing family opposition as the reason. Conclusions: Education significantly improved general awareness but not procedural understanding. While restricted autonomy showed a non-significant trend toward higher HrHPV positivity, spousal opposition remained a tangible barrier. Notably, the program achieved 62.5% follow-up retention, proving effective in navigating these social dynamics. Scalable strategies must therefore target procedural misconceptions and actively engage family decision-makers to support comprehensive care. Keywords: Cervical Cancer Screening, Human Papillomavirus (HPV), Nepal, Female Community Health Volunteers (FCHVs), Healthcare Decision-Making, LMICs.