Equality impact assessment: the use of HPV self-sampling in under-screened people eligible for NHS cervical screening

Question 1

Cervical screening and human papillomavirus self-sampling

Accepted Answer

Ministers have agreed to offer self-sampling (self-testing) for human papillomavirus (HPV) to under-screened people eligible for the NHS Cervical Screening Programme in England, where service commissioners think it would be a helpful addition to the programme. The HPV self-sampling option will be offered to under-screened people alongside the offer of clinician-collected sampling by a nurse or doctor.

An under-screened person is an individual who is overdue for their routine cervical screening appointment by at least 6 months or who has never attended.

Background information about screening

Screening is the process of identifying people who are asymptomatic (have no symptoms) but who have an increased risk of developing a disease or condition. NHS screening programmes are an efficient and proven method for early diagnosis while minimising false positive and false negative results as much as possible.

Each individual offered screening should be supported to understand what the possible benefits and risks of screening are and decide for themselves whether to accept or not. This is referred to as making a ‘personal informed choice’.

Early detection for some conditions has direct health benefits, with individuals identified as being at greater risk of developing a condition being supported to take preventative interventions or treatments to reduce their likelihood of becoming unwell. For those where a condition is detected, individuals can make informed decisions around their treatment. Early detection is likely to make any required treatment more effective and therefore lead to better health outcomes.

The UK National Screening Committee (UK NSC) is an independent scientific advisory committee that advises ministers across the UK on all aspects of screening, including evidence-based modifications to existing screening programmes.

The NHS Cervical Screening Programme

The NHS offers cervical screening to all women and people with a cervix aged 25 to 64. Every person who has a cervix and is within the screening age range is eligible for NHS cervical screening regardless of their gender identity.

The NHS Cervical Screening Programme in England aims to reduce the number of people who develop invasive cervical cancer and reduce the numbers who die from it.

Cervical screening does not test for cancer; it is a test to help detect the risk of developing cervical cancer. This is because since December 2019, the primary screening test (the first part of the screening process) has been to check for high-risk human papillomavirus (hrHPV) which causes nearly all cervical cancers. The use of hrHPV primary testing provides the opportunity to expand the methods of sample collection to include self-collected samples in addition to clinician-collected sampling. For the rest of this equality impact assessment, the term HPV will be used to refer to hrHPV.

The UK NSC’s recommendation for the use of HPV self-sampling was permissive, meaning the NHS can, but does not have to, implement it. They should use it where they believe it can have a useful impact on supporting uptake. The recommendation provides the following 3 options for the delivery of a self-sampling kit to under-screened people:

via an opportunistic offer in primary care
using a direct mail-out
offering both a direct mail-out and an opportunistic offer

The chosen approach may vary from region to region. Any alternative delivery strategies should be supported by robust evidence demonstrating their effectiveness and cost-effectiveness.

Question 2

Intended aims of HPV self-sampling

Accepted Answer

Barriers to cervical screening such as discomfort, embarrassment and inconvenience can put people off attending. Approximately 3 in 10 people do not take up the offer of screening. Individuals who rarely or never attend their cervical screening appointment are described as ‘under-screened’. They are at higher risk of undetected cervical abnormalities and associated disease than people who are regularly screened.

National and international evidence now suggests that offering the option of HPV self-sampling could help overcome some of the barriers among the under-screened group, leading to improved informed participation in screening and ultimately preventing more deaths from cervical cancer.

The effect of HPV self-sampling on GP practices

Due to removing the need to attend a GP practice (or another provider such as an integrated sexual health service) for a cervical screen, there is potential for self-sampling to reduce pressure on appointments (as some people offered self-sampling may have come forward for cervical screening later anyway). This could therefore increase GP practices’ capacity to offer clinician-taken screens, and increase their capacity generally.

There is a chance that this may lead to some GP practices over-promoting self-sampling to free up capacity and reduce their workload. However, it is expected that the overall impact of offering HPV self-sampling will be positive for GP practices, not least because it may provide the opportunity for healthcare professionals to re-engage with patients from underserved populations. Underserved populations include people living in poverty and people from minority ethnic groups. While there is some overlap with the under-screened population, it is important to note that there are people within the under-screened cohort who are not part of an underserved population and vice versa.

There is a risk that a move to self-sampling could lead to workforce de-skilling in undertaking speculum examinations, and that taking the clinician out of the testing process could potentially result in lost opportunities for wider health discussions and physical examinations (which can currently happen as part of a clinician-taken screen). However, as self-sampling will only be offered to under-screened people, some of whom may never have attended a clinician-taken screen, we would not expect this to have as big an impact as it would if self-sampling were being rolled out more widely.

As the opportunistic approach would involve a healthcare professional discussing HPV self-sampling with a patient who has come in for a separate issue, this may include an additional administrative burden in terms of reporting. This is likely to take time from the appointment itself and could potentially have a knock-on effect on the healthcare professional’s capacity. Healthcare professionals are also likely to be required to take time out to access training around how to use the self-sampling kit and how to communicate this to patients.

Effect on service users

Introducing a self-sampling option is expected to increase informed participation in the cervical screening programme, particularly among underserved populations. Ultimately, it is hoped that increasing attendance in the under and never-screened populations through offering self-sampling may help to contribute to lowering the numbers of people developing and dying of cervical cancer. This ‘under-screened’ group is at a higher risk of HPV infection and associated development of cervical disease.

However, it is possible that the permissive nature of this recommendation could exacerbate health inequalities. Different regions may adopt varying implementation strategies, potentially benefiting some groups and not others.

Self-sampling is currently recommended only for people who are under-screened, as a self-collected sample is considered better than not being screened at all. Under-screened groups are at higher risk of HPV infection and related disease, making it essential to find effective ways to support their participation in the screening programme. Self-sampling is one way to help improve screening access for these groups.

There is currently not enough UK-based evidence to support offering self-sampling routinely to everyone eligible for the NHS Cervical Screening Programme. Uncertainties include:

how a universal offer of self-sampling might affect the subsequent stages of the screening pathway
whether it is acceptable to participants (regular attenders)
how self-sampling compares with a programme based on clinician-collected samples

To address these knowledge gaps, further evidence is being gathered through a National Institute for Health and Care Research (NIHR) commissioned in-service evaluation (ISE).

Given that this recommendation is to offer self-sampling to the under-screened population only, it is possible that this may be perceived as unfair. There is a risk that some people who currently regularly attend their clinician-taken screens might choose to delay attending so they can be offered self-sampling. However, it should be noted that self-sampling is not necessarily more acceptable to everyone. Anecdotal evidence shows that some women prefer the reassurance of the test being carried out accurately and effectively by a trained health professional.

While a self-sampling option might make the initial stage of cervical screening more accessible and acceptable to under-screened people, it is important to note that the next stage in the pathway for anyone who tests positive for HPV via self-sampling would be an appointment for a clinician-taken test. At this point, there may be a risk of people opting out of the screening pathway, as the barriers that prevented them from attending a clinician-taken screen in the first place may still exist. However, at the start of the YouScreen study, 84.9% of women attended for a clinician-taken sample following an HPV-positive self-sample result. By the end of the study this figure had risen to 89.2%. This suggests that if someone receives an HPV-positive result following self-sampling, they may then be more open to having a clinician-taken sample as the next step in the pathway.

Effect on laboratories

As self-sampling is an initial offer for under-screened people only, the expected impact will be an increase in HPV tests for laboratories. As an HPV-positive result will necessitate a clinician-taken sample, there will also be a small increase in the demand for cytology.

Working on the assumption of a 20% take-up of self-sampling (across the whole under-screened population), this would result in about 800,000 additional HPV tests (across a yet to be determined timescale).

Concerns were raised via the UK NSC public consultation that this increased workload may lead to a requirement for additional screening resources such as estates, staffing and equipment.

Self-samples require additional preparation steps prior to being loaded onto laboratory analysers for HPV testing. Automation is not yet readily available for most sampling devices to perform these additional steps, meaning additional hands-on time is required by laboratory personnel to process self-samples. Findings from the HPValidate study suggest that this manual aspect could increase the risk of contamination when testing is scaled up.

Processes will need to be set up so laboratories can identify that the sample is from a self-sample kit rather than clinician-taken. The reporting of these samples will also need to be agreed. If the test result is HPV-positive the result needs to trigger an invitation to a clinician-taken cervical screen. Cytology is not undertaken on a self-sample, as cells from the cervix are not collected.

Effect on colposcopy services

Colposcopy volumes may increase due to under-screened people engaging in screening for the first time (or more frequently), some of whom have risk factors that may make them more likely to test positive for HPV. Some under-screened people may have a persistent HPV infection they are unaware of which, over time, could result in abnormal cervical cell changes.

Currently, around 250,000 people are referred to colposcopy each year in England. This figure includes both symptomatic and screening referrals. However, screening referrals make up the majority (around 81% - equating to approximately 63 people referred per 1,000 screened). It should be noted that the number of screening referrals to colposcopy in the year does not arise directly from the number of people tested in the same year due to differences in data collection. Self-sampling may increase referral numbers through both screening and symptomatic routes, as people attending for a clinician-taken test following a positive self-sample may be found to need symptomatic referral irrespective of their screening test result.

The impact of an increase on colposcopy services may require a review of the resource within the service to meet the national cervical screening programme standard of offering an appointment at either 2 or 6 weeks depending on the grade of the cytology changes identified. The impact will depend on actual response rates to the self-sampling offer, and the HPV-positive rates of those screened via self-sampling. The impact may therefore vary between colposcopy clinics both around the country and within regions.

Question 3

Evidence

Accepted Answer

We have considered the following main sources of data to determine the potential impact of offering HPV self-sampling to under-screened people who have protected characteristics.

YouScreen study

In 2021, the YouScreen study was established in the NHS Cervical Screening Programme in North London. It marked the first time self-sampling was integrated into the NHS. The aim of the study was to assess whether introducing the offer of self-sampling to under-screened people in the NHS Cervical Screening Programme would substantially increase screening participation in this group. The study completed in 2024, and findings have now been published (see link above).

YouScreen found encouraging evidence that self-sampling could increase equity in cervical screening and reach underserved populations. Women from minority ethnic and deprived backgrounds are traditionally less likely to participate in cervical screening but were well-represented among respondents. Almost two-thirds of those who responded to the self-sampling offer were from minority ethnic groups, and this was largely reflective of the demographics of the under-screened population. Feedback from GPs and participants in the study indicated that self-sampling increased screening access for transgender (trans) men, people with a learning disability, people with mental health issues, and people with a history of abuse.

In comparing self-sampling kit delivery methods, the YouScreen study found that offering kits opportunistically in primary care resulted in nearly 5 times higher participation compared with direct mail-out.

UK NSC 2024 rapid evidence review

UK NSC commissioned a rapid evidence review of HPV self-sampling in the under-screened population (see ‘supporting documents from the 2025 review’ on the UK NSC’s cervical screening recommendation page) . The aim of the review was to explore the published evidence relating to UK NSC evidence criteria on the:

test accuracy of self-sampling
effect of self-sampling as a strategy to improve screening participation in under-screened people
acceptability of self-sampling

The rapid review sets the YouScreen results within the context of the international evidence base and should be considered alongside the study. The review, which was conducted by the Glasgow University National Institute for Health and Care Research Evidence Synthesis Group, concluded that self-sampling is a feasible strategy for reaching under-screened people and should be considered in the national cervical screening programme. However, the review also highlighted that understanding the cost-effectiveness, logistics and implementation strategies through country-specific research and local piloting is important.

UK NSC public consultation exercise

The UK NSC held a public consultation exercise on self-sampling for HPV testing from 4 December 2024 until 26 February 2025.

Further details can be found in the ‘Engagement and involvement’ section of this document.

Question 4

Analysis of impacts

Accepted Answer

Disability

Evidence shows that, in general, people who have a learning disability and/or are autistic are less likely to access screening ^{[footnote 1]} and that women with a learning disability are less likely to participate in cervical screening compared with those without a learning disability.^{[footnote 2]} Having a self-sampling option for under-screened people in this group, alongside clear and accessible instructions, might help to increase informed participation among people who have a learning disability and/or are autistic and who have capacity to consent to being screened. However, it is likely that some people in this group may need additional support to understand the process and to use the test kit. This support may be from a healthcare professional in a primary care setting or from a family carer or support worker in the community.

People with severe mental illnesses are 30% more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests (such as breast, cervical and bowel cancer screening) by people with mental illness.^{[footnote 3]}

The Severe mental illness (SMI): inequalities in cancer screening uptake report by Public Health England in 2018 found that people with severe mental health issues are known to have lower levels of screening uptake. They are:

18% less likely to have participated in breast screening
20% less likely to have participated in cervical screening
31% less likely to have participated in bowel cancer screening

Cervical screening can often be particularly challenging for people with SMI. This can be due to a range of factors, including:

accessibility issues
a history of trauma
the absence of familiar healthcare providers
not receiving screening invitations due to not having a fixed address

Offering a self-sampling option to under-screened people in this group could help to remove some of these barriers, particularly if self-sampling is offered through secondary mental health services.

Accessing cervical screening can be difficult for some people with physical disabilities. This is due to a number of factors, including a lack of equipment such as hoists and difficulty travelling to appointments, particularly for individuals who are house-bound or bed-bound.

A survey of cervical screening for women with physical disabilities by Jo’s Cervical Cancer Trust found that of 335 women with a physical disability or physically debilitating symptoms as a result of a long-term health condition:

88% said it is harder for women with physical disabilities to attend or access cervical screening
63% said they have been unable to attend cervical screening because of their disability
49% said they have chosen not to attend cervical screening in the past for reasons such as previous bad experiences related to their disability or worries about how people might react

Self-sampling could therefore be a helpful option for people with disabilities who struggle with accessing appointments in person. However, it would need to be made clear that anyone who tests positive for HPV through self-sampling would still then need to attend an appointment for a clinician-taken sample. This would then likely present the same barriers they were seeking to avoid by choosing the self-sampling option in the first place, unless clinician-taken screening is made more accessible. See the ‘Summary of analysis’ section for information on NHS guidance to screening providers on making reasonable adjustments for disabled people.

In a 2025 study looking at barriers to cervical screening and perspectives on self-sampling among under-served groups, some participants reported concerns around dexterity and ease of use in terms of carrying out the test themselves. This could be a particular barrier for some people with disabilities (including people with a learning disability), and could result in them needing help to use the test.

People who are blind or visually impaired can face specific barriers to accessing cervical screening, including the fact that it has previously not been possible for the screening IT system to recognise that they require invitation letters in an alternative format. As a result, some blind people may be unaware that they are due a screen. Having to ask someone else to read the letter for them could be experienced as a violation of their right to privacy, particularly as it concerns their health. See the ‘Addressing the impact on equalities’ section of this document for information on the action NHS England is taking to address this through their updated screening IT system.

Other barriers faced by blind and visually impaired individuals include difficulties in travelling to appointments and navigating within the GP practice once they arrive. Having the option of a self-sampling kit that could be used in their own home could therefore help to remove some of these barriers. The kit and its instructions would need to be accessible for blind and visually impaired people.

Sex

Women and people with a cervix aged 25 to 64 will only be directly affected by this recommendation if they are currently part of the under-screened population.

People assigned male at birth are not eligible for this screening programme as they do not have a cervix.

Sexual orientation

Lesbian, gay and bisexual people are more likely to have had negative experiences of using healthcare systems ^{[footnote 4]} and may be less likely to attend cervical screening.^{[footnote 4]} ^{[footnote 5]} Figures show that 15% of lesbian and bisexual women over 25 have never had a cervical screening test compared with 7% of women over 25 in the general population.^{[footnote 6]}

This lower coverage is partly due to a misconception that women who only have sex with women do not need cervical screening tests. However, nearly all cases of cervical cancer are associated with HPV, which is passed on by skin-to-skin contact through any type of sexual activity including between women.

Possible reasons for this misconception are highlighted by a 2011 study of cervical screening attitudes and experiences of lesbian, gay and bisexual women which found that 37% of lesbian and bisexual women had been told at some point that they did not need cervical screening because of their sexual orientation. In some instances, this information had come from healthcare professionals. The study found 14% had been actively refused or discouraged from having a cervical screening by a healthcare professional as a result of their sexual orientation.

Self-sampling could therefore be a helpful option for this group. A self-administered test that can be carried out in the privacy of their own home would remove the anxiety that some lesbian and bisexual women feel around interacting with healthcare professionals, whether due to previous bad experiences or concerns about being turned away or misinformed.

As part of the UK NSC public consultation, some stakeholders raised concerns that offering self-sampling kits opportunistically (rather than via a mail-out) could potentially exclude lesbian and bisexual women if these opportunistic offers were more likely to be made during contraceptive or gynaecological health visits, which lesbian and bisexual women are less likely to attend. However, this would not be the case, as the aim would be to offer a self-sampling kit opportunistically at any time an individual comes in for an appointment.

Race

There are known barriers to accessing healthcare for certain racial groups. Women from Black, Asian and minority ethnic backgrounds are less likely to attend cervical screening than White British women.^{[footnote 7]} Black women have the smallest percentage of those diagnosed via screening for cervical and breast cancer and have the highest percentage of those diagnosed through emergency presentation for ovarian and cervical cancer compared with other ethnicities.^{[footnote 8]} Research has identified that that Gypsy, Roma and Traveller populations across Europe experience significantly worse health outcomes when compared with majority populations.^{[footnote 9]}

The YouScreen study provided evidence that offering self-sampling can help to improve cervical screening coverage and remove some of the barriers to screening participation that people in minority ethnic groups can experience. Extending self-sampling as an option to all under-screened people could therefore help to address health inequalities within the cervical screening programme.

People who have emigrated to the UK may not have registered with a GP and may be unaware of services they are entitled to. This could create an obstacle to their engagement with screening services (although cervical screening can be offered to those who are not registered with a GP practice through the offer made in sexual health settings). Even if an individual has registered with a GP practice, they may not be aware that they are eligible for cervical screening. Guidance on the health entitlements for asylum seekers and refugees is available on GOV.UK.

Groups who do not speak English as their first language are also less able to access health services due to language barriers. People who do not speak English report greater barriers accessing primary care than those who do not, have a poorer patient experience and are more likely to be in poor health.^{[footnote 10]}

Language barriers may impact people’s ability to make an informed choice about taking up their screening offer and some under-screened people may have difficulties understanding why they are being offered a self-sampling option and how the kit works. See the section ‘Addressing the impact on equalities’ for information on the steps that are being taken to reduce these barriers.

Age

UK NSC recommended that self-sampling should be for women and people with a cervix aged 25 to 64 who are currently ‘under-screened’. Women under the age of 25 are not eligible for cervical screening and therefore will not be affected.

Cervical screening statistics from 2023 to 2024 show that coverage in the younger age cohort (25 to 49) is generally lower than that of the older age cohort (50 to 64 years). On 31 March 2024, national coverage for individuals registered as female aged 25 to 49 was 66.1% compared with 74.4% for women aged 50 to 64.

Findings from the Healthwatch report Cervical screening my way showed that young women aged 24 to 29 were more worried about feeling physical discomfort compared with women aged 60 to 64.

Furthermore, the study on ‘Exploring the barriers to cervical screening and perspectives on new self-sampling methods amongst under-served groups’ (see previous link) suggested that some younger people may have concerns around cervical screening due to anxiety, fear of being disempowered and changing values around bodily autonomy. This study also highlighted concerns that some people have regarding the use of a speculum. Offering self-sampling as a choice could therefore benefit some individuals in the younger age cohort by shifting the perception that screening is something you are subjected to with little choice in what happens, to something that individuals can make an empowered and informed choice to engage in. Self-sampling also removes the issue of a speculum being used for the initial screening test.

Some younger people may also mistakenly believe that they do not need to have cervical screening if they have been vaccinated against HPV. A proportion of the under-screened consist of this cohort, and self-sampling may be viewed as a suitable alternative for them to clinician-taken screening.

Self-sampling is expected to be particularly beneficial for under-screened women in the current older age cohort, particularly as they will not have been offered the HPV vaccine at school. If there has been a gap in their cervical screening attendance, any persistent HPV infection which may have caused cervical cell changes would be unidentified.

Data from the NHS Cervical Screening Programme audit of invasive cervical cancer shows that an increasing number of late-stage cervical cancers are being seen in the older age group. This may be due to a number of factors including an increase in people in their 50s entering new relationships following divorce and being exposed to HPV, and a mistaken belief that cervical screening is no longer relevant to women at that age. It is therefore possible that offering self-sampling to this group could result in an increase in cervical cancer diagnoses or in the identification of HPV which requires management through the appropriate treatment pathway. People screened at least once between the ages of 50 and 64 are less likely to go on to develop cervical cancer after the end of the cervical screening programme.

Responses to the public consultation on HPV self-sampling also highlighted barriers that menopausal and post-menopausal women can face when accessing cervical screening, including fear of both embarrassment and of an increased level of discomfort due to hormonal changes. It is therefore expected that self-sampling could be a useful alternative option for under-screened people within this group.

Gender reassignment

Transgender (trans) men and non-binary people assigned female at birth have lower cervical screening uptake.^{[footnote 11]} According to a Stonewall report on LGBT health, a quarter of lesbian, gay, bisexual and trans (LGBT) people overall have faced a lack of understanding for their specific health needs by healthcare staff - this rises dramatically to more than 3 in 5 for trans people. And 1 in 6 (16%) trans people said they have been refused healthcare because of being LGBT. This could partly be due to issues and confusion about eligibility for screening. Trans men and non-binary people with a ‘male’ marker on their health record will have been missed by screening call and recall systems, so it may be difficult to identify that they are overdue for screening.

See the section ‘Addressing the impact on equalities’ for information on the new ‘opt in’ approach for cervical screening for trans and non-binary people.

Self-sampling is expected to be a beneficial option for this group, as it will remove the need to ‘come out’ to health professionals as someone eligible for cervical screening. It will also help avoid situations where individuals may potentially face confusion or questioning from medical or administrative staff.

As part of the UK NSC public consultation, some stakeholders raised concerns that offering self-sampling kits opportunistically (rather than via a mail-out) could potentially exclude trans men and non-binary people with a cervix if these opportunistic offers would be more likely to be made during contraceptive or gynaecological health visits (which trans men and non-binary people are less likely to attend). However, this would not be the case as the aim would be to offer a self-sampling kit opportunistically at any time an individual comes in for an appointment.

Trans and non-binary people have spoken of the need for inclusive general resources with language that does not exclude the experiences of people who may need screening that are not women. They also requested specific literature aimed at trans and non-binary people, with more details about their care needs.^{[footnote 11]}

Religion or belief

Analysis of NHS data for England showed that areas with the largest Muslim populations had, on average, a 12% lower uptake of cervical screening in the year leading up to July 2022 compared with areas with the smallest Muslim populations.^{[footnote 12]}

There is also evidence that engagement with cervical screening is low among immigrant women, particularly Muslim women, because of barriers relating to religious values, beliefs, and fatalism relating to health.^{[footnote 13]}

NHS England say that experience has shown that faith and religion can have a huge impact on people’s willingness to attend for cervical screening, have the HPV vaccination or access support if they are found to have HPV. Patients have spoken about shame and embarrassment regarding the screening process, believing that screening is unnecessary if married, and feeling shame about sexual relationships outside marriage and about HPV.

It is possible that a self-sampling option, which can be carried out in private and removes the need for an intimate examination, may help to increase screening uptake in people who hold these beliefs. However, given the perceived impact that a test of this nature could have on someone’s virginity, it may still be considered unacceptable for use by unmarried women in some religious communities.

The fact that an HPV-positive result could result in a clinician-taken test may mean self-sampling is not the entire solution to addressing the barriers faced by people with this protected characteristic. However, as stated previously, the YouScreen study did show encouraging results with regard to follow-up clinician-taken sampling.

Pregnancy and maternity

Women who are pregnant are usually deferred from cervical screening until 3 months after the pregnancy has ended. This is because pregnancy can make it harder to get clear results from the cervical screening test. However, where a woman has had a previous abnormal result from a cervical screening test, they may need to be screened while pregnant and this will be under the guidance of colposcopy or other health professionals.

Women with children may find it difficult to attend cervical screening appointments due to childcare issues. A self-sampling option may help improve uptake as it would remove the need to arrange a screening appointment around childcare availability. However, should they test positive for HPV, the next step in the pathway would be an appointment to have a sample taken by a clinician - which does not help overcome the original barrier to access.

Marriage and civil partnership

In some communities, it may be considered unacceptable for unmarried women to have an ‘intimate’ screen due to concerns around modesty, shame and the perceived effect on a woman’s virginity. Such communities may also tend to be more fatalistic about health, and there may be more stigma around HPV infection. Self-sampling could potentially be a helpful option in such circumstances, as it can be carried out privately without having to attend an appointment, there is no speculum used, and it would not involve another person conducting an intimate physical examination.

In marriages where a wife speaks little or no English, communication may happen through her English-speaking husband. This could present a barrier to reaching women in communities where cervical screening may be less accepted. See the section ‘Addressing the impact on equalities’ for information on the steps that are being taken to reduce language barriers to accessing cervical screening.

Other identified groups

Women in inclusion health groups such as sex workers, substance misusers, individuals with multiple sexual partners and those who experience homelessness are less likely to attend cervical screening and are therefore at higher risk of presenting to the health system with symptomatic cervical cancer. They may also be at higher risk of being exposed to HPV infection, which is the main risk factor for developing cervical cancer.

Although it is not necessary to have a home or proof of address to access medical care (including antenatal and postnatal care), 8% of homeless people are not registered with a GP.^{[footnote 14]} People experiencing homelessness are also exposed to increased risk factors for cancer such as substance abuse, risky sexual practices and environmental pollutants.^{[footnote 15]}

Data from Homeless Link’s Unhealthy State of Homelessness report (2022) shows that just 54% of eligible homeless people had accessed cervical screening in the previous 3 years compared with 70% of the general population. This may be due to a number of factors including difficulty attending appointments, a lack of health information in accessible formats (including other languages) and anxiety about the screening process.

Having a self-sampling option could therefore potentially help with some of the practical challenges that people in inclusion health groups face in accessing screening. However, anyone who tests positive for HPV via self-sampling would still then need to attend an appointment for a clinician-taken sample. So without additional changes to the pathway, the previous barriers are likely to still exist.

Other under-screened groups include women who live in socially deprived areas ^{[footnote 16]} and women who have experienced sexual violence.^{[footnote 17]} In the latter group, concerns tend to focus on the invasive nature of a clinician-taken screen (particularly the use of a speculum) and anxiety around becoming distressed or having a trauma response during the procedure.

Self-sampling could be a positive option for people who have experienced sexual trauma, as this approach gives the individual autonomy and control over the process. As the test can be carried out privately in a safe and familiar environment, and does not involve using a speculum or being examined by a healthcare professional, this could help to reduce feelings of stress and anxiety.

However, even without a speculum, self-sampling may still cause trauma flashbacks due to the intimate nature of the test. There is also anecdotal evidence suggesting some women who have experienced sexual violence would actually prefer a clinician-taken screen rather than doing the test themselves. This may be because they do not want to run the risk of having to repeat the test if they have not done it correctly first time around.

Trauma is also often a major barrier to clinician-taken screening for women in prison, where a significant proportion of women may be former sex workers, survivors of sexual abuse, and/or may have experienced domestic violence. Self-sampling could be an empowering option for this group of people, as by choosing to undertake screening themselves they would be taking control of their own health. While there may be a slight risk that a self-sampling kit could potentially be adapted to create a weapon, this risk would need to be balanced against the risk to the woman’s health if she does not access screening. As sexual health testing is already successfully carried out via self-swabbing in female prisons, this suggests that the risk of kits being misused in this way would be low. We have heard that the high population turnover in female prisons can make it particularly difficult to arrange cervical screening, especially for women who are only detained for short periods of time. Having access to self-sampling kits within the prison that could be offered to anyone who is overdue screening when they are admitted could help to remove this barrier.

Question 5

Engagement and involvement

Accepted Answer

UK NSC public consultation exercise

UK NSC held a public consultation exercise on the following proposed recommendation:

“Self-sampling for HPV testing can be offered to under-screened people eligible for the Cervical Screening Programme in the 4 UK countries, where service commissioners think self-sampling would be a helpful addition to the programme. If implemented, the option would be provided alongside traditional clinician-collected sampling.”

The consultation ran from 4 December 2024 until 26 February 2025, and UK NSC received 39 responses. A summary of the main points is embedded in the coversheet provided on the UK NSC cervical cancer recommendation page (under the subheading ‘Supporting documents from the 2025 review’). A list of the consultation responders and their comments is available via the same link.

In addition to seeking consultation responses, UK NSC engaged with a wide range of stakeholders including health trusts, local authorities, universities (including the University of Sydney), charities and professional bodies.

Question 6

Summary of analysis

Accepted Answer

Overall impact

Introducing self-sampling for under-screened groups has the potential to improve participation in cervical screening by reducing a number of the barriers to participation experienced by people with different protected characteristics.

There is currently no evidence that self-sampling would increase health inequalities or have any negative impacts for a particular group or groups. Indeed, the existing evidence suggests that self-sampling would be particularly beneficial to historically underserved groups.

However, it is clear that self-sampling is not a ‘magic wand’ and that barriers will continue to exist - particularly later in the pathway for people who test positive for HPV. Instead, self-sampling should be considered as another ‘tool in the box’ (alongside clinician-taken screening) which, it is hoped, will provide more choice, autonomy and flexibility for under-screened people.

Question 7

Addressing the impact on equalities

Accepted Answer

It is planned that a suite of resources will be co-developed including translations (posters, social media assets, email footers, visual display unit (VDU) assets) that the NHS and public health teams can use to promote cervical screening to all eligible people with a cervix. This includes people who do not have a GP or NHS number. Resources will need to include easy-read versions for people with a learning disability, as well as translations into other languages and resources for visually impaired people. A range of resources specifically to support people with different needs to carry out a cervical self-sampling will be developed.

Guidance on reducing inequalities in screening for people with a learning disability, autism or both is already available to health professionals and can be used to help improve informed participation in the NHS Cervical Screening Programme. This publication includes guidance and resources for local screening providers, commissioners and other partners to help reduce barriers to screening for people who have a learning disability and/or are autistic. It includes sections on informed choice, barriers to screening, improving access to screening and working with primary care. This publication will need to be updated to include information about the self-sampling offer for under-screened people.

As previously mentioned, offering self-sampling within secondary mental health services (including inpatient units) could help to reduce barriers to cervical screening for people with SMI, and potentially also for people with a learning disability and people with autism who are detained under the Mental Health Act. This opportunity will be explored by NHS England.

Contractually, providers of NHS screening services are required to make reasonable adjustments to ensure that their services are accessible to people with disabilities. For example, providers must ensure that their premises are suitable for the delivery of services and are sufficient to meet the needs of their patients, including those with disabilities. If an individual needs specialist equipment, providers must ensure that they have access to its use in a safe environment. Current guidance on reasonable adjustments sets out that providers should make reasonable adjustments for people so they are supported to access screening programmes.

NHS England is improving its screening IT systems. A ‘reasonable adjustment flag’ is now available for screening call and recall. This automatically indicates that reasonable adjustments (such as accessible information) are required by an individual to help them access screening. The NHS Digital webpage on the reasonable adjustment flag has full details.

As previously mentioned, it is vital that the HPV self-sampling kit and instructions are fully accessible to people who are blind or visually impaired.

NHS England has identified the collection of ethnicity data and mapping it against Index of Multiple Deprivation data as a priority for all cancer screening programmes. The introduction of the new IT Cervical Screening Management System (CSMS) will provide an opportunity in that regard. It is important to raise awareness about the importance of recording ethnicity, disability and reasonable adjustment requirements with any service change including introducing self-sampling. The rollout of CSMS will allow ethnicity data to be collected and published. This will enable local regions to understand which sub-groups of their population to focus on to improve engagement with screening.

The CSMS also has the functionality to give trans men and non-binary people who have a cervix the option to receive automatic invitations for cervical screening, regardless of the gender status recorded on their NHS health record. From April 2025, individuals can ‘opt-in’ by contacting their cervical screening provider - for example, their GP or practice nurse, sexual health clinic or transgender health clinic.

Communications to under-screened people about HPV self-sampling should make it clear who is eligible for screening, particularly for those groups who may have previously been told that cervical screening was not for them (such as lesbian and bisexual women), and for younger women who may mistakenly believe that they do not need cervical screening as they have received the HPV vaccination. Letters and other communications to under-screened people should seek to address these specific misconceptions.

The Survivors Trust and The Eve Appeal have published a cervical screening guide for health professionals, providing advice about supporting service users who are survivors of rape, sexual assault or sexual abuse. Given that a significant number of individuals within the under-screened population have experienced sexual violence, this guide could now be updated in light of the introduction of a self-sampling option for under-screened people.

Consideration should be given to engaging with both current female prisoners and women who have lived experience of detained estates to understand their experiences around cervical screening and explore with them how self-sampling might work best for female prisoners in practice.

Question 8

Monitoring and evaluation

Accepted Answer

Under current arrangements, NHS screening programmes are monitored under section 7A of the NHS Act 2006, as amended by the Health and Social Care Act 2012. This may change in future when NHS England is merged with the Department of Health and Social Care.

NHS England has updated its data collection processes in anticipation of being able to report on self-samples in the programme. This will ensure that the impact of self-sampling, and that of different approaches, can be measured and evaluated as part of ongoing performance monitoring and quality assurance activities.

Question 9

Conclusion

Accepted Answer

The findings of this equality impact assessment suggest that there is potential for HPV self-sampling to have a positive impact on cervical screening participation. This impact could ultimately prevent more deaths from cervical cancer.

A self-sampling option could help to reduce a significant number of barriers to screening, including anxiety and embarrassment, difficulty accessing appointments, and the fear of discomfort. It is likely to be an easier and more convenient option for many under-screened people, offering increased choice and flexibility. Having the option to carry out the test privately, whether at home or within a primary care setting, should help to address concerns that some under-screened people have around shame and modesty, as well as offering a potentially less stressful experience for survivors of sexual trauma.

However, it is also clear that self-sampling alone will not remove all the barriers that under-screened people face in accessing cervical screening, particularly for those people who test positive for HPV and then need to have a sample taken by a clinician. For example, while self-sampling might be an accessible option for a disabled person who is housebound, if they test HPV-positive and need a clinician-taken sample they would currently still potentially find themselves in a position of not being able to access that appointment. This is why it is so important that screening providers make reasonable adjustments for disabled people, as set out in the ‘Addressing the impact on equalities’ section above.

Concerns have also been raised around how difficult it might be to use the test due to issues around dexterity or people struggling to understand the instructions. This is one of the many reasons why clear, accessible communications about self-sampling will be absolutely vital to ensure that under-screened people have all the information they need.

There is also a potential risk with this policy that regular screening attenders seek access to self-sampling by ignoring their next invitation for a clinician-taken screen. However, given the anecdotal evidence that self-sampling is not in fact preferred by everyone, this may not be as big an issue as is currently expected. It is vital that all communications on HPV self-sampling make it clear who this is for and why it is being offered.

In conclusion, the findings of this assessment suggest that the offer of HPV self-sampling to under-screened people will likely help to reduce health inequalities within the cervical screening programme. This recommendation has clear support among stakeholders, and its potential to increase participation within the under-screened population is widely recognised. While it is by no means a perfect solution to every barrier to screening and there are still some unknowns (for instance, around the comparative accuracy of the test compared with clinician-taken sampling), the evidence strongly suggests that the benefits of offering self-sampling to under-screened people will outweigh any harms. The actions set out in the ‘Addressing the impact on equalities’ section of this document will play a vitally important role in ensuring that the introduction of HPV self-sampling is able to benefit as many under-screened people as possible.

Equality impact assessment: the use of HPV self-sampling in under-screened people eligible for NHS cervical screening

Cervical screening and human papillomavirus self-sampling

Background information about screening

The NHS Cervical Screening Programme

Intended aims of HPV self-sampling

The effect of HPV self-sampling on GP practices

Effect on service users

Effect on laboratories

Effect on colposcopy services

Evidence

YouScreen study

UK NSC 2024 rapid evidence review

UK NSC public consultation exercise

Analysis of impacts

Disability

Sex

Sexual orientation

Race

Age

Gender reassignment

Religion or belief

Pregnancy and maternity

Marriage and civil partnership

Other identified groups

Engagement and involvement

UK NSC public consultation exercise

Summary of analysis

Overall impact

Addressing the impact on equalities

Monitoring and evaluation

Conclusion

Is this page useful?

Help us improve GOV.UK

Help us improve GOV.UK

Cookies on GOV.UK

Cervical screening and human papillomavirus self-sampling

Background information about screening

The NHS Cervical Screening Programme

Intended aims of HPV self-sampling

The effect of HPV self-sampling on GP practices

Effect on service users

Effect on laboratories

Effect on colposcopy services

Evidence

YouScreen study

UK NSC 2024 rapid evidence review

UK NSC public consultation exercise

Analysis of impacts

Disability

Sex

Sexual orientation

Race

Age

Gender reassignment

Religion or belief

Pregnancy and maternity

Marriage and civil partnership

Other identified groups

Engagement and involvement

UK NSC public consultation exercise

Summary of analysis

Overall impact

Addressing the impact on equalities

Monitoring and evaluation

Conclusion

Is this page useful?

Help us improve GOV.UK

Help us improve GOV.UK