China accounted for approximately 18.7% (106,430 new cases) and 15.3% (47,739 deaths) of the global annual incidence and mortality from cervical cancer in 2018. [1] Even though cervical cancer is preventable through screening tests, such as the clinic-based Pap smear test or human papilloma virus (HPV) test, these diagnostic tests are not readily available or practical for many people in China.
There are a number of reasons that contribute to the limited availability of screening in China. The capacity of China’s healthcare system, particularly in rural settings, is limited, and the ratio of healthcare professionals to population is low. [2] The historical design of healthcare in China means that quality healthcare facilities primarily serve major cities with large populations. For economically poor populations and those with low or no health insurance coverage, costly diagnostics are naturally never a priority. China has also experienced massive population mobility since the economic reform policy was introduced in late 1970s with more than 200 million migrants living outside of their household registration towns or cities. [3] This means medical costs incurred in non-registrant localities may not be reimbursed through a patient’s insurance premium, if they have one, creating an additional obstacle for routine diagnostic screening.
HPV vaccines as primary prevention for cervical cancer are yet to benefit every woman at risk in China. The vaccines have only recently become available in major Chinese cities where long waiting lists are common. In most rural areas and in many second and third tier cities, where HPV-related cervical abnormalities and cancers are significantly higher, the vaccines are not available. [4] Worse still, the cost of vaccination, which is usually not covered by health insurance, limits its broader reach to those in need.
Privacy concerns, social stigma, and misconceptions around gynecological tests in China can limit the attendance and willingness of women to engage in screening programmes in clinics. This is especially true for women with a lower level of education and from poorer backgrounds. Chinese culture, which focuses on health crises rather than disease prevention, is another barrier that limits clinic attendance for screening by women with no obvious abnormality. [5]
An easy-to-use, low-cost, self sampling kit that allows users to conduct tests at home or in privacy has the potential to overcome many barriers in accessing HPV screening for under-served women in China. Women with the greatest needs are likely to benefit the most because bricks-and-mortar infrastructure, and large workforces and budgets, do not need to be sustained. [6] From the perspective of cost-effectiveness, home-based self sampling vastly reduces the cost of screening by eliminating the need of a clinic visit, while still maintaining comparable and possibly even better effectiveness. [7]
Thanks to a centuries-old tradition of self care that is highly influenced by the philosophy of traditional Chinese medicine, [8] self sampling is seen as acceptable in China, with women willing to use self sampling devices. [9] Furthermore, self sampling for cervical cancer could help reduce the pressure on crowded hospitals and clinics in China.
The Chinese central government is conscious of the urgent need to increase the availability of services to maximize coverage of HPV screening throughout China. From 2009 to 2011, the Chinese Ministry of Health and All-China Women’s Federation successfully launched a 3-year nationwide free cervical cancer screening project targeting 10 million women in rural China. [10] However, the goal of scaling up screening to the whole of the country will be hard to accomplish without a concerted move towards self sampling. Moreover, overcoming the hurdles in implementing HPV self sampling screening will require commitments by government at all levels to promote and develop implementation programmes with allocated financial resources, and coordinate with established healthcare to provide training and consultation services.
Prompt action to provide the millions of women in China with self care interventions that meet their needs and rights is critical.
Zhou Tian, a health policy student from Nanjing University and Yale School of Public Health
Allen Z. Wu, Professor and Director of Center for Public Health Research, Medical School, Nanjing University
Competing Interests: The authors declare no competing interests.
Acknowledgments: The authors would like to thank Dr. Manjulaa Narasimhan from WHO Department of Reproductive Health and Research for creating opportunities for engaging youth and voices from China to actively participate in WHO work
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