Human papillomavirus (HPV) is a prevalent cause of vulvar., vaginal, and cervical cancers, with approximately 50–80% of sexually active women acquiring an HPV infection at some stage of their lives (1, 2). Although some women may develop antibodies against HPV, these are detected in only a minority of infected individuals and offer modest protection against reinfection, which is unlikely to significantly contribute to viral clearance (3). Persistent infection with high-risk HPV strains, such as 16 and 18, poses a substantial risk of progressing to precancerous lesions, eventually evolving into invasive cancers (4). Primary prevention of HPV through prophylactic vaccination is crucial as it aims to prevent the initial infection with the virus, thereby reducing the risk of advancing to cancerous stages (5). This preventive strategy complements efforts focused on the early detection and treatment of HPV infections, which are vital in preventing their progression to advanced stages (6).

HPV testing is a valuable method for preventing cervical cancer due to its superior negative predictive value and higher sensitivity compared to cytology-based screening (7). It is particularly beneficial in identifying precancerous lesions and early-stage cancers (8). This enables longer screening intervals, which is especially advantageous in resource-limited settings (9). Recent meta-analyses showed that self-sampling significantly boosts cervical cancer screening participation, especially in low-income settings, with mail-to-all strategies being the most effective. However, further studies are needed to assess its economic and full-scale implementation viability (10–12). Given that many women are either underscreened or undergo screening too frequently (13, 14), the significance of self-sampling for HPV testing is underscored. Self-sampling, by improving screening rates and enabling timely detection of cervical abnormalities, empowers women to take control of their cervical health, overcoming barriers such as embarrassment, inconvenience, and limited healthcare access (11, 15).

HPV self-sampling testing in China has yielded mixed results in terms of acceptability. Studies have reported that 83.27% of participants were willing to choose self-sampling for cervical cancer screening (16), while another study found that only 12.5% of women had heard of and undergone self-sampling (17). These findings highlight regional and population-specific variations in the acceptability of HPV self-sampling in China. Thus, it is important to further investigate and understand the factors that influence the acceptability of HPV self-sampling in China to develop effective strategies for increasing screening participation rates.

This study aimed to assess the knowledge, attitude, and practice (KAP) of HPV and self-sampling among adult women in Shanghai, China, as KAP studies are crucial for understanding the current landscape and identifying areas for improvement, ensuring informed decision-making and promoting better healthcare outcomes (18). The results can potentially guide the development of policies and interventions aimed at promoting HPV prevention and early detection strategies.

In the study, participants scored an average of 50.45% in knowledge, 66.9% in attitude, and 52% in practice regarding HPV and self-sampling. Significant variations in knowledge, attitudes, and practices were observed based on demographic factors such as age, education level, employment status, marital status, sexual activity, history of HPV infection, and ethnicity. This highlights the need for targeted educational interventions to improve knowledge and promote positive attitudes and practices related to HPV and self-sampling, particularly focusing on rural populations, individuals with lower education levels, and those with limited understanding of HPV concepts.

The participants in this study and a similar study in Brazil demonstrated a lack of knowledge regarding HPV and self-sampling, with average knowledge scores of 50.45 and 51.79%, respectively (22). This study highlighted the highest levels of knowledge among participants regarding the link between HPV and vulvar., vaginal, and cervical cancer (66.74%) and the transmission of HPV through unprotected sexual activity (69.94%). Significant knowledge gaps were observed in understanding the connection between persistent HPV infection and cervical cancer (4.83%) as well as HPV self-sampling (12.70%). Another study conducted in Dhaka district, Bangladesh, revealed that although a high percentage of women were aware of cervical cancer (87%), only a small proportion knew about HPV as a risk factor (13%) (23). Similarly, in a study conducted in Romania, 69.2% of women were aware of HPV, but their knowledge was limited (24). These findings highlight the need for comprehensive educational interventions to improve knowledge and awareness about HPV and its associated risks, particularly in relation to persistent HPV infection and self-sampling.

The study showed that a significant proportion of participants (56.43% strongly agreed and 32.39% agreed) had doubts about the ability of HPV self-sampling to ensure sample quality. Additionally, 16.23% expressed reservations about the accuracy of self-sampling results. Concerns about sample contamination during the process of sending self-samples were also prevalent, with 16.22% strongly agreeing and 48.29% agreeing. On the other hand, in studies conducted in South Africa and Chengdu, China, 57.7 and 42.32% of participants, respectively, expressed willingness to undergo future screening if allowed to self-sample (19, 20), indicating a more positive attitude towards HPV self-sampling. Further, in a study conducted in rural indigenous communities in Guatemala, there was significant acceptance and willingness to use self-collection for HPV testing. In one community, 94% of the age-eligible participants completed self-collection, and in another community, 53% of participants chose self-collection (25). The varying attitudes towards HPV self-sampling across regions may indicate differences in health literacy, cultural norms, trust in medical procedures, and access to healthcare. This suggests a need for comprehensive education and awareness efforts to address doubts and concerns, emphasizing the effectiveness and reliability of HPV self-sampling.

In this study, factors associated with good knowledge about HPV and self-sampling included living in urban or suburban areas, higher education levels, unmarried status, and a history of HPV infection. Consistently, higher education has been identified as a key factor linked to better knowledge about HPV in the general population (22, 24, 26). Interestingly, it seems that unique factors contribute to the understanding of HPV-related topics in specific demographic groups. A study conducted in Turkey among nursing and medical students revealed that factors such as age (26 and over), female gender, good economic status, being registered at the faculty of medicine, being in a higher year of study, having sexual experience, and recommending HPV vaccination were associated with higher knowledge scores on HPV, HPV testing, and HPV vaccination (27). Therefore, interventions aimed at improving HPV knowledge and promoting self-sampling may need to consider both general population trends and the unique characteristics of subpopulations.

In this study, higher knowledge scores and higher education levels were associated with a positive attitude towards HPV and self-sampling. On the other hand, the factors influencing attitude towards self-sampling compared to conventional Pap smears among multiethnic Malaysian women were age, ethnicity, and previous Pap smear experience (28). Additionally, in a study focused on a multi-ethnic Asian female population, influencing factors towards the attitude of preference for vaginal self-sampling for HPV testing included higher household income, full-time employment status, not having undergone a Pap test, convenience, and women’s confidence in performing the self-sampling (15). These findings indicate that various factors influence attitudes towards HPV and self-sampling, emphasizing the importance of targeted strategies for promoting cervical screening.

Factors influencing practice varied across different studies and populations. In this study, higher knowledge and attitude scores were associated with good practice. Additionally, being married, engaging in sexual activity, and having a history of HPV infection were also factors associated with favorable practices. However, in a study with female university students in South Africa, knowledge about HPV testing did not positively impact screening practice (19). Factors influencing practice in the United Kingdom included self-efficacy, education level, perceived importance of HPV, knowledge about self-sampling, confidence in self-sampling ability and results, and concerns about sample contamination and identity theft (29). In Gondar, Ethiopia, factors influencing practice encompassed husband disapproval, social influence, lack of knowledge and health education, religious influence, fear of self-sampling, and difficulties with sample collectors and instructions (30). The findings highlight the complex nature of factors influencing HPV self-testing. Understanding these factors is essential for developing targeted interventions and enhancing HPV screening programs.

In this study, higher knowledge and attitude scores were inversely associated with self-sampling for HPV testing. Conversely, belonging to a minority ethnic group and having multiple sexual partners were associated with a higher likelihood of self-sampling. The apparent contradiction between higher knowledge and attitude scores predicting good practice, while lower knowledge and attitude scores are associated with self-sampling, may be due to the fact that individuals with higher scores may perceive traditional methods as more reliable, whereas individuals with lower scores may be more open to considering self-sampling as a convenient and accessible alternative. A study conducted in Geneva adds further relevance by highlighting that women with higher education and professional occupations still prefer clinician sampling, possibly due to their perceived lack of expertise in self-sampling (31). These findings underscore the importance of considering individual preferences and addressing concerns when designing effective HPV screening programs and interventions.

Despite the insightful findings, this study carries some limitations. Firstly, the study’s cross-sectional design inhibits the ability to infer causality between the observed variables and the KAP scores. In addition, the use of self-reported questionnaires may introduce recall bias, social desirability bias, or misunderstandings due to the language or complexity of the questionnaire. The results might also not be generalizable to other populations given the specific demographics of the study participants. Importantly, our research design did not include a sample size calculation nor an explicit strategy to address potential biases, which could affect the robustness and reliability of the findings. Furthermore, the study did not control for some potential confounding factors such as access to healthcare services or the influence of healthcare providers’ advice. The lack of qualitative data may also limit the depth of understanding about the reasons behind certain attitudes and practices. Lastly, the study did not explore the impact of media exposure or health education on the KAP scores, which could play a critical role in shaping knowledge, attitudes, and practices towards HPV and self-sampling.

In conclusion, our study in Shanghai, China, reveals significant disparities in KAP scores regarding HPV and self-sampling among different demographic groups. While individuals in urban areas and with higher education levels generally exhibited better knowledge, certain misconceptions and concerns regarding self-sampling were prevalent, particularly among married individuals and those with lower knowledge scores. Targeted educational interventions are needed to address these gaps and promote informed decision-making regarding HPV screening. Furthermore, our findings underscore the importance of understanding the complex interplay between knowledge, attitudes, and practices to tailor interventions effectively. By addressing these challenges, we can enhance cervical cancer prevention efforts and reduce the burden of HPV-related diseases in our community.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

The studies involving humans were approved by Shanghai Pudong Hospital Medical Ethics Committee(WZ-019). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin in accordance with the national legislation and institutional requirements.

JS: Conceptualization, Writing – original draft, Writing review & editing. HK: Writing – original draft, Writing review & editing. CJ: Resources, Formal analysis, Writing original – draft, Writing review & editing. HS: Formal analysis, Writing original – draft, Writing review & editing. HH: Formal analysis, Writing original – draft, Writing review & editing. JZ: Project administration, Writing original – draft, Writing review & editing. LC: Resources, Writing original – draft, Writing review & editing. YW: Resources, Writing original – draft, Writing review & editing. JG: Methodology, Supervision, Writing original – draft, Writing review & editing. YD: Writing original - draft, Writing – review & editing, Funding acquisition.