Background
HPV-based cervical cancer screening is rapidly adopted in China for its convenience, high sensitivity, and cost-effectiveness, especially following the 2023 national guidelines prioritized HR-HPV testing as primary screening method. As HPV testing implemented at scale, a growing number of women receive positive results, with limited knowledge of HPV, insufficient access to professional medical interpretation, exposure to gynecological and sexuality-related stigma, and lacking psychosocial support services in limited health resource areas. These may intensify emotional distress and contribute to maladaptive follow-up behaviors, posing challenges to screening strategies’ effective implementation.
Objectives
This study aims to explore the psychological responses (anxiety symptoms and distress), underlying cognitive and social mechanisms (illness perceptions, self-stigma, and support networks), and influence on follow-up intentions among women in limited health resource areas in China after receiving an HPV-positive screening result.
Methods
Guided by a cognitive-behavioral theory (CBT), the mixed-methods study was conducted using explanatory sequential design in 2025.
Quantitative study was set in Xiangyuan and Yangcheng counties of Shanxi Province. Along with local usual screening process, 198 women (aged 49.37±7.73) who received HPV-positive result within one month were recruited to complete online questionnaire, with 188 (94.95%) valid responses. Key measures assessed anxiety (STAI-6), distress (GHQ-12), illness perceptions (B-IPQ), self-stigma (SSS-S), and perceived social support. Descriptive, univariate analysis, and multivariable linear regression were performed to explore the associations between demographics, HPV-related variables, and psychological outcomes.
Qualitative study was conducted thereafter, through CBT-based semi-structured interviews. 33 women, who have received their HPV positive result within three months from Xiangyuan, Yangcheng, and Shimian counties, were recruited. Transcripts were analyzed thematically using grounded theory. Ethics approval: CAMS&PUMC-IEC-2025-126.
Results
The prevalence of anxiety and distress were 77.13% and 30.32% respectively. Illness perception elevated (B-IPQ: 45.58±17.77), with 59.57% perceiving HPV infection as moderate-to-high threat. Mean self-stigma score was 2.37±0.62, indicating moderate stigma. Higher anxiety was significantly associated with more threatening illness perceptions (OR = 1.11, p = 0.006) and higher self-stigma (OR = 12.25, p = 0.013). Distress was associated with illness perceptions (OR=1.07, p=0.010), self-stigma (OR = 6.12, p < 0.001), and protected by perceived social support (OR = 0.92, p=0.010).
Qualitative findings elucidated these associations. Limited HPV-related knowledge heightened perceived illness threat, triggering anxiety and fear of cancer progression. Gynecological and sexuality-related stigma intensified self-blame and concealment, reinforcing anxiety and psychological distress, while stigma-driven non-disclosure reduced social support and contributed to distress. Trust in healthcare providers mitigated distress, whereas poor communication and privacy concerns exacerbated it. These responses influenced subsequent behaviors: some women adopted proactive coping strategies (lifestyle changes, vaccination planning), while others engaged in excessive hygiene practices, inappropriate medication to clear HPV, or avoided follow-up due to fear or hopelessness.
Conclusions
This CBT-guided mixed-methods study in China demonstrates that emotional distress after receiving HPV-positive result is driven by misinformed illness perceptions, stigma, and inadequate support. These responses negatively influence health behaviors and threaten follow-up compliance. Interventions should integrate structured counseling and targeted education with improvements in provider communication, privacy protection, and psychosocial care within limited health resource systems.