Introduction
Cervical cancer (CC) is a preventable disease with existing evidence and technologies. For this reason, the World Health Organization (WHO) has launched a worldwide initiative to eliminate CC through vaccination, screening and treatment [
1]. In Argentina, every year 4600 new cases of CC are diagnosed, and some 2600 women die due to the disease [
2].
Human papillomavirus (HPV) DNA testing is a highly effective screening method to prevent CC [
3] that allows women to self-collect samples. HPV self-collection has been shown to increase screening uptake among socially vulnerable women [
4], especially when offered by community health workers (CHWs) during home visits [
5]. In an HPV self-collection program, the triage of HPV-positive women is a key step in identifying who will need to continue with diagnosis and treatment.
Nevertheless, the low adherence to triage and treatment is a longstanding problem for CC programs in low- and middle-income countries (LMIC) [
6], especially among women with limited access to health care [
7]. In Argentina, where HPV self-collection was introduced as a programmatic strategy in 2014, adherence to triage continues to be a challenge [
7,
8]; only around 25% of women with HPV-positive self-collected tests successfully triage within 120 days after screening positive [
8]. One key issue is the delivery of test results and referral of HPV-positive women for triage [
9]. In the case of self-collection, receiving results is challenging, as women collect their samples offered by CHWs during home visits. Given that CHWs are a scarce human resource responsible for the provision of a variety of health services, it is often not viable for them to re-visit all HPV + women (around 13% of all tested women) to deliver results and refer them to health centers for triage [
8]. Therefore, effective interventions aimed at improving triage adherence that do not require the intensive use of human resources in health are needed.
Mobile phone text messages (SMS messages) are useful to remind patients about medication adherence, such as antiretroviral therapy and asthma treatment [
10‐
12], and in reducing non-attendance rates to preventive health care centers in many LMIC [
11,
13‐
15]. Similarly, mHealth tools targeted at providers, such as SMS reminders for CHWs, have been shown to improve the quality of service provided to the population, mostly through decision support, alert and reminder tools [
16‐
19]. SMS messages have advantages over other reminder systems, including that they can be sent to patients simultaneously and require less staff [
10,
13,
20]. SMS reminders are easy to use and useful for patients [
10,
20,
21]. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) is a hybrid type I cluster randomized effectiveness-implementation trial (C-RCT) to evaluate the effectiveness of a multi-component mHealth intervention (ATICA strategy) to increase adherence to triage by women with a positive self-collected test [
22]. ATICA C-RCT results showed that SMS sent to HPV-positive women combined with e-mail/SMS sent to CHWs to visit women without Pap triage after 60 days effectively increased triage [
23]. For this reason, scaling-up of the ATICA strategy into routine CC screening programs using self-collected tests could have great impact in CC prevention programs by facilitating the continuity of care for HPV-positive women.
Evidence indicates that in low-middle income countries, adoption of innovations is unreliable and slow, and there is a dearth of evidence about what factors influence the delivery of evidence-based interventions at scale [
24]. Incorporation of an evidence-based innovation as ATICA strategy into the health system depends on the potential users’ intention to utilize the innovation, the set of practices and processes that make up the implementation, and, in particular, is highly influenced by the perception of the actors involved in the intervention’s implementation and use [
25]. In ATICA study, both acceptability of the intervention by HPV-tested women, and its adoption by CHWs were high [
23]. However, incorporation of the multicomponent intervention as a routine programmatic public health policy will also depend on health authorities’ and health care providers’ (HCP) acceptability and perceptions about barriers and facilitators of the intervention implementation. However, to our knowledge, very few evidence exists regarding these key stakeholders’ perspectives about using mHealth interventions to increase adherence to triage of women with HPV self-collected tests. In this paper, we present an evaluation of health decision-makers’ and health-care providers’ (HCPs) perceptions about implementation of the ATICA strategy. This qualitative analysis allows for a better understanding of key factors for scaling up ATICA strategy and builds on the effectiveness data from the C-RCT [
23].
Discussion
Low levels of triage after a positive result have been identified as a major drawback of HPV self-collection. ATICA C-RCT resulted in a 15% increase in the percentage of women with triage Pap after the HPV result, showing that the multi-component mobile health intervention was effective in improving triage adherence. It also showed that the intervention was of high reach, adequately implemented, and highly accepted by HPV-positive women and adopted by CHWS [
23]. However, to fully capture the likelihood of the intervention being implemented and sustained over time, it was essential to evaluate the perceptions of health decision-makers and HCPs regarding implementation and scaling-up of ATICA strategy. To our knowledge, this is the first analysis of the perspective of health decision-makers and HCPs regarding a multicomponent mHealth intervention to increase adherence to follow-up among women with HPV self-collected tests. The study design combined the application of CFIR [
25] and RE-AIM [
29], two conceptual frameworks from implementation science appropriate for evaluating implementation and sustainability of health interventions. Results showed that both HCPs and decision-makers had a positive assessment of the intervention through most included constructs. However, some potential barriers were identified in complexity, leadership engagement, external policies, economic cost and maintenance constructs. Thus, stakeholders conditioned the strategy’s sustainability to the political commitment of national and provincial health authorities to prioritize CC prevention, and to the establishment of the ATICA strategy as a programmatic line of work by health authorities. They also highlighted the need to ensure, above all, the availability of staff to take the Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-test.
The evidence shows that the legitimacy of the origin of an intervention is associated with success in its implementation [
36]. Key ideas for improving health care provision that come from outside the organization and that are then effectively tailored to the organization have been highly related to successful implementation [
37]. In our study, stakeholders considered that ATICA strategy was proposed by prestigious external institutions and then designed and implemented collaboratively through consensus with local institutions and health providers. In addition, interviewees highly valued the fact that local stakeholders were involved in the design and implementation of the intervention since its early stages. Respondents also pointed out the importance of ATICA as a research study that would provide data on the strategy effectiveness. Integrating research activities into existing health systems with involvement of local stakeholders, as done in ATICA study, has been identified in the literature as an important factor for successful incorporation of evidence-based interventions [
38,
39]. The perception of collaborative work and early involvement might also be factors that explain why respondents did not perceive the need for substantial adaptations of the intervention.
Our study found that for decision-makers and HCPs the implementation of ATICA would offer important relative advantages in relation to the current programmatic situation regarding delivery of results. These findings are important because stakeholder’s acknowledgement of the relative advantages of an intervention constitute a
sine qua non for implementation/adoption [
40]. A study carried out in Canada [
41] showed that a main factor facilitating adoption on the part of clinicians of a mobile application for monitoring heart patients was the perception that the application had several advantages over other telemonitoring systems. In our study, no disadvantages were identified, probably because the existing procedure for result delivery by which HPV-tested women are instructed to go to the health center within 30 days to pick up results has been shown to be highly deficient [
42‐
44]. The intervention was perceived as implying a more efficient use of PHC resources, with a reduction in CHW workload and an improvement in the communication of self-collection results. The fact that in the ATICA strategy CHWs only visit positive women who have not responded to the SMS messages was perceived as an advantage over the existing situation as at present, very often CHWs are asked to visit all non-adherent positive women, which results in the incorporation of a high number of unplanned visits into their daily tasks.
The perception of the relative advantage of the intervention over the existing situation must be shared by all involved actors to assure effective implementation [
40]. Undoubtedly, a key stakeholder in ATICA strategy scaling-up are the CHWs, as implementation of both intervention components is highly dependent on them explaining the intervention during the offer of HPV self-collection, and the visit to positive women who have not triaged at 60 days to be included as part of their tasks. Acceptability of interventions by CHWs is correlated with potential work overburden that those might impose on their daily tasks [
45]. Although our study did not interview CHWs, previously reported results showed that 87% of CHWs accepted the incorporation of the ATICA strategy into their daily activities and 91% visited HPV + women who did not respond to the SMS [
23]. It is therefore possible to assume that interviewees’ perception of the intervention as advantageous for CHWs is also shared by CHWs.
The complexity of an intervention and its compatibility with existing practices are concepts related to factors that can promote or hinder implementation [
46]. Evidence has shown that when there is a good perceived fit between e-health systems and workflows, and when systems positively influence workplace efficiency, their use is facilitated [
47]. Our results showed that the intervention was perceived both by health decision-makers and HCPs as highly compatible with PHC existing organization and ways of functioning. They also agreed that the ATICA strategy could be easily integrated into processes that health services regularly carry out. Complexity is also increased by the process length, i.e. the number of sequential subprocesses and actors involved in health service provision [
48]. This process complexity was signaled by some of the interviewees by highlighting that the SMS is a simple tool for communicating with women and CHWs which is integrated into a multi-step screening process. Thus, our results suggest that, for successful integration of the ATICA strategy into CC screening programs, coordination of actors, institutions and activities involved in the screening continuum should be assured.
Our study also identified some potential obstacles related to the costs of implementing the ATICA strategy, as mHealth interventions require ongoing technological maintenance and support [
49]. In the ATICA study, the cost of operating MATYS, the SMS system, was met by the research study, but in the strategy scaling-up the cost should be integrated into provincial/national MoH budgets. This could represent an obstacle for assuring scaling-up of the intervention. Eze et al. [
50] have shown that educating health decision-makers regarding the long-term benefits of mHealth tools might favor long-term financial support by increasing health authorities understanding of clear return of investment for mHealth technologies and reasoning out the potential for future projects. In the ATICA study, both national and provincial health authorities were involved in the intervention design, implementation, and evaluation. Along the project, several meetings and workshops were carried out regarding ATICA implementation, which were also an opportunity to discuss with them about the role of mHealth interventions in reducing unequal access to cervical cancer prevention and how the multi-component intervention could be latter adapted for increasing continuity in the care continuum of other tumors or health conditions. Therefore, following Eze et al. [
50] we might expect that these activities will increase shared values about using mHealth technology, with a positive impact on the long-term financial support.
Interviewees in our study raised the issue of up to what extent an mHealth strategy based on PHC should rely on CHWs personal cell phones and access to internet. This is certainly a point to be considered when designing mHealth strategies, especially in settings with unequal access to internet across the health system. As suggested by some interviewees, a solution might be to have institutional cell phones at health centers to be shared by CHWs and other health services. However, the high level of coordination needed for this might be difficult to achieve in LMIC health systems. As a result, CHWs might end up with the additional burden of having to assure access to cellphones whenever they need them. Providing professional phones might be an alternative solution, however this might create new concerns for CHWs as protecting the phones from loss, theft or damage can be challenging [
51]. Feasibility of assuring access to mobile data by CHWs should be evaluated.
In CFIR, inner setting related constructs allows to understand how factors related to the organizational context might associate with implementation and scaling-up of an evidence-based intervention. Maintenance is a RE-AIM dimension that refers to the degree of institutionalization of an intervention, to the point that it begins to form part of the routine practices of an institution or organization [
29]. Used together, RE-AIM and CFIR allow elucidating relationships between factors which potentially could lead to optimal post-trial maintenance outcomes [
52]. In our study, interviewees’ perceptions suggested a likely high level of post-trial adoption of the intervention, as they assigned a high relative priority to the intervention implementation and perceived a high potential commitment of health authorities with its scaling-up. Nonetheless, interviewees also mentioned the high turnover of policy makers as a note of concern regarding future health authorities’ commitment with the scalability of the strategy. In the case of the ATICA strategy, policy-maker high turnover might have a negative impact in its scaling-up, as establishing the strategy as a programmatic activity will be highly dependent on decisions that have to be taken at high level health authorities. An example of this is the inclusion of the visit of the CHWs to women who do not have Pap triage at 60 days as part of the routine PHC activities, or incorporating and funding the SMS sending system as a component of the national screening information system (SITAM) so SMS can be sent. Since completion of ATICA C-RCT in 2019, national highest health authorities in charge of cancer control changed several times. Although collaborative work to plan scaling-up activities was initiated [
23] each change of health authority has slowed down the actual incorporation of the strategy as a programmatic routine activity. Thus, our study underscores the need to produce evidence about implementation of effective strategies to increase maintenance of an evidence-based intervention in contexts of high turnover of health authorities.
In our study, respondents valuated the ATICA strategy as highly effective in increasing triage of HPV + women and facilitating access to an early diagnosis; this assessment coincides with the results of the C-RCT [
23]. This is a key result, as the perception of effectiveness of the intervention is an influential factor of the intervention’s sustainability [
53,
54]. Research on the use of mobile phones for sending SMS, voice and video messages among patients and HCPs [
55] showed that the perception of effectiveness of the intervention on the part of patients, decision-makers and HCPs facilitated its sustainability in different health systems (urban and rural environments in Canada, Kenya and Uganda). A systematic review that evaluated the use of tele-homecare for the management of chronic diseases showed that uncertainty regarding the clinical effectiveness of this type of interventions by key actors was a barrier to its sustainability [
56].
Regarding the extent to which the intervention responded to women’s needs, respondents recognized the importance of the ATICA strategy to facilitate access to timely triage. Nonetheless, they also signaled that women’s first priority was the health system to guarantee human resources for taking triage Paps and processing HPV-tests, and the constant provision of HPV-tests and related supplies. These findings are consistent with the literature, which shows that the provision of supplies and human resources are key factors that influence the sustainability of any health intervention [
53]. The availability of supplies and human resources for taking and reading Pap tests has historically been highlighted as one of the primary barriers to CC screening [
57‐
59]. A study carried out in Malawi, that used CFIR to evaluate the implementation of a screening and treatment program to prevent CC found that resource availability (the lack of human resources as well as supply shortages) negatively affected the CC screening program implementation [
60]. The introduction of HPV-testing has served as a tool for improving the organizational capacity of CC prevention programs [
8,
61]. A study carried out in Argentina showed that after the introduction of the HPV-test, problems related to cytology technical staff and supplies for reading Pap tests were reduced [
62]. Additionally, introduction of HPV self-collection reduced problems related to the lack of screening sample takers [
62]. Nevertheless, variations in the dollar exchange rate and national policies restricting importation during certain periods disrupted the purchase of HPV reagents, which led to interruptions in the availability of the test. Thus, the perception of the stakeholders regarding the need to guarantee essential resources for the screening system to work is a recognition that ATICA strategy should be implemented in the context of a CC prevention program that works adequately and has the necessary resources. Guarantying a permanent and uninterrupted supply of HPV-testing should be a priority.
A limitation of the study is that it evaluated the perspective of health decision-makers and HCPs in a specific setting, which limits the generalization of the results. In this sense, future research is needed to adjust the ATICA strategy to other health systems, local contexts and population needs. Also, our study did not interview national health authorities involved in cervical cancer prevention, so perception of this key actor might differ from provincial decision-makers. However, the research team is working with authorities of the Argentinean National Cancer Institute on scaling-up of the ATICA strategy, suggesting that the positive perception of provincial policy makers identified in our study also applies to national health authorities.
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