Background SMS interventions are effective in promoting a variety of health behaviors; however, there is limited information regarding the use of SMS for cervical cancer screening and follow-up care. The Application of Communication and Information Technologies to Self-Collection study aims to evaluate a multicomponent mobile health intervention to increase triage adherence among women with human papillomavirus (HPV)–positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. Objective This study aimed to understand the cultural and contextual elements, women’s beliefs, and perceptions regarding the use of SMS by the health care system and women’s preferences about the message content. Methods We conducted five focus groups (FGs), stratified by rural or urban residence and age. All participants were aged 30 years or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification, and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding the SMS content. Messages for both HPV-negative and HPV-positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot-tested. Results A total of 48 women participated in the FGs. Participants rejected receiving both negative and positive HPV results by SMS because, for them, the delivery of results should be done in a face-to-face interaction with health professionals. They stressed the importance of the SMS content informing them that results were available for pick up and reflecting the kind of relationship that they have with the community health workers and the nearest health center. Women considered that a personalized SMS was important, as was the use of a formal yet warm tone. Owing to confidentiality issues, not using the word “HPV” was also a key component of the desired SMS content; therefore, the final message included the term “self-collection” without the mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message. Conclusions The results suggest that SMS is accepted when notifying women about the availability of the HPV test result, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. In addition, messages must be tailored and must have a persuasive tone to motivate women to adhere to the triage.

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BACKGROUND SMS interventions are effective in promoting a variety of health behaviors; however, there is scarce information regarding SMS use for cervical cancer screening and follow-up care. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) aims to evaluate a multi-component mHealth intervention to increase triage adherence among women with HPV-positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. OBJECTIVE To understand cultural and contextual elements, women’s beliefs and perceptions regarding the use of SMS by the health care system, and women’s preferences about the message content. METHODS We conducted five focus groups, stratified by rural/urban residence and age. All participants were aged 30 or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding SMS content. Messages for both HPV negative and positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot tested. RESULTS Forty-eight women participated in the FGs. Participant women rejected receiving both negative and positive HPV-results by SMS, as for them delivery of results should be done in a face-to-face encounter with health professionals. They stressed the importance of SMS content informing them that results were available to pick them up while highlighting the link they had with CHWs and the nearest health center. Women considered that a personalized SMS was important, as well as the use of a formal yet warm tone. Due to confidentiality issues, not using the word HPV was also a key component of the desired SMS content; therefore the final message included the term “self-collection” without mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message. CONCLUSIONS Results suggest SMS is accepted when notifying women about HPV result availability, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. Messages must be tailored and have a persuasive tone in order to motivate women to adhere to triage. CLINICALTRIAL ClinicalTrials.gov, NCT03478397. Registered on March 20th, 2018.

https: //doi.org/10.21149/8854 Resumen Objetivo. Evaluar la adopción e implementación en escala de la estrategia orientada a ofrecer puerta a puerta la autotoma de la prueba del virus del papiloma humano (AT-VPH), por parte de agentes sanitarios (AS), en Jujuy, Argentina. Material y métodos. Se aplicó una encuesta autoadministrada a 478 AS. Las dimensiones de adopción e implementación fueron evaluadas con el modelo RE-AIM. Resultados. Adopción: 81.8% de los AS ofreció la AT-VPH y 86.4% expresó gratificación con la estrategia. Implementación: los problemas encontrados fueron la demora en la entrega de tubos (61.3%) y resultados (70.0%); falta de recursos humanos (28.3%), y dificultades al obtener turnos para realizar el triage (26.1%). El principal obstáculo fue la sobrecarga de trabajo (50.2%), mientras que la capacitación (38.0%) y el listado de mujeres a contactar (28.7%) fueron los elementos facilitadores. Conclusiones. La adopción de la AT-VPH fue alta entre los AS. Deben reforzarse las estrategias programáticas para motivar a los AS y reducir su carga de trabajo al implementar la AT-VPH.Palabras clave: agentes comunitarios de salud; papillomaviridae; tamizaje masivo; evaluación en salud; programas de prevención de cáncer de cuello del útero AbstractObjective. To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered doorto-door by Community Health Workers (CHWs) in Jujuy, Argentina. Materials and methods. A self-administered questionnaire was applied to 478 CHWs. RE-AIM model was used to evaluate adoption and implementation dimensions. Results. Adoption: 81.8% offered SC and 86.4% were satisfied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%). Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators. Conclusions. The adoption of SC strategy was high among CHWs. Program strategies should be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

Background In Argentina, HPV  self-collection offered by community health workers was demonstrated to be effective to improve cervical cancer screening uptake. Based on these findings, the EMA strategy was scaled up in nine Argentinian provinces. However, there is no evidence about the degree of fidelity—in relation to the core components proposed by the National Program on Cervical Cancer Prevention—with which this strategy was implemented in the new jurisdictions. We carried out a fidelity evaluation of the EMA strategy scaling-up aimed at evaluating the level of adherence to the core components of the EMA strategy, and how different moderating factors affected the implementation fidelity. Methods This descriptive study used a multi-method approach involving quantitative and qualitative evaluations of the implementation fidelity using the Conceptual Framework for Implementation Fidelity. Evaluation of the degree of adherence to the core components of the EMA strategy was carried out through the analysis of a self-administered survey of health promoters, observations, and secondary data from the National Screening Information System. The analysis of moderating factors was carried out through analysis of field notes, and semi-structured interviews with key stakeholders. Results Our results showed that the core components with highest fidelity were training, sample handling, and transportation. Regarding the offer of HPV self-collection, we found some adaptations such as locations in which health promoters offered HPV self-collection, and fewer pieces of information provided to women during the offer. In the follow-up and treatment core component, we found a reduced adherence to triage and colposcopy. Some contextual factors had a negative impact on implementation fidelity, such as urban insecurity and the reduction in the number of health promoters that offered HPV self-collection. Moderating factors that contributed to achieve high level of fidelity included a well-defined strategy with clear steps to follow, permanent feedback and high level of engagement among implementers. Conclusions Our study shows how the analysis of fidelity and adaptations of HPV self-collection in real-world contexts are key to measure and maximize its effectiveness in low-middle-income settings.