Adoption and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): Perceptions of health decision-makers and health-care providers

Adoption and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): Perceptions of health decision-makers and health-care providers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Adoption and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): Perceptions of health decision-makers and health-care providers Cecilia Straw, Victoria Sanchez-Antelo, Racquel Kohler, Melisa Paolino, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2064981/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Jan, 2023 Read the published version in BMC Health Services Research → Version 1 posted 8 You are reading this latest preprint version Abstract Background: The ATICA study was a Hybrid I type randomized effectiveness-implementation trial that demonstrated effectiveness of a multicomponent mHealth intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), to increase adherence to triage of HPV positive women (ATICA Study). We report data on perceptions of health decision-makers and healthcare providers regarding the intervention adoption and scaling-up. Methods: A qualitative study was carried out based on individual, semi-structured interviews with health decision-makers (n=10) and health care providers (n= 10). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Results: Both health care providers and decision-makers had a positive assessment of the intervention through most included constructs: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women’s needs, and relative priority. However, some potential barriers were also identified including complexity, leadership engagement, external policies, economic cost, women needs and maintenance. Stakeholders conditioned the strategy’s sustainability to the political commitment of national and provincial health authorities to prioritize cervical cancer 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, that there is staff to take the Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-test. Conclusions: Health decision-makers and healthcare providers had a positive perception regarding implementation of the multicomponent mHealth intervention designed to increase adherence to triage among women with HPV self-collected tests. This increases the potential for a successful scaling-up of the intervention, with great implications for not only to Argentina but also for middle and low-income countries considering using mHealth interventions to enhance the cervical screening/follow-up/treatment process. mHealth Self-collection HPV Adoption Scaling-up Implementation Introduction Cervical cancer (CC) is a disease preventable 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, 4600 new cases of CC are diagnosed every year, 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 increasing 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 [ 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 at homes offered by CHWs. 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 the homes of 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. Using mobile phone text messages (SMS messages) as reminders has proven to be effective in a variety of settings and for different health problems [ 10 – 11 ]; they can be sent to providers and patients, are automated and require less staff [ 10 – 11 ]. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) is a hybrid type I effectiveness-implementation trial 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 [ 12 ]. Results of the CRT showed that sending SMS to encourage women with positive self-collected tests to visit a health center for triage combined with an e-mail/SMS to the CHWs to encourage them to visit women without Pap triage after 60 days effectively increased triage [ 13 ]. 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 little evidence exist about what factors influence the delivery of evidence-based interventions at scale [ 14 ]. Adoption and incorporation of an evidence-based innovation as the 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 [ 15 ]. However, to our knowledge, very few evidence exist regarding adopters’ 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 the decision-makers and healthcare providers (HCPs) perceptions of the ATICA strategy. This qualitative analysis allows for a better understanding of key factors for scaling up the ATICA strategy and builds on the effectiveness data from the CTR [ 13 ]. Methods Study Design Methods of the ATICA study have been extensively described elsewhere [ 12 ]. In this qualitative study, perception of HCPs and decision-makers were gathered through individual, semi-structured interviews. The themes explored were selected and analyzed using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) [ 15 ], and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) conceptual framework [ 16 ], as presented in Table 1 . Table 1 CFIR and RE-AIM Domains, constructs and definitions CFIR Domains Construct Definition I. Intervention characteristics Intervention Source The legitimacy of ATICA as an intervention external to the institution to which the HCPs and decision-makers belong. Legitimacy of the institutions to lead the implementation and adoption of the intervention. Relative advantage The advantage of implementing ATICA versus an alternative solution and/or current usual practices. Adaptability The degree to which the ATICA components can be adapted or refined to meet local needs. Complexity The perceived difficulty of the intervention. Design quality Perceived excellence in how the intervention was bundled, presented, and assembled. Cost and resources The costs of the intervention and costs associated with its implementation, including investment, supply and opportunity costs. II. Outer Setting Patient needs and resources The perception of the degree to which ATICA responds to the patient needs. External policies and incentives Strategies to promote ATICA through policies and regulations. III. Inner Setting Access to knowledge and information Ease of access to information and knowledge about the intervention and how to incorporate it into work tasks. Implementation climate Compatibility The compatibility of ATICA with the norms, values, and existing workflows and systems. Relative priority The individuals’ shared perception of the importance of the ATICA implementation within the institution. Readiness for Implementation Leadership engagement Commitment, involvement, and accountability of health authorities with regard to the ATICA implementation. IV. Characteristics of Individuals Knowledge and beliefs about the intervention. Knowledge and attitudes regarding the ATICA strategy. RE-AIM Dimension Maintenance Intention to incorporate the intervention on the part of the provincial CC prevention program. Own elaboration based on an adaptation of Damschroder [ 15 ] and Glasgow [ 16 ]. Study setting The province of Jujuy is located in northwest Argentina. It has approximately 673,000 inhabitants, of which 51% are women, 87% live in urban areas, 32% are poor, and approximately 45% have public health insurance [ 17 ]. Mobile phone penetration in urban areas was 86% in 2019 [ 18 ]. The public health system includes a primary hospital and 270 primary health care (PHC) centers. The PHC system employs about 700 full-time CHWs that visit approximately 110,000 homes twice a year to carry out health-related tasks such as vaccination and child-maternal health promotion [ 12 ]. The Jujuy CC prevention, screening and treatment program has been extensively described elsewhere [ 19 ]. Briefly, since 2012 HPV-testing is the primary screening method for women 30 years and older who receive care in the public health sector. In 2014, self-collection was introduced as a screening strategy for women not tested in the last 5 years and with public health insurance [ 12 ]. CHWs offer self-collection during home visits. Women who perform self-collection are told to visit a health center within 30 days to receive the results, and if results are positive, to carry out cytology-based triage in the health center [ 12 ]. All testing/diagnosis/treatment procedures performed in the public health system are registered in the national screening information system (SITAM, for its initials in Spanish) to generate a diagnosis form, which is instantly available online to all providers at public health establishments. Target population and sampling The sampling was purposive. Decision-makers with institutional responsibilities in Jujuy’s health system were interviewed; they are state officials in charge of the design and management of policies aimed at CC cancer prevention at the provincial level. Those decision-makers who performed healthcare functions at PHC level were excluded. In addition, HCPs responsible for patient care in Jujuy’s public health system were interviewed. HCPs should have clinical, nursing or gynecology training, and provide CC prevention services for patients at provincial PHC centers. Those HCPs who were involved in managing cancer control and prevention policies were excluded. Instrument for information collection Individual semi-structured interviews were conducted using a guide based on dimensions and construct of CFIR and RE-AIM (Table 1 ). Questions related to the external policies and costs constructs were only asked of decision-makers. They were carried out on a virtual platform and lasted on average one hour. As part of the interview, interviewees were shown three cards illustrating the ATICA multi-component mHealth intervention and content of the SMS [ 20 ]. Data collection Data were collected between December 2020-February 2021 by a researcher trained in qualitative research. Analyses The collected data were analyzed thematically [ 21 ]. Once the interview transcriptions were completed, all interviews were entered into the software ATLAS.ti (version 7.5.4; ATLAS.ti Scientific Software Development GmbH , Berlin). The coding and analysis were done in accordance with the domains, constructs and dimensions presented in Table 1 . In the analysis the perspectives of health decision-makers and HCPs were compared; points of agreement and disagreement were highlighted. The analysis was carried out by two researchers; the results were discussed in joint sessions with the research team, and any disagreements were resolved through discussions. The details of the methods and results of the semi-structured interviews are presented following the Consolidated Criteria for Reporting Qualitative Studies [ 22 ] as presented in an additional table file [see Supplementary Table 1]. Ethical aspects and participant consent The research study was performed in accordance with the Declaration of Helsinki. The ATICA study’s protocol including research on health decision-makers and HCPs perspectives was approved by the CEMIC Institutional Review Board, the Ethics Research Committee of the Jujuy Ministry of Health, The Institutional Review Board of the Harvard T.H. Chan School of Public Health, and the Deakin University Human Research Ethics Committee. Before the interview, the study objectives were explained to each participant who then signed an informed consent form. The confidentiality and anonymity of the participants was guaranteed. Results Respondents’ characteristics Ten health decision-makers and 10 HCPs were interviewed. The average amount of time that health decision-makers had occupied their roles was 11 years (range 2–30 years). Six of the decision-makers were women and four were men. HCPs had been practicing on average for 11.4 years (range 5–25 years). Eight HCPs were women and two were men. The results coded according to the CFIR constructs and themes that emerged in the analysis are presented in an additional table file [see Supplementary Table 2]. Knowledge of the strategy The level of knowledge regarding the ATICA strategy was high among the majority of the health decision-makers and HCPs. The interviewees were able to describe both intervention components and the implementation process. “The experience [with ATICA] was designed strategically and taking into account a number of factors: previous planning meetings, trainings, the type of message and how many times to send it” [Decision-maker 1]. “The majority of women came in after the first message and if they didn’t they got sent another” [HCP 6]. Characteristics of the intervention Intervention source The health decision-makers and HCPs positively assessed the fact that the ATICA study began as an initiative headed by CEDES (Centre for the Study of State and Society) in collaboration with Harvard University, institutions considered to have academic prestige and experience in mHealth research. Some health decision-makers and HCPs highlighted that ATICA was designed and implemented collaboratively through articulation and consensus with provincial and national institutions (Argentinean National Cancer Institute, provincial Cancer Institute and PHC Direction). They also assessed positively their early engagement in ATICA implementation. “[In workshops to implement ATICA], we listened and contributed ideas. We were there from the start” [Decision-maker 1]. “We never felt competition or like the idea was imposed. The provincial guidelines and ways of doing things were respected” [HCP 8]. Another positive aspect perceived by the majority of those interviewed was that ATICA began as a research study. In their opinion, this was a guarantee that scientific methods were applied to evaluate whether incorporation of mobile technology in PHC would work in the local context. “The fact that ATICA begun as a research project was an advantage, like that you can demonstrate that it works, there is an evaluation of results” [Decision-maker 5]. Design quality and Access to knowledge and Information Health decision-makers and HCPs mostly stated that the ATICA strategy components worked in an articulated and complementary way, and that the training and information received were adequate. They also considered that the printed materials contained clear, concise information with graphics and drawings that favored an intuitive understanding and recall of the messages. “The two options are complementary. If the patient doesn’t go to the health center after receiving the messages, it’s necessary for the community health worker to go see her” [HCP 6]. Adaptability The majority of the respondents agreed that adaptations to the ATICA components were not necessary. It was unanimous that the content of the SMS was appropriate as it was clear, precise and in agreement with the legal norms regarding the communication of health information. They also considered the frequency of the SMS to be adequate. “I wouldn’t change the content because the messages are respectful, subtle, and say “we need you to come in” especially when the HPV result is positive” [HCP 10]. Regarding the e-mail/SMS sent to the CHWs to inform them of women without Pap triage after 60 days, the respondents agreed that sending WhatsApp messages would improve the communication and make it more dynamic. They also considered that this information should be sent to authorities with decision-making power (for example, the coordinator of the provincial CC prevention program, the PHC director and supervisors), so responsibility for assuring that women are triaged is shared with HCPs and CC prevention program authorities. “Other members of the health team should also receive [the SMS], like the intermediate supervisors or the head of the CC prevention program, so CHWs do not bear all the responsibility [HCP 5]. Complexity and compatibility The respondents predominantly evaluated ATICA as a low-complexity strategy and, at the same time, considered it compatible with the existing organization and way of functioning within the health centers. In both cases, they agreed that the strategy was integrated into other processes that health services routinely perform (seek out, receive, and care for patients; inform medical results; input information regarding screening, triage, diagnosis and treatment in the national screening information system (SITAM); among others). “ATICA doesn’t change or interfere with any process of the cervical cancer program” [Decision-maker 1]. “The strategy is compatible because it facilitates the community health care worker’s everyday work, and the professional continues the flowchart examining the positive self-collected tests” [HCP 1]. The interviewees also considered that the intervention was compatible with the forms of communication between health care services and women. In their opinion, this was evidenced by the women’s high acceptance of the SMS as a channel of communication. “Perfect as a form of communication. It absolutely favored the communication between the health center and the patient” [HCP 6]. There were some decision-makers and HCPs who perceived the strategy as complex due to the need to logistically coordinate the actions of different actors (CHWs, staff from the HPV test/cytology/histology laboratory, staff registering self-collection results in SITAM). They also saw the functioning of the system sending the SMS as complex, because the algorithm must consider different diagnoses and the time passed between self-collection and later steps of the continuum of care. Relative advantage The interviewees mentioned several advantages –and no disadvantages– to the intervention in relation to the existing practices for communicating results to women with self-collected tests: -Simplifying the process of delivering results increased adherence to timely triage. “This lets the user know directly [about results availability] without being mediated by a doctor or a community health care worker who visits her. It brings the HPV-positive person in more quickly” [HCP 1]. -Improving the health system’s communication with women, by sending information via a personalized, direct, opportune, and timely SMS. “It is a marvelous intervention for facilitating communication. One hundred percent useful because the information mechanisms were greatly improved” [Decision-maker 4]. -Reducing the workload of CHWs in seeking out HPV + women without triage, especially those who require several visits to be reached. For the respondents, this meant a more efficient use of the human resources in the health system. “Before this, the community health worker had to go four times to remind a woman to get a Papanicolaou. Now it’s four messages. Taking better advantage of human resources is extremely important” [HCP 8]. -Incorporating mobile phones in the provision of PHC services increased the willingness of staff at this level of care to adopt mobile technology in their work processes, with a benefit to the population. “Now technology is an extension of the community health worker’s work and is somewhat more of a friend to primary health care” [Decision-maker 5]. Consideration of women’s needs ATICA was mainly viewed as a strategy responding to women needs, by facilitating timely triage. Nevertheless, some interviewees highlighted that the main barrier faced by some women to access triage was the lack of sample takers, and therefore the priority to meet women´s needs was to assure that in all health centers there was staff to take Paps. In this sense, they perceived that ATICA did not respond to a high-priority need. “The priority for women is to not delay their appointment to get a Papanicolaou. ATICA was very well aimed at quick communication and information” [Decision-maker 8]. “Some women couldn’t get access [to a Pap test], and that is why it is necessary to guarantee greater coverage of professionals to take Pap tests” [HCP 5]. Relative priority Both HCPs and decision-makers unanimously assigned a high priority to the incorporation of the ATICA strategy to ensure Pap triage and early diagnosis in women with positive self-collected tests. The strategy was seen as fundamental to complete the screening program goals in the target population. “It is absolutely crucial in encouraging the women to finish the path they started and get Pap triage” [Decision-maker 5]. Maintenance The interviewees perceived the programmatic incorporation of ATICA into the provincial CC prevention program as viable; they considered that the provincial health system had the organizational and technological conditions necessary to implement it, and that the usefulness of the ATICA strategy had been demonstrated. They also mentioned that the wide availability of cellular phones in the population would contribute to the programmatic scaling-up of the strategy. “The implementation is very viable because we have a key actor that is the community health worker” [HCP 5]. “It should be incorporated because we saw that it is useful for the prevention of cervical cancer” [Decision-maker 2]. A few decision-makers and HCPs conditioned the viability of the programmatic incorporation of the intervention to the provision of cell phones to the health facilities and to CHWs, as well as to the possibility of connecting to internet and mobile data at no cost. “With mobile devices, internet connection and mobile data in the health facilities… Otherwise, it won’t be very viable” [Decision-maker 3]. Regarding the strategy scaling-up, the interviewees agreed that it should be led by the provincial Ministry of Health (MoH), with ample involvement of PHC authorities and CHWs, the provincial CC prevention program, and the provincial Cancer Institute. With regard to the elements necessary for guaranteeing ATICA’s programmatic functioning, the decision-makers agreed to assign importance to the political decision to prioritize CC prevention both by the provincial health authorities (MoH and hospital directors) and the Argentinean National Cancer Institute. They also highlighted the importance of the highest health authority, i.e., the provincial health minister, to establish ATICA as high priority line of work. Additionally, the respondents agreed in highlighting the need to ensure human resources both for the HPV lab and for taking Pap tests at PHC centers, as well as the continued provision of HPV-tests and collectors. “[To have the ATICA strategy] as part of the cervical cancer prevention routine we need HPV kits always available, and the necessary reagents because otherwise the tests have to be suspended. And laboratory personnel so that the readings and results aren’t delayed” [HCP 4]. “We need to have gynecologists in all PHC centers, at least once a week” [Decision-maker 10]. Leadership engagement Almost all interviewees considered that the provincial health authorities would commit to the programmatic incorporation of the strategy in the long term. In first place, the authorities have for years shown their commitment to CC prevention. Besides, the fact that authorities had formed part of the design and implementation of ATICA, in addition to the demonstrated effectiveness of the strategy, increased the possibility of commitment to the implementation. “Yes, they will commit, we’ve been fighting for years against cervical cancer” [Decision-maker 5] The few decision-makers that doubted the commitment of the provincial health authorities considered that, in public policy management, resolution of urgent matters prevail in detriment to other important issues like the low adherence to the CC care process. Additionally, their doubts had to do with the high rotation of health authorities. Thus, they considered that new authorities might not continue lines of work developed by previous administrations. External policies In regard to the need for specific policies and regulations to extend ATICA at a provincial level, the opinions of those consulted were divided. On one hand, some considered it necessary, given that all programs have norms for functioning, target populations and procedures. Thus, to implement ATICA, guidelines regarding the digital communication of the health system with the population would be necessary. This would facilitate ATICA’s uniform implementation in all health institutions. In contrast, other decision-makers considered that the ATICA strategy could be carried out without additional regulations. They highlighted that the intervention was connected to an existing care protocol of CC screening, triage, diagnosis, and treatment. “I don’t think [there is a need for] specific normative frameworks. [ATICA] has to do with a referral algorithm of positive self-collected tests that is already functioning” [Decision-maker 5]. Costs of ATICA implementation The decision-makers identified three main items they believed it necessary to fund for ATICA to function. The first is related to the operation and maintenance of the software for sending the SMS (MATYS). “The program sending the text messages must have a cost, and logically sending the messages does too” [Decision-maker 2]. Second, they identified the provision of cell phones as a cost of the ATICA strategy. Thus, for some decision-makers providing CHWs with cell phones would guarantee that they could do their job without having to take on costs. However, for other decision-makers, a cell phone should be provided to every health care facility. In this case, they considered that the institutional cell phone could be used for different health programs, and the funding would not fall exclusively to ATICA’s budget. “Each CHW should be given a cell-phone and be provided with a mobile data package; some people might have problems using their own cell phone because that use has a cost” [Decision-maker 4]. “We need a cell phone per facility, not per community health worker. An institutional telephone at the health center for them to communicate with the health worker and the women” [Decision-maker 9]. A third cost had to do with the provision of free internet and WI-FI service to all health centers. For them, this was important to accessing data regarding screening, triage, diagnosis, and treatment through SITAM. However, on this issue, differences were found among decision-makers as some respondents considered that internet service was already widely available in health centers. Discussion Low levels of triage after a positive result have been identified as a major drawback of HPV self-collection. The ATICA trial resulted in a 15% increase in the percentage of women with triage Pap after the HPV result, showing that a multi-component mobile health intervention was effective in improving triage adherence. Our study evaluated the perceptions of health system decision-makers and HCPs regarding implementation and scaling-up of the 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 [ 15 ] and RE-AIM [ 16 ], two conceptual frameworks from implementation science appropriate for evaluating factors that could affect the 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: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women need, and relative priority. 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, that there is 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 [ 23 ]. 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 [ 24 ]. The ATICA strategy was perceived as the result of collaborative work between implementers and researchers from institutions both outside of and within the province, which were involved in the design and implementation of the intervention since its early stages. This involvement of local implementers has been signaled in the literature as a key factor of success in interventions scaling-up [ 25 ] and might be a reason why respondents did not perceive the need for substantial adaptations of the intervention. Respondents also pointed out the importance of ATICA start as a research study that would provide data on the strategy effectiveness. Integrating research activities into existing health systems has been identified in the literature as an important factor for successful scale-up [ 26 ]. The involvement of health authorities in the research study was one factor that prompted a positive perception of the potential political commitment of health authorities in the scaling-up of the ATICA strategy. 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, for example including the visit of the CHWs to women who do not have Pap triage in spite of having received the SMS, as part of their tasks and responsibilities, or incorporating and funding the SMS sending system as a component of the national screening information system (SITAM) so SMS can be sent. 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 and adherence to triage. These findings are important because stakeholder’s acknowledgement of the relative advantages of an intervention constitute a sine qua non for implementation/adoption [ 27 ]. A study carried out in Canada [ 28 ] 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; 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 would be an advantage over the existing situation as at present, very often CHWs are asked to visit non-adherent positive women to inform them of the results and the need to have a Pap test performed, which results in they having to incorporate into their daily tasks a high number of unplanned visits. The perception of an intervention relative advantage over the existing situation must be shared by all involved actors to assure effective implementation [ 27 ]. Undoubtedly, a key actor in the 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 [ 29 ]. 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 [ 13 ]. 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 [ 30 ]. These constructs are directly connected to the concept of maintenance, that is, 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 [ 16 ]. 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 concurred that the ATICA strategy made use of a simple tool that could be integrated into processes that health services regularly carry out (such as reporting the HPV-test results). One systematic review [ 31 ] showed that HCPs’ perceptions that e-health systems disrupt workflows and delivery of care are a barrier to both implementation and use of these systems [ 32 ]. The review highlighted 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 [ 33 – 35 ]. Complexity is also increased with higher numbers of potential target organizational units (e.g., teams, clinics) or types of people (providers, patients, managers) targeted by the intervention [ 36 ]. In the ATICA study, the SMS is a simple tool for communicating with women and CHWs which is integrated into a multi-step screening process. This complexity was recognized by some of the interviewees in highlighting the need to coordinate different actors (CHWs, laboratory staff, those carrying out SITAM data entry, etc.) to make ATICA work. Thus, our results suggest that successful integration of the ATICA strategy into CC screening programs should recognize the complexity of the program’s screening/diagnosis/treatment process and assure the coordination of actors, institutions and activities involved in the care continuum. In our study, the respondents evaluated 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 cluster-randomized trial [ 13 ]. This is a key result, as the perception of effectiveness of the intervention is an influential factor of the intervention’s sustainability [ 37 ]. Research on the use of mobile phones for sending SMS, voice and video messages among patients and HCPs [ 38 ] 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 [ 39 ]. Additionally, our study identified factors associated with ATICA’s sustainability at the provincial level, from the perspective of HCPs and decision-makers involved in its scale-up. The respondents emphasized the need to guarantee human resources for taking triage Paps and doing HPV-lab work and the constant provision of HPV-tests. 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 [ 37 ]. 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 [ 40 – 42 ]. 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 [ 43 ]. The introduction of HPV-testing has served as a tool for improving the organizational capacity of CC prevention programs [ 8 , 44 ]. 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 [ 45 ]. Additionally, introduction of HPV self-collection reduced problems related to the lack of screening sample takers [ 45 ]. 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 the 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. Our study also identified some potential obstacles related to the costs of implementing the ATICA strategy. mHealth interventions require ongoing technological maintenance and support [ 46 ]. 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. In addition, 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. Feasibility of assuring access to mobile data by CHWs and health providers should be evaluated. 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 are working in 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. Conclusions Our study showed a highly positive assessment on the part of health decision-makers and HCPs regarding a multi-component mobile health intervention that is effective to improving triage adherence among women with self-collected tests offered by CHWs. The results obtained allow for a better understanding of factors that facilitates implementation and scaling-up of mHealth interventions rooted in PHC, that are aimed at strengthening the CC screening/diagnosis/treatment care continuum. These results have important implications for middle and low-income countries implementing or considering implementing HPV self-collection with mHealth interventions to ensure high adherence to follow-up and make progress toward the WHO targets to eliminate cervical cancer. Abbreviations ATICA Application of Communication and Information Technologies to Self-Collection CC Cervical cancer CEDES Centre for the Study of State and Society CEMIC Dr. Norberto Quirno Research Ethics Committee CFIR Consolidated Framework for Implementation Research CHWs Community health workers CRT Cluster-randomized trial HCPs Healthcare providers HPV Human papillomavirus HPV+ Human papillomavirus positive MATYS Software for sending the mobile phone text messages MoH Ministry of Health Pap Papanicolaou PHC Primary health care RE-AIM Reach Effectiveness Adoption Implementation Maintenance SITAM National Screening Information System SMS Mobile phone text messages WHO World Health Organization Declarations Ethics approval and consent to participate The research study was performed in accordance with the Declaration of Helsinki. The ATICA study’s protocol including research on health decision-makers and HCPs perspectives was approved by the CEMIC Institutional Review Board, the Ethics Research Committee of the Jujuy Ministry of Health, The Institutional Review Board of the Harvard T.H. Chan School of Public Health, and the Deakin University Human Research Ethics Committee. Consent for publication Not applicable. Availability of data and materials The datasets generated during the current study are not publicly available in order to protect respondent confidentiality, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The ATICA study was funded by the National Cancer Institute of the National Institutes of Health under Award Number R01CA218306. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. ATICA study was led by the Center for the Study of State and Society, in association with the Dana Farber Cancer Institute/Harvard T.H. Chan School of Public Health, USA, Deakin University, Australia, and Rutgers University, USA, with support and in collaboration from the Argentinean National Cancer Institute and the Jujuy Ministry of Health. Authors' contributions All authors contributed to the study design and analysis. SA was the principal investigator. CS carried out the interviews and led data analysis and interpretation, and writing of the first draft of the manuscript, in consultation with SA; VSA, RK, MP and KV made substantial contributions to the conception and design of the study, data analysis, and made a critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements We would like to thank Alicia Campanera for her support during recruitment. 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Beyond performance gaps. J Gen Intern Med. 2006 Feb;21(Suppl 2):25-9. doi: 10.1111/j.1525-1497.2006.00359.x . Suppl 2 ) . Shelton RC, Rhoades Cooper B, Wiltsey Stirman S. The Sustainability of Evidence-Based Interventions and Practices in Public Health and Health Care. Annual Review of Public Health. 2018; 55–76. El Joueidi S, Bardosh K, Musoke R, Tilahun B, Abo Moslim M, Gourlay K, MacMullin A, Cook VJ, Murray M, Mbaraga G, Nsanzimana S, Lester R. Evaluation of the implementation process of the mobile health platform 'WelTel' in six sites in East Africa and Canada using the modified consolidated framework for implementation research (mCFIR). BMC Med Inform Decis Mak. 2021;21(1):293. doi: 10.1186/s12911-021-01644-1 . Radhakrishnan K, Xie B, Berkley A, Kim M. Barriers and Facilitators for Sustainability of Tele-Homecare Programs: A Systematic Review. Health Serv Res. 2016;51(1):48–75. doi: 10.1111/1475-6773.12327 . International Agency for Research on Cancer. Cervical cancer screening. IARC Handbooks of Cancer Prevention. 2022; 18:1–456. Available from https://publications.iarc.fr/Book-And-Report- Series/Iarc-Handbooks-Of-Cancer-Prevention/Cervical-Cancer-Screening-2022. Accessed 11 Sept 2022. Lazcano-Ponce EC, Moss S, Alonso de Ruiz P, Salmerón-Castro J, Hernández-Ávila M. Cervical cancer screening in developing countries: why is it ineffective? The case of Mexico. Arch Med Res. 1999;30(3):240–50. https://doi.org/10.1016/S0188-0128(99)00006-8 . Arrossi S, Paolino M. Proyecto para el mejoramiento del Programa Nacional de Prevención de Cáncer de Cuello Uterino en Argentina. Informe final: diagnóstico de situación del Programa Nacional y Programas Provinciales. Buenos Aires: OPS, 2008. Available from https://iris.paho.org/bitstream/handle/10665.2/6236/2008-ARG-cancer-cuello-uterino .pdf?sequence=1&isAllowed=y Accessed 11 Sept 2022. Moucheraud C, Kawale P, Kafwafwa S, Bastani R, Hoffman RM. 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An Implementation Strategy to Expand Mobile Health Use in HIV Care Settings: Rapid Evaluation Study Using the Consolidated Framework for Implementation Research. JMIR Mhealth Uhealth. 2021;9(4):e19163. doi: 10.2196/19163 . Additional Declarations No competing interests reported. Supplementary Files SupplementaryTable1.docx SupplementaryTable2.docx Cite Share Download PDF Status: Published Journal Publication published 18 Jan, 2023 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Major revision 09 Nov, 2022 Reviews received at journal 21 Oct, 2022 Reviewers agreed at journal 30 Sep, 2022 Reviewers invited by journal 30 Sep, 2022 Editor assigned by journal 29 Sep, 2022 Editor invited by journal 20 Sep, 2022 Submission checks completed at journal 20 Sep, 2022 First submitted to journal 14 Sep, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2064981","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":138078441,"identity":"eecd3361-85ff-489b-903d-f4f45510de1b","order_by":0,"name":"Cecilia Straw","email":"","orcid":"","institution":"Faculty of Social Sciences, University of Buenos Aires","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cecilia","middleName":"","lastName":"Straw","suffix":""},{"id":138078442,"identity":"99fb6aba-db6a-438b-9773-81abb4619e6f","order_by":1,"name":"Victoria Sanchez-Antelo","email":"","orcid":"","institution":"Centre for the Study of State and Society, National Council for Scientific and Technical Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"","lastName":"Sanchez-Antelo","suffix":""},{"id":138078443,"identity":"17ac4d66-0eee-4650-a9d4-7e9970c1e489","order_by":2,"name":"Racquel Kohler","email":"","orcid":"","institution":"Cancer Health Equity, Cancer Institute of New Jersey, Rutgers - the State University of New Jersey","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Racquel","middleName":"","lastName":"Kohler","suffix":""},{"id":138078444,"identity":"3795b1ab-4c9e-475f-b461-b8c2c91fcb72","order_by":3,"name":"Melisa Paolino","email":"","orcid":"","institution":"Centre for the Study of State and Society, National Council for Scientific and Technical Research","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Melisa","middleName":"","lastName":"Paolino","suffix":""},{"id":138078445,"identity":"1d43669d-a5bb-4530-af11-9210c54023a9","order_by":4,"name":"Kasisomayajula Viswanath","email":"","orcid":"","institution":"Department of Social and Behavioral Sciences, Harvard T.H. 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For this reason, the World Health Organization (WHO) has launched a worldwide initiative to eliminate CC through vaccination, screening and treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In Argentina, 4600 new cases of CC are diagnosed every year, and some 2600 women die due to the disease [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHuman papillomavirus (HPV) DNA testing is a highly effective screening method to prevent CC [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] that allows women to self-collect samples. HPV self-collection has been shown to increasing screening uptake among socially vulnerable women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], especially when offered by community health workers (CHWs) during home visits [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eNevertheless, the low adherence to triage and treatment is a longstanding problem for CC programs in low- and middle-income countries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], especially among women with limited access to health care [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In Argentina, where HPV self-collection was introduced as a programmatic strategy in 2014, adherence to triage continues to be a challenge [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; only around 25% of women with HPV-positive self-collected tests successfully triage within 120 days after screening positive [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. One key issue is the delivery of test results and referral of HPV-positive women for triage [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the case of self-collection, receiving results is challenging, as women collect their samples at homes offered by CHWs. 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 the homes of all HPV\u0026thinsp;+\u0026thinsp;women (around 13% of all tested women) to deliver results and refer them to health centers for triage [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, effective interventions aimed at improving triage adherence that do not require the intensive use of human resources in health are needed.\u003c/p\u003e \u003cp\u003eUsing mobile phone text messages (SMS messages) as reminders has proven to be effective in a variety of settings and for different health problems [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]; they can be sent to providers and patients, are automated and require less staff [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) is a hybrid type I effectiveness-implementation trial 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 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Results of the CRT showed that sending SMS to encourage women with positive self-collected tests to visit a health center for triage combined with an e-mail/SMS to the CHWs to encourage them to visit women without Pap triage after 60 days effectively increased triage [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. 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.\u003c/p\u003e \u003cp\u003eEvidence indicates that in low-middle income countries, adoption of innovations is unreliable and slow, and little evidence exist about what factors influence the delivery of evidence-based interventions at scale [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Adoption and incorporation of an evidence-based innovation as the ATICA strategy into the health system depends on the potential users\u0026rsquo; 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\u0026rsquo;s implementation and use [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, to our knowledge, very few evidence exist regarding adopters\u0026rsquo; 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 the decision-makers and healthcare providers (HCPs) perceptions of the ATICA strategy. This qualitative analysis allows for a better understanding of key factors for scaling up the ATICA strategy and builds on the effectiveness data from the CTR [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eMethods of the ATICA study have been extensively described elsewhere [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this qualitative study, perception of HCPs and decision-makers were gathered through individual, semi-structured interviews. The themes explored were selected and analyzed using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) conceptual framework [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], as presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCFIR and RE-AIM Domains, constructs and definitions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCFIR Domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eConstruct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eI. Intervention characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIntervention Source\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe legitimacy of ATICA as an intervention external to the institution to which the HCPs and decision-makers belong. Legitimacy of the institutions to lead the implementation and adoption of the intervention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRelative advantage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe advantage of implementing ATICA versus an alternative solution and/or current usual practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAdaptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe degree to which the ATICA components can be adapted or refined to meet local needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eComplexity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe perceived difficulty of the intervention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eDesign quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePerceived excellence in how the intervention was bundled, presented, and assembled.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCost and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe costs of the intervention and costs associated with its implementation, including investment, supply and opportunity costs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eII. Outer Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePatient needs and resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe perception of the degree to which ATICA responds to the patient needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExternal policies and incentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStrategies to promote ATICA through policies and regulations.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eIII. Inner Setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAccess to knowledge and information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEase of access to information and knowledge about the intervention and how to incorporate it into work tasks.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eImplementation climate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCompatibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe compatibility of ATICA with the norms, values, and existing workflows and systems.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelative priority\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe individuals\u0026rsquo; shared perception of the importance of the ATICA implementation within the institution.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReadiness for Implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeadership engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommitment, involvement, and accountability of health authorities with regard to the ATICA implementation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV. Characteristics of Individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eKnowledge and beliefs about the intervention.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnowledge and attitudes regarding the ATICA strategy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRE-AIM Dimension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eMaintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntention to incorporate the intervention on the part of the provincial CC prevention program.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eOwn elaboration based on an adaptation of Damschroder [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Glasgow [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting\u003c/h2\u003e \u003cp\u003eThe province of Jujuy is located in northwest Argentina. It has approximately 673,000 inhabitants, of which 51% are women, 87% live in urban areas, 32% are poor, and approximately 45% have public health insurance [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Mobile phone penetration in urban areas was 86% in 2019 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe public health system includes a primary hospital and 270 primary health care (PHC) centers. The PHC system employs about 700 full-time CHWs that visit approximately 110,000 homes twice a year to carry out health-related tasks such as vaccination and child-maternal health promotion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Jujuy CC prevention, screening and treatment program has been extensively described elsewhere [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Briefly, since 2012 HPV-testing is the primary screening method for women 30 years and older who receive care in the public health sector. In 2014, self-collection was introduced as a screening strategy for women not tested in the last 5 years and with public health insurance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. CHWs offer self-collection during home visits. Women who perform self-collection are told to visit a health center within 30 days to receive the results, and if results are positive, to carry out cytology-based triage in the health center [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. All testing/diagnosis/treatment procedures performed in the public health system are registered in the national screening information system (SITAM, for its initials in Spanish) to generate a diagnosis form, which is instantly available online to all providers at public health establishments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTarget population and sampling\u003c/h2\u003e \u003cp\u003eThe sampling was purposive. Decision-makers with institutional responsibilities in Jujuy\u0026rsquo;s health system were interviewed; they are state officials in charge of the design and management of policies aimed at CC cancer prevention at the provincial level. Those decision-makers who performed healthcare functions at PHC level were excluded. In addition, HCPs responsible for patient care in Jujuy\u0026rsquo;s public health system were interviewed. HCPs should have clinical, nursing or gynecology training, and provide CC prevention services for patients at provincial PHC centers. Those HCPs who were involved in managing cancer control and prevention policies were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInstrument for information collection\u003c/h2\u003e \u003cp\u003eIndividual semi-structured interviews were conducted using a guide based on dimensions and construct of CFIR and RE-AIM (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Questions related to the external policies and costs constructs were only asked of decision-makers. They were carried out on a virtual platform and lasted on average one hour. As part of the interview, interviewees were shown three cards illustrating the ATICA multi-component mHealth intervention and content of the SMS [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eData were collected between December 2020-February 2021 by a researcher trained in qualitative research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003eThe collected data were analyzed thematically [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Once the interview transcriptions were completed, all interviews were entered into the software ATLAS.ti (version 7.5.4; ATLAS.ti \u003cem\u003eScientific Software Development GmbH\u003c/em\u003e, Berlin). The coding and analysis were done in accordance with the domains, constructs and dimensions presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In the analysis the perspectives of health decision-makers and HCPs were compared; points of agreement and disagreement were highlighted.\u003c/p\u003e \u003cp\u003eThe analysis was carried out by two researchers; the results were discussed in joint sessions with the research team, and any disagreements were resolved through discussions.\u003c/p\u003e \u003cp\u003eThe details of the methods and results of the semi-structured interviews are presented following the Consolidated Criteria for Reporting Qualitative Studies [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] as presented in an additional table file [see Supplementary Table\u0026nbsp;1].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthical aspects and participant consent\u003c/h2\u003e \u003cp\u003e The research study was performed in accordance with the Declaration of Helsinki. The ATICA study\u0026rsquo;s protocol including research on health decision-makers and HCPs perspectives was approved by the CEMIC Institutional Review Board, the Ethics Research Committee of the Jujuy Ministry of Health, The Institutional Review Board of the Harvard T.H. Chan School of Public Health, and the Deakin University Human Research Ethics Committee. Before the interview, the study objectives were explained to each participant who then signed an informed consent form. The confidentiality and anonymity of the participants was guaranteed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRespondents\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eTen health decision-makers and 10 HCPs were interviewed. The average amount of time that health decision-makers had occupied their roles was 11 years (range 2\u0026ndash;30 years). Six of the decision-makers were women and four were men. HCPs had been practicing on average for 11.4 years (range 5\u0026ndash;25 years). Eight HCPs were women and two were men.\u003c/p\u003e \u003cp\u003eThe results coded according to the CFIR constructs and themes that emerged in the analysis are presented in an additional table file [see Supplementary Table\u0026nbsp;2].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of the strategy\u003c/h2\u003e \u003cp\u003eThe level of knowledge regarding the ATICA strategy was high among the majority of the health decision-makers and HCPs. The interviewees were able to describe both intervention components and the implementation process.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The experience [with ATICA] was designed strategically and taking into account a number of factors: previous planning meetings, trainings, the type of message and how many times to send it\u0026rdquo; [Decision-maker 1].\u003c/p\u003e\u003cp\u003e\u0026ldquo;The majority of women came in after the first message and if they didn\u0026rsquo;t they got sent another\u0026rdquo; [HCP 6].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the intervention\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eIntervention source\u003c/h2\u003e \u003cp\u003eThe health decision-makers and HCPs positively assessed the fact that the ATICA study began as an initiative headed by CEDES (Centre for the Study of State and Society) in collaboration with Harvard University, institutions considered to have academic prestige and experience in mHealth research. Some health decision-makers and HCPs highlighted that ATICA was designed and implemented collaboratively through articulation and consensus with provincial and national institutions (Argentinean National Cancer Institute, provincial Cancer Institute and PHC Direction). They also assessed positively their early engagement in ATICA implementation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;[In workshops to implement ATICA], we listened and contributed ideas. We were there from the start\u0026rdquo; [Decision-maker 1].\u003c/p\u003e\u003cp\u003e\u0026ldquo;We never felt competition or like the idea was imposed. The provincial guidelines and ways of doing things were respected\u0026rdquo; [HCP 8].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother positive aspect perceived by the majority of those interviewed was that ATICA began as a research study. In their opinion, this was a guarantee that scientific methods were applied to evaluate whether incorporation of mobile technology in PHC would work in the local context.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The fact that ATICA begun as a research project was an advantage, like that you can demonstrate that it works, there is an evaluation of results\u0026rdquo; [Decision-maker 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eDesign quality and Access to knowledge and Information\u003c/h2\u003e \u003cp\u003eHealth decision-makers and HCPs mostly stated that the ATICA strategy components worked in an articulated and complementary way, and that the training and information received were adequate. They also considered that the printed materials contained clear, concise information with graphics and drawings that favored an intuitive understanding and recall of the messages.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The two options are complementary. If the patient doesn\u0026rsquo;t go to the health center after receiving the messages, it\u0026rsquo;s necessary for the community health worker to go see her\u0026rdquo; [HCP 6].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003eAdaptability\u003c/h2\u003e \u003cp\u003eThe majority of the respondents agreed that adaptations to the ATICA components were not necessary. It was unanimous that the content of the SMS was appropriate as it was clear, precise and in agreement with the legal norms regarding the communication of health information. They also considered the frequency of the SMS to be adequate.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I wouldn\u0026rsquo;t change the content because the messages are respectful, subtle, and say \u0026ldquo;we need you to come in\u0026rdquo; especially when the HPV result is positive\u0026rdquo; [HCP 10].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Regarding the e-mail/SMS sent to the CHWs to inform them of women without Pap triage after 60 days, the respondents agreed that sending WhatsApp messages would improve the communication and make it more dynamic. They also considered that this information should be sent to authorities with decision-making power (for example, the coordinator of the provincial CC prevention program, the PHC director and supervisors), so responsibility for assuring that women are triaged is shared with HCPs and CC prevention program authorities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Other members of the health team should also receive [the SMS], like the intermediate supervisors or the head of the CC prevention program, so CHWs do not bear all the responsibility [HCP 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eComplexity and compatibility\u003c/h2\u003e \u003cp\u003eThe respondents predominantly evaluated ATICA as a low-complexity strategy and, at the same time, considered it compatible with the existing organization and way of functioning within the health centers. In both cases, they agreed that the strategy was integrated into other processes that health services routinely perform (seek out, receive, and care for patients; inform medical results; input information regarding screening, triage, diagnosis and treatment in the national screening information system (SITAM); among others).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;ATICA doesn\u0026rsquo;t change or interfere with any process of the cervical cancer program\u0026rdquo; [Decision-maker 1].\u003c/p\u003e\u003cp\u003e\u0026ldquo;The strategy is compatible because it facilitates the community health care worker\u0026rsquo;s everyday work, and the professional continues the flowchart examining the positive self-collected tests\u0026rdquo; [HCP 1].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e The interviewees also considered that the intervention was compatible with the forms of communication between health care services and women. In their opinion, this was evidenced by the women\u0026rsquo;s high acceptance of the SMS as a channel of communication.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Perfect as a form of communication. It absolutely favored the communication between the health center and the patient\u0026rdquo; [HCP 6].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere were some decision-makers and HCPs who perceived the strategy as complex due to the need to logistically coordinate the actions of different actors (CHWs, staff from the HPV test/cytology/histology laboratory, staff registering self-collection results in SITAM). They also saw the functioning of the system sending the SMS as complex, because the algorithm must consider different diagnoses and the time passed between self-collection and later steps of the continuum of care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eRelative advantage\u003c/h2\u003e \u003cp\u003eThe interviewees mentioned several advantages \u0026ndash;and no disadvantages\u0026ndash; to the intervention in relation to the existing practices for communicating results to women with self-collected tests:\u003c/p\u003e \u003cp\u003e-Simplifying the process of delivering results increased adherence to timely triage.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;This lets the user know directly [about results availability] without being mediated by a doctor or a community health care worker who visits her. It brings the HPV-positive person in more quickly\u0026rdquo; [HCP 1].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e-Improving the health system\u0026rsquo;s communication with women, by sending information via a personalized, direct, opportune, and timely SMS.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is a marvelous intervention for facilitating communication. One hundred percent useful because the information mechanisms were greatly improved\u0026rdquo; [Decision-maker 4].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e-Reducing the workload of CHWs in seeking out HPV\u0026thinsp;+\u0026thinsp;women without triage, especially those who require several visits to be reached. For the respondents, this meant a more efficient use of the human resources in the health system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Before this, the community health worker had to go four times to remind a woman to get a Papanicolaou. Now it\u0026rsquo;s four messages. Taking better advantage of human resources is extremely important\u0026rdquo; [HCP 8].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e-Incorporating mobile phones in the provision of PHC services increased the willingness of staff at this level of care to adopt mobile technology in their work processes, with a benefit to the population.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u0026ldquo;Now technology is an extension of the community health worker\u0026rsquo;s work and is somewhat more of a friend to primary health care\u0026rdquo; [Decision-maker 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eConsideration of women\u0026rsquo;s needs\u003c/h2\u003e \u003cp\u003eATICA was mainly viewed as a strategy responding to women needs, by facilitating timely triage. Nevertheless, some interviewees highlighted that the main barrier faced by some women to access triage was the lack of sample takers, and therefore the priority to meet women\u0026acute;s needs was to assure that in all health centers there was staff to take Paps. In this sense, they perceived that ATICA did not respond to a high-priority need.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The priority for women is to not delay their appointment to get a Papanicolaou. ATICA was very well aimed at quick communication and information\u0026rdquo; [Decision-maker 8].\u003c/p\u003e\u003cp\u003e\u0026ldquo;Some women couldn\u0026rsquo;t get access [to a Pap test], and that is why it is necessary to guarantee greater coverage of professionals to take Pap tests\u0026rdquo; [HCP 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eRelative priority\u003c/h2\u003e \u003cp\u003eBoth HCPs and decision-makers unanimously assigned a high priority to the incorporation of the ATICA strategy to ensure Pap triage and early diagnosis in women with positive self-collected tests. The strategy was seen as fundamental to complete the screening program goals in the target population.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It is absolutely crucial in encouraging the women to finish the path they started and get Pap triage\u0026rdquo; [Decision-maker 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eMaintenance\u003c/h2\u003e \u003cp\u003eThe interviewees perceived the programmatic incorporation of ATICA into the provincial CC prevention program as viable; they considered that the provincial health system had the organizational and technological conditions necessary to implement it, and that the usefulness of the ATICA strategy had been demonstrated. They also mentioned that the wide availability of cellular phones in the population would contribute to the programmatic scaling-up of the strategy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The implementation is very viable because we have a key actor that is the community health worker\u0026rdquo; [HCP 5].\u003c/p\u003e\u003cp\u003e\u0026ldquo;It should be incorporated because we saw that it is useful for the prevention of cervical cancer\u0026rdquo; [Decision-maker 2].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few decision-makers and HCPs conditioned the viability of the programmatic incorporation of the intervention to the provision of cell phones to the health facilities and to CHWs, as well as to the possibility of connecting to internet and mobile data at no cost.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;With mobile devices, internet connection and mobile data in the health facilities\u0026hellip; Otherwise, it won\u0026rsquo;t be very viable\u0026rdquo; [Decision-maker 3].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Regarding the strategy scaling-up, the interviewees agreed that it should be led by the provincial Ministry of Health (MoH), with ample involvement of PHC authorities and CHWs, the provincial CC prevention program, and the provincial Cancer Institute.\u003c/p\u003e \u003cp\u003e With regard to the elements necessary for guaranteeing ATICA\u0026rsquo;s programmatic functioning, the decision-makers agreed to assign importance to the political decision to prioritize CC prevention both by the provincial health authorities (MoH and hospital directors) and the Argentinean National Cancer Institute. They also highlighted the importance of the highest health authority, i.e., the provincial health minister, to establish ATICA as high priority line of work.\u003c/p\u003e \u003cp\u003eAdditionally, the respondents agreed in highlighting the need to ensure human resources both for the HPV lab and for taking Pap tests at PHC centers, as well as the continued provision of HPV-tests and collectors.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;[To have the ATICA strategy] as part of the cervical cancer prevention routine we need HPV kits always available, and the necessary reagents because otherwise the tests have to be suspended. And laboratory personnel so that the readings and results aren\u0026rsquo;t delayed\u0026rdquo; [HCP 4].\u003c/p\u003e\u003cp\u003e\u0026ldquo;We need to have gynecologists in all PHC centers, at least once a week\u0026rdquo; [Decision-maker 10].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eLeadership engagement\u003c/h2\u003e \u003cp\u003eAlmost all interviewees considered that the provincial health authorities would commit to the programmatic incorporation of the strategy in the long term. In first place, the authorities have for years shown their commitment to CC prevention. Besides, the fact that authorities had formed part of the design and implementation of ATICA, in addition to the demonstrated effectiveness of the strategy, increased the possibility of commitment to the implementation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Yes, they will commit, we\u0026rsquo;ve been fighting for years against cervical cancer\u0026rdquo; [Decision-maker 5]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe few decision-makers that doubted the commitment of the provincial health authorities considered that, in public policy management, resolution of urgent matters prevail in detriment to other important issues like the low adherence to the CC care process. Additionally, their doubts had to do with the high rotation of health authorities. Thus, they considered that new authorities might not continue lines of work developed by previous administrations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eExternal policies\u003c/h2\u003e \u003cp\u003eIn regard to the need for specific policies and regulations to extend ATICA at a provincial level, the opinions of those consulted were divided. On one hand, some considered it necessary, given that all programs have norms for functioning, target populations and procedures. Thus, to implement ATICA, guidelines regarding the digital communication of the health system with the population would be necessary. This would facilitate ATICA\u0026rsquo;s uniform implementation in all health institutions.\u003c/p\u003e \u003cp\u003eIn contrast, other decision-makers considered that the ATICA strategy could be carried out without additional regulations. They highlighted that the intervention was connected to an existing care protocol of CC screening, triage, diagnosis, and treatment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t think [there is a need for] specific normative frameworks. [ATICA] has to do with a referral algorithm of positive self-collected tests that is already functioning\u0026rdquo; [Decision-maker 5].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003eCosts of ATICA implementation\u003c/h2\u003e \u003cp\u003eThe decision-makers identified three main items they believed it necessary to fund for ATICA to function. The first is related to the operation and maintenance of the software for sending the SMS (MATYS).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The program sending the text messages must have a cost, and logically sending the messages does too\u0026rdquo; [Decision-maker 2].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSecond, they identified the provision of cell phones as a cost of the ATICA strategy. Thus, for some decision-makers providing CHWs with cell phones would guarantee that they could do their job without having to take on costs. However, for other decision-makers, a cell phone should be provided to every health care facility. In this case, they considered that the institutional cell phone could be used for different health programs, and the funding would not fall exclusively to ATICA\u0026rsquo;s budget.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Each CHW should be given a cell-phone and be provided with a mobile data package; some people might have problems using their own cell phone because that use has a cost\u0026rdquo; [Decision-maker 4].\u003c/p\u003e\u003cp\u003e\u0026ldquo;We need a cell phone per facility, not per community health worker. An institutional telephone at the health center for them to communicate with the health worker and the women\u0026rdquo; [Decision-maker 9].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA third cost had to do with the provision of free internet and WI-FI service to all health centers. For them, this was important to accessing data regarding screening, triage, diagnosis, and treatment through SITAM. However, on this issue, differences were found among decision-makers as some respondents considered that internet service was already widely available in health centers.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLow levels of triage after a positive result have been identified as a major drawback of HPV self-collection. The ATICA trial resulted in a 15% increase in the percentage of women with triage Pap after the HPV result, showing that a\u003c/p\u003e \u003cp\u003emulti-component mobile health intervention was effective in improving triage adherence. Our study evaluated the perceptions of health system decision-makers and HCPs regarding implementation and scaling-up of the 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 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and RE-AIM [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], two conceptual frameworks from implementation science appropriate for evaluating factors that could affect the 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: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women need, and relative priority. However, some potential barriers were identified in complexity, leadership engagement, external policies, economic cost and maintenance constructs. Thus, stakeholders conditioned the strategy\u0026rsquo;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, that there is staff to take the Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-test.\u003c/p\u003e \u003cp\u003eThe evidence shows that the legitimacy of the origin of an intervention is associated with success in its implementation [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The ATICA strategy was perceived as the result of collaborative work between implementers and researchers from institutions both outside of and within the province, which were involved in the design and implementation of the intervention since its early stages. This involvement of local implementers has been signaled in the literature as a key factor of success in interventions scaling-up [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and might be a reason why respondents did not perceive the need for substantial adaptations of the intervention. Respondents also pointed out the importance of ATICA start as a research study that would provide data on the strategy effectiveness. Integrating research activities into existing health systems has been identified in the literature as an important factor for successful scale-up [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The involvement of health authorities in the research study was one factor that prompted a positive perception of the potential political commitment of health authorities in the scaling-up of the ATICA strategy. Nonetheless, interviewees also mentioned the high turnover of policy makers as a note of concern regarding future health authorities\u0026rsquo; 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, for example including the visit of the CHWs to women who do not have Pap triage in spite of having received the SMS, as part of their tasks and responsibilities, or incorporating and funding the SMS sending system as a component of the national screening information system (SITAM) so SMS can be sent.\u003c/p\u003e \u003cp\u003eOur 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 and adherence to triage. These findings are important because stakeholder\u0026rsquo;s acknowledgement of the relative advantages of an intervention constitute a \u003cem\u003esine qua non\u003c/em\u003e for implementation/adoption [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A study carried out in Canada [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] 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; 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 would be an advantage over the existing situation as at present, very often CHWs are asked to visit non-adherent positive women to inform them of the results and the need to have a Pap test performed, which results in they having to incorporate into their daily tasks a high number of unplanned visits.\u003c/p\u003e \u003cp\u003eThe perception of an intervention relative advantage over the existing situation must be shared by all involved actors to assure effective implementation [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Undoubtedly, a key actor in the 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 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. 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\u0026thinsp;+\u0026thinsp;women who did not respond to the SMS [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is therefore possible to assume that interviewees perception of the intervention as advantageous for CHWs is also shared by CHWs.\u003c/p\u003e \u003cp\u003eThe complexity of an intervention and its compatibility with existing practices are concepts related to factors that can promote or hinder implementation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. These constructs are directly connected to the concept of maintenance, that is, 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 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. 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 concurred that the ATICA strategy made use of a simple tool that could be integrated into processes that health services regularly carry out (such as reporting the HPV-test results). One systematic review [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] showed that HCPs\u0026rsquo; perceptions that e-health systems disrupt workflows and delivery of care are a barrier to both implementation and use of these systems [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The review highlighted 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 [\u003cspan additionalcitationids=\"CR34\" citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Complexity is also increased with higher numbers of potential target organizational units (e.g., teams, clinics) or types of people (providers, patients, managers) targeted by the intervention [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In the ATICA study, the SMS is a simple tool for communicating with women and CHWs which is integrated into a multi-step screening process. This complexity was recognized by some of the interviewees in highlighting the need to coordinate different actors (CHWs, laboratory staff, those carrying out SITAM data entry, etc.) to make ATICA work. Thus, our results suggest that successful integration of the ATICA strategy into CC screening programs should recognize the complexity of the program\u0026rsquo;s screening/diagnosis/treatment process and assure the coordination of actors, institutions and activities involved in the care continuum.\u003c/p\u003e \u003cp\u003eIn our study, the respondents evaluated the ATICA strategy as highly effective in increasing triage of HPV\u0026thinsp;+\u0026thinsp;women and facilitating access to an early diagnosis; this assessment coincides with the results of the cluster-randomized trial [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This is a key result, as the perception of effectiveness of the intervention is an influential factor of the intervention\u0026rsquo;s sustainability [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Research on the use of mobile phones for sending SMS, voice and video messages among patients and HCPs [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] 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 [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, our study identified factors associated with ATICA\u0026rsquo;s sustainability at the provincial level, from the perspective of HCPs and decision-makers involved in its scale-up. The respondents emphasized the need to guarantee human resources for taking triage Paps and doing HPV-lab work and the constant provision of HPV-tests. 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 [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. 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 [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The introduction of HPV-testing has served as a tool for improving the organizational capacity of CC prevention programs [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. 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 [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Additionally, introduction of HPV self-collection reduced problems related to the lack of screening sample takers [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. 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 the 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.\u003c/p\u003e \u003cp\u003eOur study also identified some potential obstacles related to the costs of implementing the ATICA strategy. mHealth interventions require ongoing technological maintenance and support [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. 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. In addition, 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. Feasibility of assuring access to mobile data by CHWs and health providers should be evaluated.\u003c/p\u003e \u003cp\u003eA 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 are working in 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.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur study showed a highly positive assessment on the part of health decision-makers and HCPs regarding a multi-component mobile health intervention that is effective to improving triage adherence among women with self-collected tests offered by CHWs.\u003c/p\u003e \u003cp\u003eThe results obtained allow for a better understanding of factors that facilitates implementation and scaling-up of mHealth interventions rooted in PHC, that are aimed at strengthening the CC screening/diagnosis/treatment care continuum. These results have important implications for middle and low-income countries implementing or considering implementing HPV self-collection with mHealth interventions to ensure high adherence to follow-up and make progress toward the WHO targets to eliminate cervical cancer.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATICA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eApplication of Communication and Information Technologies to Self-Collection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCervical cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCEDES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentre for the Study of State and Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCEMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e Dr. Norberto Quirno Research Ethics Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCFIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConsolidated Framework for Implementation Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHWs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity health workers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCluster-randomized trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman papillomavirus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPV+\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman papillomavirus positive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMATYS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSoftware for sending the mobile phone text messages\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMoH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePap\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePapanicolaou\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrimary health care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRE-AIM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eReach Effectiveness Adoption Implementation Maintenance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSITAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Screening Information System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMobile phone text messages\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe research study was performed in accordance with the Declaration of Helsinki. The ATICA study\u0026rsquo;s protocol including research on health decision-makers and HCPs perspectives was approved by the CEMIC Institutional Review Board, the Ethics Research Committee of the Jujuy Ministry of Health, The Institutional Review Board of the Harvard T.H. Chan School of Public Health, and the Deakin University Human Research Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated during the current study are not publicly available in\u003c/p\u003e\n\u003cp\u003eorder to protect respondent confidentiality, but are available from the\u003c/p\u003e\n\u003cp\u003ecorresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ATICA study was funded by the National Cancer Institute of the National Institutes of Health under Award Number R01CA218306. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. ATICA study was led by the Center for the Study of State and Society, in association with the Dana Farber Cancer Institute/Harvard T.H. Chan School of Public Health, USA, Deakin University, Australia, and Rutgers University, USA, with support and in collaboration from the Argentinean National Cancer Institute and the Jujuy Ministry of Health.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study design and analysis. SA was the principal investigator. CS carried out the interviews and led data analysis and interpretation, and writing of the first draft of the manuscript, in consultation with SA; VSA, RK, MP and KV made substantial contributions to the conception and design of the study, data analysis, and made a critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe would like to thank Alicia Campanera for her support during recruitment. We thank health care providers and decision makers who generously shared their time and opinions for this research.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eDas M. WHO launches strategy to accelerate elimination of cervical cancer. Lancet Oncol. 2021;22:20\u0026ndash;1. doi: 10.1016/S1470-2045(20)30729\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eIARC-WHO-GLOBALCAN Cancer Today. 2020. 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JMIR Mhealth Uhealth. 2021;9(4):e19163. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/19163\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mHealth, Self-collection HPV, Adoption, Scaling-up, Implementation","lastPublishedDoi":"10.21203/rs.3.rs-2064981/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2064981/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The ATICA study was a Hybrid I type randomized effectiveness-implementation trial that demonstrated effectiveness of a multicomponent mHealth intervention (Up to four SMS messages sent to HPV-positive women, and one SMS message to CHWs to prompt a visit of women with no triage Pap 60 days after a positive-test), to increase adherence to triage of HPV positive women (ATICA Study). We report data on perceptions of health decision-makers and healthcare providers regarding the intervention adoption and scaling-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A qualitative study was carried out based on individual, semi-structured interviews with health decision-makers (n=10) and health care providers (n= 10). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research (CFIR) and the maintenance dimension of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Both health care providers and decision-makers had a positive assessment of the intervention through most included constructs: knowledge of the intervention, intervention source, design quality, adaptability, compatibility, access to knowledge and information, relative advantage, women’s needs, and relative priority. However, some potential barriers were also identified including complexity, leadership engagement, external policies, economic cost, women needs and maintenance. Stakeholders conditioned the strategy’s sustainability to the political commitment of national and provincial health authorities to prioritize cervical cancer 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, that there is staff to take the Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Health decision-makers and healthcare providers had a positive perception regarding implementation of the multicomponent mHealth intervention designed to increase adherence to triage among women with HPV self-collected tests. This increases the potential for a successful scaling-up of the intervention, with great implications for not only to Argentina but also for middle and low-income countries considering using mHealth interventions to enhance the cervical screening/follow-up/treatment process.\u003c/p\u003e","manuscriptTitle":"Adoption and scaling-up of an effective mHealth intervention to increase adherence to triage of HPV-positive women (ATICA study): Perceptions of health decision-makers and health-care providers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-09-22 20:48:26","doi":"10.21203/rs.3.rs-2064981/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-11-09T08:07:44+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-10-21T18:30:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82c44140-25bc-45bb-be88-e9681e82a35a","date":"2022-09-30T06:06:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-09-30T05:31:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-09-29T05:07:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-09-20T09:06:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-09-20T08:58:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2022-09-14T12:32:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"01b0b0c8-0bfa-4b17-9084-e39d694bc524","owner":[],"postedDate":"September 22nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:28:06+00:00","versionOfRecord":{"articleIdentity":"rs-2064981","link":"https://doi.org/10.1186/s12913-023-09022-5","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2023-01-18 18:24:06","publishedOnDateReadable":"January 18th, 2023"},"versionCreatedAt":"2022-09-22 20:48:26","video":"","vorDoi":"10.1186/s12913-023-09022-5","vorDoiUrl":"https://doi.org/10.1186/s12913-023-09022-5","workflowStages":[]},"version":"v1","identity":"rs-2064981","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2064981","identity":"rs-2064981","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}