Incorporating a mobile application to support communication about HPV testing among women and professionals: barriers and facilitators from the perspective of health professionals in a middle- and low-income setting in Argentina.

Introduction: The delivery of positive Human papillomavirus (HPV) test results can have a psychosocial impact and act as a barrier for women to continue the cervical cancer (CC) prevention process. A previous formative research based on a woman's perspective indicated that a mobile app could be an acceptable and appropriate tool to help women obtain information and reduce fears related to a positive result. Based on these findings, we developed an app-based intervention that would function as a support for professionals who offer the HPV test and communicate their results. We report data on the perceptions of healthcare providers regarding the barriers and facilitators to the incorporation, in a low and middle-income context. Methods: Qualitative study based on individual semi-structured interviews with health professionals. All the professionals (n =13) took HPV and Pap test samples and provided information on HPV testing, in the public health system of Ituzaingó, Greater Buenos Aires, Argentina. The themes explored were selected and analysed using domains and constructs of Consolidated Framework for Implementation Research (CFIR). Results: Practitioners had a positive assessment of the intervention through most included constructs: adaptability, compatibility, complexity, relative advantage, belief in the validity and robustness of the intervention, innovation source and knowledge and beliefs about the intervention. However, some potential barriers were also identified including: adaptability, tensions for change, relative priority and leadership engagement. Practitioners conditioned the intervention's success to specific adjustments of the app (weight and interface usability), legitimmated institutions' support, and clear and sustained health authorities' commitment and directions. Conclusion: Health professionals had a positive assessment of implementing an app to support the HPV test communication and information provision process, although they conditioned its effectiveness to specific adjustments. The results allow us to identify and develop recommendations for the app to be implemented effectively and sustained over time. The findings of this study have important implications not only for Argentina, but also for other low and middle-income countries, given that the implementation could be adapted, with the aim of improving communication between patients and health institutions in the CC prevention process.

Implementation of WHO guidelines for cervical cancer screening, diagnosis and treatment: knowledge and perceptions of health providers from Argentina.

BACKGROUND: The 2021 World Health Organization (WHO) guidelines on cervical cancer screening and treatment provide countries with evidence-based recommendations to accelerate disease elimination. However, evidence shows that health providers' adherence to screening guidelines is low. We conducted a study in Argentina to analyze health providers' knowledge and perceptions regarding the 2021 WHO Guidelines. METHODS: A qualitative study was conducted based on individual, semi-structured interviews with health providers specializing in gynecology (n = 15). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research. RESULTS: Although health providers perceive WHO as a reliable institution, they do not know the 2021 guidelines, its supporting evidence, and its elaboration process. Their clinical practice is mainly guided by local recommendations developed by national professional medical associations (PMAs). For interviewees, WHO guidelines should be disseminated through health authorities and national PMAs, mainly through in-service training. Health providers had a positive assessment regarding WHO Recommendation 1 (screen, triage, and treatment for women aged 30 + with HPV-testing every 5 to 10 years) and perceived a favorable climate for its implementation. HPV-testing followed by triage was considered a low-complexity practice, enabling a better detection of HPV, a better selection of the patients who will need diagnosis and treatment, and a more efficient use of health system resources. However, they suggested adapting this recommendation by removing screening interval beyond 5 years. WHO Recommendation 2 (screen-and-treat approach with HPV-testing for women aged 30 + every 5 to 10 years) was predominantly rejected by interviewees, was considered an algorithm that did not respond to women's needs, and was not adequate for the Argentinean context. Regarding the HPV-test modality, clinician-collected tests were the preferred mode. Health providers considered that HPV self-collection should be used primarily among socially vulnerable women to increase screening coverage. CONCLUSION: WHO guidelines should be widely disseminated among health providers, especially in settings that could benefit from a screen-and-treat approach. Identifying areas of partnership and collaboration with PMAs in implementing WHO guidelines is essential.

Efecto de COVID-19 en el tratamiento del cáncer cervicouterino: estudio antes/después / Effect of COVID-19 pandemics in treatment of cervical cancer: pre/post study

Resumen Introducción : Hay escasa evidencia sobre el impacto de la pandemia de COVID-19 en el cumplimiento del tratamiento de cáncer cervicouterino. Métodos : Se llevó a cabo un estudio poblacional de cohorte retrospectivo. -antes/después- de las pacientes con cáncer cervicouterino diagnosticadas en estable cimientos públicos de la provincia de Jujuy (n = 140), entre 2017 y 2020. Las pacientes diagnosticadas en 2020 se consideraron expuestas a la pandemia (n = 21). Utili zamos la regresión logística multivariada para analizar la asociación entre pandemia y cumplimiento del tra tamiento de cáncer. Además, se midió la duración del tratamiento en aquellas con indicación de braquiterapia y el tiempo hasta el inicio al tratamiento según estadio. Resultados : Comparadas con las mujeres diagnosti cadas en 2017-2019 el odds ratio de incumplimiento del tratamiento fue de 1.77 (IC95% 0.59-5.81; p = 0.32) para las diagnosticadas durante 2020. Se encontró un mayor riesgo de incumplimiento en pacientes con indicación de braquiterapia (OR 4.14; IC 95%:1.95-9.11; p < 0.001). La mediana de duración del tratamiento para aquellas con indicación de braquiterapia fue de 12.8 y 15.7 sema nas en 2017-2019 y 2020 respectivamente (p = 0.33). La mediana de tiempo hasta el inicio del tratamiento para pacientes con enfermedad en estadio temprano fue de 9 y 5 semanas durante 2017-2019 y 2020 respectivamente (p = 0.06), versus una mediana de 7.2 y 9 semanas en 2017-2019 y 2020 respectivamente (p=0.36) para las pa cientes con enfermedad en estadio IIB+. Conclusiones : El bajo acceso a la braquiterapia fue un factor determinante de incumplimiento de tratamiento de cáncer cervicouterino, independientemente del efecto de la pandemia.

Abstract Introduction : Little evidence exists on the impact of the COVID-19 pandemics on the compliance with cervi cal cancer treatment. Methods : We carried out a population-based, be fore-and-after retrospective cohort study of all cervical cancer patients diagnosed in the Jujuy province public health sector (n=140), Argentina, between 2017 and 2020. Patients diagnosed in 2020 were considered exposed to the COVID-19 pandemic (n=21). We used multivariable logistic regression to assess the relationship between the pandemics and compliance with treatment. We also measured treatment duration for women who were indicated brachytherapy and time to treatment initia tion by stage. Results : Compared with women diagnosed in 2017- 2019 the odds ratio of non-complying with treatment was 1.77 (95%CI 0.59-5.81; p = 0.32) for women diagnosed during 2020. An increased risk of non-compliance was found in patients with prescribed brachytherapy (OR 4.14. 95%CI 1.95-9.11; p < 0.001). Median treatment dura tion for women with prescribed brachytherapy was 12.8 and 15.7 weeks in 2017-2019 vs. 2020 (p = 0.33); median time to treatment initiation for women with early-stage disease was 9 and 5 weeks during 2017-2019 and 2020 respectively (p = 0.06), vs 7.2 and 9 weeks in 2017-2019 and 2020 respectively (p = 0.36) for patients with stages IIB+ disease. Conclusions : Low access to brachytherapy was a major determinant of non-compliance. irrespective of the effect of the pandemics.

[Effect of COVID-19 pandemics in treatment of cervical cancer: pre/post study]. / Efecto de COVID-19 en el tratamiento del cáncer cervicouterino: estudio antes/después.

INTRODUCTION: Little evidence exists on the impact of the COVID-19 pandemics on the compliance with cervical cancer treatment. METHODS: We carried out a population-based, before-and-after retrospective cohort study of all cervical cancer patients diagnosed in the Jujuy province public health sector (n=140), Argentina, between 2017 and 2020. Patients diagnosed in 2020 were considered exposed to the COVID-19 pandemic (n=21). We used multivariable logistic regression to assess the relationship between the pandemics and compliance with treatment. We also measured treatment duration for women who were indicated brachytherapy and time to treatment initiation by stage. RESULTS: Compared with women diagnosed in 2017-2019 the odds ratio of non-complying with treatment was 1.77 (95%CI 0.59-5.81; p = 0.32) for women diagnosed during 2020. An increased risk of non-compliance was found in patients with prescribed brachytherapy (OR 4.14. 95%CI 1.95-9.11; p < 0.001). Median treatment duration for women with prescribed brachytherapy was 12.8 and 15.7 weeks in 2017-2019 vs. 2020 (p = 0.33); median time to treatment initiation for women with early-stage disease was 9 and 5 weeks during 2017-2019 and 2020 respectively (p = 0.06), vs 7.2 and 9 weeks in 2017-2019 and 2020 respectively (p = 0.36) for patients with stages IIB+ disease. CONCLUSIONS: Low access to brachytherapy was a major determinant of non-compliance. irrespective of the effect of the pandemics.

Introducción: Hay escasa evidencia sobre el impacto de la pandemia de COVID-19 en el cumplimiento del tratamiento de cáncer cervicouterino. Métodos: Se llevó a cabo un estudio poblacional de cohorte retrospectivo. ­antes/después­ de las pacientes con cáncer cervicouterino diagnosticadas en establecimientos públicos de la provincia de Jujuy (n = 140), entre 2017 y 2020. Las pacientes diagnosticadas en 2020 se consideraron expuestas a la pandemia (n = 21). Utilizamos la regresión logística multivariada para analizar la asociación entre pandemia y cumplimiento del tratamiento de cáncer. Además, se midió la duración del tratamiento en aquellas con indicación de braquiterapia y el tiempo hasta el inicio al tratamiento según estadio. Resultados: Comparadas con las mujeres diagnosticadas en 2017-2019 el odds ratio de incumplimiento del tratamiento fue de 1.77 (IC95% 0.59-5.81; p = 0.32) para las diagnosticadas durante 2020. Se encontró un mayor riesgo de incumplimiento en pacientes con indicación de braquiterapia (OR 4.14; IC 95%:1.95-9.11; p < 0.001). La mediana de duración del tratamiento para aquellas con indicación de braquiterapia fue de 12.8 y 15.7 semanas en 2017-2019 y 2020 respectivamente (p = 0.33). La mediana de tiempo hasta el inicio del tratamiento para pacientes con enfermedad en estadio temprano fue de 9 y 5 semanas durante 2017-2019 y 2020 respectivamente (p = 0.06), versus una mediana de 7.2 y 9 semanas en 2017-2019 y 2020 respectivamente (p=0.36) para las pacientes con enfermedad en estadio IIB+. Conclusiones: El bajo acceso a la braquiterapia fue un factor determinante de incumplimiento de tratamiento de cáncer cervicouterino, independientemente del efecto de la pandemia.

Participatory design of Short Message Service (SMS) text message to promote mammography among women in Santa Fe, Argentina / Desenho participativo de uma mensagem de texto de Serviço de Mensagens Curta (SMS) para promover a mamografia entre as mulheres em Santa Fé, Argentina / Diseño participativo de un mensaje de texto de Servicio de Mensajes Cortos (SMS) para promover la mamografía entre las mujeres de Santa Fe, Argentina

We describe results of the design process of the content of the SMS messages to promote mammography. We conducted four online focus groups with women aged 50 or more (n=14). We used participatory techniques to debate the advantages and disadvantages of different options for the five structural elements of the SMS message. Our results showed that women argued that the opening line should provide clear information about the topic of the SMS message. SMS messages should include the woman's name, information about who and how to get a mammogram and use a health institution as a sender. The closing line should encourage women to get a mammogram. A personalized SMS could be a good way of inviting women to perform the mammography. The content must be carefully designed to provide clear information about how to schedule an appointment.(AU)

Descrevemos os resultados do processo de concepção do conteúdo das mensagens SMS para promover a mamografia. Quatro grupos focais on-line foram conduzidos com mulheres com cinquenta anos ou mais (n=14). Técnicas participativas foram usadas para discutir opções para cinco elementos estruturantes da mensagem SMS. As mulheres indicaram que a linha de abertura deveria fornecer informações claras sobre o assunto da mensagem SMS. As mensagens SMS devem incluir o nome da mulher, informações sobre quem e como obter uma mamografia e usar uma instituição de saúde como remetente. A sentença final deve encorajar as mulheres a fazer uma mamografia. Um SMS personalizado poderia ser uma boa maneira de convidar mulheres, embora seu conteúdo deva ser cuidadosamente projetado para fornecer informações claras sobre como agendar uma mamografia.(AU)

Describimos los resultados del proceso de diseño del contenido de los mensajes SMS para promover la mamografía. Se realizaron cuatro grupos de discusión en línea con mujeres de 50 y más años (n=14). Se utilizaron técnicas participativas para debatir las distintas opciones para cinco elementos estructurantes del mensaje SMS. Nuestros resultados mostraron que las mujeres señalaron que la línea de apertura debía proporcionar información clara sobre el tema del mensaje SMS. Los mensajes SMS deberían incluir el nombre de la mujer, información sobre quién y cómo hacerse una mamografía y utilizar una institución sanitaria como remitente. La frase final debe animar a las mujeres a hacerse una mamografía. Un SMS personalizado podría ser una buena forma de invitar a las mujeres, aunque su contenido debe diseñarse cuidadosamente para proporcionar información clara sobre cómo programar una mamografía.(AU)

Latin America and the Caribbean Code Against Cancer 1st Edition: 17 cancer prevention recommendations to the public and to policy-makers (World Code Against Cancer Framework).

Preventable risk factors are responsible of at least 40% of cases and almost 45% of all cancer deaths worldwide. Cancer is already the leading cause of death in almost half of the Latin American and the Caribbean countries constituting a public health problem. Cost-effective measures to reduce exposures through primary prevention and screening of certain types of cancers are critical in the fight against cancer but need to be tailored to the local needs and scenarios. The Latin America and the Caribbean (LAC) Code Against Cancer, 1st edition, consists of 17 evidence-based recommendations for the general public, based on the most recent solid evidence on lifestyle, environmental, occupational, and infectious risk factors, and medical interventions. Each recommendation is accompanied by recommendations for policymakers to guide governments establishing the infrastructure needed to enable the public adopting the recommendations. The LAC Code Against Cancer has been developed in a collaborative effort by a large number of experts from the region, under the umbrella strategy and authoritative methodology of the World Code Against Cancer Framework. The Code is a structured instrument ideal for cancer prevention and control that aims to raise awareness and educate the public, while building capacity and competencies to policymakers, health professionals, stakeholders, to contribute to reduce the burden of cancer in LAC.

Latin America and the Caribbean Code Against Cancer 1st edition: Formative research on the comprehension and persuasiveness of the recommendations by the general population.

BACKGROUND: Cancer prevention is the most efficient and cost-effective strategy in cancer control. One prevention strategy is giving credible, clear, and evidence-based recommendations to the individual; however, it is key that these messages are accepted and understood properly by the public. This study aimed to pilot the draft recommendations developed as part of the Latin America and the Caribbean (LAC) Code Against Cancer 1st edition, in terms of comprehension and persuasion of each message. METHODS: A mixed method two-wave study, in which two versions of the messages were presented to the general population in five LAC countries. We used an ad-hoc questionnaire and interviews that followed the cognitive-pretesting methodology. RESULTS: Findings suggest that the messages were generally well understood, especially in Spanish speaking countries, and that the messages were generally more understandable than persuasive. We adapted and revised the recommendations based on the findings of the first Wave and held a second iteration in the Spanish speaking countries. We observed a better understanding of most messages in Wave 2. CONCLUSION: The LAC Code Against Cancer is a valuable tool of well understood messages for the public, with concrete actions everyone can take to prevent cancer. Further research should assess particularities of the region for further efficient dissemination of these important health messages, identify key messages for certain population groups and future interventions that strengthen health literacy in rural and less educated populations to increase behavior change.

Elimination of cervical cancer in Latin America (Project ECHO-ELA): lessons from phase one of implementation.

We describe the outcomes of The Extension for Community Healthcare Outcomes-Elimination of Cervical Cancer in The Americas (ECHO-ELA) program, which was developed as a tri-lateral cooperation between Pan American Health Organization (PAHO), the U.S. National Cancer Institute (NCI) and The University of Texas MD Anderson Cancer Center (MD Anderson). The program's purpose is to disseminate strategies for cervical cancer prevention and is structured around the three pillars of the World Health Organization's (WHO) Cervical Cancer Elimination Strategy and the associated 90-70-90 target goals. The target audience includes health authorities from Latin American and Caribbean countries, as well as PAHO's non-communicable disease Focal Points in country offices as well as clinical and public health collaborators. The virtual sessions are held in Spanish for 1.5 hours every month using the ECHO® format. From May 2020 to June 2021, 14 ECHO sessions were held with an average of 74 participants per session (range: 46 - 142). We conducted two anonymous surveys (baseline and follow up) and two focus groups. Respondents stated that the topics they learned the most about included the state of HPV vaccination in the region and strategies for implementing HPV vaccination. Identified needs included support between ECHO sessions and country-specific technical assistance. The ECHO-ELA program provides a forum for increased collaboration between countries in Latin America/Caribbean and the dissemination of best-practice strategies to reach the WHO Cervical Cancer Elimination target goals.

Se describen los resultados del programa ECHO® (Extension for Community Healthcare Outcomes) para la eliminación del cáncer cervicouterino en las Américas (ECHO-ELA), que se concibió como una cooperación trilateral entre la Organización Panamericana de la Salud (OPS), el Instituto Nacional del Cáncer de los Estados Unidos (NCI) y el centro contra el cáncer MD Anderson (MD Anderson) de la Universidad de Texas. La finalidad del programa es difundir las estrategias para la prevención del cáncer cervicouterino, y está estructurado en torno a los tres pilares de la estrategia para la eliminación del cáncer cervicouterino de la Organización Mundial de la Salud (OMS) y los objetivos 90-70-90 conexos. El público destinatario comprende autoridades de salud de países de América Latina y el Caribe, así como los puntos focales de la OPS para las enfermedades no transmisibles en las Representaciones en los países, además de colaboradores en el ámbito clínico y de la salud pública. Las sesiones virtuales se llevan a cabo en español, durante 1,5 horas cada mes, utilizando el formato ECHO®. De mayo del 2020 a junio del 2021 se celebraron 14 sesiones de ECHO, con un promedio de 74 participantes por sesión (límites: 46-142). Se realizaron dos encuestas anónimas (al inicio y de seguimiento) y dos grupos de opinión. Los encuestados declararon que los temas sobre los que más aprendieron fueron la situación de la vacunación contra el VPH en la región y las estrategias para poner en marcha la vacunación contra el VPH. Entre las necesidades mencionadas figuraban el apoyo entre las sesiones de ECHO y la asistencia técnica específica para cada país. El programa ECHO-ELA brinda un foro para una mayor colaboración entre los países de América Latina y el Caribe y para difundir las estrategias sobre las mejores prácticas, a fin de alcanzar los objetivos de la OMS de eliminación del cáncer cervicouterino.

Este trabalho descreve os resultados do programa Extension for Community Healthcare Outcomes para eliminação do câncer do colo do útero nas Américas (ECHO ELA), desenvolvido na forma de cooperação trilateral entre a Organização Pan-Americana da Saúde (OPAS), o Instituto Nacional do Câncer dos Estados Unidos (NCI) e o MD Anderson Cancer Center da Universidade do Texas (MD Anderson). O programa visa a disseminar estratégias para a prevenção do câncer do colo do útero e está estruturado em torno dos três pilares da estratégia de eliminação do câncer do colo do útero da Organização Mundial da Saúde (OMS) e das Metas 90-70-90 associadas. O público-alvo inclui autoridades sanitárias de países da América Latina e do Caribe, bem como os pontos focais de doenças não transmissíveis nas representações da OPAS nos países, além de colaboradores clínicos e de saúde pública. Todos os meses, são realizadas sessões virtuais de uma hora e meia em espanhol usando o formato ECHO®. No período de maio de 2020 a junho de 2021, foram realizadas 14 sessões do ECHO, com uma média de 74 participantes por sessão (variação: 46 a 142). Foram realizadas duas enquetes anônimas (linha de base e acompanhamento) e dois grupos focais. Os entrevistados afirmaram que os tópicos sobre os quais mais aprenderam foram a situação da vacinação contra o HPV na região e as estratégias para implementar a vacinação contra o HPV. As necessidades identificadas incluíam apoio entre as sessões do ECHO e assistência técnica específica para o país. O programa ECHO ELA oferece um fórum para aumentar a colaboração entre os países da América Latina e do Caribe e difundir melhores práticas para atingir as metas de eliminação do câncer do colo do útero da OMS.

Implementation of an mHealth intervention to increase adherence to triage among HPV positive women with HPV-self-collection (ATICA study): post-implementation evaluation from the women's perspective.

BACKGROUND: Low adherence to triage after positive screening is a widespread problem for cervical cancer screening programs in Low- and Middle-income Countries. Adherence to cytology-based triage can be challenging, especially among women with self-collected tests. SMS-based interventions are accepted by women and can increase screening uptake. The ATICA study was an effectiveness-implementation hybrid type I trial, combining a cluster randomized controlled trial (RCT) with a mixed-methods implementation evaluation involving quantitative and qualitative methods. Although the RCT provided evidence regarding the effectiveness of the SMS-based intervention, less is known about its acceptability, relevance, and usefulness from the women´s perspective. METHODS: We carried out a cross-sectional study based on a structured questionnaire among HPV-positive women who were enrolled in ATICA's intervention group. We measured acceptability, appropriateness, and message content comprehension. Also, we evaluated if the SMS message was considered a cue to encourage women to pick up their HPV test results and promote the triage. RESULTS: We interviewed 370 HPV-positive women. Acceptability of SMS messages among women who had received at least one message was high (97%). We found high levels of agreement in all appropriateness dimensions. More than 77% of women showed high comprehension of the content. Among women who received at least one SMS message, 76% went to the health center to pick up their results. Among those who got their results, 90% reported that the SMS message had influenced them to go. We found no significant differences in acceptability, appropriateness or message comprehension between women who adhered to triage and those who did not adhere after receiving the SMS messages. CONCLUSION: The intervention was highly acceptable, and women reported SMS was an appropriate channel to be informed about HPV test results availability. SMS was also a useful cue to go to the health center to pick up results. The implementation did not encounter barriers associated with the SMS message itself, suggesting the existence of other obstacles to triage adherence. Our results support the RCT findings that scaling up SMS is a highly acceptable intervention to promote cervical screening triage adherence.

Quantification of impact of COVID-19 pandemic on cancer screening programmes - a case study from Argentina, Bangladesh, Colombia, Morocco, Sri Lanka, and Thailand.

It is quite well documented that the COVID-19 pandemic disrupted cancer screening services in all countries, irrespective of their resources and healthcare settings. While quantitative estimates on reduction in volume of screening tests or diagnostic evaluation are readily available from the high-income countries, very little data are available from the low- and middle-income countries (LMICs). From the CanScreen5 global cancer screening data repository we identified six LMICs through purposive sampling based on the availability of cancer screening data at least for the years 2019 and 2020. These countries represented those in high human development index (HDI) categories (Argentina, Colombia, Sri Lanka, and Thailand) and medium HDI categories (Bangladesh and Morocco). No data were available from low HDI countries to perform similar analysis. The reduction in the volume of tests in 2020 compared to the previous year ranged from 14.1% in Bangladesh to 72.9% in Argentina (regional programme) for cervical screening, from 14.2% in Bangladesh to 49.4% in Morocco for breast cancer screening and 30.7% in Thailand for colorectal cancer screening. Number of colposcopies was reduced in 2020 compared to previous year by 88.9% in Argentina, 38.2% in Colombia, 27.4% in Bangladesh, and 52.2% in Morocco. The reduction in detection rates of CIN 2 or worse lesions ranged from 20.7% in Morocco to 45.4% in Argentina. Reduction of breast cancer detection by 19.1% was reported from Morocco. No association of the impact of pandemic could be seen with HDI categories. Quantifying the impact of service disruptions in screening and diagnostic tests will allow the programmes to strategize how to ramp up services to clear the backlogs in screening and more crucially in further evaluation of screen positives. The data can be used to estimate the impact on stage distribution and avoidable mortality from these common cancers.

"You are always left with doubts": information access among HPV-positive women in Greater Buenos Aires / "Siempre te quedan dudas": acceso a la información de mujeres VPH positivo en el Gran Buenos Aires

ABSTRACT Objective Women who are Human Papillomavirus (HPV) positive with a normal Pap smear (HPV+/normal Pap) present a high risk of developing high-grade lesions but they exhibit very low levels of adherence in Argentina. This study was aimed to identify the information needs, sources of information, and barriers to accessing information among HPV-positive women with normal Pap after receiving their screening results. Methods We conducted 22 semi-structured virtual interviews with HPV-positive women with normal Pap (HPV+/normal Pap) women using a qualitative research strategy. Eligible women were between 30 and 64 years old and resided in a suburban Buenos Aires area. The interview data was thematically analyzed using the modules of the interview guide. Emergent categories were coded as subthemes, enabling a thematic analysis. Results Perceived information needs among HPV-positive women with normal Pap smears include understanding: the sexual transmission of the virus (including dismantling the association with infidelity and considering non-sexual transmission possibilities), the meaning of the diagnosis in relation to cancer, and the follow-up procedures despite the absence of treatment. On the other hand, unperceived information needs encompass recognizing the association between an HPV+ result and other gynecological health problems, as well as dispelling socio-cultural misconceptions about HPV (e.g., the misconception that high-risk HPV only affects young women with multiple sexual partners). Common sources of information for these women include medical visits, internet resources, and advice from close relatives. However, barriers to accessing information include encountering inaccurate online information, receiving insufficient information from healthcare professionals, and facing difficulties in raising questions and concerns during medical consultations. Conclusions It is crucial to strengthen the processes for delivering results during the medical consultation. New formats to provide information to HPV-positive women, both with normal and abnormal Pap smear, should also be considered.

RESUMEN Objetivos Las mujeres con resultado positivo de test de Virus de Papiloma Humano (VPH) y resultados negativo o normal de Papanicolau (VPH+/Pap-) presentan un riesgo alto de desarrollar lesiones en el cuello del útero, pero tienen muy bajos niveles de adherencia al seguimiento en Argentina. Este estudio se propuso identificar las necesidades de información, las fuentes de información y las barreras de acceso a la información de mujeres con VPH positivo y Pap normal o negativo luego de haber recibido los resultados del tamizaje. Métodos Con una estrategia de investigación cualitativa, se realizaron 22 entrevistas virtuales semiestructuradas a mujeres con VPH positivo y Papanicolaou normal o negativo (VPH+/Pap-). Las mujeres elegibles tenían entre 30 y 64 años y residían en un área suburbana de Buenos Aires. Los datos de las entrevistas fueron analizados temáticamente utilizando los módulos de la guía de entrevistas. Se codificaron las categorías emergentes como subtemas, lo cual posibilitó un análisis temático. Resultados Existen necesidades de información percibidas entre las mujeres con VPH positivo y Papanicolaou normal o negativo. Estas necesidades incluyen información sobre: la transmisión sexual del virus (desmontando la asociación con la infidelidad y considerando la posibilidad de transmisión no sexual), el significado del diagnóstico y su relación con el cáncer, así como el seguimiento y la ausencia de tratamiento. Por otro lado, existen necesidades de información no percibidas, como la asociación entre el resultado y otros problemas de salud ginecológicos, y las ideas erróneas socioculturales sobre el VPH. Las fuentes de información comunes para estas mujeres son la visita médica, la consulta en internet y el diálogo con los familiares. Sin embargo, existen barreras que dificultan el acceso a la información, como la información inexacta en internet, la falta de información proporcionada por los profesionales y las dificultades para hacer preguntas durante la consulta médica. Conclusiones Es fundamental reforzar los procesos de entrega de resultados y considerar nuevos formatos para proporcionar información a las mujeres VPH+, tanto con Pap normal como anormal.

Assessing the implementation fidelity of HPV self-collection offered by community health workers during home visits (the EMA strategy): a case study in a low-middle-resource setting in Argentina.

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

Implementation 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.

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 health-care providers regarding the intervention implementation 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 was staff to take Pap tests and carry out the HPV-lab work, and to guarantee a constant provision of HPV-tests. CONCLUSION: Health decision-makers and health-care 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 not only for Argentina but also for middle and low-income countries considering using mHealth interventions to enhance the cervical screening/follow-up/treatment process.

Elimination of cervical cancer in Latin America (Project ECHO-ELA): lessons from phase one of implementation / Eliminación del cáncer cervicouterino en América Latina (Proyecto ECHO-ELA): aprendizajes de la primera fase de implementación / Eliminação do câncer do colo do útero na América Latina (Projeto ECHO-ELA): lições da primeira fase de implementação

ABSTRACT We describe the outcomes of The Extension for Community Healthcare Outcomes-Elimination of Cervical Cancer in The Americas (ECHO-ELA) program, which was developed as a tri-lateral cooperation between Pan American Health Organization (PAHO), the U.S. National Cancer Institute (NCI) and The University of Texas MD Anderson Cancer Center (MD Anderson). The program's purpose is to disseminate strategies for cervical cancer prevention and is structured around the three pillars of the World Health Organization's (WHO) Cervical Cancer Elimination Strategy and the associated 90-70-90 target goals. The target audience includes health authorities from Latin American and Caribbean countries, as well as PAHO's non-communicable disease Focal Points in country offices as well as clinical and public health collaborators. The virtual sessions are held in Spanish for 1.5 hours every month using the ECHO® format. From May 2020 to June 2021, 14 ECHO sessions were held with an average of 74 participants per session (range: 46 - 142). We conducted two anonymous surveys (baseline and follow up) and two focus groups. Respondents stated that the topics they learned the most about included the state of HPV vaccination in the region and strategies for implementing HPV vaccination. Identified needs included support between ECHO sessions and country-specific technical assistance. The ECHO-ELA program provides a forum for increased collaboration between countries in Latin America/Caribbean and the dissemination of best-practice strategies to reach the WHO Cervical Cancer Elimination target goals.

RESUMEN Se describen los resultados del programa ECHO® (Extension for Community Healthcare Outcomes) para la eliminación del cáncer cervicouterino en las Américas (ECHO-ELA), que se concibió como una cooperación trilateral entre la Organización Panamericana de la Salud (OPS), el Instituto Nacional del Cáncer de los Estados Unidos (NCI) y el centro contra el cáncer MD Anderson (MD Anderson) de la Universidad de Texas. La finalidad del programa es difundir las estrategias para la prevención del cáncer cervicouterino, y está estructurado en torno a los tres pilares de la estrategia para la eliminación del cáncer cervicouterino de la Organización Mundial de la Salud (OMS) y los objetivos 90-70-90 conexos. El público destinatario comprende autoridades de salud de países de América Latina y el Caribe, así como los puntos focales de la OPS para las enfermedades no transmisibles en las Representaciones en los países, además de colaboradores en el ámbito clínico y de la salud pública. Las sesiones virtuales se llevan a cabo en español, durante 1,5 horas cada mes, utilizando el formato ECHO®. De mayo del 2020 a junio del 2021 se celebraron 14 sesiones de ECHO, con un promedio de 74 participantes por sesión (límites: 46-142). Se realizaron dos encuestas anónimas (al inicio y de seguimiento) y dos grupos de opinión. Los encuestados declararon que los temas sobre los que más aprendieron fueron la situación de la vacunación contra el VPH en la región y las estrategias para poner en marcha la vacunación contra el VPH. Entre las necesidades mencionadas figuraban el apoyo entre las sesiones de ECHO y la asistencia técnica específica para cada país. El programa ECHO-ELA brinda un foro para una mayor colaboración entre los países de América Latina y el Caribe y para difundir las estrategias sobre las mejores prácticas, a fin de alcanzar los objetivos de la OMS de eliminación del cáncer cervicouterino.

RESUMO Este trabalho descreve os resultados do programa Extension for Community Healthcare Outcomes para eliminação do câncer do colo do útero nas Américas (ECHO ELA), desenvolvido na forma de cooperação trilateral entre a Organização Pan-Americana da Saúde (OPAS), o Instituto Nacional do Câncer dos Estados Unidos (NCI) e o MD Anderson Cancer Center da Universidade do Texas (MD Anderson). O programa visa a disseminar estratégias para a prevenção do câncer do colo do útero e está estruturado em torno dos três pilares da estratégia de eliminação do câncer do colo do útero da Organização Mundial da Saúde (OMS) e das Metas 90-70-90 associadas. O público-alvo inclui autoridades sanitárias de países da América Latina e do Caribe, bem como os pontos focais de doenças não transmissíveis nas representações da OPAS nos países, além de colaboradores clínicos e de saúde pública. Todos os meses, são realizadas sessões virtuais de uma hora e meia em espanhol usando o formato ECHO®. No período de maio de 2020 a junho de 2021, foram realizadas 14 sessões do ECHO, com uma média de 74 participantes por sessão (variação: 46 a 142). Foram realizadas duas enquetes anônimas (linha de base e acompanhamento) e dois grupos focais. Os entrevistados afirmaram que os tópicos sobre os quais mais aprenderam foram a situação da vacinação contra o HPV na região e as estratégias para implementar a vacinação contra o HPV. As necessidades identificadas incluíam apoio entre as sessões do ECHO e assistência técnica específica para o país. O programa ECHO ELA oferece um fórum para aumentar a colaboração entre os países da América Latina e do Caribe e difundir melhores práticas para atingir as metas de eliminação do câncer do colo do útero da OMS.

Ten Steps to Design a Counseling App to Reduce the Psychosocial Impact of Human Papillomavirus Testing on the Basis of a User-Centered Design Approach in a Low- and Middle-Income Setting.

PURPOSE: This study describes the 10 steps followed to produce the information architecture of a user-centered design (UCD) counseling mobile application, the first phase to develop an app. The app aims to reduce the psychosocial impact of the human papillomavirus test result and improve women's knowledge of human papilloma virus and cervical cancer. METHODS: We used a UCD approach to produce the information architecture of the app (ie, how to organize contents into features). We analyzed field notes, meeting agendas, and documentation produced during each stage of the design process. We described the goals, methods, and outcomes of each step. We also discussed the critical challenges and the strategies to address them. RESULTS: The steps are (1) knowledge, attitudes, and beliefs mapping: reanalysis of team's research findings from prior studies; (2) environmental scanning of apps available on the market; (3) stakeholders' point of view: The International Advisory Committee; (4) potential user's profile: building archetypes through the Persona method; (5) women's interviews: user's preferences and experiences; (6) effective features: scoping review to select app's features that address psychosocial impact; (7) the user journey: ideal interaction with the gynecological service and the counseling app; (8) women's focus groups: using Personas and Scenarios to discuss app's mock-up; (9) women's design sessions: prototype test and card-sorting techniques; and (10) team's design session: translating results into visual objects and features. CONCLUSION: We provide here detailed descriptions of the UCD process of an app for human papillomavirus-tested women for those venturing into the area of mHealth strategies work. Our experience can be used as a guide for future mHealth app development for a low- and middle-income setting.

Effectiveness of an mHealth intervention to increase adherence to triage of HPV DNA positive women who have performed self-collection (the ATICA study): A hybrid type I cluster randomised effectiveness-implementation trial.

Background: Human Papillomavirus (HPV) self-collection offered by community health workers (CHWs) during home visits has been hampered by low levels of triage Pap among HPV-positive women. We investigated effectiveness of a mHealth intervention to increase adherence to triage Pap. Methods: We conducted a hybrid type I cluster randomised effectiveness-implementation trial in Jujuy, Argentina. CHWs (clusters) were eligible if actively offering HPV self-collection and served at least 26 women aged 30 years and over. Women were eligible if they conducted self-collection and provided a mobile phone number. 260 CHWs were randomly allocated (3:2 ratio) to a multi-component 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), or control group (Usual care: Women instructed to attend their health centre 30 days after HPV self-collection to pick-up results). The primary effectiveness outcome was percentage of HPV-positive women with triage 120 days after the HPV-test result. We evaluated implementation of the intervention using the RE-AIM framework. Findings: 221 CHWs (132 intervention, 89 control group) contacted 5389 women; and 5351 agreed to participate (3241 intervention, 2110 control group). In total 314/445 (70·5%) HPV-positive women of the intervention group had triage at 120 days after the HPV result, compared to 163/292 (55·1%) in the control group: 15·5% point improvement; 95%CI: 6·8-24·1; relative risk: 1·28; 95%CI: 1·11-1·48. 97·2% of women accepted the intervention and 86·9% of CHWs agreed to its adoption. Interpretation: The multicomponent mHealth intervention was effective in increasing the percentage of HPV-positive women who had triage Pap, allowing for many more women at risk of cervical cancer to receive timely follow-up. Funding: National Cancer Institute of the National Institutes of Health (USA) under Award Number R01CA218306.

Acceptability, appropriateness and feasibility of the Latin American and Caribbean Code against Cancer: perceptions of decision-makers and health professionals in Argentina.

Background: Cancer is an important public health problem. In Latin America and the Caribbean, there were approximately 1,500,000 new cases of cancer and 700,000 deaths due to cancer in 2020. These figures will increase by 78% by 2040 to more than 2.5 million people diagnosed with cancer each year, who will require medical attention, care and support. However, it is estimated that at least 40% of cancers could be prevented by adopting a healthier lifestyle, reducing risky behaviours and implementing recommended health interventions. Objective: To evaluate the perceptions of health decision-makers and professionals regarding the Latin American and Caribbean Code against Cancer (CLCC) as a support tool for designing and implementing public policies for cancer prevention and control (acceptability, appropriateness and feasibility) in Argentina. Methods: A qualitative study was conducted using individual, semi-structured interviews with health decision-makers and professionals (n = 30). The questions and thematic analysis of the information gathered have been guided by the principles of the Consolidated Framework for Implementation Research: intervention characteristics, outer setting, inner setting and characteristics of individuals. Results: Health professionals and health decision-makers broadly accepted the proposal of the CLCC as a tool for supporting the design and implementation of public policies for cancer prevention and control, and considered it to be appropriate. Additionally, from the interviewees' perspective, factors should be ensured to guarantee the implementation of the CLCC as a viable public health policy. They also felt it was right to take the CECC as a model and to adapt its content to the specific characteristics of the Latin American population, customs, lifestyle habits, epidemiological characteristics and, in particular, the Argentinian socio-economic context. Interviewees perceived the CLCC as a health intervention whose complexity varied depending on the recommendation, although most of them were feasible. The broad consensus among the interviewees was that the development of the CLCC could yield numerous advantages in improving cancer prevention and control policy, and responding to the needs of the population. It was also considered to be an opportunity to introduce fundamental changes. With regard to the implementation of the CLCC, interviewees reported a favourable institutional climate, since they perceived that it would receive a priority equal to or greater than the ongoing prevention measures, and that it would have the commitment of the health authorities. They also felt that the implementation of the CLCC in their work environment would not be very complicated, and that the decision-makers and professionals had the necessary capacity to implement it. Finally, they felt that the implementation would be facilitated by the participation and consensus of health decision-makers at the primary care level, and negotiation with industrial and environmental sectors. Conclusions: Our study shows that health professionals and decision-makers consider the CLCC to be highly acceptable, appropriate and feasible. This would facilitate its implementation as a tool that could enhance current cancer prevention and control policies in Argentina. The results of the study indicate the necessity for the CLCC to be adapted to the socio-economic context of Argentina, and highlight that population adherence to the CLCC recommendations will depend on complex and diverse factors, especially those involving changing unhealthy behaviours linked to cancer risk.

A Counseling Mobile App to Reduce the Psychosocial Impact of Human Papillomavirus Testing: Formative Research Using a User-Centered Design Approach in a Low-Middle-Income Setting in Argentina.

BACKGROUND: Human papillomavirus (HPV) testing detects sexually transmitted infections with oncogenic types of HPV. For many HPV-positive women, this result has negative connotations. It produces anxiety, fear of cancer or death, and disease denial. Face-to-face counseling could present many difficulties in its implementation, but a counseling mobile app could be practical and may help HPV-positive women reduce the psychosocial impact of the result, improve their knowledge of HPV and cervical cancer, and increase adherence to follow-up. OBJECTIVE: This study aims to understand HPV-tested women's perceptions about an app as a tool to receive information and support to reduce the emotional impact of HPV-positive results. We investigated their preferences regarding app design, content, and framing. METHODS: We conducted formative research based on a user-centered design approach. We carried out 29 individual online interviews with HPV-positive women aged 30 years and over and 4 focus groups (FGs) with women through a virtual platform (n=19). We shared a draft of the app's potential screens with a provisional label of the possible content, options menus, draft illustrations, and wording. This allowed us to give women understandable triggers to debate the concepts involved on each screen. The draft content and labels were developed drawing from the health belief model (HBM) and integrative behavioral model (IBM) variables and findings of mobile health literature. We used an FG guide to generate data for the information architecture (ie, how to organize contents into features). We carried out thematic analysis using constructs from the HBM and IBM to identify content preferences and turn them into app features. We used the RQDA package of R software for data processing. RESULTS: We found that participants required more information regarding the procedures they had received, what HPV-positive means, what the causes of HPV are, and its consequences on their sexuality. The women mentioned fear of the disease and stated they had concerns and misconceptions, such as believing that an HPV-positive result is a synonym for cancer. They accepted the app as a tool to obtain information and to reduce fears related to HPV-positive results. They would use a mobile app under doctor or health authority recommendation. The women did not agree with the draft organization of screens and contents. They believed the app should first offer information about HPV and then provide customized content according to the users' needs. The app should provide information via videos with experts and testimonies of other HPV-positive women, and they suggested a medical appointment reminder feature. The app should also offer information through illustrations, or infographics, but not pictures or solely text. CONCLUSIONS: Providing information that meets women's needs and counseling could be a method to reduce fears. A mobile app seems to be an acceptable and suitable tool to help HPV-positive women.

"I'm neither here, which would be bad, nor there, which would be good": the information needs of HPV+ women. A qualitative study based on in-depth interviews and counselling sessions in Jujuy, Argentina.

The objective of this qualitative study was to explore the information needs of HPV+ women. We conducted 38 in-depth interviews with HPV+ women in the province of Jujuy, Argentina. The interviews included a counselling session to respond to women's concerns and questions. Women perceived the information provided as good, despite having several doubts and misconceptions after receiving results of an HPV+ test. They expressed difficulties in formulating questions during the consultation due to shame, excess of information provided or lack of familiarity with technical language. They valued emotional support and being treated kindly by professionals. The perceived information needs that emerged as most important were: (1) the meaning of an HPV+ result and its relationship with cervical cancer evolution and severity; (2) continuity and timing of the care process; (3) information on the sexual transmission of the virus; (4) explanation of the presence or absence of symptoms. Women's primary unperceived information needs were: (1) detailed information about colposcopy, biopsy and treatments and their effects (including fertility consequences); and (2) deconstructing the association of sexual transmission with infidelity. Sources of information included: (1) the health care system; (2) the internet; and (3) social encounters (close friends and relatives). It is crucial to strengthen the processes for delivering results, with more thorough information, improved emotional support and active listening focused on the patient, as well as to conceive new formats to provide information in stages and/or gradually, in order to facilitate women's access to the health care system and the information they need.