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.

Developing SMS Content to Promote Papanicolaou Triage Among Women Who Performed HPV Self-collection Test: Qualitative Study.

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

Adopción e implementación del ofrecimiento de la autotoma VPH por agentes sanitarios en Jujuy, Argentina / Adoption and implementation of HPV self-collection sampling by CHWs in Jujuy, Argentina

Resumen: Objetivo: Evaluar la adopción e implementación en escala de la estrategia orientada a ofrecer puerta a puerta la autotoma de la prueba del virus del papiloma humano (AT-VPH), por parte de agentes sanitarios (AS), en Jujuy, Argentina. Material y métodos: Se aplicó una encuesta autoadministrada a 478 AS. Las dimensiones de adopción e implementación fueron evaluadas con el modelo RE-AIM. Resultados: Adopción: 81.8% de los AS ofreció la AT-VPH y 86.4% expresó gratificación con la estrategia. Implementación: los problemas encontrados fueron la demora en la entrega de tubos (61.3%) y resultados (70.0%); falta de recursos humanos (28.3%), y dificultades al obtener turnos para realizar el triage (26.1%). El principal obstáculo fue la sobrecarga de trabajo (50.2%), mientras que la capacitación (38.0%) y el listado de mujeres a contactar (28.7%) fueron los elementos facilitadores. Conclusiones: La adopción de la AT-VPH fue alta entre los AS. Deben reforzarse las estrategias programáticas para motivar a los AS y reducir su carga de trabajo al implementar la AT-VPH.

Abstract: Objective: To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered door-to-door by Community Health Workers (CHWs) in Jujuy, Argentina. Materials and methods: A self-administered questionnaire was applied to 478 CHWs. RE-AIM model was used to evaluate adoption and implementation dimensions. Results: Adoption: 81.8% offered SC and 86.4% were satisfied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%). Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators. Conclusions: The adoption of SC strategy was high among CHWs. Program strategies should be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

[Adoption and implementation of HPV self-collection sampling by CHWs in Jujuy, Argentina]. / Adopción e implementación del ofrecimiento de la autotoma VPH por agentes sanitarios en Jujuy, Argentina.

OBJECTIVE: To evaluate adoption and implementation of scaling up of HPV self-collection (SC) strategy offered doorto-door by Community Health Workers CHWs) in Jujuy, Argentina. MATERIALS AND METHODS: A self-administered questionnaire was applied to 478 CHWs.RE-AIM model was used to evaluate adoption and implementation dimensions. RESULTS: Adoption:81.8% offered SC and 86.4% were satis- fied with the strategy. Implementation: main problems were delays in the delivery of tubes (61.3%) and results (70.0%), lack of human resources (28.3%) and difficulties in obtaining an appointment for triage (26.1%). The main obstacle was the excessive workload of CHWs (50.2%).Training (38.0%) and the list of women to be offered the test (28.7%) were identified as facilitators. CONCLUSIONS: The adoption of SC strategy was high among CHWs.Program strategiesshould be strengthened to motivate and reduce the excessive workload of CHWs when implementing SC strategy.

OBJETIVO: Evaluar la adopción e implementación en escala de la estrategia orientada a ofrecer puerta a puerta la autotoma de la prueba del virus del papiloma humano (AT-VPH),por parte de agentessanitarios(AS),en Jujuy,Argentina. MATERIAL Y MÉTODOS: Se aplicó una encuesta autoadministrada a 478 AS. Las dimensiones de adopción e implementación fueron evaluadas con el modelo RE-AIM. RESULTADOS: Adopción: 81.8% de los AS ofreció la AT-VPH y 86.4% expresó gratificación con la estrategia. Implementación: los problemas encontrados fueron la demora en la entrega de tubos (61.3%) y resultados (70.0%); falta de recursos humanos (28.3%), y dificultades al obtener turnos para realizar el triage (26.1%). El principal obstáculo fue la sobrecarga de trabajo (50.2%), mientras que la capacitación (38.0%) y el listado de mujeres a contactar (28.7%) fueron los elementos facilitadores. CONCLUSIONES: La adopción de la AT-VPH fue alta entre los AS. Deben reforzarse las estrategias programáticas para motivar a los AS y reducir su carga de trabajo al implementar laAT-VPH.

[Health agents' perspective on the incorporation of self-collected samples in HPV screening programs]. / La perspectiva de los agentes sanitarios sobre la incorporación programática de la autotoma del test de VPH.

The objective of this study was to analyze health agents' perception of self-collecting of samples for HPV testing among women and the degree of agreement by the agents to incorporate this approach into their daily tasks. A self-administered questionnaire was applied to 127/191 health agents that participated in the EMA Project (Proyecto Evaluación Modalidad Autotoma) in the province of Jujuy, Argentina, in 2012-2013. The health agents with and without the experience of offering self-collected sampling expressed a high degree of agreement towards adoption of the strategy (78.7%), given its potential to prevent cervical cancer and its contribution to health care for the women under their coverage. However, the health agents identified the extra work and problems linking to the formal health system as the main barriers to offering this modality in the future. The study found that self-collecting of samples is a practice that can be adopted by health agents in the province of Jujuy, but that it should be accompanied by support measures from the formal health system.

La perspectiva de los agentes sanitarios sobre la incorporación programática de la autotoma del test de VPH / Health agents’ perspective on the incorporation of self-collected samples in HPV screening programs / A perspectiva dos agentes sanitários sobre a incorporação programada da autoadministração do teste de HPV

Resumen: El objetivo de este estudio fue analizar la percepción que poseen los agentes sanitarios sobre el ofrecimiento de la autotoma del test de VPH a las mujeres y el grado de acuerdo de los agentes para incorporarla a sus tareas diarias. Para ello, se aplicó una encuesta auto-administrada a 127/191 agentes sanitarios que participaron del Proyecto EMA (Proyecto Evaluación Modalidad Autotoma), llevado a cabo en la provincia de Jujuy (Argentina) entre 2012-2013. Los agentes sanitarios que tuvieron y no la experiencia de ofrecer la autotoma manifestaron un alto grado de acuerdo para la adopción de la estrategia (78,7%), dado su potencial para prevenir el cáncer cervicouterino y los aportes que brinda al cuidado de la salud de las mujeres bajo su cobertura. Sin embargo, señalaron la sobrecarga de trabajo y los problemas de articulación con el sistema formal de salud, como los principales obstáculos para ofrecer esta modalidad en el futuro. Este estudio encontró que la autotoma es una práctica que puede ser adoptada por los agentes sanitarios de la provincia de Jujuy, pero debe ir acompañada de acciones de apoyo por parte del sistema de salud formal.

Abstract: The objective of this study was to analyze health agents’ perception of self-collecting of samples for HPV testing among women and the degree of agreement by the agents to incorporate this approach into their daily tasks. A self-administered questionnaire was applied to 127/191 health agents that participated in the EMA Project (Proyecto Evaluación Modalidad Autotoma) in the province of Jujuy, Argentina, in 2012-2013. The health agents with and without the experience of offering self-collected sampling expressed a high degree of agreement towards adoption of the strategy (78.7%), given its potential to prevent cervical cancer and its contribution to health care for the women under their coverage. However, the health agents identified the extra work and problems linking to the formal health system as the main barriers to offering this modality in the future. The study found that self-collecting of samples is a practice that can be adopted by health agents in the province of Jujuy, but that it should be accompanied by support measures from the formal health system.

Resumo: Este estudo objetivou analisar a percepção que possuem os agentes sanitários sobre o oferecimento da autoadministração do teste de HPV a mulheres e o nível de compromisso dos agentes em incorporá-la a suas tarefas diárias. Para isso, foi aplicada uma pesquisa autoadministrada entre 127/191 agentes sanitários que participaram do Projeto EMA (Proyecto Evaluación Modalidad Autotoma), realizada na província de Jujuy (Argentina) no período 2012-2013. Os agentes sanitários que tiveram e não a experiência de oferecer a autoadministração manifestaram um alto grau de compromisso para a aprovação da estratégia (78,7%), devido ao seu potencial para prevenir o câncer do colo do útero e os aportes que presenta para o cuidado da saúde das mulheres sob sua cobertura. No entanto, mostraram uma sobrecarga de trabalho e problemas de articulação com o sistema público de saúde, como os principais obstáculos para oferecer esta modalidade em um futuro. Este estudo encontrou que a autoadministração é una prática que pode ser adotada pelos agentes sanitários da província de Jujuy, no entanto deve ir acompanhada de ações de apoio por parte do sistema público de saúde.