Mixed-Methods Approach to Evaluate a mHealth Intervention to Increase Adherence to Triage of HPV+ Women Who Have Performed Self-collection

Cervical cancer is a disease of health and gender inequalities, and is primarily a cancer of poor, socially vulnerable women. Even though it is almost entirely preventable, in Latin America it is the leading cause of cancer death among women.1 In Argentina, it is the second cause of female cancer death: every year 5,000 women are diagnosed with cervical cancer and more than 1,800 die from the disease.1 In this country, and generally across Latin America, high mortality is related to problems in the continuity of the prevention process, including low screening coverage and loss to follow-up, diagnosis, and treatment.2,3 New screening tests detect the presence of high-risk types of HPV which cause cervical cancer. HPV tests have important advantages over the Pap as a primary screening test, including higher sensitivity (over 90%)4 and a high negative predictive value,5 which allow reduced screening frequencies. Very importantly, through self-collection strategies, HPV testing can reduce barriers to screening and increase coverage.6 HPV self-collection is highly accurate,7 and is acceptable among women in different countries.8-11 However, HPV screening identifies women who are HPV+ (around 10%). Triage tests for HPV+ women determine those who need additional diagnostic procedures. While several triage methods are available for detecting precancerous lesions, including cytology and colposcopy,12 to date most such triage methods require HPV+ women to attend health centers to determine appropriate follow-up. Although adherence to follow-up and treatment is a widespread problem for cervical cancer programs in Latin America,2 evidence for interventions to improve adherence to follow-up is lacking.

The introduction of self-administered HPV testing in Jujuy has been successful in increasing primary cervical cancer screening coverage. Yet the proportion of self-collected HPV+ cases who currently undertake cytological triage within 120 days of screening is low (about 30%), which hinders the impact of the increased HPV screening coverage attained.

Aims of the study

1. To evaluate the effectiveness of a mHealth intervention targeted to women and health providers to increase adherence to cytological triage among self-tested HPV+ women compared to usual practice.
2. To identify and understand the processes and factors which contribute to the success of the mHealth intervention strategy (or lack thereof).

Setting Jujuy province is located in northwest Argentina and 85% of its population live in urban areas.19 The primary health care (PHC) system has 270 health centres and employs about 700 full-time CHWs who visit approximately 110,000 households twice a year for health-related tasks.