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
Lucila Szwarc1, Paula Frejdkes1, Victoria Sánchez Antelo1,2, Melisa Paolino1,2 and Silvina Arrossi1,2
1Center for the Study of State and Society, Buenos Aires C1173, Argentina
2CONICET National Scientific and Technical Research Council, Buenos Aires C1414, Argentina
Abstract
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.
Keywords: mobile health, HPV testing, cervical cancer, implementation science, health professionals, low- and middle-income countries
Correspondence to: Lucila Szwarc
Email: lucilaszwarc@gmail.com
Published: 25/09/2024
Received: 07/02/2024
Publication costs for this article were supported by ecancer (UK Charity number 1176307).
Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
Cervical cancer (CC) is one of the leading causes of death in women in most low- and middle-income countries. In Argentina, 4,500 new cases are diagnosed each year and 2,300 women die from this disease [1]. Although CC is preventable with existing knowledge and technologies, the high mortality is due to persistent problems in the cancer control continuum, which condition adherence to it [2–4]. This includes procedures and contacts with the health system over a certain period of time and involves up to four stages: screening Human papillomavirus (HPV test, Pap test), diagnosis (colposcopy, biopsy), treatment and subsequent follow-up [5].
The failures in the CC prevention process respond to socio-structural, subjective-symbolic and institutional factors, including failures in communication between patients and health services [6–9]. The delivery of positive HPV test results (HPV+) can have a psychosocial impact on patients, arousing feelings such as anxiety, fear and shame, given that it is related to sensitive issues linked to sexuality, illness and death [10–12]. This can act as a barrier for women to continue with the process of care in health services [10]. WHO recommends individual counseling, starting with the HPV test and beyond, in which the patient can receive information in clear and simple language, and have time to reflect and express her doubts and fears [10]. However, face-to-face counseling involves a lot of time and resources, which are sometimes not available, particularly in low- and middle-income countries [11, 13, 14], such as trained providers, and sufficient time and privacy during consultations [15, 16]. As a result, women receive insufficient and/or confusing information about testing and its benefits, and how to follow up [8, 13].
In this context, there is a need to develop innovative strategies, applicable on a large scale, to improve the provision of information, counseling and support to women or other sex-gender identities who undergo HPV testing1, allowing for more efficient use of resources and enhancing autonomy with patient-centered information.
Screening for cervical cancer (HPV or Pap test, depending on availability and indication) should be indicated for all persons with a cervix, whether or not they have had vaginal penetration [17, 18]. This includes women who have sex with women, and non-binary and trans men with a uterus. Given that the literature on CC prevention in people of diversity is sparse and shows that this group goes through particular barriers and experiences [19], we focus on research focused on women. But we do not want to neglect to mention that future research, communication and information provision strategies should also include these population groups.
MHealt (mobile health) strategies can be an important resource to improve information provision and communication between users and healthcare institutions, enhanced by the changes in this field that occurred during the COVID-19 pandemic. The use of mobile applications (apps) to communicate with and support patients has been shown to improve health goals for different conditions, including mental health conditions [20–22]. Apps can be used even after the consultation is over and require fewer staff [20, 23]. In oncology care, they offer the ability to provide accessible information and education at minimal cost throughout the care continuum [24, 25].
In CC prevention, research developed in Argentina demonstrated the effectiveness of MHealth strategies to increase the coverage of Pap triage, a necessary step after HPV+ to identify if the woman needs diagnosis and follow-up [26]. Along these lines, our research team initiated a project aimed at designing an app to improve communication between professionals and patients, and thus reduce the psycho-social impact of HPV testing [27, 28]. In the framework of this research, women users indicated that they would use this technology if it were recommended by a professional and that it would be a good complement to the HPV consultation, allowing them to obtain information and reduce fears related to a positive result [28]. Based on these findings, we proposed an intervention in which health professionals recommend the app to their patients, being an active part of the implementation of the innovation. The aim is for the app to function as a tool to support the work of professionals who offer the HPV test and communicate its results to women.
According to a systematic review [29], the implementation of apps during the care process is perceived by health professionals as a facilitator of communication with patients and between colleagues, coordination and quality of care, as well as the recording of patient information. The research presented in this paper examines the perception of health professionals on the incorporation of a mobile application as a strategy to strengthen communication between patients and health services in the process of CC prevention. In particular, their perceptions about possible barriers and facilitators to the implementation of the mobile application are reviewed.
From the implementation sciences approach, it is essential to know both the point of view of the actors involved (workers and patients) and the possible conditioning factors to the intervention, in order to develop effective strategies for the implementation of the innovation [30]. Recognising the perspective of health professionals allows the consideration of a central actor for the innovation to be implemented, sustained over time and effective as a tool for articulation between women and professionals [28] This will also allow us to identify barriers and facilitators to implementation, in order to develop strategies in the aforementioned directions.
Material and methods
Framework
The project is framed within the implementation sciences and the theory of diffusion of innovations [30, 31], which provides conceptual tools for understanding the adoption, dissemination, diffusion and implementation of innovations in the field of health. We rely on the Consolidated Framework for Implementation Research (CFIR), which allows us to take into account the multilevel factors that can condition the success of an implementation, based on a wide range of constructs [30].
The CFIR constructs have been associated with the effective implementation of innovations and are organised into five domains: 1. The aspects related to the characteristics of the innovation and that will shape its implementation; 2. The external environment, which comprises the social, political and economic situation of the organisation in which the innovation will be implemented; 3. The organisational or internal environment, which includes the political, cultural and structural atmosphere through which the innovation will be processed; 4. The characteristics of the people involved in the implementation of the innovation (facilitators such as authorities, adopters and recipients); and 5. Table 1 presents the constructs that were selected and used in this research, within each domain.
Scope of research
The work was carried out in the province of Buenos Aires, in the municipality of Ituzaingó, where the formative research had previously been developed with women. This municipality established in 2015 the HPV test as primary screening for women aged 30 years or older, users of the public health system, not covered by social security. The locality has six primary health care centers, linked to the second level, which offer free care, including detection, diagnosis and treatment if necessary.
Thirteen professionals from the public health system, dedicated to the prevention of CC in the municipality, whose tasks include the provision of information on HPV testing, were interviewed.
Data collection
Individual semi-structured interviews were conducted with health professionals through the videoconferencing platform (Zoom Inc). Currently, the use of Information and Communication Technologies is accepted and valid for the collection of information, because it allows greater flexibility for a synchronous encounter, without losing certain qualities of a face-to-face meeting between informant and researcher [32]. The interview guide was organised based on specific CFIR constructs (Table 1).
To provide more clarity on the proposed implementation, during the interview, it was explained that the app would be a tool to support the work of professionals who offer HPV testing and communicate their results. A presentation with the app’s key screens was also shown.
With prior authorisation, the interviews were recorded, with an average duration of 40 minutes. The interviews were transcribed and individual codes were assigned to protect the anonymity of the participants.
Table 1. Dimensions, domains, constructs and definitions of CFIR used.
Data analysis
Data coding and analysis were performed according to the selected domains, constructs and dimensions of the CFIR (Table 1). Thematic analysis was used to identify emergents, classified as barriers and facilitators. The analysis was performed by two researchers, and then discussed together with the research team. To ensure the internal consistency of the coding, the constant comparison strategy was used and disagreements were resolved by reviewing the original data [33].
Ethical aspects
Ethical standards were in accordance with the 1975 Declaration of Helsinki on human experimentation. The project and the informed consent were approved by the Ethics Committee ‘Diagnóstico por Imagen Morón’ with registration number N°060/2016. Express informed consent was requested from all interviewees to participate in the study and to audio record the interviews, where full respect for anonymity and confidentiality was indicated.
Results
Sample characteristics
Thirteen health professionals were interviewed, 4 men and 9 women, of whom 9 were gynecology professionals, 1 general practitioner, 2 obstetrics graduates and 1 proctology professional, in charge of HPV navigation. All the professionals work in primary health care, where they take HPV and Pap test samples and provide information on HPV testing.
Table 2 summarizes the results based on the CFIR constructs as perceived as barriers or facilitators of app implementation, with verbatims for each construct and subtheme. They are presented according to the order of dimensions and constructs proposed by the CFIR.
Table 2. Dimensions, CFIR constructs and interview excerpts, analysed as barriers or facilitators.
Facilitators for the incorporation of a mobile application in CC prevention
From the analysis of the interviews, we found that, according to the professionals, seven CFIR constructs could function as facilitators when implementing the app (see a summary of the results and interview excerpts for each construct in Table 2). It is perceived that the app would be compatible with the current practice, given that technological tools are being used for communication with patients (such as institutional mail or WhatsApp) and the cell phone is being used in the framework of the consultation, either to access results in computerised records or to see those brought by women. Likewise, the people interviewed consider the app adaptable to the current way of providing information, in that it would not replace the consultation, but would complement it, so that women could, for example, clear up doubts that arise later or reorient their questions based on information from the app. Along these lines, the app is also perceived as easy to incorporate (low complexity), because it would not take much time to mention it or suggest downloading it during the meeting.
The compatibility is linked to and reinforced by the relative advantage that the app provides, in relation to other possible ways of providing information. Currently, according to professionals, women do not have information about HPV, and this leads them to search the internet where false and confusing information circulates. The app, then, would be a good tool to offer them where to look for reliable online information, instead of discouraging them from doing so, as professionals do today. Two arguments that enhance the positive perception of the relative advantage stand out: the fact that the information is available, ‘at hand’, i.e., that it is compatible with the widespread use of cell phones and, in turn, that it is supported and validated information. The latter represents an important relative advantage over information circulating on the Internet, which could negatively affect women’s perception of CC. The people interviewed also consider the advantage of being able to offer the app to those professionals who do not provide information on HPV, due to lack of training or because they only indicate the next steps in the preventive process.
Respondents believe that there is evidence of the validity and robustness of the effectiveness of implementing an app. Although they do not mention other experiences of using mobile applications to provide preventive information in the health system, the widespread use of the CUIDAR app, officially implemented in Argentina during the COVID-19 pandemic, is mentioned as a positive precedent. This app was widely used to register vaccinations, and to request and provide application appointments and circulation permits.
Regarding the origin of the intervention, the people interviewed support the app because they know the team conducting the research on its development and implementation (CEDES, Centro de Estudios de Estado y Sociedad) and mention their prestige and experience, together with those of the public institutions that financed the research, such as the National Cancer Institute of Argentina. Thus, as regards the construct that reflects the belief in the intervention, the people interviewed indicate that they would accept the app in order to recommend it to their patients, and believe that it would be accepted by the other members of the healthcare team, as it is promoted and supported by recognised and legitimized institutions and experts.
Potential barriers to the incorporation of mobile applications in QC prevention
Four CFIR constructs were associated with possible barriers to implementation. The first barrier refers to adaptability. Although the people interviewed describe that patients use apps, they also emphasize that, in order to adapt to the local context, the app design should require little memory on the cell phone and provide a user-friendly interface. They also understand that every app has a limitation in terms of content, so it would not be able to answer all possible questions.
The people interviewed have a very positive perception of how they provide information on HPV and CC prevention: they describe multiple communication strategies to ensure that women understand, that they have no doubts and that they take the necessary time to do so. Some of them also consider that, despite certain limitations in terms of available resources, the professionals are sufficiently trained to inform patients. In this sense, they do not perceive the need to implement changes in the way information is provided (Tensions for change). However, the interviewees also reported that women do not know what the HPV test is and that it is essential to explain and reinforce the information repeatedly. In this sense, they describe failures in communication, which can be recognised as the interviewees’ own, or that of other professionals who focus only on giving follow-up instructions, as can be seen below:
‘It seems to me that the fault lies in reading the booklet and saying ‘well, you have HPV, the Pap was positive, you will have to have a cone’ (...) it seems to me that the best thing you can do is to make her understand you and where we fail, we fail.’ (E5)
Linked to these problems, they also describe an environment that makes communication difficult, due to work overload or lack of time and privacy for consultation. The following testimony is exemplary:
‘In the office we can have an overload of patients. In other words, we can’t stop much in terms of information (...) we do everything quickly (...) it is a very small office, the door has no lock, we have to lock it with a stool. Inside the office there is also a bathroom shared with colleagues. So when I’m in the office, a colleague might knock on the door to let me in...’ (E4).
They also consider that an app would be an important intervention but not necessarily a priority (relative priority). However, they agree that CC is a serious problem that should not exist, and that part of the problem is related to patients’ lack of information and emotions such as embarrassment and fear of screening. In this sense, they consider that an intervention such as this could contribute to disseminating information and improving adherence.
Finally, the interviewees argue that the way the app is implemented would be substantial for the intervention to be successful. In this sense, they believe that all people working in the health center should be involved. They also highlight the importance of the role and commitment of the ward manager, along with the implementation of clear, even mandatory, guidelines (Commitment of the authorities). In general, they consider these commitments and guidelines to be a prerequisite for successful implementation.
Discussion
It has been documented that, during the CC prevention process, there are problems in communication between professionals and patients that could affect the continuity of the care process [8, 7]. To the best of our knowledge, there is no research on the development of an app aimed at improving the process of information and communication with patients, with the exception of the study conducted by our team focused on women [28]. This is the first research focused on the perspective of health professionals and key actors to ensure the effectiveness of the implementation. We followed the guidelines of the CFIR, an appropriate conceptual framework for evaluating the implementation and sustainability of health interventions [30]. Evidence suggests that incorporating theoretical approaches into implementation research in the field of public health and clinical practice can improve the diffusion and use of digital technologies [34, 35].
The results show that the professionals evaluate the app positively, which is expressed in the CFIR constructs: adaptability, compatibility, complexity and relative advantage of the intervention in relation to the current context, belief in the validity and soundness of the intervention and its origin, and knowledge and beliefs about the intervention. In turn, they identify potential barriers corresponding to the constructs: adaptability, tensions for change, relative priority and authorities’ commitment to implementation.
The barriers perceived by professionals refer, in the first place, to issues of adaptability of the innovation, such as the weight of the app and ease of use. This coincides with other studies that find accessibility barriers to mHealth interventions aimed at patients (during the intervention or pre-implementation, from the professional point of view), such as clarity in its use, or access to a cell phone and Internet signal by users [36–38]. In our research, another barrier pointed out in relation to adaptability is the fact that the app could not answer all possible questions from women, but only a finite list of doubts. Based on these and other observations, recommendations for the potential development of the app are presented in Table 3. Several research studies focused on users, health workers and/or decision-makers allowed the development of recommendations for cell phone technologies, adapted to local needs, barriers and facilitators [36, 39, 40].
Beyond the aspects related to the app design, the barriers mentioned refer mainly to the internal context. Two main barriers were identified: on the one hand, the interviews do not consider implementation as a high priority, in relation to other issues and, on the other hand, they do not identify the current situation as intolerable or in need of change. However, these two perceptions are nuanced. Although professionals do not consider the app as a priority, they do consider it important, and see CC as a serious problem that needs to be addressed urgently. In this sense, they see the app as an instrument that could effectively contribute to the prevention of CC. At the same time, although they describe their task in communicating about HPV positively, they also find failures in communication, linked to their own role, and that of their colleagues, and to environmental barriers, such as lack of time, work overload or lack of privacy during the consultation. These communication problems, reported by several studies carried out in Latin America [11, 13], would be a sufficient reason to make modifications or incorporate elements that contribute to improving the current situation.
Table 3. Recommendations for the implementation of the app based on the results obtained, by domains and constructs of the CFIR.
In addition to the above-mentioned nuance regarding relative priority and tensions for change, it is also important to note that the app is perceived as advantageous in relation to the way in which information is currently provided. According to a systematic review of health innovations [31], recognition by stakeholders of the relative advantages of an intervention is a prerequisite for its adoption. Along the same lines, research conducted in Canada found that one of the main factors that facilitated the implementation of a mobile application for monitoring cardiac patients was that physicians perceived it as advantageous with respect to other telemonitoring systems [41].
The relative advantage is related to the professional perception that the app could complement, improve and reinforce the current situation in terms of doctor-patient communication and information received by women in general. In a study conducted in Kenya on the implementation of a mHealth strategy based on text messages to improve adherence of people living with HIV, it was also found that, according to professionals and users, the intervention could be a tool to improve the relationship between patients and health institutions. As in our research, several studies have found that mobile health applications can increase patient empowerment, generating greater connection with the medical team between consultations and increasing access to medical information [42, 43]. These findings are fundamental in middle- and low-income settings, given that mHealth interventions could improve the quality of services and health outcomes in a cost-effective manner, in the short or medium term, in settings with strong structural inequities in health, which are much more complex and costly to address [42, 43].
The last barrier mentioned refers to the commitment of the authorities as a prerequisite for successful implementation. Again, this is a result that allows recommendations and adaptations to be made to the way the app is implemented, but it is a recommendation that is particularly dependent on the local context. Research conducted in Argentina on the scale-up of a mHealth strategy to improve adherence to screening found that, although collaborative work had been done to plan scale-up activities, each change of health authority had slowed the actual incorporation of the strategy as a routine programmatic activity [44]. In our case, both the research focused on women and the present one was carried out with the support of municipal and provincial health authorities that would have stability in the short term. However, it is essential, when implementing the app, to work towards retaining the support of the different authorities in order to generate clear guidelines for implementation, as well as to generate evidence on possible strategies for effective implementation in contexts of high turnover of health authorities (Table 3).
In general terms, it can be said that the barriers identified are minor and manageable. On the one hand, they are mainly counteracted by the professional perception (priority, relative advantage). On the other hand, it is possible to formulate specific, uncomplicated recommendations and adaptations for the development of the implementation. Evidence shows that when stakeholders are included, from recent stages of intervention development and during the process itself, the intervention is seen as more feasible, effective and potentially successful [25, 36]. It should be recalled that the results presented here seek to complement those of a previous survey, focused on patients’ perceptions. There, women indicated that they would use the app to obtain information on HPV and reduce fears linked to a positive result, if it were recommended by a professional or a health authority, in addition to indicating app format preferences that also allowed establishing guidelines for the intervention [28].
With respect to the facilitators, the professionals find that, in addition to being advantageous, the app is seen as adaptable to local needs and not very complex to implement, domains related to the characteristics of the intervention. They also perceive it to be compatible with the local internal context, in that it could be implemented in the practice, without the need for modifications to current practice. This is consistent with research conducted in Germany, in which about 85% (n = 108) of clinicians surveyed felt that an app for oncology patients could complement traditional care and treatments [28]. More recent research evaluating successfully adopted mHealth implementations also found facilitators in adaptability, compatibility and other constructs related to intervention characteristics, as well as compatibility with current practice (internal context) [36, 41].
The people interviewed indicated that they would accept the app in order to recommend it to their patients and believe that it would be accepted by the other members of the health team (knowledge and beliefs about the intervention), as it is promoted and supported by recognised and legitimized institutions and experts (origin of the intervention). Among them, they mention the team developing the research on the implementation of the app (CEDES, Centro de Estudios de Estado y Sociedad) highlighting their prestige and experience, together with those of the public institutions that financed the research, such as the National Cancer Institute of Argentina. This is an important finding given that the legitimacy of the origin of an intervention is also strongly related to the success of its implementation [45]. The research focused on professional perspectives on health app implementations (in general medicine and oncology) and found that trust in the source that promotes or endorses the app is the main facilitator or requirement for professionals to implement the app [46, 47]. The professionals interviewed also consider that there is valid and solid evidence to support the effectiveness of implementing the app. They mention as an important precedent an app used during the COVID-19 pandemic, recommended by the National Ministry of Health of Argentina. The mention of an effective and valid antecedent according to the professional perspective is also a key data, since it could work as an important facilitator.
Limitations
One limitation of this study is that it evaluates the professional perspective in a specific context, which limits the generalisability of the results. In addition, this is an evaluation conducted prior to the development of the app under study. In this sense, further studies should be conducted during the development and implementation of the app. Future research will also be needed to adjust the intervention to other health systems, contexts and local needs.
Conclusion
The results of our research indicate that health professionals who offer the HPV test and communicate their results to women see the implementation of an app aimed at improving the process of information and communication with patients as positive, advantageous, viable and legitimate. With great acceptance, they indicate that they and their colleagues would implement it, although they condition the success of the intervention to certain aspects. The results allow the identification of barriers and facilitators and the elaboration of specific recommendations so that the app can be implemented, sustained over time and be effective as a tool for articulation between women and professionals.
The results obtained allow a better understanding of the factors that favour the implementation of mHealth interventions that seek to complement medical consultation. They have important implications, in particular, for low- and middle-income countries, given that the implementation could be adapted to other contexts, in order to improve communication between users and health institutions and the information of women in the CC prevention process.
List of abbreviations
CC, Cervical cancer; CEDES, Center for the Study of State and Society; CFIR, Consolidated Framework for Implementation Research; HPV, Human papillomavirus;mHealth, mobile health.
Acknowledgments
To the National Cancer Institute for the grant awarded to Paula Fredjkes for the development of the research. To the Secretary of Health of the municipality of Ituzaingó, especially Silvia Masachessi, for her support and collaboration. To the people who generously gave their time for the interviews.
Conflicts of interest
The authors declare that there are no conflicts of interest.
Funding
This project was supported by the National Cancer Institute through a Cancer Research grant awarded to Paula Fredjkes. The opinions expressed are those of the authors and not necessarily those of this institution.
References
1. Sung H, Ferlay J, and Siegel RL, et al (2021) Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries CA Cancer J Clin 71(3) 209–249 https://doi.org/10.3322/caac.21660 PMID: 33538338
2. Murillo R, Almonte M, and Pereira A, et al (2008) Cervical cancer screening programs in Latin America and the Caribbean Vaccine 26(Suppl 11) L37–L48 https://doi.org/10.1016/j.vaccine.2008.06.013 PMID: 18945401
3. Arrossi S, Paolino M, and Sankaranarayanan R (2010) Challenges faced by cervical cancer prevention programs in developing countries: a situational analysis of program organization in Argentina Rev Panam Salud Publica 28(4) 249–257 https://doi.org/10.1590/S1020-49892010001000003 PMID: 21152712
4. Sharma J, Yennapu M, and Priyanka Y (2023) Screening guidelines and programs for cervical cancer control in countries of different economic groups: a narrative review Cureus 15(6) e41098 PMID: 37519623 PMCID: 10381098
5. Arrossi S, Thouyaret L, and Laudi R, et al (2015) Implementation of HPV-testing for cervical cancer screening in programmatic contexts: the Jujuy demonstration project in Argentina Int J Cancer 137(7) 1709–1718 https://doi.org/10.1002/ijc.29530 PMID: 25807897
6. Luxardo N and Manzelli H (2017) Blurred logics behind frontline staff decision-making for cancer control in Argentina Health Sociol Rev 26(3) 224–238 https://doi.org/10.1080/14461242.2017.1298973
7. Sánchez Antelo V, Kohler RE, and Szwarc L, et al (2020) Knowledge and perceptions regarding triage among human papillomavirus-tested women: a qualitative study of perspectives of low-income women in Argentina Womens Health 1600 174550652097601 https://doi.org/10.1016/j.lana.2022.100291]
8. Szwarc L, Sánchez Antelo V, and Paolino M, et al (2021) “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 Sex Reprod Health Matters 29(1) 453–463 https://doi.org/10.1080/26410397.2021.1991101
9. Yabroff KR, Gansler T, and Wender RC, et al (2019) Minimizing the burden of cancer in the United States: goals for a high-performing health care system CA A Cancer J Clinicians 69(3) 166–183 https://doi.org/10.3322/caac.21556
10. PAHO (2016) Integrating HPV Testing in Cervical Cancer Screening Program: a Manual for Program Managers (PAHO: Washington) https://hdl.handle.net/20.500.14041/1161] Date accessed: 6/2/2024
11. Szwarc L, Antelo VS, and Paolino M, et al (2021) “I felt sick”: women’s perceptions and understanding of a positive human papillomavirus test result in Jujuy, Argentina Salud Colect 17 e3572 https://doi.org/10.18294/sc.2021.3572
12. Bennett KF, Waller J, and Ryan M, et al (2019) The psychosexual impact of testing positive for high-risk cervical human papillomavirus (HPV): a systematic review Psycho-Oncology 28(10) 1959–1970 https://doi.org/10.1002/pon.5198 PMID: 31411787 PMCID: 6851776
13. León-Maldonado L, Allen-Leigh B, and Lazcano-Ponce E (2014) Counseling on HPV detection as a cervical cancer screening test: a qualitative study on needs of women in Michoacán, Mexico Salud Publica Mex 56(5) 519 https://doi.org/10.21149/spm.v56i5.7377
14. León-Maldonado L, Wentzell E, and Brown B, et al (2016) Perceptions and experiences of human papillomavirus (HPV) infection and testing among Low-Income Mexican Women PLoS One 11(5) e0153367 https://doi.org/10.1371/journal.pone.0153367 PMID: 27149525 PMCID: 4858263
15. EngenderHealth (2003) Comprehensive Counseling for Reproductive Health: An Integrated Curriculum (Washingt: EngenderHealth) https://www.comminit.com/content/comprehensive-counseling-reproductive-health-integrated-curriculum] Date accessed: 6/2/2024
16. Evans C, Nalubega S, and McLuskey J, et al (2016) The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence JBI Database System Rev Implement Rep 13(12) 130–286 https://doi.org/10.11124/jbisrir-2015-2345 PMID: 26767819
17. Public Health England (2022) PHE Document on Screening for Trans and Non Binary People https://www.gatesheadhealth.nhs.uk/resources/phe-document-on-screening-for-trans-and-non-binary-people/] Date accessed: 6/2/2024
18. National Ministry of Health. Banco de Recursos de Comunicación del Ministerio de Salud de la Nación (2020) Atención de la salud integral de personas trans, travestis y no barias. Guide for health teams https://bancos.salud.gob.ar/recurso/atencion-de-la-salud-integral-de-personas-trans-travestis-y-no-binarias] Date accessed: 6/2//2024
19. Connolly D, Hughes X, and Berner A (2020) Barriers and facilitators to cervical cancer screening among transgender men and non-binary people with a cervix: a systematic narrative review Prev Med 135 106071 https://doi.org/10.1016/j.ypmed.2020.106071 PMID: 32243938
20. Visser A, Prins JB, and Jansen L, et al (2018) Group medical consultations (GMCs) and tablet-based online support group sessions in the follow-up of breast cancer: a multicenter randomized controlled trial Breast 40 181–188 https://doi.org/10.1016/j.breast.2018.05.012 PMID: 29906741
21. Hantsoo L, Criniti S, and Khan A, et al (2018) A mobile application for monitoring and management of depressed mood in a vulnerable pregnant population Psychiatr Serv 69(1) 104–107 https://doi.org/10.1176/appi.ps.201600582 PMCID: 5750085
22. Graetz I, Anderson JN, and McKillop CN, et al (2018) Use of a web-based app to improve postoperative outcomes for patients receiving gynecologic oncology care: a randomized controlled feasibility trial Gynecol Oncol 150(2) 311–317 https://doi.org/10.1016/j.ygyno.2018.06.007 PMID: 29903391
23. Kannisto KA, Koivunen MH, and Välimäki MA (2014) Use of mobile phone text message reminders in health care services: a narrative literature review J Med Internet Res 16(10) e222 https://doi.org/10.2196/jmir.3442 PMID: 25326646 PMCID: 4211035
24. Jongerius C, Russo S, and Mazzocco K, et al (2019) Research-tested mobile apps for breast cancer care: systematic review JMIR Mhealth Uhealth 7(2) e10930 https://doi.org/10.2196/10930 PMID: 30741644 PMCID: 6388100
25. Ardito V, Golubev G, and Ciani O, et al (2023) Evaluating barriers and facilitators to the uptake of mHealth apps in cancer care using the consolidated framework for implementation research: scoping literature review JMIR Cancer 9 e42092 https://doi.org/10.2196/42092 PMID: 36995750 PMCID: 10131717
26. Arrossi S, Paolino M, and Orellana L, et al (2019) Mixed-methods approach to evaluate an mHealth intervention to increase adherence to triage of human papillomavirus-positive women who have performed self-collection (the ATICA study): study protocol for a hybrid type i cluster randomized effectiveness-imp Trials 20(1) 148 https://doi.org/10.1186/s13063-019-3229-3 PMID: 30808379 PMCID: 6390557
27. Sanchez Antelo V, Szwarc L, and Pera AL, et al (2020) 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 JCO Glob Oncol 8(8) e2200168 https://doi.org/10.1200/GO.22.001
28. Sánchez Antelo V, Szwarc L, and Paolino M, et al (2022) 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 JMIR Form Res 6(1) e32610 https://doi.org/10.2196/32610 PMID: 35023843 PMCID: 8796044
29. Odendaal WA, Watkins JA, and Leon N, et al (2020) Health workers’ perceptions and experiences of using mHealth technologies to deliver primary healthcare services: a qualitative evidence synthesis Cochrane Database Syst Rev 3 CD011942 [https://doi. org/10.1002/14651858.CD011942.pub2] PMID: 32216074 PMCID: 7098082
30. Damschroder LJ, Aron DC, and Keith RE, et al (2009) Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science Implementation Sci 4(1) 50 https://doi.org/10.1186/1748-5908-4-50
31. Greenhalgh T, Robert G, and Macfarlane F, et al (2004) Diffusion of innovations in service organizations: systematic review and recommendations Milbank Q 82(4) 581–629 https://doi.org/10.1111/j.0887-378X.2004.00325.x PMID: 15595944 PMCID: 2690184
32. Hernán-García M, Lineros-González C, and Ruiz-Azarola A (2021) How to adapt qualitative research to confinement contexts Gaceta Sanitaria 35(3) 298–301 https://doi.org/10.1016/j.gaceta.2020.06.007
33. Strauss A and Corbin J (2002) Bases of Qualitative Research: Techniques and Procedures for Developing Grounded Theory (Antioquia: Universidad de Antioquia)
34. Pingree S, Hawkins R, and Baker T, et al (2010) The value of theory for enhancing and understanding e-health interventions Am J Prev Med 38(1) 103–109 https://doi.org/10.1016/j.amepre.2009.09.035 PMID: 20117565 PMCID: 2826889
35. Jennings HM, Morrison J, and Akter K, et al (2019) Developing a theory-driven contextually relevant mHealth intervention Glob Health Action 12 1550736 https://doi.org/10.1080/16549716.2018.1550736 PMID: 31154988 PMCID: 6338268
36. Cohn WF, Canan CE, and Knight S, et al (2021) An implementation strategy to expand mobile health use in HIV care settings: rapid evaluation study using the consolidated framework for implementation research JMIR mHealth and uHealth 9(4) e19163 https://doi.org/10.2196/19163 PMID: 33908893 PMCID: 8116995
37. Iribarren SJ, Milligan H, and Chirico C, et al (2022) Patient-centered mobile tuberculosis treatment support tools (TB-TSTs) to improve treatment adherence: a pilot randomized controlled trial exploring feasibility, acceptability and refinement needs Lancet Reg Health Am 13 100291 [https://doi.org/10.1016/j.lana.2022.100291] PMID: 36061038 PMCID: 9426680
38. Ames HM, Glenton C, and Lewin S, et al (2019) Clients’ perceptions and experiences of targeted digital communication accessible via mobile devices for reproductive, maternal, newborn, child, and adolescent health: a qualitative evidence synthesis Cochrane Database Syst Rev 10(10) CD013447 [https://doi.org/10.1002/14651858.CD013447] PMID: 31608981 PMCID: 6791116
39. Iribarren SJ, Wallingford J, and Schnall R, et al (2020) Converting and expanding mobile support tools for tuberculosis treatment support: design recommendations from domain and design experts J Biomed Inform 112 100066 https://doi.org/10.1016/j.yjbinx.2019.100066
40. Aggarwal R, Visram S, and Martin G, et al (2022) Defining the enablers and barriers to the implementation of large-scale, health care-related mobile technology: qualitative case study in a Tertiary Hospital setting JMIR Mhealth Uhealth 10(2) e31497 [https://doi.org/10.2196/31497] PMID: 35133287 PMCID: 8864527
41. Ware P, Ross HJ, and Cafazzo JA, et al (2018) Evaluating the implementation of a mobile phone-based telemonitoring program: longitudinal study guided by the consolidated framework for implementation research JMIR Mhealth Uhealth 6(7) e10768 https://doi.org/10.2196/10768 PMID: 30064970 PMCID: 6092591
42. Smillie K, Borek NV, and van der Kop ML, et al (2014) Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel Retain) Afr J AIDS Res 4(13) 331–338 https://doi.org/10.2989/16085906.2014.961939
43. Vo V, Auroy L, and Sarradon-Eck A (2019) Patients’ perceptions of mHealth apps: meta-ethnographic review of qualitative studies JMIR Mhealth Uhealth 7(7) e13817 https://doi.org/10.2196/13817 PMID: 31293246 PMCID: 6652126
44. Straw C, Sanchez-Antelo V, and Kohler R, et al (2023) 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 BMC Health Serv Res 23(1) 47 https://doi.org/10.1186/s12913-023-09022-5 PMID: 36653775 PMCID: 9847147
45. Kitson A, Harvey G, and McCormack B (1998) Enabling the implementation of evidence based practice: a conceptual framework BMJ Qual Saf 7(3) 149–158 https://doi.org/10.1136/qshc.7.3.149
46. Berkowitz CM, Zullig LL, and Koontz BF, et al (2017) Prescribing an app? Oncology providers’ views on mobile health apps for cancer care JCO Clin Cancer Inform 1 1–7 https://doi.org/10.1200/CCI.17.00107 PMID: 30657404
47. Byambasuren O, Beller E, and Hoffmann T, et al (2020) Barriers to and facilitators of the prescription of mHealth apps in Australian general practice: qualitative study JMIR Mhealth Uhealth 8(7) e17447 https://doi.org/10.2196/17447 PMID: 32729839 PMCID: 7426799
