Ten health decision-makers and 10 HCPs were interviewed. The average amount of time that health decision-makers had occupied their roles was 11 years (range 2–30 years). Six of the decision-makers were women and four were men. HCPs had been practicing on average for 11.4 years (range 5–25 years). Eight HCPs were women and two were men.
Knowledge of the strategy
The level of knowledge regarding ATICA strategy was high among the majority of the health decision-makers and HCPs. The interviewees were able to describe both intervention components and the implementation process.
“The experience [with ATICA] was designed strategically and taking into account a number of factors: previous planning meetings, trainings, the type of message and how many times to send it” [Decision-maker 1].
“The majority of women came after the first message and if they didn’t they were sent another” [HCP 6].
Characteristics of the intervention
Intervention source
The health decision-makers and HCPs positively assessed the fact that the ATICA study began as an initiative headed by CEDES (Centre for the Study of State and Society) in collaboration with Harvard University, institutions considered to have academic prestige and experience in mHealth research. Health decision-makers and HCPs highlighted that ATICA was designed and implemented collaboratively through articulation and consensus with provincial and national institutions (Argentinean National Cancer Institute, provincial Cancer Institute and PHC Direction). They also assessed positively their early engagement in ATICA implementation.
“[In workshops to implement ATICA], we listened and contributed ideas. We were there from the start” [Decision-maker 1].
“We never felt competition or like the idea was imposed. The provincial guidelines and ways of doing things were respected” [HCP 8].
Another positive aspect perceived by the majority of those interviewed was that ATICA began as a research study. In their opinion, this was a guarantee that scientific methods were applied to evaluate whether incorporation of mobile technology in PHC would work in the local context.
“The fact that ATICA begun as a research project was an advantage, because you can demonstrate that it works, there is an evaluation of results” [Decision-maker 5].
Design quality and Access to knowledge and information
Health decision-makers and HCPs mostly stated that ATICA strategy components worked in an articulated and complementary way, and that the training and information received were adequate. They also considered that the printed materials contained clear, concise information with graphics and drawings that favored an intuitive understanding and recall of the messages.
“The two options are complementary. If the patient doesn’t go to the health center after receiving the messages, it’s necessary for the community health worker to go see her” [HCP 6].
Adaptability
The majority of the interviewees agreed that adaptations to ATICA components were not necessary. It was unanimous that the content of the SMS was appropriate as it was clear, precise and in agreement with the legal norms regarding the communication of health information. They also considered adequate the frequency of the SMS.
“I wouldn’t change the content because the messages are respectful, subtle, and say “we need you to come” especially when the HPV result is positive” [HCP 10].
Regarding the e-mail/SMS sent to the CHWs to inform them of women without Pap triage after 60 days, the respondents agreed that sending WhatsApp messages would improve the communication and make it more dynamic. They also considered that this information should be sent to authorities with decision-making power (for example, the coordinator of the provincial CC prevention program, the PHC director and supervisors), so responsibility for assuring that women are triaged is shared with HCPs and CC prevention program authorities.
“Other members of the health team should also receive [the SMS], like the intermediate supervisors or the head of the CC prevention program, so CHWs do not bear all the responsibility [HCP 5].
Complexity and compatibility
The respondents predominantly evaluated ATICA as a low-complexity strategy and, at the same time, considered it compatible with the existing organization and way of functioning within health centers. In both cases, they agreed that the strategy was integrated into other processes that health services routinely perform (seek out, receive, and care for patients; inform medical results; input information regarding screening, triage, diagnosis and treatment in the national screening information system (SITAM); among others).
“ATICA doesn’t change or interfere with any process of the cervical cancer program” [Decision-maker 1].
“The strategy is compatible because it facilitates the community health care worker’s everyday work, and the professional continues the flowchart examining the positive self-collected tests” [HCP 1].
The interviewees also considered that the intervention was compatible with the forms of communication between health care services and women. In their opinion, this was evidenced by women’s high acceptance of the SMS as a channel of communication.
“Perfect as a form of communication. It absolutely favored the communication between the health center and the patient” [HCP 6].
There were other decision-makers and HCPs who perceived the strategy as complex due to the need to logistically coordinate the actions of different actors (CHWs, staff from the HPV test/cytology/histology laboratory, staff registering self-collection results in SITAM). They also perceived that the SMS system was complex, since to send SMS to HPV-positive and CHWs to visit women who had not had triage at 60 days it should be programmed to consider the screening/triage algorithm as well as the established timing between the steps.
Relative advantage
The interviewees mentioned several advantages –and no disadvantages– to the intervention in relation to the existing practices for communicating results to women with self-collected tests:
-Simplifying the process of delivering results increased adherence to timely triage.
“This lets the user know directly [about results availability] without being mediated by a doctor or a community health care worker who visits her. It makes the HPV-positive person attend more quickly” [HCP 1].
-Improving the health system’s communication with women, by sending information via a personalized, direct, opportune, and timely SMS.
“It is a marvelous intervention for facilitating communication. One hundred percent useful because the information mechanisms were greatly improved” [Decision-maker 4].
-Reducing the workload of CHWs in seeking out HPV + women without triage, especially those who require several visits to be reached. For the respondents, this meant a more efficient use of the human resources in the health system.
“Before this, the community health worker had to go four times to remind a woman to get a Papanicolaou. Now it’s four messages. Taking better advantage of human resources is extremely important” [HCP 8].
-Incorporating mobile phones in the provision of PHC services increased the willingness of staff at this level of care to adopt mobile technology in their work processes, with a benefit to the population.
“Now technology is an extension of the community health worker’s work and is somewhat more of a friend to primary health care” [Decision-maker 5].
Consideration of women’s needs
ATICA was mainly viewed as a strategy responding to women needs, by facilitating timely triage. Nevertheless, it was highlighted that the main barrier faced by some women to access triage was the lack of sample takers, and therefore the priority to meet women´s needs was to assure that in all health centers there was staff to take Paps. In this sense, they perceived that ATICA did not respond to a high-priority need.
“The priority for women is to not delay their appointment to get a Papanicolaou. ATICA was very well aimed at quick communication and information” [Decision-maker 8].
“Some women couldn’t get access [to a Pap test], and that is why it is necessary to guarantee greater coverage of professionals to take Pap tests” [HCP 5].
Relative priority
Both HCPs and decision-makers unanimously assigned a high priority to the incorporation of the ATICA strategy to ensure Pap triage and early diagnosis in women with positive self-collected tests. The strategy was seen as fundamental to complete the screening program goals in the target population.
“It is absolutely crucial in encouraging women to finish the path they started and get Pap triage” [Decision-maker 5].
Leadership engagement
Almost all interviewees considered that the provincial health authorities would commit to the programmatic incorporation of the strategy in the long term. In first place, the authorities have for years shown their commitment to CC prevention. Besides, the fact that authorities had formed part of the design and implementation of ATICA, in addition to the demonstrated effectiveness of the strategy, increased the possibility of commitment to the implementation.
“Yes, they will commit, we’ve been fighting for years against cervical cancer” [Decision-maker 5]
However, some decision-makers doubted the commitment of the provincial health authorities as they considered that, in public policy management, resolution of urgent matters prevail in detriment to other important issues like the low adherence to the CC care process. Additionally, their doubts had to do with the high rotation of health authorities. Thus, they considered that new authorities might not continue the lines of work developed by previous administrations.
External policies
In regard to the need for specific policies and regulations to extend ATICA at a provincial level, the opinions of health decision-makers were divided. On one hand, some considered it necessary, given that all programs have norms for functioning, target populations and procedures. Thus, to implement ATICA, guidelines regarding digital communication of the health system with the population would be necessary. This would facilitate ATICA’s uniform implementation in all health institutions.
In contrast, other decision-makers considered that the ATICA strategy could be carried out without additional regulations. They highlighted that the intervention was connected to an existing care protocol of CC screening, triage, diagnosis, and treatment.
“I don’t think [there is a need for] specific normative frameworks. [ATICA] has to do with a referral algorithm of positive self-collected tests that is already functioning” [Decision-maker 5].
Costs of ATICA implementation
The decision-makers identified three main items they believed necessary to fund for ATICA to function. The first is related to the operation and maintenance of the software for sending the SMS (MATYS).
“The program sending the text messages must have a cost, and logically sending the messages does too” [Decision-maker 2].
Second, they identified the provision of cell phones as a cost of ATICA strategy. Thus, for some decision-makers providing CHWs with cell phones would guarantee that they could do their job without having to take on costs. However, for other decision-makers, a cell phone should be provided to every health care facility. In this case, they considered that the institutional cell phone could be used for different health programs, and the funding would not fall exclusively to ATICA’s budget.
“Each CHW should be given a cell-phone and be provided with a mobile data package; some people might have problems using their own cell phone because that use has a cost” [Decision-maker 4].
“We need a cell phone per facility, not per community health worker. An institutional telephone at the health center for them to communicate with the health worker and the women” [Decision-maker 9].
A third cost had to do with the provision of free internet and WI-FI service to all health centers. For them, this was important to accessing data regarding screening, triage, diagnosis, and treatment through SITAM. However, on this issue, differences were found among decision-makers as some respondents considered that internet service was already widely available in health centers.
Maintenance
The interviewees perceived the programmatic incorporation of ATICA into the provincial CC prevention program as viable; they considered that the provincial health system had the organizational and technological conditions necessary to implement it, and that the usefulness of the ATICA strategy had been demonstrated. They also mentioned that the wide availability of cellular phones in the population would contribute to the programmatic scaling-up of the strategy.
“The implementation is very viable because we have a key actor that is the community health worker” [HCP 5].
“It should be incorporated because we saw that it is useful for the prevention of cervical cancer” [Decision-maker 2].
Several decision-makers and HCPs conditioned the viability of the programmatic incorporation of the intervention to the provision of cell phones to the health facilities and to CHWs, as well as to the possibility of connecting to internet and mobile data at no cost.
“With mobile devices, internet connection and mobile data in the health facilities… Otherwise, it won’t be very viable” [Decision-maker 3].
Regarding the strategy scaling-up, the interviewees agreed that it should be led by the provincial Ministry of Health (MoH), with ample involvement of PHC authorities and CHWs, the provincial CC prevention program, and the provincial Cancer Institute.
With regard to the elements necessary for guaranteeing ATICA’s programmatic functioning, the decision-makers agreed to assign importance to the political decision to prioritize CC prevention both by the provincial health authorities (MoH and hospital directors) and the Argentinean National Cancer Institute. They also highlighted the importance of the highest health authority, i.e., the provincial health minister, to establish ATICA as high priority line of work.
Additionally, the respondents agreed in highlighting the need to ensure human resources both for the HPV lab and for taking Pap tests at PHC centers, as well as the continued provision of HPV-tests and collectors.
“[To have ATICA strategy] as part of the cervical cancer prevention routine we need HPV kits always available, and the necessary reagents because otherwise the tests have to be suspended. And laboratory personnel so that the readings and results aren’t delayed” [HCP 4].
“We need to have gynecologists in all PHC centers, at least once a week” [Decision-maker 10].