[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.

Latin America and the Caribbean Code Against Cancer 1st Edition: Medical interventions including hormone replacement therapy and cancer screening.

Prostate, breast, colorectal, cervical, and lung cancers are the leading cause of cancer in Latin America and the Caribbean (LAC) accounting for nearly 50% of cancer cases and cancer deaths in the region. Following the IARC Code Against Cancer methodology, a group of Latin American experts evaluated the evidence on several medical interventions to reduce cancer incidence and mortality considering the cancer burden in the region. A recommendation to limit the use of HRT was issued based on the risk associated to develop breast, endometrial, and ovarian cancer and on growing concerns related to the over-the-counter and without prescription sales, which in turn bias estimations on current use in LAC. In alignment with WHO breast and cervical cancer initiatives, biennial screening by clinical breast examination (performed by trained health professionals) from the age of 40 years and biennial screening by mammography from the age of 50 years to 74, as well as cervical screening by HPV testing (either self-sampling or provider-sampling) every 5-10 years for women aged 30-64 years, were recommended. The steadily increasing rates of colorectal cancer in LAC also led to recommend colorectal screening by occult blood testing every two years or by endoscopic examination of the colorectum every 10 years for both men and women aged 50-74 years. After evaluating the evidence, the experts decided not to issue recommendations for prostate and lung cancer screening; while there was insufficient evidence on prostate cancer mortality reduction by prostate-specific antigen (PSA) testing, there was evidence of mortality reduction by low-dose computed tomography (LDCT) targeting high-risk individuals (mainly heavy and/or long-term smokers) but not individuals with average risk to whom recommendations of this Code are directed. Finally, the group of experts adapted the gathered evidence to develop a competency-based online microlearning program for building cancer prevention capacity of primary care health professionals.

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.

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.

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 felt myself getting sick:" women's perceptions and understandings of a positive human papillomavirus test in Jujuy, Argentina]. / "Me sentí enfermar": percepciones y comprensión de las mujeres del resultado positivo de un test de virus del papiloma humano en Jujuy, Argentina.

With the purpose of analyzing women's perceptions and classifying their modes of understanding a positive human papillomavirus (HPV+) test, we conducted 38 in-depth interviews with women who had received an HPV diagnosis (normal and abnormal Pap smear), screened in Jujuy's public health system in 2016. A typology based on women's understandings of the result was developed: 1) understanding; 2) lack of understanding; a) underestimation; b) overestimation; c) confusion. The interviewees who experienced confusion over the results reported contradictory perceptions in relation to a positive HPV test and its severity; those who underestimated it tended to mention the absence of symptoms and expressed little concern over the result; while those who overestimated it considered themselves sick and described concern, narrating a biographical disruption and physical pain. These findings confirm the need to improve the delivery of results and the provision of information in order to decrease psychosocial impact and increase follow-up adherence in HPV-positive women.

Con el objetivo de analizar las percepciones y clasificar las modalidades de comprensión sobre un resultado positivo del test de virus del papiloma humano (VPH+), en 2016 realizamos 38 entrevistas en profundidad a mujeres con diagnóstico de VPH+ (prueba de Papanicolaou normal y anormal), realizado en el sistema público de salud de Jujuy. Se elaboró una tipología que delimita perfiles de mujeres en función del tipo de comprensión del resultado: 1) comprensión; 2) no-comprensión, a) subestimación, b) sobreestimación, y c) confusión. Entre aquellas que no comprendían, las entrevistadas que confundían el resultado relataron percepciones contradictorias con relación al VPH y su gravedad; quienes lo subestimaban tendían a mencionar ausencia de síntomas y a expresar escasa preocupación; mientras que aquellas que lo sobreestimaban se consideraban enfermas y expresaban preocupación, relato de una ruptura biográfica y dolores físicos. Los hallazgos confirman la necesidad de mejorar los mecanismos de entrega e información sobre los resultados para disminuir el impacto psicosocial en las mujeres y aumentar la adherencia al seguimiento sugerido.

"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.

Changing the paradigm of cervical cancer prevention through introduction of HPV-testing: evaluation of the implementation process of the Jujuy Demonstration Project in Argentina.

INTRODUCTION: The Jujuy Demonstration Project (JDP) was a project carried out over the course of 4 years (2011-2014) to develop, implement and evaluate the programmatic components of a Human Papilloma Virus (HPV)-based screening programme in Argentina. The aim of this paper is to present a qualitative evaluation of the context and implementation process of the JDP. METHODS: We used an adaptation of the Health System Framework (HSF), which includes interconnected contextual factors that are considered key drivers for successful health interventions. We reviewed secondary documents, which included scientific reports, norms and regulations, information sheets, power point presentations and manuals and recommendations published by the National Programme for Cervical Cancer Prevention. We also carried out semi-structured interviews with key informants to explore their views about technology acceptability. RESULTS: Key components of the JDP implementation process were: a high level of political support and consensus among stakeholders, the demonstrated effectiveness of the technology and its acceptability by health authorities and providers, the funding of tests and diagnosis/treatment services, the implementation of an information system for monitoring and evaluation and the reorganisation of the network of screening, diagnosis and treatment services. CONCLUSION: This analysis examines the policy context in which the JDP was implemented and the system components that were key for the demonstrated effectiveness of the strategy. Such analyses provide useful insights into core components of HPV testing implementation that are needed to guarantee its potential effectiveness to reduce cervical cancer incidence and mortality.

Cáncer cervicouterino en Jujuy: Descripción de casos y evaluación de cumplimiento de tratamiento oncológico / Cervical Cancer in Jujuy province: description of cases and evaluation of compliance with oncological treatment

INTRODUCCIÓN: El cáncer cervicouterino (CC) es la cuarta causa de muerte por cáncer en mujeres. Las demoras en el tratamiento se asocian a un peor control de la enfermedad. Los objetivos de este estudio fueron describir las características de mujeres con diagnóstico de CC en la red pública de Jujuy y evaluar el grado de cumplimiento del tratamiento oncológico. MÉTODOS: Se realizó un estudio observacional de cohorte retrospectiva de mujeres con diagnóstico de CC en 2015 y 2016 en el Hospital Pablo Soria (centro de derivación provincial). Se registraron las fechas de las principales modalidades terapéuticas: cirugía, quimioterapia, radioterapia y braquiterapia. Se definió la duración recomendada de tratamiento según la literatura, considerando las diferentes combinaciones de terapéuticas (60, 90 o 120 días). RESULTADOS: Se incluyó a 78 mujeres con diagnóstico de CC. Entre quienes presentaban indicación de tratamiento oncológico, el 64% (n=48) no cumplió con el tratamiento indicado, por no haberlo iniciado (n=17) o por concluirlo en un intervalo mayor al recomendado (n=31). Entre las mujeres que iniciaron tratamiento, 48% (n=28) lo finalizó a tiempo. Tener más de 5 hijos se asoció a incumplimiento de tratamiento con quimio-radioterapia. La modalidad de inicio más tardío fue la braquiterapia, que debía realizarse en otra provincia por falta de disponibilidad local. DISCUSIÓN: El cumplimiento subóptimo del tratamiento de CC continúa siendo un problema de salud pública

Cervical Cáncer in Jujuy province: description of cases and evaluation of compliance with oncological treatment / Cáncer cervicouterino en jujuy: descripción de casos y evaluación de cumplimiento de tratamiento oncológico

RESUMEN INTRODUCCIÓN : El cáncer cervicouterino (CC) es la cuarta causa de muerte por cáncer en mujeres. Las demoras en el tratamiento se asocian a un peor control de la enfermedad. Los objetivos de este estudio fueron describir las características de mujeres con diagnóstico de CC en la red pública de Jujuy y evaluar el grado de cumplimiento del tratamiento oncológico. MÉTODOS : Se realizó un estudio observacional de cohorte retrospectiva de mujeres con diagnóstico de CC en 2015 y 2016 en el Hospital Pablo Soria (centro de derivación provincial). Se registraron las fechas de las principales modalidades terapéuticas: cirugía, quimioterapia, radioterapia y braquiterapia. Se definió la duración recomendada de tratamiento según la literatura, considerando las diferentes combinaciones de terapéuticas (60, 90 o 120 días). RESULTADOS : Se incluyó a 78 mujeres con diagnóstico de CC. Entre quienes presentaban indicación de tratamiento oncológico, el 64% (n=48) no cumplió con el tratamiento indicado, por no haberlo iniciado (n=17) o por concluirlo en un intervalo mayor al recomendado (n=31). Entre las mujeres que iniciaron tratamiento, 48% (n=28) lo finalizó a tiempo. Tener más de 5 hijos se asoció a incumplimiento de tratamiento con quimio-radioterapia. La modalidad de inicio más tardío fue la braquiterapia, que debía realizarse en otra provincia por falta de disponibilidad local. DISCUSIÓN : El cumplimiento subóptimo del tratamiento de CC continúa siendo un problema de salud pública.

ABSTRACT INTRODUCTION : Cervical cáncer (CC) is the fourth cause of cancer-related death among women worldwide. Delays in treatment are associated with worse disease control. The objectives of this study were to describe the characteristics of women with newly-diagnosed CC in the Argentine province of Jujuy, and to evaluate the degree of treatment compliance. METHODS : An observational retrospective cohort study was conducted on women with CC diagnosed at Hospital Pablo Soria (state-wide referral center in Jujuy) in 2015-2016. Dates of the main treatment modalities were registered (surgery, chemotherapy, radiotherapy and brachytherapy). Recommended treatment duration was extracted from the literature, considering the different treatment combinations (60, 90 or 120 days). RESULTS : A total of 78 women with CC were included. Of all women who were prescribed oncological treatment, 64% (n=48) showed inappropriate compliance, either due to not having started treatment (n=17) or due to delays in completion of treatment (n=31). Among women who initiated treatment, 48% (n=28) completed it on time. For women receiving chemotherapy and radiotherapy, having more than 5 children was associated with treatment delays. Brachytherapy showed longer delays than other treatment modalities, due to lack of local availability and the need to travel to a different province for treatment. DISCUSSION : Suboptimal compliance with CC treatment remains a public health issue.

Evaluación de la segunda ronda de tamizaje con test de VPH en la provincia de Jujuy / Evaluation of the second round of screening with HPV test in the province of Jujuy

INTRODUCCIÓN En Argentina, el tamizaje con test de VPH fue introducido en 2012-2014 en el marco del Proyecto Demostración Jujuy (PDJ) para las mujeres de 30 años y más. Las mujeres VPH- deben realizar una segunda ronda de tamizaje (o re-tamizaje) a los 5 años. Sin embargo, no se cuenta con evidencia acerca de la implementación del test de VPH en el largo plazo. OBJETIVOS 1. Evaluar la implementación de la estrategia de tamizaje con test de VPH de segunda ronda de tamizaje. 2. Caracterizar el perfil de las mujeres no adherentes al tamizaje, diagnóstico y tratamiento en segunda ronda de tamizaje. METODOLOGÍA Estudio de cohorte retrospectiva. Se realizó el análisis de datos secundarios provenientes del Sistema de Información para el tamizaje de la provincia d Jujuy. Se utilizó el marco conceptual RE-AIM (alcance, efectividad, adopción implementación y sustentabilidad). Se analizaron la características de las adherentes/no adherentes a la segunda ronda de tamizaje mediante el análisis de regresión logística. RESULTADOS El 47,9% de las mujeres registraron re-tamizaje a los 3 años y más (Alcance) y 13,3% lo realizaron a los 5 años (Implementación). El 69,2% de los centros de salud realizó re-tamizaje a los 5 años (adopción). 87,3% de las mujeres VPH+ en segunda ronda registró un Pap de triaje (94% toma dirigida/70% autotoma). 74% de mujeres ASCUS+ registró una colposcopia. 85% de las mujeres CIN2+ registraron tratamiento. La tasa de detección en segunda ronda fue de 5,1/1000 mujeres tamizadas (efectividad). El re-tamizaje de las tamizadas en 2015-2017 fue de 3,6% (Sustentabilidad). Las mujeres de hasta 35 años, con cobertura pública y que residen en San Salvador de Jujuy poseen mayor probabilidad de adherencia al re-tamizaje. DISCUSIÓN El re-tamizaje a 5 años de las mujeres VPH negativas fue bajo. La adherencia al triaje, diagnóstico y tratamiento en segunda ronda fue adecuado. Es necesario desarrollar estrategias para lograr mayores coberturas de re-tamizaje.

"Me sentí enfermar": percepciones y comprensión de las mujeres del resultado positivo de un test de virus del papiloma humano en Jujuy, Argentina / "I felt myself getting sick:" women's perceptions and understandings of a positive human papillomavirus test in Jujuy, Argentina

RESUMEN Con el objetivo de analizar las percepciones y clasificar las modalidades de comprensión sobre un resultado positivo del test de virus del papiloma humano (VPH+), en 2016 realizamos 38 entrevistas en profundidad a mujeres con diagnóstico de VPH+ (prueba de Papanicolaou normal y anormal), realizado en el sistema público de salud de Jujuy. Se elaboró una tipología que delimita perfiles de mujeres en función del tipo de comprensión del resultado: 1) comprensión; 2) no-comprensión, a) subestimación, b) sobreestimación, y c) confusión. Entre aquellas que no comprendían, las entrevistadas que confundían el resultado relataron percepciones contradictorias con relación al VPH y su gravedad; quienes lo subestimaban tendían a mencionar ausencia de síntomas y a expresar escasa preocupación; mientras que aquellas que lo sobreestimaban se consideraban enfermas y expresaban preocupación, relato de una ruptura biográfica y dolores físicos. Los hallazgos confirman la necesidad de mejorar los mecanismos de entrega e información sobre los resultados para disminuir el impacto psicosocial en las mujeres y aumentar la adherencia al seguimiento sugerido.

ABSTRACT With the purpose of analyzing women's perceptions and classifying their modes of understanding a positive human papillomavirus (HPV+) test, we conducted 38 in-depth interviews with women who had received an HPV diagnosis (normal and abnormal Pap smear), screened in Jujuy's public health system in 2016. A typology based on women's understandings of the result was developed: 1) understanding; 2) lack of understanding; a) underestimation; b) overestimation; c) confusion. The interviewees who experienced confusion over the results reported contradictory perceptions in relation to a positive HPV test and its severity; those who underestimated it tended to mention the absence of symptoms and expressed little concern over the result; while those who overestimated it considered themselves sick and described concern, narrating a biographical disruption and physical pain. These findings confirm the need to improve the delivery of results and the provision of information in order to decrease psychosocial impact and increase follow-up adherence in HPV-positive women.

Adherence to triage among women with HPV-positive self-collection: a study in a middle-low income population in Argentina.

INTRODUCTION: Screening for cervical cancer (CC) prevention has substantially changed with the introduction of human papillomavirus (HPV) tests. This technology compared to cytology has increased the detection of pre-malignant and malignant cervical lesions in real-world programmes in different settings. Very importantly, through self-collection, HPV testing can reduce barriers to screening and increase coverage. However, when using HPV self-collection, triage tests are a key step in the CC prevention process, and high adherence to triage has been difficult to obtain in low-middle income settings. The aim of this study was to measure adherence to triage among women with HPV+ self-collection and analysed factors associated with this adherence in a middle-low resource setting in Argentina. We also evaluated key indicators related to the implementation of the HPV self-collection strategy. METHODS: We analysed data on screening/triage/diagnosis/treatment from women aged 30+ who performed self-collection between 2015 and 2017 (n = 15,763), in the public health system in Tucuman, Argentina. We analysed secondary data from the national screening information system. The primary outcomes were: 1) adherence to cytology triage within the recommended timeframe (120 days) and 2) overall adherence to cytology triage including data at 18 months after screening. Multivariable regression was used to examine the association between age group, year of the screening test, record of the previous Pap-based screening and health insurance status with adherence to triage test as a primary outcome. We reported odds ratios, 95% confidence intervals and p-value of 0.05, which was considered the threshold for p-values). RESULTS: We analysed data of 2,389 HPV+ women. The overall adherence to triage at 18 months was 42.9%. The percentage of women completing cytology triage within the recommended timeframe of 120 days was lower (25.2%). Women with the record of a previous Pap-based screening had 1.86 times the odds of having a triage compared to women without a record of a previous Pap-based screening (95% CI: 1.64-2.64, p <0.001). Furthermore, the probability of having triage at the recommended timeframe was higher among women who were older and women with public health insurance. CONCLUSIONS: Our results showed that adherence to triage in the recommended timeframe was low. In addition, the probability of having triage at the recommended timeframe was higher among women with a record of a previous Pap-based screening, a proxy of the use of health services. Our results showed that adherence to triage in the context of the HPV-self-collection strategy is challenging. The implementation of alternative approaches that might facilitate adherence to triage should be further investigated.

Psycho-social impact of positive human papillomavirus testing in Jujuy, Argentina results from the Psycho-Estampa study.

Human papillomavirus (HPV) testing can have a negative impact on women's lives which might also result in abandoning the follow-up and treatment process. This study measured the psycho-social impact of HPV-positivity among HPV-tested women from Jujuy, Argentina, a middle-low income setting. In this cross-sectional study (2015-2016), the psycho-social impact of HPV-positivity was measured using the Psycho-Estampa Scale, specifically designed and validated to be used in screening contexts. We measured mean scores for each of the five scale domains, and the Overall Impact score (Values from 1: No impact to 4: Heavy impact). We compared scores according to cytology triage diagnosis using ordinal logistic regression. A total of 163 HPV-positive women were recruited at the Centro Carlos Alvarado hospital and included in the study sample; of these, 124 (76.1%) had normal triage cytologies. The overall Impact score was between low and moderate (mean:2.56, SD:0.65). The highest psycho-social impact was measured in the Worries about cancer and treatment domain (mean score:3.60, SD:0.60), followed by Sexuality domain (mean:2.50; SD:1.00). The Uncertainty about information provided by health providers domain had the lowest mean score (mean:2.14, SD:0.73). Compared to women with normal cytologies (n = 124), women with abnormal cytologies (n = 39) had a higher likelihood of greater overall Psycho-social Impact (OR: 2.91; p = 0.0036). No statistically significant differences were found in scores of specific domains according to cytology results. It is important to devise specific counseling interventions to reduce the psycho-social impact of HPV-Testing as primary screening and its potential effect on completion of the diagnosis/ treatment process.

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.

Adherencia al triaje en contexto de tamizaje con autotoma del test de virus del papiloma humano en la provincia de Jujuy / riage of Women with Human Papillomavirus Self-Collection in Jujuy Province

INTRODUCCIÓN: Es reconocida la efectividad del test del virus del papiloma humano (VPH) para prevenir el cáncer cervicouterino (CC), así como su potencial para reducir barreras de acceso al tamizaje a través de su modalidad autotoma (ATVPH). Uno de los principales desafíos consiste en garantizar el acceso a la citología de triaje de las mujeres con AT-VPH positivas (VPH+). El objetivo de este estudio fue analizar la magnitud y los determinantes sociales de la adherencia al triaje (realización de citología posterior a un resultado de test de VPH+) en mujeres de 30 años o más con AT-VPH+ dentro del sistema público de salud de la provincia de Jujuy. MÉTODOS: Se efectuó un estudio descriptivo transversal con análisis del Sistema de Información para el Tamizaje (SITAM) y encuestas domiciliarias a mujeres de 30 años o más con autotomas positivas en Jujuy durante 2015-2016, sin registro de triaje. RESULTADOS: El porcentaje estimado de adherencia al triaje fue de entre 96% y 81%. Estos porcentajes son menores a los 60 y 120 días de realizada la AT (18% y 35%, respectivamente). Las mujeres con cobertura de obra social/privada y sin condición de hacinamiento poseen mayor probabilidad de adherir al triaje. El principal motivo de no adherencia fueron los problemas con la entrega de resultados. CONCLUSIONES: Pese a los altos niveles de adherencia al triaje, es necesario incorporar intervenciones que mejoren la entrega de resultados y ayuden a enfrentar las barreras socioestructurales