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.

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.

Caesarean birth in public maternities in Argentina: a formative research study on the views of obstetricians, midwives and trainees.

OBJECTIVES: To explore obstetricians', midwives' and trainees' perceptions of caesarean section (CS) determinants in the context of public obstetric care services provision in Argentina. Our hypothesis is that known determinants of CS use may differ in settings with limited access to essential obstetric services. SETTING: We conducted a formative research study in 19 public maternity hospitals in Argentina. An institutional survey assessed the availability of essential obstetric services. Subsequently, we conducted online surveys and semistructured interviews to assess the opinions of providers on known CS determinants. RESULTS: Obstetric services showed an adequate provision of emergency obstetric care but limited services to support women during birth. Midwives, with some exceptions, are not involved during labour. We received 680 surveys from obstetricians, residents and midwives (response rate of 63%) and interviewed 26 key informants. Six out of 10 providers (411, 61%) indicated that the use of CS is associated with the complexities of our caseload. Limited pain management access was deemed a potential contributing factor for CS in adolescents and first-time mothers. Providers have conflicting views on the adequacy of training to deal with complex or prolonged labour. Obstetricians with more than 10 years of clinical experience indicated that fear of litigation was also associated with CS. Overall, there is consensus on the need to implement interventions to reduce unnecessary CS. CONCLUSIONS: Public maternity hospitals in Argentina have made significant improvements in the provision of emergency services. The environment of service provision does not seem to facilitate the physiological process of vaginal birth. Providers acknowledged some of these challenges.

Optimizing the use of cesarean section in Argentina: design and methodology of a formative research for the development of interventions.

BACKGROUND: While cesarean section is an essential life-saving strategy for women and newborns, its current overuse constitutes a global problem. The aim of this formative research is to collect information from hospitals, health professionals and women regarding the use of cesarean section in Argentina. This article describes the methodology of the study, the characteristics of the hospitals and the profile of the participants. METHODS: This formative research is a mixed-method study that will be conducted in seven provinces of Argentina. The eligibility criteria for the hospitals are (a) use of the Perinatal Information System, (b) cesarean section rate higher than 27% in 2016, (c) ≥ 1000 deliveries per year. Quantitative and qualitative research techniques will be used for data collection and analysis. The main inquiry points are the determining factors for the use of cesarean section, the potential interventions to optimize the use of cesarean section and, in the case of women, their preferred type of delivery. DISCUSSION: It is expected that the findings will provide a situation diagnosis to help a context-sensitive implementation of the interventions recommended by the World Health Organization to optimize cesarean section use. Trial registration IS002316 Cesarean section is an essential medical tool for mothers and their children, but nowadays its overuse is a problem worldwide. Our purpose is to get information from hospitals, health professionals and women about how cesarean section is used in Argentina. In this protocol we describe how we will carry out the study and the characteristics of the hospitals and participants. We will implement this study in seven provinces of Argentina, in hospitals that have more than 1,000 births each year, had a cesarean section rate higher than 27% in 2016 and use the Perinatal Information System. We will gather information using forms, surveys and interviews. We want to identify the factors that decide the use of a cesarean section, the potential interventions that can improve the use of cesarean section and, in the case of women, the type of delivery they prefer. We expect that this study will give us a diagnosis of how cesarean section is used in Argentina, and that this will help to apply the interventions that the World Health Organization recommends to optimize the use of cesarean section in our specific context.

RESUMEN: INTRODUCCIóN: Aun cuando la cesárea es una intervención que puede ser esencial para salvar la vida de una mujer y su hijo, el crecimiento excesivo de su uso  es un problema global. El propósito de esta investigación formativa es recolectar información sobre las instituciones, profesionales de la salud y mujeres acerca del uso de la cesárea en la Argentina. Este artículo describe la metodología del estudio, las características de los hospitales y el perfil de los participantes. METODOLOGíA: Esta investigación formativa usa un diseño mixto aplicado en siete provincias del país. Los criterios de elegibilidad para los hospitales son: (a) uso del Sistema Informático Perinatal, (b) tasa de cesáreas mayor al 27% en 2016, y (c) ≥ 1000 partos por año. Se usarán técnicas cualitativas y cuantitativas para la recolección de datos y el análisis. Los principales temas a indagar son los determinantes del uso de la cesárea, las intervenciones para optimizar su uso y, en el caso de las mujeres, sus preferencias sobre el modo de parto. DISCUSIóN: Se espera que los resultados den lugar a un diagnóstico de situación que permita una implementación de las intervenciones propuesas por la OMS para optimizar el uso de la cesárea más ajustada al contexto. Registro del estudio IS002316.

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

Barreras y facilitadores en las trayectorias de mujeres con cáncer de mama usuarias de hospitales públicos / Barriers And Facilitators of Health Seeking Behavior Among Women with Breast Cancer Users of Public Hospitals

El cáncer de mama (CM) es el segundo más común en el mundo y el más frecuente entre las mujeres. La incidencia varía entre regiones. Además, el CM es la quinta causa de muerte por cáncer a nivel mundial, la más frecuente en las regiones menos desarrolladas y la segunda en las más desarrolladas y en Sudamérica. En Argentina, registra las mayores tasas de incidencia y mortalidad entre las mujeres. OBJETIVOS: Comprender los motivos de las demoras, las consecuencias y las estrategias usadas por mujeres con diagnóstico de CM para afrontar barreras durante sus trayectorias de atención. MÉTODOS: Se realizó un estudio descriptivo transversal con abordaje cualitativo, basado en mujeres diagnosticadas con CM en dos hospitales públicos de la provincia de Santa Fe. Se efectuaron entrevistas semiestructuradas, que fueron grabadas previo consentimiento informado. Se utilizó el programa Atlas-ti (V.7.2) para el análisis del material. RESULTADOS: Se identificaron barreras a nivel personal (cuestiones financieras, creencias de las pacientes), interpersonal (cuestiones laborales, responsabilidad familiar, comunicación médico-paciente) y del sistema de salud (organización de servicios, calidad de atención). CONCLUSIONES: La investigación aporta evidencia para comprender las barreras que enfrentan las mujeres diagnosticadas con CM y muestra las oportunidades para implementar la estrategia de navegación de pacientes a fin de reducir o mitigar las demoras en la atención

Trayectorias en pacientes con cáncer / Trajectories in cancer patients

INTRODUCCIÓN Este estudio busca generar conocimiento que informe políticas sanitarias que mejorar el acceso al diagnóstico de los pacientes con cáncer. OBJETIVO Describir la trayectoria de pacientes con cáncer de mama, pulmón y colon de 2 hospitales públicos de la Provincia de Buenos Aires desde el inicio de los síntomas hasta el diagnóstico de la enfermedad. PACIENTES Y MÉTODOS Se incluyeron personas con diagnóstico inicial de cáncer de mama, pulmón o colorrectal entre 1/3/2014 y el 29/6/2016 tratados en los hospitales Juan C Sanguinetti de Pilar y Alejandro Posadas de El Palomar. Los pacientes tuvieron cualquier estadio y estado funcional. Se excluyeron pacientes con recaídas o 2° tumores. Se realizó una revisión de historias clínicas, una encuesta telefónica para indagar tiempos, barreras y facilitadores y entrevistas en profundidad para caracterizar cualitativamente barreras y facilitadores. RESULTADOS Se revisaron 111 historias clínicas de pacientes del H. Sanguinetti. 14.4% se diagnosticaron por tamizaje y 85.6% como enfermedad sintomática. El 64.9% tuvo enfermedad localizada al diagnóstico y 35.1% enfermedad avanzada. Se realizaron 127 encuestas en ambos hospitales a 83 pacientes con cáncer de mama, 37 de colon y 7 de pulmón. 100 pacientes tuvieron enfermedad sintomática al diagnóstico y 27 fueron diagnosticados por tamizaje. El 28% consultó a más de 3 meses de iniciados los síntomas. Barreras referidas incluyen falta de jerarquización de los síntomas, miedo y problemas logísticos para turnos y consultas. Facilitadores referidos incluyen el conocimiento del hospital y de los profesionales y el apoyo de familiares y amigos. DISCUSIÓN En esta muestra, el diagnóstico de enfermedad sintomática y avanzada fue frecuente. Las barreras y facilitadores de la trayectoria son múltiples. Su reconocimiento brinda una oportunidad para establecer políticas activas para aumentar la conciencia sobre la enfermedad y allanar los obstáculos en al acceso al cuidado de la salud

HPV testing: a mixed-method approach to understand why women prefer self-collection in a middle-income country.

BACKGROUND: HPV test self-collection has been shown to reduce barriers to cervical screening and increase uptake. However, little is known about women's preferences when given the choice between self-collected and clinician-collected tests. This paper aims to describe experiences with HPV self-collection among women in Jujuy, the first Argentinean province to have introduced HPV testing as the primary screening method, provided free of cost in all public health centers. METHODS: Between July and December 2012, data on acceptability of HPV self-collection and several social variables including past screening were collected from 2616 self-collection accepters and 433 non-accepters, and were analyzed using multivariate regression. In addition, in-depth interviews (n = 30) and 2 focus groups were carried out and analyzed using thematic analysis. RESULTS: Quantitative findings indicate that main reasons for choosing self-collection are those reducing barriers related to women's roles of responsibility for domestic work and work/family organization, and to health care services' organization. No social variables were significantly associated with acceptability. Among those who preferred clinician-collection, the main reasons were trust in health professionals and fear of hurting themselves. Qualitative findings also showed that self-collection allows women to overcome barriers related to the health system (i.e. long wait times), without sacrificing time devoted to work/domestic responsibilities. CONCLUSIONS: Findings have implications for self-collection recommendations, as they show it is the preferred method when women are given the choice, even if they are not screening non-attenders. Findings also highlight the importance of incorporating women's needs/preferences in HPV screening recommendations.

Demoras en el proceso de atención de pacientes con cáncer de mama en dos hospitales públicos de la provincia de Santa Fe / Delays in the process of care of patients with breast cancer in two public hospitals in the province of Santa Fe

INTRODUCCIÓN: el retraso en el inicio de untratamiento efectivo del cáncer de mama reduce la tasa desupervivencia y está asociado a estadios más avanzados aldiagnóstico y a la necesidad de tratamientos más agresivos ycostosos. OBJETIVOS: Describir la trayectoria de la atención médicade mujeres con diagnóstico de cáncer de mama desde la apariciónde un signo o síntoma hasta la finalización del tratamiento.MÉTODOS: Se realizó un estudio descriptivo retrospectivo, quecombinó técnicas cuantitativas y cualitativas. Se estimaron lostiempos utilizados en cada etapa del proceso de atención de cáncerde mama en mujeres diagnosticadas y/o tratadas durante 2012 endos hospitales de la provincia de Santa Fe. RESULTADOS: Se incluyóa 62 pacientes en la muestra. El 20,3% obtuvo su diagnósticodentro del mes posterior a la mamografía y/o ecografía, y sólola mitad fue operada dentro del mes posterior al diagnóstico. El60% de las pacientes con necesidad de quimioterapia adyuvantey el 72,4% con necesidad de radioterapia tras la cirugía tuvierondemoras mayores a 60 días. Ninguna de las pacientes en estadio IVcomenzó el tratamiento antes de los 30 días. CONCLUSIONES: Si secompara con los parámetros establecidos en la guía del ProgramaNacional de Cáncer de Mama, hay demoras en todas las etapas. Esnecesario establecer estrategias que reduzcan los tiempos para laconfirmación diagnóstica en mujeres con sospecha, así como lostiempos de tratamiento en pacientes con cáncer confirmado.

INTRODUCTION: the delay to start an effectivetreatment for breast cancer reduces survival rate and is associatedto advanced stages at diagnosis and to the need for moreaggressive and costly treatments. OBJECTIVES: To describe thehealth care path of women with diagnosis of breast cancersince the first sign or symptom until the end of the treatment.METHODS: A retrospective descriptive study was performed,combining quantitative and qualitative techniques. It estimatedthe time used in each stage of the health care process amongwomen with breast cancer, diagnosed and/or treated during2012 in two hospitals of the province of Santa Fe, Argentina.RESULTS: A total of 62 patients were included in the sample.Of them, 20.3% received her diagnosis within 30 days of themammogram and/or ultrasound and 50% were operatedwithin one month of the diagnosis. There were delays of morethan 60 days in 60% and 72.4% of the patients who had toundergo adjuvant chemotherapy and radiotherapy, respectively.None of the patients with stage IV began the treatment withinthe first 30 days. CONCLUSIONS: Compared to the guidelinesof the National Program of Breast Cancer, there are delaysat all stages. It is necessary to develop strategies to shortenthe time for diagnosis confirmation in women with suspectedbreast cancer and for the access to treatment in patients withcancer confirmed.