title: Evaluation of scaling-up of HPV self-collection offered by community health workers at home visits to increase screening among socially vulnerable under-screened women in Jujuy Province, Argentina.
abstract: Self-collection has been proposed as a strategy to increase cervical screening coverage among hard-to-reach women. However, evaluations of the implementation of this strategy on a large scale are scarce. This paper describes the process and measurement of the scaling-up of self-collection offered by community health workers during home visits as a strategy to reach under-screened women aged 30+ with public health coverage, defined as the target women.
  
  
  
  We used an adaptation of the Health System Framework to analyze key drivers of scaling-up. A content analysis approach was used to collect and analyze information from different sources. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) model was used to evaluate the impact of the strategy.
  
  
  
  HPV self-collection was scaled-up in the province of Jujuy in 2014 after a RCT (Self-collection Modality Trial, initials EMA in Spanish) was carried out locally in 2012 and demonstrated effectiveness of the strategy to increase screening uptake. Facilitators of scaling-up were the organizational capacity of the provincial health system, sustainable funding for HPV testing, and local consensus about the value of the technology. Reach: In 2014, 9% (2983/33,245) of target women were screened through self-collection in the Jujuy public health sector. Effectiveness: In 2014, 17% (n = 5657/33,245) of target women were screened with any HPV test (self-collected and clinician-collected tests) vs. 11.7% (4579/38,981) in 2013, the pre-scaling-up period (p < 0.0001).
  
  
  
  Training about the strategy was provided to 84.2% (n = 609/723) of total community health workers (CHWs). Of 414 HPV+ women, 77.5% (n = 320) had follow-up procedures. Of 113 women with positive triage, 66.4% (n = 75) had colposcopic diagnosis. Treatment was provided to 80.7% of CIN2+ women (n = 21/26). Adoption: Of trained CHWs, 69.3% (n = 422/609) had at least one woman with self-collection; 85.2% (n = 315/368) of CHWs who responded to an evaluation survey were satisfied with self-collection strategy. Maintenance: During 2015, 100.0% (723/723) CHWs were operational and 63.8% (461/723) had at least one woman with self-collection.
  
  
  
  The strategy was successfully scaled-up, with a high level of adoption among CHWs, which resulted in increased screening among socially vulnerable under-screened women.
authors.affiliation: Centro de Estudios de Estado y Sociedad/Consejo Nacional de Investigaciones Científicas y Técnicas, Sánchez de Bustamante 27, Buenos Aires, 1193, Argentina. silviarrossi2020@gmail.com.
authors.forename: Silvina
authors.initials: S
authors.lastname: Arrossi
authors.affiliation: Programa Nacional de Prevención de Cáncer Cervicouterino/Instituto Nacional del Cáncer, Julio A. Roca 781, Buenos Aires, 1067, Argentina.
authors.forename: Melisa
authors.initials: M
authors.lastname: Paolino
authors.affiliation: Programa Nacional de Prevención de Cáncer Cervicouterino/Instituto Nacional del Cáncer, Julio A. Roca 781, Buenos Aires, 1067, Argentina.
authors.forename: Laura
authors.initials: L
authors.lastname: Thouyaret
authors.affiliation: Programa Nacional de Prevención de Cáncer Cervicouterino/Instituto Nacional del Cáncer, Julio A. Roca 781, Buenos Aires, 1067, Argentina.
authors.forename: Rosa
authors.initials: R
authors.lastname: Laudi
authors.affiliation: Ministerio de Salud de la Provincia de Jujuy, Av. Italia esq. Independencia, San Salvador de Jujuy, 4600, Argentina.
authors.forename: Alicia
authors.initials: A
authors.lastname: Campanera
mesh_terms: D000328:Adult; D000368:Aged; D001118:Argentina; D003150:Community Health Workers; D055088:Early Detection of Cancer / Q000379:methods; D005260:Female; D006792:House Calls; D006801:Humans; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D030361:Papillomavirus Infections / Q000175:diagnosis*; D012648:Self Care / Q000379:methods*; D014626:Vaginal Smears / Q000379:methods*; D035862:Vulnerable Populations
keywords: Argentina; Cervical cancer prevention; Health System Framework; Implementation research; RE-AIM Framework; Scaling-up; Self-collection HPV test