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

Paolino et al. Implementation Science Communications (2023) 4:4 https://doi.org/10.1186/s43058-022-00367-2 Implementation Science Communications Open Access RESEARCH 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 Melisa Paolino1, Victoria Sánchez Antelo1, Milca Cuberli2, Mariana Curotto2, Anabella Le Pera3, Fernando Binder3, Juan David Mazzadi3, Beatriz Firmenich4 and Silvina Arrossi1*    Abstract 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. *Correspondence: Silvina Arrossi Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Paolino et al. Implementation Science Communications (2023) 4:4 Page 2 of 19 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. Keywords Implementation fidelity; Cervical cancer prevention, HPV self-collection test, Argentina Contributions to the literature –Our case study is the first that analyzed the implementation fidelity of an HPV self-collection strategy (EMA strategy) using an implementation science framework (the Conceptual Framework for Implementation Fidelity-CFIF) in a low-middle-resource setting. –Data showed that core components of the EMA strategy were implemented with different levels of fidelity and adaptation. The use of CFIF allowed us to identify key factors that influenced the implementation process in a real-word context. Our results highlighted the need of context-adapted strategies. –This case study provides useful evidence about implementation fidelity during a scaling-up process that is key for countries that are considering the incorporation of HPV self-collection into their cervical cancer prevention programs. Background Cervical cancer is one of the leading causes of cancer death among women from low- and middle-income countries (LMIC). The disease is highly preventable with existing knowledge and technologies, and that is why the World Health Organization (WHO) has launched a global initiative to eliminate cervical cancer [1]. One key strategy to control the disease is HPV self-collection, which is effective at increasing screening uptake, especially among hard-to-reach women who are at a higher risk of this disease [2–7]. However, for HPV self-collection to have an impact in screening coverage and disease detection at the population level, it needs to be implemented in programmatic contexts. In Argentina, HPV self-collection was implemented in the province of Jujuy as part of the EMA study (Self-collection Modality Trial, for its initials EMA in Spanish), a mixed methods study that included a cluster-randomized controlled trial to evaluate the effectiveness of HPV selfcollection offered by community health workers (CHWs) at home visits to increase screening uptake [3]. The strategy resulted in a fourfold increase in screening uptake (from 20.2 to 85.9%), demonstrating that the strategy was effective to improve cervical cancer screening [3]. In 2014, EMA strategy was scaled up to the whole province [8].Evaluation of the scaling-up in Jujuy showed that the strategy resulted in a 45% increase in screening of vulnerable population, and allowed the identification of core components of the strategy, which could be implemented in new contexts. Based on these findings, the EMA strategy was scaled to other settings, and at present, nine Argentinian provinces use it to increase screening uptake among vulnerable women. The scaling-up in Argentina was carried out by the provincial programs through joint work with the team of the National Cervical Cancer Prevention Program (NCCPP). Argentina is a federal country, (...truncated)