Among the HPV-Screened women recruited, the median age was 36 years. Specifically, 13 women completed primary-level education, while 7 completed secondary-level education. In terms of marital status, five women were divorced, whereas 15 were married. Regarding their living conditions, 12 women had access to electricity at home, while eight did not. Additionally, 13 women had running water, in contrast to 7 who did not.

Similarly, the HCPs and DHO officials interviewed had a median age of 37 years. Within this group, 6 providers completed secondary education, while 9 achieved tertiary education. Furthermore, the marital status of the HCPs indicated that 14 were married and 1 was single. Of these participants, 2 were male, while the remaining 11 were female.

We organized the data collected from the in-depth interviews (IDIs) into five distinct themes that capture perceived barriers and facilitators to delivering HPV screening results via mobile phones. Theme 1, Complexity of mobile phone communication for HPV results, reflects perceived barriers such as women’s resistance due to concerns about privacy and limited technological familiarity. Theme 2, Adaptability and security measures, highlights perceived facilitators through tailored strategies that address the needs of women, HCPs, and health officials within their contextual challenges. Theme 3, Advantages of mobile phone communication for HPV results, represents perceived facilitators by emphasizing the convenience and efficiency perceived by both providers and users. Theme 4, Implementation climate, identifies perceived barriers and facilitators related to institutional readiness, as well as support from HCPs and health officials for integrating mobile phone communication into cervical cancer screening. Finally, Theme 5, Essential resources for sustainable implementation, describes perceived barriers such as inadequate infrastructure, along with perceived facilitators like the availability of tools and staff training necessary to sustain the intervention.

Complexity of mobile phone communication for HPV results: reasons for women’s resistance to its use

We interviewed women who had been screened for HPV to understand why they might choose not to receive their HPV results via mobile phone. Their responses varied regarding the reasons for their reluctance to use phone messaging for HPV results. Some expressed concerns about not having enough money for airtime, as well as worries about privacy breaches and possible treatment delays, which influenced their preference against receiving results this way. Others mentioned challenges like difficulty responding to calls or messages in group settings, as well as reading and writing difficulties. Additionally, some worried that getting results over the phone might surprise them and cause anxiety. Others preferred visiting the healthcare center for immediate assistance available at hospitals. Personal preferences and privacy concerns also played a role in their hesitation to use mobile messaging or calls for HPV result delivery. For instance, one woman explained that some women are illiterate and might need help from friends or family to read text messages. Furthermore, some women may not have phones and rely on devices owned by their husbands, friends, or family members, which means they depend on others to pass on information from healthcare providers. This can lead to accidental disclosure of personal information about their sexual health, which might be embarrassing and uncomfortable.

“Some people may prefer not to do that because they cannot read or write and rely on others to tell them. For those individuals, it’s better to wait or come in person. They might feel embarrassed if they’re with friends.” (49-year-old HPV-Screened Woman).

For a more detailed summary of the findings for this theme, see Supplementary Table 1.

The perceived challenge of airtime was also echoed among many HCPs, with most (n = 12/15) stating that airtime should be provided to ensure the successful implementation of the strategy. For example, one of the HCPs said:

“Only if resources are made available, like airtime and phones. If these resources are not available, health workers will not use their resources to fulfill this. So, if the resources are available, this method can be sustainable because it is an easy enough method. Resources should be readily available, including the phone, airtime, phone chargers, and overall maintenance of the phone.” (Female Nurse, 44 Years).

Adaptability and security measures: tailoring strategies to HPV-Screened women, HCPs, and health officials’ needs and contextual factors

When asked about tailoring the strategy to accommodate diverse needs and contextual factors, both HCPs and HPV-screened women emphasized the importance of considering perceived security measures. This included determining which factors to include or avoid when implementing the strategy. Most HPV-screened women (n = 16/20) stressed the perceived necessity of verifying the patient’s identity before disclosing screening results. For example, one client mentioned:

“So, maybe you can start with knowing her name, like what’s your name, and you will see if she is the right person depending on your records, and you can make conclusions whether she is the right person, maybe you recorded her age, or you ask her several things….” (33-year-old HPV-Screened Woman).

This was concurred by a HCP who said:

“First, we should make sure that the contact number of that client is hers because if we are not sure of that contact, we can send the message to the wrong person.” (Male Senior Health Surveillance Assistant, 52 years).

Concerning factors to avoid, the HPV-screened women in our study advised HCPs against directly sending or calling patients to disclose their results. Instead, they proposed scheduling an appointment with the patient to discuss their results. They emphasized the importance of encouraging the patient to visit the health center to access their screening results. For instance, one client stated:

“I believe that when informing someone of their HPV-positive status, it’s best to refrain from providing details about cancer staging. Instead, simply advise them to visit the hospital.” (40-year-old HPV-Screened Woman).

Most HPV-Screened women (n = 14/20) also proposed the inclusion of greetings and words of encouragement in messages or phone calls before delivering HPV screening results.

“No, it’s preferable for them to commence with greetings. Following that, they can proceed with sharing, ‘This is the current situation’ or ‘This is what has occurred.’ Then, they may inquire about the next steps, to which you can respond by suggesting, ‘We will meet at such a place.’” (32-year-old HPV-Screened Woman).

Aligned with the client’s suggestions, most HCPs (n = 11/15) recommended sensitizing the women to prevent surprise upon receiving their HPV screening results via text or phone call.

“Perhaps we should consider sensitizing the clients, so they won’t be surprised when we call them. Sometimes issues arise when we call and find the phone in someone else’s hands, and they ask what we want. Therefore, it’s important to educate people in the community, informing them that we might call them during their HPV screening appointment to avoid confusion. When they receive a call from us providers, they shouldn’t be surprised about its purpose.” (Male Health Surveillance Assistant, 35 Years).

Advantages of mobile phone communication for HPV results: provider and user perspectives

In this section, mobile phone communication encompasses both voice calls and text messaging, which fall under the broader category of mobile phone communication. Where applicable, we specify the mode of communication referenced by participants.

Most HCPs (n = 13/15) and HPV-screened women (n = 16/20) believed that phone calls and text messages were more advantageous than traditional methods for delivering HPV results and reminders. Many HPV-screened women noted the benefit of avoiding the need to travel to the hospital for HPV results, thereby saving on transportation costs. One woman said,

“I would feel good because it would mean that I would not have to travel. I would have had to travel to get here but the results would find me at home….” (36-year-old HPV-Screened Woman).

Another woman said,

“There’s no issue. Additionally, it would be beneficial if I didn’t have transportation funds, or perhaps there’s a funeral, or my child is ill. The phone approach is constructive and effective. Numerous unforeseeable circumstances may arise; you never know what the next day holds after planning to visit the hospital.” (44-year-old HPV-Screened Woman).

Additionally, most HCPs (n = 14/15) agreed with the women, emphasizing the perceived advantage that phone calls provide for following up with women whose HPV screening results are positive but who were unable to access them due to delays. These women require immediate assistance, and because of the delays in obtaining HPV screening results, some choose not to return to the health facility, resulting in missed treatment opportunities. This method is seen as helpful in reaching out to these women so they can learn about their results and seek treatment. For example, one HCP stated:

“Making phone calls is beneficial. As I mentioned before, many women with cervical cancer are unaware of their illness initially, as they exhibit no symptoms. Even persuading them to come for screening is challenging. Therefore, for these women, if there are delays in receiving their results after multiple visits to the facility, they may stop coming altogether. Hence, I believe a phone call is essential. You can promptly inform them. However, when discussing results, a negative outcome is easier to convey. A positive result is more challenging to deliver.” (Female Nurse, 44 years).

Implementation climate: readiness to incorporate mobile phone communication in cervical cancer screening

Many perceived themselves as prepared and willing when asked about the readiness and openness among HCPs and DHO officials to incorporate mobile phone calls and messaging into the cervical cancer screening program. They believed the strategy would streamline their work, especially during challenging circumstances when following up with patients is difficult. For example, one HCP said:

“I believe this approach could be warmly welcomed. For instance, navigating during the rainy season can be quite challenging, as we often need to cover long distances. So, traveling such distances and then being unable to locate the person can be frustrating. Health Surveillance Assistants (HSA’s) would appreciate this.” (Female Health Surveillance Assistant, 44 Years).

Another HCP said:

“I believe this method could greatly assist us as HSAs. As I mentioned earlier, HSAs are responsible for specific catchment areas, typically encompassing four to five villages per HSA. By utilizing phones or text messages, we can easily reach all the residents of these villages within a day. This way, if they wish to attend our services, they can easily do so by utilizing their phones”. (Male Senior Health Surveillance Assistant, 52 Years)

Essential resources for sustainable implementation of mobile phone messaging in cervical cancer screening programs

Many HCPs (n = 14/15) identified key areas perceived to be essential for making the strategy sustainable. Several resources were noted as necessary to ensure this sustainability. The resources seen as vital for effective implementation included sufficient airtime for communication, transportation to reach remote patients, mobile phones for efficient communication, and incentives to motivate healthcare workers. For example, one healthcare provider said:

“As I already mentioned, the availability of cell phones, airtime, and brushes (self-collection brushes for HPV testing) for women to use is crucial. If there are cell phones and airtime but no brushes, the program will not be sustainable or effective. However, if all these resources are available, the program will be successful”. (Male, Senior Health Surveillance Assistant, 52 Years)

Another HCP said:

“I think there should also be incentives, especially for those who regularly work in the cervical cancer screening area and do the job. That will be motivating for them. On that note, sustainability issues will not be a problem. And for the clients, we could even give them airtime or just transport. Although it’s not ideal because everyone should take responsibility for their health, it will encourage more women to come for the services. By doing so, we will help to prevent cervical cancer.” (Female Nursing Officer, 42 Years).

Additionally, access to necessary equipment, such as HPV testing kits, in-service training for updated protocols, and logbooks for tracking patient interactions, was perceived as essential. These resources were viewed as supporting HCPs in delivering quality healthcare services and ensuring effective communication with patients undergoing screening. For example, one HCP said:

“Yeah, so I am saying the resources are not only for the providers but also for the ones doing the testing, like the lab people we take the samples to. They should also be supported. We need to have materials available; for example, in January, we did not have the HPV DNA kits. We should ensure that the kits are available, along with other resources like vinegar, and that the probes for thermocoagulation are in good condition and working. There should be no power interruptions because, when we are treating women with positive HPV DNA results, we need power to have a good visualization of the cervix”. (Female Clinic Nurse, 32 Years)

The HCP also emphasized the importance of in-service training and supervision:

“In-service training is also important because it reminds providers of how best to do their jobs. This is crucial because things are changing every day. The way we used to screen for cancer in the past is not the same as the way we do it now. There is an advancement of knowledge. We should also have units, a communal phone, and proper supervision. People should be observed and checked to see if they are doing the right things. Occasionally, those in charge should make a call to ask about any challenges or bottlenecks. When someone asks for progress, it makes you feel that they are interested in what you are doing. That support helps the provider. Time is also an important factor.” (Female Clinic Nurse, 32 Years).

To successfully implement a strategy for delivering screening results via text or phone call, HCPs identified several key responsibilities. They specified that they must thoroughly understand the strategy and its procedures and receive adequate training to effectively make calls and send texts. Additionally, educating patients about the strategy—including how to interpret results and the importance of timely follow-up—was also viewed as essential. Finally, HCPs noted the importance of confirming they were communicating with the correct person before disclosing sensitive information and managing resources such as airtime and office phones to ensure reliable communication. For example, one HCP said:

“First of all, the health workers should understand this model, what is required, and how it is supposed to work. After that, we should teach our clients the importance and benefits of receiving their results through a call. If we can manage to sensitize the community and give them the right information, it will be effective. But if they don’t know anything about the phone call, they cannot easily access it. Sensitization should be a must.” (Female Health Facility In-charge, 36 Years).

Additionally, they emphasized the perceived need to engage in their roles with passion and dedication, demonstrating a commitment to patient care while maintaining a positive attitude. They noted that HCPs should also deliver health education and be devoted to clear, supportive, and effective communication. These responsibilities underscored the perceived importance of well-trained and dedicated HCPs in enhancing client care and satisfaction. For instance, one HCP said:

“Dedication is very important. Even when the materials are available, I have seen people relaxing and clients suffering despite having all the resources. So, dedication is crucial. Empathy is also important. When you are empathetic, it helps to treat the clients better. Providers should not only look at their benefits but also consider the benefits to the clients. The client should be a priority. That will help as well.” (Female Clinic Nurse, 32 Years).

Another HCP said:

“Yeah, first, have a positive attitude that you are going to deliver the message even if you receive negative feedback. As I already mentioned, some people sometimes respond negatively, thinking you have certain intentions toward them, but your aim was just to call them to come to the hospital or maybe to give them the results. In that way, you shouldn’t be discouraged because you intend to deliver the message, either to come to the hospital or to get the results. You shouldn’t be discouraged.” (Female Community Health Nurse, Midwife, and District Coordinator for Cervical Cancer, 46 Years).