Exploring perceived barriers and facilitators to using mobile phone technology for delivering HPV test results in malawi: a qualitative study with HPV-Screened women, healthcare providers, and health officials

Abstract

Background

Cervical cancer, the fourth most common cancer among women globally, disproportionately affects low- and middle-income countries, such as Malawi, which has the world’s highest cervical cancer mortality rate. Efforts to implement human papillomavirus (HPV) testing for primary screening face challenges, including delays in delivering HPV results, hindering the retention of HPV-positive women in the care cascade. We conducted a study to identify the perceived barriers and facilitators to using mobile phones for delivering HPV results, aiming to improve the retention of HPV-positive women in care. We also explored the perspectives of women, health care providers, and health officials in Malawi’s cervical cancer screening program to provide a comprehensive view of challenges and opportunities.

Methods

This exploratory sub-study evaluated the perceived barriers and facilitators to delivering HPV screening results to women via mobile phones at four government-run health facilities in Lilongwe, Malawi. A trained research assistant conducted in-depth interviews (IDIs) with women who underwent HPV-based primary screening and received their HPV results, through a cluster randomized trial that compared two models of HPV-based screening. We also interviewed healthcare providers from these four health facilities and officials from the Lilongwe District Health Office (DHO). Data collected through the IDIs were recorded, transcribed, and translated. The transcripts were coded in NVivo 14 and analyzed using thematic analysis.

Results

Between January-March 2022, 35 participants completed the IDIs: 20 women who underwent HPV screening, 13 healthcare providers, and 2 DHO officials. The study findings revealed several critical factors influencing the implementation of HPV result delivery via mobile phone. Key challenges included low literacy and privacy concerns, which complicate the adoption of this method. Additionally, there was a perceived risk of unintended receipt of HPV results by partners or family members, in that many women do not own mobile phones and rely on shared handsets. However, incentives such as airtime, functional phones, and appropriate equipment could support healthcare providers in delivering effective communication and healthcare services.

Conclusion

While mobile phone communication has the potential to enhance HPV result delivery, its success relies on overcoming perceived barriers such as low literacy, privacy concerns, inadequate resources, and the need for a supportive implementation environment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-23857-z.

Background

Cervical cancer is the fourth most common cancer among women globally, with approximately 660,000 new cases and around 350,000 deaths in 2022 [1]. The highest rates of cervical cancer incidence and mortality are found in low- and middle-income countries (LMICs) [1]. This is driven by limited access to Human Papillomavirus (HPV) vaccination, cervical cancer screening, treatment services, and various social and economic determinants [1]. Malawi, a LMIC in sub-Saharan Africa, has the highest age-standardized incidence rate of cervical cancer in the world, with 70.9. incidences per 100,000 women per year [2]. Furthermore, Malawi also has the highest age-standardized mortality rate of cervical cancer in the world, with 54.1 deaths per 100,000 women per year [2]. Despite efforts by the Malawi Ministry of Health (MoH) to implement national HPV vaccination and a cervical cancer screening program, challenges persist in achieving widespread coverage [3, 4].

The World Health Organization now recommends HPV testing for primary screening of cervical cancer among women [1]. However, several countries in LMICs have yet to roll out HPV-based primary screening. To accelerate the introduction of HPV-based screening, the University of North Carolina at Chapel Hill (UNC), in collaboration with the Kamuzu University of Health Sciences (KUHeS), launched the Partnerships for Enhanced Engagement in Research (PEER) Cervical Cancer Screening Study. The PEER Study was a cluster-randomized trial that integrated HPV self-collection for cervical cancer screening into family planning services, utilizing GeneXpert^® assays (Cepheid, Sunnyvale, CA, USA) for high-risk HPV (hr-HPV) screening [5]. GeneXpert^® can process HPV results within 1–2 h, allowing same-day notification of results [6]. Two models were compared in PEER Study: Model 1 involved only clinic-based HPV self-collection, while Model 2 included both clinic-based and community-based HPV self-collection [3, 5]. In Model 1, the integration of HPV self-collection into facility-based services was prioritized, where educational talks were conducted in the family planning clinic waiting rooms, and women were offered HPV self-collection kits while they awaited other services [3]. Training was provided to healthcare providers (HCPs) in these facilities to facilitate the implementation of HPV testing and thermal ablation treatment on the same day for women with positive results [3]. In contrast, Model 2 involved extending HPV self-collection services into community-based clinics, where Health Surveillance Assistants (HSAs), who are also known as community health workers (CHWs), were trained to distribute HPV self-collection kits during their outreach clinics [3]. Samples collected in the community were returned by the HSAs to the health facilities for testing, with women receiving their results either at the facility or during the next community visit [3]. Further details of the study are published in the literature [3, 5].

However, some factors affected the retention of women at the clinics and impacted the same-day delivery of HPV results. In the PEER study, logistical constraints such as power outages, equipment downtime, and staff shortages were some of the barriers that often prevented same-day result delivery [3, 5]. In addition, some women were unable to wait at the clinic to receive their results due to competing responsibilities such as childcare, household duties, or travel constraints, which contributed to delays in result delivery and follow-up care [7]. Finally, women who underwent HPV self-collection in the community had to wait for the next community clinic or travel to the nearest government health center to receive their HPV results [3, 5].

Although precise data on the proportion of women who did not receive their HPV results within one month is unavailable, qualitative feedback and field reports from the PEER study indicated that a substantial number of women experienced delays in receiving their results within 1 month [3, 5]. These delays were primarily due to logistical challenges and contributed to delayed treatment initiation for women who tested HPV-positive [8].

In other healthcare settings, the utilization of mobile technology for result delivery has been deemed potentially impactful in addressing such challenges in screening programs [9, 10]. Prior studies in other LMICs have explored the use of mobile phone-based interventions to address these retention challenges. For example, studies in Ghana and Tanzania investigated the use of SMS reminders for cervical cancer screening follow-up. While these messages were well received, they were not always effective in improving attendance, suggesting that more interactive or context-specific communication strategies may be needed [9, 11]. In Ghana, it was revealed that, despite no increase in cervical cancer screening uptake, SMS messages about cervical cancer sent from a central research team were well received by the intended audience [9]. However, their findings suggested that sending one-way SMS text messages to women in urban areas may not be sufficient to encourage attendance at screening clinics [9]. Similarly, a study in Tanzania revealed that one-way text messages did not impact attendance rates [11]. It is plausible that more interactive methods, such as phone calls or outreach services offering HPV testing at home, could prove more effective than one-way messages and repeat screenings at clinics [11]. While the utilization of mHealth technologies shows promise, as indicated by another study in Tanzania focusing on behavior change through SMS, successfully harnessing their potential requires a multifaceted, equity-focused approach that includes interpersonal elements [12].

Given the increasing availability of mobile phones in Malawi and their growing role in healthcare communication [13], mobile phone-based result delivery presents a potentially effective strategy for enhancing timely follow-up. However, previous studies indicate that the success of such strategies depends on contextual factors, including the type of communication (e.g., one-way SMS vs. phone calls) and women’s access to and comfort with mobile technology [13, 14]. Despite this potential, little is known about how mobile phones can effectively communicate HPV test results in low-resource settings like Malawi. Moreover, there is limited evidence on the perceived barriers and facilitators to implementing such approaches, from the perspectives of HCPs, women, and district health officials. Understanding these perspectives is essential to inform the design of acceptable and contextually appropriate interventions to improve follow-up in cervical cancer screening programs.

We conducted this qualitative sub-study as part of the PEER Cervical Cancer Screening Study, a cluster-randomized trial that evaluated the integration of HPV self-collection into family planning services using the GeneXpert^® platform for HPV testing. The primary objective of the PEER study was to assess the feasibility and effectiveness of incorporating HPV-based cervical cancer screening into routine reproductive health services. This qualitative sub-study was designed to explore the perceived barriers and facilitators to delivering HPV test results via mobile phones, an implementation challenge identified during the main trial. Specifically, we assessed the acceptability and feasibility of using text messages or phone calls to communicate results, particularly for women who could not receive same-day results following self-collection.

Methods

Study setting and population

This sub-study adopted a qualitative design to explore the perceived barriers and facilitators associated with delivering HPV screening results via mobile phones in Malawi. It was conducted at four government health facilities (Area 18 Health Center, Chileka Health Center, Lumbadzi Health Center, and Bwaila District Hospital) in Lilongwe District, central Malawi. The four facilities were purposively selected from among the 16 participating in the PEER Study to capture a range of implementation experiences and contexts. They had the infrastructure and supplies required for HPV self-collection screening and treatment of HPV-positive women. The selection of these four facilities also considered their longstanding research collaboration with the UNC Project, a research site established through a partnership between UNC-Chapel Hill and the Malawi Ministry of Health to improve health through research, capacity building, and clinical care. We interviewed women aged 25–49 years screened for HPV at the four facilities, along with HCPs, such as cervical cancer screening clinic nurses, clinic in-charges at the facilities, district coordinators, and Lilongwe District Health Office (DHO) officials. The women’s age group was chosen as that is the age range during which routine cervical cancer screening is recommended in Malawi [15].

Participant recruitment

Between November 2021 and October 2022, we purposively enrolled 35 participants from four health facilities in the PEER Study. These included 20 women who had undergone HPV self-collection and 15 HCPs, such as cervical screening nurses, clinic in-charges, district coordinators, and officials from the Lilongwe District Health Office. The aim was to gather their perspectives on implementing mobile phone-based HPV result delivery.

We recruited women from facilities randomized to both models 1 (Area 18 Health Center & Bwaila District Hospital) and 2 (Chileka Health Center & Lumbadzi Health Center) [3], who had undergone HPV self-collection and received their results. Women who had received their HPV results were included in this sub-study because they were best positioned to reflect on their experience with result communication and provide informed feedback on the acceptability and feasibility of mobile phone-based result delivery. Including only those who received results ensured that participants could meaningfully engage with questions related to timing, method, and preferences around result notification—core aspects of our research objectives. The interviews for women, HCPs, and Lilongwe DHO officials were all conducted in person, though the scheduling process differed. Interviews with women were scheduled both in-person and via mobile phone, while HCPs and DHO officials were scheduled via mobile phone. The timing of the interviews was based on participants’ availability. Informed consent was obtained from all participants before the interviews, which lasted approximately 45 min.

Data collection

Participants underwent individual in-depth interviews (IDIs) administered by a locally recruited and trained research assistant fluent in both Chichewa (the local language) and English. Purposive sampling was used to recruit women, healthcare professionals (HCPs), and District Health Office (DHO) officials. Women who underwent HPV self-collection and/or received their HPV results were interviewed using a semi-structured guide developed for this study. The guide covered the following topics: [1] their views on mobile phone messaging and calls for sharing HPV results and treatment reminders; and [2] perceived barriers and facilitators to using mobile phones for delivering HPV results in cervical cancer screening. Interviews with HCPs and DHO officials focused on: [1] perceived barriers and facilitators to phone messaging and calls for HPV result sharing and treatment reminders; [2] the sustainability of the strategy; and [3] the role of health personnel in its success. The topics were chosen based on the need to explore key aspects of mobile phone-based HPV result delivery and its integration into cervical cancer screening, including user perspectives, community treatment preferences, perceived barriers and facilitators to mobile phone use, and the sustainability and effectiveness of the strategy from the viewpoints of women, HCPs, and DHO officials. All interviews were digitally audio-recorded following informed consent.

Data analysis

The recordings were transcribed and translated into English for analysis. Identifiers were redacted from the interview transcripts before analysis, and participants were assigned a unique study ID number for data capture. A total of 35 transcripts were transcribed by the research assistant, WD, and two other research assistants, MT and AT. Thematic analysis was employed to analyze the data, which involved several steps. First, the data was thoroughly reviewed to achieve familiarity, and emergent themes were extracted. Next, a codebook was created based on identified themes and structural codes from the initial interview topics and questions, with all 35 transcripts coded by the main author, JC, and the research assistant, WD, using NVivo version 14. To ensure intercoder reliability, 10% of the data was double-coded, yielding an intercoder reliability of 85%. Data related to each code was then reviewed to identify principal sub-themes, noting variations and differences between individuals. Finally, a qualitative data matrix was developed, summarizing the data in rows and columns, with results for each theme and corresponding quotes displayed in tables.

Results

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).

Discussion

In this qualitative sub-study, we evaluated the perceived barriers and facilitators to using mobile phones for delivering HPV results, and assessed the acceptability and adaptability of this delivery modality among women who had undergone HPV self-collection, HCPs, and health officials. We found that several perceived factors could influence the implementation of delivering HPV screening results through mobile phones. These factors reflect a range of perceived challenges and opportunities that shape the acceptance and adaptability of this communication approach within cervical cancer screening programs.

In this qualitative sub-study, we identified several perceived barriers and facilitators influencing the use of mobile phones to deliver HPV screening results. Key perceived barriers included limited literacy, privacy concerns, and reliance on others for message interpretation, which can compromise confidentiality and hinder adoption. Conversely, perceived facilitators—such as adaptable communication strategies, a supportive implementation climate, and essential resources (e.g., airtime, mobile devices, training)—were critical for acceptability and sustainability. The dedication and positive attitudes of HCPs also emerged as important facilitators, although resource constraints and lack of incentives remain ongoing concerns.

The research highlights the complexity of using mobile phone platforms to deliver HPV results, with literacy challenges and privacy concerns emerging as significant perceived barriers. In addition, the research highlights concern among women who either do not own mobile phones or are illiterate. These women often rely on their husbands, friends, or family members to read messages for them, or, in cases where they lack phones, to relay information from HCPs. This dependence can lead to the unintended disclosure of personal information [16, 17] related to their sexual health, causing feelings of embarrassment or discomfort. Such concerns may hinder the adoption of mobile phone communication for delivering HPV screening results [18].

Based on the results, it is evident that ensuring that messages are clear, concise, and accessible to individuals with varying literacy levels is paramount [19]. Digital communication tools have shown significant potential to improve health literacy, ultimately leading to better health outcomes [20]. However, our study demonstrates that communication through digital means must be approached with caution, as some patients may lack sufficient literacy and struggle to understand messages delivered via digital platforms like mobile phones. Moreover, the study underlines the necessity of robust security measures to uphold patient privacy and confidentiality, essential elements for building trust in the health system. Ensuring that security is upheld is important because HCPs and institutions risk civil liability if patient data stored on mobile devices is not handled securely [21]. Other studies have proposed that, in addition to implementing security measures, establishing appropriate legislation is crucial [22]. Failing to protect the privacy of patients’ medical information, such as diagnostic results, can lead to disciplinary, regulatory, and criminal penalties, as patient data can easily become public without sufficient safeguards [21].

Furthermore, results from the implementation climate theme emphasize the importance of creating a supportive environment conducive to readiness and openness among HCPs, policymakers, and health officials [19]. This includes fostering an understanding of the benefits of mobile phone messaging in streamlining communication and improving patient outcomes [23]. Communicating health results via digital platforms, such as mobile phones, saves time for both patients and HCPs and reduces treatment costs [24]. Additionally, due to its speed and efficiency, it can streamline the workflow of hospitals and clinics [24]. This innovation facilitates the monitoring and management of patients’ recovery following treatment [24, 25]. Consequently, using digital platforms for health communication can create a win-win situation [24]. However, patients and service providers need to understand the significance of this intervention for it to be effective.

While much of the literature on digital health communication emphasizes text messaging, voice calls also play a critical role, particularly in low-literacy contexts. Studies from similar low-resource settings have found that voice calls can enhance comprehension and reduce misinterpretation of sensitive health information, such as HIV test results and maternal health reminders [26, 27]. Unlike text messages, which rely heavily on the recipient’s literacy, voice calls offer a more direct and interactive method of communication that allows for real-time clarification and emotional support [26–28]. In the context of HPV results, this could be particularly valuable for ensuring that women fully understand the implications of their results and the next steps in care.

However, voice calls are not without challenges. They require both parties to be available simultaneously, which can lead to missed connections. Privacy concerns may also be heightened during voice calls, especially if clients cannot speak freely due to household dynamics [28, 29]. Despite these limitations, incorporating voice calls as part of a hybrid communication strategy may offer a more inclusive and patient-centered approach to delivering sensitive health information.

Our study also highlights the pivotal resources and strategies necessary for the sustainable implementation of mobile phone use in cervical cancer screening programs. The HCPs identified several key elements crucial for ensuring the effectiveness and longevity of such strategies, which included the provision of adequate airtime, functional mobile phones, transportation for reaching clients in remote settings, and incentives for healthcare workers. Airtime and mobile phones are fundamental for maintaining consistent communication between HCPs and patients [30]. Providers noted that having these resources alone is insufficient without complementary tools and support. For example, the availability of necessary medical supplies, such as HPV testing kits and brushes, was emphasized as essential for the strategy’s success. This indicates that while digital communication is a powerful tool, its effectiveness is contingent upon the availability of all requisite materials and resources [31].

In addition to resources and incentives, the study highlights the importance of training and dedication among HCPs. Proper training ensures that providers can effectively use mobile technology to deliver results and educate patients on how to interpret these results [32]. Furthermore, the commitment and positive attitude of HCPs play a crucial role in overcoming potential challenges and delivering high-quality care [33]. Providers emphasized the need for dedication and empathy, noting that even with all resources in place, the effectiveness of the strategy hinges on the providers’ engagement and approach.

However, despite the importance of dedication, HCPs often express expectations for incentives, especially given the demanding nature of their work and the high caseloads, limited support, and challenging work environments typical in resource-limited settings like Malawi [34, 35]. Although incentives can serve as valuable motivators, the Malawian healthcare system currently cannot support these requests due to limited funding [36]. It is, therefore, essential that these incentives, when feasible, complement rather than replace the intrinsic commitment that drives effective patient care. The dedication of HCPs should remain the primary force behind quality service delivery, as true engagement stems from a commitment to patient well-being. Ultimately, incentives should be structured to reinforce and support providers’ dedication, maintaining a balance between external motivation and a genuine drive to deliver compassionate care.

Strengths and limitations

A key strength of this study lies in its comprehensive qualitative approach, which captured diverse perspectives from multiple participants, including women who underwent HPV self-collection, HCPs, and district health officials. This multi-level engagement enabled an in-depth understanding of the perceived contextual barriers and facilitators influencing the mobile phone-based delivery of HPV results. Additionally, purposive sampling across different health facilities provided insights relevant to varied healthcare settings within the PEER Study framework. The use of in-depth interviews enabled participants to share detailed experiences and perceptions, enriching the data quality and contributing to the depth of analysis. Finally, grounding the study within an ongoing HPV screening program ensured the findings are directly applicable and timely for informing scalable interventions in Malawi and similar low-resource contexts.

Despite the valuable insights gained from this study, it is essential to acknowledge its limitations. Initially, our target was to recruit 40 participants, evenly distributed between 20 women and 20 HCPs. However, we faced challenges in enrolling 20 HCPs, as some held multiple positions. This led to a reduction of 5 HCPs from our initial proposal, as we opted to conduct a single interview for those who occupied multiple roles. Despite this, all 20 clients approached agreed to participate.

The reliance on self-report data and the qualitative nature of the research may introduce biases and limit the generalizability of the findings [37]. Future research endeavors could address these limitations by employing mixed-methods approaches and incorporating objective measures of strategy effectiveness. Moreover, exploring additional perceived contextual factors—such as cultural attitudes and system-level barriers—could further elucidate the complexities of implementing mobile phone communication in cervical cancer screening programs.

Furthermore, this study focused on perceived barriers and facilitators related to the mobile phone delivery of HPV test results from the perspectives of women and HCPs. However, it did not comprehensively explore broader health systems and contextual factors, such as infrastructure capacity, policy frameworks, and financial considerations, that are critical for the successful implementation and scale-up of such interventions. Future research should address these wider determinants to inform sustainable integration of mobile technology into cervical cancer screening programs.

Moving forward, identifying additional strategies to address the perceived barriers and enhance the facilitators will be paramount to improving the delivery of HPV screening results through mobile phones. Tailored communication approaches, enhanced privacy measures, and supportive implementation environments are essential considerations for HCPs, policymakers, and health officials involved in cervical cancer screening programs [38]. Furthermore, providing multiple secure options for receiving results, such as returning to the clinic, getting the results in-person from their HSA (if tested in the community), secure phone calls, or secure text messages, allows patients to choose the method that works best for them for communicating HPV results. By collaboratively addressing these perceived factors, HCPs and health officials, including women can optimize the effectiveness and accessibility of mobile health technologies, ultimately improve patient outcomes and reducing the burden of cervical cancer.

Conclusion

This qualitative sub-study demonstrates that mobile phone communication presents a promising approach to enhance HPV result delivery in Malawi. Both HCPs and HPV-Screened women recognized the potential benefits of mobile phone-based communication, including convenience, cost savings, and improved follow-up for women unable to return to health facilities. However, the study also highlights several critical perceived barriers that must be addressed for successful implementation. These include concerns about privacy, limited literacy and phone ownership among women, including other challenges such as a lack of airtime and functional equipment for health workers, and the need for culturally appropriate messaging strategies. Importantly, participants emphasized the significance of tailoring communication methods to ensure confidentiality and trust, as well as sensitizing clients in advance. Ultimately, while mobile phone communication can facilitate timely result delivery and reduce delays in treatment, its success depends on addressing perceived barriers and ensuring that implementation is contextually grounded, adequately resourced, and supported by both clients and healthcare systems.

Abbreviations

CHWs

Community health workers

DHO

District health office

HCPs

Health care providers

HPV

Human papillomavirus

HSAs

Health surveillance assistants

IDIs

In-depth interviews

KUHeS

Kamuzu university of health sciences

LMICs

Low and middle-income countries

MoH

Malawi ministry of health

PEER

Partnerships for enhanced engagement in research

SMS

Short Message Service

UNC

University of North Carolina

Authors’ contributions

JC assisted with the study design, supervised its implementation, conducted the analysis, and contributed to manuscript writing. WD assisted with coding and data collection, served as a research assistant, administered interviews, and translated them from Chichewa to English. LC, JHT, and AB designed the study, supervised its implementation and analysis, and contributed to manuscript writing. All authors reviewed and approved the final manuscript.

Funding

This work was funded by the UNC Project Malawi Cancer Program through the Mentored Pilot Grant Program, supported by the UNC Lineberger Comprehensive Cancer Center (LCCC). The grant aimed to stimulate new research initiatives by providing support to generate preliminary data for future funding applications.

Data availability

The data supporting the findings of this study are not publicly available due to considerations related to participant privacy and confidentiality but can be made available upon reasonable request from the corresponding author. Requests will be evaluated in accordance with ethical guidelines and institutional policies to ensure the responsible sharing of research data while safeguarding the anonymity and well-being of study participants.

Declarations

Ethics approval and consent to participate

The study protocol, the informed consent form, and study-related documents were reviewed and approved by the Malawi National Health Sciences Research Ethics Committee (NHSRC) (Approval number #21/08/2758) and the University of North Carolina Institutional Review Board (UNC IRB) (Approval number LC 2122). Before beginning the study, approval was also sought from local authorities and the Lilongwe District Director of Health and Social Services. Informed consent was also obtained from all participants prior to their participation in the study. This study did not involve any experiments on humans or the use of human tissue samples. It involved interviews using in-depth interviews (IDIs) only. All procedures were conducted following relevant guidelines and regulations, including the Declaration of Helsinki, and ethical principles were adhered to throughout the study. The main study on which this sub-study was built is registered under ClinicalTrials.gov ID NCT04286243.

Consent for publication

This manuscript includes the personal details of participants. Explicit written consent for publication has been obtained from all participants to ensure compliance with BioMed Central policies. In cases where identifying information such as age, gender, and profession is presented alongside other details, care has been taken to limit the risk of compromising participant anonymity. Copies of consent forms will be made available upon request to verify compliance.

Competing interests

The authors declare no competing interests.