Table 1.

Experiences and perceptions of CHNs, smartphone-based VIA cervical cancer screening, Accra, Ghana, 2015

Theme	Quote
Perceptions and experiences regarding onsite training and smartphone-based mentorship
In-person training perceptions	“During the training because of the way our teacher taught us, the whole thing, I became very much confident that when it comes to screening a client it wouldn’t be difficult for me because from the beginning we learnt about the theory and as the time went on we learnt about the practical. At least I had the chance during a day to screen about three to four clients by the end of the program (so) I was very much confident to screen clients for cervical cancer” [CHN3].
	“…the theory was a bit in a haste, I didn’t understand what (the lecturer) was saying and that was my first time of hearing those big big words but when I got to the practical stage I understood” [CHN6]
Importance of 3-month support period	“That one it has been very much helpful to us because there’re some cases that you will see them to be positive or sometimes you will see them to be negative but when you communicate with them (mentors) you will see that sometimes the feedback or the answer they give you is quite different from what you see… after we communicate with them (mentors) sometimes they freshen our memories on what we learnt so far so that you will be able to know (why) that that this is also a positive or a negative so communicating with them has been very good.” [CHN7]
Importance of exposure to positive cases in learning	“…when we went for the training and we came back, it wasn’t easy to locate the SC junction and those things so for the first one month it was very perfect that we had to send the pictures to them, there were sometimes that we misjudged, for instance I had a client within that month from the first month I thought she was negative but then when I sent the picture to (mentor) she said she is not negative but positive…I didn’t see the pre-cancerous there like the way I was expecting to see but then she was able to let me see it that the person was positive so it was good that they were there to correct us before we got used to the whole thing.” [CHN7]
Adequacy of 3-month training time	“More benefits because at least I had the opportunity to train on cervical cancer and even though I may not know many things about it at least I have gotten the opportunity to know certain things about cervical cancer, I can conduct screening without any support from any facilitator, it’s a big plus for me.” [CHN4]
Peer-to-peer support and feedback	“I call some of my colleagues to help me…I will tell them I got negative so come and check, the person too will come and check, we do collaborative work we don’t do it alone, with the help of our colleagues its ok.” [CHN6]
Perceptions and experiences with using smartphone for VIA screening
Comfort with smartphone imaging	“It was very much comfortable and it was good for the clients because we made the clients aware that…we will take a picture and send it to our (expert) for them to confirm on the results that would come… (and) we made it clear to them that we would take a picture and allow them to see how their cervix is looking like so working with the smart phone has been very very good.” [CHN3]
Dealing with technical challenges for smartphone use	“…at first when we were taking the pictures it was somehow challenging so we just told our facilitator and she told us to zoom and take the picture so when we started doing that it was ok.” [CHN4]
Views on the feasibility of implementation within national programme (CHPS)
Feasibility of continuing programme	“It is possible because even now people are still asking, we give talks on it, and even after this three months we give talks, before then when we started we were finding it difficult to get the clients in doing it but after we’ve got some of them they also sent the information to others” [CHN2]
Nurses’ views and experiences regarding acceptance and comfort of screening by patients
Lack of perceived susceptibility as a challenge to recruitment for screening	“…you are not feeling sick and nothing is wrong with you and somebody just comes and says that it is harmful it can cause this and that while she knows that she is not sick so it wasn’t easy that way so you have to convince and convince before they will accept it that way” [CHN2]
Education to overcome lack of knowledge and fear of screening results	“…it was very difficult and some too were afraid that eeeiii what if I go and they tell me that I have cancer what am I going to do? So that fear was there but the education that we gave them we managed to bring them (in)” [CHN1]
Importance of existing relationships with patients	“It depends on the relationship we have with them, for the churches that we went to, my church per se I have been with them all the time so after I gave them the talk they were like ok and they received the (cervical) screening…” [CHN7]
Minimal privacy concerns	“(patients think) even if someone sees the picture of the cervix they wouldn’t know that it is you” [CHN7]
Technical, logistical and financial challenges during VIA screening
Challenges conducting the procedure screening	“For me (it) would be finding the cervix, some of them immediately you enter you find the cervix some too you suffer, some you have to try, push side and side before you get the cervix” [CHN2]
Logistic challenges conducting the screenings	“…you know the speculum we have different sizes, there was a time I was about to do a screening and I couldn’t get a speculum, all those around were small so I had to go to the other facility and get it from there and explain things to my client and ask her to go home and call her back the next day” [CHN6]
Patients lost to follow-up	“I will say some are very difficult bringing them here, when we even call them they will say I will come but at long last they don’t come.” [CHN1]
Importance of screening as a free service	“…it was free to them but now when we start doing it as part of our duty then it means the speculum and other things they would have to pay for it so it will be a bit of a challenge” [CHN3].
Overall feedback and suggestions to improvement
Pride in ability to provide screenings	“It was rewarding, being able to do it alone and then knowing that I was able to do (it), I was able to identify whether the person was negative or positive before showing it to my supervisor and the supervisor too will check and say its negative, you did a great job, its rewarding.” [CHN6]
Certificate of completion	“…we need to get certificate to prove to people because there are some educated people when they come to do the screening they expect to see something that shows that you are really trained to do the screening on them.” [CHN3]
Suggestion to use mass media for education	“Making the community know about the cervical cancer screen so creating awareness with the information … I think it will help, telling them what it is.” [CHN4] “the education must be mass as in nationwide in the media and all this.” [CHN1]
Suggestion to expand screenings to community-based locations	“…provide us with logistics …like the beds for the cervical cancer screening…all the bed were normal beds so it wouldn’t be easy for our clients to lie down for the procedure…at our weighing centers, where we do our weighing so that we will just clean the place small for privacy and then do the cervical cancer for our nursing mothers because all of them really love to do it…” [CHN3]
Suggestion to add additional chronic disease screenings	“…anytime we go into the community it is health education, health education so the community members are expecting us to do something practical to help them like checking their BP and other things and they are expecting all of these things to be free so actually we also would love to provide them with all these services (blood pressure and checking sugar).” [CHN3]

Numbers indicate the specific nurses.

CHN, community health nurse; CHPS, Community-based Health Planning and Services; VIA, visual inspection with acetic acid.