Objective Many women in Africa are diagnosed with advanced breast cancer. We explored Malawian breast cancer patients’ perspectives about their diagnosis and ability to access care to identify help-seeking behaviors and to describe factors influencing delay. Methods We purposively sampled 20 Malawian breast cancer patients to conduct in-depth interviews. Transcripts were double coded to identify major themes of breast cancer help-seeking behaviors and what delayed or facilitated access to care. Results We outlined a breast cancer help-seeking pathway describing decisions, behaviors, and interactions from symptom presentation to receipt of cancer care. Patients were largely unaware of breast cancer and did not immediately notice or interpret symptoms. As symptoms progressed, women inferred illness and sought help from social networks, traditional remedies, and medical care. Economic hardship, distance to the facility, provider knowledge, health system factors, and social norms often delayed reaching the facility, referrals, diagnosis, and receipt of care. Conclusions Social-contextual factors at the individual, interpersonal, and health system, and societal level delay decisions, behaviors, and access to breast cancer detection and appropriate care. Practice Implications A comprehensive approach to improving breast cancer early detection must address public awareness and misconceptions, provider knowledge and communication, and cancer care delivery.

Background Cervical cancer is one of the leading causes of cancer death among women worldwide, with more than 85% of cases occurring in low- and middle-income countries. Human papillomavirus (HPV) screening allows for self-collection with the potential to increase coverage, but still requires triage to identify which HPV+ women need diagnostic and treatment procedures. However, achieving high levels of triage adherence can be challenging, especially among socially vulnerable women. This paper describes the ATICA protocol (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish), aimed at evaluating the implementation strategy and the effectiveness of a multi-component mobile health (mHealth) intervention to increase adherence to triage among women with HPV+ self-collected tests. Methods We will use an effectiveness-implementation hybrid type I trial with a mixed-methods evaluation approach. A cluster randomized trial design including 200 community health workers (CHWs) will evaluate whether the mHealth intervention increases adherence to triage among HPV+ women who self-collected at home during a CHW visit within 120 days after a positive result. The intervention includes an initial mobile phone text message (SMS) alert and subsequent reminders sent to HPV+ women. For those who do not adhere to triage within 60 days of a positive HPV test, an email and SMS will be sent to the CHWs to promote contact with these women during home visits. We will use the Consolidated Framework for Implementation Research (CFIR) as an organizing and analytic framework to evaluate the implementation of the intervention while also drawing on Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM). We will conduct a self-administered, semi-structured survey of CHWs, semi-structured interviews with local health authorities, and a survey of HPV+ women. Combining both qualitative and quantitative data will provide rich insights into local implementation challenges and successes. Discussion Findings from the implementation evaluation will be applicable to programs that use or are planning to incorporate HPV self-collection and/or mHealth interventions in different settings and countries. This innovative study will also serve as a model for using implementation science in the region. Trial registration ClinicalTrials.gov, NCT03478397 . Registered on 20 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3229-3) contains supplementary material, which is available to authorized users.

Objective To assess the acceptability and preferences of HPV screening with self‐sampling and mobile phone results delivery among women living with HIV (WLWH) in Botswana, as an alternative to traditional speculum screening. Methods WLWH aged 25 years or older attending an infectious disease clinic in Gaborone were enrolled in a cross‐sectional study between March and April 2017. Women self‐sampled with a flocked swab, had a speculum exam, and completed an interviewer‐administered questionnaire about screening acceptability, experiences, and preferences. Results Of the 104 WLWH recruited, 98 (94%) had a history of traditional screening. Over 90% agreed self‐sampling was easy and comfortable. Ninety‐five percent were willing to self‐sample again; however, only 19% preferred self‐sampling over speculum exam for future screening. Preferences differed by education and residence with self‐sampling being considered more convenient, easier, less embarrassing, and less painful. Speculum exams were preferred because of trust in providers’ skills and women's low self‐efficacy to sample correctly. Almost half (47%) preferred to receive results via mobile phone call. Knowledge of cervical cancer did not affect preferences. Conclusion HPV self‐sampling is acceptable among WLWH in Botswana; however, preferences vary. Although self‐sampling is an important alternative to traditional speculum screening, education and support will be critical to address women's low self‐efficacy to self‐sample correctly.