Background
In 2023–2024, the Mexican Institute of Social Security (IMSS), which provides healthcare to approximately 51% of Mexico’s population, implemented a pilot HPV self-sampling program for cervical cancer screening among socioeconomically disadvantaged female factory workers. While workplace-based kit distribution and collection reduced initial access barriers, substantial gaps in diagnostic completion persisted. These gaps highlight a critical implementation challenge: ensuring continuity across the cervical cancer prevention cascade from screening to diagnosis and treatment. Understanding the multilevel determinants shaping diagnostic follow-up among HPV-positive women is essential to address structural inequities that limit the preventive potential of HPV-based screening.
Objectives
To identify individual-, interpersonal-, and health system–level barriers and facilitators influencing diagnostic completion among HPV-positive women, from triage through diagnostic confirmation and treatment.
Methods
We conducted semi-structured interviews with 19 HPV-positive female factory workers from 10 maquilas. Given the program’s risk-based triage strategy, we also interviewed healthcare personnel from 11 primary care clinics providing cytology triage for women with non-HPV16/18 positivity (n=11) and clinical staff from two colposcopy units responsible for diagnosis and treatment (n=5). Interviews explored experiences navigating follow-up, perceptions of care, communication processes, and organizational factors shaping diagnostic trajectories. A multidisciplinary team conducted inductive thematic analysis to identify barriers and facilitators across the diagnostic pathway.
Results
Women commonly described IMSS services as time-consuming and difficult to navigate, citing long waiting times and indirect costs. Program innovations—including workplace-based delivery, self-sampling, electronic delivery of screening results, and centralized colposcopy scheduling by phone—were widely perceived as facilitators that reduced clinic visits and logistical burden. However, these same processes created challenges for women with limited digital literacy or unstable contact information, contributing to missed appointments and delays.
Receiving HPV-positive results often triggered anxiety, fear of cancer, and confusion, compounded by limited knowledge of HPV and stigma related to sexual transmission. Social support networks positively influenced follow-up by helping women cope with distress and navigate next steps. Among women who continued care within IMSS, nurses played a pivotal role in addressing emotional concerns, clarifying the HPV–cancer relationship, and mitigating stigma. Some women sought private care to expedite evaluation, particularly given the novelty of HPV testing within a historically cytology-based screening system.
Inadequate clinician communication—especially regarding discordant results (HPV-positive/cytology-negative)—undermined understanding of triage pathways and appropriate follow-up. Deviations from protocols and inconsistent interpretation of triage criteria generated inefficiencies, unnecessary clinic visits, and delays in diagnostic resolution. Although cost savings motivated continued IMSS use, this was often weighed against perceptions of poor quality of care.
Conclusions/Implications
Expanding screening access alone is insufficient to achieve cervical cancer prevention goals. Strengthening the diagnostic cascade requires implementation strategies that address emotional, informational, and organizational barriers following HPV-positive results, while reinforcing clear communication, protocol fidelity, and referral coordination. These findings provide actionable insights for optimizing HPV-based screening programs and reducing inequities in resource-constrained health systems.