Design and Evaluation of an mHealth Intervention for HPV Knowledge and Cervical Cancer Screening

Abstract

Background: Human papillomavirus (HPV) is a leading cause of cervical cancer, ranking fourth globally and eleventh in Iran. Although the incidence in Iran is about one-tenth of that in western countries, the average age of onset is approximately ten years higher than the global average. Nevertheless, screening rates remain low, largely due to limited knowledge among women. Objectives: This study aimed to develop a mobile application to enhance women's knowledge of HPV, cervical cancer, and Pap smear. Methods: A mixed-method study was conducted in Ardabil (northwest Iran) from 2023 to 2024, involving the development of a user-centered mobile application and a single-blind clinical trial to assess its effectiveness. The application was designed based on the health belief model (HBM), with educational and screening content developed in accordance with World Health Organization (WHO) guidelines and evidence-based sources and validated by both app users [Content Validity Index (CVI) = 0.88] and healthcare professionals (CVI = 0.87). In the randomized clinical trial, 380 eligible women (aged 15 - 45 years) were assigned to either the intervention (app user) or control groups using simple random sampling. The intervention group received access to the mobile application while the control group received routine health center care. Women’s HPV knowledge and health belief about Pap smear were evaluated at baseline, immediately after the intervention, and eight weeks later using expert-validated questionnaires. Data were analyzed using SPSS software employing chi-square tests, and repeated measures ANOVA analysis (RM-ANOVA). Results: Among the 357 women analyzed, the mean age was 30.59 years. The majority were housekeepers [234 (65.5%)] and college graduates [195 (54.6%)]. Among participants, 30% reported no history of childbirth. Before the intervention, no significant differences were observed between the intervention group (n = 175) and the control group (n = 182) in knowledge or HBM constructs. Post-intervention, the user group showed significant improvements in knowledge (MD: 0.79; 95% CI: 0.41 to 1.17), perceived susceptibility (MD: 4.17; 95% CI: 3.26 to 5.08), severity (MD: 4.03; 95% CI: 3.13 to 4.93), benefits (MD: 3.46; 95% CI: 2.59 to 4.33), self-efficacy (MD: 2.66; 95% CI: 1.92 to 3.40), and cues to action (MD: 2.35; 95% CI: 1.62 to 3.08; all P < 0.001), along with a reduction in perceived barriers (MD: -4.60; 95% CI: -5.53 to -3.67) compared with control group (all P < 0.001). The Pap smear uptake rate in the user group increased significantly (30.28%) compared to the control group (10.44%, P = 0.001). Conclusions: The mobile application developed based on the HBM effectively enhanced women's knowledge and health beliefs regarding cervical cancer and Pap smear screening. It also significantly increased screening uptake, underscoring the potential of mobile health (mHealth) interventions in promoting preventive behaviors and supporting public health initiatives.