Integrating the behavior change wheel and co-design approach in selecting strategies for improving cervical cancer screening literacy among rural women living with HIV in Eastern Uganda

Women living with HIV (WLHIV) require more frequent cervical cancer screening than HIV negative women. However, uptake of cervical cancer screening services integrated into HIV care at most rural public health facilities in Eastern Uganda is low, below 50%. This is attributed to low cervical cancer screening literacy among rural WLHIV: limited ability to access, understand, and apply cervical cancer screening information. There is a need for evidence-based, context-specific, theory-informed strategies that target multi-level barriers and facilitators of cervical cancer literacy among these women. This study used research evidence, theory, and stakeholder engagement in selecting strategies for improving cervical cancer screening literacy among rural WLHIV. This qualitative study applied research evidence to the Behavior Change Wheel (BCW) and co-design approach. The eight steps of the BCW included: 1) defining the problem in behavioral terms, 2) selecting the target behavior, 3) specifying the target behavior, 4) identifying what needs to change, 5) identifying intervention functions, 6) identifying policy categories, 7) identifying Behavior Change Techniques (BCT), and 8) identifying the mode of delivery. We conducted four parallel co-design sessions with 12 health care providers and 16 rural women at steps 3 and 4 of the BCW. We formulated eighteen behavioral targets that were linked to all Capability, Opportunity, and Motivation-Behavior (COM-B) behavioral determinants. Nine behavioral targets were selected under the education, persuasion, enablement, and training intervention functions, as well as the communication/marketing and service provision policy categories. We identified ten most appropriate BCTs and four modes of delivery, which translated into four strategies, namely: 1) trained cervical cancer screening peer educators, 2) cervical cancer screening education video, 3) improved cervical cancer screening IEC charts, and 4) train midwives to prepare small portions of acetic acid for individual patient screening. The BCW provided a comprehensive framework that integrated a co-design approach and applied research evidence in selecting context-specific and feasible strategies for improving cervical cancer screening literacy among rural WLHIV. Future research is needed to design and evaluate these strategies.