Abstract
BackgroundCervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. “Screen and treat” (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing “screen and treat” from the provider perspective, or about thermocoagulation as a lesion removal technique.MethodsInformed by the Consolidated Framework for Implementation Research (CFIR), we conducted interviews with ten experienced “screen and treat” providers in Malawi. We asked questions based on the CFIR Guide, used the CFIR Guide codebook for a descriptive analysis in NVivo, and added recommended modifications for studies in low-income settings.ResultsSeven CFIR constructs were identified as positively influencing implementation, and six as negatively influencing implementation. The two strong positive influences were the relative advantage of thermocoagulation versus cryotherapy (Innovation Characteristics) and respondents’ knowledge and beliefs about providing “screen and treat” (Individual Characteristics). The two strong negative influences were the availability of ongoing refresher trainings to stay up-to-date on skills (Inner Setting, Implementation Climate) and insufficient resources (staffing, infrastructure, supplies) to provide “screen and treat” to all women who need it (Inner Setting, Readiness for Implementation). Weak positive factors included perceived scalability and access to knowledge/information, as well as compatibility, leadership engagement, and team characteristics, but these latter three were mixed in valence. Weak negative influences were structural characteristics and donor priorities; and mixed but weakly negative influences were relative priority and engaging clients. Cross-cutting themes included the importance of broad buy-in (including different cadres of health workers and leadership at the facility and in the government) and the opportunities and challenges of offering integrated care (screening plus other services).ConclusionsAlthough “screen and treat” is viewed as effective and important, many implementation barriers remain. Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment.
Highlights
Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches
Our findings suggest that implementation strategies will need to be multi-level, include a diverse set of stakeholders, and explicitly address both screening and treatment
Providers in Malawi report considerable benefits of thermocoagulation versus cryotherapy, and enthusiasm for providing “screen and treat” -- but many challenges persist especially related to the Inner Setting, Process, and Systems
Summary
Cervical cancer remains a major cause of mortality and morbidity in low- and middle-income countries, despite the availability of effective prevention approaches. “Screen and treat” (a single-visit strategy to identify and remove abnormal cervical cells) is the recommended secondary prevention approach in low-resource settings, but there has been relatively scarce robust implementation science evidence on barriers and facilitators to providing “screen and treat” from the provider perspective, or about thermocoagulation as a lesion removal technique. In lower-resource settings like Malawi— which has the greatest cervical cancer burden in the world [6, 7]—the World Health Organization recommends a single-visit “screen and treat” (S&T) strategy using visual inspection with acetic acid (VIA) to examine the cervix and immediate removal of any abnormal cells (with referral to specialist care for more complicated cases) [3]. Previous studies about women’s experiences with S&T have identified challenges including supply/equipment stock-outs, lack of available providers, hesitations about male providers, and poor patient-provider communication [32,33,34,35]—but very little research has focused on the experiences of health care workers as providers of S&T
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