Leveraging implementation science for secondary prevention of cervical cancer in South Africa

Abstract

Aim Cervical cancer is the second most common cancer and the top cause of cancer deaths amongst women in South Africa. Evidence-based interventions for secondary prevention of cervical cancer (cervical screening followed by treatment of identified pre-cancerous lesions) are available in South Africa’s health system, yet cervical cancer incidence remains high. This paper argues that this is partly due to implementation failure, i.e., deploying a good intervention ineffectively. Interventions found efficacious in controlled research settings may not achieve desired health outcomes when deployed in the real world due to implementation failure. Methods The field of implementation science offers frameworks for enhancing effective implementation. These frameworks guide the identification of implementation barriers and selection of context-relevant strategies for addressing them. This paper applies implementation science frameworks to secondary prevention in South Africa and promotes using such frameworks in cervical cancer prevention programming. Findings The problem of secondary prevention of cervical cancer in South Africa is contextualised. The paper conceptualises effective implementation as the attainment of implementation outcomes including acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, reach, and sustainability of evidence-based interventions. Drawing from the South African literature, examples of ineffective and failed implementation of secondary prevention interventions are presented including: low acceptability of screening by users and providers, sub-optimal adoption of screening provision by providers, low feasibility of hospital-centred pre-cancer treatment provision, low implementation fidelity, and limited reach of screening and pre-cancer treatment. Finally, using two examples, the paper provides practical guidance on how implementation science frameworks could be leveraged in South Africa to mitigate implementation failure. Conclusions Greater application of and capacity building in implementation science are recommended to contribute towards strengthening cervical cancer secondary prevention in South Africa.