It is not uncommon for health programs to be characterized by non-adoption, abandonment, failure to scale, or failure to integrate sustainably into practice (1). This is especially problematic, given the existing research-to-practice gap of 17 years (2). Without stakeholder engagement and program adaptation, new health programs or related innovations run the risk of experiencing poor fit to the implementation context (3). This in turn may result in barriers to acceptance, adoption, and sustainability (3). To explore and counteract these barriers, implementation science (IS) theories, models, and frameworks (TMFs), and stakeholder-engaged research approaches like systems-thinking (ST) and participatory action research (PAR) could be operationalized to increase acceptance, adoption, and sustainability of evidence-based, locally adapted screening methods, while facilitating de-implementation of technologies and systems that prove burdensome and ineffective in low-resource settings.
The focus of this case study is a strategy designed for the elimination of cervical cancer, a preventable disease that remains the 4th most common cause of female cancer worldwide, with 80% of the disease burden occurring in low-and-middle-income countries (LMICs) and higher disease burdens in low-resource settings (4). This reflects strong disparities in terms of access to care and reflects the need for adoption of effective, context-adapted prevention strategies to increase fit-to-context. In 2020, the World Health Organization launched a global strategy to accelerate the elimination of cervical cancer as a public health problem (5). For countries to be on the path towards cervical cancer elimination, the following targets should be met by 2030:
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90% of girls fully vaccinated with the HPV vaccine by 15 years of age
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70% of women screened with high-performance tests by 35 years of age, and again by 45 years of age
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90% of women identified with cervical disease treated
With less than a decade remaining before 2030, the WHO’s proposed elimination goals require rapid scale-up of effective, sustainable, and context-adapted cervical cancer screening and management programs (CCSM) (6). However, in practice, sustainable implementation and adoption of these programs has been elusive, reflecting challenges inherent in implementing multilevel interventions in complex adaptive health systems subject to frequent change and competing incentives (7).
In Perú, cervical cancer is the second leading cause of cancer death among women (8). Mortality rates are especially high in the country’s rainforest region, where women are less likely to have had a Pap test than women living on the coast (9). Since 1998, cervical cancer control has been a national priority(10); however, longstanding structural barriers to Pap-based cervical cancer screening and treatment have existed throughout Perú for decades, pointing to the need for system-wide improvement that would reliably increase women’s access to screening (11).
The aim of the Proyecto Precancer (PP) research program is to facilitate the adoption of new technologies and systems for cervical cancer screening and completion of care in the Peruvian Amazon with high cervical cancer incidence rates (6). Over the past five years, PP has engaged more than 90 stakeholders from all levels of the health system in Lima (Peru’s capital), Loreto (a large region in the Amazon, in northeastern Perú), and the Micro Red Iquitos Sur (MRIS) health network (the largest health network in Iquitos—Loreto’s capital) (6).
The MRIS network covers a population of 150,000, with a target population of 20,000 women 30–49 years of age, eligible for cervical cancer screening via HPV testing. Comprised of urban, peri-urban, and rural communities, Iquitos (~ population 400K) is the largest city in the world that is accessible only by air or river. Within Iquitos, transportation routes include networks of paved and unpaved roads that connect communities to each other, one main paved highway, and boat travel by river.
Given the setting and its influence on access to health care, local champions and researchers felt that HPV-based screening (including patient self-collection) might ameliorate some of the barriers presented by cytology-based screening programs, with the added benefit of highly sensitive and objective results. Additionally, referring all positive women to the regional hospital with limited availability of colposcopy triage appointments created significant bottlenecks for continuum of care. Hence, system stakeholders agreed to manage all eligible HPV positive women at primary health facilities, with a medical professional conducting visual triage for treatment, and managing all eligible women with ablative therapy (thermocoagulation). Only women with suspected cancer, large lesions (> 75% of transformation zone), or a transformation zone that was hard to see were referred to hospital specialists. Moreover, it was clear that a top-down approach to implementation would be unlikely to yield sustainable results, and any new evidence-based interventions would need to be supported by stakeholders, adapted to the unique local-context, and owned by the health system.
The complexity inherent in making changes to the healthcare system required reflection, understanding of a new system and the engagement of multi-level stakeholders, and a guiding map for both implementers and partners. These needs led to the development of the INSPIRE (Integrative Systems Praxis for Implementation Research) research methodology, which combined ST and PAR-based approaches with existing IS models and frameworks (REFER PATTI paper). As INSPIRE was developed, PP iteratively sought to explore the following question: “How can the use of IS models and frameworks, combined with ST and PAR approaches, influence the adoption and sustainability of new evidence-based CCSM services in a complex health system located in the Peruvian Amazon?”
The aim of this case study is to detail PP’s use of a participatory, ST and IS-guided process with stakeholders throughout the MRIS health system – and with health authorities at regional and national levels – to guide the implementation, adoption, and sustainment of new technologies for CCSM in the Peruvian Amazon (see Fig. 1).