Implementation of new technologies designed to improve cervical cancer screening and completion of care in low-resource settings: a case study from the Proyecto Precancer
Authors: Gilman Sarah D. , Gravitt Patti E. , Paz-Soldán Valerie A. ,   on behalf of the Proyecto Precancer Study Group, Brown Joanna , Carrillo Lita , Cordova Jhonny , del Cuadro Hidalgo Daniel Lenin , Figueredo Escudero Dora Magaly , Gonzales Diaz Karina , Jerónimo José , Jorges Alcedo , Jurczuk Magdalena , Kosek Margaret , Ladrón de Guevarra Gabriela , Lopez Renso , Matos Andrea , Maria Mattos Yap Diana , Marín Jaime , Meza Graciela , Mori Jessica , Morse Rachel , Palacios Cabrejos Victor , Ríos Reyles , Ríos Jennifer , Salva Gessy , Raquel Rivas Saurin Patricia , Román Karina , Rositch Anne F. , Silva Hermánn , Smith Anna , Santos Ortiz Carlos , Soto Sandra , Tangoa Nolberto , Tracy J. Kathleen , Vásquez Javier , Vásquez del Águila Gladys Giannina 
Published: April 2024

Abstract
Background
This case study details the experience of the Proyecto Precancer in applying the Integrative Systems Praxis for Implementation Research (INSPIRE) methodology to guide the co-development, planning, implementation, adoption, and sustainment of new technologies and screening practices in a cervical cancer screening and management (CCSM) program in the Peruvian Amazon. We briefly describe the theoretical grounding of the INSPIRE framework, the phases of the INSPIRE process, the activities within each phase, and the RE-AIM outcomes used to evaluate program outcomes.

Methods
Proyecto Precancer iteratively engaged over 90 stakeholders in the Micro Red Iquitos Sur (MRIS) health network in the Amazonian region of Loreto, Perú, through the INSPIRE phases. INSPIRE is an integrative research methodology grounded in systems thinking, participatory action research, and implementation science frameworks such as the Consolidated Framework for Implementation Research. An interrupted time-series design with a mixed-methods RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) evaluation framework was used to examine the adoption of human papillomavirus (HPV) testing (including self-sampling), with direct treatment after visual inspection with portable thermal ablation, at the primary level.

Results
This approach, blending participatory action research, implementation science, and systems-thinking, led to rapid adoption and successful implementation of the new cervical cancer screening and management program within 6 months, using an HPV-based screen-and-treat strategy across 17 health facilities in one of the largest public health networks of the Peruvian Amazon. Monitoring and evaluation data revealed that, within 6 months, the MRIS had surpassed their monthly screening goals, tripling their original screening rate, with approximately 70% of HPV-positive women reaching a completion of care endpoint, compared with around 30% prior to the new CCSM strategy.

Conclusions
Proyecto Precancer facilitated the adoption and sustainment of HPV testing with subsequent treatment of HPV-positive women (after visual inspection) using portable thermal ablation at the primary level. This was accompanied by the de-implementation of existing visual inspection-based screening strategies and colposcopy for routine precancer triage at the hospital level. This case study highlights how implementation science approaches were used to guide the sustained adoption of a new screen-and-treat strategy in the Peruvian Amazon, while facilitating de-implementation of older screening practices.