Implementing Botwana's National Cervical Cancer Prevention Programme: Providers' Fidelity To The See-And-Treat Algorithms

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Doctor of Philosophy (PhD)
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cervical cancer prevention
implementation science
program fidelity
sub-Saharan Africa
Public Health Education and Promotion
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Johnson, Lauren Gabrielle
Johnson, Lauren Gabrielle

Precancerous cervical lesions can be easily prevented and treated. Yet, cervical cancer remains the most commonly diagnosed cancer and leading cause of cancer-related deaths for women in Botswana. To address this high burden, Botswana’s Ministry of Health (MOH) established the National Cervical Cancer Prevention Programme (NCCPP), which primarily focused on secondary prevention using the evidence-based, see-and-treat approach. See-and-treat is an alternative to Pap smear that combines screening (visual inspection with acetic acid, VIA) and treatment (cryotherapy) in a single visit approach. After successful pilot testing in the capital city of Gaborone, the program was scaled-up in 2014 to 5 additional sites (Lobatse, Selebi-Phikwe, Maun, Francistown, and Mahalapye). To achieve population-level reductions in cervical cancer, the goal of scale-up is to implement health innovations with high fidelity and achieve desired coverage. Therefore, the overarching goal of this dissertation was to comprehensively assess providers’ fidelity during scale-up of see-and-treat in Botswana. Fidelity was composed of two key aspects: (1) adherence, how well nurses’ treatment and referral choices aligned with the NCCPP see-and-treat algorithm and (2) competence, the level of skill maintained when nurses performed VIA screenings. Despite significant barriers to practice, results from this dissertation suggest that Botswana’s MOH accomplished a successful scale-up. Adherence was maintained during scale-up and competence was sustained over time. When controlling for covariates using log-binomial regression, adherence did not differ significantly between pilot and scaled-up sites (p=.2205). In addition, nurses at the pilot site achieved 75.4% sensitivity and 92.4% specificity when comparing their performance in conducting VIA to that of expert physicians, which was comparable to estimates attained in the pilot test. The quantitative data collected in this study has helped to identify problematic segments of the NCCPP see-and-treat algorithm. Future qualitative interviews will further elicit how and why providers experience implementation challenges in their daily practice and the implications for program fidelity. Botswana and other resource-limited countries can utilize these results to modify the see-and-treat algorithm, develop a fidelity instrument to facilitate ongoing monitoring, and/or test strategies to improve the scale-up process moving forward.

Alison M. Buttenheim
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