School of Nursing, University of Pennsylvania, Philadelphia, PA, USA.
Implement Sci. 2018 Feb 9;13(1):28. doi: 10.1186/s13012-018-0718-9.
Developed countries, such as the USA, have achieved significant decreases in cervical cancer burden since the introduction of Pap smear-based programs in the 1960s. Due to implementation barriers and limited resources, many countries in sub-Saharan Africa (SSA) have been unable to attain such reductions. The purpose of this review is to evaluate implementation strategies used to improve the uptake and sustainability of cervical cancer prevention programs in SSA.
A reviewer (LJ) independently searched PubMed, Ovid/MEDLINE, Scopus, and Web of Science databases for relevant articles with the following search limits: English language, peer reviewed, and published between 1996 and 2017. The 4575 search results were screened for eligibility (CJ, LJ) to identify original research that empirically evaluated or tested implementation strategies to improve cervical cancer prevention in SSA. Fifty-three articles met criteria for inclusion in the final review. AA, CJ, and LJ abstracted the included articles for implementation-related content and evaluated them for risk of bias according to study design with the National Heart, Lung, and Blood Institute's (NHLBI) Quality Assessment Tools. Results were reported according to PRISMA guidelines.
The 53 included studies are well represented among all sub-Saharan regions: South (n = 16, 30.2%), West (n = 16, 30.2%), East (n = 14, 26.4%), and Middle (n = 7, 13.2%). There are 34 cross-sectional studies (64.2%), 10 pre-posttests (18.9%), 8 randomized control trials (15.1%), and one nonrandomized control trial (1.9%). Most studies are "fair" quality (n = 22, 41.5%). Visual inspection with acetic acid (VIA) (n = 19, 35.8%) was used as the main prevention method more frequently than HPV DNA/mRNA testing (n = 15, 28.3%), Pap smear (n = 13, 24.5%), and HPV vaccine (n = 9, 17.0%). Effectiveness of strategies to improve program implementation was measured using implementation outcomes of penetration (n = 33, 62.3%), acceptability (n = 15, 28.3%), fidelity (n = 14, 26.4%), feasibility (n = 8, 15.1%), adoption (n = 6, 11.3%), sustainability (n = 2, 3.8%), and cost (n = 1, 1.9%). Education strategies (n = 38, 71.7%) were used most often but have shown limited effectiveness.
This systematic review highlights the need to diversify strategies that are used to improve implementation for cervical cancer prevention programs. While education is important, implementation science literature reveals that education is not as effective in generating change. There is a need for additional organizational support to further incentivize and sustain improvements in implementation.
自 20 世纪 60 年代巴氏涂片检测项目引入以来，发达国家（如美国）在降低宫颈癌负担方面取得了显著成效。由于实施障碍和资源有限，撒哈拉以南非洲（SSA）的许多国家无法实现这种减少。本综述的目的是评估在 SSA 提高宫颈癌预防计划的采用和可持续性的实施策略。
审查员（LJ）独立检索了 PubMed、Ovid/MEDLINE、Scopus 和 Web of Science 数据库中与以下搜索限制相关的文章：英语、同行评审、发表于 1996 年至 2017 年之间。对 4575 个搜索结果进行了筛选，以确定符合条件的原始研究，这些研究通过实证评估或测试实施策略来改善 SSA 的宫颈癌预防。53 篇文章符合纳入最终综述的标准。AA、CJ 和 LJ 对纳入的文章进行了与实施相关的内容提取，并根据研究设计（国家心脏、肺和血液研究所（NHLBI）的质量评估工具）评估了它们的偏倚风险。结果根据 PRISMA 指南报告。
53 项纳入的研究在所有撒哈拉以南地区都有很好的代表性：南部（n=16，30.2%）、西部（n=16，30.2%）、东部（n=14，26.4%）和中部（n=7，13.2%）。有 34 项横断面研究（64.2%）、10 项前后测试（18.9%）、8 项随机对照试验（15.1%）和 1 项非随机对照试验（1.9%）。大多数研究的质量为“中等”（n=22，41.5%）。醋酸视觉检查（VIA）（n=19，35.8%）的使用频率高于 HPV DNA/mRNA 检测（n=15，28.3%）、巴氏涂片（n=13，24.5%）和 HPV 疫苗（n=9，17.0%）。改善计划实施的策略的有效性是通过实施结果来衡量的，包括渗透率（n=33，62.3%）、可接受性（n=15，28.3%）、保真度（n=14，26.4%）、可行性（n=8，15.1%）、采用（n=6，11.3%）、可持续性（n=2，3.8%）和成本（n=1，1.9%）。教育策略（n=38，71.7%）是最常用的，但效果有限。
本系统综述强调需要使用于改善宫颈癌预防计划实施的策略多样化。虽然教育很重要，但实施科学文献表明，教育在产生变化方面并不那么有效。需要更多的组织支持，以进一步激励和维持实施方面的改进。
