DeBoer Rebecca J, Ndumbalo Jerry, Meena Stephen, Ngoma Mamsau T, Mvungi Nanzoke, Siu Sadiq, Selekwa Msiba, Nyagabona Sarah K, Luhar Rohan, Buckle Geoffrey, Lin Tracy Kuo, Breithaupt Lindsay, Kennell-Heiling Stephanie, Mushi Beatrice, Philipo Godfrey Sama, Mmbaga Elia J, Mwaiselage Julius, Van Loon Katherine
Global Cancer Program, University of California San Francisco (UCSF) Helen Diller Family Comprehensive Cancer Center, San Francisco, CA USA.
Ocean Road Cancer Institute, Dar es Salaam, Tanzania.
Implement Sci Commun. 2020 Feb 25;1:24. doi: 10.1186/s43058-020-00007-7. eCollection 2020.
Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes.
In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach.
We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of "proven" guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.
尽管近期国际上努力制定针对不同资源状况的癌症临床实践指南，但对于在低收入和中等收入国家（LMICs）进行传播和实施的最佳策略，却鲜有研究进行评估。仅发布指南是不够的。大量研究表明，针对指南应用障碍的结构化、多方面实施策略最有可能提高依从性；然而，大部分此类研究是在高收入国家开展的。迫切需要为LMICs制定并评估癌症管理的指南实施策略，以解决癌症治疗结果方面的巨大差距。
为筹备坦桑尼亚首部《国家癌症治疗指南》的发布，我们为达累斯萨拉姆海洋路癌症研究所（ORCI）基于指南的实践制定了一种理论驱动的实施策略。在此，我们使用干预映射框架对我们的过程进行详细的逐步描述。首先，我们进行了需求评估，以确定ORCI基于指南实践的障碍和促进因素。其次，我们为实施策略定义了近端目标和绩效目标。第三，我们使用能力、机会、动机和行为/行为改变轮（COM-B/BCW）框架对障碍和促进因素进行分类，选择最有可能克服目标障碍并利用促进因素的行为改变技术，并为每种技术选择可行的传播方式。第四，我们将这些传播方式组织成一个分阶段的实施策略。第五，我们将策略的每个组成部分付诸实施。第六，我们确定了干预过程、结果和影响的指标，并制定了一个评估计划，使用混合方法对其进行测量。
我们从一个著名的行为改变理论中推导出了一个强大的、多方面的指南实施策略，用于坦桑尼亚。我们确定的障碍和策略与文献中已确立的一致，增强了我们过程和结果的有效性和普遍性。通过我们严格的评估计划以及对修改和调整的系统记录，我们将描述“经过验证的”指南实施策略向LMICs的可转移性。我们希望通过详细描述我们的过程，其他人可能会努力复制它，满足在LMICs专门实施癌症指南的广泛需求。
