Evaluating the adoption, implementation, and maintenance of a cervical precancer treatment in El Salvador

PROJECT ABSTRACT Much of what we know about how and why evidence-based interventions (EBIs) are adopted, spread, and sustained comes from high-income countries; lack of research produced in low- and middle-income countries (LMICs) limits the generalizability of current data. To bridge this gap, it is critical to understand how features commonly found in LMICs shape implementation outcomes. The recent World Health Organization's (WHO) call to eliminate cervical cancer (CC) provides a timely opportunity to gather such evidence, as it has generated significant momentum to introduce prevention-focused EBIs to regions with moderate and high disease burden. Vaccination, screening, and triage have received some attention, but there is very limited data on the uptake, implementation, and sustainability of cervical precancer treatments. Thermal ablation (TA) is a safe and effective treatment that has rapidly gained popularity as a point-of-care alternative to gas-based cryotherapy, the most widely used cervical precancer treatment in LMICs. TA was added to WHO recommendations in 2019, and several LMICs have included it in their guidelines, including El Salvador. US-based and international agencies have made TA devices available to at least 14 LMICs, and there is great interest in expanding this practice. El Salvador, which recently included TA in its cancer control guidelines, received a donation of 70 TA units as part of this trend and began to roll out the treatment in October 2022. As an early adopter, El Salvador provides a unique opportunity to investigate the integration of a new EBI in the national health system, assess current implementation outcomes, and identify leverage points that can promote sustainability. We have assembled a multi-disciplinary team of US and El Salvador-based researchers with extensive experience in the country to assess the early implementation of TA in the cervical cancer prevention program and generate evidence for future scale-up and sustainment. The research will be completed through the following: Specific Aim 1) Conduct an observational mixed-method post-implementation evaluation of the early implementation of TA in El Salvador guided by the Expanded RE-AIM framework; Sub-Specific Aim 1.1) Conduct a micro-costing analysis to compare delivery costs of cryotherapy vs. TA as treatments for cervical precancer; and Specific Aim 2) Using an implementation mapping approach, identify successes and gaps in the implementation strategies used to introduce TA in El Salvador. Findings will be instrumental in developing an R01 study to develop and test implementation strategies of cervical cancer prevention EBIs in El Salvador and other LMICs.