Evaluating Determinants and Strategy Implementation of the Single-Visit Screen and Treat Approach with Thermal Ablation in Kenya

Abstract

Introduction: The availability of effective cervical cancer prevention interventions creates a clear pathway towards elimination. However, cervical cancer remains the leading cause of cancer-related deaths among women in low- and middle-income countries, primarily attributed to persistent implementation gaps. This dissertation explores the implementation of the single-visit, screen and treat approach with visual inspection with acetic acid (VIA) and thermal ablation (SV-SAT+TA) by identifying key determinants, characterizing provider-led strategy adaptations, and evaluating the alignment between implementation strategies and contextual barriers. Methods: This dissertation is nested within a hybrid type III implementation trial aimed at developing and evaluating implementation strategies to support the national scale-up of the single-visit screen and treat approach using VIA and thermal ablation across 10 health facilities in Kenya. Chapter 2 used qualitative methods to identify barriers and facilitators to the implementation of the SV-SAT+TA among 34 participants: 20 frontline health care providers, 10 health facility managers, and 5 policymakers. In-depth interviews were conducted and guided by the adapted Consolidated Framework for Implementation Research (CFIR) for LMICs. In Chapter 3, we applied the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) to systematically document and track adaptations to the TIBA implementation strategies across the 10 health facilities. FRAME-IS guided the development of the Excel tracking sheets. Data was collected monthly by Technical Assistants through site visits, direct observations, and field notes. Chapter 4 employed a convergent mixed-methods approach to evaluate barrier-strategy matching using surveys and small group discussions with 40 participants, mainly frontline healthcare providers and facility managers. Results: Findings from Chapter 2 identified leadership engagement, the relative advantage of thermal ablation over cryotherapy, and self-efficacy among providers as drivers of successful SV-SAT+TA implementation. Conversely, lack of essential commodities, infrastructural limitations, shortage of trained staff, and recruitment challenges emerged as barriers to implementation. Building on Chapter 2, findings from Chapter 3 revealed that most adaptations occurred early in implementation and were primarily education (57%) and resource-related (21%). Adaptations mainly targeted provider adoption of the SV-SAT+TA, and the rate of adaptations declined over time. In Chapter 4, we found that 71% of the pre-identified barriers were successfully addressed through well-matched strategies focusing on improving clinic workflows, training, and community engagement. However, structural issues such as staffing, client follow-up remained inadequately addressed. Conclusion: This dissertation provides critical insights into the contextual and system-level factors influencing the implementation of cervical cancer prevention interventions in Kenya. The lessons learned have a broad relevance for scaling and sustaining cervical cancer prevention efforts across LMICs.