Our Work

Project Precáncer seeks to demonstrate that the WHO’s elimination targets are achievable by piloting the participatory design and implementation of an improved screening program in the Iquitos-sur health network of Loreto. We work within the complex and adaptive regional health system seeking to reconcile different perspectives and practices through collaboration with local health professionals, authorities, and decision-makers to reach a common goal: participatory design of a sustainable and effective cervical cancer screening program.



Sustainable improvement of cervical cancer screening effectiveness is an implementation research challenge. The INSPIRE (Integrative Systems Praxis for Implementation Research) model is an operational roadmap that combines and draws upon different frameworks, theories and strategies and was developed to overcome this specific challenge. There are four iterative phases to the model, all of which have a specific objective and are theoretically grounded in the consolidated framework for implementation research (CFIR) and health systems frameworks. Phase 1 seeks to create a shared understanding of the current system, including using mixed methods research and soft systems methodology (SSM). This is done by creating visuals, particularly process maps and flowcharts, of the current system to highlight differences in stakeholder perspectives and the system’s interconnected nature.  The phase 2 objective is to find leverage for change through facilitating discussions and analyses comparing different scenarios that might be successful in sustainably improving screening system effectiveness. The objective of phase 3 is to act strategically by collaboratively designing and executing the implementation plan.  In phase 4, the research team and collaborators learn and adapt. Changes in system function are monitored using an interrupted time-series design and elements of SSM are used to monitor the human agency affecting system performance. The INSPIRE model is grounded in participatory action research (PAR), acknowledging that an internally derived intervention is essential for high adoption and sustainability in global implementation research. 

To learn more about the INSPIRE model from Patti Gravitt, one of our principal investigators, click here.

What is Participatory Action Research (PAR)?

Participatory Action Research (PAR) emphasizes a collaborative environment between researchers and local stakeholders. It recognizes the unique strengths and realities of the target population and seeks to facilitate sustainable implementation of an intervention that is locally adapted, appropriate, acceptable, feasible, and cost-effective.  “Taking a Participatory Research approach results in increased capacity of community members and researchers, productive conflicts followed by useful negotiation, increases the quality of outputs and outcomes over time, increases the sustainability of project goals beyond funded time frames and during gaps in external funding and creates system changes and new unanticipated projects and activities” -Jagosh, et al. [1] Integrating PAR into implementation research designs can lead to broader capacity building of the health system which can translate beyond the initial intervention target.

How did we apply PAR?

The origins of Proyecto Precáncer came directly from a desire of local stakeholders to translate technologies used in HPV-related research [2]  to clinical practice. Stakeholder engagement is the core of our four-phased INSPIRE model. Because the local stakeholders are so fundamental to Proyecto Precáncer, we refer to them as our collaborators.  Since the project’s inception, the research team has informed local opinion leaders about the project’s goals and strategically identified and recruited individuals to become project collaborators participating in work group meetings and design workshops. The Proyecto Precáncer research team functions as facilitators, consultants, and technical assistants who support the stakeholders through compiling information, calling upon professional partnerships and coordinating the logistical resources necessary. This allows local stakeholders to be prepared to make informed decisions and to take action to improve the cervical cancer screening program that serves their community. We applied the following research methods to operationalize the INSPIRE model. 
the system
We identified key players in the system and assessed their engagement and participation with help of the Alignment, Interest and Influence Matrix (AIIM) tool. We held introductory meetings with them which led to obtaining formal cooperation agreements and defining roles.

Identified stakeholders in screening program

The team then developed mental models (visual maps) of an ideal system and of the current screening program, including screening and treatment outcomes. This helped stakeholders analyze their system, ask themselves questions, and consider barriers, resource constraints, and policies.
In order to establish the narrative of the system, we conducted key informant interviews and focus group discussions with health professionals asking them about their perspectives on the current system and what the system looks like. Participating stakeholders were stratified according to their position in the health system hierarchy as suggested by the Strategic Assumption Surfacing and Testing (SAST) systems tool. Understanding of the user´s (women) perspective was possible through qualitative interviews with women, a Knowledge, Attitudes, and Practices (KAP) survey and Time-cost-distance analysis of screening level of care.
Different process maps were developed over time to make the system visible. Initial flowcharts depicted the cervical cancer prevention system from three perspectives: user’s perspective (women), specimen sample, and data flow (registry information). These flowcharts highlighted barriers such as fragmentation, redundancies, and delays. Swim-lane diagrams were then developed for each of the three thematic flowcharts by the team and reviewed and validated by stakeholders in order to organize processes by physical spaces and to “see” where steps could be reduced.

Patient flow: positive screen referral through the regional hospital for colposcopy 

Stakeholders were invited to participate in design workshops to review the visuals of the system and identify barriers and facilitators. Simple simulation models using our scenario analysis tool, “Cervical cancer screening impact filtering tool” (CxCaSIFT), allowed participatory evaluation of the impact of possible changes across the screening pathway. These changes were selected from the options for screening in the national guidelines. In the workshop, dialectic debates were facilitated keeping stakeholders mindful of implementation outcomes such as feasibility, cost, sustainability, etc.
*Note: This is a ‘beta version’ of CxCaSIFT. We are revising it to be more user friendly in a web-based format. Any and all feedback is welcome and can be emailed to PGravitt@som.umaryland.edu. Please reference Proyecto Precáncer (Gravitt/Paz-Soldán, Principal Investigators) - Funding from the US National Cancer Institute Grant 1R01-CA190366 if using CxCaSIFT.

CxCaSIFT Output

Using work group soft systems methodology, stakeholders designed context-tailored cervical cancer elimination strategies (HPV testing and visual triage for ablative therapy (TVT-TA) at the primary level) and a formal implementation blueprint.
The working groups developed implementation planning at primary and referral levels including: training sessions for health professionals (TVT-TA, HPV laboratory testing, M & E, communication, and counseling) and infrastructure development for the laboratory and health establishments. The team also initiated staging for implementation scale-up.
updated prueba-vph-OurWork.
Learn and
M & E for primary implementation outcomes will be ongoing and shared with stakeholder groups. Multilevel key informant interviews and focus group discussions with health professionals will be held to identify the way the initial implementation plan is being adopted in each health establishment. These interviews and discussions will also identify health professionals' views on how the strategy could be improved and identify barriers and facilitators. The user’s (women) perspective will be captured through key informant interviews with HPV+ women treated with TA about their experiences with TVT-TA right after treatment and 6 weeks after. 
Re-design workshops will be held with key stakeholders to discuss strengths and barriers of the implementation strategy and adapt the implementation plan as needed. These discussions are always guided by the implementation outcome variables (adoption, acceptability, appropriateness, feasibility, fidelity, cost, penetration, and sustainability). Once the new screening strategy is more stabilized post-implementation, media will be used to increase reach and advisory boards, working groups, and clinical implementation team meetings will be held.