Bridging Evidence and Equity: Advancing Cervical Cancer Screening Across the Care Cascade in Botswana Using Implementation Science Frameworks

Cervical cancer is the leading cause of cancer death among women in Botswana, with a disproportionate burden borne by women experiencing socio-economic and geographic disadvantages and those living with HIV.[1-3] Although effective screening and treatment modalities are available, inequities manifest across the cervical cancer screening cascade, including gaps in screening uptake, barriers to diagnostic follow-up, treatment, and continuity of care.[4-5] These disparities reflect the need for equity-centered implementation approaches, which require context-appropriate strategies, stakeholder engagement, and health system consolidation to move evidence-based interventions into practice.

The objective of this study is to apply implementation science frameworks to identify inequities across the cervical cancer screening cascade in Botswana to generate contextual, scalable strategies to improve equitable access, delivery, and sustainment of screening and follow-up services within the public health system.

Guided by the Consolidated Framework for Implementation Research (CFIR) and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks, this mixed-methods study aims to assess the multilevel determinants of inequitable implementation of evidence-based cervical cancer screening strategies, including HPV testing and visual inspection with acetic acid (VIA). The mixed-methods approach combines quantitative analyses of screening cascade performance across patient, geographic, and facility-level equity factors with qualitative insights from interviews, surveys, and focus groups involving patients, providers, and health system stakeholders. Implementation strategies are selected and adapted using the Expert Recommendations for Implementing Change (ERIC) taxonomy, emphasizing task-shifting, decentralization of services, and patient navigation.

Expected outcomes include increased reach of screening services and diagnostic follow-up, improved feasibility and uptake of screening interventions across underserved communities and enhanced fidelity to screening protocols in resource-limited contexts.

By embedding health equity into implementation science frameworks with a view to bolstering the cervical cancer screening cascade, this research could bridge the gap between evidence and practice by generating actionable knowledge and insights to inform policy and advance equitable national cervical cancer elimination efforts in Botswana.