Brotherton JML, McDermott T, Smith MA, Machalek DA, Shilling H, Prang KH, Jennett C, Nightingale C, Zammit C, Pagotto A, Rankin NM, and Kelaher M
In this study, we aimed to document stakeholders' experiences of implementing Australia's renewed National Cervical Screening Program. In December 2017, the program changed from 2nd yearly cytology for 20-69 year olds to 5 yearly human papillomavirus (HPV) screening for women 25-74 years. We undertook semi-structured interviews with key stakeholders including government, program administrators, register staff, clinicians and health care workers, non-government organisations, professional bodies, and pathology laboratories from across Australia between Nov 2018 - Aug 2019. Response rate to emailed invitations was 49/85 (58%). We used Proctor et al's (2011) implementation outcomes framework to guide our questions and thematic analysis. We found that stakeholders were evenly divided over whether implementation was successful. There was strong support for change, but concern over aspects of the implementation. There was some frustration related to the delayed start, timeliness of communication and education, shortcomings in change management, lack of inclusion of Aboriginal and Torres Strait Islander people in planning and implementation, failure to make self-collection widely available, and delays in the National Cancer Screening Register. Barriers centred around a perceived failure to appreciate the enormity of the change and register build, and consequent failure to resource, project manage and communicate effectively. Facilitators included the good will and dedication of stakeholders, strong evidence base for change and the support of jurisdictions during the delay. We documented substantial implementation challenges, offering learnings for other countries transitioning to HPV screening. Sufficient planning, significant and transparent engagement and communication with stakeholders, and change management are critical., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: The CRE is a collaboration led by the Daffodil Centre (Cancer Council NSW and University of Sydney), the Australian Centre for the Prevention of Cervical Cancer (ACPCC), the University of Melbourne and the Kirby Institute, University of NSW. Both Cancer Council NSW and ACPCC participated in the implementation of the rNCSP and employees/representatives of these organisations were represented on the research team and invited to participate as stakeholders in the interviews. Where such potential conflict of interests could have arisen between interviewer/interviewee, interviews were conducted by people who were not conflicted and all interviews were analysed deidentified and consistently through thematic, coded analysis. The study was overseen by a scientific advisory committee.Box 1Facilitators and barriers to the implementation of Renewal identified by 49 stakeholders, 2018-2019 Facilitators to date1)Strong evidence base for change2)Goodwill and dedication of stakeholders, including ongoing advice and support from committees and advisory groups3)Ability of State and Territory programs to continue/ resume pre-Renewal operations (eg ongoing registry functions, program management and communications) during delay in transition and national registry operations Perceived future facilitators1)Clear communications to participants and providers, including data to show the program is working2)Getting the National Register up to full functionality, including:a.invitations, reminders, follow-up, and ready access to screening historiesb.improving data completeness and qualityc.using it to monitor and drive improvementd.moving away from paper-based communications and faxese.improving integration with laboratory and practice management systemsf.ensuring its algorithms provide clinical safety3)Good governance and planning, with sufficient capacity and dedicated resources.4)Specific improvements suggested included:a.simplifying some processes (such as colposcopy data collection and the layout of the guidelines)b.providing more support and information for practitionersc.timely guideline updatesd.continuous education and raising awareness in the population, including targeted campaigns for Aboriginal and Torres Strait Islander peoplee.expanding who can provide cervical screening, especially in rural and remote areas Barriers1.Failure to appreciate the enormity of the change and register build2.Importance of change management not acknowledged early enough3.Expertise of States and Territories not utilised adequately4.Absence of consistent central oversight, leadership and project management5.Workload of those responsible for implementing change was very high, with staff turnover and loss of knowledge6.Human cost of stress across all stakeholder groups7.Delays and issues with Register meant other important aspects of the rNCSP were insufficiently addressed8.Suboptimal communication, consultation, and transparency9.Late communication, particularly the announcement to delay the program. a.Program delay created operational issues, due to staff redundancies for State registers and cytologists in pathology labs, which happened too earlyb.Delay commonly conflated by the public with the belief that the program itself was flawed, creating mistrustc.Some practitioners had already told patients that their next screen would be the new test, or had patients hold off screening for the new test, only to have to explain to them on their return that it was not yet available10.Insufficient education for providers and the public.a.Not consistent or well-timed communication or education to support practitioners implementing the programb.Lack of clear and timely communication with the public11.Other practitioner level barriers included:a.Insufficient time to discuss cervical screening in consultationsb.Loss of the nurse led cervical screening MBS numberc.Difficulties implementing new clinical guidelines when providers and laboratories were not yet familiar with the detail and complexity (especially for people with previous abnormalities)d.Errors and frustrations with incorrect Register correspondence chasing colposcopy results12.Lack of a registered on-label indication for HPV testing on self-collected samples, creating lack of test availability which limited access13.Length of colposcopy waiting lists and associated delays in women being seen at colposcopy, (© 2023 The Authors.)