Applying the INSPIRE framework to the CBIG-SCREEN study: selection of tailored strategies for increasing cervical cancer screening participation among vulnerable populations in Estonia, Portugal and Romania

Cervical cancer disproportionately affects vulnerable women due to their low participation in cervical screening. Tailored strategies were co-designed to address context-specific barriers to screening participation among vulnerable women in Estonia, Portugal, and Romania using principles of implementation research. This descriptive study applied the Integrative Systems Praxis for Implementation Research (INSPIRE) framework, a four-phase dynamic learning process designated to promote the adoption of evidence-based interventions to improve participation in cervical screening, within the CBIG-SCREEN project. It focuses on how Phases I and II of the framework, which involved conducting a scoping review of barriers and facilitators to screening participation, engaging in discussions with local stakeholders, and performing a structured capacity assessment of cervical cancer screening in the three countries, led to the co-designing of context-specific strategies for implementation in Phase III. Crucial barriers identified in Phase I included stigma, ineffective communication and invitations, appointment scheduling problems, transport challenges for women in remote areas, and time constraints, affecting both screening and follow up. Through deliberative dialogues with stakeholders (in Phase II) and focusing on the barriers and leverage points we co-designed strategies for each intervention country to be implemented and evaluated in Phase III. The strategies that were co-designed and prioritized by stakeholders included using clearer, more easily understandable language in invitations and educational materials (in Estonia and Portugal), sending prepaid HPV self-sampling kits to women’s homes (in Estonia and Portugal), and improving communication methods (in Estonia). Other strategies were supporting patient navigation, such as offering a helpline or support service for scheduling appointments and addressing concerns that may arise along the screening pathway (in Portugal), and innovative solutions for ensuring access to self-collection kits through pharmacies (in Romania). These strategies were incorporated in a country-specific protocol for implementation and evaluation in Phase III. The INSPIRE approach has facilitated the workflow designing and planning implementation strategies for the three intervention countries. The strategies have been implemented and evaluation is ongoing and will be reported in our future communications. Phases I, II and III (partially completed) results highlight the value of implementation science in understanding barriers to cervical cancer screening and selecting tailored strategies to address them in close collaboration with stakeholders.