Using implementation mapping to select strategies for a primary health care–based breast cancer screening intervention: a case study from urban and peri-urban Johannesburg, South Africa

Abstract Background Most breast cancers in South Africa are diagnosed at stage III–IV. Despite national guidelines recommending screening clinical breast examination (CBE) at the primary healthcare (PHC) level, implementation of CBE remains limited. This study aimed to use Implementation Mapping (IM) to develop implementation strategies for introducing screening CBE into South Africa’s PHC setting. Methods Implementation Mapping (IM) is a five-task process that integrates theory, evidence, and stakeholder input to design and pilot strategies for implementation of evidence-based interventions. We completed the first four tasks of the IM process to prepare for delivery of CBE at four participating facilities in two urban and peri-urban townships of Johannesburg: Soweto and Orange Farm. Tasks included (1) a quantitative and qualitative needs assessment at each facility, (2) defining stakeholder-specific implementation outcomes, performance objectives, determinants, and change objectives, (3) linking determinants to theory-informed implementation methods and practical strategies, and (4) preparing relevant materials. Each task was informed by the preceding tasks, and we organized our findings using the Capability, Opportunity, Motivation–Behaviour model, the Behaviour Change Wheel, and the Expert Recommendations for Implementing Change strategy taxonomy. Results Identified actors in Task 1 included Department of Health officials, facility managers, screening nurses, other clinicians, community health workers, clerical staff, and a newly created role: CBE navigators. The most significant barrier to implementation identified in Task 1 was staff’s heavy existing workload. Change objectives highlighted in Task 2 were the need for facility managers to allocate space and staff, for providers to feel screening services did not significantly add to their workload, and for improving providers’ breast health competencies. Practical strategies selected in Task 3 included early partnership with clinic leadership, multi-day CBE training, introduction of a CBE navigator to support screening and referral coordination, and development of an electronic data system for patient tracking. Training curricula, staff and patient educational materials, clinical algorithms, a REDCap database, and standard operating procedures were drafted for Task 4. Conclusion Stakeholder engagement supported co-creation of contextually tailored strategies and materials for introducing screening CBE into South Africa’s urban PHC setting. Our strategies provide a blueprint for subsequent piloting and evaluation.