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Implementation Science at UW

Keywords: Benjamin O. Anderson

✪ Implementation science frameworks and strategies to promote adoption of and adherence to oncology clinical practice guidelines in low- and middle-income countries: a scoping review

Authors:

Anya Romanoff, Kathleen Lynch, Lily Martin, Olayide Agodirin, Shilpa Murthy, Olalekan Olasehinde, Chukwuma Okereke, Julia M. Jackman, Betel Yibrehu, William E. Rosa, Catherine Zivanov, Erica Mann, Joy O. Ogunmuyiwa, Colleen E. Witty, Victoria L. Mango, Olusegun Isaac Alatise, T. Peter Kingham, Rachel Vreeman, Benjamin O. Anderson & Jamie S. Ostroff

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: July 2026

Read the full text in the open access journal BMC Global Public Health

Abstract:

Background

Clinical practice guidelines (CPGs) were developed to standardize and optimize cancer care delivery in low- and middle-income countries (LMICs). The aim of this scoping review is to identify implementation science (IS) frameworks and strategies to promote CPG adoption and adherence in LMICs.

Methods

We identified studies that describe, develop, reference, or utilize IS frameworks or strategies to deliver or evaluate adoption of oncology CPGs in LMICs. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we searched Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), African Journals Online, Latin American and Caribbean Health Sciences Literature, Scopus, Web of Science, and PsycINFO on 3/21/2022, 12/20/2022, 01/26/2024, and 10/03/2025. Publications in all languages and of all study types were eligible for inclusion. Titles, abstracts, and full text were screened by two reviewers with conflicts resolved by a third reviewer. Excluded studies did not use an IS framework or strategy, did not focus on cancer care, or were conducted in a high-income country.

Results

Searches identified 17,806 unique publications for title/abstract screening. 182 studies met criteria for full-text review; 35 were included. Twenty-four studies were country-specific, most commonly India (n = 5) and Nigeria (n = 5). The most frequent CPGs referenced were national/country-specific guidelines (n = 13) and Breast Health Global Initiative (BHGI) guidelines (n = 9). Only 16 full-text publications described original research to promote or evaluate evidence-based CPG interventions in LMICs. Established IS frameworks used in more than one study were the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework (n = 2) and Consolidated Framework for Implementation Research (CFIR) (n = 2).

Conclusions

There is limited research utilizing IS frameworks and strategies to promote CPG adoption and adherence in LMICs and substantial heterogeneity in reporting. Greater utilization of IS frameworks, strengthening implementation capacity and improving consistency in reporting, are needed to improve CPG uptake in LMICs.

Systematic review registration

Open Science Framework (https://osf.io/nb75s).

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Health Care Professional Adherence to Breast Cancer Management Guidelines in Nigeria

Authors:

Anya Romanoff, Olalekan Olasehinde, Kathleen Lynch, Sharif Folorunso, Oluwatosin Omoyiola, Betiku Omolade, Adeleye Omisore, Chukwuma Eze Okereke, Olayide Agodirin, Abubakar Bala Muhammad, Nuhu Ali, Omorodion Irowa, Nneka Sunday Nweke, Uchechukwu Emmanuel Nwokwu, Adewale Aderounmu, Funmilola Wuraola, Hannah L Kalvin, Rivka Kahn, Grace Fitzgerald, Cristina Olcese, Alexia Iasonos, Victoria L Mango, Jamie S Ostroff, Rachel Vreeman, Benjamin O Anderson, T Peter Kingha, and Olusegun Isaac Alatise

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: February 2025

Read the full text in the open access journal JAMA Network Open

Abstract:

Importance

In Nigeria, 80% of breast cancer is diagnosed at an advanced stage, when clinical management is complex and necessitates multidisciplinary collaboration. The Nigerian Federal Ministry of Health promotes multidisciplinary tumor board (MDT) discussions and endorses the National Comprehensive Cancer Network Harmonized Guidelines for Sub-Saharan Africa (Harmonized Guidelines) to standardize breast cancer care, but the extent of their clinical utilization is not well understood.

Objective

To identify barriers to and facilitators of the standardization of breast cancer care in Nigeria as reflected by awareness and consultation of resource-adapted guidelines.

Design, Setting, and Participants

For this survey study, health care professionals (HCPs) involved in breast cancer care in Nigeria were recruited electronically through medical societies and snowball sampling from November 1, 2023, to January 31, 2024.

Exposure

Breast cancer care guidelines.

Main Outcomes and Measures

Current breast cancer guideline awareness, adherence among specialties, and multidisciplinary management in Nigeria were evaluated. A multinational, multidisciplinary team developed and distributed an HCP questionnaire. Cochran-Armitage trend tests and logistic regression assessed associations with guideline awareness and use.

Results

A total of 277 HCPs (median [IQR] age, 42 [38-48] years; 211 of 275 [77%] male), including 124 surgeons (45%), 59 radiologists (21%), 49 clinical oncologists (18%), and 45 pathologists (16%), responded to the survey. Of 274 HCPs, 253 (92%) believed that breast cancer guidelines contribute to better patient outcomes, and 100 of 195 (51%) routinely consulted guidelines. Of 273 HCPs, 103 (38%) had regular engagement in breast cancer MDT discussions. Only 93 of 277 HCPs (34%) were aware of resource-adapted Harmonized Guidelines; both guideline awareness and consultation increased with the frequency of MDT participation. Completing a cancer-related fellowship (OR, 14.56; 95% CI, 6.24-40.00; P < .001), clinical oncology specialization (OR vs surgery, 0.20 [95% CI, 0.09-0.42]; OR vs pathology, 0.05 [95% CI, 0.02-0.14]; OR vs radiology, 0.02 [95% CI, 0.01-0.06]; P < .001), devoting more time to breast health care delivery (OR, 1.04; 95% CI, 1.02-1.05; P < .001), and regular MDT engagement (OR for weekly vs none, 5.13; 95% CI, 1.69-17.35; P = .04) were associated with consulting guidelines regularly on univariable analysis. To improve guideline adherence, 230 of 277 HCPs (83%) reported needing regular MDT discussions.

Conclusions and Relevance

In this survey of HCPs across Nigeria, half reported routinely consulting guidelines and only one-third were aware of the Harmonized Guidelines, which are resource adapted and endorsed by the Nigerian Federal Ministry of Health. Approximately one-third of HCPs reported engaging in regular breast cancer MDT discussions; guideline awareness and consultation increased as frequency of MDT participation increased. Opportunities for disseminating knowledge, such as MDT discussions and fellowship training, are essential to standardize breast cancer care delivery in Nigeria.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ A phased approach to implementing the Breast Imaging Reporting and Data System (BI‐RADS) in low‐income and middle‐income countries

Authors:

Diana L. Lam, Pegah Entezari, Catherine Duggan, Zeridah Muyinda, Andres Vasquez, Jorge Huayanay, Benjamin O. Anderson, & John R. Scheel

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

Successful breast cancer detection programs rely on standardized reporting and interpreting systems, such as the Breast Imaging Reporting and Data System (BI‐RADS), to improve system performance. In low‐income and middle‐income countries, evolving diagnostic programs have insufficient resources to either fully implement BI‐RADS or to periodically evaluate the program's performance, which is a necessary component of BI‐RADS. This leads to inconsistent breast ultrasound interpretation and a failure to improve performance.

Methods

The authors applied the Breast Health Global Initiative's phased implementation strategy to implement diagnostic ultrasound and BI‐RADS within the context of a limited‐resource setting.

Results

The authors recommended starting with triage ultrasound to distinguish suspicious masses from normal breast tissue and benign masses such as cysts because the majority of health workers performing ultrasounds at this level have minimal breast imaging experience. Transitioning to full diagnostic ultrasound with condensed or full BI‐RADS should occur after performance and quality metrics have been met.

Conclusions

Transitioning through these phases across facilities likely will occur at different times, particularly in rural versus urban settings.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Situational analysis of breast health care systems: Why context matters

Authors:

Catherine Duggan, Allison Dvaladze, John R. Scheel, Lisa M. Stevens, & Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

Implementation of evidence‐based, resource‐appropriate guidelines for breast cancer control should be preceded by a baseline assessment or situational analysis to assess breast health infrastructure, workforce capacity, patient pathways, existing practices, accessibility, and costs.

Methods

To support the assessment of breast health care systems within the broader context in which they exist, the Breast Health Global Initiative (BHGI) developed, tested, and refined a set of situational analysis tools with which to guide the assessment of breast health care capacity, identify the relative strengths and weaknesses of the health system, and support stakeholders in prioritizing actionable items to advance breast cancer care using evidence‐based strategies tailored to their setting. The tools address 6 domains of breast health care delivery: 1) breast cancer early detection practices; 2) breast cancer awareness programs; 3) the availability of breast cancer surgery; 4) the availability of pathology; 5) the availability of radiotherapy, and 6) the availability of systemic therapy services. The current study also describes the more comprehensive International Atomic Energy Agency Programme of Action for Cancer Therapy (PACT) integrated missions for PACT (imPACT) review.

Results

As of 2020, 5 formal BHGI situational analyses have been performed in India, Brazil, Panama, Tanzania, and Uganda. As of August 2019, a total of 100 imPACT reviews have been conducted in 91 countries. These assessments can contribute to more informed policymaking.

Conclusions

Situational analyses are a prerequisite for the development of resource‐appropriate strategies with which to advance breast cancer control in any setting and should assess services across the entire breast health care continuum as well as the broader structural, sociocultural, personal, and financial contexts within which they operate.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Breast cancer treatment: A phased approach to implementation

Authors:

Miriam Mutebi, Benjamin O. Anderson, Catherine Duggan, Clement Adebamowo, Gaurav Agarwal, Zipporah Ali, Peter Bird, Jean‐Marc Bourque, Rebecca DeBoer, Luiz Henrique Gebrim, Riccardo Masetti, Shahla Masood, Manoj Menon, Gertrude Nakigudde, Anne Ng’ang’a, Nixon Niyonzima, Anne F. Rositch, Karla Unger‐Saldaña, Cynthia Villarreal‐Garza, Allison Dvaladze, Nagi S. El Saghir, Julie R. Gralow, and Alexandru Eniu

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low‐ and middle‐income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited‐resource settings by creating roadmaps that are individualized and adapted to the baseline environment.

This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late‐stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements.

A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1‐stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ The Breast Health Global Initiative 2018 Global Summit on Improving Breast Healthcare Through Resource‐Stratified Phased Implementation: Methods and overview

Authors:

Catherine Duggan, Allison Dvaladze, Anne F. Rositch, Ophira Ginsburg, Cheng‐Har Yip, Susan Horton, Rolando Camacho Rodriguez, Alexandru Eniu, Miriam Mutebi, Jean‐Marc Bourque, Shahla Masood, Karla Unger‐Saldaña, Anna Cabanes, Robert W. Carlson, Julie R. Gralow, and Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

Background

The Breast Health Global Initiative (BHGI) established a series of resource‐stratified, evidence‐based guidelines to address breast cancer control in the context of available resources. Here, the authors describe methodologies and health system prerequisites to support the translation and implementation of these guidelines into practice.

Methods

In October 2018, the BHGI convened the Sixth Global Summit on Improving Breast Healthcare Through Resource‐Stratified Phased Implementation. The purpose of the summit was to define a stepwise methodology (phased implementation ) for guiding the translation of resource‐appropriate breast cancer control guidelines into real‐world practice. Three expert consensus panels developed stepwise, resource‐appropriate recommendations for implementing these guidelines in low‐income and middle‐income countries as well as underserved communities in high‐income countries. Each panel focused on 1 of 3 specific aspects of breast cancer care: 1) early detection, 2) treatment, and 3) health system strengthening.

Results

Key findings from the summit and subsequent article preparation included the identification of phased‐implementation prerequisites that were explored during consensus debates. These core issues and concepts are key components for implementing breast health care that consider real‐world resource constraints. Communication and engagement across all levels of care is vital to any effectively operating health care system, including effective communication with ministries of health and of finance, to demonstrate needs, outcomes, and cost benefits.

Conclusions

Underserved communities at all economic levels require effective strategies to deploy scarce resources to ensure access to timely, effective, and affordable health care. Systematically strategic approaches translating guidelines into practice are needed to build health system capacity to meet the current and anticipated global breast cancer burden.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**

✪ Breast cancer early detection: A phased approach to implementation

Authors:

Ophira Ginsburg, Cheng‐Har Yip, Ari Brooks, Anna Cabanes, Maira Caleffi, Jorge Antonio, Dunstan Yataco, Bishal Gyawali, Valerie McCormack, Myrna McLaughlin de Anderson, Ravi Mehrotra, Alejandro Mohar, Raul Murillo, Lydia E. Pace, Electra D. Paskett, Anya Romanoff, Anne F. Rositch, John R. Scheel, Miriam Schneidman, Karla Unger‐Saldaña, Verna Vanderpuye, Tsu‐Yin Wu, Safina Yuma, Allison Dvaladze, Catherine Duggan, and Benjamin O. Anderson

University of Washington affiliated authors are displayed in bold.

✪ Open Access

Published: April 2020

Read the full text in the open access journal Cancer

Abstract:

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource‐stratified guidelines for the early detection and diagnosis of breast cancer.

In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting.

Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real‐world settings are considered.

**This abstract is posted with permission under the Creative Commons Attribution 4.0 International License**