title: Adherence to guidelines on cervical cancer screening in general practice: programme elements of successful implementation.
abstract: BACKGROUND
  There is still only limited understanding of whether and why interventions to facilitate the implementation of guidelines for improving primary care are successful. It is therefore important to look inside the 'black box' of the intervention, to ascertain which elements work well or less well.
  
  
  OBJECTIVE
  To assess the associations of key elements of a nationwide multifaceted prevention programme with the successful implementation of cervical screening guidelines in general practice.
  
  
  METHODS
  A nationwide prospective cohort study.
  
  
  METHODS
  A random sample of one-third of all 4,758 general practices in The Netherlands (n = 1,586).
  
  
  METHODS
  General practitioners (GPs) in The Netherlands were exposed to a two-and-a-half-year nationwide multifaceted prevention programme to improve the adherence to national guidelines for cervical cancer screening. Adherence to guidelines at baseline and after the intervention and actual exposure to programme elements were assessed in the sample using self-administered questionnaires.
  
  
  RESULTS
  Both baseline and post-measurement questionnaires were returned by 988 practices (response rate = 62%). No major differences in baseline practice characteristics between study population, non-responders, and all Netherlands practices were observed. After the intervention all practices improved markedly (P<0.001) in their incorporation of nine out of 10 guideline indicators for effective cervical screening into practice. The most important elements for successful implementation were: specific software modules (odds ratios and 95% confidence intervalsfor all nine indicators ranged from OR = 1.85 [95% CI = 1.24-2.77] to OR = 10.2 [95% CI = 7.58-14.1]); two or more 'practice visits' by outreach visitors (ORs and 95% CIs for six indicators ranged from OR = 1.46 [95% CI= 1.01-2.12] to OR = 2.35 [95% CI = 1.63-3.38]); and an educational programme for practice assistants (ORs and 95% CIs for four indicators ranged from OR = 1.57 [95% CI = 1.00-1.92] to OR = 1.90 [95% CI = 1.25-2.88]).
  
  
  CONCLUSIONS
  A multifaceted programme targeting GPs, including facilitating software modules, outreach visits, and educational sessions for PAs, contributes to the successful implementation of national guidelines for cervical screening.
authors.affiliation: Centre for Quality of Care Research (WOK), University of Nijmegen, The Netherlands. R.Hermens@hsv.kun.nl
authors.forename: R P
authors.initials: RP
authors.lastname: Hermens
authors.forename: E
authors.initials: E
authors.lastname: Hak
authors.forename: M E
authors.initials: ME
authors.lastname: Hulscher
authors.forename: J C
authors.initials: JC
authors.lastname: Braspenning
authors.forename: R P
authors.initials: RP
authors.lastname: Grol
mesh_terms: D005194:Family Practice / Q000592:standards*; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008403:Mass Screening / Q000592:standards*; D009426:Netherlands; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*