背景：宫颈癌是唯一可知病因的人类恶性肿瘤。我国宫颈癌负担占全球宫颈癌疾病负担的1/5，中国宫颈癌防治为重要议题。宫颈癌筛查常为多阶段筛查，HPV或细胞学（TCT）初筛阳性的患者需要进行阴道镜复查随访方可进行早期癌变的诊断治疗，若患者在这一环节脱落，则无法达到遏止宫颈癌早期癌变的效果。相较于发达国家，中国宫颈癌初筛随访仍处于早期阶段，筛查共识刚刚建立，患者复查率低，阴道镜检查质量低，相关的研究也处于早期阶段。对此，本文将以中国深圳市宝安区为例，聚焦于中国宫颈癌筛查随访质量的影响因素。方法：定量研究部分，本文对开展宫颈癌免费筛查的医院A及其下属13家社区健康卫生服务中心（社康）近1年内宫颈癌初筛异常的患者数据进行分析，采用组间比较、单因素与多因素分析（SAS 9.4），比较医院与社康初筛患者随访的不同与相关的影响因素。定性研究部分，在实施性研究构成要素综合框架（CFIR）的指导下，对在医院与社康进行宫颈癌筛查相关工作的10位工作人员进行了半结构化访谈，在NVivo v.12中采用CFIR指南代码进行了描述性分析与倾向分析。结果：根据研究结果，为了更好地实施宫颈癌筛查随访，应该让社康更深度参与宫颈癌筛查随访工作，更好地起到吸纳“新鲜”患者（p<0.01）、照顾外来务工人群（p<0.01）、更及时更便捷随访的作用（p<0.05）。年龄（p<0.01）、医保参保状况（p<0.05）、沟通及时性与沟通方式（p<0.1）是宫颈癌随访的重要影响因素。对当前随访方案的实施，首当其冲应该优化方案流程，降低方案的复杂性，例如采用人工智能与人工相结合的方式进行随访，同时让更多的相关方如社区站长、妇科医生参与其中。其次，可以通过与其他医疗机构交流竞争的方式提升能力，在外部政策安排与内部绩效安排上都给予个人一定的绩效激励，并为筛查随访的开展准备专门的人力物力资源，除此之外，需要让医疗服务提供者对个人效能有更高的认识。在改进过程中，当前积极因素也需要进一步考虑与保留，如以体检中心为中轴的组织模式，社康良好的慢病随访传统。癌症筛查随访与社康慢病管理有良好兼容性。结论：这些结果支持了社康参与的宫颈癌筛查干预在中国的重要性，同时建议通过提高优质医保覆盖率、降低流程复杂性、召集更多相关方参与、以体检中心为纽带、以社康为触手的方法进一步制定实施策略以提高宫颈癌筛查随访质量。
Background: Cervical cancer is the only known etiology of a human malignancy. In China, the number of new cases and deaths from cervical cancer reached 110,000 and 60,000, respectively, accounting for one-fifth of the global burden. Cervical cancer prevention and treatment is a critical issue in China. Cervical cancer screening is a typically multi-stage screening, with patients who are positive for HPV testing or cytology screening requiring colposcopy for follow-up. If the patient miss any stage, the goal of preventing cervical cancer in its early stages cannot be achieved. Although China has made strides in recent years toward improving cervical cancer prevention, it lags behind developed countries in several key areas, including consensus, patient follow-up rate, colposcopy quality, and related research. In this regard, this article will use the Baoan District of Shenzhen, China, as a pilot study, concentrating on the factors that influence the quality of cervical cancer screening and follow-up in China.Methods: The quantitative study section examined data from patients with abnormal cervical cancer screening using t-test, chi-square, univariate and multivariate analysis （SAS v.9.4） at Hospital A and its 13 community-based health centers that provided free cervical cancer screening in the previous year. For qualitative study, under the direction of the Comprehensive Framework of Implementation Research Components （CFIR）, semi-structured interviews were conducted with 10 health providers in hospitals and community-based health centers. CFIR guideline codes were used for descriptive and propensity analyses in NVivo v.12.Results: Community-based health centers should be more deeply involved in cervical cancer screening and follow-up in order to better attract new patients （p＜0.01） and care for migrant workers （p＜0.01）, and more timely and convenient follow-up （p＜0.05）. Age （p＜0.01）, medical insurance （p＜0.05）, communication timeliness and communication method （p＜0.1） were significant factors affecting cervical cancer follow-up. For current cervical cancer screening follow-up implementation, the first improvement should be optimizing the process design and reducing the complexity. Applying new technology like artificial intelligence can be a choice. They should also involve more stakeholders such as community managers and gynecologists. Secondly, communication and competition with other medical institutions can also help, while individual performance incentives should be provided both externally （via policy） and internally （via internal arrangement）, and specific human and material resources for screening and follow-up should be prepared. The current positive factors must also be considered and retained, such as the organizational model with the physical examination center as the central axis, community-based center‘s excellent chronic disease follow-up tradition, which is an excellent compatibility.Conclusions: These findings support the importance of community-based cervical cancer screening interventions in China, and also suggest further development of implementation strategies by reducing process complexity, convening more relevant stakeholders, providing more individual performance incentives, and using physical examination centers as ties to improve the accuracy and timeliness of cervical cancer screening and follow-up.
