The results of the QI program have informed activities that are clinically relevant at the health facility level and applicable to program strategy within the Kédougou regional health system. Through QI action plans, the health facilities have identified problems specific to each site, and in turn, have made recommendations that could inform higher-level programmatic development. QI meetings have led to thoughtful discussion and problem-solving among health personnel and community members across the nine demonstration sites. As a result, these quarterly meetings have also become forums for those present to exchange ideas and develop feasible solutions that can be executed at the clinical level.
QI Informed Barriers and Programmatic Recommendations
The purpose of this paper is to report community-engaged, quality improvement-identified access barriers and contextualized programmatic recommendations over time, specific to the cervical cancer screening program in the rural Kédougou region of Sénégal to describe a multi-site QI approach for informing higher-level program implementation and sustainment.
The data from the QI action plans indicate an immense need to address the capacity and knowledge gaps that exist among health personnel as well as respond to the shortage of cervical cancer screening equipment. The demonstration sites recommended training the head nurses and midwives on cervical cancer screening. Maintaining capacity has proven challenging in this isolated region. To illustrate capacity challenges, in 2011, after identifying visual inspection of the cervix with acetic acid (VIA) as an appropriate, safe, and cost-effective screening method, the partnership implemented a training of trainers for the midwives throughout the Kédougou region. Of the original 63 health care workers trained by the end of 2013, only 19 remained in the region at the end of 2015, resulting in an attrition rate of 70% over two years. By the end of 2017, an additional 24 midwives were transferred out of the region.12 Kédougou’s underdeveloped and limited infrastructure has led to many health care personnel routinely leaving the region after two to five years to move closer to urban centers. Furthermore, this growing challenge of high attrition rates is worsened by the length of time taken to replace relocated staff. As new midwives are posted in Kédougou, they are also required to receive in-service training on VIA and cryotherapy since these skills are not incorporated in their pre-service formal training. To respond to this significant challenge, the partnership has proposed collaborating with the midwifery training center in the neighboring region of Tambacounda financed by the Sénégal Ministry of Health and Social Action. This training center provides instruction for midwives posted throughout Sénégal’s southeastern regions. This programmatic proposal intends to decentralize the cervical cancer prevention training curriculum that is currently available only at the national level. The training will include VIA screening and cryotherapy procedural skills enabling the provision of comprehensive cervical cancer services to all new midwives and nurses placed in the region. This programmatic proposal will ensure reliable access to high quality training for midwives and address the issue of having to continuously train new midwives as they are assigned to the Kédougou region.
The most frequently reported barrier for the demand-side was the lack of cervical cancer prevention knowledge in the community. Action plans reported that the target population was not adequately aware of the characteristics of cervical cancer or the importance of screening for prevention. Furthermore, although women ages 40 + are at highest risk of cervical cancer, they are the least likely to seek cervical cancer screening services.19 An important aim for this participatory QI approach is to improve health equity through a heightened community voice.
Given that the teams largely interviewed clients and selected village leaders and those who seem engaged with the health center (community health committee, women’s groups), it is very hard to get information about barriers from those in the community who do not use services. From those community members who do not use services (who may be the most socially and economically marginalized), the costs of transport or time lost may be important barriers.
Misinformation is pervasive and concerns surrounding the stigmatization of HPV and cervical cancer may worsen the non-acceptance of screening, resulting in continued low screening uptake. Through the QI process, the demonstration sites recommended increasing organized sensitization activities to engage the target population as well as community leaders (e.g. village chiefs, religious leaders). In 2018, the partnership responded with the introduction of a peer-to-peer educational intervention through the Care Group model, a low-cost and evidence-based approach to educating the community. The Care Group model has been implemented in over 20 countries utilizing a train-the-trainer approach to disseminate information.29,30 Although this model has been used extensively for maternal / child care and for other topics, prior to this project, curricula focused on cervical cancer did not exist.31 To respond to the programmatic recommendation, the partnership developed an educational curriculum orienting community members to the 1) causes, risk factors, and signs and symptoms of cervical cancer, 2) screening and treatment of cancer and precancerous lesions, and 3) psychosocial considerations of prevention and follow-up after diagnosis. These resources have been translated into French and local languages. Care Groups of 10 to 15 women (ages 30 to 59) were created at each demonstration site and led by a local female health worker, the ‘Care Group Leader’. Members meet once or twice per month to learn and practice teaching the lesson plan, which they then facilitate with their assigned neighborhood group. Through this peer-to-peer network, a single Care Group has potential to reach up to 225 women each month, strengthening the effect of each educational topic and making it a high-impact, low-cost solution to addressing information gaps through a social network. Moving forward, the cervical cancer educational module that has developed as an outcome of the QI action plan recommendations may serve as a template for maximizing early impact of new cervical cancer screening services implemented in other areas of rural Sénégal.12 This effort to address demand-side barriers to cervical cancer screening implementation and sustainability has potential to improve local advocacy and communication capacity within the health system and community.
Our site selection was non-random and while it is arguable that these sites do represent the context of all sites in the region, there may be differences with the selected sites regarding their capabilities or other characteristics such as benefiting from other programs. The QI committees and QI activities do not currently function uniformly across all sites due to various challenges. At the health post/center level, the challenges included 1) high staff turnover resulting in new staff not trained in QI, 2) the absence of Peace Corps volunteers in some sites to assist with QI meeting facilitation, and 3) scheduling issues. At the regional level, health officials who are often overburdened with work had reported being unable to properly manage regional level data collection. These limitations are parallel to the challenges to which the partnership is responding through the overall project. While the QI process is participatory, it is likely that it does not represent all of the perspectives of non-users of services, therefore the access barriers of the most marginalized may not be fully identified.
Given that the implementation of service-level QI programs in the Kédougou region is recent, it is important to note that many of the same barriers to providing access to high quality cervical cancer prevention also created considerable challenges in the implementation of a quality improvement process in this setting. During the course of this study we have encountered several barriers that have limited the effectiveness of the QI program. The shortage of healthcare workforce in this rural region is a major barrier. Given time constraints of the existing workforce, the routine actualization of the QI process may at times take a back seat to pressing clinical work or administrative issues. Therefore, future research could be focused on better understanding the implementation factors related to the acceptability (e.g. relative advantage, credibility), adoption (e.g. intention to try), feasibility (e.g. practicality, utility), cost, and sustainability (e.g. institutionalization, maintenance, and routinization) of a quality improvement program at the health service level in this setting. Furthermore, better understanding is needed to improve the community engagement component of a health service quality improvement program. There appears to be a steep learning curve among stakeholders both on the supply- and the demand-sides of the equation concerning the value and process of a QI program. The effectiveness of this program and the long-term sustainment would benefit from a better understanding of these barriers.