Improving access to high quality primary health care (PHC) services in low resource settings is key to ensuring universal health coverage and health equity.1 Health service-level continuous quality improvement (QI) programs are an established iterative process for identifying and addressing existing supply-side barriers to healthcare access. The engagement of clients and communities through participatory methodologies has been shown to improve the understanding of demand-side barriers and improve health care quality.2,3 However, direct individual and community engagement in traditional QI processes is marginal.4,5 There are, furthermore, a lack of frameworks and approaches for systematically gathering perspectives from the community through a QI process for the purpose of informing higher-level decision making. In addition, in striving for high quality person-centered health care,6 there are gaps in the understanding of how regional health systems can best be informed by the perspectives of individuals who are confronted daily by challenges at the health service- and community-levels.7
Global Disparities in Cervical Cancer Prevention and Control
In 2018, globally 569,847 cervical cancer diagnoses and 311,000 deaths were estimated due to this preventable disease.8 Cervical cancer is the fourth most common cancer diagnosed among women worldwide. It has the highest cancer incidence rate among women in 28 countries and is the most common type of cancer-related mortality among women in 42 countries, with the majority being in Sub-Saharan Africa.8 While cervical cancer incidence rates are declining in high resource areas, incidence, prevalence, and mortality rates continue to rise in low- and middle-income countries (LMIC).8 Furthermore, global cervical cancer mortality is expected to increase by 42% to 442,926 deaths in the year 2030.9 The greatest rise will be in LMICs where, currently, 85% of incident cervical cancers and 87% of cervical cancer deaths occur.10,11
Various evidence-based cervical cancer screening techniques have been developed, tested, and proven to be appropriate for diverse contexts including visual inspection methods (employing acetic acid and/or Lugol’s solution) which are effective, low-cost approaches appropriate for low-resource settings. However, there are considerable challenges in implementing sustainable cervical cancer screening programs in a low-resource, rural context, especially in LMICs. Demand-side barriers include factors such as health literacy, discomfort with the procedure, trust, embarrassment or anxiety, geographic reach, inability to pay, and communication challenges.12 On the supply-side, barriers include deficient outreach, preference for a female provider, workforce shortages, lack of functional equipment, and lack of available training.12 A better understanding of how to implement evidence-based interventions into real world settings, especially at the decentralized level, is needed to achieve reasonable global progress toward the elimination of Human papillomavirus (HPV) related cancers.12,13
Cervical Cancer in Sénégal
The cervical cancer incidence rate in Sénégal (37.8) is about five times greater than that in the U.S., and Sénégal ranks 17th in the world in the age-standardized incidence rate of cervical cancer.13,14 HPV prevalence15 and the cervical cancer burden16 in urban areas of Sénégal remain high. However, adequate data to compute the prevalence of cervical cancer and dysplasia in rural regions are not available.17 In Sénégal, HPV positivity is higher in older-aged women (over age 45) compared to other countries in Africa.18 Despite the value of cervical cancer screening and treatment in reducing mortality, the estimated participation rate for cervical cancer screening in Sénégal is very low (6.9% of all women ages 18 to 69). It is especially low in rural areas as well as in older age groups (1.9% of women ages 40 to 49 and none for women 50 and above).15
In 2010, a partnership was formed among the Kédougou Medical Region in Southeastern Sénégal; the Institute of Health and Development at Cheikh Anta Diop University (UCAD), Dakar, Sénégal; Peace Corps Sénégal; and the University of Illinois at Chicago (UIC). The stated overarching goal of this partnership is to achieve health equity by improving community access to quality primary health care services. By identifying local priorities and health service gaps, Kédougou health leaders and workers established that the aims of the partnership are to: 1) improve access to cervical cancer prevention services as a key component of high quality primary health care by strengthening the health care workforce and delivery systems in the Kédougou region and 2) inform the development and implementation of cervical cancer prevention programs in other rural regions of Sénégal. The Sénégal-Peace Corps-UIC partnership has conducted implementation research on capacity building and quality improvement activities to achieve partnership, community, and research objectives that include informing priorities, improving health outcomes, and building knowledge.19,20 In 2014, the partnership began to study the impact of a QI program on the supply-side (health service-level) determinants of cervical cancer screening and the implementation of regional health programmatic strategy.
Community-Engaged Quality Improvement
Health service-level QI programs are increasingly applied in low-resource settings21 and incorporating community participation into service-level QI activities may improve person-centered care.3 However, few traditional QI programs in LMICs routinely inform service-level QI activities by including a community voice. Some QI interventions, therefore, may not fully capture demand-side concerns or community recommendations for addressing context-specific barriers.
To overcome this challenge, we adapted the EngenderHealth-developed Client Oriented Provider Efficient (COPE®) quality improvement process as a structured QI approach within our partnership. The EngenderHealth-developed COPE® cervical cancer quality improvement process uses a clients’ rights and providers’ needs framework and is a well-documented and well-established QI approach used at the primary health care level in many countries globally.22–25 The COPE® process employs client surveys, health leader interviews, and the quarterly development of action plans for each health facility. The action planning process is managed by a quality improvement committee at each facility. Our partnership adapted the process by including community health committee representatives, a formal part of the Sénégalese health system, in the QI Committee and at the action planning meetings. This process provided local health staff and community members with the opportunity to evaluate the local health services while also generating participatory input for the partnership.
The purpose of this paper is to describe how a multi-site quality improvement (QI) approach can identify access barriers and provide contextualized programmatic recommendations to strengthen the cervical cancer screening program in the rural Kédougou region of Sénégal and inform higher-level program implementation and sustainment.