This partnership was initially formed between the health district of Saraya, Senegal; Peace Corps, Senegal; and the University of Illinois at Chicago (UIC) to improve health care delivery within the local existing health care system as well as provide training in global health and cultural competency for U.S. health care trainees. The primary focus of the project was cervical cancer preventive services implementation, as determined by the assessment of local health concerns, the status of the health service delivery infrastructure, and the priorities of the local health care leadership. Partnership efforts have subsequently focused on the Kedougou Regional level and are advancing the work of cervical cancer preventative services implementation. The Health Region of Kedougou is located in the South-Eastern part of Senegal with an estimated population of 143,000 inhabitants and comprises twenty-three health posts, three health centers, and the regional hospital. This project, continuing through 2013, has implemented regional-level service guidelines, a cervical cancer preventative service accessible to an estimated 10,000 women in the target population, trained 60 health workers in visual inspection of the cervix with acetic acid, and trained 1 health worker in cryotherapy as a treatment modality for precancers.
This project utilizes the Global Community Health Collaborative (GCHC) model and holds as its principle goal to positively impact global health disparities by specifically addressing the global burden of disease, the global shortage of health care workers, the deficiency of primary health care in low-income countries, and the deficiency of global health research. Access to quality health care in areas where this partnership is focused is difficult to obtain, primarily due to the geographically dispersed area and the limited number of trained personnel. In training additional health care workers and improving the skills and knowledge base of existing health care workers, individuals in remote villages will have increased access to quality medical care.
PROJECT SUMMARY BY YEAR
Partnership Summary 2010 – 2016
This partnership was initially formed in 2010 between the health district of Saraya, Senegal; Peace Corps, Senegal; and the University of Illinois at Chicago (UIC) to improve community access to quality primary health care services. A participatory approach was used to design and conduct an assessment. Input was gathered through 23 focus groups in 6 convenience-sampled communities representing the district, one health worker focus group at the district level, and seven key-informant interviews with health leaders at the district and regional levels. Comments directed at women’s health themes comprised 56 of the 341 (16%) suggested health priorities. Among the many local health priorities that were identified, it was noted that there was no identified strategic plan to address cervical cancer prevention at the regional level. With significant input from all partners, this topic was chosen, therefore, as the project priority. The partnership project objective was defined as implementing cervical cancer prevention services in the Saraya District of the Kedougou region of Southeastern Senegal through service capacity building and regional health system policy implementation.
This partnership designed a strategic plan to implement a functional and sustainable cervical cancer prevention service in this decentralized region using appropriate technology. A realist synthesis of the literature concluded that with careful attention to quality assurance, Visual Inspection of the Cervix with Acetic Acid (VIA) is a safe and cost-effective approach for cervical cancer screening appropriate for this region. VIA has a sensitivity of 80% (79-82%) which is better than that of cytology (sensitivity of 61%, range of 52-70%) in low resource settings. The specificity of VIA is 92% (range, 91-92%).
In late 2010, we adapted World Health Organization approved curricular materials through a collaborative process to develop a training program. As no readily accessible technological expertise was available, in 2011 UIC faculty with experience in education of visual inspection conducted a clinical training of five regional personnel. This group was designated to become the regional clinical training team and to complete a training-of-trainers (TOT) course, following the JHPIEGO proscribed Trainer Pathway (cite). Responding to the identified capacity challenges throughout the region, health leaders prioritized a task sharing personnel approach in which midwives and nurses were VIA trained. Subsequent to the initial clinical training, the five Qualified VIA Trainers trained 14 additional personnel while advancing toward Certified Trainer status.
In 2012, the partnership expanded to the Kedougou regional level, which is comprised of the Saraya, Kedougou, and Salemata Districts. A priority was placed on building service capacity at the district health centers and zone-level posts throughout the region. By the end of 2012, three trainers were lost to attrition, two trainers remained in the region, three additional personnel advanced to candidate trainer status, and 39 total health workers had completed the VIA clinical training. With the anticipation of more screenings occurring, a theoretical training for cryotherapy implementation was conducted and the region began immediate preparations to implement this service. The partnership initiated a quality improvement process to guide further service implementation, programmatic development, and policy creation at the regional level. Programmatic development, being guided by the World Health Organization building blocks for health systems strengthening was centered around 1) clinical guidelines, 2) governance norms, 3) workforce development planning, 4) quality control, 5) health information systems, 6) resources management, 7) community-level information and education and 8) strategic partnerships.
In 2013, all personnel were encouraged to integrate routine screenings as a part of their clinical practice. Refresher courses were completed by all trained personnel to assure continuation of adequate skills. At the end of this year, 5 local trainers remained in the region, 55 total health workers had completed the VIA training, and 1 local health worker was qualified to perform cryotherapy. A region-wide prevalence study was planned and initiated in late 2013. As well, in 2013, a quality improvement activities continued to improve health service utilization and guide further service implementation and policy development. Local Policy development as well as strategic planning discussions were ongoing to detail guidelines and norms and provide insight into the next steps in expansion of the project.
In 2014, the partnership established the prevalence of cervical dysplasia in the Kedougou region in Senegal, a setting where this data was previously unavailable. The overall prevalence (2.1%) was found to be lower than what was anticipated, yet we did find different rates in the three districts. The highest prevalence (4.3%), found in the Saraya district, was deemed likely due to a developing gold mining industry that is largely isolated to that district. The study sample was significantly skewed away from the higher risk age group of 40 to 49 yo, with data suggesting higher risk of cervical dysplasia with increasing age. It is likely that with greater numbers of screening in the 40 to 49 age group, we will identify higher prevalence in this region. Next steps are to identify barriers to cervical cancer screenings, especially among older, higher risk women. The partnership goals expanded to increase service utilization, assure sustainability, and assure health service quality.
In 2015, the partnership initiated a five-year research project to continue to strengthen this community health service. The project uses health service implementation and delivery science through a participatory approach. This will bring together the practicality of capacity-building, the necessity of community participation, and the need of building knowledge that will be applicable to further community health systems strengthening in Senegal and beyond. The intervention uses community participation in health services quality improvement and policy adaptation to implement policy that promotes access to cervical cancer prevention services in Kedougou, Senegal and studies the horizontal scaling of this cervical cancer prevention health services policy and capacity to Sédhiou, Senegal.
This project to date has implemented regional-level cervical cancer prevention guidelines, a service accessible to an estimated 10,000 women in the target population of ages 30 to 49, trained 63 health workers in visual inspection of the cervix with acetic acid, and trained 1 health worker in cryotherapy as a treatment modality for pre-cancers. We have completed a region-wide cervical dysplasia prevalence study. Identified next steps are formal policy development through a community participatory approach and the horizontal scaling of this policy and health service to the neighboring region of Sédhiou.