Multi-site community-engaged quality improvement to inform regional cervical cancer screening implementation and sustainment in rural Sénégal
Authors: Jesus Elle De , Thiam Hamidou , Sagna Landing , Collins Zola , Danfakha Nicole , Komarek Tess , Hendrix Ellen , Lang Emma Luu Van , Peters Karen , Kasse Abdoul Aziz , Diaw Mammadou , Ndiaye Youssoupha , Faye Adama , Peterson Caryn , Hirschhorn Lisa R , Peters David , Dykens Jon Andrew 
Published: February 2020

Abstract
Background The improvement of quality at the primary health care level in low resource settings is key to addressing health equity challenges around the world. In 2014, a Sénégal-Peace Corps-University of Illinois at Chicago partnership began to study the impact of a community-engaged quality improvement program on health services and regional health system determinants to prevent cervical cancer, the leading cause of cancer deaths among women in Sénégal. The purpose of this paper is to describe how a multi-site participatory 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. Methods : We adapted a facility-level quality improvement process by involving community health committee representatives. Using a mixed methods case study approach, we collected data at nine demonstration sites in the K é dougou region from quality improvement program action plans, client surveys, health leader interviews, and service guidelines discussions at the regional level from January 2015 through June 2019. We calculated the demand and supply-side barriers and organized them into the Levesque Patient-Centered Access to Health Care Framework. Results During the study period, 27 quality improvement meetings took place. There were a total of 50 (14 unique) stated access barriers to cervical cancer prevention across all sites. The health service barriers were concentrated in approachability (5) and availability and accommodation (16), whereas the demand-side barriers were concentrated in the ability to perceive (14) and ability to seek care (3). Individual health facilities responded with increased community outreach among other interventions while regional programmatic recommendations led to strategic partnership initiatives such as social mobilization and peer-to-peer education activities. Conclusions The community-engaged QI process has meaningfully contributed to strategic planning of the implementation and sustainment of a cervical cancer screening program within the context of rural Kédougou, Sénégal. The iterative and patient-focused nature of QI has allowed health personnel to continually strengthen how they deliver their health services to meet the community’s needs while data aggregated from QI action plans across multiple sites has helped inform responsive health policies to ensure program sustainment. The parallel and iterative application of participatory capacity building and QI activities across multiple sites provides a useful approach for implementing sustainable cervical cancer programs.