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Background: Equitable access to women’s health services, including cancer prevention programs, is lacking in many countries. Sénégal ranks 17 th in the world in the age-standardized incidence rate of cervical cancer. The Kédougou region is located in the southeastern corner of Sénégal and has many structural barriers to preventive care, including economic disadvantage, a low literacy rate, and a shortage of healthcare workers. The goal of this study was to investigate the barriers and facilitators of cervical cancer screening uptake in this region. Methods: We conducted a cross-sectional survey of 158 participants, 101 women and 57 men (ages 30 - 59) across nine non-probability-sampled communities located throughout three districts in the Kédougou region of Sénégal from October 2018 through January 2019. We collected demographic information and data on health service utilization, cervical cancer knowledge, and experience of cervical cancer screening. Associations were tested using the Fisher’s Exact test statistic. Results: The majority of our study population speaks one or both of the prevalent local languages, Malinké (62.7%) and Pulaar (59.5%), with fewer Wolof (26.6%) and French (31%) speakers. Among the women in our sample, 84.2% had never been screened for cervical cancer. Among men, 78.9% stated that they have the final say at home regarding healthcare decisions. In contrast, only 16.0% of women made their own healthcare decisions. For those who speak Malinké, 48.0% received services in another language. We found significant gender differences between women and men in the knowledge that a woman is at risk if she has multiple sexual partners (p = 0.010) and that a woman is at increased risk if her partner has multiple sexual partners (p < 0.001). Conclusions: This study demonstrates the critical need to overcome both clinical and informational barriers, as well as structural barriers, to ensure the implementation and sustainment of an equitable health service. In this highly underdeveloped region where workforce challenges are extraordinary, innovative solutions are needed to address these underlying social determinants of health while simultaneously improving quality of care at the point of service. Trial registration: This study is registered on clinicaltrials.gov with the Clinical Trials Study Identifier: NCT03540069

BackgroundThe 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 Kédougou 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.ResultsDuring the study period, 27 quality improvement meetings took place. There was 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. ConclusionsThe 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.

Cervical cancer is the leading cause of female cancer deaths in Senegal which is ranked 17th in incidence globally, however, the screening rate there is very low. Nuanced gendered perceptions and health behaviors of both women and men play a significant role in women's health. Our study analyzed gender differences on perceptions of gender roles, discrimination, cancer attitudes, cancer stigma, and influences in healthcare decision making within our study population to inform ongoing cervical cancer prevention work in the rural region of Kedougou, Senegal. We conducted a cross-sectional survey of 158 participants, 101 women and 57 men (ages 30-59) across nine non-probability-sampled communities from October 2018 through February 2019. Bivariate analysis was conducted to assess gender differences across all variables. We also conducted analyses to determine whether there were significant differences in beliefs and attitudes, by screening behavior and by education. We found significant gender differences regarding the perception of a woman's role (P < 0.001) and a man's role (P = 0.007) as well as in the everyday discrimination questions of "decreased respect by spouse" (P < 0.001). Regarding cancer stigma, among women, 18.00% disagreed and 10.00% strongly disagreed while among men, 3.6% disagreed and 1.8% strongly disagreed that "If I had cancer, I would want my family to know that I have it." When making decisions about one's healthcare, women are more likely than men to trust social contacts such as their spouse (46.5% vs 5.3%, p < 0.001) while men are more likely than women to trust health service personnel such as a nurse (50.9% vs 18.8%, p < 0.001). Furthermore, men and women were both more likely to state that men have the final decision regarding the healthcare decisions of women (p < 0.001). Our data reveal structural disadvantages for women within our study population as well as gender differences in the adapted everyday discrimination scale and cancer stigma scale. Higher rates of both personal and perceived cancer stigma among women has profound implications for how population and community level communication strategies for cancer prevention and control should be designed. Efforts to advance the goal of the elimination of cervical cancer should, in the short-term, seek to gain a more profound understanding of the ways that gender, language, and other social determinants impact negative social influences and other barriers addressable through interventions. Social and behavior change communication may be one approach that can focus both on education while seeking to leverage the social influences that exist in achieving immediate and long-term goals.

Background: Worldwide, nearly 570,000 women are diagnosed with cervical cancer each year, with 85% of new cases in low- and middle-income countries. The African continent is home to 35 of 40 countries with the highest cervical cancer mortality rates. In 2014, a partnership involving a rural region of Senegal, West Africa, was facing cervical cancer screening service sustainability barriers and began adapting regional-level policy to address implementation challenges. Objective: This manuscript reports the findings of a systematic literature review describing the implementation of decentralized cervical cancer prevention services in Africa, relevant in context to the Senegal partnership. We report barriers and policy-relevant recommendations through Levesque’s Patient-Centered Access to Healthcare Framework and discuss the impact of this information on the partnership’s approach to shaping Senegal’s regional cervical cancer screening policy. Methods: The systematic review search strategy comprised two complementary sub-searches. We conducted an initial search identifying 4272 articles, then applied inclusion criteria, and ultimately 19 studies were included. Data abstraction focused on implementation barriers categorized with the Levesque framework and by policy relevance. Results: Our findings identified specific demand-side (clients and community) and supply-side (health service-level) barriers to implementation of cervical cancer screening services. We identify the most commonly reported demand- and supply-side barriers and summarize salient policy recommendations discussed within the reviewed literature. Conclusions: Overall, there is a paucity of published literature regarding barriers to and best practices in implementation of cervical cancer screening services in rural Africa. Many articles in this literature review did describe findings with notable policy implications. The Senegal partnership has consulted this literature when faced with various similar barriers and has developed two principal initiatives to address contextual challenges. Other initiatives implementing cervical cancer visual screening services in decentralized areas may find this contextual reporting of a literature review helpful as a construct for identifying evidence for the purpose of guiding ongoing health service policy adaptation.