Partnership Report Cervical Cancer Preventive Services Implementation, Kedougou Region, Senegal 2010 - 2015

Kedougou / Sédhiou, Senegal

Peace Corps Senegal

University of Illinois at Chicago

Peace Care

This partnership is being funded with support from:

Peace Care

In-kind support through the US Peace Corps, the UIC Department of Family Medicine, and the UIC Center for

Global Health

Grant funding from the CDC GTHRN #1U48DP005010 and

The UIC Chancellor’s Global Health & Well-Being Seed Grant.

Acknowledgments

We would like to acknowledge the following organizations and individuals who have given significantly toward

the successful implementation of this project, in terms of hours of labor, financial support, and encouragement.

Kedougou Region Health Leaders and Staff. In particular:

Dr. Abib Ndiaye, Kedougou Region Medical Director

Elhadji Mamadou Dioukhane, MCD Kédougou

Dr. Evrard Kabou, Saraya District Medical Director

Hamidou Thiam, Supervseur Soins de Sante

Landing Sagna, Superviseur des soins de santé primaire: District de Kédougou

Primailes Region Kédougou

Fatou Traore, Lead Regional Midwife

Mariama Touré, Coordinatrice SR du D.S. Saraya

Marguerite Thiaré, Sage Femme de CSKdg

Ngoné Gueye, MSF CC Salemata

Oulimata Sane, Midwife, Sage Femme de Khossanto

Dr. Cheikh Senghor, Kedougou District Medical Director

Dr. Mamadouba Camara, Kedougou District Surgical Oncologist

Diouma Diallo, “Mdme. Diop”, Midwife

Sédhiou Region Health Leaders and Staff

Dr. Youssoupha Ndiaye, Sédhiou Regional Medical Director

Senegal National Level Collaborators, Advisors, Consultants, and Mentors

Dr. Anta Tal Dia, Director of the Institute of Health and Development (ISED), UCAD, Dakar

Dr. Mayassine Diongue, ISED

Dr. Kasse, Dakar

Peace Corps Senegal Admin and Volunteers. In particular:

Cheryl Faye, Peace Corps Senegal Country Director

Mamadou Diaw, Peace Corps Senegal Health APCD

Vanessa Dickey, Peace Corps Senegal Associate Director of Programming and Training

Katie Wallner / Aissatou Souare

Tess Komarek / Tiguida Tandian

Nicole Aspros / Niama Damba

Sarah Mollenkopf / Diabou Tounkara

Laurie Ohlstein / Binta Barry

Emily Johnson / Dienaba Dansokho

Aaron Persing / Sory Kandia Diakhaby

Peace Corps Volunteer Alumni

Peace Corps Washington

Office of Global Health and HIV

Peace Corps Masters International Program

The UIC Center for Global Health, The UIC Departments of Family Medicine and the School of Public Health,

& The UIC Institute for Health Policy and Research

The UIC Team

Andrew Dykens, MD, MPH

Karen Peters, DrPH

Tracy Irwin, MD, MPH

Memoona Hasnain, MD MHPE PhD

Trainees: Fri Awasum, Paul Rotert, Rina Dave', Tyrisha Clary, Sarah Johnson, Rithvik Balakrishnan,

Elly DeJesus

UIC Team Alumni:

Peace Care Board of Directors and Staff

Peace Care Advisory Panel

Partnership Summary 2010 – 2015

Community Focus and Project Impact

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. Through a process emphasizing local prioritization, the primary focus of the project became cervical

cancer preventive services implementation. This process included 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 been focused on the Kedougou Regional level. 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 to date

has implemented regional-level cervical cancer prevention guidelines, a service accessible to an estimated

10,000 women in the target population, 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 prevalence study with data indicating 2.27% prevalence of cervical dysplasia. 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.

Peace Corps Engagement

Since the partnership inception, a total of 7 generations of Peace Corps Senegal Volunteers have contributed

to this partnership. Among this group there have been 18 total Volunteers, of which 4 are Peace Corps

Masters International Students, who have worked extensively on this project. All Returned Peace Corps

Volunteers have contributed to this project after their return by way of translation, coordination, planning, or

other support including acting as ambassadors for the ongoing partnership.

Educational Impact

Since the partnership inception, a total of 12 Resident Physicians and 8 students in the UIC College of

Medicine, School of Public Health or Department of Communication has contributed to the project and learned

from the partnership approach and cultural aspects of the partnership.

Scholarly Impact

Since 2010, this partnership model has been presented at more than 10 national or international scientific

meetings including the Network: Toward Unity for Health Conference, The Consortium of Universities of Global

Health, The Global Health Education Consortium Annual Conference, The American Public Health Association

Annual Conference, the International Federation of Gynecology and Obstetrics Conference, The American

Association of Family Physicians Global Health Conference, The Society of Teachers of Family Medicine

Conference. This project and partnership is the main focus of 2 published scientific journal articles. One other

scientific article has been submitted and three additional articles are in the writing phase. Coauthors on all

papers have included local researchers and Peace Corps Volunteers in addition to the researchers at US

academic institutions. The Senegal project is being funded by two research grants: CDC GTHRN

#1U48DP005010 and the UIC Chancellor’s Global Health & Well-Being Seed Grant.

PROJECT SUMMARY BY YEAR

2010-2011: The partnership began through 2009 initial discussions and a partnership formation site visit in May

of 2010. Community and health systems level assessments were conducted in 2010. A participatory approach

was used to design and conduct the 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. These assessments were followed by

an evidence-based and participatory project development phase in preparation for the first stages of project

implementation occurring in early 2011. Many regional health priorities were identified, but 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 was

defined as implementing cervical cancer prevention services in the Kedougou region of Southeastern Senegal

through service capacity building and regional health system policy implementation. World Health Organization

approved curricular materials were adapted through a collaborative process. Beginning in early 2011 teams

comprised of members from the UIC Department of Family Medicine and representative faculty from the UIC

School of Public Health as well as the OB/Gyne Department traveled to Senegal to begin project implementation.

Throughout the course of the assessment, project development, and project implementation phases locally

placed Peace Corps Volunteers played an instrumental role in community advocacy, information transference

and translation, project coordination, project logistics facilitation, data gathering, and visiting team cultural and

language orientation.

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

informed the selection of this technical approach. The conclusions of the realist synthesis illustrated that Visual

Inspection of the Cervix with Acetic Acid (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%). With careful attention to quality assurance, VIA has proven to be safe and cost-effective. In order to

respond to the identified capacity challenges of the region in implementing this evidence-based solution, the

specified approach involved task sharing by educating midwives on the screening technique through the training-

of-trainers approach. In 2011, there were five trainers trained in the technique of visual inspection of the cervix

with acetic acid (VIA). These trainers, in turn, initially trained 14 additional personnel as a secondary training, to

advance workforce development and as a component of advancement toward Master Trainer status as defined

through the JHPIEGO Trainer Pathway. The District level medical director, as a strategy for scaling the project,

expressed a desire to illustrate this model as a successful means by which to initiate cervical cancer screening

throughout rural Senegal, where few efforts previously existed. It is through this motivation that discussions with

officials at the regional level subsequently occurred.

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 and post

level. During this time, the local trainers continued to train additional health personnel in the technique of

visual inspection of the cervix with acetic acid to complete access to this service throughout the Saraya District

and advance the goal of covering the entire region. By the end of 2012, two trainers remained in the region,

three candidate trainers advanced their skills, and 39 total health workers had completed the VIA training. The

process for formal integration of this service into the Regional level health service policy began. A theoretical

training for cryotherapy implementation, as well, occurred and the region began preparations to implement this

service. A quality improvement process was initiated to guide further service implementation, programmatic

development, and policy creation. Health service implementation was guided by the themes specified by the

World Health Organization building blocks for health systems strengthening. Therefore, programmatic

development is centered around 1) clinical guidelines, 2) governance norms, 3) workforce development plan,

4) quality control, 5) health information systems, 6) resources management, 7) community-level information

and education and 8) strategic partnerships.

With resources and trained personnel in place, the determination of burden of disease within the region

was prioritized to help guide the advancement of the project and illustrate the relative burden. The goal to

provide self-sufficiency through the creation of Master Trainers and a local Management Team for future

scaling of the service implementation was, as well, stated.

2013: The partnership continued to advance at the Kedougou Regional level. Through this year of the

partnership, the local trainers trained additional health personnel in the technique of visual inspection of the

cervix with acetic acid to complete access to this service throughout the Saraya District and advance the goal

of covering the entire region. 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. The careful planning of a region-

wide prevalence study was concluded and initiated in late 2013. As well, in 2013, a quality improvement

process was 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.

2014: The region-wide Kedougou cervical dysplasia prevalence study was concluded in 2014. This study

sought to utilize VIA, a low cost cervical cancer screening tool, to establish 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, is likely due to a developing gold mining industry

that is largely isolated to that district. Such mining projects have been associated with increased STI rates due

to migratory workers and increased sex work.18 Higher STI rates are an established risk factor of cervical

dysplasia and cancer. The Saraya district also has one of the highest HIV prevalence rates, another emerging

risk factor for cervical cancer, in Senegal.17 Our findings highlight an area of need for cervical cancer

prevention and possibly STI reduction. Given the low number of positives, it is expected that the risk factor

data do not reveal any significant correlations. It was interesting that all the positive VIA cases were 30-39

years old. Our screening sample consists of very few screenings of women between the ages of 40 and 50.

While the greatest number of screenings were in the 30 to 35 group and fewer screenings in the 36 to 40

group, the trend still showed an increase number of positives with an increase in age. It is likely that with

greater numbers of screening in the 40 to 50 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

goal is to increase service utilization, assure sustainability, assure health service quality; there were trends

toward fewer pregnancies and births and later sexual debut among the positives, but additional data would be

needed to confirm this. STI rates were high in this sample, with 43% of women reporting ever having had an

STI, while only 38% were aware of cervical cancer. This highlights STI prevention, detection and treatment as

another potential service need for women in this rural part of Senegal.

With full capacity in place and the illustration of clinical need for this service, it was noted that service

utilization remained low region-wide. In response to this concern, the partners submitted and successfully

received two grants to address certain questions with the hopes of improving the overall effectiveness of the

cervical cancer prevention program.

2015: In 2015, the partnership is initiating 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 will use 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 Sédhiou, Senegal. In this research, we will assess the horizontal and

vertical scaling of health policy and evaluate a partnership between the local communities and health system in

Kedougou, Senegal; Sédhiou, Senegal; Peace Corps Senegal; the Institute of Health and Development in

Dakar, Senegal; and the University of Illinois at Chicago. We will achieve the project aims through a

community-based participatory research (CBPR) partnership with community members, health workers and

leaders, Peace Corps volunteers, and academic personnel. CBPR partners will conduct a quality improvement

process for cervical cancer prevention services at intervention health posts while basic cervical cancer

screening capacity is grant supported at all posts. Both quantitative and qualitative data will be gathered to

assess 1) how community involvement will improve cervical cancer prevention service delivery approaches to

help local populations utilize this new clinical service, 2) how health service implementation can be scaled

horizontally into the Sedhiou region, 3) how health service quality improvement occurs at local levels and 4)

how this global health partnership functions. We will assess the impact of the horizontally-scaled community-

developed health services policy promoting access to cervical cancer on service community access and health

outcomes as well as the service process. We will ultimately recommend a Senegal national-level cervical

cancer prevention services policy approach for implementation in decentralized regions where this policy does

not currently exist by conducting an analysis of the existing Kedougou policy and its horizontal scale to the

region of Sédhiou, Senegal.

January 2015 Site Visit Jan 21, 2015 - Dakar Research Meeting at ISED

This productive meeting set the basis for a strong collaboration with the Institute of Health and Development

(ISED) and the Peace Corps over the course of this project. Each partner introduced her or himself and the

representative institution. We oriented all partners in attendance on the history of the project, the research

protocol and all data collection instruments in their current form, and set goals. All attendees expressed

dedication to the project. We will continue to develop the research protocol with the aim of submitting the

protocol for Institutional Review Board (IRB) approval by the end of February, 2015 to both the IRB at UIC and

the University of Cheikh Anta Diop (UCAD) in Dakar. All partners are enthusiastic to contribute to the

development of research dissemination and further grants development.

January 22, 2015 Meeting with Peace Corps Senegal at Headquarters

The meeting with Peace Corps Senegal was exceptional. The UIC / Peace Care team provided a brief

overview of the history of our collaboration. In addition, we were able to highlight the significant role of the

Peace Corps Volunteers (PCVs), the forward activities of the project, the funding of the research, and the study

of the partnership model. We discussed recent conference presentations and publications. We updated

headquarters on the selection of a PCMI student, Elly Dejesus, for the Senegal cervical cancer prevention

program. We also discussed the evolving relationship with Peace Corps Headquarters in Washington DC. We

expressed our sincere gratitude for the continuation of the partnership and our anticipation of continued

productive collaborative work.

January 24, 2015 – Sédhiou Regional Leadership Meeting at the Regional Medical Office

The UIC / Peace Care team met for the first time with the Sédhiou region medical direction. Dr. Youssoupha

Ndiaye described our history of collaboration and praised our working relationship. He summarized the

development of the project in Kedougou and explained the logic of advancing the project to this region.

Andrew Dykens introduced the research project, clarifying the intervention of community engagement in health

services quality improvement. He also described the planned activities and timeline for regional capacity

building. It was discussed that it is likely that the prevalence for dysplasia and cervical cancer is higher in the

Sédhiou region relative to some other districts. Sédhiou recently had the opportunity for some capacity

development in cervical cancer screening on a very small scale and during those screenings several positives

and two suspicions for cervical cancer were found. They are anxious to scale up the capacity throughout the

region as it is evident that cervical cancer is a priority. Questions were raised about the approach and

limitations of the financing. Both Dr. Ndiaye and Andrew Dykens reassured the group that cryotherapy will be

immediately available at the regional level for the treatment of precancers. We also discussed that we will

collectively identify funding, if necessary, to assure the treatment of women identified as having frank cervical

cancer. It was reiterated that policy considerations are an aspect of this research and our intention over time is

to assure sound and responsive cervical cancer prevention policy at the regional and national levels that is

people centered. We also discussed other priority needs of this region. The priority of Sickle Cell is an

identified issue of significant need. Currently, there is minimal capacity to deal with this issue. Emergency

services are also severely lacking. Additionally, it is noted that strokes are a leading mortality indicator and

further information to understand the primary etiology is needed. Diabetes is prevalent in the region, but there

are no activities to date in this area.

Next steps were discussed. The UIC / Peace Care team will work alongside our Senegalese co-investigators,

namely Dr. Youssoupha Ndiaye and Myassine Diongue to finalize the protocol and instruments and,

subsequently, submitted these documents to the IRB’s at UIC and Cheikh Anta Diop University in Dakar for

approval. We will plan to begin mobilization of personnel in the region in April with specific planning and

preparatory activities. In the mean time, the local leadership will specify their capacity needs and recommend a

timeline. The UIC / Peace Care teams will adapt our proposed timeline when and where possible. Currently,

our anticipated initiation of capacity building activities, namely the training of trainers and initiation of

cryotherapy training will occur in August of 2015. Concerning other priority areas for the Sédhiou Region, the

UIC / Peace Care team will begin aligning the Sédhiou Region with institutions and programs of parallel

interest.

January 25, 2014 – Kedougou Regional Leadership Meeting at the Regional Hospital

Our meeting with the leadership in the Kedougou region was thoughtful and energizing. We spent time

reflecting on the project to date and identified several barriers to achieving our goals. It was reassuring to note

that the proposed solutions by the Regional Direction are parallel to the perceived steps forward iterated in the

protocol, and as specified by our local partners and Senegalese research colleagues. The meeting identified

concrete next steps in reporting the progress to date and preparing for the initiation of the research as phase

two.

January 26, 2015 – Kedougou Partnership, Project Reporting, and Research Orientation Meeting

An exceptionally formative meeting, we discussed the theory and values of the partnership including the

partnership evaluation component. There were several questions about the type of partnership corresponding

to the role of research vs health systems development vs policy and the manner these all overlap. There were

questions about the nature and purpose of the relationship with ISED, the role they play and the importance of

their involvement. The response to these questions generally revolved around the importance of research at

decentralized levels in local communities, especially the needed pursuit of implementation and delivery

science. It was also stated that the development of knowledge around policy development at local levels is

important not only for raising awareness of the context of decentralized regions but sharing the lessons learned

with similarly situated populations within and exterior to Senegal. The necessity of integrating the research and

cervical cancer prevention service into the general health services consideration was expressed and agreed.

We discussed the approach to the research and received several suggestions and comments. A summary of

comments are noted here with a brief overview of the response.

Currently there are health committees present at all health system levels within the region, with various

functionality. – Therefore, concerning intervention sites, we will work with the existing health

committees. At control sites we will inform the existing committees but will not include them in the

COPE training.

The Regional Direction will prepare a summary report to send to the National Ministry to inform them of

the project. It was emphasized that we must well-inform the leadership within the National Ministry. –

The UIC / Peace Care team expressed the necessity that all correspondence to National level Ministry

officials occur through the expected chain. The UIC / Peace Care team prefers to remain as

collaborators and support the continued direct communication within the existing health system.

The question was raised about the responsibility of treating women who screen positive or with

suspicion for cervical cancer. – The UIC / Peace Care team reiterated the importance of the regional

medical system to provide full assurance that women who screen positive would be adequately treated

in a timely fashion. The UIC / Peace Care team refrains from offering formal support for this necessity.

In the future it will be absolutely necessary to assure sustainability of the program that the regional

health system take full responsibility for this issue. The UIC / Peace Care team stated that we are

available to help informally (through fundraising or solicitation of funds) in this area if funds are not

readily available to deal with a specific case. The UIC / Peace Care team expressed the importance of

offering a cryotherapy treatment session for all women who have been screened positive up to this

date.

The suggestion was made to create a research committee at the regional level and the involvement of

multiple personnel at the district level to oversee and carry out the functions of the research project. –

The grant makes available adequate funds for research oversight at these levels. We will respect the

decision by regional leadership on the specification of these funds. The expectations for continued

funding of the project were reiterated and will remain consistent. Thus, as long as all research

requirements are met, there is flexibility in the project management.

Subsequently, we discussed the COPE quality improvement process. There were comments at district

leadership levels, notably from Saraya and Kedougou leadership, in support of the implementation and

continuation of this model of quality improvement. The quarterly completion of activities was expressed

and agreed.

The tone of the meeting was highly collaborative. There were multiple research methodological suggestions

that were valuable, appreciated, and well-noted. There was agreement on next steps and the enthusiasm for

the collaboration and project.

January 27, 2015 COPE Meeting

The first quarterly Client Oriented Provider Efficient (COPE) quality improvement meeting as a part of this

study has occurred at the District level in Saraya. The meeting was opened by Dr Kabou and then Mariama

Toure led the entirety of the meeting. The meeting focused on the theory of COPE including the rights of

clients and the needs of health providers. Subsequently, the group broke into two groups: one group for client

questionnaires, one group for self-evaluation. The plan was for the two groups to complete their activities on

the following morning.

January 27, 28, & 29, 2015 COPE TOT and Research Coordinator training

We spent three days together with the candidate COPE trainers, also identified as District Research

Coordinators. During this time, these leaders learned the COPE process and discussed a strategic plan to

implement this at the district level and the specified intervention and control sites. The research plan was

discussed in depth, including the manner that these individuals would oversee the data collection. The district

research coordinator personnel will be further supported by the Peace Corps Volunteers in the region for all

research activities. All data collection instruments were revised and the plan for a research guide was

elaborated, to be completed in the very near future for distribution prior to the initiation of the research.

January 30, 2015 Intervention and Control Site Research and COPE Orientation

Representatives for the health posts and community health committees from all specified intervention and

control sites were invited to Kedougou for a half-day research orientation meeting. The objectives of the

research were discussed and the plan for the implementation of the research was detailed. In order to carry out

the proposed research, the COPE quality improvement process will need to be initiated at each site. Therefore,

a brief introduction of COPE was provided and a preliminary plan for the COPE training at each site was

discussed. These representatives will be invited to attend the Partnership Research meeting at the Regional

level every six months as detailed in the protocol and research guide.

February 2, 2015 Meeting with Peace Corps Senegal at Headquarters

The UIC / Peace Care team was proud to report a highly successful site visit to the Peace Corps office in

Dakar. The team expressed sincere gratitude to the highly organized, efficient, and effective volunteers onsite

for their significant support. The team discussed the accomplishments of the trip including evidence of regional

ownership of the project and the ideal of developing sustainability. The outcomes of the research plan were

clarified and next steps were discussed. The UIC team will initiate the research upon approval by the UIC and

Cheikh Anta Diop University’s research ethics board (likely in March) and will begin preparations for a late

August site visit to continue the research. The Peace Corps office will assist with coordinating some document

translation and the printing of research guides for local application. Both the Peace Corps office and UIC

expressed gratitude for the partnership.

Additional meetings were held with Mr. Matt McLaughlin, the Director of the Malaria Bootcamp initiative for

bednet distribution and the ProaCT malaria prevention program, Mr. Diouf, the Director of Human Resources

at the Minister of Health’s Office, Dr. Issakha Diallo, a past Director of the Institute of Health and Development

in Dakar, and a visit to the Bargney Men’s and Women’s Basketball Club.

Discussion

This project is advancing well and has illustrated that a participatory approach is effective in

implementing cervical cancer preventive services through a community, university, Peace Corps partnership.

In assuring a sustainable end result, the project has been shaped by strong attention to the local context.

The Partnership – This project is illustrating the efficiency of engaging academic resources and the US

Peace Corps in addressing health service capacity needs at a decentralized community health

system level in order to provide access to a quality primary health care service to the local population.

The partnership emphasizes an understanding of local context through a longitudinal approach,

continuous engagement, and flexibility in the approach. There is ongoing refinement of the strategic

plan that responds to identified barriers and the expressed priorities of all partners.

Task Sharing – We have effectively utilized task shifting by utilizing midwives as the primary screening

practitioners. The Master Trainer team for teaching visual inspection of the cervix with acetic acid

(VIA) are all midwives. Nurses have, as well, been taught the clinical skill of VIA. The approach of

using practitioners who are disbursed more widely throughout the region than physicians is proving

valuable and will likely result in greater service utilization by the population.

Appropriate Technology – The selection of VIA as a screening methodology and cryotherapy as a

treatment modality for cervical precancerous is useful for several reasons. This can effectively be

performed as a single visit screen and treat. In addition, minimal infrastructure is needed to support

this highly affordable and easily attainable technology.

Training of Trainers – The primary training team in place in the Kedougou Region have been provided

additional training in advanced clinical training skills and are all highly effective educators for this

focused issue. The fact that a training team remains in place will allow the service to continue to self-

maintain with natural attrition of health workers. This capacity in place will also facilitate the horizontal

scaling of capacity to the neighboring region of Sedhiou. Therefore, this approach emphasizes clinical

skills, clinical training skills, and service management capacity.

Health Service Policy – Health service programmatic and policy development will continue to be a

central focus of the project. This includes considerations such as the following: a) Planning,

Monitoring and Evaluation, b) Resources and Capacity including Financing, Workforce Capacity, and

Resources Management, c) Community and Health Service Activities including Clinical Service

Guidelines and Health Information Systems, d) Networks and Partnerships, 3) Management,

Accountability, and Leadership, and e) Communication and Outreach. Attention to these details and

the development of formal service policy integrates the service into the local context with more

specificity and is likely to more greatly assure sustainability. We will continue to strengthen the

programmatic plan and health service policy through an approach that utilizes the COPE quality

improvement process and the Civil Society Community Systems Strengthening Framework.

PARTNERSHIP MODEL INTRODUCTION

This project utilizes the Global Community Health Partnership (GCHP) model and holds as its principle goal to

Foster health equity by improving community access to quality primary health care services. Through this goal

we strive 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 primary 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.

GCHC Model Description

The partnership approach links 1) LMIC community members and local health care providers to 2) U.S. and

LMIC university faculty through the assistance of the 3) Peace Corps. The approach incorporates CBPR,

empowering the community to set priorities and guide the implementation of the research. The Peace Corps

facilitates the partnership by offering community expertise, cultural guidance, onsite project coordination, and

community advocacy. The universities offer professional technical and public health training resources and

evaluation support. Partnership project planning meetings occur longitudinally through distance communication

and document sharing. Community Advisory Board (CAB) meetings, focus groups, data collection, policy

discussions, and technical trainings occur primarily during biannual university site visits. The participatory

partnership and CAB meetings guide the health service adaptation, implementation, quality improvement, and

the evaluation. The outcome of a partnership is a sustainable health service, trained health care providers,

service guidelines directed at a locally-prioritized health issue, and health service implementation research

using mixed methods to evaluate the process and impact of the health service. The expansion of a community-

Peace Corps-academic approach will continue to foster the development of global health partnerships that 1)

consistently use participatory approaches to address the need of sustainable health systems in low resource

communities and 2) focus on primary health care services implementation research.

GCH Partnership Structure and Function

There are six phases of a GCH partnership. The Partnership, Assessment, and Development phases

culminate in the adaptation of a curriculum aimed at developing evidence-based primary health care capacity

for a community priority. During the Intervention, the academic institution leads curriculum implementation

through the training-of-trainers, ensuring long-term local ownership of the service enhancement initiative. In

addition, health service policy is enacted through a participatory process involving local health leaders. In the

Evaluation phase, a continuous quality improvement process is enacted through iterative self-assessments.

Service- and population-level data are gathered to measure the impact of the partnership. Through the

Dissemination phase findings and recommendations are distributed to partners and the academic community

through presentations, publications, and a research repository.

The GCH partnership approach emphasizes policy and programmatic development that is responsive to the

needs at the local level, and rejects centralized models or external policy development that may fall short of

addressing community needs. Although the model develops partnerships that are academic institution-advised

and Peace Corps-facilitated, they are intended to remain community-led; this enables researchers to assess

evidence-based translations of technologies or interventions that build capacity, and to study the

implementation of these technologies within the complicated realities of local health systems at the community

level. The GCH partnership model utilizes the established framework of training trainers, continuous quality

improvement, evidence-based global health translational research, and a participatory approach

IRB Approval

While this Community Based Participatory Research Project carries minimal risk it upholds the highest ethical

standards of human research. In regards to this, all key personnel with access to research data and with a role

in terms of project evaluation completed the required ethics and IRB course on research with human subjects.

Figure 1: Global Community Health Partnership Model

GCH Partnership Objective: Foster health equity by improving community access to quality primary health

care services.

Figure 2: Community-Peace Corps-Academic Partnership as an Enhanced Approach

Global Health Disparities

Low and middle income countries are disproportionately affected by the global disease burden, and experience

a double burden of disease, with a significant prevalence of both infectious diseases and non-communicable

diseases. Because of this poor state of health, local communities in LMICs experience slowed development

and economic growth, and individuals experience greater morbidity and mortality. Many low technological,

inexpensive, and low-resource-appropriate solutions have strong evidence of effectiveness for impacting the

most common health issues. In order for implemented solutions to have sustainable effect, strong local

primary health care systems are needed. There exists a significant shortage of health care workers in low

income countries, especially at the local levels. Therefore, expanding workforce capacity can have a

significant impact on local health systems. This local workforce capacity expansion can be sustainably

accomplished through effective global health partnerships. Furthermore, focusing on decentralized (local)

health systems greatly benefits workforce capacity policy development and improves retention and attrition

rates.1 Among the multiple tiers of policy making, including national, regional, district, city, and institutional

levels, there are marked differences between theory and practice in health systems operation.2 Therefore, in

order to inform global health partnerships, research devoted to the implementation of locally-focused health

services and policy is needed. 3

Implementation Research

Siddiqi et al. (2009) illustrated that health services development at the national level is dependent on

responsible governance.4 Brinkerhoff established that poor governance contributes to ineffective health

systems.5 Decentralization of health policy has many potential benefits, including a more rational and unified

health service that caters to local preferences, reduction of inequalities between rural and urban areas, and

improved intersectoral coordination, particularly in local government and rural development activities.6

However, relatively little is understood about the manner in which partnerships assist health systems at

decentralized levels in LMICs to develop and implement health policy and service delivery programs. In these

settings, capacity development arises from centrally initiated policy, often with barriers to implementation at the

local level.

Significance

This study focuses on understanding the role of partnerships within local health system policy development in

the context of being aligned with national-level health system priorities and with national-level health system

awareness, yet independent of a centralized catalyst or directive. This research builds knowledge on the role

partnerships play on health service policy development needed to inform the design, implementation, and

evaluation of local health service policy in low resource settings such that it is sustainable, effective, efficient,

and scalable. The development of this scholarly work will encompass this focus (as suggested by Hyder et al.)

as it is further developed and will, thus, as well, focus on understanding the ways in which academic centers,

communities, and development agencies collaborate and the benefits and disadvantages of partnerships on

each of these partners. This research builds knowledge that can be used to inform the development,

implementation, and evaluation of global health partnership programs with the goal of creating a synergism

among (1) dis-empowered yet highly-motivated communities; (2) trusted development agencies rich in field

experience and infrastructure but limited by technical expertise; and (3) academic institutions, resource-rich but

limited in local experience.

Health systems strengthening will impact population-level health outcomes. In order to effectively impact local

health systems in LMICs, the translation of evidence-based solutions from similar contexts into systems of

identified need and priority is needed. As well, due to the shortage of healthcare workforce, globally, capacity

building and development of human resources is needed. The GCHP model could address these challenges

through leveraging already existing, extensive infrastructure. The Peace Corps currently has over 9000

volunteers and operates in 76 countries while there is significant movement among US universities to develop

global health partnerships. By partnering communities, the Peace Corps, and US universities, the GCHP

partnership model could have significant impact.

APPENDIX 1

Community Health Assessment

The baseline health assessment of the Saraya district in Senegal was conducted in November 2010 by Chris

Brown, PCV, and the field ethics trained local advisory board. Using the interview tools, community member

focus groups and key informants, including health care workers, were interviewed with the goal of obtaining

information regarding community assets for health care, primary health problems within the community, the

state of health care utilization, and the state of patient satisfaction.

Focus Groups

Saraya-4 focus groups

Barabiri-4 focus groups

Bembou-3 focus groups

Mandokholing-4 focus groups

Bambadji-4 focus groups

Moussala-4 focus groups

Community Health Workers -Saraya-1 focus group

Key Informant Interviews

Nurses-3

Doctors-1

Midwives-1

Laboratory Technician-1

Issue Selection

Through the baseline health assessment, several health issues were identified by the community as primary

health concerns, notably sexually transmitted infection (STI) prevention and diarrhea.

An additional issue, Cervical Cancer Screening, was initially identified by the Chief Medical Officer at the

district level as a health service need by this community. It was noted that, at that time, no cervical cancer

screening program was in place. While lacking from the community level assessment data, it was noted to be

a significant public health issue from the analysis of the collected epidemiological data.

Health Care Delivery Assessment

After the community health assessment and issue identification, the Peace Corps Volunteer and the Local

Advisory Board performed a focused assessment of the local health care delivery system directed at the

selected issues, and, along with local health care workers and the guidance of Peace Care, identified the

assets and needs of the local community in this regard. This work was accomplished along with the local board

of health to foster sustainability and local autonomy.

APPENDIX 2

Cervical Cancer

The World Health Organization Report on Cervical Cancer in Senegal reports,

"Senegal has a population of 3.20 million women ages 15 years and older who are at risk of developing

cervical cancer. Current estimates indicate that every year 1197 women are diagnosed with cervical

cancer and 795 die from the disease. Cervical cancer ranks as the most frequent cancer among

women in Senegal, and the most frequent cancer among women between 15 and 44 years of age.

About 12.6% of women in the general population are estimated to harbor cervical HPV infection at a

given time and 43.6% of invasive cervical cancers are attributed to HPVs 16 or 18.”

Realist Synthesis

A realist synthesis of the literature was performed to guide the team in the development of the curriculum for

the issue of cervical cancer.

Abstract

Realist Synthesis: Cervical Cancer Screening in Low Resource Settings

Background: The effective implementation of interventions in low-resource settings requires attention to

specific factors. This realist synthesis approach reviewed literature to identify these elements. The focus was

on identifying the most effective cervical cancer screening interventions for low-resource settings, where it is

estimated that about 85 percent of cervical cancer deaths occur.

Methods: Publications pertaining to cervical cancer screening methods in low-resource settings from 1990 to

2010 were retrieved using Pubmed, Cochrane, Cervical Cancer Library, and the Alliance for Cervical Cancer

Prevention. Studies were included if: (1) performed in low or middle-income countries, (2) focused on

screening methods, and (3) included assessments relevant to the implementation of cervical screening

programs to low-resource settings. Twenty-seven publications were reviewed and the information categorized

into the different elements.

Results: The key findings showed a wide range of sensitivity and specificity among tests. VIA had a lower

sensitivity and higher specificity, but compared to cytology, it had lower specificity leading to a significant

number of false positives. However with VIA, patients can be treated immediately and it is a cost-effective test.

In a significant number of the studies the screening was performed by non-physicians. Many of the

interventions recommended performing a community-based formative research prior to developing the

intervention.

Conclusions: This realist synthesis showed that despite its limitations, VIA is currently a safe and feasible

screening test for low-resource settings. It also showed that this method can allow developers to identify

elements that could be incorporated into new interventions.

APPENDIX 3

Project Development / Adaptation

Based on the assessment phase findings high quality curricula and training materials were adapted for

implementation. These curricula are based on materials developed or approved by the World Health

Organization, as listed below.

Curriculum Development - Cervical Cancer Screening

Alliance for Cervical Cancer Prevention (ACCP): Planning and Implementing Cervical Cancer Prevention and

Control Programs: A Manual for Managers. Seattle: ACCP; 2004.

English: http://screening.iarc.fr/doc/ACCP_screen.pdf

French: http://screening.iarc.fr/doc/MfM_French_final.pdf

Sankaranarayanan R, Wesley R (2003) A Practical Manual on Visual Screening for Cervical Neoplasia, IARC

Technical Publication No. 41. Lyon: IARC Press.

English: http://screening.iarc.fr/viavili.php

French: http://screening.iarc.fr/viavili.php?lang=2

World Health Organization (2006) Comprehensive cervical cancer control: A guide to Essential Practice.

English: http://screening.iarc.fr/doc/cervicalcancergep.pdf

French: http://screening.iarc.fr/doc/text_fr.pdf

Digital learning series. A training course in visual inspection with 5% acetic acid (VIA). IARC, 2005.

English: http://screening.iarc.fr/digitallearningserie.php

French: http://screening.iarc.fr/digitallearningserie.php?lang=2

A Training Course in Visual Inspection using 4% Acetic Acid (VIA) - theory and practice. IARC

English: http://screening.iarc.fr/movieVIA.php

French: http://screening.iarc.fr/movieVIA.php?lang=2

Sankaranarayanan R, Wesley. Quick Clinical Reference Chart for Visual Inspection with Acetic Acid

(VIA). IARC

English: http://screening.iarc.fr/doc/schartvia.pdf

French: http://screening.iarc.fr/doc/schartviafr.pdf

Sellors J, Camacho Carr K, Bingham A, Winkler J. Course in Visual Methods for Cervical Cancer Screening:

Visual Inspection With Acetic Acid and Lugol’s Iodine. Seattle, WA: PATH; 2004.

APPENDIX 4

Cervical Cancer Preventive Services

Screening: Visual Inspection with Acetic Acid

Treatment of Precancers: Cryotherapy

Kedougou Region Service Guidelines 2010-2015

These guidelines are adapted from the World Health Organization Guidelines for implementation of cervical

cancer screening programs and in consideration of the available resources in the health system and the

region.

Target Population: Women aged 30 – 50 years of age

Workforce Objective

All midwives region-wide should have the skills to perform cervical cancer screening using visual

inspection with acetic acid (VIA)

All ICPs should be aware of cervical cancer prevention services and facilitate cervical cancer

prevention in their health zone

Cryotherapy services should be offered at district hospitals by midwives with supervision by doctors

who have been trained within the local health system

Certification and Health Services Expansion

Initial Provider Certification in VIA requires the following:

o Successful completion of a provider training certified by the health system. Must achieve a

score of 70% on a photo exam testing interpretation of visual inspection with acetic acid, as well

as an adequate observed standardized clinical exam.

Initial Qualified Trainer Certification in VIA requires the following:

o Successful completion of a training of trainer course certified by the health system. This entails

a score of 80% on both a written exam and photo exam testing interpretation of visual

inspection with acetic acid, a successful observed standardized clinical exam, and

demonstrated competence when observed performing a training session.

Initial Cryotherapy Provider Certification requires the following:

o Successful completion of a training certified by the health system. This training should include a

didactic component and a practical component. We recommend a score of 80% on a photo

exam test that evaluates skill in both VIA and appropriate management of lesions. This health

care worker should demonstrate competence in the procedure and have observed performance

of cryotherapy on at least 10 patients.

Maintenance of Certification

o Refresher Course: There will be a one day required refresher course one year after initial

certification. One must achieve a score of 70% on a photo test to maintain certification to

provide clinical services and a score of 80% on a photo test to maintain certification as a trainer.

o Clinical Practice: Clinicians are expected to perform 50 cervical cancer screenings with VIA

during the first year after certification to retain certification. A report of individual performance

will be gathered from the submitted quarterly reports.

Information and Education

A communication plan should be developed and implemented in the local language to bring awareness

about cervical cancer and how it can be prevented.

Cervical cancer screening should be incorporated into usual clinical services offered at health posts

and district hospitals.

Mass screening and mobilization campaigns can be considered.

Village aunts should be resources of information concerning cervical cancer prevention and services

offered in their area.

Clinical Services:

Costs

o Screening: There is no charge for VIA cervical cancer screening

o Cryotherapy Treatment: To be determined by district hospitals where equipment is

maintained

Location

o Screening

Health Posts: if staffed by trained midwife

District Hospitals

o Treatment of Precancerous Lesions

District Hospitals: If have equipment and staff trained to perform cryotherapy

Cervical Cancer Screening Centers

Clinical Management

o Negative Results – Follow up in 2 years until the age of 50 years old.

o Positive Results – All positive results should be confirmed by a certified VIA trainer or health

professional that performs cryotherapy. Referral and management options for confirmed VIA

positives include:

Refer to District Hospital for management.

VIA is repeated to confirm the lesion

Cryotherapy to be performed if lesion meets inclusion criteria

o Same day “see and treat” is recommended

It is not recommended to confirm VIA positive results with a pap smear as this

confers no significant advantage over visual inspection with acetic acid in terms

of sensitivity and specificity.

If available diagnostic colposcopy with biopsy and endocervical curettage could

be performed.

Refer to surgical oncologist, gynecologist or cervical cancer screening center

If cryotherapy cannot be performed at the district

If the lesion is too large

If a loop electrosurgical excision procedure (LEEP) or cold knife cone is

necessary to remove precancerous lesion

o Suspicion of Cancer –

Refer to district hospital to confirm diagnosis

Refer to closest surgical oncologist, gynecologist or cervical cancer screening center

Attempt to obtain a biopsy for confirmation of diagnosis in the district or region

Refer to DANTEC, Dakar

Counseling and palliative care can provide comfort to patient and families if patient is

unable to be referred for treatment

Documentation:

VIA Screening Register: Keep account of all women screened, their results and disposition

Patient Carried Note: A small card for the woman to keep that will document that she was screened

and disposition (when needs future screening or if referred for treatment)

Referral Form: information about the patient and findings including a drawing that depicts the size and

location of the lesion for the verifying/treating clinician

Quarterly Reports: Each health post will keep account of women screened and treated. Information

from all quarterly reports will be combined to produce a district level quarterly report.

APPENDIX 5

KEDOUGOU PROGRAMMATIC PLAN FOR CERVICAL CANCER SCREENING

AND PREVENTION

Policy Summary

Current State of Program - Overview

Program Achievements - Summary

Programmatic Plan 1. Planning and Monitoring & Evaluation

o Overview

Needs assessment, gap analysis, mapping, knowledge management, M&E and

evidence building (impact evaluation), and research

2. Resources and capacity

o Financing

Service Budget oversight, accounting, and processes for remuneration

Budget Overview (Past overview and projections)

o Workforce Capacity

Training team (Members, training plan for maintaining capacity)

Workforce development (Providers trained and training plan for maintaining capacity) (for

each technical area)

Quality control (evidence / plan for quality of training team and workforce)

o Resources Management

Equipment and supplies management (VIA and cryotherapy equipment inventory, usage

monitoring, and functional state)

Forecasting of need / upkeep

3. Community / health activities and services

o Health Service

Service Delivery

Service Clinical Guidelines

Continuous quality improvement report

o Health Information Systems

Assurance of usage and responsiveness of patient level medical records and referral

process

Data reporting process and reliability

4. Networks, linkages, and partnerships

o Professional

Development and maintenance

o Community

Development and maintenance

5. Management, Accountability, and Leadership

o Governance

Director & management team

Service communication norms and accountability

Service management reporting norms and stewardship of resources

6. Communication and Outreach

o Advocacy

Policy development

o Social mobilization

Community mobilisers

Community stake in design, delivery, and oversight of program

Innovative use of technology

o Communication and education

Community Information and Education activities (coordination of activities to ensure

service utilization - i.e. community education)

Programmatic Needs Funds / consultation request for trainings, equipment / supplies, health information systems materials

Identify cost sharing and secondary sources of support

Specify plan for future needs

APPENDIX 6

Sedhiou Regional Meeting Attendance

Names Qualifications Fonctions Phone E mail Abdel Kader Diéye Informaticien Planificateur 770434908 k2rdieye@gmail.com

Cellé DIAME Agent d'Assainissement

Comptable des matières 775110276 cellediame@gmail.com

Ndéye Khady Diouf Technicienne Supérieur Administration

Coordinatrice Santé de la Reproduction

775447256 ndeykhadydiouf@hotmail.com

Kissouma DIEDHIOU

Agent de développement

Coordinateur de zone AFRICARE 776525547 kadiedhiou@africare.org

Abdoulaye KA Conseiller en affaire sociale

Chef service régional de l'action sociale

776576498 ka.laye@yahoo.fr

Dr Youssoupha NDIAYE

Médecin santé publique

Médecin Chef de Région 776370453 youndiaye@hotmail.com

Dr Abdoul Khadre SOW

Gynécologue Chef de service maternité établissement publique de santé type I Sédhiou

775509482 sow_abdoukhadre@yahoo.fr

Mansour FAYE Technicien Supérieur Administration

Superviseur des soins de santé primaires

776148335 manouraffo@gmail.com

January 2015 Site Visit – Meeting Attendance Regional Leadership Meeting - Region Medicale de la Kédougou / District Sanitaire de Kédougou

25 January, 2015 (Sunday)

Senegal

1 Mariama Touré Coordinatrice SR du D.S. Saraya

77 541 4625 yamadjedje@yahoo.fr

2 Dr. Papa Saliou Ndoye Responsable Ma D.S. Kédougou

77 534 5630 bayezale@hotmail.com

3 Dr. Abib Ndiaye MCR Kédougou 77 574 8752

4 Hamidou Thiam Supervseur Soins de Sante Primailes Region Kédougou

77 550 6584 hamidouthiam@yahoo.fr

5 Oulimata Sané Sage Femme de Khossanto

77 550 6584 oulimata1005@gmail.com

6 Marguerite Thiaré Sage Femme de CSKdg 77 511 8478 margueritethiare56@gmail.com

7 Fatou Traoré 77 647 9536 fatoucha85@yahoo.fr

8 Tess Komarek Corps de la Paix 77 118 0534 tesskomarek13@uic.edu

9 Sarah Mollenkopf / Diabou Tounkara

Corps de la Paix 77 673 0087 smollenk@gmail.com

10 Katie Wallner / Aïssatou Souaré Corps de la Paix 77 673 0111 kewallner@gmail.com

11 Nicole Aspros / Niama Demba Corps de la Paix 77 883 8425 nicoleasprose@gmail.com

12 Laurie Ohlstein / Binta Barry Corps de la Paix 77 118 1185 laurie.ohlstein@gmail.com

USA

13 Rithvik Balakrishnan Rush University rithvik_balakrishnan@rush.edu

14 Sarah Johnson UIC sejohnson15@gmail.com

15 Crystal Patil UIC 708 244 500 cpatil@uic.edu

16 Andrew Dykens UIC / Peace Care 573 355 0452 andrew.dykens@peacecare.org

26 January 2015 (Monday) District Research and Partnership Orientation

Senegal

1 Evrard Kabou MCD Saraya (Kédougou) 221 77 648 9336

evjodka@yahoo.fr

2 Elhadji Mamadou Dioukhane MCD Kédougou 77 286 4244 assdiokhane@gmail.com el.hadji.diokhane@umontréal.ca

3 Landing Sagna Superviseur des soins de santé primaire: District de Kédougou

77 505 3731 landingsagna88@yahoo.fr

4 Mamadouba Camara Chirurgien Cancérologue 77 222 0096 madoubacamara66@yahoo.fr

5 Ngoné Gueye MSF CC Salemata 77 619 5206 ngone_gueye@yahoo.fr

6 Marguerite Thiare Sage Femme de CS Kdg 77 511 8478 margueritethiaré56@gmail.com

7 Fatou Traore Regional Head Sage Femme 77 647 9536 fatoucha85@yahoo.fr

8 Yayo Sane Responsible Regional de Progammes Intrahealth (NGO)

77 735 5244

9 Katie Wallner / Aissatou Souare

Corps de la Paix - Salemata 77 673 0111 kewallner@gmail.com

10 Nicole Aspros / Niama Damba

Corps de la Paix – Diakhaba 77 883 8425 Nicole.aspros@gmail.com

11 Tess Komarek / Tiguida Tandian

Corps de la Paix – Missira Dantila

77 118 0534 tesskomarek13@gmail.edu

12 Sarah Mollenkopf / Diabou Tounkara

Corps de la Paix - Saraya 77 673 0087 smollenk@gmail.com

13 Laurie Ohlstein / Binta Barry Corps de la Paix - Kédougou 77 118 1185 laurie.ohlstein@gmail.com

USA

14 Rithvik Balakrishnan Rush University rithvik_balakrishnan@rush.edu

15 Sarah Johnson UIC sejohnson15@gmail.com

16 Crystal Patil UIC 708 244 500 cpatil@uic.edu

17 Andrew Dykens UIC / Peace Care 573 355 0452 andrew.dykens@peacecare.org

Saraya

Name Position/Title COPE QI Meeting 27 January 2015

COPE Action Planning Meeting 29 January 2015

1 Dr. Evrard Kabou MCD de Saraya X

2 Julienne Addogue SF X

3 Ndeye Camara SF X

4 Mariana Toure MSF Saraha X

5 Balla Toure X

6 Feny Danfakha ASC X

7 Sally Fall ICP Saraya X

8 Pierrelle Mendy SF Saraya X

9 Mme. Tanga SF Saraya X

0 Goundou Danfakha Matrone X

11 Mme Diarra Head SF for Saraya District

X X

12 Makhan Danfakha Chauffeur X X

13 Youssouph Cissokho Chauffeur X X

14 Yvonne Sarr SF X X

15 Coumba Diouf SF X X

16 Fily Toumare President du Comite du Sante

X X

17 Ngone Gueye MSF du Salemata X X

18 Ngor Ndour Medecin X X

12 Elodi Mauga Infirmiere X

13 Victimae Paissa Manga MSF X

14 Mamadou S Ba Medecin X

15 Fatou Traore Coordinatrice SR X

16 Ndeye Coumba Guana SFE X

17 Landing Sagna SSP X

18 Cheikh Ba X

19 Sga Danfakha X

Research Site Orientation Meeting 30 January, 2015 (Friday)

Senegal

1 Alioune Faye ICP, Nafadji 77 609 8374

2 Ngor Ndour Medecin, Saraya 77 353 8696

3 Mariama Marena SF, Dakately 77 441 0284

4 Fatou Bintore Ndiayo Dideg

SFT Oubaolji 77 356 1715

5 Ngone Gueye MSF du Salemata 77 619 5206

6 Baba Diakhite Pdt Comite Sante, Dindefelo 77 729 6312

7 Adama Diallo SFE, Dindefelo 77 272 6741

8 Fily Foumare Saraya 77 107 4077

9 Mariama Touré Coordinatrice SR du D.S. Saraya 77 541 4625 yamadjedje@yahoo.fr

10 Aban Diallo Oubadji 77 215 2391

11 Bocaou Sidebe Bandafassi 77 666 5318

12 Fatou Traoré MSF du Kedougou (region) 77 647 9536 fatoucha85@yahoo.fr

13 Marguerite Thiaré Sage Femme de CSKdg 77 511 8478 margueritethiare56@gmail.com

14 Lucie Basse S Bandafassi 77 535 4718

15 Mbaye Diene Ndiaye ICP, Khossanto 77 314 1634

16 Elhadji Mamadou Dioukhane

MCD Kédougou 77 286 4244

17 Youssouph Cissokho Chauffeur, Saraya 77 810 6692

18 Landing Sagna Superviseur des soins de santé primaire: District de Kédougou

77 505 3731

19 Katie Wallner / Aïssatou Souaré

Corps de la Paix, Salemata 77 673 0111 kewallner@gmail.com

20 Emily Johnson / Dienaba Dansokho

Corps de la Paix, Touba Couta 77 672 0360 ej711@gmail.com

21 Tess Komarek / Tiguida Tandian

Corps de la Paix, Missira Dantila 77 118 0534 tesskomarek13@gmail.com

22 Aaron Persing / Sory Kandia Diakhaby

Corps de la Paix, Dakateli 77 673 0099 aaron.persing@gmail.com

USA

23 Rithvik Balakrishnan Rush University rithvik_balakrishnan@rush.edu

24 Sarah Johnson UIC sejohnson15@gmail.com

25 Andrew Dykens UIC / Peace Care 573 355 0452

andrew.dykens@peacecare.org

Research and Project Summary

Intervention and Control Sites

Nafadji-Intervention (Saraya District) Dakately-Intervention (Salemata District) Oubadji-Control (Salemata District) Dindefelo-Control (Kedougou District) Bandafassi-Intervention (Kedougou District) Khossanto-Control (Saraya District)

- Partnership

Participation by key personnel at regional and national partnership meetings biannually and submission

of data collection Instruments in adequate number, in a timely manner, and in an appropriate fashion.

◦ Partnership questionnaire – biannually

◦ Partnership focus group - biannually

- Community Sites

Completion, compilation, and submission of data collection Instruments in adequate number, in a timely

manner, and in an appropriate fashion at each community site (one intervention and one control site in

each district).

◦ Barriers Analysis

◦ COPE process action plan – quarterly

◦ General Health Services – Client Interviews

◦ General Health Services – Self-evaluation

◦ Cervical Cancer Prevention Health Services – Self-evaluation

◦ T1:1,2 T2: 3,4,5 T3: 6,7 T4: 8,9,10

◦ COPE committee focus group – biannually

◦ Clinical productivity report – quarterly

◦ Health service leader questionnaire - annually

◦ Programmatic and policy recommendations - annually

- District Sites

Completion, compilation, and submission of data collection Instruments in adequate number, in a timely

manner, and in an appropriate fashion at each district center.

◦ COPE process action plan - quarterly

◦ COPE committee focus group – biannually

◦ Clinical productivity report – quarterly

◦ Health service leader questionnaire

◦ Programmatic and policy recommendations - annually

- Regional level

Completion and submission of a biannual report comprised of the following:

◦ General report of region-wide cervical cancer prevention activities

◦ Updated numbers of women screened, findings, and outcomes by location

◦ Updated numbers of cases of cryotherapy and referral to specialty service including outcome..

◦ Updated list of regional cervical cancer prevention personnel including:

◦ Cervical cancer prevention service leadership: directors and administrators at the

regional and district levels

◦ Master trainer team, dates of their training and refresher courses, and individual

participation and role in training others

◦ All personnel trained in VIA or cryotherapy, the dates of their training, the dates of

refresher courses completed, and the number of women screened per provider

Reasonable efforts toward the preparation of an annual regional cervical cancer prevention strategic

plan including the following components:

◦ Planning, Monitoring and Evaluation

◦ Resources and Capacity including Financing, Workforce Capacity, and Resources Management

◦ Community and Health Service Activities including Clinical Service Guidelines and Health

Information Systems

◦ Networks and Partnerships

◦ Management, Accountability, and Leadership

◦ Communication and Outreach

Reasonable efforts toward the preparation and annual adaptation of regional level cervical cancer

prevention health policy in response to the recommendations from districts and communities.

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