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 subsearches. 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 supplyside (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.

Background Injectable contraceptives have contributed substantially to Nigeria's rise in modern family planning methods usage. They are one of the most commonly used and preferred means of contraception among women in the country. Enabling policies are required to assure contraceptive access, security, and use. This study aimed to investigate the policy environment and how it supports or limits Nigeria's introduction and scale-up of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC). Methods The design of this mixed-methods study was cross-sectional. Desk reviews of policy papers, key informant interviews, and in-depth interviews were used to obtain information from respondents about the introduction of DMPA-SC in Nigeria and how existing policies influenced its scale-up. Data on DMPA-SC and other injectables were gathered from Nigeria's national electronic logistics management information system. Results The findings suggest that policies such as task-shifting and task-sharing, cost-free policies, reproductive health policies, and others created an enabling environment for the scale-up of DMPA-SC adoption in Nigeria. The inclusion of DMPA-SC on the essential medicines list and the approved patent medicines list facilitated the scale-up process by ensuring private sector participation, removing economic barriers to access, fostering greater collaboration among health worker cadres, improving intersectoral partnerships, and improving logistics and client access. Despite significant anomalies in some implementing policies, injectable contraceptive consumption data demonstrate a progressive increase in DMPA-SC use during the study period. The results also indicate that policy initiatives have a favorable impact on the use of DMPA-SC throughout the country. Conclusion The existence of policies, the active participation of stakeholders, and the political will of the Nigerian health system's leadership have all aided in the scaling-up of the DMPA-SC. Understanding how to build an enabling policy climate is critical for providing women with family planning options. These lessons from Nigeria emphasize the importance of these levers, which should be considered by teams intending to introduce innovative health products, particularly in developing countries.

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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.

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.