Reducing barriers and sustaining utilization of a cervical cancer screening program in rural Senegal

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PROJECT SUMMARY / ABSTRACT Senegal ranks 15th in the world in cervical cancer incidence, and this is the number one cancer killer among women there. However, the estimated participation rate for cervical cancer screening in Senegal (where incidence peaks between the ages of 45 and 54) is very low. Ten of the 13 rural Senegal regions remain with no access to cervical cancer screening services, even though screening by visual inspection of the cervix with acetic acid is highly effective and affordable. Since 2010, I, Andrew Dykens MD, MPH, Assistant Professor of Family Medicine at the University of Illinois at Chicago (UIC), have led a partnership between the Kedougou Regional health system, the Institute of Health and Development, the University of Illinois at Chicago, and the U.S. Peace Corps to implement a visual inspection cervical cancer screening program in this far southeastern, rural region. The partnership made a screening service available to over 18,300 women region-wide by 2014. However, the utilization by eligible women, especially the high-risk older cohort, remains very low. In 2014, only 509, roughly 5% of eligible women targeted through a mass campaign that year, were screened and only 10% were 45 years or older. This career development award will provide me with critical research skills through a mentored project that will expand our current research. My research proposal aims to address preliminary data describing poor uptake and barriers to screening access in this region through a multi-level mixed methods assessment of the barriers and facilitators of initial uptake. This knowledge will guide us in developing and adapting a peer education health promotion intervention to this specific context in order to demonstrate an increased rate of initial screenings and re-screenings over time. Using mixed methods, we will 1) assess cervical cancer screening access determinants in Kedougou, Senegal by identifying barriers and facilitators of service uptake over time at the person, household, and community levels; 2) develop and deploy a wide-reaching, multi-level responsive peer education curriculum aimed at motivating eligible women to seek cervical cancer screenings in Kedougou, Senegal; and 3) evaluate the impact of the peer education intervention on initial screening uptake and re-screening rates. The support provided by this mentored career development award will allow me to achieve my goal of becoming an independent implementation researcher with expertise in evaluating the access determinants for a cervical cancer screening program in a rural region of Senegal and designing and evaluating a behavioral change intervention. I will develop the necessary experience to strengthen and scale cervical cancer prevention programs in Senegal and other low- and middle-income countries, reduce barriers to cervical cancer diagnosis, and implement evidence-based screening approaches in real world settings. To achieve this goal, I have assembled an outstanding group of mentors including my primary mentors, Marian Fitzgibbon, PhD, who directs UIC's National Cancer Institute funded Cancer Education and Career Development Program, and Abdoul Aziz Kassé MD, an NIH funded epidemiologist and Professor of Gynecology Oncology at the University of Cheikh Anta Diop Cancer Institute. In addition, a team of NIH funded co-mentors will provide expertise specific to my training objectives: Jennifer Smith PhD is an expert in global cervical cancer epidemiology and an affiliate in the CDC Global Network of which I am a part, Michael Berbaum PhD is a professor of biostatistics at UIC and faculty with the Inter-university Consortium for Political and Social Research through which I will seek additional coursework, Stevan Weine MD is an expert on multi-level mixed methods research with extensive experience in international settings and is the Director of Research at the UIC Center for Global Health, of which I am a core member. Through direct mentorship I will develop my knowledge and skills in 1) epidemiology, 2) behavioral change and health promotion, 3) quantitative analysis of multi-level longitudinal data, and 4) mixed methods research. I intend to establish an implementation science research career developing scalable cervical cancer control and prevention programs in low- and middle- income countries (LMICs), translating evidence-based screening approaches to real world settings, building LMIC research capacity in implementation science, applying cancer prevention strategies in relation to local culture and local resources, and mentoring future cancer prevention health services implementation researchers. I have demonstrated extensive commitment to our partnership in Senegal since 2010, have developed a highly supportive collaborative network within and external to Senegal, and am personally committed to a career studying the access determinants, capacity implementation, and sustainability of cervical cancer prevention services in the far southeastern region of Kedougou. The lessons learned there through the introduction and strengthening of a cervical cancer screening program will be transferrable in providing access to and empowering the nearly 1,000,000 screening-eligible (ages 30 to 59) women throughout rural Senegal. Through short-term success, we will develop an evidence-based context-specific and culturally sensitive cervical cancer educational curriculum with materials in all local languages. This will facilitate long-term success as we establish an extensive network of educators and a baseline comprehension of cervical cancer in rural Senegal. This groundwork will be critical and is easily expanded to incorporate future efforts such as population-level vaccination programs. This will greatly facilitate opportunities in future years to conduct larger epidemiologic studies to guide the specific targeting of high-risk HPV subtypes through future vaccination programs. I would welcome similar research in other West African countries or other LMICs globally where there continues to be high cervical cancer incidence rates, nonexistent or inaccessible services, and gaps in understanding how to successfully and sustainably implement cervical cancer prevention services.