Phases of Project

Peace Care Senegal Collaborative

2010-2011

Saraya District, Senegal

Peace Corps Senegal / University of Illinois – Chicago

Collaborative Executive Summary

This project which is a collaboration between the University of Illinois-Chicago (UIC) Department of Family Medicine, the UIC School of Public Health, the District of Saraya, Senegal, and Peace Corps Senegal, utilized the Global Collaborative (GCHC) model and was intended 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.

Through this novel approach with a Peace Corps Senegal partnership, this Peace Care project fostered collaboration between the health district of Saraya, Senegal and UIC to improve health care delivery within the local existing health care system as well as provided training in global health and cultural competency for U.S. health care trainees. The Health District of Saraya is located in the extreme South-Eastern part of Senegal with an estimated population of 42,000 inhabitants and comprises seven health posts and one health center. Access to quality health care in the district of Saraya is difficult to obtain, primarily due to the geographically dispersed area and the small number of highly trained individuals. In training additional health care workers and improving the knowledge base of existing health care workers, individuals in remote villages will have increased access to quality medical care. The focus of this pilot project was cervical cancer screening and prevention, prevention of sexually transmitted illnesses, and diarrhea prevention, as determined by the assessment of local health concerns and the status of the health service delivery infrastructure. The curriculum carried out on site is based on World Health Organization resources and is evidence based.

A team from the UIC Department of Family Medicine accompanied by students and representative faculty from the UIC School of Public Health as well as the OB/Gyne Department traveled in early 2011 during the intervention phase. This project was led by Andrew Dykens, MD, MPH, the founder of Peace Care (www.peacecare.org) and director of the UIC Family Medicine Global Community Health Track, and is in collaboration with Peace Corps Senegal, Country Director, Chris Hedrick, as well as the Saraya District Director of Health Services, Dr. Youssoupha N’diaye.

Through this collaborative, in addition to small scale interventions addressing diarrhea and STI’s, we trained five new trainers in the technique of visual inspection of the cervix with acetic acid. These trainers, in turn, trained 14 additional personnel as a secondary training. The District level medical director, Dr. N’diaye, as a strategy for scaling the project, intends to have all clinicians within the Saraya District trained by May, 2011 and hopes to expand the training to cover the entire Kedougou region by the end of 2011. Dr. N’diaye has expressed a desire to illustrate this model as a successful means by which to initiate cervical cancer screening throughout rural Senegal, where none previously existed. Peace Care and UIC hopes to continue to support these trainings. Concerning next steps, UIC has also begun initial discussions with the Saraya Health District of bringing a training course in cryotherapy as a management option for positive cervical cancer screens. This would reinforce the local health system’s ability to manage positive results without displacing patients. We will hope to implement in early 2012.

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Phases of Project

Partnership formation – August 2009 to January 2011

Assessment – October 2010 – November 2010

Project Development – November 2010 – January 2011

Project Implementation – January 2011 – February 2011

Project Evaluation – January 2011 – May 2011

Dissemination – May 2011 – Ongoing

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Acknowledgments

Peace Care would like to acknowledge the following organizations and individuals who have given an enormous amount of effort toward the successful implementation of this project, in terms of hours of labor, financial support, and encouragement.

Saraya District Health Leaders and Staff

Saraya District Communities

Peace Corps Senegal Admin and Volunteers

Peace Care Working Board of Directors

Peace Care Advisory Board

The UIC Team

Our Families, Friends, and Colleagues

and

All those who gave a little, so that we might have enough.

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Partnership Formation

Initial Site Visit

The project leader visited Senegal over a 7 day period in April / May 2010 to further clarify roles, responsibilities, and the scope of the project.

  • April 29, 2010 – Peace Corps Senegal Headquarters, meeting with Chris Hedrick (Country Director) and Dr. Brian Lombard (Peace Care advisory group member and US physician currently living in Senegal)
  • April 29, 2010 – Dakar, Senegal, meeting with Brian Lombard
  • April 29, 2010 – Peace Corps Senegal Headquarters, meeting with various PCVs
  • April 30, 2010 – Kedougou Peace Corps Regional House, meeting with Matt McLaughlin and Chris Brown
  • May 1, 2010 – Saraya Health Post, meeting with Dr. Youssoupha N’diaye and Chris Brown
  • May 1, 2010 – Dalafing Village, meeting with Danfakha (Village Chief, Dalafing), Dr. Youssoupha N’diaye, and Chris Brown
  • May 1, 2010 – Saraya, Senegal, meeting with Danfakha (Village Chief, Saraya), Dr. Youssoupha N’diaye, and Chris Brown
  • May 1, 2010 – Saraya, Senegal, meeting with Prefect and Sous Prefect of Saraya, Dr. Youssoupha N’diaye, and Chris Brown
  • May 2, 2010 – Kedougou, Senegal, meeting with Dr. Senghor (Kedougou District Physician), Matt McLaughlin, and Chris Brown
  • May 2, 2010 – Kedougou, Senegal, attempted to meet with Regional Chief Medical Officer. Being unavailable, the PCVs visited and presented to him at a later date.
  • May 3, 2010 – Peace Corps Senegal Headquarters, meeting with Mamadou Diaw (Health APCD)

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Team Definition:

Research Personnel

Principal Investigator: Andrew Dykens, MD, MPH

Co-investigator(s):

  • Karen Peters DrPH
  • Laura Sadowski, MD, MPH
  • Youssoupha N’Diaye, MD, MPH, PhDc
  • Memoona Hasnain, MD, MHPE, PhD
  • Tracy Irwin, MD
  • Paulette Grey, MD, MPH
  • Melody Mumford, MD

Additional Key Research Personnel:

  • Christopher Brown, BS – Peace Corps volunteer and Onsite Coordinator
  • Catherine Lind, MA – UIC Qualitative Data Analyst
  • Emily Pela, MA – UIC Research Coordinator
  • Nora Burns – Medical Student
  • Yury Parra – Medical Student

Local Advisory Board

  • Mr. Moussa Danfakha
  • Mrs. Sadio Danfakha
  • Mrs. Cire Diaby
  • Mr. Mamoudou Kaaba

Support Personnel

Peace Corps

  • Chris Hedrick, Country Director Peace Corps Senegal
  • Mamadou Diaw, Associate Peace Corps Director for Health
  • Matt McLaughlin, PCV, Early project planning and support
  • Leah Moriarty, PCV, Logistics and project planning, local language translation at project level
  • Meera Sarathi, PCV, French translation at project level

Peace Care

  • Eric Markin, Peace Care – Budget
  • Michael Swaine, Peace Care – Project Advisor
  • Stephen Stabile, MD, Peace Care – Project Advisor
  • Brian Lombard, MD – Peace Care Advisory Board
  • Rithvik Balakrishnan – RPCV Senegal – Process Documentation
  • Evan Lowy – RPCV Senegal – Literature Review
  • Martine Mumford – French Translation
  • Peace Care Board of Directors 

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Project Definition

The Global Community Health Collaborative model is a one of collaborative research between academic institutions, communities, and the Peace Corps and seeks to positively impact global health disparities by specifically addressing the global shortage of health care workers, the deficiency of primary health care in low-income countries, and the lack of community partnered global health research. This specific initiative enabled the establishment of community-engaged research and a clinical service provision infrastructure that was responsible for collaborative strategic planning, implementation, evaluation and dissemination of innovative models of local health care service delivery that are responsive to the clinical and population health needs of the Saraya District in the country of Senegal. This Peace Care Initiative was a collaboration between the U.S. Peace Corps Senegal, U.S. health care professionals at the University of Illinois-Chicago, and the district of Saraya, Senegal. By transferring skills and knowledge to health care workers in place within a low resource community in the Saraya District of Senegal through a health collaborative, we enhanced new local research and clinical service capacities, aided in further developing local health care workforce, enhanced the quality of delivered care for specific clinical issues, and improved individual and population health outcomes.

Specific Aims

The specific objectives were to:

  • Implement training curricula for cervical cancer screening, diarrhea prevention, and sexually transmitted infection prevention and treatment to health care workers and community members, and
  • Evaluate the project process activities and outcomes.

Assessment

October 2010 – November 2010

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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

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Project Development

November 2010 – January 2011

Realist Literature Review(s)

An informal literature review was conducted to identify the curricula for STI prevention and treatment as well as diarrheal prevention. A realist synthesis of the literature was performed to guide the team in the development of the curriculum for the issue of cervical cancer. Please See Appendix 2 for a description of the Realist Synthesis.

STI prevention. Based on primary survey data and global health reports, Senegal STI prevalence is as follows: HIV (0.8 -3%), syphilis (0.9.-7%), gonorrhea (0.2-2%), chlamydia ( 0.3-13%), with the higher percentages representing older data and in urban areas. Despite the lack of overwhelming epidemiological data on STI prevalence in Senegal, particularly in rural areas, the community concerns for STI prevention yet remained.

Diarrheal disease prevention. Epidemiological data suggests that this issue is a considerable burden to the Senegalese population. According to the WHO, diarrheal diseases are the 7th leading cause of death in Senegal (7 % of death). Of the many contributing factors, a lack of access to improved sanitation, a clean water source, and a lack of education regarding disease prevention are the main causes.

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.”

The abstract of the realist synthesis as performed by Yury Parra, a UIC medical student, under the direction of Andrew Dykens, MD, MPH can be read in Appendix 2 and concluded 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.

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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. 

Curriculum Development - Sexually Transmitted Infections

Training modules for the syndromic management of sexually transmitted infections. 2007. World Health Organization - ISBN 978 92 4 159340 7

English and French:

http://www.who.int/reproductivehealth/publications/rtis/9789241593407/en/index.html

Curriculum Development – Diarrhea

Facts for Life. 4th edition. 2010. World Health Organization - ISBN: 978-92-806-4466-1. English and French editions.

Sustainability Component Planning

Cervical Cancer Screening

During this phase, The UIC team initiated discussions concerning implementation of the proposed screening program into the existing health structure. Discussions with Dr. N’Diaye, preliminarily addressed the following considerations:

  • Health Service Implementation
  • Health Service Management
  • Health Service Financing
  • Quality Control
  • Strategic Planning

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Project Implementation

January 2011 – February 2011

See Appendix 3 for the Senegal Collaborative Trip Overview Calendar

Orientation – Local Milieu

The UIC team was very fortunate to have Peace Corps Volunteers and Peace Corps Senegal Administration guide us on certain practical components of the manner in which we should respect local norms and assimilate into the local culture. The UIC team participated in several formal lectures and, in addition, the Peace Corps Volunteers continued to offer informal advice and education on these topics throughout our stay in country. The topics included the following:

  • Local Culture and Norms
  • Personal Safety
  • Local Language
  • Local Health System

Peace Care Project

Cervical Cancer Screening

With the use of materials made available by the International Agency for Research on Cancer through the World Health Organization and adaptation of curricular materials made available by PATH, we implemented a two stage educational seminar teaching visual cervical cancer screening through application of acetic acid. The first stage was a training of trainers through which we taught the screening technique as well as guided the “trainers” on teaching techniques. This initial training, concluding with a mass screening campaign within Saraya, was immediately followed by a secondary training during which the trainers, in turn, taught an additional 14 health workers covering eleven health posts. This health worker training concluded with two mass screenings as a component of practical application. Please see the Training Schedules for an overview of the agenda.

Training of Trainers

January 18, 2011 through January 29, 2011

Five Trainers Trained

  1. Aissatou Samba – Head Midwife – Kedougou Region
  2. Fatou Khan – Lab Technician – Saraya District
  3. Fatou Traore – Midwife – Saraya District
  4. Fatou N’Dour – Midwife – Saraya District
  5. Maguette Fall – Physician – Saraya District

Health Worker Training

January 24, 2011 through January 29, 2011

Nineteen Clinicians Trained (five of whom were the aforementioned trainers)

  1. Aissatou Sarr – Midwife in Kedougou
  2. Boubacar Diop – Nurse in Missira Dantilo
  3. Bamody N’diaye – Nurse in Salemata
  4. Insa Bassama – Nurse in Diakha Madina
  5. Diounkou Diop – Nurse in Saensoutou
  6. Kanessou Diatta – Nurse in Diakhaba
  7. NDeye Penda Diop – Midwife in Salemata
  8. Oulimata Sane – Midwife in Khossanto
  9. Agathe Elvire Faye – Midwife in Daloto
  10. Hamidou Thiam – Nurse in Kedougou
  11. Ige Sylviane Mbinky – Midwife in Nindafecha
  12. Jonas Bassene – Nurse in Saraya
  13. Youssou Diene – Physician in Saraya
  14. Isaac Manga – Physician in Saraya

Please refer to the training schedules. Appendices 4 & 5

Diarrhea Prevention

On January 25th, the Peace Care team of Karen, Leah, Paulette, Melody and Nora travelled to the Village of Nafadji to deliver a health education session on diarrhea. This topic was identified as a priority health issue during the assessment phase of the Senegal project. The curriculum was adapted from the book Facts for Life (4th edition, 2010; WHO ISBN: 978-92-806-4466-1. English and French editions). The team arrived in Nafadji around 2:15PM and was introduced to the PCV’s host family and other community residents. We also participated in a walking tour of the village (approximately 1 hour) which included visits to several villagers’ homes, the school, the store and the clinic. During this tour, villagers were told that we were there to do an education session on diarrhea and that it would start around 4PM. With the beating of a large drum, the education presentation began. Approximately 100 women and children attended the presentation.

The curriculum consisted of a general question and answer about diarrhea facilitated by Leah, the PCV in the village. The questions focused on general knowledge about diarrhea, what causes it, how to prevent it, what can be done about it in the community. This was followed by a skit presentation facilitated by Nora that involved 2 villagers who served as volunteers.

Following the educational presentation, the women of the village began to dance and the UIC team also participated. The educational presentation and the dancing were all captured on video and a condensed educational video will be edited and made available to the village once the UIC team returns to the US.

Resources left include the Facts for Life book (French) for the PCV and the forthcoming video.

Follow-up evaluation recommendation: Conduct focus groups with participants to ascertain changes in knowledge and behaviors concerning diarrhea prevention as well as demonstration of proper preparation of ORS.

Sexually Transmitted Infection Prevention and Management

The curriculum was introduced as an opportunity for knowledge exchange, cross-cultural collaboration, and familiarity with WHO recommendations on STI management. The UIC team introduced themselves as facilitators for the discussion, with eagerness to equally give and receive information on the topic at hand. The group consisted of 15 participants: 2 sage-femmes, 12 nurses, and 1 physician. Each participant voiced anticipated learning goals and introduced his or her respective role and depth of experience as a health worker. Overwhelmingly, the group expressed highest anticipation for discussing STI treatment.

Introduction to STI Prevention and Control

The discussion in this section centered upon each health worker’s perspective on the burden of STIs in Senegal. Likewise, we discussed STI epidemiology in the United States. The group, as a whole, discussed similarities and differences of STI presentation and management in Senegal and in the United States.

Introducing STI Syndromic Case Management

We discussed etiologic, clinical, and syndromic approach to STI management. We introduced the latter approach as a WHO recommendation in low resource settings. We discussed the seven STI syndromes and their respective causes.

History-taking and Examination

We discussed the importance of eliciting from the patient an accurate history, as well as the specific barriers that exist with eliciting a sexual history—both in Senegal and in the United States. Particularly, the group exchanged regional cases that highlighted the medical and social impacts of STIs in combination with situations of rape, incest, child abuse, and homosexuality.

Diagnosis and Treatment

Through case-based learning, we reviewed diagnosis and treatment of each STI syndrome. We discussed similarities and differences in treatment in the United States.

Educating and Counseling the Patient

We highlighted the importance of teaching the patient about the transmission and prevention of STIs. The group discussed universal low acceptability of the female condom. A group member demonstrated male condom insertion and removal on our Styrofoam model. We reinforced the need to counsel the patient on HIV and its facilitation via other STIs.

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Partner Management

There was group consensus about the critical nature of partner management, as well as the difficulty with achieving adherence with partner management. Barriers that were discussed included lack of follow up, difficulty in identifying or notifying partners, patient and/or partner denial of STIs, and complex social situations that impede adequate treatment (e.g. polygamy, incest, rape).

Service Component

As part of the Cervical Cancer Screening Training, our team offered cervical cancer screening every morning during the time of our visit as well as three large Cervical Cancer Mass Screening Days, one in Saraya and two in smaller villages, Diakha Medina and Khossanto. We were able to screen a total of 79 women and noted 2 positive results and 0 cases of suspected cervical cancer.

Sustainability Component

Through discussions during the training of trainers and with the District Level health officials, guidelines were finalized for the implementation of cervical cancer screening by way of visual inspection with acetic acid into the existing health structure. Please see the guidelines in Appendix 6.

Health Service Implementation

  • Identification of target Population
  • Public Health Education Outreach
  • Clinical Patient Management
    • Referral and Management options
    • Patient follow-up
  • Documentation
    • Documentation of Results
    • Health Center and District Level reports

Health Service Management

  • Identification of managerial body and delineation of oversight process

Health Service Financing

  • Patient Level Screening Costs
  • Financing for referral and management

Quality Control

  • Certification of Clinicians
  • Certification of Trainers
  • Confirmation of Results
  • In-service training / refresher course for trained health workers

Strategic Planning

  • Expansion of services and trainings for additional health workers within Saraya Health District
  • Population Mass Screening Campaign
  • Projection of subsequent Peace Care partnerships and additional service implementation
  • Preliminary plan for expansion of services to neighboring districts and regions.

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Global Health Education Component

Clinical Teaching

Each morning the resident physicians and medical student had the opportunity to participate in morning hospital rounds with the Saraya medical team. The time of year for this particular visit was a relatively slow period for the medical service. Nonetheless, we were able to see several interesting cases.

Formal Didactics

During the course of our visit our resident physicians and medical student (as well as the entire team) participated in didactics exchange with local health care staff.

Lectures:

  • Malaria – presented by Dr. Isaac Manga
  • Preparation of Malaria Slide and Rapid Test – presented by Fatu Khan, lab technician
  • Clinical Case Review: A case of Malaria and Tetanus – presented by Dr. Isaac Manga
  • Senegal Health System – presented by Dr. Youssoupha N’Diaye
  • Breech Delivery: Clinical Approach – presented by Dr. Tracy Irwin

Medical Education

The UIC team resident physicians and medical student received invaluable experience throughout the planning and implementation stages through the following:

  • Participated in the planning and implementation of a community based participatory research project,
  • Prepared and delivered lectures for the Cervical Cancer Screening Curriculum,
  • Adapted the STI Curriculum,
  • Prepared and Delivered Lectures in the STI Curriculum,
  • Evaluated trainees through the STI Curriculum, and
  • Delivered health messaging as part of the diarrhea curriculum.

Global Health Theory

During the course of the implementation phase, the UIC team also participated in dynamic discussions concerning:

  • Health disparities,
  • Health systems utilization,
  • Global health ethics,
  • Health care financing,
  • Health infrastructure development, and
  • Development and international aid.

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Personal Reflection

The UIC team residents and student kept a daily journal of their experiences. In addition, they answered a series of questions about their Pre-trip and Post-trip expectations and perceptions.

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Project Evaluation

January 2011 – May 2011

Outcomes Evaluation

Data collection tools based on WHO recommended forms were adapted to work within the local health system. Through population based data collection the outcomes evaluation of this project will give further clarification to prevalence of cervical cancer and pre-cancers as well as screening rates and referral data. These data will be gathered and evaluated quarterly and will give the researchers insight into project impact and future direction.

Process Evaluation

A complete report on project process evaluating this model of collaboration is forthcoming. The process evaluation will consider viewpoints and feedback from all involved stakeholders in regards to each of the following project phases:

  • Partnership Formation
  • Assessment
  • Project Development
  • Project Implementation
  • Project Evaluation
  • Project Dissemination

Dissemination

May 2011 – Ongoing

All outcomes and results in addition to recommendations for future collaborative work will be published in report and presentation form.

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Future Plans

Upon concluding the UIC team visit to Senegal, formal meetings were conducted with the Saraya District Health System administrators and the Peace Corps Senegal leadership and contributing volunteers. In regards to cervical cancer screening, initial discussions were held on the following future plans. Peace Care and the University of Illinois – Chicago hold every intention of continuing this fruitful collaboration and supporting this work.

Saraya District Health System Strategic Planning

Cervical Cancer Screening

The next steps for the Saraya District are as follows:

  • Hold two additional trainings in May and June 2011 to complete the training of health workers for the entire district such that all health posts have qualified personnel for cervical cancer screening.
  • Hold additional mass screenings in villages within the Saraya District to raise awareness and provide opportunity to improve clinician’s skills.
  • Continue the collaboration with UIC to evaluate the project in terms of understanding incidence and prevalence of cervical pre-cancers and cancers.
  • Prepare for upcoming trainings that will address workforce development for management of pre-cancers within the district through cryotherapy and expand palliative care services within the region.
  • Strengthen the health care financing availability within the district to reliably assist women who have positive screens.
  • Further adapt clinical services documentation and screening guidelines to sustainably work within the local health system.

Senegal Health System Strategic Planning

Regional Strategic Planning will take place in 2011 to:

  • Expand screening services to districts neighboring Saraya and throughout the Kedougou region.
  • Formalize cervical cancer screening oversight and management within the national health system.
  • Plan strategic expansion to neighboring regions with the intention of expanding throughout Senegal.