Optimising the proportion of eligible women attending public primary health care clinics in Eswatini who are up to date with cervical screening: a multiple-baseline study evaluating the Eswatini Screening Cascade Optimisation (ESCO) intervention

The Eswatini Screening Cascade Optimisation (ESCO) intervention is a multicomponent, community-informed, service-strengthening intervention delivered within routine public primary health care in Eswatini. It is being evaluated in relation to cervical screening, referral, treatment and follow-up processes among eligible women attending participating public primary health care clinics. The intervention is delivered by Ministry of Health-recognised Community Health Workers, also known locally as Rural Health Motivators, regional Community Health Worker programme coordinators, clinic nurses, clinic champions, and Ministry of Health/National Cancer Control Unit staff, with implementation support from the research team. Community Health Worker coordinators receive training-of-trainers preparation and support delivery of competency-based training to approximately 160 Community Health Workers. Clinic-based components are delivered by clinic nurses and supported by clinic champions, who are typically experienced screening nurses involved in cervical screening delivery and local service coordination. The intervention components are: (1) Community Health Worker / Rural Health Motivator capacity-building and household outreach: Regional Community Health Worker coordinators receive training-of-trainers preparation and support delivery of competency-based training for approximately 160 Community Health Workers. Trained Community Health Workers then deliver face-to-face household outreach in their usual clinic catchment areas. Outreach includes verbal cervical cancer education, eligibility screening for women aged 18–69 years, barrier discussion, informed-choice support, numbered referral slips, reminders, follow-up, and navigation support. Community Health Workers / Rural Health Motivators may use hard-copy visual and written materials during household outreach. These include plain-language pictorial key-message prompt cards, an eligibility screening script, and numbered referral slips. These materials were developed specifically for the ESCO study and are not pre-existing publicly available resources. They are used to support consistent delivery of verbal education and referral information; they are not used to record clinical results, HIV status, suspected diagnoses or treatment outcomes. Reminders to eligible women are provided face to face by Community Health Workers / Rural Health Motivators during routine household follow-up visits or other routine community contact within the clinic catchment area. No email, postal-letter or bulk SMS reminder system is planned for the community outreach component. (2) Provider-initiated screening workflow integrated into routine patient flow: Clinic nurses deliver this component face to face during routine clinic visits. The workflow includes a non-identifying visual prompt at triage or reception, systematic eligibility assessment, private offer of cervical screening, same-day screening where appropriate, and same-day treatment readiness for eligible screen-positive women. (3) Clinic readiness strengthening: Clinic staff, clinic champions, Ministry of Health/National Cancer Control Unit staff, and the research team conduct structured readiness assessment and remediation at each participating clinic. This includes identifying and addressing practical barriers to screening delivery, such as staffing, patient flow, equipment, supplies, space, privacy, documentation, and referral pathways. (4) Monthly audit-and-feedback with quality-improvement cycles: Clinic champions and clinic staff participate in monthly audit-and-feedback meetings using clinic dashboards. These meetings review screening, referral, treatment, follow-up, and implementation data, and use Plan–Do–Study–Act quality-improvement cycles to identify local service-delivery issues and document agreed local actions. (5) Patient-experience monitoring: Patient experience is monitored through structured exit surveys and anonymous suggestion boxes at participating clinics. The structured exit surveys are administered face to face by trained research staff in English or SiSwati, according to participant preference, after the participant’s clinic encounter. Surveys are expected to take approximately 10–15 minutes to complete. Responses are recorded electronically on secure tablets where feasible, with paper-based forms used as a backup. Anonymous suggestion boxes are available at participating clinics throughout the intervention period. The intervention is delivered in three public primary health care clinics and their surrounding catchment communities: Mpolonjeni-Siteki, Luyengo, and Ndzevane. ESCO is introduced sequentially across the clinics during the 18-month study period, starting at Clinic 1 in Month 7, Clinic 2 in Month 9, and Clinic 3 in Month 11. Active implementation therefore continues for approximately 12 months at Clinic 1, 10 months at Clinic 2, and 8 months at Clinic 3. Community outreach and clinic workflow activities occur throughout each clinic’s active intervention period; audit-and-feedback meetings occur monthly; and patient-experience monitoring occurs during the intervention period. Adherence and fidelity are monitored using training attendance records, competency assessments, refresher coaching where required, Community Health Worker logbooks, numbered referral slips, clinic attendance records, Client Management Information System data, clinic registers, monthly dashboards, Plan–Do–Study–Act documentation, supervision tools, clinic monitoring records, and patient-reported exposure data from exit surveys. These data are used to document delivery of intervention components and implementation issues requiring local remediation.