A two-step quality-improvement intervention to address Pap smear quality at public health facilities in South Africa.

Background. The endocervical component of Pap smear is an important indicator of sample quality or 'adequacy' However, only 6 of 52 districts in South Africa (SA) meet the Department of Health (DoH) performance benchmark: a 70% adequacy rate. We implemented a quality-improvement (QI) intervention to address suboptimal Pap smear quality in Tshwane District, Gauteng Province, SA. Objectives. To determine whether training with the wooden Ayre spatula (step 1) or introduction of the cytobroom (step 2) resulted in greater improvements in Pap smear adequacy rates. Methods. Two Tshwane District health facilities participated in our QI project between May 2016 and February 2017. In step 1, staff received training on the Ayre spatula. In step 2, the spatula was replaced with the cytobroom. Pap smear volumes, adequacy rates and results are reported for the pre-intervention period and after each QI step. We compared adequacy rates using Fisher's exact test, with a significance level of p=0.05. Results. In the pre-intervention period, 304 of 965 Pap smears were deemed adequate (32%; 95% confidence interval (CI) 29 - 35%). After step 1, the proportion increased to 109 of 191 (57%; 95% CI 50 - 64%; p<0.01). Similarly, after step 2, the proportion increased to 155 of 192 (81%; 95% CI 74 - 86%; p<0.01). The proportion of abnormal smears increased from 13% before the Q1 intervention to 17% after step I and 22% after step 2. Conclusion. Although training in Pap smear collection using the Ayre spatula resulted in modest improvements in quality, facilities only achieved the Doll benchmark of a 70% adequacy rate after the introduction of the cytobroom.