Glenn J. Wagner

Correlates of cervical cancer prevention advocacy and cervical cancer screening in Uganda: Cross-sectional evaluation of a conceptual model

An approach to increasing cervical cancer (CC) screening is to empower women who have been screened to act as advocates and encourage other women they know to get screened. We examined correlates of CC screening advocacy and CC screening uptake among constructs in our conceptual model of factors driving engagement in advocacy. A cross-sectional, correlational analysis was conducted with survey data from 40 women (index participants) who had recently screened for CC, and 103 female members of their social network (alter participants) who had not been screened. Variables measured included CC prevention advocacy, as well as internalized CC stigma, sharing of CC screening result, CC knowledge, healthy bodily intake (i.e., diet; alcohol and cigarette use) and self-efficacy related to CC service utilization and CC prevention advocacy, which were hypothesized to be associated with advocacy. Bivariate and multivariable regression analyses, controlling for clustering, were conducted. Among index participants, greater engagement in advocacy was positively correlated with CC knowledge, sharing of CC screening result, and CC service utilization self-efficacy. Women who had screened positive and received treatment for precancerous lesions reported greater CC prevention advocacy, CC knowledge and healthy living, compared to those who screened negative. In multiple regression analyses, CC screening was positively associated with CC prevention advocacy and being age 36 or older, and CC prevention advocacy was also positively associated with CC service utilization self-efficacy. These findings support the validity of our conceptual model regarding factors associated with engagement in CC prevention advocacy among women screened for CC. The strong association between CC prevention advocacy and both CC screening uptake and CC service utilization self-efficacy suggests the potential value of advocacy promotion among women who have been screened, as well as for increasing screening uptake.

Study protocol for a hybrid implementation-effectiveness trial of Game Changers for Cervical Cancer Prevention in Uganda

Introduction Cervical cancer (CC) is the leading cause of cancer-related deaths among Uganda women, yet rates of CC screening are very low. Training women who have recently screened to engage in advocacy for screening among women in their social network is a network-based strategy for promoting information dissemination and CC screening uptake. Methods Drawing on the Exploration, Preparation, Implementation and Sustainment (EPIS) framework for implementation science, this hybrid type 1 randomized controlled trial (RCT) of a peer-led, group advocacy training intervention, Game Changers for Cervical Cancer Prevention (GC-CCP), will examine efficacy for increasing CC screening uptake as well as how it can be implemented and sustained in diverse clinic settings. In the Preparation phase we will prepare the four study clinics for implementation of GC-CCP and the expected increase in demand for CC screening, by using qualitative methods (stakeholder interviews and client focus groups) to identify and address structural barriers to easy access to CC screening. In the Implementation phase, GC-CCP will be implemented over 36 months at each clinic, with screened women (index participants) enrolled as research participants receiving the intervention in the first 6 months as part of a parallel group RCT overseen by the research study team to evaluate efficacy for CC screening uptake among their enrolled social network members. All research participants will be assessed at baseline and months 6 and 12. Intervention implementation and supervision will then be transitioned to clinic staff and offered as part of usual care in the subsequent 30 months as part of the Sustainability phase. Using the RE-AIM framework, we will evaluate engagement in GC-CCP and CC advocacy (reach), alter CC screening (effectiveness), adoption into clinic operations, implementation outcomes (acceptability, feasibility, fidelity, cost-effectiveness) and maintenance. Discussion This is one of the first studies to use a network-driven approach and empowerment of CC screened peers as change agents to increase CC screening. If shown to be an effective and sustainable implementation strategy for promoting CC screening, this peer advocacy model could be applied to other preventative health behaviors and disease contexts. Trial registration NIH Clinical Trial Registry NCT06010160 (clinicaltrials.gov; date: 8/17/2023).

Knowledge Mediates the Effects of Game Changers for Cervical Cancer Prevention (GC-CCP) Intervention on Increased VIA Screening Advocacy in Uganda

Abstract Game Changers for Cervical Cancer Prevention (GC-CCP), a group advocacy training intervention, has been shown to increase cervical cancer prevention and screening advocacy. In this secondary analysis, we examined mediators and moderators of this effect. A randomized controlled trial of GC-CCP—a 7-session, peer led intervention designed to empower women to engage in cervical cancer prevention advocacy—was conducted with women who had recently been screened by visual inspection of the cervix with acetic acid for cervical cancer. Participants were assessed at baseline and month 6 follow-up. Cervical cancer–related constructs targeted by the intervention were examined as mediators using multivariate linear regression analysis. Individual and social network characteristics were examined as moderators. Change in cervical cancer knowledge fully mediated the intervention effect on increased cervical cancer prevention advocacy; change in cervical cancer risk management self-efficacy was a partial mediator. Moderators of the effect included no secondary education, having a main sex partner, and having trustworthy, supportive, non-stigmatizing peers. The effect of GC-CCP on cervical cancer prevention advocacy seems largely driven by its impact on cervical cancer knowledge, and the intervention may be most effective among women who are partnered, less educated, and have trusting, supportive social networks. Prevention Relevance: Enhancing cervical cancer knowledge among women who have screened for cervical cancer is key to empowering these women to engage in cervical cancer prevention advocacy and acting as change agents for encouraging other women to screen.