"Con Amor Aprendemos": Evaluating a Cervical Cancer Education Intervention in El Salvador Open Access

Abstract

Introduction. Few cervical cancer prevention programs exist in Latin America. Research highlights the need to couple public health education with health care access to address the excessive cervical cancer burden in low-resource settings. Interventions like "Con Amor Aprendemos" (CAA) are vital to enhancing public health literacy on topics related to HPV and cervical cancer. This evaluation was done to determine the effectiveness of the CAA program six to twelve months post-implementation.

Literature Review. Cervical cancer is one of the greatest contributors to the disease burden women face in Latin America. In El Salvador, it is the leading cause of cancer mortality among women. Using the social ecological model as a framework, the various macrosocial factors that contribute to a woman's ability to acquire screening and vaccination in this setting are evident. While some cervical cancer education programs exist, most were developed for use in the United States and few specifically focus on enhancing knowledge to modify behavior.

Methodology. CAA is a seven-week course offered through a network of churches in El Salvador. A knowledge, attitudes, and practices (KAP) survey was developed to collect quantitative data from past CAA participants in six different Departamentos of El Salvador. In addition, qualitative data from focus groups discussions (FGDs) with men and women in Sonsonate, El Salvador further informed KAP survey data.

Results. 159 individuals completed the KAP survey; six women and seven men participated in gender-specific FGDs. Data demonstrated that individuals who participated in the CAA program sustained knowledge six to twelve months post-intervention. FGD participants emphasized their increased knowledge regarding HPV and cervical cancer, as well as the value of their participation in the intervention.

Discussion. CAA effectively improves knowledge regarding HPV and cervical cancer. However, the data revealed some gaps in understanding. This further emphasizes the need for public health education, which can significantly improve efforts of prevention. Interventions like CAA can help transform cultural norms that impact HPV infection and cervical cancer. The CAA program effectively increases knowledge of participants and can ultimately modify behavior, which will contribute to the reduction of the cervical cancer burden in El Salvador.

Table of Contents

Table of Contents

Chapter I: Introduction …..……………………...................…………………………………………. 1

Cervical Cancer……………………………………………………………….......................…………... 1

Disease Burden of Cervical Cancer in Latin America……..........……………………………… 1

Disease Burden of Cervical Cancer in El Salvador…………...........…………………………… 2

Cervical Cancer Screening Interventions…………………………...........…………………….... 3

Cervical Cancer Vaccination Interventions……………………….............……………………… 5

Determinants Related to Cervical Cancer Screening and Vaccination…………………... 7

"Con Amor Aprendemos" Education Intervention…………………………………...........……. 8

Significance………………………………………………………………………….........................……. 9

Research Questions…………………………………………………………….....................………... 10

Chapter II: Literature Review .….………………...………………………...............…………….. 12

El Salvador Demographic Information………………………………………................…………. 12

Basic Cervical Cancer Biology and Epidemiology……………………............……………….. 13

Cervical Cancer in El Salvador…………………………………………………..................………. 14

The Social Ecological Model………………………………………………………....................…… 14

Issues Surrounding HPV Vaccination……………………………………………................…….. 21

Existing Effective Cervical Cancer Screening Programs………………........………………. 22

The Guide to Community Preventive Services………………………………...........…………. 22

Research-Tested Intervention Programs………………………………………...........………... 23

Effective Behavioral Interventions…………………………………………………...............…... 25

Evaluation of Effective Interventions…………………………………………………................ 27

Successful Cervical Cancer Prevention Programs Abroad………………….....…………... 28

Summary…………………………………………………………………………….........................…... 29

Chapter III: Methodology ……..………..………………………………………................……….. 31

CAA Program Description………………………………………………....................……….……… 31

Initial CAA Evaluation Plan…………………………………………………………....................…. 33

Actual CAA Implementation and Evaluation in El Salvador…………….....……….……... 33

Data Collection Instruments…………………………………………………………..................…. 34

KAP Survey……………………………………………………………………..................... 34

Focus Group Discussions……………………………………………............………….. 37

Data Analysis………………………………………………………………………….......................... 38

KAP Survey………………………………………………………………..................…….. 38

Focus Group Discussions………………………………………….............……………. 39

Chapter IV: Results ………………………………………………………………...................….….. 40

KAP Survey Demographic Data……………………………………………................……….….. 41

Research Question 1…………………………………………………………...................…….……. 43

Research Question 2…………………………………………………………...................…….……. 48

Research Question 3…………………………………………………………...................…….……. 52

Research Question 4…………………………………………………………...................…….……. 56

Research Question 5………………………………………………………...................……….……. 59

Chapter V: Discussion and Conclusion.. .……………………………..........……………….…. 63

Conclusions……………………………………………………………………….....................…….... 63

Implications for Public Health……………………………………………...............……………... 68

Limitations………………………………………………………………………….......................……. 69

Recommendations for "Con Amor Aprendemos" ……………………………………........... 71

Recommendations for Future Studies…………………………………………………............. 71

References…………………………………………………………………………….....................…. 73

Appendices…………........……………............................................................ 82

Appendix A………………….......................................................…... 82

Appendix B……………….......................................................……... 94

Table of Tables

Table 1.1 Outline and Objectives of CAA Workshop…………………….....…………….. 32

Table 1.2 Key Items Addressed in the KAP Survey………………………..........………. 34

Table 2.1 KAP Survey Demographic Data…………………………………………............... 41

Table 2.2 KAP Survey Data, Knowledge of Cervical Cancer and Prevention..…. 44

Table 2.3 KAP Survey Data, Individual Risk Perception……………………….....………. 49

Table 2.4 KAP Survey Data, Behavioral Outcomes of the CAA Intervention……. 53

Table 2.5 KAP Survey Data, Awareness and Use of Condoms……………………...... 57

Table of Figures

Figure 1.1 Cancer Incidence and Mortality in Latin America and El Salvador….…. 2

About this Master's Thesis

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School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Education
Keyword	Evaluation El Salvador Education Intervention
Committee Chair / Thesis Advisor	Escoffery, Ngoc-Cam, Emory University
Committee Members	Andes, Karen, Emory University
Partnering Agencies	National or regional non-profit organization (e.g., American Cancer Society)

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