Cervical Cancer Prevention Advocacy Among Ugandan Women Who Have Screened for Cervical Cancer: Cross-Sectional Evaluation of a Conceptual Framework

Cervical Cancer Prevention Advocacy Among Ugandan Women Who Have Screened for Cervical Cancer: Cross-Sectional Evaluation of a Conceptual Framework | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cervical Cancer Prevention Advocacy Among Ugandan Women Who Have Screened for Cervical Cancer: Cross-Sectional Evaluation of a Conceptual Framework Glenn Wagner, Laura Bogart, Joseph Matovu, Harold Green, Ryan McBain, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6214047/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Cervical cancer (CC) is the most prevalent cancer among Ugandan women, yet about 10% of women have ever been screened. One approach to increasing CC screening is to empower screened women to encourage women in their social network (alters) to get screened. Based on our conceptual framework for psychosocial drivers of advocacy engagement, we examined correlates of CC prevention advocacy among screened women in Uganda. Methods : 160 women who had screened for CC were surveyed. We assessed two measures of CC prevention advocacy (a general measure of frequency of discussions with other women about six specific CC prevention topics in the past 6 months, and an alter-specific measure of percentage of alters whom the respondent encouraged to get screened in the past 6 months), internalized CC stigma, sharing of personal CC screening experience, CC knowledge, and self-efficacy related to both CC service utilization and CC prevention advocacy, as well as socio-demographic and social network characteristics. Bivariate and multiple linear regression analyses were conducted to assess cross-sectional correlates of CC prevention advocacy. Results : Each psychosocial construct in our conceptual framework was significantly associated with at least one of the two measures of CC prevention advocacy; however, In multiple regression analysis that controlled for each of the psychosocial constructs, the percentage of alters with whom the respondent shared their CC screening result was an independent correlate of both the general [beta (SE) = 1.04 (.23); p<.001] and alter-specific measure of CC prevention advocacy [beta (SE) = .62 (.08); p<.001]; CC knowledge was also an independent correlate of the general measure [beta (SE) = .16 (.03); p<.001]. The general CC prevention advocacy measure was significantly correlated with percentage of alters perceived to have ever screened for CC (r= .25, p= .002). Conclusions : These findings support the validity of our conceptual framework regarding engagement in CC prevention advocacy and suggest the importance of sharing of one’s personal CC screening experience and CC knowledge for laying a foundation for advocacy and the need for peer advocacy training to focus on these components. cervical cancer screening advocacy Uganda disclosure knowledge conceptual framework Figures Figure 1 Introduction Cervical cancer (CC) is the most prevalent cancer among women in Uganda[1,2], and it is the leading cause of cancer-related deaths among women not only in Uganda [1,2] but also across low- and middle-income countries (LMICs) generally [3]. Over 250,000 women die of CC worldwide each year [4], most of whom are in LMICs and largely due to late screening coupled with limited access to CC screening and treatment. In Uganda, treatment for CC is scarcely available outside its capital city Kampala and is unaffordable for most women, which heightens the importance of timely CC screening and prevention. Unfortunately, most (80%) Ugandan women have advanced disease at initial presentation for CC care [5], and as few as 5-10% of women have ever screened for CC [5–7]. Sustainable, low resource strategies are needed to dramatically increase CC screening rates if Uganda and other developing countries are to progress towards the WHO global target of 70% of women receiving timely CC screening [8]. Peer-based interventions, most of which are in the form of education, social support or advocacy performed by a lay person from a similar population as that targeted by the intervention [9], have been used to promote health behavior in a wide array of health and disease contexts [10], including in resource-constrained settings [11]. Controlled studies of peer-based interventions have produced mixed results regarding the ability to change behaviors such as smoking, condom use, reproductive health screening, and substance use [10,11]. Peer advocacy interventions (i.e., peers encouraging behavior change amongst peers by providing information, sharing personal experiences, and addressing questions and concerns) have been shown to increase prevention behaviors and reduce stigma in the context of HIV [11] and substance use [12,13]. However, such interventions are understudied in the context of CC screening promotion, despite evidence that facilitators of CC screening include encouragement from others to get screened and knowing someone who has been screened for or diagnosed with CC [7,14]. Peer-based interventions have been largely justified on pragmatic means (e.g., resource conservation) rather than theoretical underpinnings [9,15]. Nonetheless, theories of social diffusion [16] and social influence [17] suggest that behaviors used by a few can be transferred to others through modeling, advocacy, and shifts in social norms. These theories help to explain how peer advocacy can influence behavior in others, but they do not address the factors that determine whether someone engages in advocacy. Furthermore, studies have published effects of advocacy on the behavior of the recipient of advocacy, but seldom do these studies report the determinants of engagement in advocacy itself, which may mediate the effects of advocacy on the targeted behavior. To inform an intervention to train women who have screened for CC to engage in advocacy for CC screening among women in their personal social networks, we developed a conceptual framework for how to empower these women to engage in peer advocacy (see Figure 1). The framework posits that self-acceptance (or low internalized stigma) regarding one’s risk for CC (e.g., not feeling shame about getting screened for CC, being at risk for CC, or screening positive for pre-cancerous or cancerous lesions) facilitates comfort with sharing one’s CC screening experience with others . Sharing one’s personal experience with CC screening lends credibility to their role as an advocate for screening. Accurate knowledge about CC (e.g., what causes CC, how it can be prevented, and available treatments) is important for motivation and confidence to seek CC-related services and treatment ( self-efficacy for CC-related service utilization ), as well as to engage in advocacy and for the accuracy of such advocacy. Lastly, communication skills for how to start and sustain advocacy discussions further bolster confidence and self-efficacy for conducting advocacy . These factors are hypothesized by the conceptual framework to determine the level of engagement in CC prevention advocacy and are the focus of the Game Changers for Cervical Cancer Prevention (GC-CCP) peer advocacy intervention. GC-CCP targets these factors with the most direct goal of increasing engagement in CC screening advocacy, which in turn is intended to increase uptake of CC screening within the social network. In prior research with a small sample of 40 women in Uganda who had recently screened for CC, engagement in CC prevention advocacy was significantly associated with CC knowledge, sharing of personal CC screening experience, and CC service utilization self-efficacy as hypothesized in our conceptual framework, but not prevention advocacy self-efficacy nor internalized CC stigma [18]. These results were with respect to a general measure of CC prevention advocacy. The analyses did not include a measure of advocacy that was specific to the advocacy targeted at the social network members enrolled in the study, which may be more relevant to influencing screening uptake among those social network members. We are currently conducting a larger study with 160 women who have screened for CC [19]. We sought to more fully evaluate our conceptual framework for engagement in CC prevention advocacy by examining both general and social network member-specific measures of advocacy. We hypothesized that engagement in CC prevention advocacy would be associated with lower internalized CC stigma, and greater sharing of personal CC screening experience, CC knowledge, and self-efficacy related to CC-service utilization and engagement in CC prevention advocacy. We also examined correlates among these constructs and with their association with perceived CC screening among the participant’s social network. Methods Study Design We conducted a cross-sectional correlational analysis with baseline data from an ongoing randomized controlled trial of GC-CCP—an intervention that empowers CC screened women (referred to as index participants) to advocate for CC screening and treatment among female members of their social network. Further details of the study protocol are available in a prior publication [19]. Ethical review and approval were obtained from the [BLIND REVIEW]. All participants provided written informed consent. Setting The study is being conducted at two public and two private-not-for-profit (PNFP) health facilities—Nsambya Hospital (PNFP) and Kawempe National Referral Hospital (public) in urban Kampala, and St. Charles Lwanga Hospital (PNFP) and Kayunga Regional Referral Hospital (public) in rural districts near the town of Jinja. Public and PNFP clinics are each utilized by about 40% of the Ugandan population [20]. Each of these sites provides CC screening and treatment for pre-cancerous lesions; women in need of treatment for CC are referred to the Uganda Cancer Institute in Kampala. Participants Participants were enrolled between September and February 2025. Women were eligible to enroll as index participants if they were age 18 years or older, had ever screened for CC, did not have advanced disease (i.e., likely healthy enough to complete the 12-month study follow-up), had shared their CC screening experience with at least one woman in their social network, and were fluent in Luganda (the primary language in the study setting). Clients were informed of the study by health care providers and those who expressed interest were referred to the study coordinator for eligibility screening and consent procedures. Measures The assessment was interviewer-administered using Network Canvas software and conducted in Luganda or English, depending on participant preference. Measures were translated into Luganda using standard translation/backtranslation methodology. The assessment included a survey and a social network assessment. For the social network assessment, each index participant was asked to list 10 women in their social network (referred to as “alters”) with whom they interact most. For each alter, we gathered information to assess network composition including age, HIV status, relation to index, perceived history with CC screening, and knowledge of index’s CC screening experience, as well as other variables described in detail below. Self-reported CC screening and treatment utilization were verified with abstracted medical chart data. All measures were developed by the study team, except those in which an attribution is provided. For measures developed by the study team that included at least three items, we cite internal reliability statistics (Cronbach’s alpha). Participants received 30,000 Uganda Shillings (~$8 USD) after completing the assessment for transportation costs. CC screening and treatment Participants reported whether they had ever been screened for CC using visual inspection with acetic acid (VIA), HPV test, or pap test. Those who had been screened were asked if the screening resulted in pre-cancerous lesions or potential cancerous lesions, in separate items; if either type of lesion was reported, receipt of added diagnostic tests (e.g., pap test or biopsy) and treatment were assessed. CC prevention advocacy A general measure [18] was assessed by asking respondents to report the frequency of discussing seven CC-related topics [getting screened for CC, how and where to get screened, physical symptoms that can be a sign of CC, limiting risk for HPV and CC by having fewer sexual partners, need for treatment if screening shows signs of CC risk, HPV vaccination to prevent HPV, and cervical cancer prevention (in general)] with women they know in the past six months. Response options ranged from 1 ‘not at all’ to 5 ‘very much’; a mean item score was calculated (Cronbach’s alpha = .95), and higher scores represent greater engagement in advocacy. To assess alter-specific advocacy, for each alter named in the social network assessment, the respondent was asked (yes/no) if they had discussed with the alter the importance of getting screened for CC in the past six months. The percentage of named alters with whom the respondent had discussed the importance of CC screening was calculated. Theoretical constructs for engagement in CC prevention advocacy Internalized CC stigma was measured with 5 items adapted from a scale of HIV internalized stigma [21] (e.g., my cervical cancer screening makes me feel ashamed of myself; I think it is safer to keep my cervical cancer screening to myself), that assess the respondent’s feelings about her CC screening and sharing her screening experience with others. Response options were 1 ‘disagree’, 2 ‘I neither agree nor disagree; I do not have a feeling either way’, and 3 ‘agree’; the mean item score was calculated and higher scores reflect greater stigma (Cronbach’s alpha = .57). Sharing of CC screening experience was assessed by asking the respondent, for each named alter, whether she had told the alter the result of her CC screening. The percentage of named alters who were informed by the respondent of her CC screening result was calculated. CC knowledge was assessed with 16 statements that reflect the etiology, prevention and treatment of CC [22] (e.g., CC is caused by a virus called Human Papilloma Virus; men can be infected with HPV; how long should a woman wait to have sexual intercourse when receiving treatment for precancerous lesions?); participants responded by indicating whether the statement was ‘true’ or ‘false’ (or ‘don’t know’) and the sum of correct responses was calculated (Cronbach’s alpha = .75). CC service utilization self-efficacy was assessed with three items indicating confidence to notice a symptom of CC risk, seek health services for a symptom of CC risk, and obtaining treatment if screening revealed signs of CC risk [18]. Response options ranged from 0 ‘you cannot do it at all’ to 10 ‘you are completely certain you can do it’; a mean item score was calculated (Cronbach’s alpha = .44) and higher scores reflect greater self-efficacy. CC prevention advocacy self-efficacy was assessed with three items assessing confidence to start a conversation about the need for: CC screening, treatment for signs of CC risk, and telling someone about their CC screening experience [18]. Response options ranged from 0 ‘you cannot do it at all’ to 10 ‘you are completely certain you can do it’; a mean item score was calculated (Cronbach’s alpha = .85) and higher scores reflect greater self-efficacy. Social network characteristics Perceived CC screening among alters. For each named alter, participants were asked to indicate whether they believed the alter had ever screened for CC. Percentage of named alters believes to have ever screened was calculated. Social support from alters . Participants were asked to rate how likely it was that each named alter would provide three types of support (get useful advice from her about important things in your life; get help from her when you are sick; feel that she cares what happens to me) using the items from the Duke-UNC Functional Social Support Questionnaire [23]. Response options were 1 ‘never’, 2 ‘much less than I would like’, 3 ‘less than I would like’, and 4 ‘as much as I would like’; a mean item score was calculated for each alter and then across all named alters, and higher scores reflect greater support from across all alters. CC stigma expressed by alters . For each alter named, participants were asked to indicate whether the alter had expressed CC stigma by rating their level of agreement to two statements (she has suggested that a person with cervical cancer must be to blame for her condition; she is uncomfortable being around women with cervical cancer) from Cancer Stigma Scale [24]. Response options were 0 ‘disagree’, 1 ‘I neither agree nor disagree; I do not have a feeling either way’, and 2 ‘agree’; a mean item score was calculated for each alter and then across all named alters, and higher scores reflect greater stigma across all alters. Trust in alters . For each alter named, the participant was asked how much she trusted the woman, with response options being 0 ‘not at all’, 1 ‘a little bit’ and 2 ‘very much’. Mean response across all named alters was calculated, with higher scores representing a greater level of trust across all alters. Sociodemographic and background characteristics These variables included age, level of formal education completed (any secondary education received), relationship status and self-reported HIV status. Data Analysis Initial analysis included an assessment of bivariate Pearson correlation coefficients between the general and alter-specific measures of CC prevention advocacy and constructs in our conceptual framework of CC prevention advocacy, as well as other variables in our assessment. We also examined inter-correlations among the constructs in the conceptual framework. We then estimated hierarchical multiple linear regression models to predict each of the two CC prevention advocacy measures, with separate models for each measure. In the first step, only measures of the five constructs posited to influence engagement in advocacy in our conceptual framework were entered as independent variables. In the second step, significant bivariate (p<.05) correlates among sociodemographic, background, and social network characteristics were added as covariates. Results Sample characteristics A sample of 160 women enrolled in the study, with 40 women enrolling at each of the four study sites. Fifty (31.3%) screened positive for signs of pre-cancerous lesions, and the remaining 110 screened negative for any sign of CC risk. From these 160 index participants, information was provided about 1,466 alters who were named during the survey [mean (SD) = 9.2 (1.6) alters named per participant]. Table 1 shows the characteristics of the index participants including sociodemographic and background characteristics, measures of the theoretical constructs of CC prevention advocacy, and psychosocial characteristics of their named alters. Mean age was 38 years (range: 18-67), 59.4% had any secondary education, 72.5% were in a committed relationship, and 46.9% were living with HIV. Levels and correlates of cervical cancer prevention advocacy Engagement in CC prevention advocacy . The sample had a mean (SD) of 2.4 (1.1) on the general measure of CC prevention advocacy, and the most common topics that participants discussed with others in the past six months were “getting screened for cervical cancer” (mean=2.8), “how and/or where to get screened for risk of cervical cancer” (mean=2.8) and “the need for treatment if screening shows signs of risk for cervical cancer” (mean=2.6). The alter-specific measure of advocacy revealed that the mean (SD) percentage of named alters with whom the participant reported engaging in CC screening advocacy with over the past six months was 48.2% (SD=37.7); most respondents [130 (81.2%)] reported engaging in such advocacy with at least one of their named alters, and 36 (22.5%) reported engaging in such advocacy with all of their named alters. Correlates of CC prevention advocacy . As shown in Table 2 and consistent with Figure 1, every construct in our conceptual framework of factors influencing engagement in CC prevention advocacy (internalized CC stigma, sharing of personal CC screening experience, CC knowledge, CC service utilization self-efficacy, CC prevention advocacy self-efficacy) was significantly correlated with either the general or alter-specific measure of advocacy. The magnitude of correlation coefficients ranged from .16 to .56 among statistically significant associations. The general measure of CC prevention advocacy was significantly correlated with all five constructs, and the alter-specific measure was significantly correlated with all but CC knowledge. Furthermore, the general measure of advocacy was significantly positively correlated with percent of named alters perceived to have ever screened for CC, while the alter-specific measure was a marginal correlate. Correlates of CC prevention advocacy among sociodemographic, background and social network characteristics. The only sociodemographic or background characteristic that was significantly correlated with CC prevention advocacy was the presence of any secondary education, which was positively correlated with the general measure of advocacy (see Table 2). Among the social network characteristics, mean level of trust and mean level of social support were each significantly positively correlated with the percentage of named alters with whom the respondent engaged in CC screening advocacy (see Table 2). In multiple linear regression analysis (see Table 3), models that included only the five constructs posited in our conceptual framework to influence engagement in CC prevention advocacy resulted in CC knowledge [beta (SE) = .18 (.03); p<.001] and percentage of named alters to whom the respondent told her CC screening result [beta (SE) = .93 (.24); p<.001] being the only significant independent correlates of the general measure of CC prevention advocacy, and the latter was the only independent correlate of the percentage of named alters with whom the respondent engaged in CC screening advocacy [beta (SE) = .58 (.08); p<.001]. When other bivariate correlates were added to the models, the independent correlates remained unchanged. Correlates among the theoretical constructs of cervical cancer prevention advocacy Table 4 lists the inter-correlations among the five constructs in our conceptual framework of factors influencing engagement in CC prevention advocacy, as well as correlations with the other variables in the assessment. As hypothesized (see Figure 1), internalized CC stigma was significantly negatively correlated (r = -.17; p = .03) with sharing of personal CC screening experience (percentage of alters who the respondent told about her CC screening result), and CC knowledge was positively correlated with CC service utilization self-efficacy (r = .24, p = .002) but not CC prevention advocacy self-efficacy. Among social network characteristics, percentage of alters perceived to know respondents’ CC screening experience was significantly positively correlated with percentage of alters with whom respondents had frequent contact and mean level of trust in and social support across alters, while negatively correlated with mean level of stigma perceived from alters (see Table 4). CC prevention advocacy self-efficacy was significantly positively correlated with mean level of trust in named alters and negatively correlated with mean level of stigma from named alters. CC knowledge was significantly positively correlated with having any secondary education and being in a committed relationship (see Table 4). Discussion In this study of Ugandan women who had screened for cervical cancer (CC), relationships posited by our conceptual framework for understanding engagement in CC prevention advocacy garnered strong empirical support from the study data. Each of the constructs in the model (i.e., internalized CC stigma, sharing personal CC screening experience, CC knowledge, and self-efficacy) was significantly associated with either the general or alter-specific measure of CC prevention advocacy, and all but CC knowledge was significantly associated with both measures. The extent of sharing one’s personal CC screening result with female social network members was an independent correlate of both measures of CC prevention advocacy, highlighting its importance for promoting engagement in advocacy. Engagement in CC prevention advocacy was positively associated with the percentage of women in their social network perceived to have ever screened for CC, adding further validity to the model. Comfort with sharing one’s personal CC screening experience establishes a foundation for engagement in CC prevention advocacy, as evidenced by it being an independent correlate of advocacy engagement when controlling for the other hypothesized constructs. This result was evident for both the general and alter-specific measures of CC prevention advocacy. We posit that advocacy is more likely to influence a woman’s decision to screen for CC if she perceives the person encouraging her to get screened to be credible. Sharing one’s personal experience with CC screening helps establish this credibility. Our data showed that women are more likely to share their personal CC screening result with women in their social network with whom they have frequent contact and whom they perceive to be trustworthy, supportive and not stigmatizing with regards to CC risk. This is consistent with other research related to disclosure of cancer risk or diagnosis [25], and supports the focus of our advocacy training intervention on promotion of CC prevention advocacy within one’s personal network. The other theoretical construct that was an independent correlate of general CC advocacy engagement was CC knowledge. CC knowledge among Ugandan women has been shown to be low [26,27]; however, women with greater knowledge may feel more motivated to encourage other women they know to also get screened for CC. The importance of CC knowledge for the success of CC prevention advocacy to promote CC screening uptake was also supported by our pilot of the GC-CCP intervention, which found that CC knowledge mediated the intervention effects on increased CC prevention advocacy [22]. One component of the intervention is providing information about facts and common myths and misconceptions related to CC etiology, prevention and treatment. The goal of CC prevention advocacy is to promote uptake of CC screening. Our data revealed a significant positive correlation between the general measure of CC prevention advocacy and percentage of female social network members perceived to have ever screened for CC; this association was marginally significant with the alter-specific measure of advocacy. The components of the GC-CCP advocacy training intervention directly target each of the five constructs in our conceptual framework; therefore, post-intervention follow-up assessments in the randomized controlled trial will enable us to further evaluate the validity and utility of the framework by assessing whether these constructs mediate any observed intervention effects on engagement in advocacy and screening uptake. There are several limitations to our analysis. The correlational nature of the analysis precludes any causal inferences, and the associations with engagement in CC prevention advocacy are likely bidirectional (e.g., reduced internalized stigma and greater sharing of one’s personal CC screening experience may facilitate more engagement in advocacy, but engagement in advocacy also provides an opportunity to share one’s personal screening experience and to receive social support, which may reduce stigma). The women in our sample decided to enroll in a study that would train them to engage in CC prevention advocacy; motivation to be such an advocate may differentiate these women from CC screened women in general with regards to CC knowledge, stigma and other constructs we measured. Established measures of the constructs assessed were often not available in the literature, requiring the study team to develop new measures, some of which showed low internal reliability. Further research is needed to establish reliable, valid measures of the constructs assessed to better examine the associations between constructs. Conclusion These findings provide support for our conceptual framework of factors influencing engagement in CC prevention advocacy among women screened for CC. Each of the theoretical constructs was significantly associated with at least one measure of CC prevention advocacy, and advocacy was significantly positively correlated with the perceived CC screening uptake among social network members. Sharing of personal CC screening experience and CC knowledge were independent correlates of CC prevention advocacy, highlighting their particular importance in promotion of advocacy. Future research with longitudinal data will enable us to further validate the conceptual model by examining the hypothesized causal pathways, and whether the constructs in the model mediate the effects of the GC-CCP advocacy training intervention on engagement in CC prevention advocacy. Declarations Ethics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Consent to participate: Written informed consent was obtained from all individual participants included in the study. Consent for publication: Not applicable. References Ferlay J, Colombet M, Soerjomataram I, Parkin DM, Piñeros M, Znaor A, et al. Cancer statistics for the year 2020: An overview. 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BMC Cancer. 2014;14:285. Hilton S, Emslie C, Hunt K, Chapple A, Ziebland S. Disclosing a Cancer Diagnosis to Friends and Family: A Gendered Analysis of Young Men’s and Women’s Experiences. Qual Health Res. 2009;19:744–54. Ndejjo R, Mukama T, Kiguli J, Musoke D. Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: a qualitative study. BMJ Open. 2017;7:e016282. Wanyenze RK, Bwanika JB, Beyeza-Kashesya J, Mugerwa S, Arinaitwe J, Matovu JKB, et al. Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda. Global Health Action. 2017;10:1380361. Tables Table 1. Measures of sociodemographic and background characteristics, theoretical constructs of cervical cancer (CC) prevention advocacy, and female social network characteristics of the sample of index participants (n=160) Mean (SD)/ n (%) Sociodemographic and background characteristics Age (years) 38.1 (10.2) Any secondary education 95 (59.4%) In a committed relationship 116 (72.5%) Living with HIV 75 (46.9%) Screened positive for pre-cancerous or cancerous lesions 50 (31.3%) Theoretical constructs of cervical cancer prevention advocacy Internalized CC stigma (range: 1-3) 1.1 (0.3) % of alters who know respondent’s CC screening result 44.6% (34.5) CC knowledge (range: 0-16) 9.2 (2.3) CC service utilization self-efficacy (range: 0-10) 9.1 (1.0) CC prevention advocacy self-efficacy (range: 0-10) 8.9 (1.3) General CC prevention advocacy engagement (range: 1-5) 2.4 (1.1) % of alters with whom the respondent has engaged with CC screening advocacy 48.2% (37.7) Mean level of CC screening advocacy across all alters (range: 0-4) 1.4 (1.2) % of alters perceived by the respondent to be screened for CC 13.4% (17.1) Characteristics of named female social networks % of alters with whom the respondent is in contact at least weekly 86.4% (17.8) Mean level of trust across all alters (range: 0-2) 1.4 (0.4) Mean level of social support across all alters (range: 1-4) 3.0 (0.7) Mean level of enacted CC stigma across all alters (range: 0-2) 0.1 (0.3) CC = cervical cancer; alters = female social network members named in the survey Table 2. Bivariate correlates of measures of cervical cancer (CC) prevention advocacy engagement Measure General CC prevention advocacy % of alters targeted with CC screening advocacy r p r p CC prevention advocacy theoretical constructs Internalized CC stigma -.16 .049 -.19 .02 % of alters who know respondent’s CC screening experience .36 <.001 .56 <.001 CC knowledge .39 <.001 .08 .30 CC service utilization self-efficacy .19 .02 .19 .02 CC prevention advocacy self-efficacy .27 <.001 .23 .003 % of alters perceived to be screened for CC .25 .002 .16 .052 Psychosocial characteristics of female social network % of alters whom respondent is in contact with at least weekly .08 .29 .14 .08 Mean level of trust in alters .12 .12 .22 .01 Mean level of social support from alters .03 .71 .18 .02 Mean level of perceived stigma from alters -.10 .20 -.02 .81 Sociodemographic and background characteristics Age .13 .10 .04 .64 Any secondary education .17 .03 -.01 .92 In a committed relationship .06 .47 .02 .83 Living with HIV -.01 .89 .07 .38 Screened positive for pre-cancerous or cancerous lesions .04 .64 .05 .55 CC = cervical cancer; alters = female social network members named in the survey Table 3. Multiple linear regression analysis of correlates of measures of cervical cancer (CC) prevention advocacy Variable General CC prevention advocacy % of alters targeted with CC screening advocacy Model 1 Model 2 Model 1 Model 2 Beta (SE); p Beta (SE); p Beta (SE); p Beta (SE); p Cervical cancer prevention advocacy theoretical constructs Internalized CC stigma -.29 (.29); .32 -.25 (.29); .39 -.09 (.09); .33 -.10 (.10); .29 % alters who respondent told their CC screening result .93 (.24); <.001 .97 (.24); <.001 .58 (.08); <.001 .56 (.08); <.001 CC knowledge .18 (.03); <.001 .17 (.04); <.001 .003 (.01); .79 .003 (.01); .79 CC service utilization self-efficacy .001 (.08); .99 .02 (.08); .85 .03 (.03); .37 .02 (.03); .39 CC prevention advocacy self-efficacy .13 (.07); .048 .12 (.07); .08 .02 (.02); .34 .02 (.02); .45 Other bivariate correlates of cervical cancer prevention advocacy Mean level of trust in alters -- .03 (.09); .73 Mean level of social support from alters -- .04 (.05); .48 Any secondary education .25 (.16); .11 -- CC = cervical cancer; alters = female social network members named in the survey Table 4. Bivariate correlates of theoretical constructs of cervical cancer (CC) prevention advocacy Internalized CC stigma % of alters who know CC screening result CC knowledge CC service utilization self-efficacy CC prevention advocacy self-efficacy Cervical cancer prevention advocacy theoretical constructs Internalized CC stigma -- -.17* .05 -.11 -.36*** % alters who respondent told their CC screening result -.17* -- .09 .17* .23** CC knowledge .05 .09 -- .24** .07 CC service utilization self-efficacy -.11 .17* .24** -- .29*** CC prevention advocacy self-efficacy -.36*** .23** .07 .29*** -- Psychosocial characteristics of female social network % of alters whom respondent is in contact with at least weekly -.15 T .15 T -.04 .18* .14 Mean level of trust in alters -.13 .24** .08 .13 .28*** Mean level of social support from alters .06 .19* .02 .06 .09 Mean level of perceived stigma from alters .09 -.25** -.11 -.11 -.18* Sociodemographic and background characteristics Age .08 .06 .04 -.01 .10 Any secondary education -.11 -.06 .16* -.04 .13 In a committed relationship .06 .02 .22** -.10 -.04 Living with HIV -.15 T .03 -.05 .06 -.12 Screened positive for pre-cancerous or cancerous lesions .16* .05 -.02 .14 T -.10 CC = cervical cancer; alters = female social network members named in the survey; T p <.10, * p <.05, ** p<.01, *** p<.001 Additional Declarations No competing interests reported. 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Jinja","correspondingAuthor":false,"prefix":"","firstName":"Sylvia","middleName":"","lastName":"Nakami","suffix":""},{"id":523884891,"identity":"9d030ca0-6916-4c7a-aa37-5c78cc0d9b18","order_by":9,"name":"Eve Namisango","email":"","orcid":"","institution":"African Palliative Care Association","correspondingAuthor":false,"prefix":"","firstName":"Eve","middleName":"","lastName":"Namisango","suffix":""},{"id":523884892,"identity":"1ad631ca-02e1-4875-acc9-dce1b0145ab0","order_by":10,"name":"Rhoda Wanyenze","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Rhoda","middleName":"","lastName":"Wanyenze","suffix":""}],"badges":[],"createdAt":"2025-03-12 17:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6214047/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6214047/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92740628,"identity":"8a7a8ea4-2deb-427f-9176-7902ffc7a8ad","added_by":"auto","created_at":"2025-10-03 17:22:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77205,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework for promotion of cervical cancer (CC) prevention advocacy among screened women to affect CC screening among social network members\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6214047/v1/f7ab5ca9a1a25892e064421e.png"},{"id":92741234,"identity":"55a24eb1-193f-4c42-8a2a-6252799dc2b3","added_by":"auto","created_at":"2025-10-03 17:30:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1639869,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6214047/v1/9e1e01f9-1121-4f97-a1c2-16cb5d43f2d0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cervical Cancer Prevention Advocacy Among Ugandan Women Who Have Screened for Cervical Cancer: Cross-Sectional Evaluation of a Conceptual Framework","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer (CC) is the most prevalent cancer among women in Uganda[1,2], and it is the leading cause of cancer-related deaths among women not only in Uganda [1,2] but also across low- and middle-income countries (LMICs) generally [3]. Over 250,000 women die of CC worldwide each year [4], most of whom are in LMICs and largely due to late screening coupled with limited access to CC screening and treatment. In Uganda, treatment for CC is scarcely available outside its capital city Kampala and is unaffordable for most women, which heightens the importance of timely CC screening and prevention. Unfortunately, most (80%) Ugandan women have advanced disease at initial presentation for CC care [5], and as few as 5-10% of women have ever screened for CC [5\u0026ndash;7]. Sustainable, low resource strategies are needed to dramatically increase CC screening rates if Uganda and other developing countries are to progress towards the WHO global target of 70% of women receiving timely CC screening [8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeer-based interventions, most of which are in the form of education, social support or advocacy performed by a lay person from a similar population as that targeted by the intervention [9], have been used to promote health behavior in a wide array of health and disease contexts [10], including in resource-constrained settings [11]. Controlled studies of peer-based interventions have produced mixed results regarding the ability to change behaviors such as smoking, condom use, reproductive health screening, and substance use [10,11].\u0026nbsp;Peer advocacy interventions (i.e., peers encouraging behavior change amongst peers by providing information, sharing personal experiences, and addressing questions and concerns) have\u0026nbsp;been shown to increase prevention behaviors and reduce stigma in the context of HIV\u0026nbsp;[11]\u0026nbsp;and substance use\u0026nbsp;[12,13]. However, such interventions are understudied in the context of CC screening promotion, despite evidence that facilitators of CC screening include encouragement from others to get screened and knowing someone who has been screened for or diagnosed with CC [7,14]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePeer-based interventions have been largely justified on pragmatic means (e.g., resource conservation) rather than theoretical underpinnings [9,15]. Nonetheless,\u0026nbsp;theories of social diffusion\u0026nbsp;[16]\u0026nbsp;and social influence\u0026nbsp;[17]\u0026nbsp;suggest that behaviors used by a few can be transferred to others through modeling, advocacy, and shifts in social norms. These theories help to explain how peer advocacy can influence behavior in others, but they do not address the factors that determine whether someone engages in advocacy. Furthermore, studies have published effects of advocacy on the behavior of the recipient of advocacy, but seldom do these studies report the determinants of engagement in advocacy itself, which may mediate the effects of advocacy on the targeted behavior.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo inform an intervention to train women who have screened for CC to engage in advocacy for CC screening among women in their personal social networks, we developed a conceptual framework for how to empower these women to engage in peer advocacy (see Figure 1). The framework posits that self-acceptance (or low \u003cem\u003einternalized stigma)\u003c/em\u003e regarding one\u0026rsquo;s risk for CC (e.g., not feeling shame about getting screened for CC, being at risk for CC, or screening positive for pre-cancerous or cancerous lesions) facilitates comfort with \u003cem\u003esharing one\u0026rsquo;s CC screening experience with others\u003c/em\u003e. Sharing one\u0026rsquo;s personal experience with CC screening lends credibility to their role as an advocate for screening. Accurate \u003cem\u003eknowledge about CC\u003c/em\u003e (e.g., what causes CC, how it can be prevented, and available treatments) is important for motivation and confidence to seek CC-related services and treatment (\u003cem\u003eself-efficacy for CC-related service utilization\u003c/em\u003e), as well as to engage in advocacy and for the accuracy of such advocacy. Lastly, communication skills for how to start and sustain advocacy discussions further bolster confidence and \u003cem\u003eself-efficacy for conducting advocacy\u003c/em\u003e. These factors are hypothesized by the conceptual framework to determine the level of engagement in CC prevention advocacy and are the focus of the Game Changers for Cervical Cancer Prevention (GC-CCP) peer advocacy intervention. GC-CCP targets these factors with the most direct goal of increasing engagement in CC screening advocacy, which in turn is intended to increase uptake of CC screening within the social network.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn prior research with a small sample of 40 women in Uganda who had recently screened for CC, engagement in CC prevention advocacy was significantly associated with CC knowledge, sharing of personal CC screening experience, and CC service utilization self-efficacy as hypothesized in our conceptual framework, but not prevention advocacy self-efficacy nor internalized CC stigma [18]. These results were with respect to a general measure of CC prevention advocacy. The analyses did not include a measure of advocacy that was specific to the advocacy targeted at the social network members enrolled in the study, which may be more relevant to influencing screening uptake among those social network members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe are currently conducting a larger study with 160 women who have screened for CC [19]. We sought to more fully evaluate our conceptual framework for engagement in CC prevention advocacy by examining both general and social network member-specific measures of advocacy. We hypothesized that engagement in CC prevention advocacy would be associated with lower internalized CC stigma, and greater sharing of personal CC screening experience, CC knowledge, and self-efficacy related to CC-service utilization and engagement in CC prevention advocacy. We also examined correlates among these constructs and with their association with perceived CC screening among the participant\u0026rsquo;s social network.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a cross-sectional correlational analysis with baseline data from an ongoing randomized controlled trial of GC-CCP\u0026mdash;an intervention that empowers CC screened women (referred to as index participants) to advocate for CC screening and treatment among female members of their social network. Further details of the study protocol are available in a prior publication [19]. Ethical review and approval were obtained from the [BLIND REVIEW]. All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study is being conducted at two public and two private-not-for-profit (PNFP) health facilities\u0026mdash;Nsambya Hospital (PNFP) and Kawempe National Referral Hospital (public) in urban Kampala, and St. Charles Lwanga Hospital (PNFP) and Kayunga Regional Referral Hospital (public) in rural districts near the town of Jinja. Public and PNFP clinics are each utilized by about 40% of the Ugandan population [20].\u003csup\u003e\u0026nbsp;\u003c/sup\u003eEach of these sites provides CC screening and treatment for pre-cancerous lesions; women in need of treatment for CC are referred to the Uganda Cancer Institute in Kampala.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were enrolled between September and February 2025. Women were eligible to enroll as index participants if they were age 18 years or older, had ever screened for CC, did not have advanced disease (i.e., likely healthy enough to complete the 12-month study follow-up), had shared their CC screening experience with at least one woman in their social network, and were fluent in Luganda (the primary language in the study setting). Clients were informed of the study by health care providers and those who expressed interest were referred to the study coordinator for eligibility screening and consent procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe assessment was interviewer-administered using Network Canvas software and conducted in Luganda or English, depending on participant preference. Measures were translated into Luganda using standard translation/backtranslation methodology. The assessment included a survey and a social network assessment. For the social network assessment,\u0026nbsp;each index participant was asked to list 10 women in their social network (referred to as \u0026ldquo;alters\u0026rdquo;) with whom they interact most. For each alter, we gathered information to assess\u003cem\u003e\u0026nbsp;\u003c/em\u003enetwork composition including age, HIV status, relation to index, perceived history with CC screening, and knowledge of index\u0026rsquo;s CC screening experience, as well as other variables described in detail below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSelf-reported CC screening and treatment utilization were verified with abstracted medical chart data. All measures were developed by the study team, except those in which an attribution is provided. For measures developed by the study team that included at least three items, we cite internal reliability statistics (Cronbach\u0026rsquo;s alpha). Participants received 30,000 Uganda Shillings (~$8 USD) after completing the assessment for transportation costs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCC screening and treatment\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reported whether they had ever been screened for CC using visual inspection with acetic acid (VIA), HPV test, or pap test. Those who had been screened were asked if the screening resulted in pre-cancerous lesions or potential cancerous lesions, in separate items; if either type of lesion was reported, receipt of added diagnostic tests (e.g., pap test or biopsy) and treatment were assessed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCC prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA \u003cstrong\u003e\u003cem\u003egeneral\u0026nbsp;\u003c/em\u003e\u003c/strong\u003emeasure [18] was assessed by asking respondents to report the frequency of discussing seven CC-related topics [getting screened for CC, how and where to get screened, physical symptoms that can be a sign of CC, limiting risk for HPV and CC by having fewer sexual partners, need for treatment if screening shows signs of CC risk, HPV vaccination to prevent HPV, and cervical cancer prevention (in general)] with women they know in the past six months. Response options ranged from 1 \u0026lsquo;not at all\u0026rsquo; to 5 \u0026lsquo;very much\u0026rsquo;; a mean item score was calculated (Cronbach\u0026rsquo;s alpha = .95), and higher scores represent greater engagement in advocacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo assess \u003cstrong\u003e\u003cem\u003ealter-specific\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eadvocacy, for each alter named in the social network assessment, the respondent was asked (yes/no) if they had discussed with the alter the importance of getting screened for CC in the past six months. The percentage of named alters with whom the respondent had discussed the importance of CC screening was calculated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical constructs for engagement in CC prevention advocacy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInternalized CC stigma\u003c/em\u003e\u003c/strong\u003e was measured with 5 items adapted from a scale of HIV internalized stigma [21] (e.g., my cervical cancer screening makes me feel ashamed of myself; I think it is safer to keep my cervical cancer screening to myself), that assess the respondent\u0026rsquo;s feelings about her CC screening and sharing her screening experience with others. Response options were 1 \u0026lsquo;disagree\u0026rsquo;, 2 \u0026lsquo;I neither agree nor disagree; I do not have a feeling either way\u0026rsquo;, and 3 \u0026lsquo;agree\u0026rsquo;; the mean item score was calculated and higher scores reflect greater stigma (Cronbach\u0026rsquo;s alpha = .57).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSharing of CC screening experience\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ewas assessed by asking the respondent, for each named alter, whether she had told the alter the result of her CC screening. The percentage of named alters who were informed by the respondent of her CC screening result was calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCC knowledge\u003c/em\u003e\u003c/strong\u003e was assessed with 16 statements that reflect the etiology, prevention and treatment of CC [22] (e.g., CC is caused by a virus called Human Papilloma Virus; men can be infected with HPV; how long should a woman wait to have sexual intercourse when receiving treatment for precancerous lesions?); participants responded by indicating whether the statement was \u0026lsquo;true\u0026rsquo; or \u0026lsquo;false\u0026rsquo; (or \u0026lsquo;don\u0026rsquo;t know\u0026rsquo;) and the sum of correct responses was calculated (Cronbach\u0026rsquo;s alpha = .75).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCC service utilization self-efficacy\u003c/em\u003e\u003c/strong\u003e was assessed with three items indicating confidence to notice a symptom of CC risk, seek health services for a symptom of CC risk, and obtaining treatment if screening revealed signs of CC risk [18]. Response options ranged from 0 \u0026lsquo;you cannot do it at all\u0026rsquo; to 10 \u0026lsquo;you are completely certain you can do it\u0026rsquo;; a mean item score was calculated (Cronbach\u0026rsquo;s alpha = .44) and higher scores reflect greater self-efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCC prevention advocacy self-efficacy\u003c/em\u003e\u003c/strong\u003e was assessed with three items assessing confidence to start a conversation about the need for: CC screening, treatment for signs of CC risk, and telling someone about their CC screening experience [18]. Response options ranged from 0 \u0026lsquo;you cannot do it at all\u0026rsquo; to 10 \u0026lsquo;you are completely certain you can do it\u0026rsquo;; a mean item score was calculated (Cronbach\u0026rsquo;s alpha = .85) and higher scores reflect greater self-efficacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSocial network characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived CC screening among alters.\u003c/em\u003e\u003c/strong\u003e For each named alter, participants were asked to indicate whether they believed the alter had ever screened for CC. Percentage of named alters believes to have ever screened was calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial support from alters\u003c/em\u003e\u003c/strong\u003e. Participants were asked to rate how likely it was that each named alter would provide three types of support (get useful advice from her about important things in your life; get help from her when you are sick; feel that she cares what happens to me) using the items from the Duke-UNC Functional Social Support Questionnaire [23]. Response options were 1 \u0026lsquo;never\u0026rsquo;, 2 \u0026lsquo;much less than I would like\u0026rsquo;, 3 \u0026lsquo;less than I would like\u0026rsquo;, and 4 \u0026lsquo;as much as I would like\u0026rsquo;; a mean item score was calculated for each alter and then across all named alters, and higher scores reflect greater support from across all alters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCC stigma expressed by alters\u003c/em\u003e\u003c/strong\u003e. For each alter named, participants were asked to indicate whether the alter had expressed CC stigma by rating their level of agreement to two statements (she has suggested that a person with cervical cancer must be to blame for her condition; she is uncomfortable being around women with cervical cancer) from Cancer Stigma Scale [24]. Response options were 0 \u0026lsquo;disagree\u0026rsquo;, 1 \u0026lsquo;I neither agree nor disagree; I do not have a feeling either way\u0026rsquo;, and 2 \u0026lsquo;agree\u0026rsquo;; a mean item score was calculated for each alter and then across all named alters, and higher scores reflect greater stigma across all alters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrust in alters\u003c/em\u003e\u003c/strong\u003e. For each alter named, the participant was asked how much she trusted the woman, with response options being 0 \u0026lsquo;not at all\u0026rsquo;, 1 \u0026lsquo;a little bit\u0026rsquo; and 2 \u0026lsquo;very much\u0026rsquo;. Mean response across all named alters was calculated, with higher scores representing a greater level of trust across all alters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic and background characteristics\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese variables included age, level of formal education completed (any secondary education received), relationship status and self-reported HIV status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitial analysis included an assessment of bivariate Pearson correlation coefficients between the general and alter-specific measures of CC prevention advocacy and constructs in our conceptual framework of CC prevention advocacy, as well as other variables in our assessment. We also examined inter-correlations among the constructs in the conceptual framework. We then estimated hierarchical multiple linear regression models to predict each of the two CC prevention advocacy measures, with separate models for each measure. In the first step, only measures of the five constructs posited to influence engagement in advocacy in our conceptual framework were entered as independent variables. In the second step, significant bivariate (p\u0026lt;.05) correlates among sociodemographic, background, and social network characteristics were added as covariates.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSample characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA sample of 160 women enrolled in the study, with 40 women enrolling at each of the four study sites. Fifty (31.3%) screened positive for signs of pre-cancerous lesions, and the remaining 110 screened negative for any sign of CC risk. From these 160 index participants, information was provided about 1,466 alters who were named during the survey [mean (SD) = 9.2 (1.6) alters named per participant]. Table 1 shows the characteristics of the index participants including sociodemographic and background characteristics, measures of the theoretical constructs of CC prevention advocacy, and psychosocial characteristics of their named alters. Mean age was 38 years (range: 18-67), 59.4% had any secondary education, 72.5% were in a committed relationship, and 46.9% were living with HIV.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevels and correlates of cervical cancer prevention advocacy\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEngagement in CC prevention advocacy\u003c/em\u003e\u003c/strong\u003e. The sample had a mean (SD) of 2.4 (1.1) on the general measure of CC prevention advocacy, and the most common topics that participants discussed with others in the past six months were \u0026ldquo;getting screened for cervical cancer\u0026rdquo; (mean=2.8), \u0026ldquo;how and/or where to get screened for risk of cervical cancer\u0026rdquo; (mean=2.8) and \u0026ldquo;the need for treatment if screening shows signs of risk for cervical cancer\u0026rdquo; (mean=2.6). The alter-specific measure of advocacy revealed that the mean (SD) percentage of named alters with whom the participant reported engaging in CC screening advocacy with over the past six months was 48.2% (SD=37.7); most respondents [130 (81.2%)] reported engaging in such advocacy with at least one of their named alters, and 36 (22.5%) reported engaging in such advocacy with all of their named alters.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorrelates of CC prevention advocacy\u003c/em\u003e\u003c/strong\u003e. As shown in Table 2 and consistent with Figure 1, every construct in our conceptual framework of factors influencing engagement in CC prevention advocacy (internalized CC stigma, sharing of personal CC screening experience, CC knowledge, CC service utilization self-efficacy, CC prevention advocacy self-efficacy) was significantly correlated with either the general or alter-specific measure of advocacy. The magnitude of correlation coefficients ranged from .16 to .56 among statistically significant associations. The general measure of CC prevention advocacy was significantly correlated with all five constructs, and the alter-specific measure was significantly correlated with all but CC knowledge. Furthermore, the general measure of advocacy was significantly positively correlated with percent of named alters perceived to have ever screened for CC, while the alter-specific measure was a marginal correlate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorrelates of CC prevention advocacy among sociodemographic, background and social network characteristics.\u003c/em\u003e\u003c/strong\u003e The only sociodemographic or background characteristic that was significantly correlated with CC prevention advocacy was the presence of any secondary education, which was positively correlated with the general measure of advocacy (see Table 2). Among the social network characteristics, mean level of trust and mean level of social support were each significantly positively correlated with the percentage of named alters with whom the respondent engaged in CC screening advocacy (see Table 2).\u003c/p\u003e\n\u003cp\u003eIn multiple linear regression analysis (see Table 3), models that included only the five constructs posited in our conceptual framework to influence engagement in CC prevention advocacy resulted in CC knowledge [beta (SE) = .18 (.03); p\u0026lt;.001] and percentage of named alters to whom the respondent told her CC screening result [beta (SE) = .93 (.24); p\u0026lt;.001] being the only significant independent correlates of the general measure of CC prevention advocacy, and the latter was the only independent correlate of the percentage of named alters with whom the respondent engaged in CC screening advocacy [beta (SE) = .58 (.08); p\u0026lt;.001]. When other bivariate correlates were added to the models, the independent correlates remained unchanged.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelates among the theoretical constructs of cervical cancer prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 lists the inter-correlations among the five constructs in our conceptual framework of factors influencing engagement in CC prevention advocacy, as well as correlations with the other variables in the assessment. As hypothesized (see Figure 1), internalized CC stigma was significantly negatively correlated (r = -.17; p = .03) with sharing of personal CC screening experience (percentage of alters who the respondent told about her CC screening result), and CC knowledge was positively correlated with CC service utilization self-efficacy (r = .24, p = .002) but not CC prevention advocacy self-efficacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong social network characteristics, percentage of alters perceived to know respondents\u0026rsquo; CC screening experience was significantly positively correlated with percentage of alters with whom respondents had frequent contact and mean level of trust in and social support across alters, while negatively correlated with mean level of stigma perceived from alters (see Table 4). CC prevention advocacy self-efficacy was significantly positively correlated with mean level of trust in named alters and negatively correlated with mean level of stigma from named alters. CC knowledge was significantly positively correlated with having any secondary education and being in a committed relationship (see Table 4).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study of Ugandan women who had screened for cervical cancer (CC), relationships posited by our conceptual framework for understanding engagement in CC prevention advocacy garnered strong empirical support from the study data. Each of the constructs in the model (i.e., internalized CC stigma, sharing personal CC screening experience, CC knowledge, and self-efficacy) was significantly associated with either the general or alter-specific measure of CC prevention advocacy, and all but CC knowledge was significantly associated with both measures. The extent of sharing one\u0026rsquo;s personal CC screening result with female social network members was an independent correlate of both measures of CC prevention advocacy, highlighting its importance for promoting engagement in advocacy. Engagement in CC prevention advocacy was positively associated with the percentage of women in their social network perceived to have ever screened for CC, adding further validity to the model.\u003c/p\u003e\n\u003cp\u003eComfort with sharing one\u0026rsquo;s personal CC screening experience establishes a foundation for engagement in CC prevention advocacy, as evidenced by it being an independent correlate of advocacy engagement when controlling for the other hypothesized constructs. This result was evident for both the general and alter-specific measures of CC prevention advocacy. We posit that advocacy is more likely to influence a woman\u0026rsquo;s decision to screen for CC if she perceives the person encouraging her to get screened to be credible. Sharing one\u0026rsquo;s personal experience with CC screening helps establish this credibility. Our data showed that women are more likely to share their personal CC screening result with women in their social network with whom they have frequent contact and whom they perceive to be trustworthy, supportive and not stigmatizing with regards to CC risk. This is consistent with other research related to disclosure of cancer risk or diagnosis [25], and supports the focus of our advocacy training intervention on promotion of CC prevention advocacy within one\u0026rsquo;s personal network.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other theoretical construct that was an independent correlate of general CC advocacy engagement was CC knowledge. CC knowledge among Ugandan women has been shown to be low [26,27]; however, women with greater knowledge may feel more motivated to encourage other women they know to also get screened for CC. The importance of CC knowledge for the success of CC prevention advocacy to promote CC screening uptake was also supported by our pilot of the GC-CCP intervention, which found that CC knowledge mediated the intervention effects on increased CC prevention advocacy [22]. One component of the intervention is providing information about facts and common myths and misconceptions related to CC etiology, prevention and treatment.\u003c/p\u003e\n\u003cp\u003eThe goal of CC prevention advocacy is to promote uptake of CC screening. Our data revealed a significant positive correlation between the general measure of CC prevention advocacy and percentage of female social network members perceived to have ever screened for CC; this association was marginally significant with the alter-specific measure of advocacy. The components of the GC-CCP advocacy training intervention directly target each of the five constructs in our conceptual framework; therefore, post-intervention follow-up assessments in the randomized controlled trial will enable us to further evaluate the validity and utility of the framework by assessing whether these constructs mediate any observed intervention effects on engagement in advocacy and screening uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are several limitations to our analysis. The correlational nature of the analysis precludes any causal inferences, and the associations with engagement in CC prevention advocacy are likely bidirectional (e.g., reduced internalized stigma and greater sharing of one\u0026rsquo;s personal CC screening experience may facilitate more engagement in advocacy, but engagement in advocacy also provides an opportunity to share one\u0026rsquo;s personal screening experience and to receive social support, which may reduce stigma). The women in our sample decided to enroll in a study that would train them to engage in CC prevention advocacy; motivation to be such an advocate may differentiate these women from CC screened women in general with regards to CC knowledge, stigma and other constructs we measured. Established measures of the constructs assessed were often not available in the literature, requiring the study team to develop new measures, some of which showed low internal reliability. Further research is needed to establish reliable, valid measures of the constructs assessed to better examine the associations between constructs.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese findings provide support for our conceptual framework of factors influencing engagement in CC prevention advocacy among women screened for CC. Each of the theoretical constructs was significantly associated with at least one measure of CC prevention advocacy, and advocacy was significantly positively correlated with the perceived CC screening uptake among social network members. Sharing of personal CC screening experience and CC knowledge were independent correlates of CC prevention advocacy, highlighting their particular importance in promotion of advocacy. Future research with longitudinal data will enable us to further validate the conceptual model by examining the hypothesized causal pathways, and whether the constructs in the model mediate the effects of the GC-CCP advocacy training intervention on engagement in CC prevention advocacy.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eThis article does not contain any studies with animals performed by any of the authors.\u003c/p\u003e\n\u003cp\u003eConsent to participate: Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFerlay J, Colombet M, Soerjomataram I, Parkin DM, Pi\u0026ntilde;eros M, Znaor A, et al. Cancer statistics for the year 2020: An overview. Intl Journal of Cancer. 2021;149:778\u0026ndash;89. \u003c/li\u003e\n\u003cli\u003eUganda - Kampala Cancer Registry [Internet]. African Cancer Registry Network. 2018 [cited 2023 Dec 10]. Available from: http://afcrn.org/membership/membership-list/81-kampala-uganda\u003c/li\u003e\n\u003cli\u003eGiannella L, Di Giuseppe J, Delli Carpini G, Grelloni C, Fichera M, Sartini G, et al. HPV-Negative Adenocarcinomas of the Uterine Cervix: From Molecular Characterization to Clinical Implications. IJMS. 2022;23:15022. \u003c/li\u003e\n\u003cli\u003eSung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA A Cancer J Clin. 2021;71:209\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eNakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. 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Urging Others to be Healthy: \u0026ldquo;Intravention\u0026rdquo; by Injection Drug Users as a Community Prevention Goal. AIDS Education and Prevention. 2004;16:250\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eLatkin CA, Sherman S, Knowlton A. HIV prevention among drug users: Outcome of a network-oriented peer outreach intervention. Health Psychology. 2003;22:332\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eBlack E, Hyslop F, Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda: a systematic review. BMC Women\u0026rsquo;s Health. 2019;19:108. \u003c/li\u003e\n\u003cli\u003eCampbell A, Deshpande S, Rundle-Thiele S, West T. Social advocacy: a conceptual model to extend post-intervention effectiveness. Journal of Strategic Marketing. 2024;32:216\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eRogers EM. Diffusion of innovations. 5th ed. 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Ministry of Health, Uganda; Available from: https://library.health.go.ug/sites/default/files/resources/Annual%20Health%20Sector%20Performance%20Report%202020-21-1.pdf\u003c/li\u003e\n\u003cli\u003eKalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21:87\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eWagner GJ, Matovu JKB, Juncker M, Namisango E, Beyeza-Kashesya J, Wanyenze RK. Knowledge Mediates the Effects of Game Changers for Cervical Cancer Prevention (GC-CCP) Intervention on Increased VIA Screening Advocacy in Uganda. Cancer Prevention Research. 2023;16:689\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eBroadhead WE, Gehlbach SH, De Gruy FV, Kaplan BH. The Duke-UNC Functional Social Support Questionnaire: Measurement of Social Support in Family Medicine Patients. Medical Care. 1988;26:709\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eMarlow LA, Wardle J. Development of a scale to assess cancer stigma in the non-patient population. BMC Cancer. 2014;14:285. \u003c/li\u003e\n\u003cli\u003eHilton S, Emslie C, Hunt K, Chapple A, Ziebland S. Disclosing a Cancer Diagnosis to Friends and Family: A Gendered Analysis of Young Men\u0026rsquo;s and Women\u0026rsquo;s Experiences. Qual Health Res. 2009;19:744\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eNdejjo R, Mukama T, Kiguli J, Musoke D. Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: a qualitative study. BMJ Open. 2017;7:e016282. \u003c/li\u003e\n\u003cli\u003eWanyenze RK, Bwanika JB, Beyeza-Kashesya J, Mugerwa S, Arinaitwe J, Matovu JKB, et al. Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda. Global Health Action. 2017;10:1380361. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Measures of sociodemographic and background characteristics, theoretical constructs of cervical cancer (CC) prevention advocacy, and female social network characteristics of the sample of index participants (n=160)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"722\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)/ n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 722px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic and background characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e38.1 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eAny secondary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e95 (59.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eIn a committed relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e116 (72.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eLiving with HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e75 (46.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eScreened positive for pre-cancerous or cancerous lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e50 (31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 722px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheoretical constructs of cervical cancer prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eInternalized CC stigma (range: 1-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e% of alters who know respondent\u0026rsquo;s CC screening result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e44.6% (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eCC knowledge (range: 0-16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e9.2 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eCC service utilization self-efficacy (range: 0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e9.1 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eCC prevention advocacy self-efficacy (range: 0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e8.9 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eGeneral CC prevention advocacy engagement (range: 1-5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e2.4 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e% of alters with whom the respondent has engaged with CC screening advocacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e48.2% (37.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eMean level of CC screening advocacy across all alters (range: 0-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.4 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e% of alters perceived by the respondent to be screened for CC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e13.4% (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 722px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics of named female social networks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e% of alters with whom the respondent is in contact at least weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e86.4% (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eMean level of trust across all alters (range: 0-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e1.4 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eMean level of social support across all alters (range: 1-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e3.0 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003eMean level of enacted CC stigma across all alters (range: 0-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 146px;\"\u003e\n \u003cp\u003e0.1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCC = cervical cancer; alters = female social network members named in the survey\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Bivariate correlates of measures of cervical cancer (CC) prevention advocacy engagement\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"714\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral CC prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of alters targeted with CC screening advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 714px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC prevention advocacy theoretical constructs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eInternalized CC stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e-.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.049\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e% of alters who know respondent\u0026rsquo;s CC screening experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eCC knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eCC service utilization self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eCC prevention advocacy self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e% of alters perceived to be screened for CC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 714px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychosocial characteristics of female social network\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003e% of alters whom respondent is in contact with at least weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eMean level of trust in alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eMean level of social support from alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eMean level of perceived stigma from alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e-.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 714px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic and background characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eAny secondary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eIn a committed relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eLiving with HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 426px;\"\u003e\n \u003cp\u003eScreened positive for pre-cancerous or cancerous lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCC = cervical cancer; alters = female social network members named in the survey\u003cstrong\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Multiple linear regression analysis of correlates of measures of cervical cancer (CC) prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"864\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneral CC prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of alters targeted with CC screening advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eModel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eModel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eBeta (SE); p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBeta (SE); p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBeta (SE); p\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBeta (SE); p\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 864px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCervical cancer prevention advocacy theoretical constructs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eInternalized CC stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.29 (.29); .32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.25 (.29); .39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.09 (.09); .33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.10 (.10); .29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003e% alters who respondent told their CC screening result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.93 (.24); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.97 (.24); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.58 (.08); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.56 (.08); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eCC knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.18 (.03); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.17 (.04); \u0026lt;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.003 (.01); .79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.003 (.01); .79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eCC service utilization self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.001 (.08); .99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.02 (.08); .85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.03 (.03); .37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.02 (.03); .39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eCC prevention advocacy self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.13 (.07); .048\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.12 (.07); .08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.02 (.02); .34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.02 (.02); .45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 864px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther bivariate correlates of cervical cancer prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eMean level of trust in alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.03 (.09); .73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eMean level of social support from alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.04 (.05); .48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 378px;\"\u003e\n \u003cp\u003eAny secondary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.25 (.16); .11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCC = cervical cancer; alters = female social network members named in the survey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Bivariate correlates of theoretical constructs of cervical cancer (CC) prevention advocacy\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternalized CC stigma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of alters who know CC screening result\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC knowledge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC service utilization self-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCC prevention advocacy self-efficacy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 858px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCervical cancer prevention advocacy theoretical constructs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eInternalized CC stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.36***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e% alters who respondent told their CC screening result\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.23**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eCC knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.24**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eCC service utilization self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.17*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.24**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.29***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eCC prevention advocacy self-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.36***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.23**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.29***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 858px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychosocial characteristics of female social network\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003e% of alters whom respondent is in contact with at least weekly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.15\u003csup\u003eT\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.15\u003csup\u003eT\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.18*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eMean level of trust in alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.24**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.28***\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eMean level of social support from alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.19*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eMean level of perceived stigma from alters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-.25**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.18*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 858px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic and background characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eAny secondary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e-.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.16*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eIn a committed relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e.22**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e-.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eLiving with HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e-.15\u003csup\u003eT\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 294px;\"\u003e\n \u003cp\u003eScreened positive for pre-cancerous or cancerous lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e.16*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e-.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e.14\u003csup\u003eT\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCC = cervical cancer; alters = female social network members named in the survey;\u003cstrong\u003e\u0026nbsp;\u003csup\u003eT\u003c/sup\u003e\u003c/strong\u003e p \u0026lt;.10, * p \u0026lt;.05, ** p\u0026lt;.01, *** p\u0026lt;.001\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cervical cancer, screening, advocacy, Uganda, disclosure, knowledge, conceptual framework","lastPublishedDoi":"10.21203/rs.3.rs-6214047/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6214047/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Cervical cancer (CC) is the most prevalent cancer among Ugandan women, yet about 10% of women have ever been screened. One approach to increasing CC screening is to empower screened women to encourage women in their social network (alters) to get screened. Based on our conceptual framework for psychosocial drivers of advocacy engagement, we examined correlates of CC prevention advocacy among screened women in Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: 160 women who had screened for CC were surveyed. We assessed two measures of CC prevention advocacy (a general measure of frequency of discussions with other women about six specific CC prevention topics in the past 6 months, and an alter-specific measure of percentage of alters whom the respondent encouraged to get screened in the past 6 months), internalized CC stigma, sharing of personal CC screening experience, CC knowledge, and self-efficacy related to both CC service utilization and CC prevention advocacy, as well as socio-demographic and social network characteristics. Bivariate and multiple linear regression analyses were conducted to assess cross-sectional correlates of CC prevention advocacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Each psychosocial construct in our conceptual framework was significantly associated with at least one of the two measures of CC prevention advocacy; however, In multiple regression analysis that controlled for each of the psychosocial constructs, the percentage of alters with whom the respondent shared their CC screening result was an independent correlate of both the general [beta (SE) = 1.04 (.23); p\u0026lt;.001] and alter-specific measure of CC prevention advocacy [beta (SE) = .62 (.08); p\u0026lt;.001]; CC knowledge was also an independent correlate of the general measure [beta (SE) = .16 (.03); p\u0026lt;.001]. The general CC prevention advocacy measure was significantly correlated with percentage of alters perceived to have ever screened for CC (r= .25, p= .002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: These findings support the validity of our conceptual framework regarding engagement in CC prevention advocacy and suggest the importance of sharing of one’s personal CC screening experience and CC knowledge for laying a foundation for advocacy and the need for peer advocacy training to focus on these components.\u003c/p\u003e","manuscriptTitle":"Cervical Cancer Prevention Advocacy Among Ugandan Women Who Have Screened for Cervical Cancer: Cross-Sectional Evaluation of a Conceptual Framework","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-03 17:22:35","doi":"10.21203/rs.3.rs-6214047/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2eae0e7e-ee6a-400b-8dd5-fdb7b671eb30","owner":[],"postedDate":"October 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-11T23:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-03 17:22:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6214047","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6214047","identity":"rs-6214047","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}