Assessing an intervention to increase knowledge related to cervical cancer and the HPV vaccine

Abstract

Human papillomavirus (HPV) infection is the primary risk factor for cervical cancer. While the HPV vaccine significantly reduces the risk of HPV infection and subsequent cervical cancer diagnosis, underuse is linked to lack of knowledge of its effectiveness in preventing cervical cancer. The purpose of this study was to evaluate a cancer educational intervention (titled “MOVENUP”) to improve knowledge of cervical cancer, HPV, and the HPV vaccine among predominantly African American communities in South Carolina. The MOVENUP cancer educational intervention was conducted among participants residing in nine South Carolina counties who were recruited by community partners. The 4.5-h MOVENUP cancer educational intervention included a 30-min module on cervical cancer, HPV, and HPV vaccination. A six-item investigator-developed instrument was used to evaluate pre- and post-intervention changes in knowledge related to these content areas. Ninety-three percent of the 276 participants were African American. Most participants reporting age and gender were 50+ years (73%) and female (91%). Nearly half of participants (46%) reported an annual household income <$40,000 and 49% had not graduated from college. Statistically significant changes were observed at post-test for four of six items on the knowledge scale (P < 0.05), as compared to pre-test scores. For the two items on the scale in which statistically significant changes were not observed, this was due primarily due to a baseline ceiling effect.

1. Introduction

1.1. Cervical cancer incidence and mortality rates in the United States (US) and in South Carolina

The American Cancer Society notes that 13,170 new cases of invasive cervical cancer were diagnosed in 2019 in the United States, and approximately 4250 women died from cervical cancer (American Cancer Society, 2019). Nationally, the cervical cancer age-adjusted incidence rate from 2008 to 2012 for NHB women was 10.0 per 100,000 reflecting an absolute difference of 2.9 and a rate ratio of 1.41 compared to Non-Hispanic white (NHW) women (American Cancer Society, 2016). African American and Latina women had the highest cervical cancer age-adjusted incidence rates (8.7 and 9.3 new cases per 100,000 persons, respectively) per year in 2012–2016 compared to white women (7.2 new cases per 100,000 persons) (National Cancer Institute, 2019). During this period, African American and Latina women also had a higher cervical cancer age-adjusted mortality rate (3.5 and 2.6 deaths per 100,000 persons, respectively) per year compared to white women (2.2 deaths per 100,000 persons) (National Cancer Institute, 2019).

According to the most recent state-level data for South Carolina from 2009 to 2017, the age-adjusted cervical cancer mortality rate for NHW women was 2.2 per 100,000 and for African American women was 3.9 per 100,000, for a total of 645 deaths during this time period (South Carolina Department of Health and Environmental Control. Public Health Statistics and Information Services: Division of Biostatistics and Health GIS, 2019b). From 2009 to 2016, the age-adjusted cervical cancer incidence rate for NHW women was lower (7.7 per 100,000) compared to African American women (9.3 per 100,000) (South Carolina Department of Health and Environmental Control. Public Health Statistics and Information Services: Division of Biostatistics and Health GIS, 2019a).

Evidence suggests there are racial and geographic factors which may contribute to the cancer disease burden with higher risk of mortality for underserved, rural women in the southern region of the United States (Moore et al., 2018). African American women and men in South Carolina also experience cancer health disparities for many preventable cancer types (South Carolina Department of Health and Environmental Control. Public Health Statistics and Information Services: Division of Biostatistics and Health GIS, 2019b).

Cervical cancer health disparities have been partially explained by the lack of early detection due to non-adherence to regular screening, and irregular or delayed follow-up after a positive screening test (Musselwhite et al., 2016; Smith et al., 2013). These differences in access to healthcare providers are usually experienced disproportionately by disenfranchised low-income and uninsured individuals. Further, cervical cancer is often described as a disease of poverty (Tsu & Ginsburg, 2017), given that it is almost entirely preventable if patients receive regular cervical cancer screening.

1.2. The importance of the HPV vaccine in preventing cervical Cancer

Human papillomavirus (HPV) is a viral infection, with over 100 different subtypes. Each year, about 14 million people in the United States, including teenagers, are newly infected with HPV (Centers for Disease Control and Prevention, 2017). HPV is most frequently transmitted through skin to skin contact via vaginal, anal, or oral sex. In total, approximately 79 million individuals in the United States are currently living with an HPV infection, most of whom are asymptomatic and do not experience negative health effects (Centers for Disease Control and Prevention, 2017). Therefore, HPV infection is fairly common, and most infections are resolved by the immune system without a person even knowing they were infected.

The progression of persistent HPV infection is the leading known contributor to cervical cancer. However, with proper screening and vaccination, 93% of cervical cancers could be prevented (Centers for Disease Control and Prevention, 2014). The HPV vaccine is recommended for males and females at ages 11–12, along with catch-up vaccination for those up to age 26 who missed vaccination at ages 11–12. The HPV vaccine is also approved by the United States. Food and Drug Administration (FDA) for administration as early as age 9 and up through the age of 45 (Centers for Disease Control and Prevention, 2019). Vaccination at ages 11–12 is optimal because younger adolescents have a strong immune response and the HPV vaccine is most effective prior to HPV exposure (Noronha, Markowitz, & Dunne, 2014).

HPV vaccines can provide protection for most cancer-causing HPV strains and prevent cervical cancer. The original 4-valent HPV vaccine was made from recombinant viral DNA of the L1 capsid protein encompassing strains 6, 11, 16, and 18 of the HPV. The 9-valent HPV vaccine, which is the vaccine used today, is similar but adds coverage to strains 31, 33, 45, 52, and 58 (Lopalco, 2017). HPV strains 16 and 18 are responsible for >80% of cervical cancer diagnoses in the United States; therefore, the HPV vaccine is highly effective in preventing cervical cancer (Lazcano-Ponce et al., 2019). A long-term, 10-year follow-up study of the 4-valent vaccine reported that no cases of HPV types 6, 11, 16, or 18-related diseases were identified (Ferris et al., 2017).

1.3. Disparities in HPV vaccination rates

According to the National Immunization Survey for Teens (NIS-Teen) data, the percentage of 13- to 17-year-old girls who initiated and completed HPV vaccination in 2018 was 69.9% and 53.7%, respectively (Walker et al., 2019). The percentage of 13- to 17-year-old-boys who initiated and completed HPV vaccination was lower at 66.3% and 48.7%, respectively (Walker et al., 2017). In terms of HPV vaccine series completion in the United States by race and ethnicity, the NIS-Teen data showed that HPV vaccine completion rates range from 47.8% for NHW adolescents to 53.3% for African American adolescents to 56.6% for Hispanic adolescents (Walker et al., 2017).

State level rates for HPV vaccine completion range from a low of 32.6% in Oklahoma to a high of 78.1% in Rhode Island. South Carolina has observed a 4.3% 5-year annual average increase in HPV vaccination coverage, and the HPV vaccine completion rate was 41.2% in 2018. This is below the regional average of 46.7% and the national average of 51.1% (Walker et al., 2019). South Carolina, and other states in the South, remain far behind HPV vaccination rates compared to states in the Northeast and the Pacific Coast.

Past studies have shown that there is a need to improve parent, patient, and provider education on HPV vaccination; reduce vaccine costs; and improve the quality of age-appropriate (11–12 years old) provider recommendations (Gilkey et al., 2016; Lake, Kasting, Christy, & Vadaparampil, 2019). Particularly important for African American patients may be the level of trust in healthcare provider advice. One study reported African American parents who had higher trust in healthcare providers were twice as likely to follow through with HPV vaccine for their children (Fu, Zimet, Latkin, & Joseph, 2017).

1.4. Impact of the lack of knowledge of cervical cancer and/or HPV infection on HPV vaccination uptake

Given the suboptimal rates of HPV vaccination completion and low levels of knowledge of cervical cancer in underserved communities in South Carolina, the investigators of the present study implemented a cancer educational intervention aimed at assessing improvement in knowledge related to cervical cancer, HPV, and the HPV vaccine among intervention participants living in predominantly African American communities. Below we describe the design, methods, and results of the cancer educational intervention to improve knowledge of cervical cancer, HPV, and the HPV vaccine in nine predominantly African American communities in South Carolina.

2. Methods

2.1. Study design

A pre-test/post-test design was used to evaluate knowledge changes as a result of the MOVENUP cancer educational intervention. Results related to cancer knowledge outcomes are reported elsewhere and demonstrated that general cancer knowledge and prostate cancer knowledge scores increased significantly after the cancer educational intervention (Ford et al., 2011). Whereas the focus of our prior work reported changes in cancer knowledge, the focus of the current study is to compare pre- and post-intervention changes in knowledge related to cervical cancer, HPV, and HPV vaccination.

2.2. IRB approval

The MOVENUP cancer educational intervention study protocol was approved by the Institutional Review Board (IRB) at the Medical University of South Carolina. Inclusion criteria included:

• Residence in the communities near the location of the intervention site.

• Self-identified gender.

• Self-identified race and ethnicity.

• Ages 21 years or older.

The pre- and post-test intervention surveys were completed by each participant and linked by an identifier that was not connected to his/her name, date of birth, or any other personal identifiers. Therefore, the investigators had no way of connecting survey responses to individual participants in the sessions, so changes in knowledge were evaluated at the group level rather than by individual participants.

2.3. Participant identification and recruitment

The study included participants from communities with large racial disparities in cancer mortality rates (Table 1). Community leaders (Champions) in each county were charged with recruiting participants to each MOVENUP session. While most of the recruited participants were African American, community members from all racial/ethnic groups were eligible to participate.

Table 1.

Age-adjusted cancer mortality rates per 100,000 population for the South Carolina (SC) countries where the MOVENUP cancer educational intervention was conducted, 2017.

County	Non-Hispanic white	African American/black
Beaufort	121.7	178.2
Charleston	147.1	189.1
Clarendon	128.8	191.8
Colleton	180.8	199.1
Greenville	145.7	159.8
Orangeburg	168.1	181.5
Pickens	161.6	248.3
Sumter	160.3	207.4
York	158.3	155.9
All Counties in SCa	156.8	186.1
United Statesb	165.4	190.6

^aAge-adjusted statewide and county rates for South Carolina use the 2000 US Standard population (South Carolina Department of Health and Environmental Control. Public Health Statistics and Information Services: Division of Biostatistics and Health GIS, 2019b).

^bUnited States rates are from 2011 to 2016 (Siegel, Miller, & Jemal, 2019).

2.4. MOVENUP cancer educational intervention

The 4.5-h cancer educational intervention (including the cervical cancer and HPV educational module) is called MOVENUP and was delivered in its entirety to participants at each of the 15 study sites between February 2015 and June 2019 (one session per site). The structure and content of the 4.5-h MOVENUP cancer educational intervention were identical across all study sites and with each group of participants. The MOVENUP cancer educational intervention is unique in South Carolina for its focus on African American, rural, and medically underserved communities experiencing cancer health disparities.

The 4.5-h evidence-based MOVENUP cancer educational intervention includes a 3-h module focused on general cancer prevention and control information, a 30-min module describing prostate cancer, a 30-min module discussing the importance of cancer clinical trial participation, and a 30-min module focused on cervical cancer, HPV, and the HPV vaccine.

The general cancer knowledge module of the MOVENUP cancer educational intervention was developed by the South Carolina Cancer Alliance, an 800-member, statewide, nonprofit organization with membership from the lay community, cancer survivorship support groups, healthcare organizations, public health associations, and academia. This component highlighted cancer prevention and control information (e.g., lifestyle interventions, cancer screening, early detection, diagnosis, and treatment options). The other modules of the MOVENUP cancer educational intervention were developed by the investigators. All four modules were developed for community audiences with no expert knowledge about cancer.

The MOVENUP cancer educational intervention was designed to be highly interactive and “hands on” rather than merely didactic. Participants engaged in role play as they practiced sharing the information they learned with others. They also participated in small group activities to review the information that was presented.

The MOVENUP cancer educational intervention employed a train-the-trainer approach in which each participant received a binder that included copies of the materials that were presented during the 4.5-h training session. The binder materials included the most up-to-date, evidence-based information related to cancer screening, early detection, and treatment as well as cervical cancer and HPV vaccine information. The binders also included overhead transparencies, flash drives, and CDs, which allowed the trained facilitators to make use of the different methods to disseminate the information. Additionally, the binders included talking points for each slide. The trained facilitators were encouraged to simply read the materials when they made presentations in their own communities and not add any extra information, to maintain the fidelity of the information and materials.

At the end of each MOVENUP cancer educational intervention session, each trained facilitator signed an agreement to conduct at least two MOVENUP cancer educational intervention training sessions in the next year. The MOVENUP investigators informed the trained facilitators that the future sessions could take place in venues ranging from large group meetings with their religious, civic, and social organizations to small group meetings held in someone’s home.

2.5. Rationale for the selected MOVENUP cancer educational intervention counties and demographic characteristics of the selected counties

The MOVENUP cancer educational intervention was conducted at 15 sites in nine different counties representing several different geographic regions of South Carolina (Table 1). These nine counties were: Beaufort, Clarendon, Colleton, Charleston, Greenville, Orangeburg, Pickens, Sumter, and York counties. The study included a sample of participants in counties with high racial disparities in cancer mortality rates as shown in Table 1. Residents of neighboring counties were also invited to participate. The sociodemographic characteristics of the counties in which the MOVENUP cancer educational intervention was conducted are displayed in Table 2.

Table 2.

Sociodemographic characteristics of the South Carolina counties receiving the MOVENUP cancer educational intervention.

County name	Population estimatesa	White	Black/AA	Amer. Indian	Asian	Native Haw. or Pacific Isl.b	Two or more races	Hisp./Latino	Median HH incomec	Per capita income	Population below the Pov. level
	N	%	%	%	%	%	%	%	USD	USD	%
United States (Reference)	327,167,434	76.5	13.4	1.3	5.9	0.2	2.7	18.3	57,652	31,177	12.3
South Carolina (Reference)	5,084,127	68.5	27.1	0.5	1.8	0.1	1.9	5.8	48,781	26,645	15.4
Beaufort	188,715	77.9	18.2	0.4	1.4	0.1	1.9	11.2	60,603	34,966	10.7
Charleston	405,905	69.2	26.8	0.4	1.8	0.1	1.7	5.1	57,822	35,587	13.3
Clarendon	33,700	50.2	47.5	0.4	0.8	–	1.0	3.2	35,838	20,616	23.2
Colleton	37,660	59.6	37.2	0.9	0.5	0.1	1.7	3.4	34,996	21,059	22.4
Greenville	514,213	76.4	18.5	0.5	2.6	0.1	2.0	9.3	53,739	29,123	12.4
Orangeburg	86,934	34.7	62.2	0.7	1.0	–	1.4	2.4	34,943	19,489	24.4
Pickens	124,937	88.9	7.0	0.3	2.1	–	1.8	3.8	45,332	23,501	15.3
Sumter	106,512	47.9	47.9	0.6	1.5	0.1	2.0	4.1	41,946	21,733	19.1
York	274,118	75.0	19.4	0.9	2.5	0.1	2.2	5.7	59,394	30,387	11.2

^aNote: Population estimates, July 2018.

^bMissing data for some of these values due to small sample size.

^cMedian Household Income/Per Capita income (in 2017 USD), 2013–2017.

Abbreviations: AA, African American; Amer., American; Haw., Hawaiian; Isl., Islander; Hisp., Hispanic; HH, household; Pov., Poverty; USD, United States Dollars.

Source: https://www.census.gov/quickfacts/fact/table/US,colletoncountysouthcarolina/PST045218, accessed on 8-6-2019

2.6. Conceptual framework of the MOVENUP cancer educational intervention

The design of the MOVENUP cancer educational intervention, which includes a cervical cancer and HPV vaccine module, was based on a conceptual framework developed to understand barriers impacting the participation of diverse populations in clinical trials (Swanson & Ward, 1995). These same barriers could negatively impact the likelihood of African American community members participating in educational forums focused on cervical cancer education. The conceptual framework for our study is shown in Fig. 1.

Fig. 1.

Conceptual framework.

In the Swanson and Ward (1995) framework, sociocultural barriers are defined as fear and mistrust of research, the investigators conducting the research, or even the institution where the research is conducted (Swanson & Ward, 1995). Sociocultural barriers also include racial and ethnic discrimination, cultural beliefs regarding illness and disease, mistrust of the health care system, and differences in health beliefs and practices (Swanson & Ward, 1995). The sociocultural barriers identified in the Swanson and Ward (1995) framework could deter African American community members from receiving the HPV vaccine. For example, African American parents may mistrust the health care system’s reassurances that the HPV vaccine is safe and effective (Fu et al., 2017).

In the present study, sociocultural barriers were addressed using the following methods. First, the MOVENUP cancer educational intervention was conducted in trusted community venues including churches, libraries, thrift stores, a community action agency, and a cancer center (see Table 3). Second, the investigators also worked with trusted community partners (“Champions,” e.g., civic, religious, and social organizational leaders) who endorsed the study and recruited participants to attend each MOVENUP cancer educational intervention session. Using community-engaged recruitment methods helped to foster a sense of trust among the study participants.

Table 3.

Location, date, and number of participants in the MOVENUP cancer educational intervention by study site (n = 276).^a

SC city (n = 10)	Urban/rural	SC county (n = 9)	Study site (n = 15)	Date of the intervention	Preregistered participants (n = 358)	Intervention participants (n = 274)b
Rock Hill	Urban	York	Mt. Hebron Baptist Church	February 21, 2015	25	22
St. Helena Island	Rural	Beaufort	St. Helena Island Branch Library	April 16, 2015	15	9
Orangeburg	Rural	Orangeburg	OCAB Community Action Agency	May 23, 2015	25	20
Charleston	Urban	Charleston	MUSC Hollings Cancer Center	June 6, 2015	26	17
Greenville	Urban	Greenville	Buncombe Street United Methodist	August 27, 2016	27	19
Greenville	Urban	Greenville	Goodwill Industries Thrift Store	October 22, 2016	22	11
Greenville	Urban	Greenville	Nicholtown Baptist Church	June 23, 2018	32	27
Pickens	Rural	Pickens	Griffin Ebenezer Baptist Church	July 14, 2018	25	27
Greenville	Urban	Greenville	Long Branch Baptist Church	July 14, 2018	22	10
Greenville	Urban	Greenville	Goodwill Industries Thrift Store	October 6, 2018	19	13
Charleston	Urban	Charleston	Morris Brown AME Church	January 19, 2019	32	34
Edisto Island	Rural	Charleston	Allen AME Church	March 2, 2019	21	12
Summerton	Rural	Clarendon	Historic Liberty Hill AME Church	April 27, 2019	25	25
Holly Hill	Rural	Orangeburg	Greater Unity AME Church	May 25, 2019	21	12
Wedgefield	Rural	Sumter	Orangehill AME Church	June 28, 2019	21	16

^aThe response rate was 77% for the intervention participants versus preregistered participants.

^bTwo participants left the training before completing the survey.

Abbreviations: SC, South Carolina; OCAB, Orangeburg-Calhoun-Allendale-Bamberg; MUSC, Medical University of South Carolina; AME, African Methodist Episcopal.

Additionally, each MOVENUP cancer educational intervention session took place in a trusted community venue that was identified and arranged by trusted local community leaders (Champions) in each community setting. The Champions were responsible for recruiting the participants for the MOVENUP cancer educational intervention trainings. Moreover, many of the investigative team members were African American, and therefore may have been more relatable to the study participants. Finally, as part of the MOVENUP cancer educational intervention, past clinical trial and ethical violations and abuses documented in the Tuskegee Syphilis Study and the Henrietta Lacks cell line controversy were presented to explain how research protections eventually led to the current high levels of protection of participants in contemporary research studies (e.g., the informed consent process, consent forms, and Data and Safety Monitoring Committees).

2.7. Measurement instrument

The study outcome was defined as a significant pre-test/post-test change in knowledge related to cervical cancer, HPV, and the HPV vaccine. A six-item investigator-developed instrument was used to evaluate these changes in knowledge. The questions were based on the investigators’ review of the contemporary literature on the topic of cervical cancer and HPV infection and included a mix of True/False and multiple choice questions (see Table 4). An overall knowledge score was also calculated that ranged from 0 to 6 for the total of the six questions, based on one point per each correctly answered question.

Table 4.

Study instrument assessing cervical cancer, HPV, and HPV vaccination knowledge.

Quiz evaluating cervical cancer, HPV, and HPV vaccination knowledge
Question 1. A Papanicolaou (Pap) test is a screening test for (circle one answer, a–e): a. Breast Cancer b. Colorectal Cancer c. Prostate Cancer d. Cervical Cancer e. None of the Above	Question 4. HPV is transmitted through (circle one answer, a–c): a. Skin-to-skin sexual contact b. Shaking hands with an HPV infected person c. Coming in contact with the blood of an HPV-infected person
Question 2. What is the major cause of cervical cancer (circle one answer, a–d): a. Hepatitis A b. Human Immunodeficiency Virus c. Human Papilloma Virus d. Influenza	Question 5. Only females can receive the HPV vaccine (circle one answer, True or False): a. True b. False
Question 3. Having an HPV infection means that you will get cervical cancer (circle one answer, True or False): a. True b. False	Question 6. Only sexually active individuals can receive the HPV vaccine (circle one answer, True or False): a. True b. False

• Two items assessed cervical cancer knowledge,

• Two items evaluated HPV knowledge, and

• Two items assessed HPV vaccination knowledge.

2.8. Statistical analysis

Frequencies and percentages were reported for demographic variables. Pre- and post-intervention changes in cervical cancer, HPV, and HPV vaccine knowledge were assessed by McNemar’s test of agreement for paired data. Regression analyses assessed the associations of demographic variables (e.g., education, income) and the overall knowledge score. SAS Version 9.4 was used to perform analyses (SAS Institute Inc., Cary, NC).

3. Results

Study sites included a number of churches, one library, two thrift stores, one community action agency, and a cancer center. The number of participants at each site varied from 9 to 34, with an average of 18 participants per site (Table 3).

Table 5 provides a summary of the demographic characteristics of the 276 study participants (93% African American). Most of the participants (73%) who reported age were 50 years of age or older. Among those who reported gender and income, 91% were female and 46% had an annual household income <$40,000. Forty-nine percent of the participants who reported their educational level had not graduated from college.

Table 5.

Summary of demographic characteristics of participants at pre-test (n = 276).

Variable	n %
Age (years)a (n = 270)
<50	74 (27.4)
51–64	94 (34.8)
65+	102 (37.8)
Gendera (n = 161)
Male	15 (9.3)
Female	146 (90.7)
Hispanic ethnicity (Yes/No)a (n = 274)
Yes	3 (1.1)
No	271 (98.9)
Racea (n = 274)
African American or Black	255 (93.1)
White	17 (6.2)
Otherb	2 (0.8)
Educationa (n = 272)
Less than high school	9 (3.34)
High school—some college	125 (45.9)
College graduate or more	138 (50.8)
Marital statusa (n = 270)
Married or living as married	114 (42.2)
Widowed	39 (14.4)
Divorced/Separated	55 (20.4)
Never married	62 (23.0)
Household income (USD) (n = 261)
0–19,999	57 (21.8)
20,000–39,999	63 (24.1)
40,000–59,999	65 (25.0)
60,000–79,999	29 (11.1)
≥80,000	47 (18.0)

^aMissing data on this variable.

^bOther race included one individual of American Indian or Alaska Native race.

Table 6 reports the outcomes of the cervical cancer questions. Overall, mean (SD) pre- (4.18 [1.42]) and post-test (4.68 [1.55]) scores differed significantly (P < 0.0001). For questions 2, 4, 5, and 6 there was a statistically significant difference between the pre- and post-test scores (P < 0.05). More participants changed from an incorrect to a correct answer for questions 2 and 4, with the greatest change in question 4 (40%) about how HPV was transmitted (skin-to-skin contact). In examining the item analysis, most participants knew the correct answer to question 1, that a Pap test is a screening test for cervical cancer, so there was no change in knowledge at post-test. Likewise, for question 3, most participants knew that having an HPV infection does not necessarily mean a person will develop cervical cancer. At post-test, the average correct response percentage for the 6 questions was 79% (range 74%–83%). In regression models, the demographic variables assessed (age, education, income, urban/rural) were not found to be predictors for the overall knowledge score.

Table 6.

Pre-test/post-test knowledge response changes by question.

Questions (correct response)	Incorrect to incorrect n (%)	Incorrect to correct n (%)	Correct to incorrect n (%)	Correct to correct n (%)	P valuea
Q1: A Papanicolaou (Pap) test is a screening test for … (cervical cancer)	20 (7.87)	31 (12.20)	23 (9.06)	180 (70.87)	0.2763
Q2: What is the major cause of cervical cancer? (human papillomavirus)	33 (12.99)	53 (20.87)	16 (6.30)	152 (59.84)	<0.0001
Q3: Having an HPV infection means that you will get cervical cancer. (False)	28 (11.02)	34 (13.39)	38 (14.96)	154 (60.63)	0.6374
Q4: HPV is transmitted through … (skin-to-skin sexual contact)	61 (24.02)	101 (39.76)	9 (3.54)	83 (32.68)	<0.0001
Q5: Only females can receive the HPV vaccine. (False)	17 (6.69)	45 (17.72)	27 (10.63)	165 (64.96)	0.0339
Q6: Only sexually active individuals can receive the HPV vaccine. (False)	18 (7.09)	21 (8.27)	41 (16.14)	174 (68.5)	0.0111

^aStatistical significance indicated by P < 0.05.

4. Discussion

The MOVENUP cancer educational intervention implemented community-based cancer education in nine counties of South Carolina to engage predominantly African American communities. During each MOVENUP session led by the investigators, important cancer educational topics relevant to African American cancer mortality rates were highlighted.

The results demonstrated that community-delivered cancer education can increase knowledge of cervical cancer in African American communities, and hopefully lead to greater uptake of the HPV vaccine. Given the suboptimal rates of HPV vaccination in South Carolina and disproportionate cervical cancer mortality rates for African American women, there have been statewide efforts to improve HPV vaccination rates and increase adherence to cervical cancer screening through the South Carolina Cancer Alliance and partner institutions (South Carolina Cancer Alliance, 2019). The state cancer plan has a modest goal to increase the HPV vaccination completion rates for 13- to 17-year olds to 50% by the end of 2021 (South Carolina Cancer Alliance, 2019). The MOVENUP cancer educational intervention complements these efforts with its focus on community-engaged educational approaches in African American communities with limited access to cancer educational information. The MOVENUP investigators, with funding from the National Cancer Institute, are now developing strategies to link their educational efforts with no-/low-cost HPV vaccination sites in each county.

Investigators from academic institutions in South Carolina are committed to conducting community-engagement strategies to reduce the glaring health disparities in the state. For example, the National Institutes of Health (NIH) Report, Principles of Community Engagement, highlights the community engagement work in health-related research in South Carolina (Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, 2011; Wilcox et al., 2007). One example was the Health-e-AME (African Methodist Episcopal) faith-based physical activity initiative. The community identified physical activity as an intervention target to decrease health disparities. This initiative partnered the AME church with the Medical University of South Carolina and the University of South Carolina to increase physical activity in their congregations. Following the initiative, there was high awareness of the intervention among parishioners, and the partnership with the AME church continues to collaborate on public health initiatives.

Another highly recognized academic-community research partnership in South Carolina was Project SuGAR, in which African Americans living in the South Carolina Sea Islands partnered with investigators at the Medical University of South Carolina to research genetic factors involved in diabetes and to engage the community in health education and health screenings for metabolic and cardiovascular diseases (Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement, 2011; Hunt et al., 2014). The Project SuGAR Citizen Advisory Committee was established in 1996 and continues to function today and support other community health research projects studying systemic lupus erythematosus and cancer disparities (Spruill et al., 2013; Wolf et al., 2018). These few examples highlight some of the long-term, community-engaged work by academic institutions in South Carolina, and the current study contributes to this literature as another successful example from the field. As in the other examples cited, the MOVENUP cancer educational intervention employed community engagement principles to improve program outcomes specifically related to access to up-to-date cancer educational resources.

The MOVENUP cancer educational intervention successfully built trust with several predominantly African American communities in rural and urban areas of South Carolina and delivered cancer educational interventions in trusted locations to engaged community members. Examples of community partners included leaders from the following organizations: the 7th Episcopal District of the AME Church of South Carolina, the South Carolina Cancer Alliance, and the American Cancer Society. By partnering with the community, the MOVENUP cancer educational intervention created learning opportunities in cancer education to improve cancer knowledge in these communities.

Other studies aiming to increase HPV vaccination knowledge in African American communities have used a community forum approach, which has also been used in community-engaged research on various health topics (Bharmal et al., 2016). For example, Teteh and colleagues reported a significant change in perceived knowledge of HPV and cervical cancer for both African Americans and Hispanics following the delivery of community forums (Teteh et al., 2019). In the analysis of the post-test scores, the authors found that having a regular doctor and trust of vaccines were associated with higher knowledge scores (Teteh et al., 2019). Survey studies with African American communities have found varied results with knowledge of cervical cancer, HPV and the HPV vaccine. A survey study in Chicago with African American women reported that 73% of participants scored less than 65% on the knowledge part of the survey. Variables associated with higher scores (>65%) included education, income, and having a child vaccinated with the HPV vaccine (Strohl et al., 2015). This study was more similar to the present study in that it studied middle-aged women and found low knowledge scores among community members. In the present study, the average correct post-test knowledge score was 78%.

Another survey study conducted in Charleston, South Carolina with Latina immigrant women focused on cervical cancer screening adherence reported that slightly more than half of the sample had heard of the HPV vaccine and two-thirds believed HPV was a sexually transmitted disease (Luque et al., 2018). In this study, factors negatively associated with cervical cancer screening included not knowing where to go to be screened, not having a regular provider and psychosocial factors such as low self-efficacy. What these other studies have in common with the present study is a demonstrated need for not only cervical cancer education in minority communities, but also additional support for healthcare seeking and addressing the challenges of finding a source of regular healthcare.

In summary, while the goal of this study was to evaluate the proportion of people who answered correctly between the pre- and post-test, the study data appear to be trending toward significant improvements in knowledge, particularly for survey items 2 and 4. The post-test results indicated that participants increased their knowledge about cervical cancer, HPV, and the HPV vaccine.

4.1. Strengths and limitations

There were both strengths and limitations of this research. While the sample was representative of counties with high rates of cervical cancer deaths, a random sampling selection scheme was not used. This could potentially limit the generalizability of the study findings. While the entire state of South Carolina is considered the catchment area of the Medical University of South Carolina Hollings Cancer Center, the MOVENUP cancer educational and outreach intervention focused on counties with sizable African American communities, and the intervention was conducted at only one time point. It is possible that the gains in knowledge related to cervical cancer, HPV, and the HPV vaccine may not be sustained over time. Booster or refresher sessions may be needed in the future to continue to engage these communities and sustain efforts. However, there were many strengths in the academic-community engagement efforts which empowered the community and increased trust in cancer educational research.

Most of the participants were women, who typically serve as the gate-keepers for their family’s health activities. Our team of investigators has found that women share the health information they gain with their families, including male relatives. Nevertheless, it will be important in the future to make a concerted effort to include more men in the MOVENUP cancer educational intervention. Changes in behavior related to the HPV vaccination were not measured. In a future study, the investigators will use federal and state data sources to evaluate changes in the pre- and post-intervention HPV vaccination rates in the nine counties where the intervention was conducted.

5. Conclusions

The purpose of this study was to evaluate the results of a cancer educational intervention to improve cervical cancer knowledge among predominantly African American communities in South Carolina. The study results show that overall, the MOVENUP cancer educational intervention led to significant increases in knowledge related to cervical cancer, HPV, and the HPV vaccine. This is especially important for content with which the participants may not have previously been familiar. However, for a few of the items on the study assessment instrument, no significant changes were seen from pre- to post-test. This was largely due to the fact that most participants responded with correct answers at pre-test, leaving little room to improve. As noted above, to measure the behavioral impact of the MOVENUP cancer educational intervention, the investigators will analyze federal and state data to evaluate changes in HPV vaccination uptake rates in the nine counties where the intervention was conducted.