Discussion
pre-cancerous lesions
RECRUITMENT
Prior analysis of the study data revealed an effect of the GC-CCP intervention on increased CC screening uptake among previously unscreened social network members (alters) (15). In the analysis reported here, we sought to understand how the intervention achieved this effect, and for whom the intervention was most successful, by examining mediators and moderators of the intervention effect on alter CC screening. The most direct effect of the intervention was engagement in CC prevention advocacy among intervention recipients (index participants); therefore, our hypothesis was that CC prevention advocacy conducted by the index participants would mediate the intervention effect on increased CC screening uptake among alters. Yet, while there was an intervention effect on increased CC prevention advocacy among index participants (Wagner et al. The GC-CCP intervention had effects on many of the constructs that compose the conceptual framework that guided the development of the intervention (see Fig. The mediating effect of increased alter engagement in CC prevention advocacy, as opposed to index engagement in advocacy, perhaps should not be surprising. The increase in alter engagement in advocacy is arguably a result of the alters being targeted with advocacy by the index participants. Furthermore, the finding that engagement in CC prevention advocacy also increased among alter participants suggests a diffusion of advocacy created by the intervention. This is particularly promising, as network-based peer advocacy interventions such as GC-CCP are designed to disseminate knowledge, motivation and self-efficacy for health behavior through diffusion of advocacy [The only variable found to moderate the intervention effect on alter CC screening was CC treatment status of the index participants. Index participants in the intervention group who had screened positive and been treated for pre-cancerous lesions were more likely to have alter participants who got screened for CC during the study follow-up period. This finding suggests that women who screen positive may be more motivated to engage in CC prevention advocacy, and they may also receive more information about CC during the process of receiving treatment, both of which encourage them to engage in more advocacy. This is consistent with our prior analysis of baseline data that showed index participant engagement in CC prevention advocacy was positively correlated with having received CC-related treatment (Wagner et al., There are several limitations to our analysis. A selection bias was likely present in the recruitment of the index participants, as they had decided to enroll in a study that would train them to engage in CC prevention advocacy; motivation to be such an advocate is likely associated with greater CC knowledge and other constructs we measured, and not representative of the general population of women who had recently screened for CC. Similarly, there was a selection bias related to the alter participants, as index participants needed to be comfortable recruiting these alters; these alters may not be representative of all women in the social networks of the index participants. Validated measures or measures used by other research groups were not available for most constructs, resulting in the need for our team to develop many of the measures used. Internal reliability statistics were moderate or good for most of these measures, but further psychometric evaluation is needed in future studies. Other limitations include the small sample size and limited statistical power.