DISCUSSION
CERVICAL CANCER
We found that a multifaceted, health literacy‐focused intervention (CHECC‐uP) can promote Pap testing among Black WLH. However, we experienced a high attrition rate in the study sample. The findings demonstrate the preliminary efficacy of CHECC‐uP for Black WLH as a potential strategy to reduce cervical cancer disparities in this population. To the best of our knowledge, CHECC‐uP is the first intervention to integrate health literacy education as an active component to promote Pap testing among WLH. The statistically significant difference in Pap test rates observed among WLH in the trial (28.1% difference) is higher than other reported rates for HIV‐negative women, ranging from 5% to 24%.Health literacy consists of multiple dimensions that go beyond one's reading ability.Our retention rate was not optimal. We had higher dropouts among younger women and women who scored higher on the cultural attitudes and beliefs scale. The role of age in cervical cancer screening participation is not at all consistent.Another important lesson learned from this pilot trial is that at least one‐third of the attrition observed in our study was early dropouts in the intervention arm, which led to a change in the education format from group sessions to individually based sessions. Benefits of group‐based education have included cost savingStudy limitations include an insufficient sample size to detect a statistically significant change in outcomes, which resulted from high attrition. Nevertheless, the effect sizes estimated for the study variables are encouraging and warrant further investigation to test the efficacy of the intervention, especially given the high acceptability and satisfaction of WLH with the study intervention. Additionally, given the multifaceted nature of the study intervention, we are unable to tease out active intervention components. The intervention acceptability indicators (e.g., satisfaction with the intervention and receipt, helpfulness and application of the intervention materials) seem to suggest overall synergy between health literacy education and follow‐up components, which should be maintained in future implementations of CHECC‐uP. Finally, the generalizability of study findings is limited by the inclusion of only Black, African American women in the study sample from a low‐income, urban community. Nationally, 41% of WLH are Black, with 49% having less than a high school education and 44% having household incomes at or below federal poverty guidelines.