title: Factors affecting attendance to cervical cancer screening among women in the Paracentral Region of El Salvador: a nested study within the CAPE HPV screening program.
abstract: BACKGROUND
  Cervical cancer is the third most commonly occurring cancer among women and the fourth leading cause of cancer-related deaths in women worldwide, with more than 85 % of these cases occurring in developing countries. These global disparities reflect the differences in cervical cancer screening rates between high-income and medium- and low-income countries. At 19 %, El Salvador has the lowest reported screening coverage of all Latin American countries. The purpose of this study is to identify factors affecting public sector HPV DNA-based cervical cancer screening participation in El Salvador.
  
  
  METHODS
  This study was nested within a public sector screening program where health promoters used door-to-door outreach to recruit women aged 30-49 years to attend educational sessions about HPV screening. A subgroup of these participants was chosen randomly and questioned about demographic factors, healthcare utilization, previous cervical cancer screening, and HPV knowledge. Women then scheduled screening appointments at their public health clinics. Screening participants were adherent if they attended their scheduled appointment or rescheduled and were screened within 6 months. The association between non-adherence and demographic variables, medical history, history of cancer, sexual history, birth control methods, and screening barriers was assessed using Chi-square tests of significance and logistic regression.
  
  
  RESULTS
  All women (n = 409) enrolled in the study scheduled HPV screening appointments, and 88 % attended. Non-adherence was associated with a higher number of lifetime partners and being under-screened-defined as not having participated in cervical cancer screening within the previous 3 years (p = 0.03 and p = 0.04, respectively); 22.8 % of participants in this study were under-screened.
  
  
  CONCLUSIONS
  Adherence to cervical cancer screening after educational sessions was higher than expected, in part due to interactions with the community-based health promoters as well as the educational session itself. More effective recruitment methods targeted toward under-screened women are required.
authors.affiliation: Basic Health International, Colonia las Mercedes, Avenida los Espliegos #5, San Salvador, El Salvador. karlaalfaro.alfaro@gmail.com.
authors.forename: Karla M
authors.initials: KM
authors.lastname: Alfaro
authors.affiliation: Division of Cancer Epidemiology and Genetic, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA. gagej@mail.nih.gov.
authors.forename: Julia C
authors.initials: JC
authors.lastname: Gage
authors.affiliation: Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA. ajr84pitt@gmail.com.|Fulbright U.S. Student Program, U.S. Department of State, 1400 K Street NW, Suite 700, Washington, DC, 20005, USA. ajr84pitt@gmail.com.|Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Columbus, OH, 43210, USA. ajr84pitt@gmail.com.
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Rosenbaum
authors.affiliation: Basic Health International, Colonia las Mercedes, Avenida los Espliegos #5, San Salvador, El Salvador. lauren.ditzian@gmail.com.
authors.forename: Lauren R
authors.initials: LR
authors.lastname: Ditzian
authors.affiliation: Basic Health International, Colonia las Mercedes, Avenida los Espliegos #5, San Salvador, El Salvador. mauriciomaza@yahoo.com.
authors.forename: Mauricio
authors.initials: M
authors.lastname: Maza
authors.affiliation: Division of Preventive Medicine, University of Alabama at Birmingham, Medical Towers 621, 1717 11th Avenue South, Birmingham, AL, 35205, USA. scarinci@uab.edu.
authors.forename: Isabel C
authors.initials: IC
authors.lastname: Scarinci
authors.affiliation: Ministry of Health of El Salvador, Calle Arce, 827, San Salvador, El Salvador. mfarer@basichealth.org.
authors.forename: Esmeralda
authors.initials: E
authors.lastname: Miranda
authors.affiliation: Ministry of Health of El Salvador, Calle Arce, 827, San Salvador, El Salvador. mfarer@basichealth.org.
authors.forename: Sofia
authors.initials: S
authors.lastname: Villalta
authors.affiliation: Department of Pathology, University of Southern California, 2011 Zonal Ave., Los Angeles, CA, 90033, USA. Juan.Felix@med.usc.edu.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Felix
authors.affiliation: Global Cancer Initiative, 100 Radcliffe Drive, Chestertown, MD, 21620, USA. castle.philip@gmail.com.
authors.forename: Philip E
authors.initials: PE
authors.lastname: Castle
authors.affiliation: OB/GYN & Women's Health Institute, Cleveland Clinic 9500 Euclid Ave., Cleveland, OH, 44195, USA. mcremer@ccf.org.
authors.forename: Miriam L
authors.initials: ML
authors.lastname: Cremer
mesh_terms: D000328:Adult; D001071:Appointments and Schedules; D003906:Developing Countries; D055088:Early Detection of Cancer; D004544:El Salvador; D005260:Female; D006293:Health Promotion; D006801:Humans; D008403:Mass Screening; D008875:Middle Aged; D027383:Papillomaviridae; D010342:Patient Acceptance of Health Care; D012725:Sexual Behavior; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control* / Q000821:virology