Evaluation of Women's Empowerment in a Community-Based Human Papillomavirus Self-Sampling Social Entrepreneurship Program (Hope Project) in Peru: A Mixed-Method Study.

Introduction: Understanding community women's relational and financial empowerment in social entrepreneurship could be the key to scaling up community-based human papillomavirus (HPV) self-sampling programs in low- and middle-income countries. The Hope Project, social entrepreneurship in Peru, trains women (Hope Ladies) to promote HPV self-sampling among other women in their communities. This study aims to evaluate the Hope Ladies' relational and financial empowerment after participating in the program. Materials and Methods: We evaluated the Hope Ladies' experiences of empowerment in social entrepreneurship using a parallel convergent mixed methods design. The Hope Ladies participated in semi-structured in-depth interviews (n = 20) and an eight-questions five-point Likert scale survey that evaluated their relational (n = 19)/financial (n = 17) empowerment. The interview and the survey questions were developed using three empowerment frameworks: Kabeer's conceptual framework, International Center for Research on Women's economic empowerment indicators, and the Relational Leadership Theory. Deductive content analysis was used to evaluate the interviews with pre-determined codes and categories of empowerment. Descriptive statistics were used to analyze the survey results. Qualitative and quantitative data were integrated through a cross-case comparison of emergent themes and corresponding survey responses during the results interpretation. Results: All Hope Ladies reported experiencing increased empowerment in social entrepreneurship. Interviews: The women reported challenges and improvement in three categories of empowerment: (1) resources (balancing between household and Hope Lady roles, recognition from the community as a resource, camaraderie with other Hope Ladies); (2) agency (increased knowledge about reproductive health, improved confidence to express themselves, and ability to speak out against male-dominant culture); and (3) achievement (increased economic assets, improved ability to make financial decisions, and widened social network and capital, and technology skills development). Survey: All (100%) agreed/totally agreed an increase in social contacts, increased unaccompanied visits to a healthcare provider (86%), improved confidence in discussing reproductive topics (100%), improved ability to make household decisions about money (57% pre-intervention vs. 92% post-intervention). Conclusions: The Hope Ladies reported improved relational and financial empowerment through participating in community-based social entrepreneurship. Future studies are needed to elucidate the relationship between empowerment and worker retention/performance to inform the scale-up of HPV self-sampling social entrepreneurship programs.

Cost of community-based human papillomavirus self-sampling in Peru: A micro-costing study.

Background: Cost data of human papillomavirus (HPV) self-sampling programs from low-and-middle-income countries is limited. We estimated the total and unit costs associated with the Hope Project, a community-based HPV self-sampling social entrepreneurship in Peru. Methods: We conducted a micro-costing analysis from the program perspective to determine the unit costs of (1) recruitment/training of community women (Hope Ladies); (2) Hope Ladies distributing HPV self-sampling kits in their communities and the laboratory testing; and (3) Hope Ladies linking screened women with follow-up care. A procedural manual was used to identify the program's activities. A structured questionnaire and in-depth interviews were conducted with administrators to estimate the resource/time associated with activities. We obtained unit costs for each input previously identified from budgets and expenditure reports. Findings: From November 2018 to March 2020, the program recruited and trained 62 Hope Ladies who distributed 4,882 HPV self-sampling kits in their communities. Of the screened women, 586 (12%) tested HPV positive. The annual cost per Hope Lady recruited/trained was $147·51 (2018 USD). The cost per HPV self-sampling kit distributed/tested was $45·39, the cost per woman followed up with results was $55·64, and the cost per HPV-positive woman identified was $378·14. Personnel and laboratory costs represented 56·1% and 24·7% of the total programmatic cost, respectively. Interpretation: Our findings indicate that implementation of a community-based HPV self-sampling has competitive prices, which increases its likelihood to be feasible in Peru. Further economic evaluation is needed to quantify the incremental benefits of HPV self-sampling compared to more established options such as Pap tests. Funding: Thomas Francis Jr. Fellowship provided funding for data collection. The Hope Project was funded by grants from Grand Challenges Canada (TTS-1812-21131), Uniting for Health Innovation, Global Initiative Against HPV and Cervical Cancer, University of Manitoba, and the John E. Fogarty International Center (5D43TW009375-05).