All 20 randomly invited Hope Ladies agreed to participate in the study, and the interviews were scheduled for early March 2020. Overall, the 20 Hope Ladies participated in the individual in-depth interviews. However, because of unforeseen logistical challenges and sudden country lockdown due to the COVID-19 pandemic during the week of the data collection, some participants were rescheduled and completed the financial (n=10), and relational empowerment (n=5) surveys at a later date in June 2021 virtually. Ultimately, 19 women completed the relational empowerment survey, and 17 women completed the financial empowerment survey completely, from which the analysis was conducted.
The Hope Ladies’ ages ranged from 32 to 64, with a median age of 45 years old, lived in the Ventanilla region for a median of 20 years (range 10-37 years), and had been involved with the Hope Project a median of 9 months (range 1 to 12 months) (Table 1). 7 (35%) were born in the Andean region, 11 (55%) in the coastal region, and 1 (5%) in the Amazon region. The participants had sold a median of 151 HPV self-sampling kits, with a median profit of 23.50 USD per month (Range: 7.20 to 72.80 USD).
In Table 2, we present the results of the relational and financial surveys. The summary of deductive content analysis of the in-depth interviews is available in the supplementary material with salient quotes from the participants. We present the results organized according to the conceptual framework presented in Figure 1. The survey data has been integrated with the qualitative data with illustrative quotes from the in-depth interviews.
Resources could be defined as those conditions that enhance the ability to exercise choice (23). The Hope Ladies described the challenge of managing their roles within the household and working as a Hope Lady and the benefit of peer support within the Hope Project, as well as being recognized as a resource for women's reproductive health in their communities.
Gender norms and roles within the household
Maintaining roles within the household and working as a Hope Lady: The majority of the Hope Ladies (n=15, 75%) mentioned during the interviews that it is difficult for them to manage their time to sell HPV self-sampling kits in their communities due to their various roles in their households, such as childrearing and caregiving. One stated, “I have a baby. When she grows a little more, I don't think I will have any obstacles with the Hope Project,” (Hope Lady, age 35), and another stated, “I have my mother-in-law in my care. She needs me to take care of her [...] because she cannot get out of bed. I go [out to sell the kits], but with the thought, 'what if she suddenly falls out of bed,' or I do not know she will urinate on herself. Sometimes I wonder, ‘Should I continue [to work as a Hope Lady] or not?’ and sometimes I stop [selling the kits]. But my friends [other Hope Ladies] tell me, ‘Don't stop, keep going for us.’” (Hope Lady, age 33). Another stated, “It's definitely not easy [...] it is a matter of organizing, it is a matter of habit, it is a matter of accustoming the family. It has its consequences, but it is possible to balance.” (Hope Lady, age 33). In contrast, others found it easy or manageable to organize their time. For example, one mentioned, "It's not difficult for me [to manage my time] because the issue here is to organize ourselves. If we organize ourselves, everything works out for us." (Hope Lady, age 45). Another emphasized the convenience of setting their own schedule saying, “Without having to have an obligatory schedule, in my free time I can go to work myself.” (Hope Lady, age 33).
Relationships at the community-level as the collective identity of Hope Ladies
Hope Ladies as a resource for the communities: In the relational empowerment survey, all participants responded “agree/totally agree” (n=19, 100%) to the question, “would you say that you have been able to help other women in moments of need since the beginning of your Hope Lady journey?” (Table 2). Half of the Hope Ladies interviewed (n=10, 50%) reported being recognized for their knowledge about cervical cancer in their communities and said, “They [the community women] talk to me more because you know in the hospital, they [the doctors] will hardly talk to them like we [Hope Ladies] talk to them.” (Hope Lady, age 45).
The camaraderie with other Hope Ladies: Nearly half (n=9, 45%) of the Hope Ladies commented on enjoying the peer support with other Hope Ladies and stated collaborating with other colleagues helped sell their kits. One said, “We would agree with other colleagues [Hope Ladies], and we would go out in a group because it is less tedious [than] when you are alone." (Hope Lady, age 64). Another person commented they look forward to the growth of the Hope Project, saying, “we are working with the Cayetano [University], so that [the Hope Project] grows and we can amplify the good work.” (Hope Lady, age 54).
Agency is defined as the capability to define one’s goal and act upon it (23). The Hope Ladies reported an increased sense of confidence and efficacy in themselves stemming from increased knowledge about reproductive health and improved communication ability and express themselves. They also discussed changes in behaviors, values, attitudes, and ideologies, such as advocating for their clients (other community women) to make autonomous decisions about HPV self-sampling against male-dominant culture (machismo).
Individual-level self-confidence and self-efficacy
Improved self-confidence and ability to communicate and express thoughts: All participants agreed (n=8, 42%) or totally agreed (n=11, 58%) in the relational empowerment survey that they felt more confident than before working as a Hope Lady because they learned about the female reproductive health system (Table 2). One person mentioned, “If it weren’t for this [the Hope Project], I wouldn’t even have taken the test,” (Hope Lady, age 44). More than half (n=12, 60%) of the participants reported improved communication abilities to express themselves. One reported, “It has helped me to have more confidence in words, that is, in being able to express myself with confidence what I am talking about.” (Hope Lady, age 33). Another emphasized the importance of ongoing support and training by the Hope Project to her and said, “I have lost the shame of communicating with people, because before I was not capable. When I started, I was very shy, but now I have enough skills. I have acquired that with [Hope Project] because of the training that they also give us. They support us in everything that we do, we also consult with them.” (Hope Lady, age 46).
Increased knowledge and self-efficacy: All (n=20, 100%) of the Hope Ladies said the increased knowledge and education about cervical cancer helped them to make informed decision-making for themselves, as well as other community women. 53% (n=10) agreed, and 37% (n=7) totally agreed that they have been able to increase unaccompanied visits to a healthcare provider to meet their personal needs since the beginning of your job as a Hope Lady?” One stated, "It has empowered me, and I have gained a lot of experience […] It taught me to express myself, to reach the families who are the most in need, and I saw that there is a lot of need in the communities that I have visited, and others thank you and tell you, 'Thanks for coming! Thank you for remembering me!' And all that makes your self-esteem rise, and you have more desire to continue working, for them, for them more than anything." (Hope Lady, age 47).
Evolving social order and change in relational dynamics
Advocating for women against male-dominant culture: Almost all (n=18, 90%) of the Hope Ladies mentioned male-dominant culture (machismo) in the households as a barrier to selling the HPV self-sampling kits and stated they advocate for community women to make autonomous decisions about their bodies by educating them and sometimes their husbands. A few (n=3, 15%) Hope Ladies reported clients who buy the HPV self-sampling kits in secret, without informing their husbands. One said, "We are not talking about the test anymore; we talked and encountered different problems. We are like a “heart” doctor. They already believe us [heart] doctors, because they ask us different things. We try to lift the woman so that they are not left saying, 'Oh, I'm going to ask my husband's permission!'" (Hope Lady, age 33). One person reported, "Women are well-trodden […] I say to them, ‘Who is the one who is going to show their body [to the doctor]? Who is the one who is going to get sick? Your husband or you?’[…] There are cultural barriers […] because the liberation of women is also being imposed!” (Hope Lady, age 64).
The Hope Ladies identified the Hope Project as a source of advocacy against the male-dominant culture, saying, "We help them so that they can become aware that the decision is in themselves, and that we do not depend on anyone. We say, 'We have come alone, and we are going to leave alone, so each one is the owner of what to do and what decisions to make.' And that is what I have learned with Hope Project." (Hope Lady, age 46). Another person said, “The empowerment that [the Hope Project] brings to us, that other institutions cannot, is women’s self-realization, their power to decide themselves, not to ask their partner.” (Hope Lady, age 48). Although the interviewers did not solicit information about domestic violence, a quarter of all participants (n=5, 25%) mentioned their clients shared that they sometimes experience it.
Achievement can be seen as the outcome of the resources and agency (23). The Hope Ladies reported an increased sense of financial autonomy and expanded social network since joining the Hope Project.
Control over assets
Increased economic assets: All (n=20, 100%) participants reported that the supplemental income from selling HPV self-sampling kits was economically helpful. One participant responded, “Of course, it has helped me a lot […] It helps me for my children's bus fares, which is daily for school.” (Hope Lady, age 45). Another stated, “Yes, it helps [financially]. It is a job that helps you financially and that you are also helping other people, other women.” (Hope Lady, age 51).
Improved financial autonomy: Most participants of the financial empowerment survey (16 of 17, 94%) reported that currently, they "always" decide on how to money in their household (Table 2). In contrast, when asked the same question before starting the Hope project, 41% (7 of 17) responded "always." In the individual interviews, the change in the ability to make financial decisions since working as a Hope Lady was more subtle. One participant who is a single-parent stated, “I'm the one who works. I am a mother and father, I have a daughter, and I am the one who says how much money comes into my house and how much I am going to spend. I try to balance what is my priority." (Hope Lady, age 47). Another stated, “Although I don't [work], I have always tried to solve all the house expenses. [My husband] is the one who contributes.” (Hope Lady, age 33).
Relationship as an outcome
Widened social network and gaining technology skills: In the relational empowerment survey, all participants responded either “agree” (n=3, 16%) or “totally agree” (n=16, 84%) that the number of social contacts within and outside the family has increased since working as a Hope Lady (Table 2). One stated, “They [the community women] comment on the program and they look for us, and they call us about this topic [of HPV self-sampling]. They call us, they leave our numbers, and other people who have never met call us, and you get to know more people.” (Hope Lady, age 45).
In relation to the widened social network, technology skills development emerged as a significant achievement. Many mentioned they had no to limited experience with social media or cell phones prior to joining the Hope Project. One stated, “I didn't know how to use [a touchscreen phone] at all. And when I joined the Hope Project, it was practically indispensable…[the project members] themselves have taught me to use it, they have taught me to enter the page, to enter the data […] I have learned everything about technology with the Hope Project, because before I didn't even care to pick up a phone, but now I do.” (Hope Lady, age 46). Another stated, “Social networks...the cell phone for me was nothing more like the phone that you go and answer, nothing at all! Now I know, well, I chat everything.” (Hope Lady, age 33).
Empowerment as the Mechanism of Action
We developed a causal pathway model for the Hope Project based on the mixed-methods findings (Figure 2). Empowerment was evident as the predominant causal mechanism to increase HPV self-sampling kit sales and cervical cancer screening in the Hope Project. In this model, the implementation strategy of microfinancing and peer-education operates through the process of Hope Ladies' empowerment to achieve the proximal and distal outcomes. The individual and collective improvement of resources, agency, and achievement, necessary for the mechanism of empowerment to be activated. The perceived value of financial and relational incentive emerged as cognitive moderators, whereas logistical and sociocultural barriers to HPV self-sampling in the community, such as male-dominant culture, were organizational moderators. As the pre-condition for the proximal outcome, the Hope Ladies must have the financial and logistical means of buying and selling HPV self-sampling kits for the sales to increase.