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Title: Flipcharts: A CBPR Approach for Cervical Cancer Prevention and Early Detection Among Haitian Women


Abstract: Women in Haiti and throughout the Haitian Diaspora are disproportionately burdened by cervical cancer (1). This excess disease burden primarily reflects lack of access to cervical cancer screening, known to prevent disease onset and progression. Our Community-Based Participatory Research (CBPR) initiative aims to improve screening access through providing women the opportunity to self-sample for the Human Papillomavirus (HPV), the principal cause of cervical cancer. Self-sampling is increasingly recognized as an effective method for cervical cancer prevention, particularly in low-resource settings (2, 3). Members of Patnè en Aksyon (Partners in Action), a campus-community collaborative tasked to improve the health of Haitians in Little Haiti, Miami (4), guided the intervention design, which was subsequently adapted for use in Haiti in partnership with Zanmi Lasante/Partners in Health. Our intervention relies on the expertise of Community Health Workers, known as Ajan Fanm in Haitian Kreyol. The Ajan Fanm verbally deliver peer education about cervical cancer, the importance of early detection, and instruction for self-sampling while using a flipchart containing culturally salient images that reinforce key educational points. The flipchart is appropriate for use with adult Haitian women who have low literacy, both in Haiti and throughout the Diaspora, and in low-resource settings.


Type of Product: PDF document


Year Created: 2009


Date Published: 10/25/2010

Author Information

Corresponding Author
Erin Kobetz
University of Miami Miller School of Medicine
1120 NW 14th Street
Suite 1033
Miami, FL 33136
United States
p: 305.243.1360
ekobetz@med.miami.edu

Authors (listed in order of authorship):
Erin Kobetz
University of Miami Miller School of Medicine

Janelle Menard
University of Miami, Division of Cancer Control

Hannah Lipshultz
University of Miami Miller School of Medicine

Sarah Marsh
Partners in Health/Zanmi Lasante

Jenny Blanco
University of Miami Miller School of Medicine

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Biological Sciences, Humanities, Public Health, Social Work


What specific topics does your product address?

Access to health care, Cancer, Communicable diseases, Community assessment, Community engagement, Community health , Community-based education, Cultural competency , Global health , Health disparities, Health education , Health equity, Health services research, Partnership building , Prevention, Rural health, Social determinants of health, Women's health , Low Income Health, Community-based participatory research


Does your product focus on a specific population(s)?

Rural, Women, Haitian


What methodological approaches were used in the development of your product, or are discussed in your product?

Arts-informed methodologies, Community-academic partnership, Community-based participatory research , Focus group , Participatory evaluation, Qualitative research, Participant observation


What resource type(s) best describe(s) your product?

Manual/how to guide, Educational Flipchart


Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Women in Haiti and throughout the Haitian Diaspora are disproportionately burdened by cervical cancer (1). This excess disease burden primarily reflects lack of access to cervical cancer screening, known to prevent disease onset and progression. Our Community-Based Participatory Research (CBPR) initiative aims to improve screening access through providing women the opportunity to self-sample for the Human Papillomavirus (HPV), the principal cause of cervical cancer. Self-sampling is increasingly recognized as an effective method for cervical cancer prevention, particularly in low-resource settings (2, 3). Members of Patnè en Aksyon (Partners in Action), a campus-community collaborative tasked to improve the health of Haitians in Little Haiti, Miami (4), guided the intervention design, which was subsequently adapted for use in Haiti in partnership with Zanmi Lasante/Partners in Health. Our intervention relies on the expertise of Community Health Workers, known as Ajan Fanm in Haitian Kreyol. The Ajan Fanm verbally deliver peer education about cervical cancer, the importance of early detection, and instruction for self-sampling while using a flipchart containing culturally salient images that reinforce key educational points. The flipchart is appropriate for use with adult Haitian women who have low literacy, both in Haiti and throughout the Diaspora, and in low-resource settings.


2. What are the goals of the product?

The immediate goal of this flipchart is to effectively use visual education media in community-based settings for health promotion and education. Specific objectives for this goal are to: 1) increase women’s knowledge and awareness of HPV, and its role in cervical carcinogenesis; and, 2) effectively demonstrate how to self-sample for HPV. The long-term goals of this flipchart include: 1) To foster sustainable campus-community collaborations for projects designed to address cancer disparities; 2) To cultivate community ownership of the project, products, and outcomes; and, 3) To utilize culturally and linguistically meaningful visual educational tools to build health knowledge and self-efficacy among Haitian women. Collectively, these goals are intended to ultimately help attenuate cervical cancer disparities among Haitian women in Haiti and the United States Haitian Diaspora.


3. Who are the intended audiences or expected users of the product?

This flipchart is intended for use with adult women in Haiti and throughout the Haitian Diaspora, who are primarily monolingual Haitian Kreyol speakers and have low levels of health literacy. A standardized protocol is used to train lay, indigenous female Ajan Fanm to deliver and discuss the educational information provided in the flipchart. The flipchart is best suited for use with small groups in comfortable settings where women can openly discuss gynecological health.


4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

Indigenous Ajan Fanm are taught to use the flipchart using a standardized training manual that covers the basics of health communication, the female anatomy, HPV, cervical cancer, and screening strategies. The flipchart can be used in a wide variety of settings, including community-based clinics, individual households, and/or any other space that is sufficient for holding small groups. In educational sessions, the Ajan Fanm sits or stands closely with women participants while explaining the flipchart content in a largely didactic manner. Following the presentation, the Ajan Fanm encourages dialogue to ensure participant comprehension. The flipchart’s spiral bound format easily allows for the Ajan Fanm to return to specific images to aid in such discussions.


5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Our work is grounded in the principles of Community-Based Participatory Research (CBPR) (5, 6), and participatory adult learning (7). As such, our flipchart represents one product of an ongoing, community-academic partnership to attenuate cervical cancer disparities among ethnically Haitian women in Florida and in Haiti (4, 8). Haitian women experience an excess disease burden from cervical cancer. Based on cervical cancer mortality in Haiti, women in Haiti are estimated to have the highest age-adjusted incidence due to cervical cancer in the world (1). Such a disparity also affects Haitian women in the Diaspora, where Haitian immigrant women tend to have poorer cervical health (9-11). Multiple determinants contribute to this disparity, including structural factors such as a lack of available/accessible screening and timely follow-up; costly screening and subsequent medical care; and transportation/geographic barriers (9). Cultural factors may also contribute to poor health outcomes, specifically those associated with shared beliefs about illnesses as fundamentally symptomatic and an orientation to maintaining health that generally does not include participation in preventive screenings (9). Individual-level factors that may also affect women’s health outcomes include communication barriers owing to low literacy and/or low English proficiency. Literacy includes the specific dimension of health literacy, which is operationally defined as, "The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (12). Low health literacy results in poorer health outcomes for a multitude of illnesses, including cancer, as it impedes understanding of prevention and early detection options (13, 14). Haitian women face unique challenges frequently arising from a lack of educational opportunities and communication barriers. Haitian Kreyol is primarily a spoken language with a relatively recent standardized orthography (15). Thus, many people speak, but do not read, Haitian Kreyol, making print media educational tools much less effective. In the Diaspora, it is also often difficult for women to find Haitian Kreyol-speaking physicians when they do have access to health care. In consideration of these conditions, we created, in partnership with women from the focus communities, a cervical cancer educational flipchart tool that focuses on factors amenable to change, addressing the necessary literacy, language, and cultural dimensions of health promotion for cervical cancer prevention.


6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Lewis MJ. A Situational Analysis of Cervical Cancer in Latin America and the Caribbean. Washington, D.C.: Noncommunicable Diseases Unit, Pan American Health Organization; 2004.
2. Castle PE, Aftab A, Saint-Jean G, Mendez L. Detection of carcinogenic human papillomavirus in specimens collected with a novel self-sampling device. Journal of Clinical Microbiology 2006;44(6):2158-2159.
3. de Alba I, Anton-Culver H, Hubbell FA, Ziogas A, Hess JR, Bracho A, et al. Self-sampling for human papillomavirus in a community setting: feasibility in Hispanic women. Cancer Epidemiol Biomarkers Prev 2008;17(8):2163-8.
4. Kobetz E, Menard J, Barton B, Pierre L, Diem J, Auguste P. Patnè en Aksyon: Addressing cancer disparities in Little Haiti through research and social action. American Journal of Public Health 2009;99(7):1163-5.
5. Israel B, Schulz A, Parker E, Becker A, Allen A, Guzman R. Critical Issues in Developing and Following Community Based Participatory Research Principles. In: M M, N W, editors. Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass Publishers; 2003.
6. Minkler M, Wallerstein N. Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2003.
7. Freire P. Pedagogy of the Oppressed. New York: Continuum; 1970.
8. Kobetz E, Menard J, Barton B, Blanco J, Diem J, Pierre L, et al. CBPR in Little Haiti: challenges and lessons learned. Partners in Community Health Progress 2009;3(2):133-137.
9. Menard J, Kobetz E, Maldonado J, Barton B, Blanco J, Diem J. Barriers to cervical cancer screening among Haitian immigrant women in Little Haiti, Miami. Journal of Cancer Education, published OnlineFirst March 16, 2010. DOI: 10.1007/s13187-010-0089-7.
10. Kobetz E, Dunn Mendoza A, Menard J, Finney Rutten L, Diem J, Barton B, et al. One size does not fit all: differences in HPV knowledge between Haitian and African American women. Cancer Epidemiol Biomarkers Prev 2010;19(2):366-70.
11. Menard J, Kobetz E, Diem J, Lifleur M, Blanco J, Barton B. The sociocultural context of gynecological health among Haitian immigrant women in Florida: applying ethnographic methods to public health inquiry. Ethnicity & Health 2010;15(3):253-67.
12. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. In. 2nd ed. Washington, D.C.: U.S. Government Printing Office; 2000.
13. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. American Journal of Obstetrics & Gynecology 2002;186(5):938-43.
14. Meade CD, Menard JM, Martinez D, Calvo A. Impacting Health Disparities Through Community Outreach: Utilizing the CLEAN Look (Culture, Literacy, Education, Assessment, and Networking). Cancer Control 2007;14(1):70-77.
15. Stepick A. Pride Against Prejudice: Haitians in the United States. Boston: Allyn & Bacon; 1998.


7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

  • For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
  • For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
  • For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The flipchart represents one of several collaborative projects resulting from a campus-community partnership, known as Patnè en Aksyon, or Partners in Action, in Little Haiti, Miami, Florida. The overall partnership goal is to attenuate cervical cancer disparities among Haitian women in Florida using culturally and linguistically appropriate intervention strategies. Academic members of Patnè en Aksyon subsequently cultivated a partnership with Zanmi Lasante (Partners in Health) for cervical cancer control and prevention in Haiti. Zanmi Lasante (ZL) is a large, well-known non-governmental organization that provides health care services for more than a million people residing in two geographic regions of Haiti, with a strong focus on women’s health. ZL uses a community-based model to implement its educational interventions and clinical care, in which local people are hired and trained as Community Health Workers (accompagnateurs), and local Haitian doctors and nurses are hired to provide clinical care.

In Haiti, nearly half of all cancer deaths among women are due to cervical cancer (1), which is a highly preventable disease when women have unfettered access to screening and timely clinical care. In an effort to increase the availability of early detection for cervical cancer, we partnered with ZL to implement cervical self-sampling for HPV among women in Haiti receiving services from ZL. The Community Health Workers (CHWs), employed by ZL, felt strongly that this initiative necessitated visually-based educational tools to appropriately inform women about HPV, cervical cancer and self-sampling. The CHWs had successfully used a flipchart tool in previous educational outreach efforts to reduce HIV risk in Haiti, and thus nominated the use of a flipchart as an ideal strategy for informing their peers about HPV and cervical cancer.

In keeping with the principles of CBPR, and guided by the CHWs’ advice, the academic members of Patnè en Aksyon developed a strategy to create a flipchart that included gathering community input and advice about stylistic representations and how to best illustrate and discuss sensitive women’s health concepts. Our strategy also included: 1) conducting basic ethnography to better understand the socio-cultural context of women’s health beliefs and meanings assigned to gynecological health and illness; 2) reviewing examples of flipcharts in the published health literature; 3) developing flipchart educational content; and, 4) testing the draft flipchart in 6 focus groups of Haitian women participants prior to implementation in Haiti. Collectively, these methods allowed us to place women’s knowledge at the forefront of flipchart design in an effort to create a teaching tool that would be consonant with cultural, linguistic and literacy needs. These methods, discussed in detail in Question 8, generated a co-learning process for academic and community members involved with the flipchart development, in which academic researchers learned from the community how to appropriately convey and portray gynecological health information, and community members learned about cervical cancer etiology and early detection.


8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

With substantial community input, we developed a strategy to create a flipchart in consideration of learning preferences, cultural health beliefs and literacy levels. First, we approached the Patnè en Aksyon Community Advisory Board (CAB) to solicit members’ opinions and advice about the utility of a flipchart educational tool for health. CAB members strongly supported the use of such tools, especially in low-resource settings such as Haiti, and believed such a tool would effectively meet women’s literacy needs in both Haiti and in Diasporic communities. CAB members offered that flipchart illustrations should be similar to a popular Haitian folk artistic style known as l’art naïf, in order to increase visual appeal of the illustrations. Second, we used basic ethnographic methods, including observation, participant observation and informal interviews with key informants in Little Haiti, to understand women’s learning preferences and beliefs about gynecological health. Third, we reviewed published literature for examples of validated flipcharts designed for use in similar social and geographic contexts, including those produced by USAID and the Carter Center. We also evaluated cultural elements in Haitian art and photographs necessary to accurately represent Haitian women in the flipchart illustrations. Such elements included hairstyles, clothing, depicting women as figures of strength, an underlying sense of community, and background settings. Fourth, the academic project leader (Erin Kobetz, Ph.D., MPH) developed the flipchart’s educational content, which included basic information about female anatomy, cervical cancer, HPV and detailed instructions for using the POI/NIH HPV cervical self-sampling device. Another project member used watercolor paints to create the illustrations similar to l’art naïf artistic style. The illustrations of the self-sampler were adapted from the instruction manual that accompanied the device. Anatomical depictions were created in the most scientific yet least graphic way, in recognition of Haitian cultural norms that emphasize personal modesty.

Information learned from observations in the community of Little Haiti, from informal interviews with key informants, and from our review of existing flipchart tools used in health interventions informed the development of the first complete flipchart draft. The flipchart draft was then formally tested in six focus groups with Haitian women in three communities, two in Florida and one in Cange, Haiti. An academic researcher and an Ajan Fanm co-moderated the focus groups. The Ajan Fanm presented the flipchart intervention to the participants. Following the presentation, the moderators used a guide consisting of open-ended questions to elicit participants’ overall impression, cultural acceptability, ease of comprehension, and linguistic appropriateness of the flipchart. Participants were asked to evaluate the images for the message(s) they communicated, particularly those that they felt may be offensive or culturally inappropriate, and to provide suggestions for change. Participants were also asked to describe several key health-related terms, and to suggest alternatives or other appropriate phrases to describe these terms in Haitian Kreyol. These terms included cancer, cervical cancer, HPV, cervix, genital warts, self-sampler, and women’s health. Participant feedback prompted revisions, including additional explanatory description to be verbalized by the Ajan Fanm, changes/additions to some illustrations to improve message clarity, and in some cases, amendments to word choices in Haitian Kreyol to describe cervical cancer and HPV.

In conjuction with development of the flipchart’s educational content, the Project Leader developed a manual for training the Ajan Fanm, which served to standardize instruction in key topics including basic female anatomy; definitions of cervical cancer and HPV; an explanation of cervical cancer risks and the role of HPV in carcinogenesis; and, a discussion of prevention strategies, including the Pap test, self-sampling for HPV, and HPV vaccination. In addition to these topics, the training oriented the Ajan Fanm to the project’s overall goals and to the role expectations of each Ajan Fanm. Lastly, the manual outlined practical training for participant recruitment in keeping with study inclusion/exclusion criteria, delivering health education to women about cervical cancer and HPV using the flipchart, and teaching participants how to use the cervical self-sampler. In Haiti, the training took place in Cange at the Zanmi Lasante/Partners in Health Socio-medical complex over a period of 4 days, including breaks for meals and team building exercises. The exercises, and the training itself, were facilitated by members of the ZL/PIH team, and when appropriate, University faculty given the language barriers. The training was based on the principles of participatory learning and, as such, included significant role playing and other non-didactic educational activities/strategies for instructing the CHWs about HPV, cervical cancer, and self-sampling.


9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

We did not conduct a formal evaluation of the flipchart or CHW educational efforts, more generally. This was not the intent of our program, which was focused more broadly on increasing access to cervical cancer screening and examining the acceptability of self-sampling among age-eligible women living in Haiti’s Central Plateau. While the setting in which this intervention was delivered precludes a systematic, formal evaluation of participant learning, feedback from the Ajan Fanm and clinical partners at ZL/PIH indicates that the flipchart format resonated strongly with women’s learning preferences, and that such a program has helped to fill important gaps in women’s understanding of cervical cancer. Our partners in Haiti explained that the women they have reached have shared with them how much they learned through their interactions with the CHWs and that such information shared appears to be helping women make informed decisions about their health and options for prevention.

Apart from the informal observations of our partners, the high percentage of cervical samples that were acceptable for laboratory HPV testing may serve as a measure of how well women learned health information in this intervention, given that women performed the self-sampling by themselves in private. Preliminary data indicate that 243 Haitian women have self-sampled. To date, 107 samples have been processed in the lab, 100 samples have yielded results, and 7 samples had an insufficient cell quantity to yield results (6.5%). Of the 100 samples with results, 17 were HPV positive (17%), and 83 were HPV negative (83%). Currently, 119 samples are in the lab for testing, and cervical samples are being collected daily in Haiti. While such evaluation is underway, this educational tool contributes to an expanding field of community-competent health education, through the involvement of the community in the flipchart’s development and subsequent use.

The educational content and imagery were developed in partnership with Haitian women to ensure maximum effectiveness of this tool. The flipchart has also contributed to community capacity-building by creating opportunities for local women to be hired and trained as Ajan Fanm to present the information in the flipchart. Importantly, this learning tool meets critical literacy needs of Haitian women through visual depictions that portray key women’s health concepts in culturally meaningful ways. This community-based learning format, which brings health education to community settings, and couples verbal explanation by Ajan Fanm with culturally salient imagery, helps to address knowledge and service access barriers. Our partners from ZL in Haiti have indicated that the intervention has been very well received in Haiti, as evidenced by the number of women actively taking part in group education sessions, the high rate of cervical self-samples acceptable for HPV testing, and the requests for additional visual media materials. Further, in spite of the myriad health problems arising nationwide in Haiti following the massive earthquake, the Ajan Fanm and ZL partners continue to make cervical cancer and women’s gynecological health a strong priority. In particular, the Ajan Fanm have played an integral role in framing how this intervention may move forward and in providing ideas for improving strategies for intervention delivery and expansion. We anticipate that the flipchart, in its current form or modified, will also be a very useful tool for expanded use among low-literacy Haitian immigrant women in Florida.


10. Please describe why you chose the presentation format you did.

With the guidance and suggestions of community members, we chose the flipchart presentation format as an ideal medium through which to deliver cervical cancer education and self-screening instruction in order to meet Haitian women’s literacy needs and learning preferences. Women in rural Haiti have fewer educational opportunities and, consequently, lower literacy levels. The illustrations, which were created in the likeness of a popular Haitian folk artistic style, portray the educational points verbalized in Haitian Kreyol by the Ajan Fanm. Due to the personal nature of gynecological health, women deliver the educational points and instruction for using the self-sampler, creating a more comfortable space for questions and open dialogue with women participants. The flipchart is also a practical, inexpensive tool for use in settings where access to electricity is limited or sporadic, such as rural Haiti. Collectively, these conditions influenced our choice of the flipchart format.


11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

Our flipchart’s greatest strength is reflected in its development process. We used CBPR methods to guide its development, implementation and current ongoing evaluation. Such a process strengthens the product’s content and presentation validity among the women who take part in the educational sessions. The words chosen to explain women’s health concepts and self-screening, and the images created to depict these concepts, were developed with critical input from Haitian women focus group participants. This process helped to ensure that complicated gynecological health concepts were accurately conveyed. Another strength of this tool is its delivery in community-based settings. Populations with limited physical/geographic proximity to language- and literacy-appropriate health information can benefit from a portable educational tool that can be used in a variety of community spaces, including homes, churches and community-based clinical settings.

The flipchart has also resulted in measurable benefits for community capacity building, through hiring and training women indigenous to the community as Ajan Fanm. Women are provided earning and skill-building opportunities, and they are connected with preventive health services that they may promote to other women throughout rural Haiti.

The flipchart is limited to use in small group settings. While fewer women are reached at any one given point in time, a smaller group creates the intimacy and comfort level necessary to encourage open dialogue about female anatomy, gynecological health and cervical cancer. Thus, for wider reach and impact, it is imperative to hold multiple educational sessions, lead by several Ajan Fanm.

Further, given our goal to formally assess women’s acceptability of the cervical self-sampler, we obtained informed consent for women to answer a questionnaire with items assessing acceptability and HPV risk. This aspect of evaluating our intervention was not aligned with the expertise or interest of the Ajan Fanm, whose experience was far more focused on delivery of health information. As a result, we are modifying this aspect of our program to reflect their input and to ensure that it is aligned with their natural helping tendencies, including simplifying informed consent and truncating the questionnaire. We are also modifying the flipchart usage based on feedback from the Ajan Fanm, who indicated that women expressed the need to have more time for questions and discussion about early detection of cervical cancer, even among women who are not age-eligible for screening.


12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

This product is one outcome of a campus-community collaboration known as Patnè en Aksyon (Partners in Action). This partnership began in 2004 and has resulted in numerous projects aimed at addressing cancer disparities in Little Haiti, Miami. Recently, our cervical cancer control efforts expanded in partnership with Zanmi Lasante/Partners in Health, based in Haiti. The flipchart was developed using CBPR methods, including six focus groups conducted in three sites (2 in Florida, 1 in Haiti), which allowed for substantial input from Haitian women participants. In Florida, we partnered with two community-based organizations (CBOs) with a strong history of reaching Haitians with health and social services to recruit focus group participants and hold focus groups at their venues. These CBOs included the Center for Haitian Studies, Health & Human Services, Inc., in Little Haiti, Miami, and the Center for Multicultural Wellness & Prevention, Inc., in Orlando. In Haiti, the focus groups were conducted at the ZL/PIH Socio-Medical Complex. All participants’ opinions and suggestions were seriously considered, and this feedback guided important amendments made to the flipchart prior to its implementation in Cange, Haiti. The collaborative nature of Patnè en Aksyon, and the guiding principles of CBPR, serve to ensure that equal voice is given to all contributors to our projects, including that which produced the flipchart. The University of Miami Institutional Review Board, and the Patnè en Aksyon advisory board approved the research protocols for the focus groups and for the ongoing educational and cervical self-screening program in Haiti. We anticipate that we will submit manuscripts to academic journals describing various aspects of the flipchart, its development and evaluation. All collaborators will be recognized in such submissions through written acknowledgments and shared authorship. All collaborators are aware of, and support, this submission to CES4Health.info.