had CUC and died as a result. In addition, because no clear
distinction was made regarding limitations for each level of
prevention, it was decided to group all responses related to
preventive activity into one category regardless of the level
to which they belonged. Other results from the cultural
domain are summarized in Fig. 1.
Although the objective of this intervention is focused on
a psychological element of behavior and not behavior in
general, it is worth noting that after the intervention, 5 new
Paps were registered (1 in the intervention group), all from
women who previously had experience with the test and 3
of whom had let 3 years pass since their last Pap. In
addition, a member of the intervention group tried to have a
Pap at the Santa Marı´a health clinic (the last one had been
done 7 years earlier) but was treated poorly and decided to
not do the test after all. Also found was an increase in
knowledge in the intervention group after the intervention,
with 85 % reporting that not all women die of CUC, that is,
they knew it is an illness that can be treated.
Discussion
The most important results of this study are the positive
changes observed at the individual as well as community
levels. At the individual level, self-efficacy showed a significant
increase in the intervention group globally. While
the increase was less than that reported by Fernandez et al.
[20] since the present intervention was multilevel [30], it
resulted in positive effects being reinforced by its community
focus. Notable changes were demonstrated at the
community level, suggesting that the women perceive a
more favorable context for accessing the Pap test, such as
two of the three main perceived barriers corresponding to
the environment and being more easily modified than when
an individual factor is involved (such as the variable
‘‘embarrassment’’). The results at this level differ from
those reported by Byrd et al. [23] which refer more to
conditions pertaining to the subject. We also have lack of
time as a reality in this group of women since, although not
formally, many combine their work at home with some
work activity outside the home. Nevertheless, this may also
be related to a cultural issue in which time is not managed
in such a way as to provide space for caring for one’s
health (especially taking preventive actions). With respect
to the test conditions, this is a field that is already established,
in which the women cannot intervene, but it being
perceived as a barrier can indicate a lack of sensitivity
towards the women regarding the procedure. Furthermore,
although it is not possible to modify the requirements andconditions of the test, the staff involved in taking the
sample can be trained to carry out the test in such a way
that places the patient’s comfort before their own, such as
having equipment that is appropriate to the physical characteristics
of each woman (variety of sizes of speculums or
adjustable leg supports). In terms of social rejection, there
is a mixed set of beliefs and cultural elements both individual
and group whose modification requires another type
of intervention. It is worth noting that it was easier for the
participants to identify obstacles to undergoing a Pap when
they were asked impersonal questions (such as the freelists).
This may be due to not wanting to show that they
have limitations or they had not previously thought about
this topic.
With regard to the facilitators, consistencies were
observed with those reported by Byrd et al. [23] in terms of
those that can decrease the strength of some of the barriers,
even culturally engrained barriers. These include the need
for female staff to perform the test and, in particular,
comprehensive information/awareness-raising for professionals,
women and the social environment as to the Pap’s
usefulness, the procedure and test results.
When asking about the usefulness of the Pap, only one of
the participants referred to the term ‘‘prevention of cervical
uterine cancer,’’ but all alluded to the female reproductive
apparatus as involved in this type of disease, using terms
such as ‘‘cancer of the vagina,’’ ‘‘cancer of the womb’’ or
‘‘uterine cancer.’’ Though this reflects more of a lack of
knowledge about the appropriate terminology than about the
disease itself, by not knowing the term, knowledge about the
test needed to detect the disease is to a certain extent lacking
and therefore so is knowledge about the particularities of the
test (frequency, age range, etc.). On the other hand, having
increased their knowledge about a woman with CUC not
necessarily dying from this cause suggests that the idea of
prevention was impressed upon them.
With respect to the test, it is notable that an adequate
frequency was observed in only a few cases, which reflects
the important role health services plays in health education,
that is, it is not enough to perform the test but it must also
be performed on a regular basis as indicated to preserve the
protective effect of the test [11]. Two of the women who
reported never having had a Pap had a secondary education,
while the rest had an elementary education. This is
consistent with the relationship found between use of the
Pap and education level [39, 40].
Some of the changes achieved by this intervention were
extended to the control group. Elements are lacking to
conclusively explain the reason for these changes since there
was no control for confounding variables. Nevertheless,
several hypotheses exist: (a) the instruments used involved
women reflecting on undergoing a Pap and/or the risk of
contracting CUC, (b) there was exposure to some type of
talk by the health clinic or another agent and (c) socialization
of the information occurred on the part of the women in
the intervention group with those in the control group.
The interpretation of the findings presented should take
into account the limitations. The participating women have
very specific characteristics, therefore the results cannot be
generalized to all Mexican women. Nevertheless, since the
intervention and the results are very similar to those
observed among women in northern Mexico [20], it is
possible that similar interventions incorporating the cultural
particularities of each community could be successfully
implemented in different contexts in the country. The
size of the sample was small but sufficient to detect
changes in self-efficacy. The duration of the changes
generated is unknown, therefore they should not be
extrapolated to longer periods of time. Although changes in
the cultural domain suggest more stable changes, this
should be verified with studies having longer follow-up
periods. In addition, it is possible that several variables not
measured or incorporated in the analysis confounded the
observed changes.
In conclusion, this study demonstrated the importance of
multilevel, culturally adapted, comprehensive interventions
to achieving successful results in the target populations. It
was evident that significant changes can be attained in
participating women in a short period of time. Nevertheless,
future experiences should assure beforehand that
health services provide effective and satisfactory care,
since an increased demand in the absence of an adequate
response by the health system can produce effects contrary
to those desired, such as the population considering
accessing such services to be useless.