Mixed blessings: cervical cancer screening in Recife, Brazil

Emelda’s Story: Applying Ethnographic Insights to Cultural Assessment and Cervical Cancer Control

This article builds a bridge between cultural research and clinical practice by applying insights from an ethnographic study of cervical cancer in Iquitos, Peru, to a cervical cancer focused cultural assessment tool and teaching guide for use with immigrant patients. This application is grounded in Campinha-Bacote’s model of cultural competency. Ethnographic research is recommended as a source of knowledge from which insights can be drawn to build assessment skill in cross-cultural clinical encounters—insights into asking the right questions.

Imagined anatomy and other lessons from learner verification interviews with Mexican immigrant women

OBJECTIVE

To identify clearer, learner-preferred, educational approaches for aspects of cervical cancer education found to be difficult to understand for low-literacy, Mexican, immigrant women.

SETTING

Kansas City, Kansas; Garden City, Kansas; San Antonio, Texas.

PARTICIPANTS

Forty-five Mexican immigrant women in the United States for 5 years or less, ninth grade education or less, and predominantly Spanish speaking.

METHODS

Interviews were conducted to evaluate preference and best comprehension among options for specific cervical cancer educational elements, including reproductive system terminology, the purpose of Pap tests and meaning of results, Human Papilloma Virus (HPV), and illustrations of anatomy and Pap procedure.

RESULTS

We identified terminology, translation, content, and illustrations preferred by participants and areas of inadequate existing knowledge needed for comprehension of concepts being taught. Analogies, illustrations, and introduction of medical terms in conjunction with equivalent common Spanish terms were effective ways of building bridges from existing knowledge to new knowledge. Participants desired detailed information and shared new information with others

CONCLUSION

We learned the importance of assessing patients' existing body knowledge. The detail desired by participants challenged common simplification approaches to teaching low-literacy learners. Participant willingness to share information challenged ideas of cultural taboo. Results provide evidence for more effective delivery of women's health education and call for further research on best approaches to teaching low-literacy learners.

Prioritizing prevention: culture, context, and cervical cancer screening among Vietnamese American women

Few studies have investigated what Vietnamese American women believe about the Pap smear or how those beliefs might influence behavior. Thirty-one Vietnamese American women recruited through snowball sampling were interviewed about their beliefs regarding the Pap smear. Interviews were qualitatively analyzed using a theoretically informed, inductive approach. The women interviewed emphasized the importance of primary prevention of disease through culturally-informed personal health regimens. They were also largely unfamiliar with the Pap smear, but believed that gynecological exams in general were effective and necessary for disease detection. Finally, when access to gynecological care was difficult, women's faith in their own preventive behaviors helped alleviate their concerns over lack of care. While culturally associated beliefs do not simply "cause" Vietnamese American women to seek or avoid Pap smears, they do influence screening behaviors to a greater or lesser degree, depending on other contextual variables.

Im perfect tools for a difficult job: colposcopy, 'colpocytology' and screening for cervical cancer in Brazil

The quasi-totality of social scientists who studied screening for cervical tumours identified such screening with a single method: the Pap smear (exfoliative cytology). This article explains that this method was not valid everywhere. The history of screening for cervical cancer in Brazil displays an alternative method for detecting cervical malignancies: a direct observation of the cervix with a specific instrument--the colposcope. The development of this method in Brazil in the 1940s and 1950s reflected a complex mixture of professional interests, government policies, and regional, local and charitable initiatives. While the use of colposcopy for cervical tumour screening was phased out in the 1970s and 1980s, the long lifespan and widespread diffusion of this method illuminates the irreducible contingency of specific developments in science, technology and medicine. Seen from the vantage point of Brazil, the Western model for preventing cervical malignancies no longer appears self-evident Alternative choices might have led to the development of different material and visual cultures of medicine, stimulated different patterns of medical specialization and division of medical labour, produced different links between malignancies, women, gynaecologists, epidemiologists and public health experts, and shaped different health policies.

The HPV Cellular Transactivator Brn-3a Can Be Used to Predict Cervical Adenocarcinoma and Squamous Carcinoma Precancer Lesions in the Developed and Developing Worlds

The cellular transactivator Brn-3a has previously been shown to be expressed at elevated levels in the cervix of women with squamous cell carcinoma of the cervix (SCC) and to activate the expression of HPV E6 mRNA. In this study, we show that common and rare cervical precancer lesions, including those of adenocarcinoma (AC), which are usually difficult to diagnose using classical procedures, also expressed high levels of Brn-3a and can be diagnosed by measuring the levels of Brn-3a and E6 mRNAs.

Detection of cervical abnormalities in a developing country using measurement of Brn-3a in cervical smears

OBJECTIVE

We have previously shown that Brn-3a is elevated in biopsies from women in the United Kingdom with high grade cervical neoplasia, and that it specifically trans-activates the HPV URR in vitro and in vivo. The aim of this study is to establish the relationship of Brn-3a, HPV E6 and pathological diagnosis in cervical smear from women in a developing country with a high prevalence of cervical disease. This is a follow-up of our previous work in which for the first time Brn-3a and E6 levels in cervical smears from women in United Kingdom were shown to correlate with the histological diagnosis of cervical neoplasia and were even better in predicting underlying pre-malignant disease than conventional procedures.

METHOD

Cervical smears from 295 women with cervical abnormalities attending gynecological clinics in Brazil were used to make RNA. The mRNA levels of Brn-3a and HPV E6 were measured and the data obtained were used to establish the relationship between Brn-3a and the histological diagnosis.

RESULTS

The cellular transcription factor Brn-3a was readily measured in cervical smears from the Brazilian population. Its presence was shown to be frequently associated with the expression of HPV E6. The measured level of Brn-3a parallels the severity of the cervical ailment and predicts the pathological categories.

CONCLUSIONS

The ability of Brn-3a to predict for cervical ailments is independent to the geographical characteristics of the population, and hence it could be used routinely as an adjunct to colposcopy and pathological diagnosis in developing and developed countries.

Influence of beliefs about cervical cancer etiology on Pap smear use among Latina immigrants

OBJECTIVE

To assess Latina immigrants' beliefs about the role of sexual activities in cervical cancer etiology and the impact of the beliefs on Papanicolaou (Pap) smear use. Previous research has found that Latinas, particularly immigrants, believe that cervical cancer is related to 'unwise' sexual activities; however, their beliefs about the nature of the relationship are unclear.

DESIGN

We conducted semi-structured face-to-face interviews with a non-probability purposive sample of 20 Mexican immigrant women who resided in Orange County, California regarding their beliefs about risk factors for cervical cancer and Pap smear use. We used qualitative content analysis to identify major themes. Three investigators independently reviewed transcripts of the audio-taped interviews to identify themes and came to a consensus about them.

RESULTS

The women had a mean age of 39 years and had resided in the USA for an average of 16.3 years. We identified several themes. The majority of respondents had limited knowledge about cervical cancer and no knowledge about human papillomavirus (HPV); believed that infections caused by physical trauma, certain sexual activities, and poor hygiene caused cervical cancer; believed that they only needed a Pap smear if they developed symptoms of a pelvic infection; and felt that women who engaged in 'unwise' sexual behaviors, in particular, should receive regular Pap smear exams.

CONCLUSION

The results suggest that culturally related beliefs about the etiology of cervical cancer play a role in the decision to obtain Pap smears for Latina immigrants. The findings may help to explain why researchers have found Latino ethnicity to be an independent predictor of Pap smear use. They also suggest that programs designed to improve cervical cancer screening, particularly among Latina immigrants, should stress the nature of HPV transmission, its role in the etiology of cervical cancer, and the importance of Pap smear screening in the absence of symptoms.

Cervical cancer in Iquitos, Peru: local realities to guide prevention planning

Cervical cancer is a major public health problem in Latin America, and in much of the underdeveloped world. This issue has not historically been addressed as a health priority, but in recent years is receiving increased attention and funding. This ethnographic study on the experience of cervical cancer was conducted in Iquitos, Peru, between August 1998 and May 1999. Research methodologies included: (1) observation and household interviews to obtain background knowledge about the region, medical systems, and local cultural understanding of illness; (2) cancer experience interviews; and (3) case studies of women in various stages of cervical cancer or diagnosis. Findings are presented related to local knowledge and experience of Pap smears and cervical cancer and the ineffectiveness of a recently initiated cervical cancer screening program. The findings guide recommendations for interventions in the region in relation to: (1) needed changes in health education, (2) screening frequency and age, (3) sites for screening and treatment, (4) type and availability of treatment, (5) payment issues, (6) documentation of care, and (7) the potential of herbal remedies.

Mot luuk problems in Northeast Thailand: why women's own health concerns matter as much as disease rates

In this paper, we consider women's illness experiences, above and beyond the presence of clinically identifiable disease. In Northeast Thailand, epidemiological data suggest that the prevalence of major women's reproductive tract infections is relatively low and not a cause for significant public health attention. Conversely, we found that self-reported rates of gynecological complaints are high and a significant women's health concern in rural Northeast villages. Women's embodied experiences and interpretations of these complaints affect their lives dramatically. Moreover, women's responses to gynecological problems (regardless of diagnosed morbidity) constitute an important health issue in their own right. In this regard, we document the dangers of women's self-treatment practices that rely largely on small doses of medically inappropriate antibiotics, the manner in which family life and sexual relations are disrupted by fears that gynecological problems will progress to cervical cancer, health care seeking patterns and expectations from health staff, and most importantly, how women's concerns about the seriousness of recurrent ailments result in substantial suffering. This study demonstrates why attention to women's own health concerns is as important to address in health programs as rates of disease, and why common gynecological problems and work-related complaints are important to take seriously rather than dismiss as psychological or routine and expected. We argue that there is a strong need to conduct ethnographic research on women's health problems as a complement to, and not merely a support for, epidemiological research. An evidence-based approach to health policy needs to be accompanied by a more humanistic approach to understanding health care needs.