Social Construction of Cervical Cancer Screening Among Women in Panama City, Panama by Arlene Calvo, M.P.H. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Community and Family Health College of Public Health University of South Florida Major Professor: Kelli McCormack Brown, Ph.D. Carol A. Bryant, Ph.D. Jeaninne Coreil, Ph.D. Donileene R. Loseke, Ph.D. Robert J. McDermott, Ph.D. Date of Approval: July 11, 2005 Keywords: women's health; human papillomavirus; Latino women; international health; Latin America; Panama health © Copyright 2005 , Arlene Calvo DEDICATION To all the Latinas who endured too many sacrifices to reach their dreams. To my mother and father who have always been concerned with my education and to my brothers who showed me how to be tough. To MamaMerce, my dear grandma, always guiding and watching over me, I still miss you. To all the women in my life, who helped mold me into who I am today. ACKNOWLEDGEMENTS Thanks to all the men in my family who inspired me into public health and to all the women for their drive and strength. Special gratitude to Dr. Kelli McCormack Brown, who more than a mentor continues to be a friend and an inspiration. I appreciate the support shown by my committee members, Drs. Carol Bryant, Jeanine Coreil, and Robert McDermott, through this long distance experience and especially to Dr. Donilene Loseke who went a step beyond needed. Also to Cathy D. Meade, Ph.D. for the continual support. TABLE OF CONTENTS List of Tables v Abstract vi Chapter I-Statement of the Problem 1 Global Aspects 5 Overview of the Panamanian Health Care System 7 Theoretical Tenets 9 Purpose of the Study 11 Research Questions 15 Delimitations 16 Limitations 17 Definitions 18 Chapter II-Literature Review 20 Globalization and Public Health 21 The Panamanian Health Care System 24 Cervical Cancer 29 Cervical Cancer Epidemiology 29 Cervical Cancer, Human Papillomavirus and Associated Risks 30 Cervical Cancer in Latin America and the Caribbean 33 Screening and Cervical Cancer Control 39 Cervical Cancer in Panama 43 Cervical Cancer Screening among Latinas 47 Cervical Cancer Screening: Deterring Factors 48 Cervical Cancer Screening: Motivating Factors 53 Culture, Health and Cultural Competence 57 Hispanic Culture and Meanings of Health 59 Theoretical Tenet: Social Constructionism 63 Critiques of Social Constructionism 68 Social Constructionism and Public Health 71 Social Constructionism and Cervical Cancer 73 Preliminary Data Collection 76 Key Informant Interviews 77 Natural Group Interviews 78 Qualitative Research 81 Synopsis of Literature Review 84 i Chapter III- Methods 89 Research Questions 89 Methodology 91 Study Population 91 Setting 91 In-Depth Semi-Structured Interviews 92 Inclusion Criteria for Individual Interviews 92 Exclusion Criteria for Individual Interviews 93 Demographics 93 Sample 94 Recruitment 97 Recruitment of Regularly Screened Women 97 Recruitment of Not Regularly Screened Women 98 Recruitment of Unscreened Women 99 Group Interviews 100 Recruitment of Women for Group Interviews 101 The Process of Data Collection 101 Individual Semi-Structured Interviews 101 Freelisting 103 Pile Sorting 104 Group Interviews 105 Technical Process of Research 106 Pretesting Instrument 106 Audio-Taping Interviews 107 Transcription 107 Translation 108 Debriefing 108 Non-participation 109 Social Process of Research 109 Incentives 110 Field Notes 111 Log 111 Jotting 111 Field Notes 112 Role of the Research Assistants 112 Conducting the Interviews 114 Assessing Rigor, Validity, Reliability, Transferability and 114 Reflexivity Rigor 114 Validity 115 Reliability 116 Transferability 117 Reflexivity 118 Data Analysis 119 Summary 122 ii Chapter IV-Results 124 Demographic Information 125 Individual Interviews 125 Group Interviews 126 Screening Status 127 Sociocultural Factors Important in Women’s Lives 127 Family 128 Religion 129 Health Beliefs and Practices 130 Staying Healthy 134 Preventive Care 136 Vaginal Hygiene 137 Getting Tested as Prevention 141 Self-Medication 143 Cervical Cancer Knowledge 146 Structural Factors 148 Cost of Screening 149 Experiences with the Panamanian Health Care System 150 Reproductive Health 153 Female Anatomy 155 Understanding of the Pap Test 156 Understanding of the Human Papillomavirus 158 Cervical Cancer and Screening 160 Who Should Get screened? 160 Why Women do not Get Screened? 162 Fears about Cancer and Screening 167 Mortality 168 Fear of the Unknown 170 Fear of the Pap Test 174 Pain and Discomfort 175 Embarrassment 176 Modesty 176 Loss of Confidentiality 177 Morality 179 Social Influence 180 Media Influence 180 Physician’s Influence 183 Female Influence 185 The Mother Factor 189 Male Influence 191 Key Messages 192 Summary 196 iii Chapter V-Summary, Discussion and Recommendations 198 Summary of the Study 198 Discussion of Findings 200 Structural Factors 200 Sociocultural Factors Important in Women’s Lives 202 Family 202 Religion 203 Health Beliefs and Practices 203 Cancer, Cervical Cancer, and Screening Awareness 205 Cultural Beliefs and Cervical Cancer 207 Societal Influences in Panamanian Women’s Understandings of 209 Health How Panamanian Women Construct Understandings about Health, 211 Cervical Cancer, and Screening Influence of Media on Panamanian Women 214 Construction of Cervical Cancer Screening Among Panamanian 216 Women Panamanian Women’s Health Education Preferences 217 Strengths and Weaknesses of the Study 218 Strengths 218 Weaknesses 219 Recommendations for Health Care Practitioners 220 Recommendations for Public Health Education Interventions 221 Using Social Construction in Health Education 222 Recommendations for Future Research 223 Platform for Future Research 225 References 227 Appendices 266 Appendix A: World Facts and Map of Panama 266 Appendix B: IRB Letter of Approval 269 Appendix C: Interview Inclusion-Exclusion Criteria Tool 271 Appendix D: Demographics Information Instrument 273 Appendix E: Sample of Local Newspaper Article 275 Appendix F: Interview Guide 278 Appendix G: Certification of Professional Translation 284 Appendix H: Codebook for Analysis 286 Appendix I: Samples of Local Brochure 297 About the Author End page iv LIST OF TABLES Table 1 Risk Factors Associated with Cervical Cancer 32 Table 2 Malignant Cervical Cancer Age Standardized Incidence and Mortality 34 Rates per 100,000 Population by Region Table 3 Cost of Cervical Cancer Screening in Panama 46 Table 4 Quota Sampling Matrix for Interviews with Women 96 Table 5 Demographic Information of Women Interviewed 126 Table 6 Activities a Woman Can Do to Stay Healthy 132 v Social Construction of Cervical Cancer Screening Among Women in Panama City, Panama Arlene Calvo ABSTRACT To learn how to address health issues specific to Hispanic cultures in an effort to address health disparities, learning from cultural aspects that affect health from the countries of origin would be most useful. Community programs built on rigorous and systematic research prove to be more powerful than ad-hoc programs. Qualitative research techniques offer powerful alternatives for public health professionals to develop adequate and directed programs at the community level, especially among underserved communities and those represented by oral/spoken traditions. The study was conducted among 132 working class single and married Mestizo women between the ages of 20-40 living in Panama City, Panama. This group of women has the highest incidence of HPV in Panama so are at the highest risk of cervical cancer. Using social construction as the theoretical framework, this study uses four different qualitative research techniques: free listing, pile sorting, individual semi-structured, and group interviews. Key findings include the importance of religion and family, women’s understandings of the relationship between sexuality and health, influence of media, other women, and husbands help construct screening knowledge among women in the study. Culturally relevant health education interventions and programs delivered in a group format at the community level in a participatory mode would be most effective in reaching women in Panama and other Hispanic populations. Future quantitative studies and influences of social networks are suggested. vi CHAPTER I-STATEMENT OF THE PROBLEM Reaching the public health goal of health for all can only be accomplished if specific research and programs aimed at decreasing the unequal burden of disease are developed. In 2001, Dr. George Alleyne, Director of the Pan American Health Organization, stated that the search for equity in health is a vital concern for the Region of the Americas, particularly in Latin America and the Caribbean, which display the most inequitable income distribution in the world. Therefore, public health efforts to decrease health disparities should be addressed at an international level as well as within the United States (American Pubic Health Association, 2001; Bauer, 2000; Hawe & Shiell, 2000; Mathews, Manor & Power, 1999). One of the public health goals in the United States is to decrease health disparities among diverse, at-risk and medically underserved populations. The Healthy People 2010 document cites eliminating health disparities as one of the primary health goals for the nation (U.S. Department of Health and Human Services, 2000a). In late 1999, the Institute of Medicine (IOM) released a document, titled The Unequal Burden of Cancer, which presents the status, issues, and recommendations regarding the