Acceptability of HPV testing and stages-of-change in Papanicolaou test use among disadvantaged, indigenous and non-indigenous women in Mexico: Policy recommendations for adherence to screening

The study objectives were to explore the socio-cultural elements of human papilloma virus (HPV) test acceptability and stages-of-change in cervical cancer screening behavior among disadvantaged women in Mexico to inform policy recommendations for improving adherence to cervical cancer screening. This was a qualitative study among convenience samples of four groups of women near or below the poverty line: Nahuas from Puebla, Huicholas from Jalisco, Mames from Chiapas and Mestizas (non-indigenous) from Morelos. Participants received free (self-collected) HPV testing and counseling; women with positive HPV results received free follow-up Papanicolaou (Pap) testing and those with positive Pap results were referred for free treatment in the public health system. After women received HPV test results and provided verbal informed consent, individual interviews were carried out. Healthcare providers (nurses, physicians and administrators) from one state-level (Morelos) screening program were also interviewed. Field notes were taken during and after all interviews, and most interviews were taped and transcribed. Qualitative analyses using cultural consensus theory and the constant comparative method were carried out with Excell and NVIVO software. Although cultural consensus on the salience of specific elements of HPV test acceptability varied by ethnic group, the main components of acceptability were: knowing one's HPV diagnosis, preference for self-collection versus pelvic exam, less painful and faster than Pap test, opportunity for self-care. Aspects of screening behavior include: knowledge (about HPV, cervical cancer and its treatment, screening program organization), representations (of HPV, cervical cancer, reproductive health), attitudes (towards the healthcare program and providers, HPV and Pap tests, health and illness, intentions and motivations towards screening), experiences (of cervical cancer screening program, other healthcare services, cervical cancer in others), practices (Pap and other healthcare use and self-care). Data support the following stages-of-change in cervical cancer screening behavior: contemplation (considering using HPV or Pap tests), preparation (initial actions leading up to HPV or Pap test use or extremely sporadic Pap test use), reluctant action (use of Pap testing as a means to obtain other services without perceiving it as useful itself), action (regular Pap test use over a short period of time), maintenance (regular Pap test use over a prolonged period of time). Based on this qualitative data, we propose implementing and evaluating an intervention to train healthcare providers in the stages-of-change model, in order to tailor health promotion and counseling focusing on HPV and Pap testing to women's individual stage-of-change in terms of screening behavior.