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2009-11-18
Development and Testing of a Questionnaire:
Beliefs about Cervical Cancer and Pap Test in
Chilean Women
Maria Teresa Urrutia
University of Miami, murrutia@miami.edu
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Urrutia, Maria Teresa, "Development and Testing of a Questionnaire: Beliefs about Cervical Cancer and Pap Test in Chilean Women"
(2009). Open Access Dissertations. Paper 309.







UNIVERSITY OF MIAMI





DEVELOPMENT AND TESTING OF A QUESTIONNAIRE:
BELIEFS ABOUT CERVICAL CANCER AND PAP TEST IN CHILEAN WOMEN




By

Mara Teresa Urrutia Soto


A DISSERTATION


Submitted to the Faculty
of the University of Miami
in partial fulfillment of the requirements for
the degree of Doctor of Philosophy





Coral Gables, Florida

December 2009












































2009
Mara Teresa Urrutia Soto
All Rights Reserved
UNIVERSITY OF MIAMI



A dissertation submitted in partial fulfillment of
the requirements for the degree of
Doctor of Philosophy



DEVELOPMENT AND TESTING OF A QUESTIONNAIRE:
BELIEFS ABOUT CERVICAL CANCER AND PAP TEST IN CHILEAN WOMEN


Mara Teresa Urrutia Soto




Approved:




________________ _________________
Rosemary Hall, Ph.D. Terri A. Scandura, Ph.D.
Associate Clinical Professor of Nursing Dean of the Graduate School



________________ _________________
JoAnn Trybulski, Ph.D. Kandyce M. Richards, Ph.D.
Associate Clinical Professor of Nursing Assistant Professor of Nursing


________________
JoNell Efantis Potter, Ph.D.
Associate Professor of Clinical Obstetrics & Gynecology
School of Medicine


URRUTIA SOTO, MARIA TERESA (Ph.D., Nursing)
Development and Testing of a Questionnaire: (December 2009)
Beliefs about Cervical Cancer and Pap Test
in Chilean Women

Abstract of a dissertation at the University of Miami.

Dissertation supervised by Professor Rosemary Hall.
No. of pages in text. (242)

Every year 33,000 women die of cervical cancer in Latin American and the Caribbean.
Cervical cancer has been the leading cause of potential years of life lost in Chile.
Identifying factors that increase Pap test adherence will be extremely useful for
developing interventions to increase the use of the Pap test and to reduce the prevalence
of cervical cancer. The purpose of this study was to develop and validate a questionnaire
to examine womens beliefs about cervical cancer and the Pap test in Chilean women.
The questionnaire, developed following the guidelines by Robert de Vellis, is based on
the Health Belief Model. The content validity index was 0.93 after 10 Chilean experts
review. A cross-sectional design was implemented to validate the questionnaire. The
sample included 333 women recruited from a womens health care center in Santiago,
Chile. Exploratory factor analysis was used to evaluate validity and coefficient alpha to
evaluate reliability. After six models were computed, the questionnaire was reduced from
53 to 28 items. The new questionnaire,CPC-28 includes six domains: the barriers
domain to take a Pap test considers problems related with a health care center, lack of
knowledge and time, being afraid, and embarrassment; the cues to action domain
considers cues from family, the health care professional, friend and media; the severity
domain considers cervical cancer as a serious problem, the possibility to have a
hysterectomy, radiation and chemotherapy, and to die from this disease; the susceptibility
domain to take a Pap test considers symptoms, having children, and intercourse; the
susceptibility to cervical cancer domain considers the risk to have the disease, age, and
possibility to die; and the benefit domain includes to save a life, feel good, and to take
care of health. An unexpected salient factor need to have a Pap test was found as part
of the susceptibility domain. This finding is an important topic for future research. The
CPC-28 questionnaire explained 49% of the total variance, and the reliability was .735. It
was concluded that the CPC-28 questionnaire will have important implications on
research, educative, and administrative role of nursing.

Dedication

I dedicate this dissertation to God, my family and friends.

To God, who gave me the necessary energy and focus to finish this stage of my
life.

To my parents, for their unwavering support and unconditional love as well as for
instilling in me the importance of hard work to achieve my goals. They truly are a
blessing from God.

To my favorite sister, who was always there for me, encouraging me to
continue the task that I began. Thank you for your support.

To my friend Rosina, who was always there to support me during this process.
Thank you, I will always remember your friendship.

To my friend Alejandra, who through her optimism and sensitivity gave me
endless support to continue. Thank you, distance was not an impediment for her
encouragement.


iii

Dedicatoria

Esta tesis est dedicada a Dios, mi familia y amigas.

A Dios, quien me dio la fuerza y el enfoque necesario para finalizar esta etapa de
mi vida.

A mis padres, que con su apoyo contaste y amor incondicional, me ensearon la
importancia de estudiar y trabajar para conseguir mis metas. Son una verdadera bendicin
de Dios.

A mi hermana favorita, quien estuvo siempre presente para alentarme a
continuar la tarea que comenc. Gracias por tu apoyo.

A mi amiga Rosina, quien siempre estuvo conmigo apoyndome durante este
proceso. Gracias, siempre recordar nuestra amistad.

A mi amiga Alejandra, quien con su optimismo y sensibilidad me acompa en
este camino. Gracias, la distancia no fue un impedimento.





iv

Acknowledgment


To the women who participated in this study. Thank you for your cooperation.

To Dr. Rosemary Hall, who gave to me the necessary support to finish this
process. Thank you, I will never forget your assistance and guidance.

To Dr. Nicholas Myers, for your willingness, gracious assistance, and guidance
you gave me with data analysis. Your expert knowledge gave me the reassurance I
needed with this complex process.

To my dissertation committee who were always available and provided ongoing
recommendations.

To Pontificia Universidad Catolica de Chile, School of Nursing. Thank you for
your earnest support for giving me the opportunity to achieve my PhD degree; your
interest and belief in me will always be remembered.

To Sigma Theta Tau International, Beta Tau Chapter for awarding me a research
grant to assist with the completion of my dissertation.

v

TABLE OF CONTENTS


Page

LIST OF FIGURES ..................................................................................................... ix

LIST OF TABLES ....................................................................................................... x


Chapter

1 INTRODUCTION .......................................................................................... 1
Significance ..................................................................................................... 4
Purpose of the Study ........................................................................................ 5
Goals of the study .................................................................................... 5
Summary ........................................................................................................ 5

2 REVIEW OF THE LITERATURE ............................................................... 7
Epidemiology of Cervical Cancer .................................................................... 7
Etiology of Cervical Cancer ............................................................................ 8
Papanicolaou Test ........................................................................................... 9
Pap test screening recommendations ......................................................... 10
Pap test rates.............................................................................................. 11
Health Belief Model ......................................................................................... 14
Research Methodologies Related to Cervical Cancer and the
Papanicolaou Test Beliefs................................................................................ 20
Beliefs related to Cervical Cancer and Pap test .............................................. 23
1. Benefits. .................................................................................................. 23
2. Severity. .................................................................................................. 24
3. Susceptibility .......................................................................................... 25
4. Barriers ................................................................................................. 28
5. Cues to action ........................................................................................ 33
Predictor Factors of Pap Test Screening ........................................................ 35
Health Belief Model and Needs for Developing Cervical
Cancer Instrument ........................................................................................... 36
Measurement Issues Related to Development of a
Validated and Reliable Questionnaire ............................................................. 38
Summary .......................................................................................................... 40

3 METHODS AND PROCEDURES ................................................................. 41
Design .............................................................................................................. 41
Setting and Population Served ......................................................................... 41
Sample .............................................................................................................. 41
Recruitment ..................................................................................................... 42
Consent Procedure........................................................................................... 43
vi

Data Collection and variables ......................................................................... 43
Construction Methodology for Beliefs Questionnaire ..................................... 44
1. Determine the construct that will be measured. ................................... 45
2. Determine the items to be included in the scale. ................................... 45
3. Determine the format of the questionnaire. ........................................... 46
4. Have an expert panel review the questionnaire. .................................... 46
5. Administer items to 300 women. ............................................................ 53
6. Evaluate the items. ................................................................................. 53
7. Optimize the scale length. ...................................................................... 54
Data Analysis ................................................................................................... 54
Data analysis: demographics questionnaire. ............................................ 54
Data analysis: the beliefs questionnaire. ................................................... 55
Ethical Aspects ................................................................................................. 56
Summary .......................................................................................................... 56

4 RESULTS ........................................................................................................ 57
Data Collection Procedure .............................................................................. 57
Items Score and Score Direction ..................................................................... 57
Data Cleaning and Missing Data .................................................................... 58
Demographics Data Analysis .......................................................................... 59
Beliefs Questionnaire Data Analysis ............................................................... 63
Normal distribution. ................................................................................... 63
Factorability of correlation matrix. ........................................................... 67
Correlation matrix indexes. ....................................................................... 68
Factor extraction. ...................................................................................... 75
Factor rotation. .......................................................................................... 76
Factor retention criteria. ........................................................................... 78
Exploratory factor analysis of beliefs 49-items questionnaire. ................. 82
CPC-28 Questionnaire. The Final Model. ....................................................... 95
Correlations between the Factors. ............................................................. 97
Reliability analysis of CPC-28 questionnaire. .......................................... 97
Summary .......................................................................................................... 102

5 DISCUSSION .................................................................................................. 103
Demographics Characteristics of the Sample.................................................. 103
General characteristics. ............................................................................. 103
Pap test and cervical cancer characteristics ............................................. 104
Causes attributes to cervical cancer. ......................................................... 105
Beliefs 53-items Questionnaire: Analysis of Items Deleted ............................. 106
1. Barriers. ................................................................................................. 107
2. Cues to action. ....................................................................................... 112
3. Severity. .................................................................................................. 114
4. Susceptibility. ......................................................................................... 116
5. Benefit. ................................................................................................... 118
Strengths of CPC-28 Questionnaire ................................................................ 120
Domains of CPC-28 Questionnaire ................................................................. 121
vii

Domain 1: Barriers to have a Pap test. ..................................................... 121
Domain 2: Cues to action to have a Pap test. ............................................ 127
Domain 3: Severity of cervical cancer. ...................................................... 129
Domain 4: Need to have a Pap test. .......................................................... 131
Domain 5: Susceptibility to cervical cancer. ............................................. 133
Domain 6: Benefit to have a Pap test. ....................................................... 135
Correlations between CPC-28 Questionnaire Factors .................................... 137
Implications of this Research for Nursing ....................................................... 147
Research role ............................................................................................. 148
Educative role ............................................................................................ 150
Administrative role .................................................................................... 154
Limitations and Strengths of this Study ........................................................... 157
Limitations ................................................................................................ 157
Strengths ................................................................................................... 157
Summary ......................................................................................................... 159

REFERENCES .................................................................................................. 160

APPENDICES .................................................................................................. 178
Appendix A: Flyer. Spanish Version ..................................................................... 178
Appendix B: Flyer. English Version ...................................................................... 179
Appendix C: Consent Form. Spanish Version ....................................................... 180
Appendix D: Consent Form. English Version ....................................................... 182
Appendix E: Participant Letter. Spanish Version ................................................. 184
Appendix F: Participant Letter. English Version .................................................. 185
Appendix G: Demographics Questionnaire. Spanish Version .............................. 186
Appendix H: Demographics Questionnaire. English Version ............................... 188
Appendix I: Final Version Beliefs Questionnaire. Spanish Version .................... 190
Appendix J: Final Version Beliefs Questionnaire. English Version ...................... 195
Appendix K: Guideline for Content Validity. Spanish Version ........................... 200
Appendix L: Guideline for Content Validity. English Version ............................. 210
Appendix M: Item Content Validity Index (I-CVI) .............................................. 221
Appendix N: Scale Content Validity Index (S-CVI) ............................................ 223
Appendix O: Modified, Deleted or Added Items, after the Expert
Panel Validation. Spanish Version ..................................................... 224
Appendix P: Modified, Deleted or Added items, after the Expert
Panel Validation. English Version ...................................................... 226
Appendix Q: Pilot Instruction. Spanish Version ................................................... 228
Appendix R: Pilot Instruction. English Version .................................................... 229
Appendix S: IRB Approval Letter. University of Miami ...................................... 230
Appendix T: IRB Approval Letter. Servicio de Salud Metropolitano
Sur Oriente ............................................................................................................. 232
Appendix U: CPC-28 Questionnaire. Spanish Version ........................................ 235
Appendix V: CPC-28 Questionnaire. English Version ......................................... 239
viii

LIST OF FIGURES


Page

Figure 1: Scree Test Beliefs 49-items Questionnaire .................................................. 84

Figure 2: Scree Test Beliefs 28-items Questionnaire (CPC-28 Questionnaire) ......... 89

Figure 3: Meaning of Correlations between Factors in the CPC-28 Questionnaire .. 138

Figure 4: Requirements to Have a Pap Test ............................................................... 140
ix

x

LIST OF TABLES

Page

Table 1: Key Variables in the Health Belief Model .................................................... 18

Table 2: Domain and Items: Urrutias Questionnaire ............................................... 49

Table 3: Missing Items in Demographics and Beliefs Questionnaires ........................ 60

Table 4: Demographic Characteristics of the Sample ................................................ 61

Table 5: Family History of Cervical Cancer, Relatives with Cervical Cancer,
and Pap Test Characteristics in the Sample ................................................... 62

Table 6: Causes of Cervical Cancer Reported by the Women .................................... 64

Table 7: Skewness and Kurtosis Values in Beliefs 53-items Questionnaire ............... 65

Table 8: Correlation Matrix Beliefs 53-Items Questionnaire ..................................... 69

Table 9: Total Variance Explained by Beliefs 49-Items Questionnaire ..................... 83

Table 10: Total Variance Explained by 28-items Questionnaire
(CPC-28 Questionnaire) ................................................................................. 88

Table 11: Pattern Matrix Beliefs 28-items Questionnaire
(CPC-28 Questionnaire) ................................................................................. 90

Table 12: Structure Matrix Beliefs 28-items Questionnaire
(CPC-28 Questionnaire) ................................................................................ 91

Table 13: Factor and Corresponding Items in Beliefs 28-Items
Questionnaire (CPC-28 Questionnaire) .......................................................... 92

Table 14: Communalities Beliefs 28-Items Questionnaire
(CPC-28 Questionnaire) .................................................................................. 96

Table 15: Factor Correlation Matrix Beliefs 28-Items Questionnaire
(CPC-28 Questionnaire) .................................................................................. 98

Table 16: Meaning of Correlations between Factors in the
CPC-28 Questionnaire..................................................................................... 99

Table 17: Cronbachs Coefficient Alpha and Inter-Item Correlation
in the CPC-28 Questionnaire .......................................................................... 101
Chapter 1. Introduction
Worldwide, cervical cancer accounts for 470,606 new cases annually
(Organizacin Panamericana de la Salud [OPS],2004). In 2005, there were over 500,000
new cases of cervical cancer, of which over 90% were in developing countries (World
Health Organization [WHO],2006). Chile is one of the developing countries considered
in this statistic accounting for the new cases of cervical cancer worldwide.
Cervical cancer is one of the cancers with the highest mortality in the world
(OPS,2007c). Every year 33,000 women die of cervical cancer in Latin American and the
Caribbean (OPS,2008b). In Chile, cervical cancer has been the leading cause of potential
years of life lost (Ministerio de Salud [MINSAL],2005a).
If a comparison is done between developed and developing countries, it is
necessary to establish the difference in mortality and incidence rates between them. North
America, specifically Canada and the U.S., have a mortality rate near 2.0/100,000 women
(Canadian Cancer Society & National Cancer Institute of Canada, 2008; Center for
Disease Control and Prevention [CDC],2004), but countries in South America have rates
of cervical cancer as high as 22.2/100,000 women (OPS,2004). Chile has a mortality rate
of 8.0/100,000 women (Donoso, Cuello, & Villarroel, 2006).
Regarding incidence rates of cervical cancer in the Americas, they are lower than
7.0/100,000 in North America (Canadian Cancer Society & National Cancer Institute of
Canada, 2008; Center for Disease Control and Prevention, 2004), and higher than
93.9/100,000 in Haiti (OPS,2004). The incidence of cervical cancer rate in Chile was
29.2/100,000 women in 2000 (OPS,2004). The difference in the incidence and mortality
1
2
rates between developed and developing countries is a health disparity, and these rates
present a challenge (Donoso et al., 2006) for many disciplines including nursing.
The human papillomavirus (HPV) is a common sexually transmitted infection
among men and women (Gerend & Barley, 2009). The HPV vaccine is available to
prevent cervical cancer, but in spite of the advances of the HPV vaccine to prevent
cervical cancer, it is necessary to emphasize that this vaccine will not replace cervical
cancer screening programs (OPS,2008b; Pan American Health Organization and World
Health Organization, 2007). Therefore, it is still important to support resources for
screening.
The Papanicolaou test (Pap test) has been shown to reduce cervical cancer
incidence and mortality rates (WHO,2006), but has not been utilized with adequate
frequency by the Hispanic population (Bazargan, Bazargan, Farooq, & Baker, 2004;
Owusu et al., 2005). This has led to cervical cancer being a bigger problem among
Hispanics in the U.S. as well as with Hispanic women in other countries (Aguilar Perez,
Leyva Lopez, Angulo Najera, Salinas, & Lazcano Ponce, 2003; Bazargan et al., 2004;
Fernandez, Tortolero Luna, & Gold, 1998; Lazcano Ponce et al., 1999; Owusu et al.,
2005). The percentage of women who report having had a Pap test in the last three years
ranges between 7% in Brazil (Pinho, Frana Junior, Schraiber, & D'Oliveira, 2003) to
69% in Colombia (Lucumi & Gomez, 2004). In Chile the percentage of the women who
had up-to-date Pap tests in 2006 was 66% (MINSAL,2008). The differences in the
percentages could be explained by the barriers that the women have to have the Pap test.
Cervical cancer is an important challenge for developing countries (OPS,2007b)
and there are many factors that have led to failures of screening programs. Among these
3
factors are the beliefs among women regarding cervical cancer screening. Therefore, if
the idea is that the women use health care services, it is necessary to provide to them
health care in which their opinions are considered (OPS,2007b). Therefore, it is an
important step to measure womens beliefs about cervical cancer and Pap test to improve
adherence to cervical cancer screening.
There are many different beliefs about cervical cancer screening described in the
literature, and these beliefs are related with the womens screening behaviors (Burak &
Meyer, 1997; Byrd, Peterson, Chavez, & Heckert, 2004; Denny Smith, Bairan, & Page,
2006; Eaker, Adami, & Sparen, 2001; Fernandez Esquer & Cardenas Turanza, 2004;
Fernandez et al., 1998; Ho et al., 2005; McFarland, 2003; Risendal, DeZapien, Fowler,
Papenfuss, & Giuliano, 1999; A. Smith, Christopher, & McCormick, 2004). In Chilean
literature, the beliefs have been described as knowledge (Lamadrid, 1996), ways to
prevent cervical cancer (Lamadrid, 1998), and/or the barriers to receiving the Pap test
(Urrutia et al., 2008; Valenzuela & Miranda, 2001).
The health belief model (Rosenstock, 1974b) indicates that the ways of knowing
and behaving are governed by beliefs and emotions and these can change over time based
on temporal decision making (Finfgeld, Wongvatunyu, Conn, Grando, & Riussell, 2003).
While the literature reports beliefs related to cervical cancer and the Pap test, research did
not identify instruments to measure beliefs about cervical cancer and Pap test with good
validity and reliability (Byrd et al., 2004; Fernandez et al., 1998; Price, Easton,
Telljohann, & Wallace, 1996). Furthermore, no instruments were found that tested the
health belief model with Chilean women. Therefore, it is necessary to develop a new,
validated, and reliable questionnaire that will explore beliefs related to cervical cancer
4
and Pap test. Upon review of the literature, the health belief model was found to be the
best framework for understanding beliefs related to cervical cancer and the Pap test and
why women decide to seek or not to seek Pap test screening. It is hoped that this new
questionnaire will provide researchers the opportunity to explore the relationship between
the health belief models components, specifically in the Chilean population. Therefore, it
is important to consider that the goal of understanding certain behaviors is to encourage
people to improve their health promotion practices (Rosenstock, 1966) and to achieve
this goal, a reliable, validated and culturally sensitive questionnaire is needed.
Significance
The importance of this study is to develop a questionnaire to address the five
health belief model components (severity, susceptibility, benefits, barriers, and cues to
action) and then validate these components with Chilean women. Ideally, the findings
will hopefully increase the understanding and knowledge of womens behaviors in
relation to cervical cancer screening.
The need to develop and validate a questionnaire is based on the lack of validated
and reliable instruments that can be used. The measurement of Chilean womens beliefs
about cervical cancer and Pap test using a validated and reliable method that is culturally
sensitive to achieve a deeper understanding of Chilean womens beliefs is needed. It is
hoped that the development and testing of the questionnaire will identify and lead to an
understanding of Chilean womens beliefs and based on this knowledge make it possible
to create interventions with this population.
It is necessary to develop effective interventions to increase the use of the Pap test
in order to reduce the prevalence of cervical cancer and identify factors that increase
5
adherence to Pap test screening. The findings of the results of the questionnaire will be
important considerations when designing effective and culturally specific intervention
programs to increase Pap testing targeting Chilean women.
The WHO has asked health care professionals to implement interventions to
reduce the incidence of cervical cancer in the Latin population (WHO,2006); therefore,
the results will allow Chilean health care professionals to use their skills to transform this
knowledge into effective strategies (Glanz, Rimer, & Lewis, 2002b) to increase
adherence to Pap test screening.
Purpose of the Study
The purpose of this study is to develop and validate a questionnaire to examine
Chilean womens beliefs about cervical cancer and the Pap test screening.
Goals of the study:
1. Describe the development of the questionnaire items.
2. Identify how the items are distributed in the developed questionnaire (factor
structure).
3. Identify the reliability of the developed questionnaire.
4. Develop a validated and reliable questionnaire to measure health beliefs related to
cervical cancer and the Pap test screening in Chilean women.
Summary
Chapter 1 provided an introduction of the problem of cervical cancer in the world
and the differences of this problem between developed and developing countries. The
beliefs related to cervical cancer and Pap tests were summarized. The health belief model
by Rosenstock was highlighted as the appropriate framework for development of a new,
6
validated and reliable questionnaire related to Chilean womens beliefs about cervical
cancer and the Pap test. Chapter 2 presents a literature review that supports this proposal.

Chapter 2. Review of the Literature
As noted in Chapter 1, cervical cancer accounts for approximately 10% of all new
cases of cancer worldwide (Orbell, Hagger, Brown, & Tidy, 2006). More than 288,000
women die from cervical cancer each year throughout the world (OPS,2008a) and one
woman dies every two minutes in developing countries from this disease (Suarez, Cuello,
& Nazzal, 2006).
Over the past three decades, cervical cancer rates have fallen in most of the
developed world. In contrast, the death rates in most developing countries have either
risen or remained unchanged (WHO,2006).
Cervical cancer is the leading cause of mortality in the Caribbean and the second
cause of mortality in Latin America (OPS,2007c; PAHO & WHO,2007). In Chile,
cervical cancer is the second cause of mortality overall in women between 20 and 44
years of age, the leading cause of cancer mortalities in women 20 to 44 years, and the
fifth cause in the group of women 45 to 64 years of age (MINSAL,2005b).
Epidemiology of Cervical Cancer
Cervical cancer incidence and mortality rates in Latin America and the Caribbean
are seven times greater than those observed in North America (PAHO & WHO,2007).
Canada and the U.S. showed a mortality rate from cervical cancer of 2.0/100,000 women
(Canadian Cancer Society & National Cancer Institute of Canada, 2008) and 2.4 /100,000
women respectively (CDC,2004). In South America, the mortality rates oscillate between
7.6 /100,000 and 22.2 /100,000 women (OPS,2004). In Chile the mortality rate was
8.5/100,000 women in 2003 (Donoso et al., 2006), or 2 deaths per day. The difference
7
8
between developed and developing countries reflects inequalities in health care and
presents a challenge for global health (Donoso et al., 2006; WHO,2006).
The incidence of cervical cancer was 7.5/100,000 in Canada (Canadian Cancer
Society & National Cancer Institute of Canada, 2008) and 7.9/100,000 in the U.S.
(CDC,2004). In certain countries of the Americas, the rates oscillate between
13.8/100,000 women in Uruguay to 93.9/100,000 women in Haiti (OPS,2004). The
incidence rate in Chile was 29.2/100,000 women in 2000 (OPS,2004), decreasing to
18.7/100,000 women in 2003 with 1,100 new cases this year (MINSAL,2005a). Latin
America and the Caribbean have one of the highest rates of mortality and incidence in the
world with 72,000 new cases and 33,0000 deaths annually (PAHO & WHO,2007),
surpassed only by some countries in Africa and Asia (Drain, Holmes, Hughes, &
Koutsky, 2002; OPS,2004; PAHO & WHO,2007). Despite the fact that cervical cancer is
preventable, it has been impossible to decrease the incidence in the Americas (OPS,2004;
PAHO & WHO,2007).
Etiology of Cervical Cancer
Almost all cases of cervical cancer are caused by HPV, a common virus that can
be passed from one person to another during sexual contact (Gerend & Barley, 2009).
Cervical cancer usually does not cause signs and symptoms in the early stages but
advanced cervical cancer may cause bleeding or discharge (CDC,2008b). Cervical cancer
is considered the easiest female cancer to prevent now that the HPV vaccine is available
(CDC,2008a).
The expensive technology needed for the HPV vaccine is outside the reach of the
majority of developing countries (OPS,2007a). Experts have recognized that the vaccine
9
is very important in cervical cancer prevention, but it does not replace screening
programs (OPS,2008b; PAHO & WHO,2007), because this is focused in prevention, not
in detection. Screening will still need to continue (PAHO & WHO,2007).
Papanicolaou Test
Cervical cytology is still considered the principal method for early diagnosis of
the precursor lesions of carcinoma of the cervix (Michalas, 2000). The evolution from the
precancerous stage to cervical cancer is slow; therefore, routine screening makes it a
preventable disease (Vilos, 1998).
George Papanicolaou, named the father of modern cytopathology (Anand, Singh,
& Anand, 2005), emphasized the need to develop a simple, inexpensive method of
diagnosis that could be applied to a large number of women (Michalas, 2000). The Pap
test was reported in 1928 and its efficacy was made known in 1941(Vilos, 1998). The
Pap test is a procedure in which cells are scraped from the cervix and examined under a
microscope. It is used to detect cancer and changes that may lead to cancer (National
Cancer Institute, 2008). Once these changes are treated, cancer can be prevented
(American College of Obstetricians and Gynecologists [ACOG],2004). The Pap test is
not a diagnostic, but a screening test that identifies women who need further assessment
(Michalas, 2000).
The Pap test is commonly used as a clinical tool for the early detection of cervical
cancer (OPS,2007a; Vilos, 1998), and is the most successful cancer screening test
currently used (Michalas, 2000). Papanicolaous discovery of the screening test is
recognized as the most significant advance in the control of cancer in the 20th century
(Michalas, 2000; Zachariadou-Veneti, 2000).
10
Pap test screening recommendations.
Cervical cancer rates can be reduced through screening (American Cancer
Society, 2001; Michalas, 2000; PAHO & WHO,2007; WHO,2006) and cervical cancer
control can be achieved if screening is organized and the largest possible number of
women in the target group is screened (PAHO & WHO,2007; WHO,2006).
The first step towards a cervical cancer program in Chile was taken in 1965 with
the establishment of a central cytology laboratory in Santiago, the capitol of Chile (Salas,
2006). Between 1970 and 1985, the Servicio Nacional de Salud (National Health Service)
gradually established different laboratories in different regions of the country (Salas,
2006). In 1987, the National Cervical Cancer Program was reorganized (Donoso et al.,
2006) following WHO guidelines (Sepulveda & Prado, 2005) and in 1988 the National
Cervical Cancer Program guidelines were published (Donoso et al., 2006). In 1997,
cervical cancer screening was officially included among the 10 national health priorities
of the Ministry of Health (Sepulveda & Prado, 2005). In 2003, cervical cancer screening,
diagnosis and treatment were incorporated into Chiles new health system, AUGE
(Acceso Universal de Garantias Explicitas en Salud, Universal access to explicit
guaranties in health).
The American Cancer Society guidelines recommend that the Pap test be given
every year, starting about three years after the first vaginal intercourse and by 21 years of
age. Beginning at age 30 and with three previous normal Pap tests, the screening may be
done every two or three years (American Cancer Society, 2006). The Chilean guidelines
say that women must have a Pap test between 25 and 64 years of age and the periodicity
must be every three years (MINSAL,2008).
11
The Pap test has been shown to reduce cervical cancer incidence and mortality
rates (WHO,2006) by as much as 70% in some countries (Michalas, 2000). The United
States Centers for Disease Control and Prevention (CDC,2005 ) have found that it is
necessary to increase access to early detection and treatment services for cervical cancer,
develop strategies to improve screening, and implement public education.
Pap test rates.
The Pap test is underutilized by the Hispanic population and by minorities in the
U.S. (Bazargan et al., 2004; Owusu et al., 2005). In fact, half of the women in the U.S.
who are diagnosed with cervical cancer have never had a Pap smear (Owusu et al., 2005).
There are many ways to measure cervical cancer screening. Different authors
discuss different frequencies regarding cervical cancer screening, but the typical and most
important question to ask is whether the woman has ever had the Pap test. According to
this question, Yi (1998) and Moreland (2006) showed percentages between 37% in a
group of Vietnamese women in the U.S. and 97% in a group of Native Americans in the
U.S.
If one focuses specifically on the Hispanic population in the U.S., the percentage
of women who have ever had a Pap test is near 90% (Fernandez et al., 1998; Koval,
Riganti, & Foley, 2006), but if the focus is on Hispanic women in their countries of
origin, the frequencies decrease to values between 45% (Aguilar Perez et al., 2003) and
63% (Lazcano Ponce et al., 1999). The percentage difference indicates womens
screening behavior and Hispanic womens behavior is influenced by the environment in
which they are living. However, there is little knowledge about the cause of this behavior.
12
If cervical cancer is a problem in the Hispanic population in the U.S., this problem is
even greater among Hispanic women in their countries of origin.
The other point of view for measuring cervical cancer screening is to indicate if a
woman who has had a Pap test, follows the screening recommendations according to a
specific guideline. Not all literature shows this information in the same way. Some
authors report women who have not had the Pap test in the previous year (A. Smith et al.,
2004); others record the number of Pap tests a woman has had in the previous three years
(Park, Chang, & Chung, 2005; Risendal et al., 1999), and/or the number of Pap tests in
the previous five years (Fernandez Esquer & Cardenas Turanza, 2004; Price et al., 1996),
and/or the number of Pap tests without specifying a time period (Aguilar Perez et al.,
2003; Byrd et al., 2004; Lazcano Ponce et al., 1999; Lee Lin et al., 2007; McFarland,
2003).
Independently, how the follow up screening variable has been measured and when
the topic is the screening frequency requirement, the percentages decrease. About 42%
(Fernandez et al., 1998) to 89% (Ho et al., 2005) of women report they have had a Pap
test within the previous year. The Hispanic population shows a lower percentage than the
non-Hispanics (Pinho et al., 2003; Wiesner Ceballos, Vejarano Velandia, Caicedo Mera,
Tovar Murillo, & Cendales Duarte, 2006). WHO recommends screening every three
years in Latin America and the Caribbean (Pinho & Franca Junior, 2003). The percentage
of women who report this frequency varies between 7% in Brazil (Pinho et al., 2003) and
69% in Colombia (Lucumi & Gomez, 2004).
The national survey in Chile (Sepulveda & Prado, 2005) showed that 79% of the
women between 25 and 64 years of age have had a Pap test at least once in their lives and
13
66% within the previous 3 years. According to the CASEN national survey 2006, 48.6%
of the women in Chile reported having had a Pap test in the previous three years
(Ministerio de Planificacin [MIDEPLAN],2006a). The higher the socioeconomic level,
the higher the percentage of the women who have had Pap tests in the previous three
years (MIDEPLAN,2006a). The percentage is higher in the private health system than in
the public health system (Sepulveda & Prado, 2005). The percentage of the women
between 25 and 64 years of age with a current Pap test increased from 26% in 1990, to
66% in 2006 in Chile (MINSAL,2008).
Increasing cervical cancer screening rate is one of the most important challenges
with Hispanic women. Latin America and the Caribbean countries must confront this
problem (PAHO & WHO,2007). There are many factors that have led to failures of
screening programs, like limited access to diagnostic service, inadequate capacity for
treatment for women with invasive cervical cancer, inability to sustain quality services,
and one of the most importance is the low awareness among women of the importance to
have cervical cancer screening (PAHO & WHO,2007). To find the answers to these
failures is a way to address this topic and to develop a validated and reliable
questionnaire is a way to contribute to this work. A validated and reliable questionnaire is
hoped to identify reasons why Chilean women do not have cervical cancer screening.
In the Hispanic population, to have children (Ramos, Palha, Costa Jnior,
Sant'Anna, & Lenza, 2006; Watkins, Gabali, Winkleby, Gaona, & Lebaron, 2002), being
older (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999; Lucumi & Gomez, 2004),
having health insurance (Ramos et al., 2006), having higher education (Aguilar Perez et
al., 2003; Lazcano Ponce et al., 1999; Lucumi & Gomez, 2004; Ramos et al., 2006), and
14
using a family planning method (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999)
are good predictors for women to have a Pap test. Lazcano et al.(1999) found that the
antecedent of the Pap test was 4.5 times more frequent in women between 45 to 50 years,
compared with women 20 years of age or less. Women with one or more family planning
methods in their life increased their use of the Pap test compared with the group without
any family planning method (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999).
Health Belief Model
The health belief model was developed to explain why people did not engage in
behaviors for prevention or early detection of disease (Institute of Medicine, 2001;
Rosenstock, 1974b; Rosenstock, Derryberry, & Carriger, 1959) and to encourage
participation in onetime preventive programs, such as polio vaccination (Rosenstock,
1974b).
An important factor in the failure of women to be screened is their low awareness
of the importance of screening (PAHO & WHO,2007). Health care providers should
provide information about cervical cancer screening. If we want women to use health
care services, it is necessary to give them health care in which their needs are considered
(OPS,2007b). Therefore, it is important to identify and measure womens beliefs about
cervical cancer and Pap test. In order to do this, it is necessary to select an appropriate
framework to support this aim.
A formal theory is a complete and closed deductive system of propositions that
identifies interrelationships and determines a systematic view of the phenomena (Glanz,
Rimer, & Lewis, 2002c). Theories can explain behaviors and suggest ways to achieve
behavioral changes (Glanz et al., 2002c). Nursing can borrow theories from other
15
disciplines and/or adapt them to the nursing situation (Polifroni & Packard, 1999). The
adaptation makes it possible to frame the practice and develop the research plan
(Polifroni & Packard, 1999). The health belief model is a useful framework for this study
and is used as a guide to develop a validated and reliable questionnaire related to cervical
cancer and Pap test beliefs.
The individual is the essential unit in health behavior theory and research because
groups, organizations, and communities are composed of individuals (Glanz, Rimer, &
Lewis, 2002a). Preventive health behaviors, such as cervical cancer screening, require
individual actions and the health belief model is an appropriate framework for measuring
these actions.
Cognitive theories emphasize the role of expectations or subjective hypotheses
held by the subjects; behavior is a function of the value of an outcome and of the
probability that a particular action will achieve that outcome (Rosenstock, Strecher, &
Becker, 1988). All behavior is motivated, but the motivation is not sufficient to account
for a specific health behavior (Rosenstock, 1960); for instance, health behavior is a
function of a health motive and the individuals beliefs (Rosenstock, 1960).
One of the models in nursing that is related with health beliefs is the model
developed by Nola Pender (Pender, 1987). This model was not chosen, because the health
belief model from Rosenstock specifically addresses screening behaviors, and
furthermore, many articles were found based on this model that related to cervical cancer
and Pap test behaviors.
The health belief model, which was developed in the 1950s (Rosenstock, 1974b),
is one of the oldest, most extensively used, and most resilient models of health behaviors
16
(Rimer, 2002). It has been used by health professionals for many years in different
contexts (Finfgeld et al., 2003; Janz & Becker, 1984; Rimer, 2002) and most of the
concepts have received substantial empirical support (Janz & Becker, 1984; Rimer,
2002). Health behavior change is not viewed as a long-term process (Finfgeld et al.,
2003). Pap test screening is a situation where health behavior is not viewed as a long-
term process, therefore, the health belief model of Rosenstock can be useful for studying
cervical cancer and Pap test beliefs in Chilean women.
Rosenstock postulates that people will take action to prevent or to screen for ill-
health conditions in the absence of symptoms, if three conditions are present:
1. The individual is ready to take action relative to a particular condition (readiness).
The extent of readiness is defined by the individuals feeling susceptible
(susceptibility) and the extent to which its possible occurrence is viewed as
having serious personal consequences (severity) (Rosenstock, 1966). In this area
of beliefs concerning susceptibility and severity, the emphasis is on personal
beliefs and not on objective reality (Rosenstock, 1960);
2. The individual believes that a particular action would be a benefit in reducing
susceptibility or the perceived severity (benefits), and that action would not
involve overcoming barriers (barriers).
3. A stimulus or cue occurs to trigger the response (Polifroni & Packard, 1999;
Rosenstock, 1966; Rosenstock et al., 1988). Therefore, the behavior is influenced
by interactions of the beliefs related to the individuals perception of the key
variables or a balance of multiple beliefs (Finfgeld et al., 2003). The major
17
concepts in the health belief model and the definitions of each are presented in
Table 1 (page 18).
Perceived barriers may be the most influential belief system affecting behavior
change. It has been shown that a person exhibiting an optimal level of belief in
susceptibility and severity would not be expected to accept any recommended health
action unless that action was also perceived as potentially efficacious, and without, or
with only minimal barriers (Finfgeld et al., 2003; Janz, Champion, & Strecher, 2002).
Susceptibility and severity are hypothesized to provide the energy force to act, whereas
diminishing barriers is thought to provide an accessible path for action (Finfgeld et al.,
2003). A cue to action is a key concept that refers to factors such as environmental events
and bodily events that instigate action. Behavior change is initiated by environmental
factors and readiness to take action (Finfgeld et al., 2003). Cues to action have not been
systematically studied (Rosenstock, 1966).
An important consideration of this model is the recognition that prevention
requires people to take action in the absence of illness (Institute of Medicine, 2001;
Rosenstock, 1966, 1974b). The health belief model indicates that the ways of knowing
and behaving are governed by beliefs and emotions, and they can change over time
(Finfgeld et al., 2003).
Self-efficacy is another element that has been included in the health belief model
in recent years; however, modifying lifelong habits like drinking or smoking is obviously
far more difficult than receiving a onetime immunization or screening test. Therefore, it
is not mandatory to include this variable for measuring screening aspects (Rosenstock et
al., 1988).
18
Table 1
Key Variables in the Health Belief Model
Perceived susceptibility:
Subjective risks of contracting a condition (Institute of Medicine, 2001). This is the
perception of ones own personal risk of developing a particular condition, and it
involves a subjective evaluation of risk (Institute of Medicine, 2001; Rosenstock,
1974b). Urrutias questionnaire considers the belief about the possibility
(susceptibility) to acquire the disease (cervical cancer) or the condition (to have an
abnormal Pap test) and therefore, the desire to have the Pap test .
Perceived susceptibility:
Ones belief of how serious a condition is and its sequel are. This is the degree to
which the person attributes negative medical, clinical, or social consequences to being
diagnosed with an illness (Institute of Medicine, 2001; Rosenstock, 1974b). Urrutias
questionnaire considers the belief about how serious it is to have cervical cancer or an
abnormal Pap test, and their sequels.
Perceived benefits:
Ones belief in the efficacy of the advised action to reduce risk or seriousness of
impact. It is the belief about the effectiveness of different actions (Institute of
Medicine, 2001; Rosenstock, 1974b). Urrutias questionnaire considers the belief
about the efficacy of having the Pap test to reduce the risk or the seriousness of
cervical cancer.
Perceived barriers:
Ones beliefs about the tangible and psychological cost of the advised action and the
potential negative aspects of a particular action (Janz et al., 2002; Rosenstock, 1974b).
Urrutias questionnaire considers the psychological or tangible cost of having the Pap
test.
Cues to action:
Strategies that people carry out to activate the preventive action, like publicity or
bodily events. Urrutias questionnaire considers strategies that cause women to have
the Pap test.

19
The health belief model may appear easy to implement in research projects
because of its limited number of components; however, the relationships among its
component have not been frequently studied. The five concepts (barrier, susceptibility,
severity, benefit and cues to action) have been studied as independent components, and
for this reason the model has frequently been misused (Finfgeld et al., 2003). The
concepts that have been measured are inconsistent with the theory, and the direct cause-
and-effect relationship between beliefs and behaviors has not been fully examined
(Finfgeld et al., 2003; Rosenstock, 1966). Therefore, research in the area of validity and
reliability could be very useful in attempting to comprehend the beliefs that people have.
A new validated and reliable questionnaire will contribute to obtaining data about
Chilean women beliefs related to cervical cancer and Pap test, and then, this information
could be useful for analyzing the relationships between the health belief models
components.
The health belief model can be applied to cervical cancer screening, specifically
to the Pap test. Cervical cancer disease is an excellent example in which there is an
effective test to detect the disease. The disease can be cured if treated in its early stages,
but it can be fatal if allowed to continue without treatment (Kegeles, Kirscht, Haefner, &
Rosenstock, 1965). The health belief model can provide a framework for developing
instruments for understanding the beliefs related to cervical cancer and the Pap test, and
for understanding why women decide to adhere or not to adhere to Pap test screening
guidelines. It is important to consider that the goal of understanding a behavior must
precede attempts to persuade people to modify their health care practices (Rosenstock,
20
1966). Therefore, the goal to understand womens behaviors can be achieved by
developing and testing a culturally sensitive questionnaire for Chilean women.
Research Methodologies Related to Cervical Cancer and the Papanicolaou Test Beliefs
According to the belief definitions (Merriam-Webster Dictionary, 2008; Online
Medical Dictionary, 2008), this term includes aspects of habit, trust, or confidence that
can lead a woman to a particular behavior. The researcher feels strongly in the belief that
this trust or confidence about the screening and the disease will lead the women to have
the test or not, and to believe correctly or incorrectly about different aspects of the test
and cervical cancer.
Hispanics in general and Hispanic immigrants in particular are more likely to
have fatalistic beliefs, like the belief that they could not reduce the chance of getting
cervical cancer (Peragallo, Melinda, & Berenice, 1997) or that the cervical cancer is not
easily cured (Byrd et al., 2004). These beliefs have been related to women being less
likely to seek out preventive care including the Pap test (Owusu et al., 2005). This
fatalism has been described as a part of the Hispanic culture (Antshel, 2002).
The methodologies used and how the belief concept has been used is different.
The authors talk about knowledge and beliefs (Lartey, Joubert, & Cronje, 2003; Lee Lin
et al., 2007; Watkins et al., 2002), barriers to Pap test (Agurto, Bishop, Sanchez,
Betancourt, & Robles, 2004; Ho et al., 2005; M. C. Lee, 2000), attitudes regarding
screening (Brenna, Hardy, Zeferino, & Namura, 2001; Byrd et al., 2004; Lartey et al.,
2003), or factors influencing the womens decisions (Aguilar Perez et al., 2003; Lucumi
& Gomez, 2004; Yi, 1998). All of these articles talk about beliefs, but do not address the
concept explicitly.
21
The methodology more frequently used is quantitative over qualitative research.
Qualitative methodologies show different perspectives: the authors studying the
phenomena using ethnographic research (Hunter, 2005) describe the results from focus
groups (Lamadrid, 1998; M. Smith, French, & Barry, 2003; Valenzuela & Miranda,
2001), grounded theory methodology (McMullin, DeAlba, Chavez, & Hubell, 2005),
content analysis (Urrutia et al., 2008), and individual and in depth interviews (Agurto et
al., 2004; Boyer, Williams, Callister, & Marshall, 2001).
There are multicenter studies with women from different countries (Agurto et al.,
2004; Bingham et al., 2003), studies with immigrant women (Ho et al., 2005; Jirojwong,
Maclennan, & Manderson, 2001; Lee Lin et al., 2007; M. C. Lee, 2000), with European
(Eaker et al., 2001; Idestrom, Milsom, & Andersson Ellstrom, 2002; Markovic, Kesic,
Topic, & Matejic, 2005) and from ethnic groups like American Indian (Becker, Affonso,
& Beard, 2006; Steven et al., 2004).
Studies of minorities in the U.S. are published frequently, including studies of
Latinas (Byrd et al., 2004; Fernandez Esquer & Cardenas Turanza, 2004; Fernandez et
al., 1998; Koval et al., 2006), Asians (Ho et al., 2005; M. C. Lee, 2000; P. Lee et al.,
2007; Taylor et al., 2002; Yi, 1998), and Native Indian (Becker et al., 2006; Moreland et
al., 2006; Risendal et al., 1999; A. Smith et al., 2004). These groups have been studied
because minorities are part of the health disparity problems and cervical cancer is one of
the health disparity diseases in the US (Glanz, Croyle, Chollette, & Pinn, 2003; Rao,
Graubard, Breen, & Gastwirth, 2004).
The research on women living in their countries of origin permits one to know the
behavior of the women in their country; and therefore, to compare this with the rate of
22
women living in others countries. The samples include Hispanic women (Hunter, 2005;
Lamadrid, 1998; Valenzuela & Miranda, 2001; Wiesner Ceballos et al., 2006), European
women (Idestrom et al., 2002; Markovic et al., 2005) and Asian women (Hou & Luh,
2005; Park et al., 2005). Regarding Hispanic samples, the most frequently researched
populations are from Mexico (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999;
McMullin et al., 2005; Watkins et al., 2002) and Brazil (Brenna et al., 2001; Pinho &
Franca Junior, 2003; Ramos et al., 2006).
In the literature there are only four Chilean articles specific to cervical cancer and
Pap test beliefs. One of them, published in 1996 (Lamadrid, 1996), talked about
knowledge and fear, but not directly about beliefs; it is a quantitative study that does not
report information about the reliability and validity of the instrument. The other three
articles are qualitative studies. The first one, published in 1998 (Lamadrid, 1998), talks
about the ways to prevent cervical cancer; the second, published in 2001 (Valenzuela &
Miranda, 2001), talks about reasons for not getting the Pap test; and the third one,
published in 2008 (Urrutia et al., 2008), also talks about womens reasons for not having
the Pap test. The Urrutia study was done with 237 women, who have had precursor
lesions, and the results are about the barriers that the women perceived about the Pap test.
The findings were an incentive to the author to continue studying this topic with another
methodology. Therefore, this dissertation will be an important step that will contribute to
cervical cancer disease and the Pap test topic in Chile. It is necessary to know in greater
depth about Chilean womens beliefs related to cervical cancer and the Pap test and the
quantitative approach will determine measurement about these beliefs.

23
Beliefs Related to Cervical Cancer and Pap Test
The different results from the literature review regarding beliefs about cervical
cancer and the Pap test will be presented according to the five health belief model
components:
1. Benefit.
The benefit of having a Pap test has been reported in different aspects. One of the
most important characteristics has been that the Pap test can detect cervical cancer early.
This is a quality reported by qualitative and quantitative studies. More than 85% of
women recognize that early detection is important (Byrd et al., 2004; Holroyd, Taylor
Piliae, & Twinn, 2003; Jirojwong & Manderson, 2001; Risendal et al., 1999), and the
idea that an early-stage change detected by the Pap test is curable, is another benefit that
the research has reported (Burak & Meyer, 1997; Byrd et al., 2004; Moreland et al., 2006;
Price et al., 1996; Seow, Wong, Smith, & Lee, 1995).
It is necessary to stress, however, that not all women recognized this last benefit.
Among Hispanic women, 30% reported that cervical cancer is easily cured, and 89.9%
believe that if the cervical changes are found early, they are easily cured (Byrd et al.,
2004).
Other benefits reported are the importance to a woman to know if she is healthy
or the fact that having a Pap test can bring peace of mind. A high percentage of Hispanic
women recognized that these are good reasons for having a Pap test (Agurto et al., 2004;
Boyer et al., 2001; Byrd et al., 2004; Moreland et al., 2006).
Other reasons associated with providing a benefit have been that one can find out
if one has a reproductive problem (Jirojwong & Manderson, 2001; Price et al., 1996), if
24
one has contracted an STD (Agurto et al., 2004; Moreland et al., 2006), if the partner has
been unfaithful (Boyer et al., 2001) or about some disease that the partner can transmit to
her (Wiesner Ceballos et al., 2006). The last two reasons were given by Hispanic women.
2. Severity.
The severity perception that the women could have regarding cervical cancer
disease is an important component of the model. The belief that cancer is a death
sentence was reported by 77% of the Hispanic women (Fernandez et al., 1998), and the
idea that the woman can die from cervical cancer was described in a qualitative study in
Colombia (Wiesner Ceballos et al., 2006). The fatalism in the Hispanic population that
some authors discussed (Antshel, 2002; Boyer et al., 2001) was also observed in Asian
(Jirojwong & Manderson, 2001; Lee Lin et al., 2007), African, (McFarland, 2003), U.S.
(Price et al., 1996), Native American (Becker et al., 2006; Risendal et al., 1999) , and
European women (Tacken et al., 2007). This belief must be considered at the time of
planning interventions because the perception that having cervical cancer means that one
is near death could be an important barrier, or a good incentive for having the Pap test.
The relationship between cervical cancer and an abnormal Pap test was
recognized by 50% of Hispanic women in the U.S. and only by 16% of Native American
women (Moreland et al., 2006). The perception that a woman is at risk for having an
abnormal Pap test was reported by 41% of Swedish women (Eaker et al., 2001). In a
study of Filipino women in Hong Kong, 20% of the women believed that the Pap test is
unnecessary (Holroyd et al., 2003). In spite of the results regarding the importance of
having a Pap test, more than 90% of women believe that cervical cancer is a serious
problem (Burak & Meyer, 1997; Holroyd et al., 2003; Moreland et al., 2006), and 72%, a
25
group of Hispanic women recognized that this disease would make a womans life
difficult (Byrd et al., 2004). The contradiction between the importance that the women
give to cervical cancer and to the Pap test must be carefully analyzed, because it is
expressed in the womans behavior.
The family is another important aspect considered by some authors in the severity
items. Nearly 80% of women believe that cervical cancer can affect the family (Holroyd
et al., 2003; Seow et al., 1995), and according to Hispanic values (Antshel, 2002), the
family is very important to Hispanic women, and it must be considered in Hispanic
research.
Finally, the severity of cervical cancer disease has been measured by the
consequences of its treatment. Surgical intervention (hysterectomy) and the beliefs
regarding surgery are the most frequent aspects researched. For women, the severity of
the disease is expressed in the fear of being a hysterectomized woman (Agurto et al.,
2004; Bingham et al., 2003); close to 33% of women believe that the uterus will be
removed if they have cervical cancer (McFarland, 2003; Price et al., 1996). The belief
about hysterectomy is an important cultural aspect that must be considered, particularly
with research on Chilean women (Urrutia, Araya, Rivera, Viviani, & Villarroel, 2007;
Urrutia, Araya, Villarroel, & Viales, 2004; Urrutia, Riquelme, & Araya, 2006).
3. Susceptibility.
Susceptibility refers to a womans perception of her risk of having cervical
cancer. To feel at risk is related to the characteristics that a woman perceives that she has
or does not have. Some authors have reported on womens beliefs about symptoms
because some women need to feel sick or notice something different about their bodies
26
before they will have a Pap test (Bingham et al., 2003; Lartey et al., 2003; Lee Lin et al.,
2007; McFarland, 2003).
Some women see the lack of symptoms as a signal that they do not need to have a
Pap test (Bingham et al., 2003; Lartey et al., 2003; Lee Lin et al., 2007; McFarland,
2003). In the Hispanic population, a great number of women reported the lack of
symptoms as a reason for not having a Pap test (Agurto et al., 2004; Boyer et al., 2001;
McMullin et al., 2005; Pinho et al., 2003; Watkins et al., 2002; Wiesner Ceballos et al.,
2006). In a Brazilian study, 88% of the women indicated that they go to the physician
only when they have symptoms (Brenna et al., 2001) and 45.3% of the women reported
needing symptoms before they will have a Pap test (Pinho et al., 2003). The need to have
symptoms is less frequent in populations like Chinese (Taylor et al., 2002), Filipino
(Holroyd et al., 2003), and Australian (Girgis, Bonevski, Perkins, & Sanson Fisher,
1999). It is important to remember that many times the Pap test is part of a visit for
prenatal care or birth control (McMullin et al., 2005) and many times the women did not
know that the test was taken.
There have been some misconceptions about the requirements for having a Pap
test. One of the common mistakes in the Hispanic population is the idea that a woman
needs to have had intercourse or have an active sexual life for it to make sense to have a
Pap test; therefore, if they are not sexually active, they do not need it. Among Asian
women, this belief was reported as a barrier to having a Pap test (Holroyd et al., 2003;
Jirojwong & Manderson, 2001; Taylor et al., 2002).
The other requirement is that there are women who feel it is necessary to be
premenopausal to have the test; Chinese women (Holroyd et al., 2003; Lee Lin et al.,
27
2007; Taylor et al., 2002), Hispanic women (Koval et al., 2006), and Serbian women
(Markovic et al., 2005) reported this belief. On the other hand, a group of Korean women
believed that menopause could be the reason for having cervical cancer (M. C. Lee,
2000).
Another misconception is that women need to have had babies before having a
Pap test (Byrd et al., 2004) and that the Pap test is more useful for women with children
(Agurto et al., 2004). Both ideas were reported only in the Hispanic population.
The age as a requirement is a variable that has confused women. They do not
understand what the age is for having a Pap test, and therefore, it has been transformed
into a barrier to the screening (Holroyd et al., 2003; Lee Lin et al., 2007). Women
perceive that after 50 years of age, the Pap test is unnecessary (Byrd et al., 2004; Koval et
al., 2006; A. Smith et al., 2004), but others believe that with increasing age is a cause of
cervical cancer (P. Lee et al., 2007).
A family history of cancer is another aspect that different authors considered.
Women reported that heredity is a factor that increases susceptibility (Jirojwong &
Manderson, 2001; M. C. Lee, 2000; P. Lee et al., 2007; McFarland, 2003). This topic has
not been studied in Chilean population and it is important to know what women think
about this, because the family history could be an important barrier or a good incentive
for having the Pap test.
Women have been asked directly what their perception was of their risk of
developing cervical cancer. In Hispanic studies, almost 20% of the women did not feel
susceptible to cervical cancer (Byrd et al., 2004; Fernandez et al., 1998), and these values
were similar in other populations (McFarland, 2003; Moreland et al., 2006; Tacken et al.,
28
2007). In the U.S. population, the perception of the risk is smaller than in the other
groups (Price et al., 1996). In a multicenter study, the authors reported that the women
believed that an abnormal Pap test means that one is dirty and promiscuous (Bingham et
al., 2003). This misconception was also reported among Thai women living in Australia
(Jirojwong & Manderson, 2001), where it was found that women having an abortion
history were at risk.
According to the factors previously found by authors, the lack of education or a
clear explanation from a health care professional could be the real cause related to the
phenomenon. It is necessary that professionals are very clear when explaining the Pap
test screening and clarifying which of the populations beliefs are erroneous; thus the
explanation and intervention could be carried out in way that focuses more on the
womens needs.
4. Barriers.
The barrier is the component of the health belief model described very frequently.
Many articles reported only barriers to cervical cancer screening and others talk about
beliefs regarding cervical cancer and the Pap test as synonymous with the concept of
barriers.
Among Chilean women the fear of pain was reported as a barrier to have a Pap
test (Lamadrid, 1996; Urrutia et al., 2008; Valenzuela & Miranda, 2001).The pain is
associated with the pelvic exam (Agurto et al., 2004) or the Pap test itself (Burak &
Meyer, 1997; Hunter, 2005; Wiesner Ceballos et al., 2006). Close to 40% of Hispanic
women in the U.S. reported that the pain was a psychological barrier (Fernandez Esquer
& Cardenas Turanza, 2004; Koval et al., 2006), and this value was similar or higher in
29
other populations (Holroyd et al., 2003; Holroyd, Twinn, & Shia, 2001; Jirojwong &
Manderson, 2001).
Fear has been reported as related to the pain but also related to the diagnosis
(Agurto et al., 2004; Hunter, 2005; Urrutia et al., 2008; Valenzuela & Miranda, 2001).
This has also been a reason for not having the Pap test (Lee Lin et al., 2007). In a Cuban
study, the authors compared the women who had the Pap test with women who had not
had it, and 84% of those who had not had the test reported fear of diagnosis, while 32%
of those who had had it reported this barrier (Soto, Martin, Carballo, & Benitez, 2003).
Another feeling associated with the fear is the embarrassment related to having a
Pap test and showing the genital area (Becker et al., 2006; Boyer et al., 2001; Henning &
Knowles, 1990). In Chile, women gave it as a reason for not having a Pap test (Urrutia et
al., 2008). The percentage of Hispanic women (50%) have described the embarrassment
to be a barrier (Fernandez Esquer & Cardenas Turanza, 2004; Fernandez et al., 1998;
Watkins et al., 2002), and as high as 87% was reported in a study of Brazilian women
(Brenna et al., 2001).
Lack of time has been given as a reason for not taking advantage of health care in
many areas and this reason is not absent in the reasons for not having a Pap test. Women
say that they never have enough time for that (Holroyd et al., 2003; Koval et al., 2006)
and the principal cause is their work responsibilities (Markovic et al., 2005; Wiesner
Ceballos et al., 2006). Chilean women also referred to this barrier (Lamadrid, 1996, 1998;
Urrutia et al., 2008). It is interesting that in two studies, the Pap test was considered a
waste of time (Eaker et al., 2001; Fernandez Esquer & Cardenas Turanza, 2004).
30
Knowledge is a variable that has not been consistently defined and therefore the
researchers have considered different definitions. The information about the risk factors
(Lee Lin et al., 2007; Price et al., 1996), what the Pap test means and why it is useful
(Brenna et al., 2001; Hunter, 2005; Valenzuela & Miranda, 2001; Watkins et al., 2002),
the guidelines regarding frequency and criteria for having it (Fernandez et al., 1998;
Lartey et al., 2003; Risendal et al., 1999; Soto et al., 2003), the relationship between HPV
and cervical cancer (McMullin et al., 2005), and the importance of the test as a
component of prevention (M. Smith et al., 2003) have been considered like a knowledge
variable. Different articles have reported lack of knowledge to be a barrier and Chilean
women are in agreement with that (Urrutia et al., 2008). Hispanic women reported lack of
knowledge about the recommended frequency of the Pap test (Fernandez et al., 1998), the
criteria (Valenzuela & Miranda, 2001) and available services (Boyer et al., 2001). In a
Thai study, 29% of the women did not know how the Pap test is done (Jirojwong &
Manderson, 2001).
Cost was found to be a significant barrier. The cost could be related with
transportation or access to the service. The lack of transportation was a concern among
Crow Indians in the U.S. (A. Smith et al., 2004), women living in Australia (Girgis et al.,
1999) and Chinese women in the U.S. (Taylor et al., 2002). The cost of the exam could
be another barrier (Byrd et al., 2004; Fernandez et al., 1998; Taylor et al., 2002; Wiesner
Ceballos et al., 2006), particularly when the women do not have health insurance (M.
Smith et al., 2003) or when they do not know how much they will need to pay (Bingham
et al., 2003; Boyer et al., 2001). The perception that the Pap test is expensive was
31
reported among U.S. women (Burak & Meyer, 1997), Hispanic women (Fernandez
Esquer & Cardenas Turanza, 2004), and Chinese women (Taylor et al., 2002).
Quality of care is an important variable that must be considered in health care and
if one is addressing adherence to some screening, this could be an enormous barrier.
Disrespectful and discourteous manners were reported in research with a Hispanic
population (Agurto et al., 2004; M. Smith et al., 2003; Wiesner Ceballos et al., 2006).
The women expected to be treated with respect (Boyer et al., 2001), but the providers
were impersonal and uninformative (Koval et al., 2006). In a Chilean study (Lamadrid,
1996), researchers reported that 60% of the women were afraid of the midwifes, because
the women had forgotten to ask for a previous appointment. This aspect must be
considered a part of the Hispanic culture: personalismo (personal relationships) and
respeto (respect) are typical values that are important to Hispanic people (Antshel, 2002).
The frustration of the women with regard to the health care system stems from
bureaucratic problems (Becker et al., 2006), lack of privacy (Bingham et al., 2003),
negative staff attitudes (McFarland, 2003), and mistrust of the providers. Long waiting
times (Agurto et al., 2004; Brenna et al., 2001; Valenzuela & Miranda, 2001) and
crowded waiting rooms (Markovic et al., 2005) are some of the barriers of the health care
system. The women reported having problems with the hours that the health care systems
had for having Pap tests (Pinho et al., 2003; Wiesner Ceballos et al., 2006) and a need for
more flexible appointment schedules (Boyer et al., 2001) that would not conflict with
their work hours (Girgis et al., 1999; Moreland et al., 2006).
The partner permission or agreement with the test has been frequently reported in
studies with Hispanic women (Aguilar Perez et al., 2003; Agurto et al., 2004; Byrd et al.,
32
2004; Koval et al., 2006; Wiesner Ceballos et al., 2006). The belief that the partner must
support the woman in having this exam has been found in other cultures, such as African
(Bingham et al., 2003), Chinese (Hou & Luh, 2005), and Australian (Henning &
Knowles, 1990) cultures. Hispanic partners think that the Pap test means manoseo (to
handle or touch excessively) (Wiesner Ceballos et al., 2006) and they do not want the
women to be examined by a male (Koval et al., 2006). This behavior could be associated
with one of the most typical characteristics in Hispanic culture: machismo (male
dominance) (Antshel, 2002).
The gender of the provider is also a barrier for women (Agurto et al., 2004;
Bingham et al., 2003; Hou & Luh, 2005). Many women feel embarrassed with a male
doctor (Jirojwong & Manderson, 2001) and the majority of them prefer female health
care providers (Boyer et al., 2001; Girgis et al., 1999; Henning & Knowles, 1990;
Holroyd et al., 2001; Lee Lin et al., 2007; Steven et al., 2004). The Chilean women also
reported this (Urrutia et al., 2008; Valenzuela & Miranda, 2001) and talked about
embarrassment and pudor (modesty, reserve) associated with being examined by male
providers.
Two Chilean studies mentioned the womens fear of the test itself could cause the
intrauterine device (IUD) to be expelled (Lamadrid, 1996; Valenzuela & Miranda, 2001).
Denny Smith et al. (2006) reported that a group of nursing students in the U.S. believed
that IUDs could cause cervical cancer.
The importance of the family over the individual, called Familism, is another
Hispanic value that must be considered in the reported results (Antshel, 2002; Wiesner
Ceballos et al., 2006). Hispanic women find this to be a barrier to obtain a Pap test and
33
specifically Chilean women (Urrutia et al., 2008). The women prefer to resolve the
family concerns before having the Pap test. Also, the women refer to be delayed to have a
Pap test because of their families (Urrutia et al., 2008; Wiesner Ceballos et al., 2006).
Urrutia et al. (2008) cited a womans answer las mujeres se postergan, primero el
grupo familiar despus ellas (women delay themselves, first the family group and later
themselves).
5. Cues to Action.
This concept has not been treated as such because many authors talk about cues as
benefits and the lack of cues as barriers. However, according to Rosenstocks definition
the variables discussed below should be considered cues.
The most studied cue is the importance of the health care providers
recommendation; this is a very important stimulus for having a Pap test (Holroyd et al.,
2003; Lee Lin et al., 2007). In a Brazilian study, 25% of the women reported that they
have a Pap test based on the physician recommendation (Pinho et al., 2003) and in the
U.S., 59% of the Hispanic women (Fernandez Esquer & Cardenas Turanza, 2004) and
58% of the Chinese women (Taylor et al., 2002) think that the physician should
recommend the Pap test. In a study in which the authors used the health belief model for
their framework, this cue was the main stimulus for having the Pap test (Henning &
Knowles, 1990). The fact that women do not have the Pap test if the physician does not
recommend it (Henning & Knowles, 1990; Ho et al., 2005; Holroyd et al., 2003; Lartey et
al., 2003) positions women as passive recipients of medical care (Markovic et al., 2005).
This is an important factor that must be considered in research.
34
Experience or contact with women who have cervical cancer is another cue
discussed in the literature and it has been described like a powerful experience (M. Smith
et al., 2003), and good motivation among Hispanic women (Boyer et al., 2001).
According to Hennig (1990), this is the second most influential cue for the women.
However, this motivation must be considered according to the percentage of women who
have had relatives or friends with cervical cancer because studies have reported relatives
with cancer in 12% in a Chinese study (Lee Lin et al., 2007), 8% in Vietnamese women
(Ho et al., 2005), and 50% in an African study (McFarland, 2003). In a Filipino study,
only 1% of the women had the Pap test because they had known some person with
cervical cancer (Holroyd et al., 2003).
Advice from a mother or a friend has been another signal of action. Henning
(1990) indicated that the recommendation from a relative or a significant person is the
third most important cue. Holroyd (2003) said that 15% of women reported that a friend
talked to her about having a Pap test, and 30% of them had the Pap test based on this
recommendation. In a Chinese study, 20% of the women reported that a friends advice
was a reinforcing factor (Taylor et al., 2002), and among Vietnamese women, it was a
factor for 9% of the women (Ho et al., 2005).
Self-care could be a good cue, but it has not been reported frequently in the
literature. Procrastination and laziness were reported in previous studies (Agurto et al.,
2004; Boyer et al., 2001) including a qualitative Chilean study (Urrutia et al., 2008). In a
Brazilian study, 55% of the women reported they had the Pap test spontaneously (Pinho
et al., 2003), and self-care was named as a motivation for taking action in studies of
Colombian (Wiesner Ceballos et al., 2006) and Korean women (Park et al., 2005).
35
Media advice by television, radio, and magazines is a cue reported to have had
little impact on the population. In a study in Singapore, 25% of the women declared they
had received information about cervical cancer from television or radio, and only 8%
from magazines (Seow et al., 1995), In another study, this information was a cue to have
a Pap test for only 1% of the sample (Ho et al., 2005; Holroyd et al., 2003). However, for
Hispanic women it has been considered a good strategy for improving cervical cancer
screening (Boyer et al., 2001). More women want to receive more information about
cervical cancer disease and screening through the media or by education delivered to
them directly (Markovic et al., 2005; Wiesner Ceballos et al., 2006).
Predictor Factors of Pap Test Screening
Where beliefs were related to screening, the literature reported some results from
predictive studies. A logistic model that was employed to predict the use of the Pap test
found that one of the variables that predicted the Pap test screening was the lack of
barriers (Ho et al., 2005). McFarland (McFarland, 2003) reported that barriers was the
only belief variable related with screening behaviors.
If the women believe that the doctor will be honest, it is a good predictor that they
will have the Pap test (Kahn, Goodman, Huang, Slap, & Emans, 2003). Fears of the
screening, embarrassment, and lack of knowledge are others barriers shown to be related
to Pap test screening in a logistic model (Fernandez et al., 1998). In an Indian study, pain
was the most important barrier related to Pap test screening (A. Smith et al., 2004), and in
the Hispanic study, the embarrassment was a predictor of failure to have the screening
(Fernandez et al., 1998).
36
Benefit has been reported as a predictor of receiving the Pap test and a barrier for
not receiving it (Eaker et al., 2001). A belief in the benefit that the Pap test can prevent
cervical cancer was associated with having a Pap test (Kahn et al., 2003), and
susceptibility was related to the womans perception of severity (Denny Smith et al.,
2006).
Having received cues to obtain a Pap test is an important variable related to a
womens behavior and the Pap test (Kahn, Goodman, Slap, Huang, & Emans, 2001). The
women who have had Pap tests also have received more cues (Burak & Meyer, 1997).
The belief that the physician must recommend the Pap test was an important factor for
women (A. Smith et al., 2004).
Multiple regressions analyses were conducted by Burak and Meyer (1997) to
determine the utility of the health belief model constructs in predicting cervical cancer
screening; they were successful in predicting approximately 15% of the variance: benefit
minus barriers and cues to action contributed the strongest weight to the model. The
women who had the Pap test believe that benefits outweighed the barriers and they had
more cues to action than the group of women without the Pap test (Burak & Meyer,
1997).
Health Belief Model and Needs for Developing Cervical Cancer Screening Instruments
The key constructs of the health belief model posit that individuals will engage in
a health behavior. In the of case cervical cancer screening, if they perceive themselves to
be susceptible to the disease, believe the consequences of having cervical cancer or an
abnormal Pap test to be severe, recognize both the benefits and barriers of screening, and
37
receive positive cues to undergo screening, the women will engage in Pap test screening
(Guilfoyle, Franco, & Gorin, 2007; Janz & Becker, 1984).
One weakness in the articles reviewed between 1959 and 2008 was the
inconsistent reporting of the reliability and validity of the questionnaires used. Authors
define the variables, describe the number of items, but they do not report how the
questionnaire was developed or the validation process (Blake, Weber, & Fletcher, 2004;
Brenna et al., 2001; Koval et al., 2006; Lartey et al., 2003; Moreland et al., 2006;
Risendal et al., 1999; A. Smith et al., 2004; Taylor et al., 2002; Watkins et al., 2002).
Some authors only report reliability but not validity (Byrd et al., 2004; Fernandez et al.,
1998; Jirojwong & Manderson, 2001; Tacken et al., 2007); others say the questionnaire
was validated and that it is reliable without giving information that permits the reader to
know the procedure and results (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999;
Pinho et al., 2003). The Cronbachs coefficient alpha determines the most appropriate
index to report reliability, and it was used frequently by the researchers (Fernandez
Esquer & Cardenas Turanza, 2004; Ho et al., 2005; Hou & Luh, 2005; Jirojwong &
Manderson, 2001; Park et al., 2005; Price et al., 1996).
Another aspect related to the validation process that was very significant in the
literature review was that authors tend to minimize the report on validity, confining it to
one aspect only: either content validity or construct validity (Eaker et al., 2001; Ho et al.,
2005; Holroyd et al., 2001; Hou & Luh, 2005; Jirojwong et al., 2001; Lee Lin et al.,
2007; McFarland, 2003). The pretest or validation process is the process most frequently
reported (Ho et al., 2005; Holroyd et al., 2001; Jirojwong et al., 2001; Lamadrid, 1996;
McFarland, 2003; Yi, 1998) and the review by an expert panel is named but without
38
information about how the procedure was done (Burak & Meyer, 1997; Denny Smith et
al., 2006; Hasenyager, 1999). Construct validity is reported in less frequency (Eaker et
al., 2001; Hou & Luh, 2005). The lack of a reliable, validated questionnaire is another
reason to support the development of an instrument to find out the beliefs that Chilean
women have about the Pap test and cervical cancer.
The validation and reliability problem with the different instruments was a reason
for not using the existing questionnaires described in the literature review, but rather for
developing and testing a new questionnaire designed specifically for Chilean women.
There does not exist an instrument that addresses the beliefs that are culturally sensitive
to Chilean women. This new instrument will include items that include culturally
sensitive content.
Measurement Issues Related to the Development of a Validated and Reliable
Questionnaire.
Measurement is a fundamental activity for researchers and a great concern in
social science research is to acquire knowledge about people and events (De Vellis,
2003b). Nursing science needs to build a body of knowledge to develop its own
measurement procedures or to improve questionnaires. Refining existing instruments is
the most cost-effective step that can be taken to improve the quality of research (Fowler,
1995), but sometimes it is necessary to develop new instruments that are appropriate to
address the research question.
When there is not an appropriate questionnaire for a research topic, it is necessary
to build new, reliable, and valid instruments. The literature review supports the need to
develop a new and reliable instrument, and then validate the new instrument for Chilean
women. During the building process, it is important to consider many aspects for
39
improving prior research. One of the most important aspects is the health belief model
theory that the author of this study will use, which will help to conceptualize the
measures being developed. Another aspect to consider is the psychometric properties of
the instrument. These considerations are important, and if carefully applied, will result in
an instrument that can address the research topic. This dissertation has considered both
requirements.
Adequate sample size with adequate participants is needed to validate a
questionnaire. Two central risks with using too few participants include: (a) patterns of
covariation may not be stable because chance can substantially influence correlations
among items when the ratio of participants to items is relatively low and (b) the sample
would not be representative of the population (De Vellis, 2003b).
The best analysis is where large Ns and high ratios (person/item) are present
(Osborne & Costello, 2004). Larger samples in factor analysis provide more precise and
stable estimates of factor loading in the population (Hogarty, Hines, Kromrey, Ferron, &
Mumford, 2005). When validity is estimated for small samples, the errors are relatively
large, and the statistical power of the inferential procedures may be substantially reduced
(Crocker & Algina, 2008b).
Nunally (1994a) and other authors (Clark & Watson, 1995; Ferguson & Cox,
1993; Pett, Lackey, & Sullivan, 2003b; Worthington & Whittaker, 2006) emphasize the
need to have the sample size of at least 300 cases for factor analysis. In relation to the
ratio subject/item, a minimum of five people per variable is recommended (DeVon et al.,
2007; Fabrigar, Wegener, MacCallun, & Strahan, 1999; McDowell, 2006). These criteria
40
are emphasized to provide stability to the analysis. The stability means that the factors
identified in this sample can be generalized to all possible samples (Velicer, 1974).
Developing questionnaires may be more demanding than using informal
measures, but it is the way to obtain the best results and consequently improve nursing
practice. Research indicates that there is not a reliable and validated instrument to
measure Chilean womens beliefs about Pap test screening; therefore, this work will
develop and test a new questionnaire regarding cervical cancer and Pap tests for the
Chilean population. This need is strongly supported by the literature review.
Summary
This chapter has provided an overview of a review of literature on cervical cancer
mortality and incidence rates, the Pap test and cervical cancer screening, health belief
model history and its relationship to cervical cancer screening, the research of different
authors related to beliefs regarding cervical cancer screening and the Pap test, and a lack
of appropriate instruments to answer the research question. Chapter 3 outlines the
methodology used to develop and validate an instrument to measure health beliefs of
cervical cancer and Pap test screening in Chilean women.

Chapter 3. Methods and Procedures
Design
A cross-sectional design was implemented to validate a newly developed
questionnaire about beliefs related to cervical cancer and the Pap test in Chilean women.
This design allowed the researcher to apply and test a new instrument for Chilean women
and to identify the questionnaire structure by exploratory factor analysis (EFA).
Setting and Population Served
Data was collected in a womens health care center in an urban neighborhood in
Santiago, Chile. This health care center is the ambulatory part of the hospital, Doctor
Stero del Rio, in Santiago, Chile. This public hospital serves a population of
approximately 1,347,000 people and is part of the Servicio de Salud Metropolitano Sur-
Oriente (Southeast Metropolitan Public Health Service) of Santiago. The ambulatory
womens health care center serves close to 300 Chilean women per week, who are 15
years or older (Gobierno de Chile, 2008). The women come from different ambulatory
clinics from Servicio de Salud Metropolitano Sur-Oriente (Southeast Metropolitan Public
Health Service) and the majority of women have public health care insurance. The
women need an appointment to attend the clinic for care and the majority of cases are
referred from primary health care centers within the area.
Sample
The researcher continued recruitment until a sample of 300 women was obtained.
This sample permitted the researcher to provide stability to the data analysis. During the
data collection process, the sample was increased from 300 to 333, because 33
questionnaires had one item that was not answered; therefore, it was considered to
41
42
replace the questionnaire by another questionnaire to obtain 300 completed questionnaire
according to criteria explained in chapter 2.
Recruitment
Recruitment was initiated by the researcher, who placed flyers (Appendix A and
B) at the receptionist desk, and also posted them in the waiting room of the ambulatory
womens health care center. The researcher was at the center every day and available
during patients scheduled hours (Monday to Friday, 8:30 to 17:00 hours).
The flyers provided information about the study, the inclusion criteria and contact
information. The researcher was available each day to explain the study to the women
using the participant letter, answer their questions, and obtain informed consent. Upon
receipt of the signed informed consent, each participant received the questionnaire.
The inclusion criteria were women who are 18 to 64 years of age. The exclusion
criteria were women who are younger than 18 years of age and older than 64 years of
age, have had a hysterectomy, and have cervical cancer disease. The first exclusion
criterion was selected because women younger than 18 years of age must obtain consent
from their parents, and it is not mandatory for women younger than 18 years of age in
Chile to have a Pap test. Women older than 64 years of age were chosen because this age
is not considered the targeted group of women at risk to have a Pap test in Chile
(MINSAL,2008). Women with a history of a hysterectomy and cancer do not need to
follow the Pap test screening recommendation; their beliefs will possibly be influenced
by the surgery or the disease.

43
Consent Procedure
The consent form (Appendix C and D) followed the template of the University of
Miami, Coral Gables, FL and it was obtained upon IRB approval of Doctor Sotero del
Rio hospital in Chile and University of Miami. The researcher collected the signed
informed consent form from the women who had previously read a participant letter
(Appendix E and F), which was provided by the researcher. The answers selected by the
participant were confidential. The names of the participants did not appear in any
document. The participants were identified through a correlate number (1, 2, 3, 4, so on)
in the questionnaire, which was assigned by the researcher prior to being given to the
participants. The relationship between the name of the participants and their answers is
not possible to be linked. The participants were identified in the data base only by the
number assigned. The informed consents and questionnaires will be secured in a locked
cabinet in the researchers office for five years in Santiago, Chile. For security reasons,
the researcher scanned the documents and these scanned documents were carried by the
researcher to the University of Miami, Coral Gables. The documents and the scanned
archives will be stored in a locked cabinet of the researchers office in Santiago Chile for
five years.
Data Collection and Variables
After the women signed the consent forms and agreed to participate in the study,
each participant received the 53 item beliefs questionnaire and 11 item demographic
questionnaire to answer. The questionnaires take 15-20 minutes to answer. The structured
questionnaires include demographic items and the beliefs questionnaire (beliefs related to
cervical cancer and Pap test variables). The demographic questionnaire is presented in
44
Appendix G in Spanish and the English version in Appendix H; and the final version of
the beliefs questionnaire is reported in Appendix I in Spanish and Appendix J in English.
The demographic items included are age, educational level, marital status, number
of children, type of health insurance, employment status, and health variables related to
cervical cancer and the Pap test (date of the last Pap test, results of the last Pap test, and
family history of cervical cancer). All of these variables permitted the researcher to
describe the sample. These variables were chosen because research findings support Pap
screening behaviors (Aguilar Perez et al., 2003; Lazcano Ponce et al., 1999; Lucumi &
Gomez, 2004; Ramos et al., 2006; Watkins et al., 2002).
Construction Methodology for Beliefs Questionnaire
The Beliefs questionnaire was developed to answer the gap of knowledge for Pap
test and cervical cancer beliefs of Chilean women. This questionnaire was based on the
health belief model and the items were generated to represent the properties of the five
health belief model domains: susceptibility, severity, barriers, benefits, and cues to action
(Table 1, page 18).
The questionnaire followed the guidelines by Robert de Vellis (2003b) in scale
development. De Vellis (2003b) described eight steps, seven of which were followed: (1)
determine clearly what it is you want to measure, (2) generate an item pool, (3) determine
the format for measurement, (4) have the initial item pool reviewed by experts, (5)
administer items to a development sample, (6) evaluate the items, and (7) optimize scale
length. The step, in which de Vellis considered the inclusion of validation items from
other scales, was not followed because it was not the aim of this dissertation.
45
The next paragraphs describe the development of the questionnaire according to
the seven steps described by De Vellis.
1. Determine the construct that will be measured.
The original questionnaire was developed following an extensive review of
quantitative and qualitative literature on beliefs about cervical cancer, the Pap test, the
health belief model, and questionnaires related to beliefs with or without the health belief
model as the framework. The review of literature was addressed in Chapter 2 and this
review included articles in Spanish, Portuguese, and English. Spanish and Portuguese
languages are the native language in Latin America; therefore, to review the literature in
these languages was mandatory to address the topic in the Hispanic population and
specifically in the Chilean population. The construct that was measured is beliefs related
to cervical cancer and the Pap test and the beliefs were supported by the health belief
model framework (Rosenstock, 1974b).
2. Determine the items to be included in the scale.
According to the construct and based on the literature review, the initial pool of
items was developed. The items represent each of the five health belief model domains
with the variables reported in the literature review. The researcher reviewed each article
and selected the relevant variables that would support the items. All items that were
included in the initial pool have the properties described by the health belief model
definition (Table 1, page 18).
The initial item pool consisted of 60 items: seven items about severity, 11 items
about susceptibility, eight items about benefits, 22 items about barriers, and 12 items
about cues to action. The number of items for each domain was determined by the
46
literature review and the frequency that each domain is researched. The barriers are the
most frequently reported domain by the literature; therefore, 22 items in this domain
reflect its entirety.
3. Determine the format of the questionnaire.
The items were scored on a 4-point Likert scale, ranging from strongly agree to
strongly disagree. An even number in the scale was chosen because it was considered
important for the women to choose an answer in one direction or the other (De Vellis,
2003b). In the Hispanic culture, there is a tendency to avoid conflicts (Antshel, 2002) and
to not have a neutral answer will avoid this tendency. The instructions asked participants
to choose the level of agreement for each item, and emphasized that there is no right or
wrong answer. Subjects will be told that if they feel that they dont have information or
knowledge about some items, they need only to select the answer closest to their beliefs.
This is an important element in the instructions because the women need to feel
comfortable answering the questions (instructions in Appendix I and J).
4. Have an expert panel review the questionnaire.
Content validity was done following the guidelines described by Lynn (1986).
After the item pool was developed, 10 Chilean experts were asked to review the
questionnaire. Lynn (1986) reported that a minimum of five and no more than 10 experts
would provide a good level of control for chance agreement. All the experts were health
care professionals associated with womens health and field of cervical cancer: seven
nurse-midwives (four are faculty members in the School of Nursing, Pontificia
Universidad Catlica de Chile, and one in the School of Nursing, University of Miami,
Coral Gables), and three physicians who are specialists in obstetrics and gynecology (one
47
is a faculty member in the School of Medicine, Pontificia Universidad Catlica de Chile).
The experts were chosen because they are native Chilean professionals; therefore, they
know the Chilean culture and how the women may feel about cervical cancer and the Pap
test.
The reviewers considered the clarity of the items, relevance to the concept
domain, and whether the items should remain in the questionnaire. The definitions of the
construct, presented in Table 1 (page 18), were provided to the expert panel. The panel
was asked to rate each item on a 4-point Likert scale, ranging from strongly agree to
strongly disagree, and to provide suggestions for modifications, alternative wording, or
moving the items to another domain. The 4-point Likert scale was chosen according to
Lynns recommendation (Lynn, 1986). The guideline for the content validity revision
was provided to the experts (Appendix K in Spanish and the English version in Appendix
L).
Feedback from the expert panel was carefully reviewed. Content validity
calculation according to Lynn was used (Beck & Gable, 2001; DeVon et al., 2007; Lynn,
1986; Polit, Tatano Beck, & Owen, 2007). The content validity index (CVI) by Lynn,
was selected because of its concrete method of construction, it is the most used
quantification of content validity (Lynn, 1986; Polit et al., 2007), and its use has been
recommended by the experts in research methodology (Polit et al., 2007). The item-CVI
(I-CVI) is calculated by the number of experts giving a rating of agree or strongly
agree. The scale-CVI (S-CVI) represented the average I-CVI across the item (Polit et al.,
2007). The I-CVI and the S-CVI were calculated by the content experts, who rated two
aspects: if the item was part of one of the five health belief model domains and if the item
48
should remain in the questionnaire. According to Lynns recommendation (1986), an
acceptable value for both I-CVI and S-CVI, when the number of experts is 10, must be at
least .80; therefore the items with a I-CVI lesser than .80 were eliminated (Appendix M).
The S-CVI was .90 for the health belief model domain and .91 for the items that will
remain in the questionnaire. The recommendation is to obtain .90 or higher (Polit et al.,
2007). The S-CVI is presented in Appendix N.
After content validity was established by the experts, the questionnaire consisted
of 53 items. Eight items were deleted based on I-CVI less than .80, three items from the
benefit domain, because the items did not target the domain and they would confuse the
women; one from the severity domain because the item was considered vague and not
related to the domain; one from the susceptibility domain because it was considered to be
more related to the barrier domain; and three from the barriers domain because they were
not considered to be a barrier. Five items were rewritten because the experts suggested
adding or replacing some words to clarify the items. There were 47 items that remained
unchanged. One item was added to the susceptibility domain at the suggestion of two
experts (Appendix O for Spanish version and Appendix P for English version).
The S-CVI of this modified questionnaire was .93 for the health belief model
domain and .93 the domains remain in the questionnaire. The different domains with the
respective items are presented in Table 2 (page 49).
The questionnaire was piloted with 25 Chilean women in Doctor Sotero del Rio
Hospital, Santiago, Chile, the same hospital that the researcher applied the new
instrument. Participants were invited only to read the items without answering the
questionnaire, evaluate verbally if the items were difficult for them to comprehend,

Table 2
Domain and Items: Urrutias Questionnaire
Health Belief
Model
Component
Urrutias Questionnaire Domain Urrutias Item
Severity

Of getting an unsatisfactory test result An abnormal Pap test, without treatment, can lead to
cervical cancer.
Getting a Pap test can avoid a serious health problem.
Of having a cervical cancer. Cervical cancer may lead to death.
Cervical cancer is a serious health problem.
Of having cervical cancer treatment. Cervical cancer may lead to a woman having a
hysterectomy.
Cervical cancer can lead to a woman needing to receive
chemotherapy or radiotherapy treatment.
Susceptibility

To have an abnormal Pap test or cervical
cancer
I am not at risk for an abnormal Pap test.
I am not at risk for developing cervical cancer.
If she has symptoms If I do not have symptoms, I do not need a Pap test.
If she has children If I have not had children, I do not need a Pap test.
If she is pregnant If I am pregnant, I do not need a Pap test.
If she has a sexual active life If I do not have intercourse, I do not need a Pap test.
4
9


If she has menopause If I am in menopause, I do not need a Pap test.
If she has sterility If I am sterilized, I do not need a Pap test.
If she has family history If I do not have a history of cervical cancer in my family, it
is not likely that I am going to have it.
If she has a specific range of age. Cervical cancer is one of the most common
cancers among women my age.
Regarding to die by a cervical cancer If I have cervical cancer, I can die.
Benefit To take care about her health Getting a Pap test makes me feel good because it means
that I take care of my health.
To find early cervical cancer Getting a Pap test allows for early detection of cervical
cancer.
To make a good investment of time Getting a Pap test is a good investment of my time in
health.
To treat early the cervical cancer A Pap test can find cervical cancer when it is still possible
to cure it.
To save her life. The Pap test can save my life.
Barrier Pain Getting a Pap test is painful.
Embarrassment Getting a Pap test is embarrassing for me.
I have not taken the Pap test because I am embarrassed to
have a genital exam.
5
0


Health care gender I prefer that a female gives me the Pap test, because it is
uncomfortable for me if a man does it.
Lack of knowledge about the procedure I do not have information about where to go to get a Pap
test.
I do not know if I need to have a Pap test.
I do not know at what age it is necessary to have a Pap test.
I do not know how often I need to get a Pap test.
Economic cost Getting a Pap test is expensive.
It is difficult to get a Pap test because I do not have money
for transportation (take a bus, subway).
Lack of time I do not have time to get a Pap test.
Fear of cervical cancer diagnosis I have not taken the Pap test because I am afraid to find out
if I have cancer.
Difficulties in the access to health care system I have not taken a Pap test because when I go, I need to
wait a long time to be seen.
I have not taken the Pap test because the health care center
is only open during hours when I cannot go.
I have not taken a Pap test because it is difficult to get an
appointment.
Bad previous experiences in the healthcare I have not taken the Pap test because they treat me badly in
5
1



5
2

system the health care center.
Lack of partner consent My partner/husband does want me to get a Pap test.
The risk to move the intrauterine device A Pap test can move the intra uterine device (IUD).
The risk to give her social problems. If an unmarried or single woman gets a Pap test, people
may think that she is having sex.
Cues to action Self care To take care of my health.
Information received After hearing something about cervical cancer.
Health care providers prescription Because a nurse or midwife told me.
Because a doctor told me.
Family or friends advice Because my mother spoke to me about it.
Because a friend or neighbor spoke to me about it.
Because members of my family told me to get it.
Media motivation Because I listened to or read something in the newspaper
or in a television or radio program.
Development of symptoms Because I had genital bleeding.
Because I had pain in my genitals.
Because I had discomfort in my genitals.
Cervical cancer experience related to a friend
or family member.
Because someone I know well (family, friend, neighbor)
had cervical cancer.
53
recommend items for deletion or modification, and/or suggest new items. The
53recommendations were noted. The instructions are in Appendix Q and R.
The number of items did not change. Ten items were modified, adding some
synonyms or changing some words to improve understanding. Of the total pretest sample,
seven women commented that they had problems because I do not know the answer;
therefore, a sentence was added to the instructions, clarifying that if they were not sure
about an answer they were free to answer only what they believed. The final
questionnaire in Spanish is in Appendix I, and the English version is in Appendix J. The
final Spanish questionnaire was translated to an English version and then was translated
to Spanish (back-translation). Both versions were reviewed by an expert bilingual
translator, a US native person, who certified that the translation was accurate and correct.
5. Administer items to 300 women.
The questionnaire was administered once signed informed consent was received.
Upon completion questionnaires were returned to the researcher. During this time the
researcher was available in the hospital setting to address questions and collect the
completed questionnaires.
6. Evaluate the items.
EFA using Principle Axis Factoring (PAF) was used to evaluate the items and
structure of the Beliefs questionnaire (De Vellis, 2003a). Cronbachs coefficient alpha
was applied and used to indicate the reliability of the questionnaire items (De Vellis,
2003b). This step has been considered a critical component in the scale development
process and it will be described in depth in Chapter 4.
54
7. Optimize the scale length.
According to De Vellis (2003b), this is the last step in the scale construction, and
the scale length depends on the results from step 6. The items deleted or maintained and
the reason for this step has been described in Chapter 4.
Data Analysis
Data were analyzed using the Statistical Package for Social Sciences (SPSS) 16.0
software (Field, 2005; Green & Salkind, 2005). For each domain, the researcher entered
the data in a logical sequence. Frequencies were run on each variable to identify missing
data or data error. Table frequencies and means of the variables with minimal and
maximal values were run to identify any mistakes in the data; if a mistake was found, the
answer from the questionnaires were checked to address the error. For example, if the age
was not correct according to the range established in the inclusion criteria, this
information was reviewed in the corresponding questionnaire.
Data analysis: demographics questionnaire.
Descriptive statistics of the demographics variables were analyzed. Age and
educational level were analyzed to determine means, standard deviations, and minimal
and maximal values. Marital status, number of children, employment status, type of
health insurance, and family history of cervical cancer were analyzed with percentages.
These descriptive statistics were selected to determine if there is a relationship between
the demographic variables and beliefs of cervical cancer and the Pap test.
In addition, the adherence to Pap test guidelines were measured according to the
Chilean guidelines (MINSAL,2008) with two dichotomous indicators: if the woman had
ever had a Pap test in her life: lifetime Pap (yes/no); and if she had had a follow-up test in
55
the previous 3 years: up to date on Pap (yes/no). These indicators were selected to
provide information about Pap test adherence of Chilean women. The analyses included
frequencies of both answers. These analyses permitted the researcher to determine the
relationship between the beliefs and adherence to Pap test screening.
Data analysis: the beliefs questionnaire.
The determination of internal consistency is a critical step for instrument
development. Internal consistency describes estimates of reliability based on the average
correlation among items within a scale. According to Nunnaly and Bernstein (1994a),
coefficient alpha should be calculated for all new measurement methods to assess
reliability. Coefficient alpha was calculated on all the items of the Beliefs questionnaire.
Factor analysis was used to assess construct validity, an important aspect of
questionnaire design (Nunnaly & Bernstein, 1994a). Factor analysis is a tool used to
determine how many constructs or factors underlie a set of items; therefore, it is useful to
identify which items need to be deleted or maintained in the instrument (De Vellis,
2003a). EFA was used to measure construct validity because new items were developed
in the instrument (Worthington & Whittaker, 2006). Determining the nature of the latent
variable (i.e. a variable that is not directly observed, but inferred) is the principal function
of EFA (De Vellis, 2003b) and EFA was used to determine how many constructs underlie
the set of new items in the Beliefs questionnaire (De Vellis, 2003a).

56
Ethical Aspects
The IRB of the University of Miami (United States) and the Servicio de Salud
Metropolitano Sur-Oriente (Southeast Metropolitan Public Health Service) in Chile
reviewed and approved the research proposal. The Spanish version of the informed
consent is in Appendix C, the English version in Appendix D, and the participant letter is
in Appendix E and F. The IRB approval letter from University of Miami is in Appendix
S, and the IRB approval letter from Servicio de Salud Metropolitano Sur Oriente is in
Appendix T.
Summary
This chapter presented the methodology which included the study design, setting,
sample, recruitment, consent procedures, data collection, and data analysis. The
development of the questionnaire was discussed, and data analysis and ethical aspects
were described. Chapter 4 will present the statistical results of the study.

Chapter 4: Results
The results of the data analysis are presented. This analysis includes: data
collection procedures, followed by items score and score direction, data cleaning and
missing data, demographic data analysis, and beliefs questionnaire analysis that including
the exploratory factor analysis (EFA) and reliability analysis.
Data Collection Procedure
Upon signed informed consent, each study subject received the questionnaire to
answer. Each woman answered the questionnaire according to the written instructions.
The majority of the woman answered the questionnaire without asking further questions.
A few of the women asked about the demographic questionnaire items: one asked if it is
possible to include the relatives with cancer who died and the other one asked if they
could choose more than one answer like cause of cervical cancer. To both questions the
answer was yes. Questions about belief items were not asked.
Items Score and Score Direction
The items were scored on a 4-point Likert scale, ranging from strongly agree
(value 1), agree (value 2), disagree (value 3), and to strongly disagree (value 4).
According to recommendations by Pett (2003b), it is important to maintain the similarity
of response direction for all items in the questionnaire. After the data was entered into the
statistical computer package, the variables were recoded to reflect the desired direction.
The score direction assigned to each domain was:
- Barrier domain: The higher score values mean that the barriers that the women
have to the Pap test are very low. No barrier domain items were recoded
because all of the items reflect the same direction.
57
58
- Severity domain: The higher score values mean that the severity of cervical
cancer disease perceived by the women is very low. No severity domain items
were recoded because all of the items reflect the same direction.
- Benefit domain: The higher score values mean that the benefit to have a Pap
test perceived by the women is very low. No benefit domain items were
recoded because all of the items reflect the same direction.
- Susceptibility domain: The higher score values mean that the susceptibility to
have cervical cancer or to need to have a Pap test as perceived by the women
is high. However, the items B8 (I am at risk for developing cervical cancer),
B9 (If I have cervical cancer, I can die) and B10 (Cervical cancer is one of
the most common cancers among women my age) were recoded because
their meanings were in opposite direction to the other items of the same
domain.
- Cues to action: The higher values mean that the cues that the women have or
have had are very low. No cues to action domain items were recoded because
all of the items reflect the same direction
Data Cleaning and Missing Data
For each domain, the researcher entered the data in a logical sequence. Data
analysis was done after the researcher had determined and was confident that the data
entry was accurate. Frequencies were run on each variable to identify missing data or
data error. Table frequencies and means of the variables with minimal and maximal
values were run for identifying any mistakes in the data (i.e. out of range values). No data
entry errors were found.
59
The sample included 333 women. Thirty three questionnaires had one item
missed. The percentage of missing data ranged from 0.3% to 1.5% (Table 3, page 60).
Demographic Data Analysis
The age of the women ranged from 18 to 64 years, with a mean of 37.96 years
and a standard deviation of 10.84. The mean educational level was 11.04 years with a
standard deviation of 2.43. Of the women, 58.8% (169/333) are married, and 85.9%
(286/333) have children. Forty seven percent (155/333) of the women are employed, and
32.7% (109/333) of the women have FONASA A health insurance. FONASA (Fondo
Nacional de Salud National Fund of health) is a public health care insurance, and it is
divided in five groups according to income (Table 4, page 61).
Family history of cervical cancer was found in 17.1% (57/333) of the sample. In
the group of women with relatives with cervical cancer, the relative with the highest
frequency was the mother with 22.4% of the cases (13/57). The number of women who
have never had a Pap test was 43/333 (12.9%). In the group of women between 25 to 64
years of age (cervical cancer screening group in Chile), the percentage of women who
never have had a Pap test decreased to 3% (9/299).
In the group of women who have had the Pap test, 3.4% (10/290) have had a Pap
test more than 3 years ago. The last Pap test was normal in 87.6% (254/290) of the
sample (Table 5, page 62).

60
Table 3
Missing Items in Demographic and Beliefs Questionnaires
Questionnaire Item n %

Demographic 5
(Health insurance item)
1 0.3
11
(Vaccine item)
1 0.3
Beliefs
Part A A4 (Intra uterine device) 1 0.3
A8 (Unmarried or single) 2 0.6
A11 (Where to go) 1 0.3
A12 (Investment of time) 1 0.3
A15 (Knowledge) 1 0.3
A16 (Find cervical cancer) 1 0.3
A17 (Age requirement) 3 0.9
A19 (Husband) 1 0.3
A20 (Save the life) 2 0.6
A23 (Schedule problems) 1 0.3
A26 (Get an appointment) 3 0.9
A30 (Chemo or radiotherapy) 1 0.3
Part B B3 (Have children) 1 0.3
B5 (Pregnancy) 3 0.9
B7 (Sterilized) 1 0.3
B8 (Risk) 5 1.5
B10 (Age) 2 0.6
Part C C2 (Information received) 1 0.3
C4 (Doctor) 1 0.3
C11 (Development of symptoms) 1 0.3
C12 (Cervical cancer experience) 2 0.6
61
Table 4
Demographic Characteristics of the Sample
Variable n % M SD Minimal and
Maximal
Values
Age 37.96 10.84 18 to 64
Educational level (years) 11.04 2.43 3 to 19
I did not go 5 1.5
Basic 60 18
Media 196 58.9
Technical 59 17.7
University 13 3.9


Marital Status
Single 70 21
Married 169 50.8
Separated 30 9.0
Widowed 8 2.4
Relationship,
not legally married
56 16.8



Have Children 2.39 1.24 1 to 8
Yes 286 85.9
No 47 14.1


Employed
Yes 155 46.5
No 178 53.5


Health Insurance
FONASA A 109 32.8
FONASA B 87 26.2
FONASA C 63 19.0
FONASA D 36 10.8
Isapre 5 1.5
PRAIS 13 3.9
FFAA 1 0.3
Without
Health Insurance
18 5.4
62
Table 5
Family History of Cervical Cancer, Relatives with Cervical Cancer, and Pap Test
Characteristics in the Sample

Variable n %

Family History
Yes 57 17.10
No 276 82.90
Relatives
Mother 13 22.80
Sister 12 21.05
Grandmother 10 17.54
Aunt 10 17.50
Cousin 4 7.01
Sister in law 2 3.50
Daughter 2 3.50
Niece 1 1.75
Mother in law 1 1.75
Not specified 3 3.50
Pap Test (Total Group)
Yes 290 87.08
No 43 12.90
Pap Test (Screening group)
Yes 290 96.98
No 9 3.01
Last time of Pap Test
Less than 1 year 167 57.60
Between 1 to 2 years 90 31.00
Between 2 to 3 years 15 5.20
More than 3 years 10 3.40
Do not remember 8 2.80
Last Pap Test result
Normal 254 87.60
Abnormal 27 9.30
I do not know 9 3.10


63
Family history of cervical cancer was the principal cause that the women believed
cause cervical cancer (Table 6, page 64). If the HPV vaccine is available to prevent
cervical cancer, 97% (322/332) of the women would receive the vaccine.
Beliefs Questionnaire Data Analysis
Normal distribution.
Exploratory factor analysis requires that the variables demonstrate normal
distribution (Green & Salkind, 2005; Karpe, 2005; McDowell, 2006). The coefficients of
skewness and kurtosis inform whether or not each variable shows normality (Ferguson &
Cox, 1993). Positive values of kurtosis indicate a pointed distribution and negative values
indicate a flat distribution (Field, 2005). Positive values of skewness indicate a pile-up of
scores on the left of the distribution and negative values indicate a pile-up of scores on
the right. When a variable is perfectly normally distributed, its skewness and kurtosis
coefficients are both zero. It has been argued that some degree of univariate skew and
kurtosis is acceptable for the majority of the variables, if neither coefficient exceed 2.0
3

(Ferguson & Cox, 1993). If the data has variables affected by skewness and kurtosis, the
cut off point for acceptability is less than 25% of the variables (Ferguson & Cox, 1993).
The range of kurtosis for the Beliefs -53 items questionnaire was -0.01 to 8.71; and
skewness range was -0.07 to 2.75. The percentage of skewness and kurtosis coefficient
was calculated for the 53 items: the item A20 showed a kurtosis more than 2
3
but because
it represents 1.8% of the items, it was not deleted (Table 7, page 65).

64
Table 6
Causes of Cervical Cancer Reported by the Women
Cause

n %
Family History
Yes 166 49.8
No 167 50.2
Virus
Yes 133 39.9
No 200 60.1
Sex
Yes 92 27.6
No 241 72.4
Bad Luck
Yes 38 11.4
No 295 88.6
Getting Older
Yes 16 4.8
No 317 95.2
Papillomavirus Vaccine
Yes 322 97
No 10 3


65
Table 7
Skewness and Kurtosis Values in Beliefs 53-items Questionnaire
Part Item Skewness SE Kurtosis SE

A 1 2.50 .13 7.53 .27
2 1.34 .13 2.04 .27
3 -1.33 .13 1.49 .27
4 -0.78 .13 -0.01 .27
5 - 0.70 .13 -0.25 .27
6 2.50 .13 6.41 .27
7 2.50 .13 6.61 .27
8 -0.41 .13 -0.88 .27
9 -1.55 .13 2.33 .27
10 -1.11 .13 0.35 .27
11 -1.58 .13 2.32 .27
12 1.94 .13 3.86 .27
13 -0.07 .13 -1.36 .27
14 -1.24 .13 1.34 .27
15 -1.16 .13 0.50 .27
16 1.55 .13 2.33 .27
17 -0.47 .13 -0.90 .27
18 -0.70 .13 -0.55 .27
19 -1.74 .13 2.35 .27
20 2.75 .13 8.71 .27
21 -1.33 .13 1.51 .27
22 -1.15 .13 0.49 .27
23 -1.08 .13 0.31 .27
24 -1.40 .13 1.38 .27
25 -0.67 .13 -0.51 .27
26 -0.94 .13 0.10 .27
27 1.52 .13 1.50 .27
66
28 1.45 .13 1.70 .27
29 2.20 .13 5.54 .27
30 1.52 .13 2.67 .27
B 1 -0.67 .13 -0.24 .27
2 -1.20 .13 1.32 .27
3 -1.09 .13 0.96 .27
4 -1.02 .13 0.78 .27
5 -0.42 .13 -0.74 .27
6 -0.99 .13 0.31 .27
7 -0.93 .13 0.16 .27
8 -0.44 .14 -1.03 .27
9 -0.94 .13 0.01 .27
10 -0.90 .13 0.02 .27
11 -0.43 .13 -0.53 .27
C 1 2.43 .13 7.90 .27
2 1.36 .13 1.19 .27
3 0.41 .13 -0.96 .27
4 0.48 .13 -0.79 .27
5 0.24 .13 -1.12 .27
6 -0.03 .13 -1.09 .27
7 0.04 .13 -1.18 .27
8 0.30 .13 -1.07 .27
9 -0.22 .13 -1.20 .27
10 -0.11 .13 -1.24 .27
11 -0.06 .13 -1.25 .27
12 0.10 .13 -1.36 .27


67
Factorability of correlation matrix.
Analysis of the correlation matrix for all items is the first step in factor analysis.
De Vellis (2003a) emphasizes the importance of analyzing the patterns of co-variation
and correlations among items. The correlation matrix must achieve psychometric
requirements and show there are some systematic co-variations among the items. If the
requirements of demonstrable covariation are not met, then the results are not
interpretable (Ferguson & Cox, 1993).
Barletts test of sphericity and Kaiser-Meyer-Olkin (KMO) tests are two statistical
tests that determine suitability of data for factor analysis. Bartletts test of sphericity tests
the null hypothesis that no relationships exist between any of the variables (items)
(Nunnaly & Bernstein, 1994c). If the Chi square test is significant, it means there are
discoverable relationships in the data and there is at least one factor (Ferguson & Cox,
1993; Nunnaly & Bernstein, 1994c). If it is not found to be significant, the matrix should
not be factor analyzed (Karpe, 2005; Pett, Lackey, & Sullivan, 2003a).The Bartletts test
in the Beliefs 53- items questionnaire was highly statistically significant (
2
(1378,
N=333) = 6923.28, p<.001) indicating a meaningful relationship between the items.
Therefore, the null hypothesis (no relationships existed between any of items) was
rejected.
Kaiser -Meyer-Olkins (KMO) measure of sampling adequacy is useful for
evaluating factorability (Worthington & Whittaker, 2006). The KMO compares the
magnitudes of the correlation coefficients to the magnitudes of the partial correlation
coefficients (Pett et al., 2003a). It indicates the extent to which a correlation matrix
actually contains factors or chance correlations between a small subset of items or
68
variables (Worthington & Whittaker, 2006). The KMO measure can range between 0 and
1 (Pett et al., 2003a). A value of .60 and higher is required for good factor analysis
(Worthington & Whittaker, 2006). Above .90 is marvelous, .80 is meritorious,.70 is
just middling, and less than .60 is mediocre, or unacceptable values. The KMO
statistic for the Beliefs 53-items questionnaire was considered meritorious at .826 thus
supporting the use of factor analysis for these data.
Because satisfactory results were obtained with both tests, it is possible to proceed
to extraction of the factors with confidence that the matrix derived from the data is
appropriate for factor analysis (Ferguson & Cox, 1993).
Correlation matrix indexes.
Inter-items correlations should show that each variable included items that
correlate highly with at least one other variable. Correlations between .30 and .70 are
acceptable (Karpe, 2005). When inter-items correlations are greater than .80, they must
be examined for their clinical usefulness and one or more of the items should be deleted
from the analysis (Pett, Lackey, & Sullivan, 2003d). The items insufficiently correlated
with all of the others in the matrix (correlation less than .30) must be eliminated from the
analysis (Pett et al., 2003d). Both decisions will achieve satisfactory factor analysis (Pett,
Lackey, & Sullivan, 2003c).
The correlation matrix for the Beliefs 53-items questionnaire was analyzed (Table
8, page 69), and the item C10 (because I had pain in my genitals) has a correlation
equal to .849 with the item C11 (because I had discomfort in my genitals). The
significance of both items was examined and the item C10 (because I had pain in my

Table 8
Correlation Matrix Beliefs 53-Items Questionnaire
a
A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18
A1 1
A2 -- 1
A3 -.210 -- 1
A4 -- -- .157 1
A5 -.205 -- .216 .310 1
A6 .104 .246 -- -- -- 1
A7 .146 .214 -.131 -- -.162 .438 1
A8 -- .108 .130 .217 .160 -- -- 1
A9 -- -- .263 .108 .376 -- -.131 .135 1
A10 -.148 -- .273 .136 .339 -- -- .203 .363 1
A11 -.120 -- .309 .123 .267 -- -.156 .128 .367 .333 1
A12 .166 -- -- -.117 -.130 .374 .251 -- -- -- -- 1
A13 -- -- .201 -- .174 -- -- .163 .175 .428 .304 -- 1
A14 -.131 -- .248 .125 .243 -.113 -- -- .215 .296 .415 -.115 .213 1
A15 -.138 -.157 .384 .134 .198 -- -.217 .137 .293 .349 .415 -- .237 .303 1
A16 -- .209 -- -- -.133 .277 .139 -- -.100 -- -- .162 -- -.125 -.100 1
A17 -- -- .323 -- .194 -.104 -.116 -- .262 .203 .330 -- .216 .253 .350 -- 1
A18 -.114 -- .326 -- .180 -- -.130 -- .248 .248 .394 -- .148 .406 .351 -- .413 1
A19 -- -- .164 .176 .221 -- -.125 .118 .264 .232 .421 -- .204 .292 .290 -.106 .214 .239
A20 .312 .167 -.161 -.113 -.105 .198 .153 -- -- -- -.137 .196 -- -.184 -.144 -- -- --
A21 -- -- .259 -- .197 -- -.232 -- .337 .313 .418 -- .213 .310 .387 -- .221 .345
A22 -- -.122 .283 .149 .201 -- -.147 -- .239 .368 .326 -- .276 .313 .388 -- .342 .400
A23 -.118 -.159 .364 -- .138 -- -- -- .218 .402 .321 -- .247 .433 .348 -- .324 .555
A24 -.127 -.136 .310 .146 .292 -- -.180 .117 .342 .497 .409 -- .426 .309 .415 -- .415 .416
A25 -- -- .251 .118 .226 -- -- -- .222 .218 .359 -.113 .206 .313 .269 -- .372 .273
A26 -.134 -.108 -- .152 .247 -- -- -- -.302 .351 .378 -- .213 .473 .383 -- .316 .461
6
9


A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18
A27 -- .214 -- -- -- .141 .167 -- -- -- -- .186 -- -- -- .268 -- --
A28 -- .179 -- -- -.105 .115 .191 -- -- -- -- .195 -- -- -- .303 -- --
A29 -- .183 -- -- -- .177 .219 -- -- -- -- .143 -- -- -- .298 -- -.127
A30 .103 .251 -- -- -- .141 .211 -- -- -- -- .229 -- -- -- .265 -- --
B1 -.030 -.124 .220 .182 .195 -.128 -.160 .216 .140 .165 .251 -- .182 .101 .257 -.130 .176 --
B2 -.130 -.112 .239 .139 .223 -- -.216 .235 .289 .281 .376 -- .226 .179 .371 -.179 .169 .120
B3 -.121 -- .230 .155 .203 -- -.174 .209 .241 .264 .328 -- .204 .153 .336 -- .222 .155
B4 -- -- .150 -- .174 -- -.194 .182 .208 .206 .235 -- .132 -- .309 -- .220 .155
B5 -- -- .154 .182 .202 -- -.113 .215 .181 .252 .184 -- .153 .181 .139 -- .219 .209
B6 -- -- .118 -- .147 -- -.233 .166 .246 .214 .234 -- .121 .129 .319 -.177 .213 .132
B7 -- -- .177 -- .232 -- -.180 .205 .258 .260 .314 -- .183 .196 .309 -.124 .242 .153
B8 -- -- .129 .101 -- -- -- -- -- -- -- -.107 -- -- -- -.125 -- --
B9 -- -.220 -- -- -- -.127 -- -- -- -- -- -.278 -- -- -- -.183 -- --
B10 -- -.234 -- -- -- -.139 -- -.104 -- -- -- -.282 -- -- -- -.285 -- --
B11 -- -.108 -- .117 .206 -- -- .191 .118 .172 .178 -- .141 -- -- -- .111 --
C1 .319 .192 -.180 -- -.131 .209 .177 -- -- -- -- .258 -- -- -.163 .241 -- --
C2 .171 .148 -.110 -- -.147 .125 -- -- -- -- -- .202 -- -- -- .231 -- --
C3 -- -- -- -- -- -- -- -- -- .129 -- -- -- -- -- -- -- --
C4 -- -- -- -- -- -- -- .107 -- -- -- -- -- -- -- .122 -- .103
C5 -- -- -- -.145 -.188 -- -- -- -- -- -- -- -- -- -- .151 -- --
C6 -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --
C7 .103 -- -- -- -- -- .103 -- -- -- -- -- -- -- -- -- -- --
C8 .153 -- -- -- -- -- -- -- -- .123 -- -- -- -- -- .138 -- .121
C9 -- -- -- -- -- -- -- -- .107 -- -- -- -- .183 .121 -- .147 .108
C10 -- -- -- -- -- -- .131 -- -- -- -- -- -- .185 -- -- -- .110
C11 -- -- -- -- -- -.132 .107 -- -- .155 -- -- -- .167 -- -- -- .155
C12 .114 -- -- -- -- -- -- -- .100 .139 -- -- -- -- -- -- -.120 --
7
0



A19 A20 A21 A22 A23 A24 A25 A26 A27 A28 A29 A30 B1 B2 B3 B4 B5 B6
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19 1
A20 -- 1
A21 .426 -- 1
A22 .362 -- .511 1
A23 .239 -- .415 .493 1
A24 .424 -- .469 .606 .479 1
A25 .197 -.105 .324 .444 .371 .307 1
A26 .182 -- .341 .425 .519 .349 .536 1

7
1




A19 A20 A21 A22 A23 A24 A25 A26 A27 A28 A29 A30 B1 B2 B3 B4 B5 B6
A27 -- .241 -.123 -- -- -- -- -- 1
A28 -- .197 -- -- -- -.124 -- -- .613 1
A29 -.150 .213 -.105 -- -.117 -.166 -- -- .538 .602 1
A30 -.111 .325 -- -- -- -.141 -- -- .534 .596 .665 1
B1 .226 -.152 .288 .192 .137 .218 .152 -- 1
B2 .297 -.166 .336 .234 .183 .331 .223 .209 -.159 -.159 -.126 -.216 .396 1
B3 .330 -.175 .321 .231 .204 .303 .275 .247 -- -- -- -.173 .296 .740 1
B4 .190 -.141 .258 .170 -- .227 .185 .156 -.134 -.125 -- -.170 .250 .569 .624 1
B5 .184 -- .247 .207 .239 .270 -- .175 -- -.135 -- -- .296 .254 .270 .230 1
B6 .352 -- .342 .261 .103 .269 .133 .166 -- -- -- -.143 .263 .440 .449 .491 .343 1
B7 .290 -.106 .279 .271 -- .334 .223 .287 -- -- -- -.103 .328 .425 .443 .448 .377 .679
B8 -- -- -- -- -- -- -- -- -.144 -.124 -.130 -.149 -- -- -- -- -- -.121
B9 -- -.127 -- -- -- -- -- -- -.406 -.360 -.210 -.353 -- -- -- -- -- --
B10 -- -.157 -- -- -- -- .120 .136 -.331 -.377 -.270 -.329 -- .125 -- -- -- --
B11 .113 -- -- -- -- -- .168 -- -- -- -- -- .324 .257 .321 .290 .108 .281
C1 -- .500 -- -- -- -- -.099 -- .225 .226 .278 .327 -- -.204 -.183 -.178 -- --
C2 -- .250 -- -- -- -- -.110 -- .156 -- .189 .201 -- -- -- -- -- --
C3 -- -- -- -- -- -- -- -- .200 .103 .110 .153 -- .138 -- -- -- --
C4 -- .141 -- -- -- -- -- -- .126 .146 .112 .155 -- -- -- -- -- --
C5 -- .128 -- -- -- -- -- -- .098 -- -- .113 -- -- -- -- -- --
C6 -- -- -.109 -- -- -- -- -- .189 -- -- -- -- -- -- -- -- --
C7 -- .109 -- .124 -- -- -- -- .118 -- -- .103 -- -- -.109 -- -- --
C8 -- .173 -- -- -- -- -- -- .192 .164 -- .142 -- -- -- -- -.101 --
C9 -- -- -- .200 .112 -- .247 .173 .116 -- -- -- -- -- -- -- -- --
C10 -- -- -- .111 -- -- .214 .102 .104 -- -- -- -- -- -- -- -- --
C11 -- -- -- .145 .122 -- .114 -- -- .085 -- -- -- -- -- -- -- --
C12 -- -- -- -- -- -- -- -- .101 .133 -- -- -- -- -- -- -- --
7
2

7
3

B7 B8 B9 B10 B11 C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12
A27
A28
A29
A30
B1
B2
B3
B4
B5
B6
B7 1
B8 -- 1
B9 -- .382 1
B10 .148 .290 .550 1
B11 .281 -- -- -- 1
C1 -- -.160 -.218 -.271 -- 1
C2 -- -- -.226 -.190 -- .412 1
C3 -- -- -.182 -.132 .127 .146 .252 1
C4 -- -- -.131 -.160 .099 .157 .198 .653 1
C5 -- -- -- -.110 -- .133 .287 .402 .455 1
C6 -.132 -- -.106 -.114 -- -- .255 .370 .479 .523 1
C7 -- -- -- -.134 -- .167 .337 .408 .472 .502 .605 1
C8 -.109 -- -.126 -.229 -- .224 .305 .411 .498 .379 .628 .565 1
C9 -- -- -- -- -- .099 .105 .337 .347 .283 .382 .389 .399 1
C10 -- -- -- -- -- -- .134 .305 .376 .349 .470 .446 .447 .774 1
C11 -- -- -- -- -- -- .179 .331 .402 .343 .533 .461 .509 .743 .849 1
C12 -- -- -.101 -.147 -- -- .164 .293 .318 .298 .477 .444 .459 .396 .467 .552 1

a
The correlation matrix table only shows the significant correlation values between items.
74
genitals) was deleted because the mean of the item C11 (because I had discomfort in
my genitals) involved or it is similar to the mean of the deleted item. Both items are
from cues to action domain.
Two items were found to have correlations less than .30. The first item A2 (an
abnormal Pap test, without treatment, can lead to cervical cancer) is from the severity
domain and the second item A8 (if an unmarried or single women gets a Pap test, people
may think that she is having sex) is from the barrier domain. Both items were deleted,
based on the finding that the items with correlations less than .30 will not have shared
common variance in factor analysis (Pett et al., 2003d).
There are four items with one correlation greater than .30. The items were
carefully examined and based on the analysis were deleted or maintained. The
explanation of each follows:
- Item A4 (a Pap test can move the intra uterine device): this item has a
correlation equal to .310 with the item A5 (getting a Pap test is painful).
Both items are from the barrier domain; therefore, item A4 was kept in the
analysis based on the correlation this item has with an item from the same
domain.
- Item A12 (getting in Pap test is a good investment of my time in health):
this item has a correlation equal to .374 with the item A6 (getting a Pap test
allows for early detection of cervical cancer). Both items are from the
benefit domain; therefore, item A12 was kept in the analysis based on the
correlation this item has with an item from the same domain.
75
- Item A16 (a Pap test can find cervical cancer when it is still possible to cure
it): This item has a correlation equal to .303 with the item A28 (cervical
cancer may lead to a women having hysterectomy). Item A16 was deleted
from the analysis because both items are from different domains: A16 is a
benefit item and A28 is a severity item.
- Item B8 (I am not at risk for developing cancer): this item has a correlation
equal to .382 with item B9 (if I have cervical cancer I can die). Both items
are from the susceptibility domain; therefore, item B8 was kept in the
analysis based on the correlation this item has with an item from the same
domain.
In summary, items A2 and A8 were deleted because their correlations were less
than .30. Item A16 was deleted because it had one correlation with an item from another
domain. Item C10 was deleted because it had a correlation greater than .80. Based on
these deletions, EFA was computed with a Belief 49-items questionnaire.
Factor extraction.
There are a variety of factor extraction models available and these can be
categorized as either a common factor model or a component model (Conway &
Huffcutt, 2003). Principal-components analysis (PCA) is the most popular of the
component models and principal axis factoring (PAF) is one of the most popular common
factor models (Conway & Huffcutt, 2003; Pett et al., 2003d).
The goal of PAF is to determine the latent variable that can account for the
relationships among measured variables (Conway & Huffcutt, 2003; Worthington &
Whittaker, 2006). The aim of PCA is simply to reduce the number of variables by
76
creating combinations that retain as much of the original measures of variance as possible
(Conway & Huffcutt, 2003). The nature of the variance explained is one important
difference between PCA and PAF. The PCA accounts for a specified portion of the total
variance among the original variables; whereas the PAF accounts for a shared or common
variance. As a result, the proportion of variance explained by a set of comparable
components and factors will not be equal or conceptually equivalent. PAF will explain a
proportion of a restricted variance (shared variance) while PCA will explain a proportion
of total variance (De Vellis, 2003a; Ford, MacCallun, & Tait, 1986; Shultz & Whitney,
2005b).
Due to the usefulness for identifying the latent variable, PAF has been described
with the development of new scales. It was selected as a factor extraction method for this
instrument study following recommendations from several authors (Conway & Huffcutt,
2003; Costello & Osborne, 2005; Fabrigar et al., 1999; Shultz & Whitney, 2005b;
Worthington & Whittaker, 2006).
Factor rotation.
Factor rotation strengthens the relationship between variables (items) and a factor
(Nunnaly & Bernstein, 1994b), producing a solution with the best structure (Brown,
2006). Factor rotation increases interpretability by identifying clusters of variables (items
with a strong association with only one and the same factor) (De Vellis, 2003a). Factor
rotation has been considered a critical issue in factor analysis (Kline, 1994b).
The rotation method includes 2 types: orthogonal and oblique (Kline, 1994b;
Worthington & Whittaker, 2006). The choice of each one is important because it will
77
reflect the perspectives on the theory underlying the constructs being considered
(Osterlind, 2006).
Orthogonal rotation is used when the set of factors underlying a given item set are
assumed or known to be uncorrelated. Oblique rotation is used when the factors are
assumed or known to be correlated (Costello & Osborne, 2005; De Vellis, 2003a;
Worthington & Whittaker, 2006). Oblique rotation represents the complexity of the
variables because constructs or domains in the real world are rarely uncorrelated (Ford et
al., 1986). Oblique rotation is preferred because it provides a more realistic representation
of how factors are interrelated. If the factors are uncorrelated, oblique rotation will
produce a solution virtually the same as the one produced by orthogonal rotation (Brown,
2006; Conway & Huffcutt, 2003).
The Beliefs 49-items questionnaire will be analyzed by PAF with oblique
rotation, because it is assumed that the factors are correlated (Rosenstock, 1960, 1966;
Rosenstock et al., 1988). This assumption is based on the theory that the health belief
model domains are correlated; therefore, they will be correlated in the data analysis.
There are three oblique rotation methods: direct Oblimin, Promax and Quartimin
(Costello & Osborne, 2005; Shultz & Whitney, 2005b). No specified method of rotation
is preferred, because all tend to produce similar results (Costello & Osborne, 2005).
Promax rotation method uses a target matrix. Oblique rotation that closely
matches the target matrix will be the final solution (Conway & Huffcutt, 2003). The goal
of Promax rotation is to maximize the spread of pattern elements on a factor (Nunnaly &
Bernstein, 1994b). Promax and the Harris-Kaiser criteria offer the best oblique procedure
and was chosen for the factor analysis of Beliefs 49-items questionnaire. The kappa
78
value=4 will be used in beliefs questionnaire analysis rotation. To use the default kappa
(4) value in the SPSS software is acceptable because manipulating the kappa value
changes the amount of the rotation procedure and this introduces unnecessary complexity
for interpretations of results (Costello & Osborne, 2005).
It is important to clarify that rotating factors change the factor loading and
meaning of the factors, but the different factor solutions are equivalent because they
explain the same amount of variance in each variable and in the matrix as a whole. The
rotated factors reproduce the original correlations as well as the unrotated solution (Kline,
1994b).
Factor retention criteria.
The correct extraction of the factor is a critical step in factor analysis (Conway &
Huffcutt, 2003; Ford et al., 1986; Hayton, Allen, & Scarpello, 2004; Henson & Roberts,
2006). The principal idea is to keep those factors that are meaningful descriptions of the
data and delete the others (Osterlind, 2006). Both over-extraction and under-extraction of
factors retained can have deleterious effects on the results (Costello & Osborne, 2005;
Hayton et al., 2004) because they lead to a poor factor-loading pattern reproduction and
interpretation (Hayton et al., 2004). Over factoring introduces much less error to factor
loading estimates than under factoring (Fabrigar et al., 1999).
The most recommended approaches for factor extraction are the Kaiser and
Cattell methods, based on eigenvalues (Worthington & Whittaker, 2006). The amount of
information captured by a factor is represented by an eigenvalue (De Vellis, 2003a;
Green & Salkind, 2005) and the initial eigenvalue shows the contribution of every item in
the data set (Nunnaly & Bernstein, 1994c; Osterlind, 2006; Pett et al., 2003c). An
79
eigenvalue for a factor should be greater than or equal to zero and cannot exceed the total
variance (Green & Salkind, 2005).
Kaiser establishes that eigenvalues less than 1.0 reflect unstable factors
(Worthington & Whittaker, 2006) and is one of the most commonly used method (Hayton
et al., 2004). According to the Kaiser criterion, factors with eigenvalues less than 1.0
should not be retained and factors whose eigenvalues are greater than or equal to 1.0
should be retained (De Vellis, 2003a; Pett et al., 2003d; Shultz & Whitney, 2005b). The
logic of the Kaiser rule is that when an eigenvalue is less than 1.0, the variance explained
by a factor is less than the variance of a single indicator (Brown, 2006). This criterion
represents a reasonable percent of variance in most data sets (Osterlind, 2006). A concern
with Kaiser criterion is when a large number of items are included in the analysis, a
relatively large number of factors will be extracted (Conway & Huffcutt, 2003; Shultz &
Whitney, 2005b). Kaiser criterion will be considered as one of the criterion to establish
the number of factors to retain.
The Cattells criterion uses the relative values of eigenvalues to estimate the
correct number of factors to retain in factor analysis. This procedure, known as the scree
test (De Vellis, 2003a; Worthington & Whittaker, 2006) is a visual inspection of the data
(Osterlind, 2006) that permits examination of the descending eigenvalues locating a break
in a size of eigenvalues, after which the remaining values tend to a level off horizontally
(Worthington & Whittaker, 2006).The vertical portion of the scree plot has the substantial
factors while the horizontal portion is the scree that should be discarded (De Vellis,
2003a). Cattells criterion asks for retaining those factors that lie above the elbow of the
plot (De Vellis, 2003a). The scree test will be used as one of the factor retention criteria.
80
The number of items per factor is another criterion recommended for factor
retention. Research suggests that EFA procedures provide more accurate results when
each common factor is represented by multiple measured variables in the analysis
(Fabrigar et al., 1999). The recommendation is to retain factors with more than three
items (Floyd & Widaman, 1995; Gorsuch, 1997; Worthington & Whittaker, 2006) and
the items have significant factor loading on the factor (Fabrigar et al., 1999; Floyd &
Widaman, 1995). Both criteria will be considered in the factors and items analyses.
The number of items by factor is an important criterion for interpretability of the
factors, referred as simple structure. Simple structure means that each factor has a
group of variables with high factor loadings and the rest with low factor loading. Each
variable has high loadings on only some of factors and low loading on the rest (Conway
& Huffcutt, 2003). A factor loading is a correlation of a variable with a factor and a
factor is a construct operationally defined by its factor loading (Crocker & Algina, 2008a;
Kline, 1994a).
Factor loading greater than or equal to .30 or .40 are often interpreted as salient or
significant and used in defining a factor (Brown, 2006; Ford et al., 1986). Because a
factor loading of .40 for a variable is recommended rather than the usual .30 (Ferguson &
Cox, 1993), this criterion will be used in the factor analysis for Beliefs 49-items
questionnaire. The items that do not load highly on any interpretable factor will be
eliminated in this analysis. A cross-loaded item will be inspected in terms of content
categorized into the factor that is seemingly most relevant (Shultz & Whitney, 2005b).
It is necessary to consider that in orthogonal rotation, factor loading represents the
correlation between the indicator and the factors. However in oblique rotation this is not
81
the case because the correlations are inflated by the covariation of the factors (Brown,
2006).
Conceptual interpretability is a definitive factor-retention criterion. A factor must
be retained only if it can be interpreted in a meaningful way, no matter how solid the
evidence for its retention based on the empirical criteria described earlier (Pett et al.,
2003d; Worthington & Whittaker, 2006). Therefore, the recommendation is to consider
relevant theory when determining the appropriate number of factors to retain (Fabrigar et
al., 1999). This criterion will be used in the factor analysis of Beliefs 49-items
questionnaire.
The procedure recommended is to select a range of factor solutions (Tinsley &
Tinsley, 1987) and to use a number of decision rules for examining a number of solutions
prior to a final conclusion on the retention issue (Ford et al., 1986). It is suggested that
the highest and the lowest number of factors be examined until the most interpretable
solution can be found (Ford et al., 1986).
Item deletion is a common and expected part of the process and inevitably
overlaps with determining the number of factors that will be retained (Worthington &
Whittaker, 2006). Some items that will need to be dropped and some factors do not have
sufficient items loading on them to contribute meaningfully to the solution (Pett et al.,
2003d).
The simultaneous use of multiple decision rules is appropriate and often desirable
(Conway & Huffcutt, 2003). Therefore, the examination of several solutions for factor
retention will be the recommendation considered: the eigenvalues, explained variance,
scree test, number of items per factor, factor loading, cross loading, and meaning of the
82
items. The different solutions will be computed and each criterion will be examined for
each model (Pett et al., 2003d).
Exploratory factor analysis of beliefs 49-items questionnaire.
Seven models were computed in order to achieve the best fit with the data. All
models were computed using oblique Promax rotation for reasons previously discussed.
The first model was computed with 49 items. According to Kaisers criterion 12
factors were retained accounting for 50.043% of the shared variance (Table 9, page 83).
The scree test indicated a four factor solution (Figure 1, page 84). The pattern and
structure matrices were examined, and all items with factor loadings less than .40 and
without cross loadings were deleted. According to these criteria, three items were deleted:
items A9 (getting a Pap test is expensive), item A13 (I prefer that a female gives me
the Pap test, because it is uncomfortable for me if a man does it), and B5 (if I am
pregnant, I do not need a Pap test). Items A9 and A13 were from the barrier domain,
and item B5 from the susceptibility domain.
The second model was computed with 46 items. Using Kaisers criterion, 12
factors were retained, accounting for 51.552% of the shared variance. According to result
of the scree test, four factors were retained. The pattern and structure matrix were
examined, and all items with factor loadings less than .40 were deleted. According to
these criteria, four items were deleted: items B1 (I am not at risk for an abnormal Pap
test), B11 (If I do not have history of cervical cancer un my family, it is not likely that I
am going to have it), C2 (after hearing something about cervical cancer), and C12
(because someone I know well had cervical cancer). Items B1 and B11 are from the
susceptibility domain, while items C2 and C12 are from the cues to action domain.
83
Table 9
Total Variance Explained by Beliefs 49-Items Questionnaire
Factor Initial Eigenvalues Extraction Sums of Squared
Loading
Rotation Sums
of Squaring
Loading
a
Total % of
Variance
Cumulative
%
Total % of
Variance
Cumulative
%
Total
1 8.117 16.565 16.565 7.618 15.548 15.548 6.336
2 5.549 11.325 27.890 5.138 10.485 26.033 4.325
3 3.314 6.763 34.653 2.907 5.933 31.966 4.341
4 2.581 5.266 39.919 2.144 4.375 36.341 3.508
5 1.821 3.715 43.634 1.319 2.692 39.033 3.159
6 1.618 3.302 46.937 1.093 2.230 41.263 2.368
7 1.381 2.819 49.756 .885 1.807 43.070 1.808
8 1.372 2.801 52.557 .849 1.732 44.802 2.756
9 1.261 2.572 55.129 .790 1.612 46.414 3.276
10 1.201 2.451 57.580 .715 1.460 47.874 2.684
11 1.059 2.162 59.741 .544 1.110 48.984 2.289
12 1.035 2.112 61.854 .519 1.059 50.043 .990
13 .997 2.035 63.889
14 .984 2.007 65.896
15 .937 1.913 67.809
16 .921 1.880 69.689
17 .855 1.746 71.434
18 .812 1.656 73.091
19 .796 1.624 74.714
20 .759 1.549 76.264
21 .740 1.511 77.774
22 .651 1.329 79.103
23 .620 1.265 80.368
24 .593 1.210 81.578
25 .576 1.176 82.754
26 .561 1.144 83.898
27 .538 1.097 84.995
28 .526 1.073 86.068
29 .508 1.038 87.106
30 .490 1.001 88.107
31 .447 .913 89.019
32 .431 .880 89.899
33 .425 .867 90.767
34 .416 .849 91.616
35 .401 .817 92.434
36 .383 .781 93.215
37 .362 .740 93.955
38 .337 .689 94.643
39 .323 .660 95.303
40 .319 .651 95.954
84
41 .300 .612 96.567
42 .271 .554 97.120
43 .254 .518 97.638
44 .249 .509 98.147
45 .224 .456 98.604
46 .197 .402 99.006
47 .183 .373 99.379
48 .171 .348 99.727
49 .134 .273 100.00
a
When factors ares correlated, sums of squared loading cannot be added to obtain a total
variance.




Figure 1
Scree Test Beliefs 49-Items Questionnaire


85
The third model was computed with 42 items. Using Kaisers criterion, 10 factors
were retained accounting for 50.169% of the shared variance. Results of the scree test
suggested a four factor solution. The pattern and structure matrix were examined, and all
the items with factor loadings less than .40 were deleted. According to these criteria, two
items were deleted: items A10 (getting a Pap test is embarrassing for me), and
A11 (I do not have information about where to go to get a Pap test). Both items were
from the barrier domain.
The fourth model was computed with 40 items. Using Kaisers criterion, 10
factors were retained accounting for 50.736% of the shared variance. Results of the scree
test suggested a five factor solution. The pattern and structure matrices were examined,
and all items with factor loadings less than .40 were deleted. According to these criteria,
two items were deleted: items A12 (getting a Pap test is a good investment of time in
health) and A15 (I do not know if I need to have a Pap test). Item A12 is from the
benefit domain, and item A15 is from the barrier domain.
The fifth model was computed with 38 items. Using Kaisers criterion, 10 factors
were retained accounting for 51.389% of the shared variance. Results from the scree test
suggest a five factor solution. The pattern and structure matrices were examined, and all
items loading on factors in groups of less than three were deleted. According to these
criteria six items were deleted: items A4 (a Pap test can move the intra uterine device),
A5 (getting a Pap test is painful), A6 (getting a Pap test allows for early detection of
cervical cancer), A7 (getting a Pap test can avoid a serious health problem), C9
(because I had genital bleeding), and C11 (because I had discomfort in my genitals).
Items A4 and A5 are from the barrier domain. Item A6 is from the benefit domain.
86
Item A7 is from the severity domain and items C9 and C11 are from the cues to
action domain.
The sixth model was computed with 32 items. Using Kaisers criterion, eight
factors were retained accounting for 51.796% of the shared variance. Results of the scree
test suggest that six factors be retained. The pattern and structure matrices were
examined, and all items with factor loads of less than three items were deleted. According
to these criteria two items were deleted: items B6 (if I am in menopause, I do not need a
Pap test), and B7 (if I am sterilized, I do not need a Pap test). Both items were from
the susceptibility domain.
The seventh model was computed with 30 items. Using Kaisers criterion, seven
factors were retained accounting for 49.925% of the shared variance. Results of the scree
test suggested a six factor solution. The pattern and structure matrices were examined.
The items of each domain follow:
- The first factor has seven items from the barrier domain.
- The second factor has six items from the cues to action domain.
- The third factor has four items from the severity domain.
- The fourth factor has three items from the susceptibility domain.
- The fifth factor has three items from the susceptibility domain.
- The sixth factor has three items from the benefit domain.
- The seventh factor has four items from the barrier domain.
The seventh factor has four items, and two of the items (A22 and A24) have a
cross loading with the factor one, therefore, these two items were maintained. The item
A22 (I have not taken the Pap test because I am afraid to find out if I have cancer), and
87
A24 (I have not taken the Pap test because I am embarrassed to have a genital exam),
both are from the barrier domain. The other two items (A19 and A21) from seventh
factor were deleted because they did not have a cross loading with some factor. The items
A19 (my partner/husband does not want me to get a Pap test), and A21 (it is difficult
to get a Pap test because I do not have money for transportation), both are from the
barrier domain.
The eighth model was computed with 28 items. Using Kaisers criterion, six
factors were retained accounting for 48.977% of the shared variance (Table 10, page 88).
Results of the scree test suggested six factor solution (Figure 2, page 89). This model
shows concordance between Kaiser and Cattells criteria, because both criteria result in
retention of six factors.
The pattern matrix (Table 11, page 90) and structure matrix (Table 12, page 91)
were examined. The items of each domain follow:
- The first factor has nine items from the barrier domain.
- The second factor has six items from the cues to action domain.
- The third factor has four items from the severity domain.
- The fourth factor has three items from the susceptibility domain.
- The fifth factor has three items from the susceptibility domain.
- The sixth factor has three items from the benefit domain.
The factors with the corresponding items are presented in Table 13 (page 92). The
first factor was called barriers to have a Pap test and nine items retained in this factor
are from the barrier domain. The barriers considered are the health care center, lack of

88
Table 10
Total Variance Explained by Beliefs 28-Items Questionnaire (CPC-28 Questionnaire)

Factor Initial Eigenvalues Extraction Sums of Squared
Loading
Rotation Sums
of Squaring
Loading
a
Total % of
Variance
Cumulative
%
Total % of
Variance
Cumulative
%
Total
1 4.901 17.502 17.502 4.414 15.765 15.765 3.842
2 4.313 15.404 32.906 3.819 13.641 29.405 3.241
3 2.707 9.669 42.575 2.241 8.004 37.409 3.157
4 1.917 6.845 49.420 1.515 5.409 42.818 2.731
5 1.414 5.052 54.472 .871 3.110 45.929 2.212
6 1.364 4.871 59.342 .854 3.049 48.977 2.202
7 .974 3.479 62.821
8 .913 3.260 66.081
9 .842 3.007 69.088
10 .789 2.818 71.907
11 .727 2.598 74.505
12 .722 2.578 77.083
13 .637 2.274 79.357
14 .589 2.103 81.460
15 .548 1.959 83.419
16 .527 1.881 85.299
17 .520 1.857 87.156
18 .421 1.502 88.659
19 .415 1.481 90.140
20 .391 1.397 91.537
21 .374 1.337 92.873
22 .364 1.301 94.174
23 .358 1.279 95.453
24 .284 1.014 96.467
25 .278 .994 97.460
26 .266 .952 98.412
27 .226 .809 99.221
28 .218 .779 100.00

a
When factors ares correlated, sums of squared loading cannot be added to obtain a total
variance.
89
Figure 2
Scree Test Beliefs 28-Items Questionnaire (CPC- 28 Questionnaire)




90
Table 11
Pattern Matrix Beliefs 28-Items Questionnaire (CPC-28 Questionnaire)
*

Factor
1 2 3 4 5 6
A23 .758
A26 .721
A18 .709
A22 .664
A24 .595
A14 .560
A25 .542
A17 .509
A3 .436
C6 .775
C7 .751
C4 .713
C8 .696
C5 .626
C3 .623
A29 .838
A28 .762
A30 .726
A27 .641
B3 .889
B2 .797
B4 .697
B9 .734
B10 .672
B8 .473
A20 .690
C1 .624
A1 .519

*
Factor Loading less than .30 were omitted in this table. Rotation converged in six
iterations.

91
Table 12
Structure Matrix Beliefs 28-Items Questionnaire (CPC-28 Questionnaire)
*

Factor
1 2 3 4 5 6
A23 .735
A26 .702
A18 .677
A22 .670
A24 .650
A14 .570
A25 .550
A17 .531
A3 .482
C6 .749
C7 .743
C4 .724
C8 .715
C5 .628
C3 .626
A29 .794
A28 .785
A30 .782
A27 .711
B3 .885
B2 .818
B4 .691
B9 .753
B10 .715
B8 .446
A20 .702
C1 .684
A1 .484

*
Values less than .30 were omitted in this table.


92
Table 13
Factor and Corresponding Items in Beliefs 28-Items Questionnaire
(CPP-28 Questionnaire)

Factor Name Item Item Wording

1 Barrier to have
a Pap test
A23 I have not taking the Pap test because the health care center is
only open during hours when I cannot go
A26 I have not taking the Pap test because it is difficult to get an
appointment
A18 I have not taking the Pap test because when I go, I need to
wait a long time to be seen
A22 I have not taking the Pap test because I am afraid to find out
if I have cancer
A24 I have not taking the Pap test because I am embarrassed to
have a genital exam
A14 I have not taking the Pap test because they treat me badly in
the health care center
A25 I do not know how often I need to get a Pap test
A17 I do not know at what age it is necessary to have a Pap test
A3 I do not have time to get a Pap test

2 Cues to Action
to have a Pap
test
C6 (One reason to get a Pap test has been or will be) because a
friend or neighbor spoke to me about it
C7 (One reason to get a Pap test has been or will be) because
member of family told me to get I
C4 (One reason to get a Pap test has been or will be) because a
doctor told me
C8 (One reason to get a Pap test has been or will be) because I
listened to or read something in the newspaper or in a
television or radio programs
C5 (One reason to get a Pap test has been or will be) because my
mother spoke to me about it
C3 (One reason to get a Pap test has been or will be) because a
nurse or midwife told me

3 Severity of
Cervical Cancer
A29 Cervical cancer is a serious health problem
A28 Cervical cancer may lead to a woman having hysterectomy
A30 Cervical cancer can lead to a woman needing to receive
chemotherapy or radiotherapy
A27 Cervical cancer may lead to death

4 Need to have a
Pap test
B3 If I do not have children, I do not need a Pap test
B2 If I do not have symptoms, I do not need a Pap test
B4 If I do not have intercourse, I do not need a Pap test


93
5 Susceptibility to
Cervical Cancer
B9 If I have cervical cancer, I can die
B10 Cervical cancer is one of the most common cancers among
women my age
B8 I am at risk for developing cervical cancer

6 Benefit to have
a Pap test
A20 The Pap test can save my life
C1 (One reason to get a Pap test has been or will be) to take care
of my health
A1 Getting a Pap test makes me feel good because it means that I
take care of my health


94
knowledge, embarrassment, afraid to have cervical cancer, and lack of time. This factor
accounted for 15.765% of the shared variance, and its meaning is concordant with the key
concept of the health belief model (Table 1 on page 18).
The second factor was called cues to action to have a Pap test and six items
retained in this factor are from the cues to action domain. The cues to action considered
are members of the family, friends, media, and health care professional. This factor
accounted for 13.641% of the shared variance, and its meaning is compatible with the key
concept of the health belief model.
The third factor was called severity of cervical cancer and four items retained in
this factor are from the severity domain. The severities considered are the seriousness
of cervical cancer, and the consequences of having this disease (having a hysterectomy,
chemotherapy or radiotherapy, and death). This factor accounted for 8.004% of the
shared variance, and its meaning is concordant with the key concept of the health belief
model.
The fourth and fifth factors come from susceptibility domain. The fourth factor
was called need to have a Pap test and the three items retained in this factor are from
the susceptibility domain. The needs to have a Pap test are related to the reasons that
women may feel the need to have or not a Pap test, such as having symptoms, children or
intercourse. The fifth factor was called susceptibility to cervical cancer and the three
items retained in this factor are also from the susceptibility domain. The susceptibilities
to cervical cancer are related to the susceptibility that the women feel to have cervical
cancer and to die from this disease. Both factors are important because they point out two
important aspects of the susceptibility domain. The fourth factor accounted for 5.409%
95
of the variance, and the fifth one for 3.110%. Meanings of both factors are concordant
with the key concept of the health belief model.
The last factor was called benefit to have a Pap test. Two benefit items are from
the benefit and one item is from cues to action domain. The benefit items are related
to take care of health, the possibility to save a life, and to feel good. It is important to
point out that the item C1 that originally was created like cues to action item, it was
factored like a benefit item. This factor accounted for 3.049% of the shared variance,
and its meaning is concordant with the key concept of the health belief model.
CPC-28 Questionnaire. The Final Model
The eighth model with six factors was chosen as the final model, constituting the
Beliefs 28-items questionnaire titled CPC-28 (Creencias, Papanicolaou, Cancer - 28/
Beliefs, Papanicolaou, Cancer - 28) (Appendixes U and V). The decision to retain this
model is based on:
- Concordance between the eigenvalues and results of the scree test
- Shared explained variance accounted for
- Number of items per factor (all the factors have 3 or more items)
- Factor loadings of the items (>.4)
- Comprehensive meaning of each factor
- Structure of the questionnaire (corresponds with the health belief model
domains)
Table 14 describes (page 96) the communalities for each item in the final model.
The communality has been defined as total amount of variance in each item that it is
96
Table 14
Communalities Beliefs 28-Items Questionnaire (CPC-28 Questionnaire)

Part Item Initial Extraction

A 1 .216 .265
3 .310 .279
14 .346 .323
17 .338 .294
18 .485 .491
20 .365 .497
22 .521 .451
23 .512 .551
24 .512 .478
25 .397 .366
26 .523 .512
27 .518 .529
28 .563 .621
29 .565 .650
30 .578 .639
B 2 .604 .678
3 .638 .788
4 .444 .483
8 .251 .216
9 .457 .578
10 .433 .524
C 1 .364 .489
3 .515 .422
4 .558 .519
5 .399 .394
6 .569 .568
7 .522 .570
8 .543 .537


97
explained by the factors extracted (Hogarty et al., 2005; Pett et al., 2003d; Worthington &
Whittaker, 2006). The common communalities range from low (.40) to moderate (.70)
values (Costello & Osborne, 2005). If an item has a communality of less than .40, it may
not be related to the other items and the researcher should consider why that item is
included in the data (Costello & Osborne, 2005). These communalities values in CPC-28
questionnaire range from .216 to .788. There are seven items (A1, A3, A14, A17, A25,
B8, C5) with communalities less than .40. All seven items were included in the data
analysis because their factor loadings were greater than .40, and relationships with the
other items in the same factor were concordant.
Correlations between the factors.
The correlations between the six factors are presented in Table 15 (page 98).
Correlations less than .20 are considered low, while correlations greater than .50 are
considered high. If all the correlations in an oblique rotation are low, orthogonal rotation
is recommended. Higher correlations suggest the need to replace the two factors with one
factor (Nunnaly & Bernstein, 1994c).
The factor correlation matrix showed correlations greater than .30; therefore,
oblique rotation is supported. No correlations greater than .80 are presented; therefore the
six factor solution is supported. The correlations between the factors greater than .20 will
be interpreted, and are presented in Table 16 (page 99).
Reliability analysis of CPC-28 questionnaire.
The ability of an instrument to measure an attribute consistently is measured by
reliability (DeVon et al., 2007) and it is considered as important part in the testing stage

98
Table 15
Factor Correlation Matrix Beliefs 28-Items Questionnaire (CPC-28 Questionnaire)

Factor 1 2 3 4 5 6
1 1.00 .082 -.068 .339 -.030 -.160
2 .082 1.00 .205 -.029 -.210 .241
3 -.068 .205 1.00 -.196 -.446 .354
4 .339 -.029 -.196 1.00 .104 -.314
5 -.030 -.210 -.446 .104 1.00 -.288
6 -.160 .241 .354 -.314 -.288 1.00


99
Table 16
Meaning of Correlations between Factors in the CPC-28 Questionnaire

Factor

Factor Correlated 1 Factor Correlated 2
Factor 1
Barrier to have a
Pap test
Lower barriers to have a Pap test
that the women have
Higher perception of
susceptibility or need to
have a Pap test

Factor 2
Cues to Action
to have a Pap test
Lower cues to action that the
women have or have had
Lower perception of
severity of cervical cancer
disease
Lower perception of
susceptibility to cervical
cancer
Lower perception of
benefit to have a Pap test

Factor 3
Severity of
Cervical Cancer
Lower perception of severity of
cervical cancer
Lower cues to action that
the women have or have
had
Lower perception of
susceptibility to cervical
cancer
Lower perception of
benefit to have a Pap test

Factor 4
Need to have a Pap test
Higher perception of susceptibility
or need to have a Pap test
Lower barriers to have a
Pap test that the women
have
Higher perception of
benefit to have a Pap test

Factor 5
Susceptibility
Cervical Cancer
Higher perception of susceptibility
to have cervical cancer
Higher cues to action that
the women have or have
had
Higher perception of
severity of cervical cancer
Higher perception of
benefit to have a Pap test

Factor 6
Benefit to have a
Pap test
Higher perception of benefit to have
a Pap test
Higher cues to action that
the women have or have
had
Higher perception of
severity of cervical cancer
Higher perception of
susceptibility or need to
have a Pap test
Higher perception of
susceptibility to have
cervical cancer disease

: Correlation between the factors

100

of a newly developed measure (Hinkin, 1995). Reliability is a fundamental way to reflect
the error in a measurement (Streiner & Norman, 2008) and the reliability index expresses
the degree of relationship between true and observed scores on a test (Crocker & Algina,
2008c).
Internal consistency refers to the degree to which the items in a scale are inter-
correlated (Clark & Watson, 1995; DeVon et al., 2007). The coefficient alpha is an
indication of internal consistency, but the problem with this coefficient is that it is
dependent on the number of items in the scale (Streiner & Norman, 2008). The common
value of a reliability estimate is .70 (Clark & Watson, 1995; DeVon et al., 2007; Shultz &
Whitney, 2005a).
The average inter-item correlation is another straightforward measure of internal
consistency. It is a more useful index than coefficient alpha (Clark & Watson, 1995).The
recommendation for new questionnaires is to achieve a target mean inter-item correlation
rather than a particular level of alpha. The average inter-item correlation should range
between .150-.50 (Clark & Watson, 1995).
Reliability analysis for the CPC-28 questionnaire which included coefficient
alpha and mean inter-item correlations were computed. Cronbachs coefficient alpha was
.735 and the average inter-item correlation was .083. Preliminary evidence of the values
of both indices provides initial support for reliability of the items on the CPC-28
questionnaire. The Cronbachs coefficient alpha and average inter-item correlations for
the individual factors are presented in Table 17 (page 101).

101
Table 17
Cronbachs Coefficient Alpha and Inter-Item Correlation in the CPC-28 Questionnaire

Factor Cronbachs
Coefficient Alpha
Inter-item Correlation
Barrier to have a Pap Test .851 .389
Cues to action to have a Pap
Test
.852 .490
Severity of Cervical Cancer .841 .584
Need to Have a Pap test .837 .631
Susceptibility to Cervical
cancer
.652 .395
Benefit to have a Pap Test .638 .371
CPC-28 Questionnaire .735 .083



102
Summary
EFA was conducted using principal axis factoring with an oblique promax
rotation. This was computed on eight factor analysis models and the different models
were run achieving the criteria recommended to retain factors and items. The model
chosen has 28 items comprised of six factors. The factor retention criteria are in
concordance with Kaiser and Cattells criteria. The Beliefs 28-items questionnaire, called
CPC-28 questionnaire (Creencias, Papanicolaou y Cancer- 28 items / Beliefs,
Papanicolaou and Cancer-28 items) accounted for 48.977% of the shared variance. The
six factors, within the domains, describe barriers to have a Pap test, cues to action to have
a Pap test, severity of cervical cancer, need to have a Pap test, susceptibility to cervical
cancer, and benefit to have a Pap test. Chapter 5 will discuss the results of these finding.

Chapter 5. Discussion
The discussion follows, beginning with demographic characteristics, followed by
the analysis of the items deleted during the factor analysis process, the structure of the
final questionnaire (CPC-28), the contribution of this new questionnaire to nursing, and
the strengths and limitations of this research.
Demographic Characteristics of the Sample
General characteristics.
The mean of age and the standard deviation reflected that women from different
ranges of ages are represented in this sample. This characteristic is important support for
factor analysis because findings of the heterogeneous sample is a recommendation for
increasing the variance and loading factor (Kline, 1994b).
The mean educational level of this sample is near the national mean in Chile. The
sample who participated in this study is similar to Chilean educational characteristics of
the general population (MIDEPLAN,2007).
The average number of children of the women in the sample is higher than the
national mean in Chile. The difference can be explained by the percentage of women
unemployed, because it is known that women who are unemployed have a higher
fecundity rate than women who are employed (Instituto Nacional de Estadsticas
[INE],2006).
The labor force in this sample is higher than the national mean in Chile
(Ministerio del Trabajo, 2009). It is important to consider that the question did not ask
about a permanent or temporal job and this could be a cause for the higher percentage in
this sample.
103
104
The majority of the women have a public health insurance system and the
percentage found is similar to the values reported in the national survey (Ministerio de
Planificacin, 2006b), and Servicio de Salud Metropolitano Sur-Oriente (Southeast
Metropolitan Public Health Service) of Santiago, Chile (Servicio de Salud Metropolitano
Sur Oriente, 2009).
Pap test and cervical cancer characteristics.
Regarding the relatives with cervical cancer in the sample, it has been reported
that this characteristic is a factor that increased the perception of susceptibility to have
cervical cancer in the population (Ho et al., 2005; McFarland, 2003) and that heredity has
been considered a cause of cervical cancer in other studies (Jirojwong & Manderson,
2001; Lartey et al., 2003; P. Lee et al., 2007). The study of Boyer (2001) illustrated that
contact with women with cervical cancer was an important motivation to have a Pap test;
therefore, this characteristic can be an important motivation in Chilean women.
The screening rate in the sample is very high and must be analyzed with caution.
The high adherence in the sample could be related to the sample characteristics and how
this variable was measured in this study. This group of women was studied in an
ambulatory womens health care center; therefore, all the women needed an appointment
to attend the clinic for care and were referred from primary health care centers within the
area. These characteristics permit one to infer that the women had previous contact with a
health care provider (midwifery, nurse, or physician); therefore, the women could have
been asked about the Pap test. The other point that must be considered is the self-report
of their last Pap test. The overestimation in the rates has been described previously by
Sawyer et al. (1989) and McGovern et al. (1998). The error rate ranges between 20%
105
(Sawyer et al., 1989) to 25% (McGovern et al., 1998) and the error increased in larger
intervals of time recalled (McGovern et al., 1998). If the error rate is considered in this
sample, the percentage of women without an updated Pap test could be achieved to
19.4% to 25%. This result comes from the range as 58 to 75 of the sample of the women
could have reported a mistake in the date of the last Pap test.
Causes attributed to cervical cancer.
It is very interesting that 49.8% of the women attributed the cause of cervical
cancer to family history. This belief can be attributed to the known relationship between
heredity and cancer described with other cancers; however, family history of cervical
cancer has not been described as a cause or risk factor of cervical cancer (National
Cancer Institute, 2009a). This belief must be considered at the time when planning
interventions with this group, because if the majority of people believed that heredity is a
cause, it could have a negative effect in the perception of susceptibility of the women to
this disease. The women need to understand that the risk of cervical cancer is related to
other factors different from heredity and could be controlled by self-care behaviors.
Regarding the virus as a cause attributed to having cervical cancer, it is known
that HPV infection is the main cause and risk factor for cervical cancer and this virus can
cause some changes to cells in the cervix that can lead to cervical cancer (National
Cancer Institute, 2009a, 2009b). With this sample, 39.9% of the woman agreed with the
relationship of the virus and cervical cancer.
The third cause of cervical cancer identified was sex. It is known that a woman
who has had many sexual partners, or a partner who has had many sexual partners, has a
106
higher than average risk of developing cervical cancer (National Cancer Institute, 2009a);
therefore, the women perceived a relationship between this factor and cervical cancer.
A high percentage of women agreed that the vaccine is concordant with the public
health practice in Chile. A national public health program of immunization started in
Chile in 1978 and it is considered one of the most successful programs in the world
(Valenzuela, 2001). The high coverage of vaccination with the population and this
program being without cost has been one of the causes of its important success
(Valenzuela, 2001). Therefore, 97% of the sample that agreed with the HPV vaccine
could be explained by these facts. It is important to consider that Chile has two HPV
vaccines available for the population (Abarca, 2007) but these are not part of the National
Plan of Immunization in Chile (Plan Ampliado de Inmunizacion); therefore, the cost to
take the vaccine is beyond the reach of the majority of the population. However, this
percentage of agreement could be considered in futures policies regarding HPV
vaccination in Chile.
Beliefs 53-items Questionnaire: Analysis of Items Deleted
From the initial Beliefs 53-items questionnaire, 25 items were deleted. The total
deletion of items was a reduction of 47% of the total items. The percentage of items
deleted ranged from 33% to 60% in the different domains. Although the factor extraction
method chosen was principal axis factoring and not principal components analysis, the
ability to reduce the number of variables was beneficial as this indicated evidence for the
items within domains.
The analysis of the items that were deleted was analyzed according to the health
belief model domains. This discussion follows:
107
1. Barriers.
The Beliefs 53-items questionnaire started with 19 items in the barrier domain;
10 items were deleted and nine were maintained. The items deleted were 52%.
The first item A8 deleted (If an unmarried or single woman gets a Pap test,
people may think that she is having sex) was removed from the correlation matrix
analysis. This item addressed the relationship between being sexually active and single
and the possibility that this could be revealed to other people. Two reasons can explain
the low correlation between these items with the other ones: if the women believe that it
is necessary to have sex for having a Pap test, they do not perceive this as a problem
(barrier) if the others know they are sexually active. The second reason is, if the women
know that to be sexually active is not a requirement for having a Pap test, they perceive
that the relationship is incorrect and not a barrier. A qualitative study by Valenzuela and
Miranda (2001) reported that fear of disrepute interfered with the Pap test if they do not
have a partner. The Yi study (1998) reported that the women did not know if the Pap test
was for unmarried women. In this Chilean sample, this concern was not considered a
barrier to having a Pap test.
The second item deleted was A9 (Getting a Pap test is expensive). This item
was deleted in the first factor analysis computed because the factor loading to the barrier
factor was below .40. The explanation why it was not considered a barrier could be
supported for the reason that the Pap test is not expensive in Chile, because the public
health care system provides this free for the women who have level A and B of
FONASA, near to 500 pesos (1 US dollar) for FONASA C, and 1,000 pesos (2 US
dollars) for FONASA D (FONASA,2009). The most expensive cost is for who do not
108
have health care insurance, but this cost is not greater than 15,000 pesos (25 US dollars).
According to the sample characteristics, 59% of the women have FONASA A or B health
care insurance; therefore, the exam is without economic cost to them and not considered
a barrier item for Chilean women in this sample.
The third item deleted was A13 (I prefer that a female gives me the Pap test,
because it is uncomfortable for me if a man does it). This item was deleted from the first
factor analysis because the factor loading to the barrier factor was below .40. The reasons
for deletion of items could be: the first reason is the majority of the women attended the
public health care system where the midwife is the professional who gives a Pap test, and
the women do not perceive that the gender is a barrier to having a Pap test; the second
reason is supported that gender could be a barrier but to have the Pap test is most
important than to not have it. However, in other research studies (McFarland, 2003;
Valenzuela & Miranda, 2001) reported that the women perceived a barrier when the
professional could be a man. Mexican women described the gender of the provider as a
barrier (Agurto et al., 2004; Girgis et al., 1999), and to be screened by a man was
reported as embarrassment (Bingham et al., 2003; Byrd, Chavez, & Wilson, 2007; M. C.
Lee, 2000; Urrutia et al., 2008). According to the results of Urrutia study, the gender of
the professional was not considered a barrier item.
In the third model analysis, two items were deleted: item A10 (Getting a Pap test
is embarrassing for me) and item A11 (I do not have information about where to go to
get a Pap test). The item A10 (Getting a Pap test is embarrassing for me) was deleted
because it had a factor loading less than .40. Embarrassment was a barrier selected by the
women in this study and it was indicated in item A24 (I have not taken the Pap test
109
because I am embarrassed to have a genital exam). Therefore, the deletion of this item
could be explained as it did not have a specific reason of embarrassment and enhanced
clarity about the cause of embarrassment than item A10 (Getting a Pap test is
embarrassing for me). Embarrassment as a barrier will be discussed in the section
analysis of the items maintained.
The item A11 (I do not have information about where to go to get a Pap test)
was deleted because of the factor loading less than .40. The women did not consider the
lack of information about the place as a barrier, because they know very well where they
can go to have a Pap test. This knowledge is based on that this population has a specific
health care center assigned. The population is assigned to a specific health care center in
Chile, and this system is very organized. Because of the tradition, the people have
knowledge about this. In essence, knowing where the Pap test can be taken was not
considered a barrier item by Chilean women.
The item A15 (I do not know if I need to have a Pap test) was deleted in the
fourth model computed by the low factor loading less than .40 within the barrier factor.
The lack of knowledge was considered a barrier by the women, but the items selected
were associated to frequency of the Pap test (A25) and age requirement (A17). The
reason why item A15 (I do not know if I need to have a Pap test) was not considered a
barrier could be explained because the women know that they needed to have a Pap test,
and therefore, the meaning of this item is not specific. The lack of knowledge as a barrier
will be discussed in the CPC-28 questionnaire analysis.
The items A4 (A Pap test can move the intra uterine device (IUD)) and A5
(Getting a Pap test is painful) were deleted in the fifth model computed, because both
110
were in a factor with less than three items. It is interesting to point out that both items
never belonged to the barrier factor. The item A4 (A Pap test can move the intra uterine
device (IUD)) speaks to the concern to remove the intra uterine device. The family
planning method with this sample is unknown, but it is known that 42 % of the
population in the area uses the IUD as a family planning method (Servicio de Salud
Metropolitano Sur Oriente, 2009). Therefore, it is possible to assume that the women are
very educated about this method, and they know that the Pap test does not move the IUD.
Therefore, they did not consider this as a barrier. The belief that the Pap test can move
the IUD was reported previously as a barrier by Valenzuela (2001), and as a fear by
Lamadrid (1996). In this research sample, the belief that the Pap test can move the IUD
was not considered a barrier.
The item A5 (Getting a Pap test is painful) considered that the Pap test is
painful; this item was not a barrier selected by the women, and it could be explained by
three reasons: the first one, because the women do not consider the exam is painful; the
second one is if the woman consider the exam to be painful, this pain is a barrier for not
having a Pap test; and the third one is because the women know the difference between
pain for the Pap test and pain for a gynecological exam. It is important to consider that
the Pap test is not a painful exam and the pain can be related to the way the professional
does the gynecological exam. Hispanic women have previously described that having the
exam is uncomfortable and the examination can be painful (Agurto et al., 2004; Byrd et
al., 2007; Lamadrid, 1996; Wiesner Ceballos et al., 2006). The fear of pain has been
reported by other authors as a barrier to having a Pap test (Byrd et al., 2004; Fernandez
Esquer & Cardenas Turanza, 2004; Hunter, 2005; Koval et al., 2006; Moreland et al.,
111
2006; Urrutia et al., 2008; Valenzuela & Miranda, 2001). In the Chilean sample, the
women did not consider the pain to be associated with having the Pap test.
In the last model computed, item A19 (My partner/husband does want me to get
a Pap test) and item A21 (It is difficult to get a Pap test because I do not have money
for transportation - take a bus, subway) were deleted. Both items were eliminated
because they were part of a residual factor without factor loading with a barrier factor. It
is interesting to consider that item A19 (My partner/husband does want me to get a Pap
test) never belonged to a barrier factor, while item A21 (It is difficult to get a Pap test
because I do not have money for transportation - take a bus, subway) was part of a
barrier factor in the first factor analysis computed and was always part of a residual
factor.
The item A19 (My partner/husband does want me to get a Pap test) addressed
the concern that the husband has with the Pap test. The deletion could be supported by
the fact that the permission or agreement from the husband is not a cultural issue in Chile.
However, partner permission as a barrier has been reported by Mexican women (Aguilar
Perez et al., 2003; Agurto et al., 2004), Colombian women (Wiesner Ceballos et al.,
2006), Hispanic women in the US (Byrd et al., 2004), and Chinese women (Hou & Luh,
2005). In this sample, this concern was not considered a barrier to having a Pap test.
The item A21 (It is difficult to get a Pap test because I do not have money for
transportation - take a bus, subway) addressed having a problem with transportation.
The deletion could be explained by two reasons: the first one is the women do not need
money for transportation because they go to the health care center nearest to their home,
and the second one is that women in the group who need transportation, the money is not
112
considered a barrier for having the Pap test. In the Bingham study (2003) the need of
transportation was associated with the distance and Girgis et al. (1999) described the
long distance as a barrier. The lack of transportation has also been reported by other
authors (Ho et al., 2005; Price et al., 1996; A. Smith et al., 2004) as a barrier. Mexican
and Ecuadorian women reported the cost of transportation as a barrier (Agurto et al.,
2004). In this study, transportation was not considered a barrier to having a Pap test.
In summary, the lack of knowledge related to the place to have the Pap test, the
need to have it, the cost of the exam, the cost of transportation, the gender of the health
care provider, the embarrassment, the fear to remove the IUD, the pain, and partner
permission were not considered barriers with this Chilean population and, therefore, were
not included as barrier factors in the CPC-28 questionnaire.
2. Cues to action.
The Beliefs 53-items questionnaire started with 12 items in the cues to action
domain; five items were deleted, six items were retained and one item was moved to the
benefit to have a Pap test domain. The items deleted were 42%.
The first item deleted was from the correlation matrix analysis. Item C10
(Because I had pain in my genitals) was deleted because of the high inter-correlation
with the item C11 (Because I had discomfort in my genitals). The pain for cues to
action has not been described by other authors and the deletion was decided because item
C11 included the mean of item C10. To have pain could be included with the discomfort
that the women can feel. It is important to remember that pain was addressed in the
barrier domain and it was not selected as a cue to action item.
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In computation of the second model, items C2 (after hearing something about
cervical cancer) and C12 (because someone I know well (family, friend, neighbor) had
cervical cancer) were eliminated because their factor loadings were less than .40. Both
items never belonged to cues to action. Regarding item C2 (after hearing something
about cervical cancer), it is important to remember that media information was selected
as a cue; therefore, this item was deleted because it could not specify who gave the
information about cervical cancer. The cue that the women need must be from someone
they recognized and must be from someone whom they respect like a health care
professional, family or friend.
The item C12 (because someone I know well (family, friend, neighbor) had
cervical cancer), asked about knowing someone who had cervical cancer. This cue was
not considered and can be explained because only 17% of the women have or had some
relatives with cervical cancer. It is important to remember that the family history of
cervical cancer was also not considered in the susceptibility domain also. Previous
studies have described relatives with cervical cancer as a cue (Henning & Knowles, 1990;
Jirojwong & Manderson, 2001; Price et al., 1996), others have described this topic as a
benefit (Ho et al., 2005), motivator (Boyer et al., 2001), or inspiration (Holroyd et al.,
2003). Therefore, to have someone with cervical cancer was not considered by this
sample as a cue to action.
The items C9 (because I had genital bleeding) and C11 (because I had
discomfort in my genitals) were deleted in the fifth model computed. Both items never
belonged to the cues to action factor and they were eliminated because both were part of
a factor with less than three items. Regarding item C9 (because I had genital bleeding),
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the deletion could be explained that the women had known that the Pap test is an exam
needed without symptoms, and therefore, bleeding is not a cue. However, Price (1996) in
a study with US women, reported it as a cue for action.
The discomfort in the genitals described in item C11 (because I had discomfort
in my genitals) was not considered a cue for action by the women and this can be
interpreted because they had known that a Pap test is needed with or without symptoms.
However, 18.3% of the women in the Pinho study (2003) described that gynecological
symptoms were the motivation to have a Pap test. This Chilean sample did not consider
the symptoms as a cue to action. This finding is a very important outcome in the Urrutia
study, because it indicated that when the women have symptoms, the stage of cervical
cancer is very advanced and that the women have a Pap test without need or as a
requirement to previously feel something (American Cancer Society, 2009b).
To have symptoms (pain, bleeding, discomfort), to hear some information, and to
know someone with cervical cancer were not selected as cues to action. Therefore, the
items related with this topic were not selected as part of cues to action factor in the CPC-
28 questionnaire.
3. Severity.
The Beliefs 53-items questionnaire started with six items in the severity domain;
two items were deleted, and four were maintained. The items deleted were 33%.
The item A2 (An abnormal Pap test, without treatment, can lead to cervical
cancer) was deleted from the correlation matrix analysis. This item addressed about the
relationship between an abnormal Pap test and development of cervical cancer. The
Chilean women did not select this item as a severity item, because they knew that an
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abnormal Pap test and a pre-malignant lesion can be treated. This topic has not been
addressed in other questionnaires. Moreland et al. (2006) and Risendal et al. (1999)
reported how a Pap test can show cancer, but they did not address the treatment. Eaker et
al. (2001) reported about womens perception related to an abnormal Pap test and this
item was in the susceptibility domain.
The second item A7 (Getting a Pap test can avoid a serious health problem) was
deleted from the fifth model, because it was part of a factor with less than three items.
The item A7 (Getting a Pap test can avoid a serious health problem) was never a part of
the severity factor. The item deletion could be supported by the fact that the women
perceived cancer as a serious problem and having a Pap test could detect this disease and
does not change severity. It is important to note that the severity of cervical cancer was
considered a severity item in this study. The perception that cervical cancer is a serious
problem and that cervical cancer could make a womans life difficult has been described
previously by research of Burak and Meyer (1997), Byrd et al. (2004), Holroyd et al.
(2003), and Moreland et al. (2006).
Both items deleted addressed the relationship between the Pap test and cervical
cancer disease. This relationship was not identified by the Chilean women within the
severity domain in the CPC-28 questionnaire. The reason is very clear: the severity
perceived by the women is related to the consequences of cervical cancer disease more
than the severity related to having an abnormal Pap test or to not having a Pap test. This
is demonstrated by the items selected in the severity domain: to have a hysterectomy,
chemotherapy, and radiation therapy, to die, and to have a serious problem. All of these
are related to the disease and not to the Pap test.
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4. Susceptibility.
The Beliefs 53-items questionnaire started with 11 items in the susceptibility
domain; five items were deleted and six were maintained. The items deleted were 45.5%.
The first item deleted was item B5 (If I am pregnant, I do not need a Pap test)
and the reason was a factor loading less than .40. The deletion was in the first model
computed and this item was never a part of the susceptibility factor. The explanation can
be supported that the women knew that to be pregnant is not a barrier to having a Pap
test. Pregnancy control in Chile is important in health care and the periodicity is well
known by the population. With this sample, 85.9% of the women have had children,
therefore, they had the experience to have or update the Pap test during this period of
their life, and this is not an impediment for having a Pap test. This item had not been
described previously as a susceptibility item.
The items B1 (I am not at risk for an abnormal Pap test) and B11 (If I do not
have a history of cervical cancer in my family, it is not likely that I am going to have it)
were eliminated in the second model computed because these did not have a factor
loading equal or greater than .40. Both items never belonged to the susceptibility factor
before the elimination. Regarding item B1 (I am not at risk for an abnormal Pap test),
the susceptibility to have an abnormal Pap test has not been described previously by other
authors in the literature review, and in this case, it was not chosen as an item in the
susceptibility domain. The reason can be supported by the fact that when the women have
a Pap test updated, they know that they have a normal Pap test. Only 3% of this sample in
the Urrutia study did not have a Pap test updated and this percentage can explain the
deletion of item B1.
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The item B11 (If I do not have a history of cervical cancer in my family, it is not
likely that I am going to have it), was not considered as part of the susceptibility factor.
In this study 49.8% of the women considered family history as a cause, but this item did
not match with the susceptibility factor, possibly because only 17% of the women
reported they have had relatives with cervical cancer and others factors were more
important. However, the perception of susceptibility related to relatives with cervical
cancer has been described previously by other authors (Ho et al., 2005; Jirojwong &
Manderson, 2001; McFarland, 2003) and this topic has been also considered as
knowledge about the causes or risk factor (M. C. Lee, 2000; P. Lee et al., 2007; Vanslyke
et al., 2008), and personal appraisal (Tacken et al., 2007).
The last two items eliminated from the susceptibility domain were B6 (If I am in
menopause, I do not need a Pap test) and B7 (If I am sterilized, I do not need a Pap
test). Both items were deleted from the sixth model and the reason was the factor had
less than three items. Both items belonged to the susceptibility factor with the Beliefs 53-
items questionnaire, however the items were removed during the factor analysis process.
The item B6 (If I am in menopause, I do not need a Pap test) addresses a specific
characteristic that women need to have to avoid the Pap test: menopause is known as not
a reason for not having a Pap test. Other authors have reported this concern as lack of
knowledge (Holroyd et al., 2003; Koval et al., 2006; Lee Lin et al., 2007; Markovic et al.,
2005), a cause of cervical cancer (M. C. Lee, 2000), or a predisposing factor (Taylor et
al., 2002), however, researchers have reported this as a susceptibility factor.
The item B7 (If I am sterilized, I do not need a Pap test) also addressed a
specific characteristic that the woman need to have for having the Pap test, but this
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requirement was not considered as a susceptibility item with this Chilean population.
This topic has not been described by other authors as a susceptibility domain.
The women did not choose the characteristics of pregnancy, menopause and
sterilization as susceptibility conditions and the feeling to be at risk for an abnormal Pap
test or to have relatives with cervical cancer were not described as susceptibility items in
the CPC-28 questionnaire.
5. Benefit.
The Beliefs 53-items questionnaire started with 5 items in the benefit domain:
three items were deleted, two were maintained, and one was moved from cues to action
domain. The items deleted were 60%.
The first item eliminated was A16 (A Pap test can find cervical cancer when it is
still possible to cure it). It was deleted from the correlation matrix because it did not
have a correlation greater than .30 with other items; therefore, it is a topic not related with
the others. The explanation for this is based on three aspects: the women do not relate the
Pap test screening with cervical cancer disease, they think that the Pap test cannot find
cervical cancer early, and the women do not believe that cervical cancer can be cured.
The last reason was explored by Seow et al. (1995) and Holroyd et al. (2003) and both
found that 17% of the women in Singapore and 16% of the women in Hong Kong
respectively thought that cervical cancer cannot be cured even if detected early. The item
A16 topic has been considered by other authors but in other domains: Burak and Meyer
(1997) and Moreland et al. (2006) included it as a severity domain, Hou and Luh (2005)
called it like pros of cervical smear, and Byrd et al. (2007) reported this belief like a
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benefit. The fact that the Pap test can find cervical cancer early was not selected as part of
a benefit factor in the CPC-28 questionnaire by this sample of Chilean women.
The second item deleted from the benefit domain was the item A12 (Getting a
Pap test is a good investment of my time in health), and this item was deleted from the
fourth model computed because the factor loading was less than .40. This item never
belonged to the benefit factor and the explanation is very easy to understand because the
lack of time was considered by the women as a barrier; therefore, it would not be
considered as a benefit. Research by other authors has also not reported this as a benefit
item.
The third item deleted was item A6 (Getting a Pap test allows for early detection
of cervical cancer). This item never belonged to the benefit domain and was eliminated
from the fifth model computed because the factor had less than three items. The meaning
of this item was very close to item A16 that was also eliminated. In this item, the
relationship between early detection of cervical cancer and the Pap test was clear, but it
was not factored as a benefit. The reason that explained this deletion is the women did
not consider having an early cervical cancer diagnosis as a benefit, even if it is detected
in the first stages. With this reason, it is important to remember that one of the barriers
that women perceived to have a Pap test was related to being afraid or fear of finding
cervical cancer. If the fear to have cervical cancer is a barrier, it cannot be considered a
benefit. This reason supported the deletion of item A16 and A6. Early detection has been
considered previously by other authors as an important benefit (Byrd et al., 2004;
Henning & Knowles, 1990; Ho et al., 2005; Jirojwong & Manderson, 2001; McFarland,
2003; Seow et al., 1995; Tacken et al., 2007); but the fear to receive the diagnosis has
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also been reported by women in a multicenter study from five Hispanic countries (Agurto
et al., 2004). Therefore, in this sample, the fear by the women could have had more
importance than to find cervical cancer early. The relationship between early detection of
cervical cancer and the Pap test has been reported by other authors as knowledge
(Fernandez et al., 1998; Holroyd et al., 2003) pros to cervical cancer (Hou & Luh, 2005)
or simply as a belief (Risendal et al., 1999).
Strengths of CPC-28 Questionnaire
The total variance that the CPC-28 questionnaire explained was 48.997%. It is
interesting to point out that the variance explained by the first model with 49 items was
50.043%; therefore, the difference between the first extraction and the last one was very
low. The level of variance achieved by the CPC-28 questionnaire was very good
considering the factor extraction was PAF and not PCA.
The CPC-28 questionnaire showed a concordance between the scree test and
eigenvalues. The factor loading without cross loading between the factors and the number
of items per factor are important reasons to support the stability of this questionnaire.
It is interesting to point out that all the items with the exception of C1 that came
from cues to action and was moved to the benefit to have a Pap test domain were
items developed by the factor where they matched. The fact that 27 items from 28 items
were matched in the corresponding domain supported the process that good content
validity was achieved, and thus the pilot test done previously supported construct
validation. Another aspect that can be recognized with successful questionnaire
construction is the extensive literature review that included many years, many countries,
and many languages. The literature review, the content validity process, and the pilot test
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supported the majority of the items developed within a specific domain were maintained
in the same domain. This is an important strength of the CPC-28 questionnaire.
To develop a new questionnaire based on the five domains of the health belief
model is a notable and important outcome achieved in this research and is illustrated with
the CPC-28 questionnaire. The health belief model, as the framework to understand the
beliefs that the women have related to Pap test and cervical cancer, will be very useful to
promote health with Chilean women. To understand the beliefs and the relationships
between the six factors described in the CPC-28 questionnaire will allow health care
providers to tailor interventions with this population.
Domains of CPC-28 Questionnaire
This section will address the items included in the CPC-28 questionnaire. The
findings supported that the health belief model dimensions were distinct for different
beliefs and the CPC-28 questionnaire had found 6 dimensions of these beliefs.
Domain 1: Barriers to have a Pap test.
The barrier to have a Pap test domain was the factor with the most items and
explained 15.965% of the shared variance of the instrument. This factor was the principal
factor described in factor analysis. The barrier domain has been the most studied domain
in the literature, and the numbers of items included in CPC-28 questionnaire address this
characteristic. The CPC-28 questionnaire has nine of the total 28 items and all of them
were developed within the original barrier domain proposed in the Beliefs 53-items
questionnaire. Barriers to have a Pap test defined as difficulties perceived by the woman
to have the Pap test are included within 9 barrier items.
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The items included in the barrier domain are: problems related with the health
care center (treat, waiting time, appointment, and schedules), lack of knowledge about the
Pap test (how often and what age), lack of time, being afraid, and embarrassment. Each
of the items will be discussed in the next paragraphs.
The items related to the problems with the health care center are A23, A26, A18,
and A14. The item A23 (I have not taken the Pap test because the health care center is
only open during hours when I cannot go) reinforced the importance of appointment
times conducive to the population served. The primary care health center in Chile is open
Monday to Friday during office hours; some health care centers open during the weekend
or after office hours (Servicio de Salud Metropolitano Sur Oriente, 2009). Since 46.5% of
this sample worked, the health care center hours were not compatible; therefore, is
comprehensible that these items have to be considered as a barrier. This barrier can be
classified as an access problem, because if the women wanted to have the Pap test, they
could not go because of the incompatible schedule. The problem of access has been
described previously by Watkins (2002) and Boyer (2001) as system barrier of limited
office hours. The health care center hours were considered within the barrier to have a
Pap test domain in the CPC-28 questionnaire.
The item A26 (I have not taken a Pap test because it is difficult to get an
appointment) confirmed another access problem the women perceived as a barrier. This
barrier is very close in meaning related to item A23 described previously. Access to an
appointment has been referred as a barrier by Brazilian women (Pinho et al., 2003),
Colombian women (Wiesner Ceballos et al., 2006) and US women (M. Smith et al.,
2003). The extension of clinical hours has been a strategy suggested by women to
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improve cervical cancer screening behaviors (Boyer et al., 2001). Girgis et al. (1999)
reported that to have a Pap clinic available during weekends is a facilitator and in the
Taylor study (2002), 30% of the women reported problems getting routine appointments.
The same of difficulty to get an appointment was considered as a barrier to have a Pap
test item in the CPC-28 questionnaire.
The waiting time as a barrier is reported in item A18 (I have not taken a Pap test
because when I go, I need to wait a long time to be seen). This item has very close
meaning to the items previously described because all are related to the time factor. The
delay with attention has been described previously in a Chilean study (Valenzuela &
Miranda, 2001). Venezuelan women reported this concern as a barrier (Agurto et al.,
2004) and 60% of the Brazilian women described that this as one of the difficulties more
common in the public health care system (Brenna et al., 2001). Markovic et al. (2005)
reported that long waiting time as a concern increased in magnitude if the place where
they needed to wait was crowded, and if the time lost met absence from work. Since
46.5% of women of this study sample worked, this finding is an important concern that
must be considered for future interventions and remained a barrier to have a Pap test
item in CPC-28 questionnaire.
The item A14 (I have not taken the Pap test because they treat me badly in the
health care center) addressed an important and ethical issue. The womans perception
about the relationship with the health care center is an important barrier and one of the
most common barriers described by other authors. There are many aspects related to the
feeling of bad treatment: how effectively and respectfully the providers communicated
information to the women and also, the respect for the privacy and confidentiality have
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been reported that influenced the perception of treatment (Bingham et al., 2003).
Examples of this are reported in Hispanic studies as women reported discourteous and
disrespectful manners from health care providers (Agurto et al., 2004; Boyer et al., 2001).
Hispanic women in the U.S. have described the providers as impersonal and
uninformative (Koval et al., 2006). Colombian women described the relationship with
health care workers like strong, inhuman, and giving minimal explanation about the
procedure (Wiesner Ceballos et al., 2006). In an African study, 47% of the women
reported negative attitudes and 26.7% reported mistrust of the providers as a barrier to
having the Pap smear (McFarland, 2003). It is interesting that in a Chilean study, the
women reported fear of punishment from the midwifes, because they were late for the
date of the Pap test (Lamadrid, 1996). The perception that the health care center treated
the women badly was considered a barrier to have a Pap test item in the CPC-28
questionnaire.
The lack of knowledge is reported as a barrier by Chilean women in items A25
and A17. The item A25 (I do not know how often I need to get a Pap test) addressed
the frequency recommended to have a Pap test and item A17 (I do not know at what age
it is necessary to have a Pap test) addressed the age. In Chile the screening
recommendation is to have a Pap test for all women is between 25 to 64 years, and the
periodicity is every 3 years (MINSAL,2008). A Hispanic study done in the US, reported
that 21% of the women did not know the periodicity to have the Pap test (Brenna et al.,
2001) and in a Thai study, 82.5% of the women knew the age when they should have a
Pap test (Boonpongmanee & Jittanoon, 2007). This topic was considered as a knowledge
domain by Koval et al. (2006) in a Hispanic study. To know these recommendations are
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basic information that women must know and the lack of this knowledge in both aspects
was perceived by the women as a barrier to have a Pap test item in the CPC-28
questionnaire.
The lack of time is reported as a barrier in item A3 (I do not have time to get a
Pap test) and this can be explained because the women have other activities, like work,
or caring for the family. This item is related heavily to the items previously described in
this domain because all of these speak about a similar problem, time. The lack of time
associated work obligations was described by Weisner Ceballos et al. (2006), Urrutia et
al. (2008) and Markovic et al. (2005) and the lack of time associated to waiting was also
described by Urrutia (2008) in a previous qualitative study. Therefore, this topic can be
analyzed from two perspectives: one is the real lack of time associated with work
obligations, waiting time, or a scheduling problem described in item A23 (I have not
taken the Pap test because the health care center is only open during hours when I cannot
go) and but the other perspective is the perception that the women have related to the
time needed for her care. Lamadrid (1998), reported that 75% of the women perceived
that they do not have time to be sick and Weisner Ceballos et al. (2006) described the
lack of time related to the time used on family issues. To feel very busy or to not have
time was reported previously as a barrier item by many authors (Henning & Knowles,
1990; Jirojwong & Manderson, 2001; Koval et al., 2006; M. C. Lee, 2000; Price et al.,
1996). Hou and Luh (2005) included the lack of time as cons of cervical smear item and
Pinho at al.(2003) and Bazan (2007) reported the lack of time as a reason for not having
a Pap test. In a previous Chilean study 12 years ago, the lack of time was reported as a
reason to avoid cervical cancer screening (Lamadrid, 1996) and this same item was
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selected by Chilean women as a barrier to have a Pap test item in the CPC-28
questionnaire.
The fear to have cervical cancer was one of the barriers selected with item A22
(I have not taken the Pap test because I am afraid to find out if I have cancer). Having a
Pap test opens the possibility to find some cervical change that can be related to a pre-
cancer lesion or cancer, and the fear for cancer diagnosis has been a concern that
transcends different cultures: African women (Lartey et al., 2003; McFarland, 2003),
Hispanic women (Agurto et al., 2004; Bazan, 2007; Byrd et al., 2007; Fernandez et al.,
1998; Hunter, 2005; Soto et al., 2003; Vanslyke et al., 2008), Asian women (Ho et al.,
2005; Holroyd et al., 2003; M. C. Lee, 2000; Seow et al., 1995; Taylor et al., 2002),
European women (Tacken et al., 2007), and Australian women (Henning & Knowles,
1990). In two previous Chilean studies (Urrutia et al., 2008; Valenzuela & Miranda,
2001), this fear was reported as a barrier to have a Pap test and the majority of the
authors have reported the same fear as a barrier to have cervical cancer screening (Agurto
et al., 2004; Bazan, 2007; Byrd et al., 2007; Fernandez et al., 1998; Henning & Knowles,
1990; Ho et al., 2005; Jirojwong & Manderson, 2001; Lee Lin et al., 2007; M. C. Lee,
2000; McFarland, 2003; Price et al., 1996; Seow et al., 1995; Urrutia et al., 2008;
Valenzuela & Miranda, 2001).
Embarrassment has been a topic studied many times, and CPC-28 questionnaire
considered this topic as a barrier with item A24 (I have not taken the Pap test because I
am embarrassed to have a genital exam). Health care professionals must consider ways
to make the gynecological examination an important component for womens preventive
health and how this is done is important. The anxiety related to the physical privacy was
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reported as a barrier by 50% of the Mexican women (Watkins et al., 2002), and women in
Canada reported they felt their privacy violated when they had a Pap test (Steven et al.,
2004). Hispanic (Vanslyke et al., 2008; Wiesner Ceballos et al., 2006), African (Bingham
et al., 2003; Byrd et al., 2007), Australian (Henning & Knowles, 1990), and Asian studies
(M. C. Lee, 2000) also reported embarrassment related to having a physical examination.
In addition, a study done in Thailand, the first reason for not having a Pap test was the
embarrassment associated with the exam (Boonpongmanee & Jittanoon, 2007). The CPC-
28 questionnaire, also, found embarrassment as a barrier to have a Pap test item.
Domain 2: Cues to action to have a Pap test.
The domain cues to action to have a Pap test has six items, and explains
13.641% of shared variance in this questionnaire. Similar to the barrier to have a Pap
test domain, all the cues to action items in the CPC-28 questionnaire were developed for
this domain. Cues to action can be defined as stimuli perceived by the woman that causes
her to have the Pap test.
The items included in this domain consider the cues to action from the family
(mother or other member), health care professionals (nurse, midwife or physician), friend
or neighbor, and media.
The cues related with the family are explained in items C5 and C7. The item C5
(Because my mother spoke to me about it) positioned the mother as one of the cues for
having a Pap test. In the Burak study (1997), the conversation with the mother about a
gynecological exam was one of the cues and it has been described and remembered by an
important person is an important cue to have a Pap test (Henning & Knowles, 1990).
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Chilean women selected a mothers advice as a cues to action to have a Pap test in the
CPC-28 questionnaire.
In reference to item C7 (Because members of my family told me to get it) was
the second item selected in the cues to action to have a Pap test factor. A member of a
family as a cue has been described by Price et al. (1996). The suggestion from a family
member to have a Pap test was described as a benefit by Ho et al. (2005) and as a
reinforced factor by Taylor et al. (2002). The selection of this item as a cue positioned the
family in an important role in Chilean women beliefs, and it is much related to the
familism, as important value in Hispanic society (Antshel, 2002).
The cue of health care professionals are represented by items C3 (because a
nurse or midwife told me) and C4 (Because a doctor told me). Women reported that if
the Pap test is not suggested by a doctor or nurse, they will not have it (Lartey et al.,
2003), and these are important cues for having the Pap test (Price et al., 1996). The lack
of a medical recommendation has been considered a barrier by many authors (Boyer et
al., 2001; Fernandez Esquer & Cardenas Turanza, 2004; Ho et al., 2005; Moreland et al.,
2006; Pinho et al., 2003), and as cons to cervical cancer smear by Hou and Luh (2005).
The recommendation from the doctor has been described as a benefit (Ho et al., 2005),
inspiration (Holroyd et al., 2003) or reinforcement factor (Taylor et al., 2002). Some
women reported that the doctor is who takes the initiative for having a Pap test (Brenna et
al., 2001; Markovic et al., 2005). The Chilean women considered the health care
professional recommendation as a cue, because they have strong beliefs about the advice
health care professionals convey. The recommendation from health care workers was
selected as a cues to action to have a Pap test item in the CPC-28 questionnaire.
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The media cue is in item C8 (Because I listened to or read something in the
newspaper or in a television or radio program). Ho et al. (2005) in a study done with
Vietnamese women reported media information as a benefit domain and Boyer et al.
(2001) reported that women recommended a television campaign as a strategy for
improving cervical cancer screening. Media information has been reported as inspiration
to have a Pap test (Holroyd et al., 2003) and a way to receive information about cervical
cancer screening (Holroyd et al., 2003; Seow et al., 1995). Hennig and Knowles (1990)
reported magazine or newspaper publications as a third cue in order of importance after a
doctor and person reminder. Hoeman et al. (1996) reported the same as a second cue in a
Chinese study. The Chilean women selected as a cue to receive information from the
media and this item was included in the CPC-28 questionnaire.
The friend or neighbor as a cue is in item C6(Because a friend or neighbor spoke
to me about it) and this cue has also been previously described by Price (1996). The
suggestion or recommendation to have a Pap test from a friend was described as a benefit
(Ho et al., 2005), a reinforcement factor (Taylor et al., 2002) and an inspiration (Holroyd
et al., 2003). The same has been found in Chilean women, and advice from a neighbor or
a friend is considered a cues to action to have a Pap test in the CPC-28 questionnaire.
Domain 3: Severity of cervical cancer.
The severity domain in the CPC-28 questionnaire included four items and all of
these were developed within this domain. Thus, severity of cervical cancer factor is
defined as belief woman perceived about how serious it is to have cervical cancer and
their sequels. The severity domain in this questionnaire is related to cervical cancer as a
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serious problem, the possibility to have a hysterectomy, radiation therapy and
chemotherapy, and to die from this disease.
The item A29 (Cervical cancer is a serious health problem) was the first item
selected as a severity item and it demonstrated the importance that the women gave to
cervical cancer as a disease. Byrd et al. (2004) and Price et al. (1996) considered that
cervical cancer is a serious problem compared with other cancers and 30.7% of the
women agreed with this in the Byrd study and 33% of the women in the Price study. In
the Seow study (1995) 96% of the women considered cancer as a serious disease. Chilean
women also recognized that cervical cancer is a serious problem and this item remained
as part of the severity of cervical cancer domain in the CPC-28 questionnaire.
The item A28 (Cervical cancer may lead to a woman having a hysterectomy)
was the second item chosen in the severity factor. The association of surgery with
cervical cancer remains an important issue as a hysterectomy per se is a severity
consequence; therefore, it is very clear why this item matched with the severity factor.
The fact that at a minimum with abnormal results, that women will be hysterectomized
has previously been described (Bingham et al., 2003; Jirojwong & Manderson, 2001;
Price et al., 1996). Agurto et al. (2004) described hysterectomy as a barrier and it was
considered as a treatment that disabled sexual function. Mc Farland (2003), Price et al.
(1996) and Jirojwong and Manderson (2001) considered this as a severity domain. Koval
(2006) described this topic as a knowledge item. The CPC-28 questionnaire considered
this consequence as part of severity of cervical cancer factor.
The item A30 (Cervical cancer can lead to a woman needing to receive
chemotherapy or radiation therapy treatment) is another consequence of having cervical
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cancer. The topic of this item had not been previously included by other authors and was
included in the Beliefs-53 items questionnaire because it was a principal concern when
women spoke about cancer. The findings of the Chilean study reported that to have
chemotherapy or radiation therapy are consequences considered in the severity of
cervical cancer factor in CPC-28 questionnaire.
The item A27 (Cervical Cancer may lead to death) was considered a severity
item. To die was selected as one of the most important concerns related to having cancer
and the Chilean population demonstrated it because it was chosen as a severity domain
and also as susceptibility domain. This has been previously studied by other authors:
Bingham et al. (2003) and Fernandez et al. (1998) reported that women thought that the
cancer is a death sentence and Mc Farland (2003) reported that 50% of the women
thought that cancer was fatal. The same finding that women diagnosed of cervical cancer
will die has been reported by Risendal et al. (1999) and Tacken et al. (2007) in previous
studies. Price et al. (1996) and Mc Farland (2003) reported this in the severity domain
similar to that reported in the CPC-28 questionnaire.
Domain 4: Need to have a Pap test.
The need to have a Pap test factor in the CPC-28 included 3 items and all of
them were developed within the susceptibility domain. The susceptibility domain
dimension was defined in the content validity process as belief about the possibility
(susceptibility) to acquire cervical cancer or to have an abnormal Pap test, and therefore
the desire to have the Pap test. During factor analysis, the susceptibility domain showed
two factors, and one of them is the need to have a Pap test defined as belief that the
woman has about the need to have the Pap test according to the requirements.
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The need to have a Pap test domain is related to the characteristics that the
women have. These include symptoms, children, and intercourse.
The item B3 (If I have not had children, I do not need a Pap test), was one of
the items selected in the need to have a Pap test factor. It is known that to have children
is not a condition for having a Pap test, but this item addressed the perception women
have related to personal conditions for having a Pap test. This item has never been
reported as a susceptibility factor. Agurto et al. (2004) reported that women felt the Pap
test is better for women with children, as a benefit item, and Byrd et al. (2004) reported
that only women, who have had babies, need a Pap test.
The item B2 (If I do not have symptoms, I do not need a Pap test), was the
second item selected in the need to have a Pap test domain. This has been reported
many times in the literature and researchers have studied it with different outcome
results. Lee-Lin et al. (2007) measured this topic within a knowledge domain and
reported that 18% of the women believed that to have symptoms is necessary to have a
Pap test. Hou and Luh (2005) reported the need to have symptoms as a perceived cons of
cervical cancer smear. This has been reported as a barrier in Mexican women (Watkins et
al., 2002), in a Botswana study (McFarland, 2003), and in an Australian sample (Girgis et
al., 1999). The literature has recognized that women need to feel sick to have the Pap test
(Agurto et al., 2004; Boyer et al., 2001; Holroyd et al., 2003; Jirojwong & Manderson,
2001; Lartey et al., 2003; McMullin et al., 2005; Pinho et al., 2003; Wiesner Ceballos et
al., 2006), and that women do not seek care of a physician if they do not feel some
symptoms (Bingham et al., 2003; Brenna et al., 2001; Risendal et al., 1999). This belief is
related to the fact that health care professionals are associated with cure of symptoms
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(Markovic et al., 2005). This same, to have or not have symptoms was a need to have a
Pap test item selected in the CPC-28 questionnaire.
The item B4 (If I do not have intercourse, I do not need a Pap test) was the third
item selected in the need to have a Pap test domain. The relationship between having
intercourse and needing a Pap test is the topic in this item. The women feel more or less
susceptible to have the Pap test if they are sexually active. It is important to point out that
Pap screening in Chile must start at 25 years of age with or without the antecedents of
intercourse; therefore, age is the most important requirement. The belief that it is
necessary to be sexually active has been previously reported (Lee Lin et al., 2007), and
the range of acceptance of this is between 9% (Holroyd et al., 2003) to 26% (Taylor et
al., 2002). In a previous Chilean study, Valenzuela and Miranda (2001) reported as a
barrier the belief that women need to be sexually active for having a Pap test and this
same belief has been reported by other authors with Hispanic women (Agurto et al.,
2004; Watkins et al., 2002; Wiesner Ceballos et al., 2006).This topic also has been
reported as a susceptibility domain by Mc Farland (2003), cons to cervical cancer
screening by Hou and Luh (2005), a predisposing factor by Taylor et al. (2002), and
knowledge domain by Holroyd et al. (2003). The CPC-28 questionnaire considered this
as a need to have a Pap test item.
Domain 5: Susceptibility to cervical cancer.
The susceptibility to cervical cancer factor in CPC-28 questionnaire included
three items and all of them were developed within the susceptibility domain. This factor
came from the original susceptibility domain that was divided into two factors.
susceptibility to cervical cancer is defined as belief that the woman has about the
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possibility to acquire cervical cancer and to die from this. The susceptibility to cervical
cancer domain is related to the risk to have a cervical cancer, the susceptibility because
of age, and the possibility to die if the women acquire cervical cancer.
The item B9 (If I have cervical cancer, I can die) considered the topic of the
death. The severity factor indicated that the women perceived that cervical cancer can
lead to death. If the women perceived the possibility of death, they felt susceptible to die,
and this relationship explained very clearly why this item was selected in the
susceptibility to cervical cancer domain. This item is related to the fatalism associated
to the cancer issue; Becker et al. (2006) described, that the women thought that cancer is
beyond control and one has to die ultimately of something. The fatality of cancer has
previously been reported (McFarland, 2003).The possibility to die was selected in the
CPC-28 questionnaire as a susceptibility to cervical cancer item.
The item B10 (Cervical cancer is one of the most common cancers among
women my age) addressed the relationship between cervical cancer and age as a risk
factor. The perception that cervical cancer is one of the most common cancers makes the
women feel more or less susceptible to development of this disease. Cervical cancer has
occurred most frequently among women in their childbearing years and beyond
(American Cancer Society, 2009a) and the mean age in this sample was 38 years old;
therefore, this perception could be supported on the incidence rate of age. In a previous
Chilean study, one of the barriers reported by the women was the age (Valenzuela &
Miranda, 2001) and this barrier has been reported by other authors (Holroyd et al., 2003;
A. Smith et al., 2004). Byrd et al. (2004) and Price et al. (1996) reported this topic as a
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susceptibility domain. Ho et al. (2005) reported the age as a benefit, because it
suggested having a Pap test.
The item B8 (I am at risk for developing cervical cancer) addressed directly
about the susceptibility to have cervical cancer. The susceptibility to have cervical cancer
has been reported previously as susceptibility domain by other authors (Burak & Meyer,
1997; Byrd et al., 2004; Denny Smith et al., 2006; Henning & Knowles, 1990; Ho et al.,
2005; McFarland, 2003; Moreland et al., 2006). Price et al. (1996) reported it as a barrier
domain, Fernandez et al. (1998) reported it as a predisposing factor, and Tacken et al.
(2007) reported it as personal appraisal. The CPC-28 questionnaire considered this item
as a susceptibility to cervical cancer domain.
Domain 6: Benefit to have a Pap test.
The CPC-28 questionnaire has three items of benefit to have a Pap test, and two
of these were developed within the original benefit domain proposed in the Beliefs 53-
items questionnaire. The third item included was developed within the cues to action
domain. The benefit to have a Pap test factor is defined as belief that the woman has
about the good consequences to have a Pap test. The items are related to: save my life, to
feel good, and to take care of my health. Each of the items will be discussed in the next
paragraphs.
The item A20 (The Pap test can save my life) addressed the importance of the
Pap test avoid one of the death. Price et al. (1996) described that 88% of the women
perceived this topic as a benefit. However Holroyd et al. (2003) described this topic as
knowledge and this author specified that having a Pap test at regular intervals could save
ones life. Hoeman et al. (1996) reported the sense of being personally safe as a benefit of
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preventive action. In this Chilean sample, the Pap test was considered an important tool.
The importance that the Chilean women give to life (like a benefit item), the feeling of
susceptibility to die (susceptibility domain), and the severity that the women attribute to
the death (in the severity domain) supported the importance that Chilean women gave to
death as a belief concept in the CPC-28 questionnaire.
The second item included in the benefit to have a Pap test domain in the CPC-
28 questionnaire was the item C1 (the reasons that have made you or would make you
get a Pap test: To take care of my health). This item was developed for the cues to
action domain but since the first factor analysis computed that this item matched with
the benefit factor. The mean of this factor was analyzed in the context of the
instructions given to the women in part C: the reasons that have made you or would
make you have a Pap test isto take care of my health. To take care of my health has
been reported previously by other authors as a benefit (Agurto et al., 2004) but also as
motivation to have the Pap test (Boyer et al., 2001). Taking care of ones health was a
benefit perceived by Chilean women and it was not selected as cues to action but as
benefit. It is interesting to point out that laziness was one of the causes for not having a
Pap test described by the women in a previous Chilean study (Urrutia et al., 2008);
therefore, to take care of ones health is considered more as a consequence of having a
Pap test than as a stimulus to do it. This outcome could be interpreted because the women
need to have cues or stimulus come from people outside, and not from themselves. All
the cues selected in the CPC-28 questionnaire are from others.
The item A1 (Getting a Pap test makes me feel good because it means that I take
care of my health) was the third item selected in the benefit to have a Pap test domain.
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This item is similar to item C1, but the item A1 added the topic to feel good about having
the Pap test. The positive feeling considered by the Chilean women is perceived as a
benefit and this feeling is a result for doing something (have a Pap) that is considered
appropriate. The good feeling has been described previously as a peace of mind by
some authors (Agurto et al., 2004; Ho et al., 2005; Price et al., 1996), as a feeling that the
Pap test can reassure health (Jirojwong & Manderson, 2001), and as having control over
their health (Hou & Luh, 2005). This fact is supported in the Byrd study (Byrd et al.,
2004) and to maintain health has been considered as a motivation to have a Pap test in the
study done by Boyer et al. (Boyer et al., 2001). To feel good because I take care of my
health was considered a benefit to have a Pap test item in the CPC-28 questionnaire.
Correlations between CPC-28 Questionnaire Factors
The factor rotation method used in this research permitted the researcher to relate
the different factors selected in the CPC-28 questionnaire. It is important to point out that
these correlations explained the relationship between two factors, but they do not
establish causality between them. Therefore, it is known how both factors move and
which directions they can take, but it is not possible to establish what is the cause or
effect in this relationship.
The analysis of correlations of factors is the first step in the understanding the
relationship between the different components in the model. Each factor correlation in the
CPC-28 questionnaire will give information about the domains and which direction they
are taking. Figure 3 (page 138) illustrates the correlations meaning between the factors.
This figure portrays the interpretation of the correlation between the factors. This

Figure 3
Meaning of Correlations between Factors in the CPC-28 Questionnaire

Need to have
a Pap test
Susceptibility
to Cervical
Cancer
Severity of
Cervical
Cancer
Benefit to
have a Pap
test
Barriers to
have a Pap
test
Cues to Action
to have a Pap
test
Meaning of Correlations between Factors in the
CPC-28 questionnaire
(-)
1
(+)
(+)
(+)
(+)
(+)
(+)
(+)
2
3
6
4
5
7
8
1
3
8

139
interpretation is necessary because the correlation indexes did not explain per se the
relationships, because the score directions of the domain must be changed for each
interpretation. This figure illustration was done to increase the visual comprehension of
the analysis of the correlation factors and meaning.
Before the interpretations of the correlations, it is necessary to address the health
belief model components for better comprehension of the explanations. According to
Rosenstock (1974b) and as applied to cervical cancer, when a woman takes some action
to avoid cervical cancer, she needs to believe that: (Figure 4, page 140).
- She is susceptible to it. The susceptibility is a subjective perception of risk of
developing cervical cancer. She could have the cervical cancer even in the
absence of symptoms.
- The occurrence of the cervical cancer would have some degree of severity on
some component of her life.
- Having a Pap test would be beneficial in: Reducing her susceptibility, and
reducing the severity of cervical cancer (if the disease occurred). This action
would not entail overcoming important barriers.
Rosenstock (1974b) pointed out that the combined levels of susceptibility and
severity provided the force to act and the path of action is provided by the perception of
benefit (minus barriers).
The health belief model (Maiman & Becker, 1974) components proposed the
following conditions: the readiness to action determined by perception of susceptibility
and severity; the individuals evaluation of the advocated health action determined by
benefit and barriers; and finally a stimulus internal or external called cue to action.

Figure 4
Requirements to Have a Pap Test.
Requirements to Have a Pap test
Feel Susceptible,
(even in the absence of
symptoms)
(Susceptibility)
Disease must be
severe
(Severity)
Take action is
beneficial
(Benefit)
reducing
Important barriers
(Barrier)
Not entail
overcoming
reducing
(According to Rosenstock principles, 1974)
1
4
0

141
As illustrated in figure 3 (page 138), there are 8 correlations between the factors
that will be discussed in the next paragraphs. Correlation number 1 addressed the
relationship between the barrier and the need to have a Pap test factor. This correlation
indicated that if the woman perceived beliefs of low barriers to have Pap test, the need to
have the test will be high, and vice versa. This relationship can be explained because if
the woman perceived high barriers to have a Pap test; for example, because she feels
embarrassed or has problems with the health care center, she will feel less need to have a
Pap test, because she will want to think that the Pap test is unnecessary or that she does
not have the conditions to have it. The other way this relationship is explained is when
the woman perceived greater need to have a Pap test, because of beliefs, she has the
requirements to have it, she will feel fewer barriers to have the test, because she needs to
have it. Allahverdipour and Emami (2008) previously reported the same correlation
between barrier and susceptibility domains. Susceptibility and barriers were two of the
three variable predictors of the Pap test intention (Henning & Knowles, 1990) and
multivariate analysis performed by Allahverdipour and Emami (2008) and Burak and
Meyer (1997), the barrier factor explained the Pap test status of the women.
If the Pap test beliefs of the barriers could be changed or decreased, it is possible
to infer the need to have a Pap test belief could be moved in a direction that permitted the
woman to feel the need to have a Pap test and have the force to do it. In essence, a barrier
can provide the path to action and susceptibility or force to do it (Rosenstock, 1974b).
It is known that the barrier factor predicted the use of the Pap test, as reported by
some authors (Boonpongmanee & Jittanoon, 2007; Ho et al., 2005; Jirojwong &
Manderson, 2001), who found that women who had perceived barriers were less likely to
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have a Pap test and that women who have obtained a Pap test had significantly fewer
barriers in comparison than those who had never had a Pap test (Boonpongmanee &
Jittanoon, 2007). The negative correlation between the barrier factor and Pap test status
was also reported by Allahverdipour and Emami (2008).It is interesting to point out that
the barrier to have a Pap test factor had one significant correlation; this met that a barrier
to have a Pap test played an independent role in the model. However, Allahverdipour and
Emami (2008) reported a negative correlation of barrier factor with severity factor.
The second correlation figure 3 (page 138), pointed out that need to have a Pap
test factor is correlated to benefit to have a Pap test. This correlation met that if a woman
had low need to have a Pap test, because of beliefs, she has low benefits to have a Pap
test because of beliefs and vice versa. This relationship can be explained because if the
woman perceived as being more needed to have a Pap test, because she has the
requirements for having a Pap test, the benefits of having the test increase, because the
women felt the need to do it. Another way is if the woman perceived fewer benefits to
have a Pap test, the need to have it decreases, because she does not feel it is necessary to
have it. A similar correlation was reported previously by Allahverdipour and Emami
(2008) in an Iran study; however , it is important to note that the correlation index
findings in the CPC-28 questionnaire analysis was stronger than the Allahverdipour
study.
The need beliefs to have a Pap test can be intervened easier with than the benefit
beliefs to have a Pap test; for example, an explanation that it is not necessary to have
intercourse, children or symptoms for having a Pap test could increase the susceptibility
to have a Pap test, and by consequence increase the perception of this benefit to have it.
143
In a Burak study (1997), the women who had a Pap test were more likely to believe that
the benefit outweighed the barriers and this benefit made an important contribution to the
variance in the prediction of having the Pap test. In essence, research finding indicated
that increasing the benefit perceptions could help to increase Pap test adherence.
The third correlation figure 3 (page 138), illustrated the relationship between the
factors of benefits and cues to action to have a Pap test. This correlation result indicated
that if the woman perceived more benefit to have a Pap test, she perceived more cues to
action to have a Pap test, and vice versa. This relationship can be explained that when the
woman received cues to action; for example, from the mother or a health care
professional, it will be perceived that the Pap test is beneficial, because the people who
send the cues are giving her the message about the importance of having the Pap test.
Another way is if the woman perceived that the Pap test is beneficial, because she felt
good or believed that it could save her life, she would be more receptive to the cues sent
by other people, and therefore be more reactive to the cues to action. It is important to
remember that benefits give the path to take action and if the woman does not perceive
the Pap test as beneficial, the cues received will not be received.
Cues to action are external motivations that can be done by the professional nurse
through nursing interventions. Interventions by increasing the cues increase the
perception of the benefits for having the Pap test. Nursing interventions such as asking
about Pap test taking in health care settings are important interventions that nurses can
achieve. It has been described that women who have beliefs of the benefits of the Pap test
are likely to have a Pap test (Burak & Meyer, 1997). This was reported by Henning and
Knowles (1990) as one of the variables that predicted the intention of women to have a
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Pap test. Therefore, increasing beliefs of benefit and cues to action through nursing
interventions are important to increase Pap test rates.
Correlation number 4 (figure 3, page 138) addressed the factors of benefit to have
a Pap test and the severity of cervical cancer. This correlation indicated that if the benefit
beliefs to have the Pap test increased, it increased the severity to have a Pap test and vice
versa. An explanation of this relationship indicated that if the woman perceived that
cervical cancer is severe, the benefits of having a Pap test will be high, because a solution
to the severity of the disease is present. Another indication is that if the benefits of the
Pap test are few, the severity of the disease will be less if one does not like to have the
Pap test, which may decrease the need to do it.
The perception of severity and susceptibility are related to providers and the force
to action; therefore, to increase the power of severity can be increased by the perceptions
of the benefits of the Pap test. A positive correlation between Pap test status and severity
domain was reported by Allahverdipour and Emami (2008). This benefit has been related
to Pap test status (Allahverdipour & Emami, 2008; Burak & Meyer, 1997) and multiple
regression analysis explained the Pap test status of women (Allahverdipour & Emami,
2008). By increasing both aspects, benefit and severity, could be very beneficial because
the woman could increase the adherence to Pap test screening. It is important to consider
that the severity domain has been described in relation to behavior in a curvilinear
manner; for example, very low and high perceptions could result in maladaptive behavior
and moderate results in adaptive behavior (Davidhizar, 1983). This finding indicated the
grade of the severity and its result is important and must be studied in future research.
145
The fifth correlation (figure 3, page 138) addressed to the benefit factor to have a
Pap test and the susceptibility factor to cervical cancer. This correlation indicated that if a
woman increased their belief of benefit to have a Pap test, it would increase the
susceptibility of beliefs to cervical cancer, and vice versa. This relationship can be
explained because if the woman perceived high benefits to have a Pap test, the
susceptibility would increase, because of the need to take the test. The other way about
this is to think if the woman felt less susceptible to cervical cancer, the Pap test would be
beneficial, because she does not need to take it. A similar correlation with Iranian women
was reported previously by Allahverdipour and Emami (2008), but the correlation value
in the Urrutia study was stronger than Allahverdipour study.
It is important to remember that Rosenstock (1974a) pointed out that a particular
preventive action (in this case to have a Pap test) is a function of two interacting beliefs:
susceptibility and benefit. In the CPC-28 questionnaire, the relationship of these two
beliefs was demonstrated and future research could demonstrate further direction of this
relationship. The positive correlation between Pap test status and benefit domain was
reported by Allahverdipour and Emami (2008) and in a study done by Burak and Meyer
(1997), the women who had a Pap test were more likely to believe that the benefit
outweighed the barriers. The Burak and Allahverdipour outcomes supported the
importance to increase the perception of benefit with this population.
The sixth correlation (figure 3, page 138) addressed the factors of cues to action
to have a Pap test and the severity of cervical cancer. This correlation indicated that if a
woman increased her beliefs in relation to action to have a Pap test, she increased the
severity of beliefs of cervical cancer, and vice versa. This relationship can be explained
146
because if the woman perceived that cervical cancer is severe, she will attend to the cues
to action from others, because she considered it important to prevent a severe problem.
Also, if the woman has had many cues, for example from mother, friends, and a nurse;
she will perceive the disease as severe because many people had talked to her about it.
Increasing cues to action is easier than increasing the severity belief; therefore,
nursing has an important role to inform women to have the Pap test and to increase the
perception of the different cues that were considered in this questionnaire (physician,
friends, and media). This statement is reinforced by Burak and Meyer (1997) who
reported that women who have had the Pap test has received more cues than the woman
who did not take it.
Correlation number 7 (figure 3, page 138) addressed factors of the cues to action
to have a Pap test and the susceptibility to cervical cancer. This correlation indicated that
if the woman increased their beliefs of cues to action to have a Pap test, increased
susceptibility to cervical cancer, and vice versa would be present. An explanation of this
correlation could be because if the woman perceives herself susceptible to have cervical
cancer, more cues to action will give her stimulus to have a Pap test. Also, in another
direction, if the woman has had many cues, she will feel more susceptible to have
cervical cancer, because others have asked her to have a Pap test.
Increasing the susceptibility of beliefs in the woman is an important intervention
that needs to be done by nurses. To teach about the risks of cervical cancer and how one
can die from this disease are important issues. In a multiple regression analysis,
susceptibility, health motivation, and barriers predicted the Pap test intention (Henning &
147
Knowles, 1990); therefore, increasing the susceptibility perception is an important
nursing intervention.
The last correlation, number 8 (figure 3, page 138), addressed factors of
susceptibility and severity of cervical cancer factor. These correlations indicated that if a
woman increased the beliefs of susceptibility to cervical cancer, she increased the
severity of cervical cancer perception, and vice versa. This relationship is described with
the explanation of the original model (Rosenstock, 1974b): severity and susceptibility
provided the force to action and both are correlated in the CPC-28 questionnaire. It is
important to consider that both factors have different meaning, but if they are correlated
similarity of findings could be shared between them, or that the movement from one
gives the direction to the other one. This same correlation was reported previously by
Allahverdipour and Emami (2008) and Denny Smith et al. (2006).
Positive correlations between Pap test status, severity, and susceptibility domains
were reported by Allahverdipour and Emami (2008). Therefore, if the perceptions of
severity or susceptibility are increased, the outcomes could be very beneficial for
increasing the rates of the Pap test, noting that severity would appear to be related to
behavior in a curvilinear manner (Davidhizar, 1983).
Implications of this Research for Nursing
The implications of this research for nursing roles will be discussed in the next
paragraphs, starting with the research role, education role and finally the administrative
role.

148
Research role.
The findings of Urrutia study have indicated the importance of the different
beliefs related to cervical cancer and Pap test. The study of health behaviors and their
determinants have been of interest to researchers for more than 30 years (Davidhizar,
1983). All the behaviors are motivated by factors, but the motivation is not sufficiently
accounted for by a specific act of health behavior (Rosenstock, 1960).
Rosenstock declared that health behavior is a function of individual beliefs and
the emphasis is aimed at the persons beliefs and not on objective reality (Rosenstock,
1960). Therefore, to know about the health beliefs is the first step for understanding
health promoting behaviors.
Research scientists and health care professionals have a need to understand why
and under what conditions and beliefs people have to take actions to prevent, detect and
treat diseases (Davidhizar, 1983; Mikhail, 1981). Health care professionals must be
concerned with health behavior and the care of clients. This statement is reinforced by
Mikhail (1981) who confirmed that women who understood the importance of health
participated in their own care.
Future research by nurses is needed to understand how beliefs impact health
preventive behaviors of women. If beliefs related to health behaviors can be identified,
nursing interventions for change of attitude could be developed, and hopefully increase
desirable health outcomes (Champion, 1984). To further reinforce this, Davidhizar (1983)
reaffirmed that understanding the reasons for behaviors are needed to tailor interventions
for health behavior changes.
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Cumming, Jette and Rosenstock (1978) pointed out that validated measures of
concepts permitted advances in science. This research study has contributed to the
advancement of nursing science, as the results have validated a reliable questionnaire for
measuring beliefs of Chilean women related to cervical cancer and the Pap test. The
validation of beliefs is the first step for explanation of Pap test screening behavior with
Chilean women in Chile. This instrument will add to this gap of knowledge as it
measures beliefs and therefore contributes to nursing science.
Behavioral research that addressed preventive behaviors and adherence with
screening guidelines is essential (Champion, Rawl, & Menon, 2002). Therefore,
continuation of this to achieve an explanation of beliefs about Pap test screening
behaviors will advance nursing science and hopefully add to the quality of life of Chilean
women. Prevention and detection of cervical cancer have tremendous potential and
hopefully will decrease morbidity and mortality rate associated with the disease
(Champion et al., 2002). To find causes of why or why not Chilean women have or do
not have the Pap test are important contributions of this research, as beliefs were
measured with a questionnaire validated in a cultural context.
Another important challenge to understand the relationships between health belief
domains is established with correlation findings between belief factors. These findings
for future research related to causality of beliefs and factors could be established. With
this, a very important question must be answered as reiterated by Bower: Do all aspects
of the model have equal significance? (Bowers, 1980, p. 46). An explanation of which
aspects contributed to having a Pap test are important considerations for future research.
As proclaimed by Rosenstock (1966), health decisions are determined by many factors
150
and it is necessary to establish which of the six domains-beliefs described in the CPC-28
questionnaire are most important in Chilean populations. This researcher recommends
that prospective studies are needed to achieve this goal.
Because of these findings from the Urrutia study, interventions for increasing Pap
test adherence can be planned. Most importantly, as Champion et al. (2002) reported
interventions must be tested in real world settings with a focus on cost-effectiveness, test
cultural measures of the population. These futures findings would be useful for baseline
assessment and evaluation. Future efforts must be directed to take advantage of the
technology now available (Champion et al., 2002), and use of media to provide education
to populations. The CPC-28 questionnaire demonstrated that media is an important cue,
therefore, to find the appropriate media message and the way to transmit the message is
indicated for future research in Chilean populations.
The support to develop this new questionnaire was based on the need to decrease
cervical cancer rates and increase Pap test rates. This research hopefully will contribute to
decreasing cervical cancer rates and increase Pap test rate by providing a validated and
reliable questionnaire for use with other research for Chilean women.
Educative role.
Nurses are placed in an optimal position as a health care professional for patient
teaching, because they spend more time with patients, can assess a patients health
education needs, and are at the forefront to provide preventive health education
(Ackerson & Preston, 2009; Knopf, 1980; McAllister & Farquhar, 1992). This researcher
strongly agrees with Bowers (1980) and Hughes (2009) that recognized the patient
151
education as an integral component of nursing responsibilities and especially that women
need to be guided by nurses to address the importance of cervical cancer and Pap test.
Health beliefs as confirmed with the Urrutia questionnaire study have important
implications for nursing education in practice and academia, given the role of the nurse in
health promotion and patient teaching (McAllister & Farquhar, 1992). The knowledge of
beliefs energize and direct behavior (Kirscht, 1974), this play an important role in
determining preventive health behavior (McAllister & Farquhar, 1992).
It is important to consider that a persons belief about health is influenced by the
culture, social background, and the experience of health/illness (McAllister & Farquhar,
1992). With women, their beliefs often play a role in feeling control over health
(McAllister & Farquhar, 1992). The combination of beliefs, attitudes, and socio-
demographic factors are different between various cultures, and because of this,
preventive behaviors need to be different (Gillam, 1991). It is important to consider
individual differences, because people may have different combinations of health beliefs
(Mikhail, 1981). Because of this, it is important to assess this difference, especially by
midwifes and nurses in Chile. These differences can be validated using the CPC-28
questionnaire, because it was developed for and tested with Chilean women. The findings
can assess the midwife and nurses to develop strategies tailored to the womens beliefs.
The health belief model has allowed nurses and midwifes to choose a intervention
strategies pertinent to a particular client and a particular situation, based on personal
knowledge of the variables that affect health behavior (Mikhail, 1981). Since nurses have
continuous contact with clients, they have multiple opportunities, spontaneous or
152
planned, to provide health education to patients and to influence client health behaviors
(Davidhizar, 1983; Mikhail, 1981).
One important and positive advantage of the health belief model is based on the
patients perceptions of their health situations and not on those of nurses or midwifes.
Both perceptions, from nurses and patients, are often not synonymous. Therefore, it is
crucial for nurses to determine the patients perceptions for planning a specific education
program. In essence, nurses must concentrate on closing the gap and reach the best
interventions to facilitate patients to become an advocate for their own health.
Important to this discussion are two questions that Rosenstock asked more than 30
years ago: "Will the program be adapted to fit people or will people be adapted to fit the
program? and Should public health programs be oriented to fit within peoples existing
motives and beliefs, or should attempts be made to change peoples motives and beliefs
in accordance with professional estimates of what changes are needed? (Rosenstock,
1960, p. 300). To answer both questions, it is important for nurses to have an
understanding of their role and develop preventive programs that are oriented to
individuals existing motives and beliefs.
To change the womens beliefs based on previous knowledge about their
perceptions is one way to answer these questions, but the issue is adapting the health care
program to their needs, based on the knowledge about their beliefs. The first way to
facilitate interventions is discussed in the next paragraphs, and the second one in the next
section (administrative role).
Nurses are in an optimal position to educate and facilitate the understanding of
their patients beliefs on health issues. This statement is reinforced by Bowers (1980),
153
who affirmed that the education process begins with an acknowledgment of the patients
current perception of severity and implications of the disease to ones health. The Urrutia
study reaffirmed that relationships between beliefs are important for future studies with
Chilean women.
It is undoubtedly true that some of the failures of individuals to take
recommended action are based on simple gaps in information, or on misconceptions
about effective courses of action (Rosenstock, 1960). Therefore, the first step in
educational planning is to know what are the beliefs about cervical cancer and the Pap
test.
Nurses need to focus on assisting women to be part to a preventive health status
(Ackerson & Preston, 2009), because they have an important role in promoting health
and well-being (McKie, 1993a, 1993b). The responsibility to inform and explain cervical
cytology for women is part of the practice of nursing (Ibbotson & Wyke, 1995). It is
important that information about screening be consistent and presented in a manner that
encourages dialogue (Ackerson & Preston, 2009) thus avoiding lack of explanation at the
moment of the test (McKie, 1993a). This action by nurses can assure that women can be
an active participant in the screening process (Ibbotson & Wyke, 1995).
Secondary prevention is an important part of nursing intervention in cervical
cancer and the Pap test, and must be offered to women in different situations, other than
gynecological clinic care (Ackerson & Preston, 2009). One of the cues to action was the
health care professionals advice, therefore, it must be considered at the moment to ask
the Pap test in different clinical setting.
154
It is important for the nurse to recognize and explain the costs as well as the
benefits of having the Pap test (Ibbotson & Wyke, 1995). The nurse and other practice
staff can do a great deal to reduce these costs to women, but may not be able to eliminate
all of them (Ibbotson & Wyke, 1995). If women feel embarrassment related to having the
Pap test, maybe it will be decreased but will not disappear completely.
There are two important goals of secondary screening with the Pap test and
cervical cancer. The first goal of secondary prevention is to assist women to understand
the aim of screening (Ackerson & Preston, 2009). The promotion of the message
concerning the positive benefits of cervical screening is an important issue in nursing
intervention (McKie, 1993b). Addressing the barriers, susceptibility, and severity are
important when planning education programs. The conversation could be guided by
topics as selected in the CPC-28 questionnaire. The themes of each domain are aspects
that should be considered. The second goal is increasing the adherence to the Pap test and
for this to happen, the womens beliefs are important considerations.
The nurse clinicians role in cervical cancer screening is to be an educator to other
health care professionals (Ginsberg, 1991). The health educator positioned in a health
care setting must convey the importance of this to other health care professionals and
nursing students.
Administrative role.
Rosenstock (1966) established the fact that to change peoples beliefs is more
difficult than to change environment, therefore, changing the environmental factor could
be very beneficial to increase the beliefs and incentives for women to have a Pap test. In
the CPC-28 questionnaire, four health care setting barriers were selected, therefore,
155
decreasing this barrier could be an important change in the environmental setting. Nurses
are in a good position to make changes in their health care setting that can better
accommodate the needs of the women.
The health belief model, as a phenomenological orientation, assumes that the
subjective world of the perceiver determines behavior rather than the objective
environment, that is represented in the mind of the behaving individual (Mikhail, 1981).
Therefore, by increasing acceptance and importance of health preventive programs can be
done by minimizing the barriers that women perceive, maximizing and providing cues to
action (Rosenstock, 1966). The concept of barrier is important because it defines the
interface between the patient and the health care system (Melnyk, 1988).
The adaptation of a program is directly related to the knowledge known about
people (Rosenstock, 1960). The CPC-28 questionnaire will permit one to know the
beliefs that women have related to cervical cancer and the Pap test, and to understand the
behavior relates to Pap test screening. Because of this, it is important to consider
especially the beliefs of the women and their opinion for developing and accepting health
programs that are integrated into the community. As previously reiterated, health
prevention programs must be designed form findings of beliefs and thinking for and with
the women.
In education and adaptation of health care programs, an important factor related to
cervical cancer screening information is the consideration of the literacy level of the
women (Lindau, Tomori, McCarville, & Bennett, 2001). Lindau (2001) affirmed that
some campaigns are often designed for a more literate population and may result in
inadequate and negative attitudes among the woman. Health literacy research designed to
156
fit the educational level can be an important barrier of adherence to preventive health
care.
It is important for the nurse to play a key role in the interdisciplinary practice
team to assure that cervical screening is organized in a way to make it accessible to all
women (Ibbotson & Wyke, 1995). The challenge for the future is to provide cost-
effective programs to deliver interventions while incorporating new technologies
(Champion et al., 2002). Media is a good method to restore the confidence with women
to have the Pap test (Ginsberg, 1991), and media was considered as a cue to action in
CPC-28 questionnaire. New technologies, such as cell-phone messages could be used to
improve media communication with the women.
Another cue found from the CPC-28 questionnaire was the health care providers
recommendations; therefore, a reminder system by providers is a way to increase Pap test
recommendations during routine health care visits (Champion et al., 2002). If this system
is implemented in the Chilean health care system, possibly the adherence to have a Pap
test would increase.
Future efforts to increase cancer screening require a trans disciplinary (Champion
et al., 2002) and multilevel approach in the administrative role as well as educational and
research role, that considers the relationship between women and the health care
professional, the health care system and community (Champion & Rawl, 2005). The
interrelationships between all these factors are recommended for future research.
In summation, implications of the result of the CPC-28 questionnaire will be very
useful in different settings. In practice, the health care provider can use the questionnaire
as an important guide in the educational setting when teaching the patients about cervical
157
cancer and Pap test. This education will permit the patients to be an active participant in
the screening process. In the research setting, the use of this new questionnaire will
permit the researcher to understand the beliefs of Chilean women, and develop
interventions to increase Pap test adherence. In the administrative setting, this new
questionnaire can be a guide for adapting health care programs to meet the needs of the
women.
Limitations and Strengths of this Study
Limitations.
This research has two limitations that must be considered. The first limitation is
that the sample used was a population that attended the womens health care clinic. This
group of women is more likely to have already adopted preventive actions. Therefore,
this characteristic could explain that only 3% of the women did not have an updated Pap
test. This rate of 3% may have been influenced by the proximal relationship they had
with the health care professionals, because if the women had been attended to in the
clinic it was because they were referred from another clinical setting.
The second limitation is that this research was a cross-sectional study, as the
relationship between belief and Pap test rate is not possible to link. Ideally, a prospective
study must be conducted to analyze the relationships between beliefs measured by CPC-
28 questionnaire and the Pap test as an outcome.
Strengths.
The first strength is related to the development of a new questionnaire for beliefs
of Chilean women concerning Pap test screening and cervical cancer for which
preliminary evidence supports initial reliability and validity. This is the first instrument
158
developed for Chilean women that was designed after the five health belief domains of
the Rosenstock health belief model (Rosenstock, 1974b). Therefore, this new
questionnaire fills a gap in knowledge of beliefs that Chilean women have related to
cervical cancer and the Pap test.
The second strength related to the findings of the questionnaire supported the
relationships between the different domains. To establish correlations between domains is
the first step in understanding the relationships between the components; therefore, in
future studies these relationships can be studied in more depth. The assumptions are made
that health behavior has resulted from health beliefs. It is possible, however, that instead
of preceding and determining health behavior (in this case to have or not have the Pap
test) health belief may develop with health behavior as a result of experience with
treatment and health care givers (Davidhizar, 1983). This is a challenge for future studies
on this topic.
The third strength of this research is the discovery of a new dimension of
susceptibility called need to have a Pap test. This new domain was not published
previously by other authors, and it could reveal an aspect that must be considered at the
moment of care to stimulate cervical cancer screening. The need to have a Pap test
appears obvious when you think about the need that women have to have or not have a
Pap test. The feeling of susceptibility to cervical cancer is not the only factor needed by
Chilean women; they need to feel the need to have a Pap test. This new discovery is
recommended for future studies, because the possibility of no connection between
cervical cancer and Pap test could be the reason for this outcome.

159
Summary
The items deleted from the original questionnaire were discussed. The
characteristics of the CPC-28 questionnaire considered the items that were included and
the correlation between factors found were discussed based on the literature review.
Implications for nursing practice are discussed in three areas: research, education, and the
administrative role. Strengths and limitations of this research with recommendations for
future studies were discussed.
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in Soacha, Colombia: social representation, barriers and motivation]. Revista de
Salud Publica (Bogota), 8(3), 185-196.

World Health Organization. (2006). Comprehensive cervical cancer control. A guide to
esential practice. Retrieved January, 25, 2007, from http://www2.alliance-
hpsr.org/reproductive-health/publications/cervical_cancer_gep/text.pdf

Worthington, R., & Whittaker, T. (2006). Scale development research: A content analysis
and recommendations for best practices. The Counseling Psychologist, 34, 806-
833.

Yi, J. K. (1998). Acculturation and Pap smear screening practices among college-aged
Vietnamese women in the United States. Cancer Nursing, 21(5), 335-341.

Zachariadou-Veneti, S. (2000). George Papanicolaou (1883-1962). Cytopathology, 11(3),
152-157.


Appendix A: Flyer. Spanish Version


UNIVERSITY OF MIAMI
ESTUDIO DE INVESTIGACION

CREENCIAS EN RELACION AL CANCER
CERVICOUTERINO Y EL TEST
PAPANICOLAOU

Usted est siendo invitada a participar en un estudio de
investigacin para mujeres entre 18 y 64 aos de edad, que
no tengan histerectoma o cncer de cuello del tero.

Se le solicitar contestar un cuestionario acerca de las
creencias que usted tiene del cncer cervicouterino y del
test Papanicolaou.

Su participacin le permitir al investigador conocer
acerca de las creencias en torno al cncer cervicouterino y
al test Papanicolaou.


Para mayor informacin, pregunte acerca del estudio a:
La investigadora en el telfono 9-826-9292 o en la
recepcin del rea de ginecologa.
178
Appendix B: Flyer. English Version

UNIVERSITY OF MIAMI
RESEARCH STUDY

BELIEFS RELATED TO CERVICAL CANCER AND
PAPANICOLAOU TEST

You are invited to participate in a research study for
women between 18 and 64 years old, without hysterectomy
and cervical cancer.

You will be asked to complete a questionnaire on your
beliefs on cervical cancer and the Papanicolaou (Pap) test.

Your participation will allow the researcher to learn about
cervical cancer and Pap test beliefs.


For more information, ask about the study to:
The researcher can be contacted: phone 9-826-9292 or
at the front desk reception (gynecology area).
179
Appendix C: Consent Form. Spanish Version
University of Miami
ACTA DE CONSENTIMIENTO INFORMADO
Desarrollo y Validacin de un Cuestionario:
Creencias acerca del Cncer Cervical y el examen Papanicolaou en Mujeres Chilenas.

La siguiente informacin describe el estudio de investigacin al cual usted est
siendo invitada a participar. Por favor lea cuidadosamente la informacin entregada. Si
usted decide participar, le pediremos que firme esta solicitud de consentimiento.

PROPSITO DEL ESTUDIO:
Usted ha sido invitada a participar en un estudio. El propsito de este estudio es conocer
las creencias que las mujeres chilenas tienen en relacin al cncer cervical (cncer del
cuello del tero) y al Papanicolaou (Pap). Usted ha sido invitada porque es chilena y tiene
entre 18 y 64 aos de edad.

PROCEDIMIENTOS:
Si usted decide participar en este estudio, la investigadora le pedir que conteste un
cuestionario de 53 preguntas acerca del cncer cervical (cncer del cuello del tero) y del
Pap y un cuestionario de 9 preguntas de caractersticas demogrficas. El cuestionario le
tomar 15-20 minutos de su tiempo y solo lo deber contestar una sola vez.

RIESGOS Y MOLESTIAS:
No creemos que exista riesgo o molestias por participar en este estudio. Usted puede
saltarse alguna pregunta si usted no desea contestarla.

BENEFICIOS:
No hay beneficios por su participacin en el estudio. Este estudio espera beneficiar a la
sociedad enseando acerca de las creencias que las mujeres chilenas tienen en relacin al
cncer cervical (cncer del cuello del tero) y al Pap.

ALTERNATIVAS:
Su alternativa es no participar en este estudio.

CONFIDENCIALIDAD:
Sus respuestas sern confidenciales. Su nombre no aparecer en ningn documento.
Usted ser identificada por un nmero, el cual ser asignado al cuestionario que usted
recibir. Su nombre y sus respuestas no podrn ser relacionados, ya que su nombre no
ser solicitado. El cuestionario y el consentimiento sern guardados en la oficina de la
investigadora, en un mueble con llave.
180
181

COSTOS:
No existe ningn costo para usted, por participar en este estudio.

COMPENSACIN:
No se le pagar por participar en este estudio.

DERECHO DE RETIRARSE:
Su participacin en este estudio es voluntaria. Usted est en el derecho de no participar en
el estudio o de retirarse en cualquier momento. La decisin de no participar en el estudio
o de retirarse en cualquier momento, no afectara el tratamiento o atencin que est
recibiendo o que va a recibir en el Complejo Asistencial Dr. Sotero del Rio.

PREGUNTAS Y CONSULTAS:
Maria Teresa Urrutia (09-826-9292) con mucho gusto le contestara cualquier pregunta
que usted tenga en relacin al propsito, procedimientos y resultados de este estudio. Si
usted tiene alguna pregunta sobre sus derechos como sujeto de investigacin, por favor
contctese con el Comit de tica de la Universidad de Miami al telfono 1-305-243-
3195. Usted tambin se puede contactar con el comit de tica del Complejo Asistencial
Dr. Sotero del Rio al telfono 56-2-57-65-163.


ACUERDO DE PARTICIPACIN:
He ledo la informacin en este consentimiento informado y estoy de acuerdo en
participar en este estudio. He tenido la oportunidad de hacer preguntas acerca del estudio,
y se me han contestado mis preguntas. He recibido una copia de este consentimiento
despus de ser leda y firmada. Basada en esta informacin, acepto voluntariamente
participar en este estudio.



___________________________________________ _______________
Firma de la mujer que participa en el estudio Fecha



___________________________________________ _______________
Firma Maria-Teresa Urrutia Fecha
(Persona que solicita el consentimiento)
Appendix D: Consent Form. English Version

University of Miami
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
Development and Testing of a Questionnaire: Beliefs about Cervical Cancer and
Papanicolaou Test in Chilean Women

The following information describes the research study in which you are being asked to
participate. Please read the information carefully. At the end, you will be asked to sign if
you agree to participate.

PURPOSE OF THE STUDY:
You are being asked to participate in a research study. The purpose of this study is to
examine the beliefs that Chilean women have related to Cervical Cancer and the
Papanicolaou test (Pap test). You are being asked to be in the study because you are
Chilean women between the ages 18 and 64 years.

PROCEDURES:
If you agree to participate in the study, the researcher will ask you to answer a 53 item
questionnaire about Cervical Cancer and Pap test and an 11 items demographic
questionnaire. The questionnaire will take approximately 15-20 minutes, and you will
need to answer only one time.

RISKS & DISCOMFORTS:
We do not anticipate that you will experience any personal risk or discomfort from taking
part of this study. You may skip any question if you do not wish to answer.

BENEFITS:
No benefit can be promised to you from your participation in this study. The study is
expected to benefit society by teaching us about the beliefs that the Chilean women have
related to cervical cancer and Pap test.

ALTERNATIVE:
Your alternative is not to participate in the study.

CONFIDENTIALITY:
Your answers will be confidential. Your name will not appear in any document. You will
be identified through a number, which will be assigned in the questionnaire that you will
receive. The relationship between your name and your answers will not be possible to
182
183
link, because your name is not required on the questionnaire. The questionnaire and the
informed consents will be secured in the researchers office, in a locked cabinet.

COSTS:
There are no costs associated with your participation in this study.

COMPENSATION:
You will not be paid for your participation in this study.

RIGHT TO DECLINE OR WITHDRAW:
Your participation in this study is voluntary. You are free to refuse to participate in the
study or withdraw your consent at any time during the study. Your withdrawal or lack of
participation will not affect the treatment you are receiving at Complejo Asistencial Dr.
Sotero del Rio.

CONTACT INFORMATION:
Maria Teresa Urrutia (09-826-9292 or 354-5834) will gladly answer any questions you
may have concerning the purpose, procedures, and outcome of this project. . If you have
questions about your rights as a research subject you may contact Human Subjects
Research Office at the University of Miami, at (305) 243-3195. You may also contact
Complejo Asistencial Dr. Sotero del Rio IRB at 56-2-57-65-163.

PARTICIPANT AGREEMENT:
I have read the information in this consent form and agree to participate in this study. I
have had the chance to ask any questions I have about this study, and they have been
answered for me. I am entitled to a copy of this form after it has been read and signed.
Based on this information, I voluntarily agree to take part in this study





_______________________________ ______________
Signature of Participant Date


______________________________
Maria-Teresa Urrutias signature


Appendix E: Participant Letter. Spanish Version

University of Miami
Carta de Participacin
Desarrollo y Validacin de un Cuestionario:
Creencias acerca del Cncer Cervicouterino y el test Papanicolaou en Mujeres Chilenas

Estimada Participante:

El propsito del este estudio es examinar las creencias que las mujeres chilenas
tienen en relacin al Cncer Cervicouterino y al test Papanicolaou (Pap). Usted ha sido
invitada a participar porque es chilena y tienen entre 18 y 64 aos de edad.

Su participacin en este estudio es voluntaria. Si usted decide participar, la
investigadora le va a pedir que conteste un cuestionario de 53 preguntas sobre el Cncer
Cervicouterino y el test Papanicolaou y un cuestionario de 9 preguntas demogrficas.
Usted puede no contestar alguna pregunta o abandonar el estudio en cualquier momento.

Sus respuestas sern confidenciales y no habr costo por participar en el estudio.

Su participacin le permitir a la investigadora conocer acerca de las creencias
acerca del Cncer Cervicouterino y del test Papanicolaou.

Muchas Gracias.
184
Appendix F: Participant Letter. English Version

University of Miami
PARTICIPANT LETTER
Development and Testing of a Questionnaire:
Beliefs about Cervical Cancer and Papanicolaou Test in Chilean Women

Dear Participant:
The purpose of this study is to examine the beliefs that Chilean women have
related to Cervical Cancer and the Papanicolaou test (Pap test). You are being asked to be
in the study because you are Chilean women between the ages of 18 and 64 years.

Your participation in this study is voluntary. If you agree to participate in the
study, the researcher will ask you to answer a 53 item questionnaire about Cervical
Cancer and Pap test and an 11 items demographic questionnaire. You may skip any
question if you do not wish to answer or withdraw your consent at any time during the
study.

Your answers will be confidential and there are no costs associated with your
participation in this study.

Your participation will allow the researcher to learn about cervical cancer and Pap
test beliefs.

Thank you.
185
Appendix G: Demographic Questionnaire. Spanish Version
Cuestionario demogrfico

Por favor complete los siguientes datos:
1. Qu edad tiene usted? ________(aos)

2. Hasta qu curso llego usted? Seale el nivel educacional y el curso que complet.
No fui al colegio ________
Educacin Bsica ________ ao Media _______ ao
Tcnica ________ ao Universitaria _______ ao

3. Seale su estado civil actual
Soltera ________ Conviviente ________
Casada ________ Separada ________
Viuda ________

4. Cuntos hijos tiene? _______ hijos No tengo hijos _______

5. Qu sistema de salud tiene?
FONASA A _______ FONASA B _______
FONASA C _______ FONASA D _______
ISAPRE _______ PRAIS _______
FFAA _______ Sin Prevision _______

6. Esta usted trabajando actualmente?
Si _____ No ______

7. Cundo fue la ltima vez que se tomo el Papanicolaou (Pap)?
Nunca me lo he tomado ______ No me acuerdo ______
Menos de 1 ao ______ Entre 1 a 2 aos ______
Entre 2 a 3 aos ______ Ms de 3 aos ______
186
187
8. Cul fue el resultado de su ltimo Papanicolaou (Pap)?
Nunca me lo he tomado ______
Normal ______
Alterado ______

9. Tiene algn familiar con Cncer Cervicouterino (Cncer al cuello del tero)?
Si ______ Quin?_______________________
No ______

10. Cul o cules son las causas del cncer cervicouterino?
Las relaciones sexuales _______
Un virus _______
El envejecimiento _______
La mala suerte _______
Los antecedentes familiares _______

11. Si la vacuna del virus papiloma estuviera disponible para prevenir el cncer
cervicouterino, usted se la colocaria?

Si _______
No _______
Appendix H: Demographic Questionnaire. English Version
Demographic questionnaire

Please, answer the following questions.
1. How old are you? ________(years)

2. What is your educational level?. Please answer the completed level
I did not go to school _______
Basic Level _______ year Media Level ________ year
Technical Level _______ year University ________ year

3. What is your marital status?
Single ________ Married ________
Separated ________ Widowed ________
Relationship, not legally married ________

4. How many children do you have? _______ I do not have children ________

5. What is your health insurance system?
FONASA A _______ FONASA B _______
FONASA C _______ FONASA D _______
ISAPRE _______ PRAIS _______
FFAA _______ Nothing _______

6. Do you have job?
Yes _____ No ______

7. When was the last time that you have a Pap test?:
I never have had a Pap test ______ I do not remember ______
Less than 1 year ______ Between 1 to 2 years ______
Between 2 to 3 years ______ More than 3 years ______
188


189
8. What was the last Pap test result?
I never have had a Pap test ______
Normal ______
Abnormal ______

9. Do you have some relatives with cervical cancer?
Yes ______ Who?____________________
No ______

10. What do you believe causes cervical cancer?
Sex _______
Virus _______
Getting Older _______
Bad Luck _______
Family History _______

11. If the human Papillomavirus vaccine is available to prevent cervical cancer, would
you take it?

Yes _______
No _______

Appendix I: Final Version Beliefs Questionnaire. Spanish Version

CREENCIAS EN RELACION AL CANCER DE CUELLO Y AL PAPANICOLAOU (PAP)
A. Las siguientes oraciones son algunas ideas relacionadas con el Papanicolau (PAP) y el cncer cervical (cncer al cuello del tero). Por favor marque con una
cruz la alternativa que ms se acerque a lo que usted cree en cada una de las oraciones. Este cuestionario no considera respuestas buenas o malas, por lo tanto
si hay alguna respuesta que usted no est segura o que no sabe, sintase libre de contestar lo que usted cree.

Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1. Tomarme el PAP me hace sentir bien porque significa que yo cuido mi
salud.

2. Si se tiene un PAP alterado (anormal) y no se trata, puede convertirse en un
cncer cervical (cncer del cuello del tero).

3. No tengo tiempo para tomarme el PAP.
4. Tomarse el PAP puede mover el dispositivo intra-uterino ( la T, la T de
cobre, el Asa, el tratamiento para no tener familia, etc.).

5. Tomarse el PAP es doloroso.

6. Tomarse el PAP permite la deteccin temprana del cncer cervical (cncer
del cuello del tero).

7. Tomarse el PAP puede evitar tener un problema de salud serio.

8. Si una mujer soltera o sin pareja se hace el PAP, se puede pensar que ella
est teniendo relaciones sexuales.

9. Tomarse el PAP es caro.



10. Tomarse el PAP me da vergenza.



1
9
0




Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
11. No tengo informacin acerca de donde tengo que ir para tomarme el PAP.



12. Tomarse el PAP significa utilizar bien el tiempo en salud.



13. Prefiero que sea una mujer la que me tome el PAP, ya que me incomoda
que me lo tome un hombre.

14. No me tomo el PAP porque en el consultorio me tratan mal.



15. Yo no s si necesito tomarme el PAP.



16. El PAP puede encontrar cncer cervical (cncer del cuello del tero)
cuando todava es posible curarlo.

17. Yo no s a qu edad es necesario tomarse el PAP.

18. No me tomo el PAP porque cuando voy necesito esperar largo tiempo para
ser atendida.

19. A mi pareja esposo no le gusta que me tome el PAP.



20. El PAP puede salvar mi vida.



21. Es difcil tomarme el PAP porque no tengo plata para movilizarme (tomar
la micro, el metro, el colectivo, etc.).

22. No me tomo el PAP porque me da miedo saber que tengo cncer.



23. No me tomo el PAP porque el consultorio atiende en horarios en ls que no
puedo ir.

24. No me tomo el PAP porque me da vergenza que me examinen los
genitales.


1
9
1



Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
25. Yo no s cada cuanto tiempo necesito ir a tomarme el PAP.



26. No me tomo el PAP porque cuesta mucho sacar una hora de atencin.



27. El cncer cervical (o cncer de cuello del tero) puede causar la muerte.



28. El cncer cervical (cncer del cuello del tero) puede llevar a una mujer a
tener que someterse a una histerectoma (sacarse el tero o matriz).

29. El cncer cervical (cncer del cuello del tero) es un problema de salud
serio.

30. El cncer cervical (o cncer del cuello del tero) puede llevar a una mujer a
tener que realizarse un tratamiento con quimioterapia o radioterapia.


1
9
2



B. Las siguientes oraciones son algunas ideas relacionadas con la necesidad que usted tiene de tomarse el PAP y el riesgo de tener un Cncer Cervical (cncer
de cuello del tero). Por favor, seale su grado de acuerdo en cada una de ellas. Recuerde que no hay respuestas buenas ni malas, por lo tanto si hay alguna
respuesta que usted no est segura o que no sabe, sintase libre de contestar lo que usted cree.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1. Yo no tengo riesgo de tener un PAP anormal (alterado).



2. Si no tengo sntomas o molestias, no necesito tomarme un PAP.



3. Si no he tenido hijos, no necesito tomarme un PAP.



4. Si no estoy teniendo relaciones sexuales, no necesito tomarme un PAP.



5. Si estoy embarazada, no necesito tomarme un PAP.



6. Si tengo menopausia (no tengo reglas), no necesito tomarme un PAP.



7. Si estoy esterilizada, no necesito tomarme un PAP.



8. Yo tengo riesgo de desarrollar un cncer cervical
(cncer del cuello del tero).

9. Si yo tengo cncer cervical me puedo morir.



10. El cncer cervical (cncer del cuello del tero) es uno de los cnceres ms
comunes entre las mujeres de mi edad.

11. Si no tengo historia en mi familia de cncer cervical (cncer del cuello del
tero), es poco probable que yo vaya a tenerlo.

1
9
3


1
9
4



C. Las siguientes son algunas razones que las mujeres pueden tener para ir a tomarse un PAP. Por favor, seale en cada una de ellas su grado de acuerdo,
pensando en las razones que me la han llevado o que la llevaran a tomarme el PAP. Recuerde que no hay respuestas buenas ni malas.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente en
desacuerdo
1. Para cuidar mi salud.



2. Despus de escuchar sobre el cncer cervical (cncer del cuello del
tero).

3. Porque una enfermera o matrona me lo pidi.



4. Porque un doctor me lo pidi.



5. Porque mi madre me habl sobre eso.



6. Porque una amiga o vecina me habl sobre eso.



7. Porque miembros de mi familia me dijeron que me lo tomara.



8. Porque escuch o le algo en el diario o en algn programa de
televisin o radio.

9. Porque tuve sangramiento por los genitales.



10. Porque tuve dolor en los genitales



11. Porque tuve molestias en los genitales



12. Porque un conocido (familiar, amiga, vecina) tuvo cncer cervical
(cncer del cuello del tero).




Appendix J: Final Version Beliefs Questionnaire. English Version

BELIEFS RELATED TO CERVICAL CANCER AND PAPANICOLAOU TEST (PAP TEST)
A. The following sentences are some ideas related to the Papanicolau test (PAP) and cervical cancer (uterine cervix cancer). Please indicate with a cross the
alternative that best describes your belief about each one of the sentences. There are no good or bad answers in this questionnaire, therefore if you are unsure or
do not know an answer, feel free to answer what you believe.

Strongly
Agree
Agree Disagree Strongly
Disagree
1. Getting a Pap test makes me feel good because it means that I take care of my health.


2. An abnormal Pap test, without treatment, can lead to cervical cancer.


3. I do not have time to get a Pap test.


4. A Pap test can move the intra uterine device (IUD).


5. Getting a Pap test is painful.


6. Getting a Pap test allows for early detection of cervical cancer.


7. Getting a Pap test can avoid a serious health problem.


8. If an unmarried or single woman gets a Pap test, people may think that she is having
sex.

9. Getting a Pap test is expensive.


10. Getting a Pap test is embarrassing for me.


1
9
5




Strongly
Agree
Agree Disagree Strongly
Disagree
11. I do not have information about where to go to get a Pap test.


12. Getting a Pap test is a good investment of my time in health.


13. I prefer that a female gives me the Pap test, because it is uncomfortable for me if a
man does it.

14. I have not taken the Pap test because they treat me badly in the health care center.


15. I do not know if I need to have a Pap test.


16. A Pap test can find cervical cancer when it is still possible to cure it.


17. I do not know at what age it is necessary to have a Pap test.


18. I have not taken a Pap test because when I go, I need to wait a long time to be seen.


19. My partner/husband does want me to get a Pap test.


20. The Pap can save my life.


21. It is difficult to get a Pap test because I do not have money for transportation (take a
bus, subway).


22. I have not taken the Pap test because I am afraid to find out if I have cancer.


23. I have not taken the Pap test because the health care center is only open during
hours when I cannot go.

24. I have not taken the Pap test because I am embarrassed to have a genital exam.


1
9
6




Strongly
Agree
Agree Disagree Strongly
Disagree
25. I do not know how often I need to get a Pap test.


26. I have not taken a Pap test because it is difficult to get an appointment.


27. Cervical Cancer may lead to death.


28. Cervical cancer may lead to a woman having a hysterectomy.


29. Cervical cancer is a serious health problem.


30. Cervical cancer can lead to a woman needing to receive chemotherapy or
radiotherapy treatment.


1
9
7



B. The following sentences are related to the need that you have to take the Pap test, and the risk of having Cervical Cancer. Please indicate the degree to
which you agree or disagree with each statement. Remember, there are no good or bad answers in this questionnaire, therefore if you are unsure or do not know
an answer, feel free to answer what you believe



Strongly
Agree
Agree Disagree Strongly
Disagree
1. I am not at risk for an abnormal Pap test.


2. If I do not have symptoms, I do not need a Pap test.


3. If I have not had children, I do not need a Pap test.


4. If I do not have intercourse, I do not need a Pap test.


5. If I am pregnant, I do not need a Pap test.


6. If I am in menopause, I do not need a Pap test.


7. If I am sterilized, I do not need a Pap test.


8. I am at risk for developing cervical cancer.


9. If I have cervical cancer, I can die.


10. Cervical cancer is one of the most common
cancers among women my age.

11. If I do not have a history of cervical cancer in my family, it is not
likely that I am going to have it.

1
9
8


1
9
9



C. The following sentences are some reasons women have for getting a Pap test. Please indicate the degree of agreement in each sentence, thinking about the
reasons that have made you or would make you get a PAP test. Remember, there are no good or bad answers in this questionnaire, therefore if you are unsure
or do not know an answer , feel free to answer what you believe.
Strongly Agree Agree Disagree Strongly Disagree
1. To take care of my health


2. After hearing something about cervical cancer.


3. Because a nurse or midwife told me.


4. Because a doctor told me.


5. Because my mother spoke to me about it.


6. Because a friend or neighbor spoke to me about it


7. Because members of my family told me to get it.


8. Because I listened to or read something in the newspaper or in a
television or radio program.

9. Because I had genital bleeding.


10. Because I had pain in my genitals.


11. Because I had discomfort in my genitals.


12. Because someone I know well (family, friend, neighbor) had
cervical cancer.



Appendix K: Guideline for Content Validity. Spanish Version

Pauta evaluacin de tems por expertos
Estimado (nombre evaluador):
Estoy construyendo un cuestionario para medir creencias en torno al Cncer Cervicouterino y al Papanicolaou. Este cuestionario est
basado en el modelo de creencias en Salud de Rosenstock.
El instrumento considera una serie de aseveraciones, frente a las cuales se les pedir a las mujeres que sealen su grado de acuerdo,
siendo las alternativas entregadas en una escala de Likert de 4 alternativas:
Totalmente en desacuerdo / Desacuerdo / De acuerdo / Totalmente de acuerdo.
2
0
0
Le pido que lea cada una de los tems / preguntas y seale su grado de acuerdo en 2 aspectos:
1. Si el tem o aseveracin corresponde a la definicin sealada para dicha dimensin
2. Si el tem o la aseveracin debe mantenerse en el cuestionario
Su participacin es de vital importancia, ya que debo contar con la validacin de expertos chilenos de este instrumento.
Por favor sintase en la libertad de escribir cualquier comentario o sugerencia en torno al cuestionario.
Muchas Gracias
Ma. Teresa Urrutia



DIMENSION BENEFICIOS:
La creencia acerca de la eficacia que tiene una determinada accin (en este caso es el tomarse el Pap) para reducir el riesgo o la seriedad de la
enfermedad (el Cncer de Cuello)
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1. Hacerme el Pap me hace sentir bien
porque significa que yo cuido mi salud.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

2. Tomarse el Pap permite la deteccin
temprana del cncer cervical.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

3. El Pap puede determinar si una mujer
tiene cncer cervical.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

4. Hacerme el Pap es una buena inversin
de mi tiempo en salud.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

5. El Pap puede encontrar cncer cervical
(cncer del cuello del tero) en un momento
que es posible curarlo.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

6. El Pap puede salvar mi vida.

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?


2
0
1





7. El Pap puede ayudar a encontrar
infecciones transmitidas sexualmente.

Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

8. Tomarme el Pap puede ayudar a
encontrar otros problemas del sistema
reproductivo (de los genitales).

El tem corresponde a la
dimensin beneficios?

Debe el tem mantenerse en el
cuestionario?

DIMENSION SEVERIDAD:
La creencia de que tan serio es una determinada enfermedad (EL Pap alterado o el cncer Cervicouterino) o sus secuelas.



Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1. Si se tiene un Pap anormal (alterado) y
no se trata, puede convertirse en un cncer
cervical (cncer del cuello del tero).
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

2. No hacerse el Pap puede llevar a tener
un problema de salud serio.
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

3. El cncer cervical (o cncer del cuello
del tero) puede causar la muerte.
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

4. El cncer cervical (o cncer del cuello
del tero) puede hacer la vida de una
mujer muy difcil.
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?


2
0
2





5. El cncer cervical puede llevar a una
mujer a tener que hacerse una
histerectoma (sacarse el tero o matriz).
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

6. El cncer cervical (o cncer del cuello
del tero) no es un problema de salud
serio.
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

7. El cncer cervical puede llevar a una
mujer a tener que realizarse una
quimioterapia o radioterapia
El tem corresponde a la
dimensin severidad?

Debe el tem mantenerse en el
cuestionario?

DIMENSION BARRERAS:
La creencia acerca del costo psicolgico o tangible de tomar una determinada accin (Tomarse el PAP)


1. No tengo tiempo para hacerme el Pap
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

2. Hacerme el Pap solamente me dar
problemas.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

3. Hacerse el Pap puede mover el
dispositivo intra-uterino (la T, la T de
cobre, el Asa, etc.)
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?


2
0
3





4. Hacerse el Pap es doloroso.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

5. Hacerse el Pap da seguridad acerca del
estado de salud.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

6. Si una mujer soltera o sin pareja se
hace el Pap, todos van a pensar que ella
est teniendo relaciones sexuales.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

7. Hacerse el Pap es caro. El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

8. Hacerse el Pap da vergenza. El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

9. No me tomo el Pap porque no tengo
informacin acerca de donde tengo que ir
a tomrmelo.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

10. Prefiero que sea una mujer la que me
tome el Pap, ya que me incomoda que me
lo tome un hombre.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?


2
0
4





11. Prefiero no ir a hacerme el Pap porque
a una la tratan mal en el consultorio.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

12. No me tomo el Pap porque cuando
voy necesito esperar un largo tiempo para
ser atendida
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

13. Yo no s si necesito tomarme un Pap. El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

14. Si una mujer no ha tenido sexo, el Pap
puede quitarle la virginidad.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

15. A mi pareja / esposo no le gusta que
me haga el Pap.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

16. Es difcil tomarme el Pap porque no
tengo plata para la micro.
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

17. No me hago el Pap porque me da
miedo saber que tengo Cncer
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

18. No me hago el Pap porque el
consultorio atiende en horarios en los que
no puedo ir
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?


2
0
5



19. No me hago el Pap porque me da
vergenza que me examinen los genitales
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

20. Yo no s a qu edad es necesario
hacerse el Pap
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

21. Yo no s cada cuanto tiempo necesito
ir a tomarme el Pap
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?

22. No me hago el Pap porque cuesta
mucho sacar una hora de atencin
El tem corresponde a la
dimensin barreras?

Debe el tem mantenerse en el
cuestionario?


DIMENSION SUSCEPTIBILIDAD:
La creencia en relacin a la posibilidad (susceptibilidad ) de adquirir la enfermedad o condicin (Tener un Pap alterado o desarrollar un Cncer
Cervical) y por lo tanto de tomarse o no el Pap dada su condicin personal.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1. Yo no tengo riesgo de tener un Pap
alterado o anormal.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?


2. Yo no tengo riesgo de tener un cncer
cervical (o cncer del cuello del tero).
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

3. Yo tengo miedo de tener un cncer
cervical (o cncer del cuello del tero).
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?


2
0
6



4. Si yo tengo cncer cervical (o cncer
del cuello del tero) me puedo morir.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

5. Dado que no tengo historia de cncer
cervical (o cncer del cuello del tero) en
mi familia, es poco probable que yo vaya
a tenerlo.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

6. El cncer cervical es uno de los
canceres mas comunes entre las mujeres
de mi edad.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

7. Si no tengo sntomas, no necesito
tomarme un Pap.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?


8. Si no he tenido hijos, no necesito
tomarme un Pap.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

9. Si no tengo relaciones sexuales, no
necesito tomarme un Pap.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

10. Si estoy esterilizada, no necesito
tomarme un Pap.
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?

11. Si no estoy embarazada no necesito
tomarme un Pap
El tem corresponde a la
dimensin susceptibilidad?

Debe el tem mantenerse en el
cuestionario?



2
0
7




DIMENSION SENALES DE ACCION:
Estrategias que hacen que la mujer tome una accin preventiva (Tomarse el Pap)
El encabezado dir: Dentro de las razones que tengo para tomarme el Pap se encuentran
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
1.Porque cuido de mi salud El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

2.Despues de escuchar algo sobre el
cncer cervical (o cncer de cuello del
tero)
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

3. Una enfermera o matrona me lo
solicit.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

4. Un doctor me lo solicit. El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

5. Mi madre me habl sobre eso. El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

6. Una amiga me habl sobre eso. El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

7. Miembros de mi familia me impulsaron
a ir a tomrmelo.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?


2
0
8




2
0
9

Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente
en desacuerdo
8. Despus de escuchar o leer algo en el
diario o algn programa de televisin o
radio.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

9. Despus de tener sangramiento por los
genitales.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

10. Despus de tener dolor en los
genitales.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

11. Despus de tener molestias en los
genitales
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?

12. Despus de que un conocido
(miembro de la familia, amiga, vecina)
desarrollo cncer cervical.
El tem corresponde a la
dimensin seales de accin?

Debe el tem mantenerse en el
cuestionario?



Appendix L: Guideline for Content Validity. English Version
Guideline expert evaluation
Dear (name of Expert):
I am developing a new questionnaire to measure beliefs related to Cervical Cancer and Pap test. This questionnaire is based on the
Health Belief Model of Rosenstock.
The Questionnaire considers a number of statements. Each of statements will be asked to the women, who will indicate their
agreement. The Likert Scale gives 4 alternatives:
Strongly agree / Agree / Disagree / Strongly disagree
2
1
0

I am asking that you read each of the items/questions, and to indicate his/her agreement in 2 aspects:
1. If the item corresponds to the definition indicated for this dimension
2. If the item must stay in the questionnaire.
Your participation is very important, because I must have a content validation from Chilean experts.
Please feel free to write any comment or give suggestion regarding to the questionnaire.
Thank you very much
Maria Teresa Urrutia.




BENEFITS
Belief about the efficacy to take the Pap test to reduce the risk or the seriousness of Cervical Cancer.
Strongly
agree
Agree Disagre
e
Strongly
disagree
1. Getting a Pap test makes me feel good
because it means that I take care of my health.

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

2. Getting a Pap test allows for early detection of
cervical cancer.

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

3. The Pap test can determine cervical cancer. Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

4. Getting a Pap test is a good investment of my
time in health.

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

5. A Pap test can find cervical cancer when it is
possible to cure it.

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

6. The Pap can save my life.

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?


2
1
1





7. The Pap test can help to find infection disease.
Strongly
agree
Agree Disagree Strongly
disagree
Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?

8.Getting a Pap test can find another
reproductive problems (genitals problems)

Is the item according to the
benefit dimension?

Must the item stay in the
questionnaire?



SEVERITY
Belief about how serious is to have Cervical Cancer or an abnormal Pap test, and their sequels.


Strongly
agree
Agree Disagree Strongly
disagree
1. An abnormal Pap test, without treatment, can
lead to cervical cancer.
Is the item according to severity
dimension?

Must the item stay in the
questionnaire?

2. Not having a Pap test could result in a serious
health problem.

Is the item according to severity
dimension?

Must the item stay in the
questionnaire?

3.Cervical cancer may lead to death Is the item according to severity
dimension?

Must the item stay in the
questionnaire?

4.Cervical cancer would make a womens life
very difficult.
Is the item according to severity
dimension?

Must the item stay in the
questionnaire?


2
1
2





5. Cervical cancer may lead to having a
hysterectomy.
Strongly
agree
Agree Disagree Strongly
disagree
Is the item according to severity
dimension?

Must the item stay in the
questionnaire?

6. Cervical cancer is not a serious health
problem.
Is the item according to severity
dimension?

Must the item stay in the
questionnaire?

7. Cervical cancer can lead to a woman needing
to receive chemotherapy or radiotherapy
treatment.
Is the item according to severity
dimension?

Must the item stay in the
questionnaire?


BARRIERS: Psychological or tangible cost to take the Pap test.

1. I do not have time to get a Pap test. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

2. Getting a Pap test only will give me problems. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

3. A Pap test can move the intra uterine device. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

4. Getting a Pap test is painful. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?


2
1
3





5. Getting a Pap test gives me some security
about my health.
Strongly
agree
Agree Disagree Strongly
disagree
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

6. I fan unmarried or single woman gets a Pap
test, people may think that she is having sex.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

7. Getting a Pap test is expensive. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

8. Getting a Pap test is embarrassment. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

9. I do not have a Pap test because I do not know
where I need to go.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

10. I prefer that a female gives me the Pap test,
because it is uncomfortable for me if a man does
it
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

11. I have not taken the Pap test because they
treat me badly in the health care center.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?


2
1
4





12. I have not taken a Pap test because when I
go, I need to wait a long time to be seen.
Strongly
agree
Agree Disagree Strongly
disagree
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

13. I do not know if I need to have a Pap test. Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

14. If a woman has not had sex, a Pap test could
take away her virginity.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

15. My partner/husband does want me to get a
Pap test.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

16. It is difficult to get a Pap test because I do
not have money for transportation (take a bus,
subway).
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

17. I have not taken the Pap test because I am
afraid to find out if I have cancer.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

18. I have not taken the Pap test because the
health care center is only open during hours
when I cannot go.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?


2
1
5



Strongly
agree
Agree Disagree Strongly
disagree
19. I have not taken the Pap test because I am
embarrassed to have a genital exam.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

20. I do not know at what age it is necessary to
have a Pap test.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

21. I do not know how often I need to get a Pap
test.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?

22. I have not taken a Pap test because it is
difficult to get an appointment.
Is the item according to barrier
dimension?

Must the item stay in the
questionnaire?



SUSCEPTIBILITY
Belief about the possibility to acquire Cervical Cancer or to have an abnormal Pap test,
and therefore to want to take the Pap test.
Strongly
agree
Agree Disagree Strongly
disagree
1. I am not at risk for an abnormal Pap test Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?



2
1
6







Strongly
agree
Agree Disagree Strongly
disagree
2. Yo no tengo riesgo de tener un cncer cervical
(o cncer del cuello del tero).
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

3. I am not at risk for developing cervical cancer Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

4. If I have cervical cancer, I can die. Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

5. Since I do not have a history of cervical
cancer in my family, it is very unlikely that I will
get cervical cancer.
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

6. Cervical cancer is one of the most common
cancers among women my age.
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

7. If I do not have symptoms, I do not need a
Pap test.
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?



2
1
7







Strongly
agree
Agree Disagree Strongly
disagree
8. If I have not had children, I do not need a Pap
test.
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

9. If I do not have intercourse, I do not need a
Pap test.
Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

10. If I am sterilized, I do not need a Pap test. Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?

11. If I am not pregnant, I do not need a Pap test Is the item according to
susceptibility dimension?

Must the item stay in the
questionnaire?



2
1
8



CUES TO ACTION
Strategies that cause that the women take the Pap test
Strongly
agree
Agree Disagree Strongly
disagree
1. To take care of my health Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

2. After hearing something about cervical
cancer.
Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

3. Because a nurse or midwife told me. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

4. Because a doctor told me. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

5. Because my mother spoke to me about it. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

6. Because a friend spoke to me about it. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

7. Because members of my family told me to get
it.
Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

8. Because I listened to or read something in the
newspaper or in a television or radio program.
Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?
2
1
9


2
2
0



Strongly
agree
Agree Disagree Strongly
disagree
9. Because I had genital bleeding. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

10. Because I had pain in my genitals. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

11. Because I had discomfort in my genitals. Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?

12. Because someone I know well (family,
friend, neighbor) had cervical cancer.
Is the item according to cues to
action dimension?

Must the item stay in the
questionnaire?




Appendix M: Item Content Validity Index (I-CVI)

Item Content Validity Index Delete Re
write
Part of one of the five
health belief domain
Remain in the
questionnaire

Benefit
Domain
Item 1 10 experts agree = 1.0 8 experts agree = .80
Item 2 10 experts agree = 1.0 9 experts agree = .90
Item 3 8 experts agree = .80 8 experts agree = .80 Yes
Item 4 10 experts agree = 1.0 10 experts agree = 1.0 Yes
Item 5 7 experts agree = .70 8 experts agree = .80
Item 6 9 experts agree = .90 8 experts agree = .80
Item 7 7 experts agree = .70 7 experts agree = .70 Yes
Item 8 7 experts agree = .70 7 experts agree = .70 Yes
Severity
Domain
Item 1 10 experts agree = 1.0 9 experts agree = .90
Item 2 9 experts agree = .90 9 experts agree = .90
Item 3 10 experts agree = 1.0 10 experts agree = 1.0
Item 4 7 experts agree = .70 7 experts agree = .70 Yes
Item 5 10 experts agree = 1.0 10 experts agree = 1.0 Yes
Item 6 10 experts agree = 1.0 10 experts agree = 1.0 Yes
Item 7 9 experts agree = .90 9 experts agree = .90
Barrier
Domain
Item 1 9 experts agree = .90 9 experts agree = .90
Item 2 8 experts agree = .80 8 experts agree = .80 Yes
Item 3 9 experts agree = .90 9 experts agree = .90
Item 4 10 experts agree = 1.0 10 experts agree = 1.0
Item 5 5 experts agree = .50 8 experts agree = .80 Yes
Item 6 8 experts agree = .80 8 experts agree = .80
Item 7 9 experts agree = .90 9 experts agree = .90
Item 8 9 experts agree = .90 9 experts agree = .90
Item 9 10 experts agree = 1.0 10 experts agree = 1.0
Item 10 10 experts agree = 1.0 10 experts agree = 1.0
Item 11 10 experts agree = 1.0 10 experts agree = 1.0
Item 12 10 experts agree = 1.0 10 experts agree = 1.0
Item 13 9 experts agree = .90 9 experts agree = .90
Item 14 7 experts agree = .70 7 experts agree = .70 Yes
Item 15 10 experts agree = 1.0 10 experts agree = 1.0
Item 16 10 experts agree = 1.0 8 experts agree = .80 Yes
Item 17 10 experts agree = 1.0 10 experts agree = 1.0
Item 18 10 experts agree = 1.0 10 experts agree = 1.0
Item 19 10 experts agree = 1.0 10 experts agree = 1.0
Item 20 9 experts agree = .90 9 experts agree = .90
Item 21 9 experts agree = .90 8 experts agree = .80
Item 22 10 experts agree = 1.0 10 experts agree = 1.0
Susceptibility
Domain
Item 1 10 experts agree = 1.0 10 experts agree = 1.0
Item 2 10 experts agree = 1.0 10 experts agree = 1.0
Item 3 8 experts agree = .80 9 experts agree = .90 Yes
Item 4 7 experts agree = .70 9 experts agree = .90
Item 5 10 experts agree = 1.0 10 experts agree = 1.0
221

222


Item 6 9 experts agree = .90 9 experts agree = .90
Item 7 10 experts agree = 1.0 10 experts agree = 1.0
Item 8 9 experts agree = .90 10 experts agree = 1.0
Item 9 9 experts agree = .90 10 experts agree = 1.0
Item 10 9 experts agree = .90 10 experts agree = 1.0
Item 11 8 experts agree = .80 9 experts agree = .90
Cues to
Action
Domain
Item 1 9 experts agree = .90 9 experts agree = .90
Item 2 8 experts agree = .80 8 experts agree = .80 Yes
Item 3 10 experts agree = 1.0 10 experts agree = 1.0
Item 4 9 experts agree = .90 9 experts agree = .90
Item 5 10 experts agree = 1.0 10 experts agree = 1.0
Item 6 10 experts agree = 1.0 10 experts agree = 1.0
Item 7 10 experts agree = 1.0 10 experts agree = 1.0
Item 8 10 experts agree = 1.0 10 experts agree = 1.0
Item 9 9 experts agree = .90 9 experts agree = .90
Item 10 7 experts agree = .70 7 experts agree = .80
Item 11 7 experts agree = .70 8 experts agree = .80
Item 12 9 experts agree = .90 10 experts agree = 1.0


Appendix N: Scale Content Validity Index (S-CVI).

Scale Content Validity Index
Part of one of the five health
belief domain
Remain in the
questionnaire
Expert 1 58 items agree from 60 = .97 58 items agree from 60 = .97
Expert 2 58 items agree from 60 = .97 55 items agree from 60 = .92
Expert 3 52 items agree from 60 = .87 52 items agree from 60 = .87
Expert 4 48 items agree from 60 = .80 48 items agree from 60 = .80
Expert 5 51 items agree from 60 = .85 55 items agree from 60 = .92
Expert 6 48 items agree from 60 = .80 48 items agree from 60 = .80
Expert 7 54 items agree from 60 = .90 58 items agree from 60 = .97
Expert 8 54 items agree from 60 = .90 55 items agree from 60 = .92
Expert 9 55 items agree from 60 = .92 58 items agree from 60 = .97
Expert 10 59 items agree from 60 = .98 55 items agree from 60 = .92

TOTAL

8.96/10 (experts)= .90

9.06 /10 (experts) = .91

223

Appendix O: Modified, Deleted or Added Items, after the Expert Panel Validation. Spanish Version

Dimensin tem Propuesto tem Posterior a la Revisin
Dimensin
Beneficios
El Pap puede determinar si una mujer tiene cncer cervical. tem eliminado:
Puede confundir a la mujer, no corresponde a la
dimensin

Tomarse el Pap es una buena inversin de mi tiempo en salud. Cambio de redaccin:
Tomarse el Pap significa utilizar bien el tiempo en salud

El Pap puede ayudar a encontrar infecciones transmitidas
sexualmente.
tem eliminado:
Puede confundir a la mujer, no corresponde a la
dimensin

Tomarme el Pap puede ayudar a encontrar otros problemas del
sistema reproductivo (de los genitales).
tem eliminado
Puede confundir a la mujer, no corresponde a la
dimensin

Dimensin
Severidad
El cncer cervical (o cncer del cuello del tero) puede hacer la
vida de una mujer muy difcil.
tem eliminado:
tem considerado poco especifico en la idea, no
corresponde a la dimensin
El cncer cervical puede llevar a una mujer a tener que hacerse una
histerectoma (sacarse el tero o matriz).
Cambio de redaccin:
El cncer cervical puede llevar a una mujer a tener que
someterse a una histerectoma (sacarse el tero o matriz).

El cncer cervical (o cncer del cuello del tero) no es un problema
de salud serio.
Cambio de redaccin:
El cncer cervical (o cncer del cuello del tero) es un
problema de salud serio.

2
2
4




Dimensin
Barreras
Hacerme el Pap solamente me dar problemas. tem eliminado:
tem considerado poco especifico en la idea, no
corresponde a la dimensin

Hacerme el Pap da seguridad acerca del estado de salud tem eliminado:
tem considerado poco especifico en la idea, no
corresponde a la dimensin

Si una mujer no ha tenido sexo, el Pap puede quitarle la virginidad. tem eliminado:
Puede confundir a la mujer, no corresponde a la
dimensin

Es difcil tomarme el Pap porque no tengo plata para la micro. Cambio de redaccin:
Es difcil tomarme el Pap porque no tengo plata para
movilizarme (tomar la micro, el metro, el colectivo, etc).

Dimensin
Susceptibilidad
Yo tengo miedo de tener un cncer cervical (o cncer del cuello del
tero).
tem eliminado:
No corresponde a la dimensin

tem agregado:
Si tengo menopausia (no tengo reglas), no necesito
tomarme un Pap

Dimensin
Seales de Accin
Despus de escuchar algo sobre el cncer cervical (o cncer de
cuello del tero)
Cambio de redaccin:
Despus de escuchar sobre el cncer cervical (o cncer de
cuello del tero)

2
2
5



Appendix P: Modified, Deleted or Added Items, after the Expert Panel Validation. English Version

Dimension Original Item Change or Delete
Benefit The Pap test can determine cervical cancer Item deleted:
It did not target the domain and they might confuse the
women

Getting a Pap test is a good investment of the time in health Item rewritten:
Getting a Pap test is a good investment of my time in health

The Pap test can help to find infection disease Item deleted:
It did not target the domain and they might confuse the
women

Getting a Pap test can find another reproductive problems (genital
problems)
Item deleted:
It did not target the domain and they might confuse the
women

Severity Cervical cancer would make a womens life very difficult. Item deleted:
Item was considered vague and not related to the domain
Cervical cancer may lead to having a hysterectomy Item rewritten:
Cervical cancer may lead to a woman having a hysterectomy

Cervical cancer is not a serious health problem Item rewritten:
Cervical cancer is a serious health problem
2
2
6





Barriers Getting a Pap test only will give me problems Item deleted:
Item was considered vague and not related to the domain

Getting a Pap test gives me some security about my health Item deleted:
Item was considered vague and not related to the domain

If a woman has not had sex, a Pap test could take away her virginity Item deleted:
It did not target the domain and they might confuse the
women

It is difficult to get a Pap test because I do not have money for the
bus
Item rewritten:
It is difficult to get a Pap test because I do not have money for
transportation (take a bus, subway, taxi)

Susceptibility I am afraid of cervical cancer Item deleted:
It did not target the domain

Item added:
If I am in menopause, I do not need a Pap test

Cues to
Action
After hearing something about cervical cancer Item rewritten:
After hearing about cervical cancer
2
2
7


Appendix Q: Pilot Instructions. Spanish Version
Instrucciones Prueba Piloto
Estimada Seora:
Estoy trabajando en mi tesis de Doctorado, y necesito saber si el cuestionario que quiero aplicar en mi estudio es entendible.
Por lo anterior le pido leer el cuestionario, y sealar si tuvo algn problema para entender alguna de las preguntas.
NO es necesario que conteste el cuestionario, ya que solo necesito me diga si hubo algn problema al tratar de contestarlo y cual fue
ese problema.
Tambin le pido sentirse en libertad de sugerir alguna otra pregunta o cambiar la redaccin de alguna de las preguntas para que su
mejor entendimiento.
2
2
8

Muchas Gracias
Mara Teresa Urrutia


Appendix R: Pilot Instructions. English Version
Pilot Instructions
Dear Lady:
I am working in my PhD Dissertation, and I need to know if the questionnaire that I want to apply in my research is understandable.
I ask you to read the questionnaire, and to indicate if you had some problem to understand some of the questions.
It is NOT necessary that you answer the questionnaire, because I only need to know if there was some problem when you tried to
answer the questionnaire and what was that problem.
Also, feel free to suggest some other question, or to change the writing of some of the questions, for better understanding.
2
2
9

Thank you very much
Maria Teresa Urrutia.




Appendix S: IRB Approval Letter. University of Miami



EXPEDITED APPROVAL
April 9, 2009
Rosemary Hall, Ph.D.
University of Miami
Department of Nursing,
Coral Gables Campus, Locator Code: 3850

HSRO STUDY
NUMBER:
20090229
STUDY TITLE: Development and Testing of a Questionnaire: Beliefs about
Cervical Cancer and Papanicolaou Test in Chilean Women.
IRB ACTION
DATE:
4/8/2009
STUDY APPROVAL
EXPIRES:
4/7/2010
On 4/8/2009, an IRB Chair approved the following items under the expedited review
process.
APPROVAL INCLUDES:
New Research Protocol
Research Materials
Informed Consent Form (English version)
Recruitment Material (2, flyer and participant letter, English
versions)
Questionnaire (2, Beliefs and Demographics, English versions)
230

231


NOTE: Translations of IRB approved study documents, including informed consent
documents, into languages other than English must be submitted to HSRO for approval
prior to use.
A request to continue this study must be submitted to the HSRO at least 45 days before
IRB approval expires. If this study does not receive continuing IRB approval prior to
expiration, all research activities must be ceased, and may officially be suspended or
terminated.
All principal investigators must abide by and comply with all policies and procedures for
the conduct of human subject research as posted on the HSRO website
(http://www.hsro.miami.edu)


Sincerely,
[This is a representation of an electronic record
that was signed electronically and this page is
the manifestation of the electronic signature]
Amanda Coltes-Rojas, MPH, CIP
Director
Regulatory Affairs & Educational Initiatives
/mdj
cc: IRB File
Maria Urrutia




Human Subjects Research Office (M809)
PO Box 016960, Miami, Florida 33101
1500 NW 12 Avenue, Suite 1002, Miami, Florida 33136
Tel: 305-243-3195
Fax: 305-243-3328



Appendix T: IRB Approval Letter. Servicio de Salud Metropolitano Sur Oriente


232

233




234





Appendix U: CPC 28 Questionnaire. Spanish Version

Cuestionario CPC-28
(Creencias acerca del Papanicolaou y Cncer Cervicouterino)

A. Las siguientes oraciones son algunas ideas relacionadas con el Papanicolau (PAP) y el cncer cervical (cncer al cuello del tero). Por favor marque con una
cruz la alternativa que ms se acerque a lo que usted cree en cada una de las oraciones. Este cuestionario no considera respuestas buenas o malas, por lo tanto
si hay alguna respuesta que usted no est segura o que no sabe, sintase libre de contestar lo que usted cree.

Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente en
desacuerdo
1. Tomarme el PAP me hace sentir bien porque significa que yo cuido mi
salud.

2. No tengo tiempo para tomarme el PAP.


3. No me tomo el PAP porque en el consultorio me tratan mal.


4. Yo no s a qu edad es necesario tomarse el PAP.

5. No me tomo el PAP porque cuando voy necesito esperar largo tiempo para
ser atendida.

6. El PAP puede salvar mi vida.


7. No me tomo el PAP porque me da miedo saber que tengo cncer.


8. No me tomo el PAP porque el consultorio atiende en horarios en los que
no puedo ir.

9. No me tomo el PAP porque me da vergenza que me examinen los
genitales.

2
3
5




Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente en
desacuerdo
10. Yo no s cada cuanto tiempo necesito ir a tomarme el PAP.


11. No me tomo el PAP porque cuesta mucho sacar una hora de atencin.


12. El cncer cervical (o cncer de cuello del tero) puede causar la muerte.


13. El cncer cervical (cncer del cuello del tero) puede llevar a una mujer a
tener que someterse a una histerectoma (sacarse el tero o matriz).

14. El cncer cervical (cncer del cuello del tero) es un problema de salud
serio.

15. El cncer cervical (o cncer del cuello del tero) puede llevar a una mujer
a tener que realizarse un tratamiento con quimioterapia o radioterapia.



2
3
6



B. Las siguientes oraciones son algunas ideas relacionadas con la necesidad que usted tiene de tomarse el PAP y el riesgo de tener un Cncer Cervical (cncer
de cuello del tero). Por favor, seale su grado de acuerdo en cada una de ellas. Recuerde que no hay respuestas buenas ni malas, por lo tanto si hay alguna
respuesta que usted no est segura o que no sabe, sintase libre de contestar lo que usted cree.

Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente en
desacuerdo
1. Si no tengo sntomas o molestias, no necesito tomarme un PAP.


2. Si no he tenido hijos, no necesito tomarme un PAP.


3. Si no estoy teniendo relaciones sexuales, no necesito tomarme un
PAP.

4. Yo tengo riesgo de desarrollar un cncer cervical
(cncer del cuello del tero).

5. Si yo tengo cncer cervical me puedo morir.


6. El cncer cervical (cncer del cuello del tero) es uno de los
cnceres ms comunes entre las mujeres de mi edad.

2
3
7


2
3
8



C. Las siguientes son algunas razones que las mujeres pueden tener para ir a tomarse un PAP. Por favor, seale en cada una de ellas su grado de acuerdo,
pensando en las razones que me la han llevado o que la llevaran a tomarme el PAP. Recuerde que no hay respuestas buenas ni malas.
Completamente
de acuerdo
De
acuerdo
En
desacuerdo
Completamente en
desacuerdo
1. Para cuidar mi salud.


2. Porque una enfermera o matrona me lo pidi.


3. Porque un doctor me lo pidi.


4. Porque mi madre me habl sobre eso.


5. Porque una amiga o vecina me habl sobre eso.


6. Porque miembros de mi familia me dijeron que me lo tomara.


7. Porque escuch o le algo en el diario o en algn programa de
televisin o radio.






Appendix V: CPC 28 Questionnaire. English Version

CPC-28 Questionnaire
(Beliefs about Papanicolaou and Cervical Cancer)

A. The following sentences are some ideas related to the Papanicolau test (PAP) and cervical cancer (uterine cervix cancer). Please indicate with a cross the
alternative that best describes your belief about each one of the sentences. There are no good or bad answers in this questionnaire, therefore if you are unsure or
do not know an answer, feel free to answer what you believe.

Strongly Agree Agree Disagree Strongly Disagree

1. Getting a Pap test makes me feel good because it means that I take care
of my health.

2. I do not have time to get a Pap test.


3. I have not taken the Pap test because they treat me badly in the health
care center.

4. I do not know at what age it is necessary to have a Pap test

5. I have not taken a Pap test because when I go, I need to wait a long time
to be seen.

6. The Pap can save my life.


7. I have not taken the Pap test because I am afraid to find out if I have
cancer.

8. I have not taken the Pap test because the health care center is only open
during hours when I cannot go.

2
3
9




Strongly Agree Agree Disagree Strongly Disagree

9. I have not taken the Pap test because I am embarrassed to have a genital
exam.


10. I do not know how often I need to get a Pap test.


11. I have not taken a Pap test because it is difficult to get an appointment.


12. Cervical Cancer may lead to death.


13. Cervical cancer may lead to a woman having a hysterectomy.


14. Cervical cancer is a serious health problem.


15. Cervical cancer can lead to a woman needing to receive chemotherapy
or radiotherapy treatment.



2
4
0



B. The following sentences are related to the need that you have to take the Pap test, and the risk of having Cervical Cancer. Please indicate the degree to
which you agree or disagree with each statement. Remember, there are no good or bad answers in this questionnaire, therefore if you are unsure or do not know
an answer, feel free to answer what you believe.

Strongly
Agree
Agree Disagree Strongly
Disagree
1. If I do not have symptoms, I do not need a Pap test.


2. If I have not had children, I do not need a Pap test.


3. If I do not have intercourse, I do not need a Pap test.


4. I am at risk for developing cervical cancer.


5. If I have cervical cancer, I can die.


6. Cervical cancer is one of the most common cancers among women my
age.

2
4
1


2
4
2



C. The following sentences are some reasons women have for getting a Pap test. Please indicate the degree of agreement in each sentence, thinking about the
reasons that have made you or would make you get a PAP test. Remember, there are no good or bad answers in this questionnaire, therefore if you are unsure
or do not know an answer , feel free to answer what you believe.
Strongly
Agree
Agree Disagree Strongly
Disagree
1. To take care of my health


2. Because a nurse or midwife told me.


3. Because a doctor told me.


4. Because my mother spoke to me about it


5. Because a friend or neighbor spoke to me about it


6. Because members of my family told me to get it.


7. Because I listened to or read something in the newspaper or in a
television or radio program.







VITA


Maria Teresa Urrutia Soto was born in Santiago, Chile, on January 20, 1971. Her
parents are Teresa Soto and Senecio Urrutia. She received her elementary education at
Corazn de Mara College and secondary education at Subercaseaux College. In March
1989 she entered the Pontificia Universidad Catlica de Chile from which she was
graduated with the BSN degree in December 1993. She was employed as instructor
teacher in the School of Nursing, Pontificia Universidad Catlica de Chile, in August
1994. She was graduated with the Master of Nutrition degree in August 1999. She was
admitted to the Graduate School of the University of Miami in August 2006, where she
was granted a PhD. degree in December 2009. She is Associate Professor on the School
of Nursing, Pontificia Universidad Catlica de Chile.

Permanent Address: Froiln Roa 4758, casa 3135, Macul, Santiago, CHILE.
E-mail: murrutis@uc.cl.