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Comparative study of HPV and Cervical 

Cancer Knowledge and Beliefs between 

Mexican Immigrant Women in the US 

and Peruvian Women 
John S. Luque1*; Jonathan Maupin2; Daron G. Ferris3,4 

1 
Institute of Public Health, Florida A&M University, Tallahassee, FL, USA 

2
 jmaupin@asu.edu School of Human Evolution and Social Change, Arizona State University, Tempe, AZ, USA 

3
 dferris@augusta.edu Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA 

4
 CerviCusco, Cusco, Peru 

*Corresponding author email: john.luque@famu.edu 

ABSTRACT 
Cervical cancer remains one of the major cancers affecting women from developing countries, 

especially those from socioeconomically disadvantaged backgrounds. In the US, Hispanic immigrant 

women experience restricted access to health care and higher incidence rates of cervical cancer 

compared to the non-Hispanic white population. Knowledge of cervical cancer risk factors and 

symptoms is associated with greater interest in participating in regular cervical cancer screening. To 

explore knowledge and beliefs about cervical cancer, survey questionnaires were administered to 

Mexican immigrant women in southeast Georgia, US and to mestizo women - primarily Quechua 

language dominant speakers - in Cusco, Peru. As part of these survey studies, there was a list of 32 

items asking participants to agree or disagree with whether certain symptoms or risk factors could 

cause cervical cancer and a pile sort of 15 of the most salient items. Cultural consensus analysis was 

used to calculate overall agreement with a cultural model of cervical cancer risk factor knowledge in 

each sample independently. For the Georgia sample, there was marginal consensus, but for the Peru 

sample, there was no consensus. Analysis of cultural competence values and residual agreement show 

significant differences across education in the Georgia study, with a positive correlation between 

education and cultural competence (r=0.50, p=0.001), but not in the Peru study. Likewise, the results of 

the pile sort data exhibited consensus for the Georgia sample for the cervical cancer risk factors, but 

not for the Peru sample. The lack of consensus among the Peru sample on either task suggests little 

widespread knowledge on risk factors of cervical cancer. Additional analyses related to factors 

associated with screening behaviors from the cultural cancer screening scale indicated more 

pronounced fatalistic beliefs and catastrophic disease expectations about cervical cancer among the 

Peruvian women compared to the Mexican immigrant women. 

KEYWORDS: cervical cancer screening, human papillomavirus, Hispanics, Peru 

Citation: Luque JS et al (2019) Comparative study of HPV and cervical cancer knowledge and beliefs 

between Mexican immigrant women in the US and Peruvian women. Cancer Health Disparities 3: e1-16. 

doi:10.9777/chd.2019.1007. 



 
 
 
 
 

 

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INTRODUCTION 

Cervical cancer is a disease that is preventable 

through public health interventions. Early 

detection of cervical cancer is critical to reduce 

mortality from the disease. The primary prevention 

strategy is the administration of the human 

papilloma virus (HPV) vaccine for adolescents and 

young adults between 9 and 26 years old. The 

secondary prevention strategy is cervical cancer 

screening (the Papanicolaou test with or without 

and HPV DNA testing or primary HPV DNA testing 

alone) combined with treatment for any detected 

pre-cancerous lesions to prevent progression to 

cervical cancer. Since the primary risk factor for 

cervical cancer is HPV infection, vaccination has 

had significant impacts in reducing cervical cancer 

incidence in countries such as Australia where 

adoption has been widespread through its school-

based vaccination programs (Smith and Canfell, 

2017). Other risk factors which may be either 

independent risk factors for cervical cancer or co-

factors modifying the risk in women infected with 

HPV include immunosuppression (e.g., caused by 

HIV infection or immunosuppressive drugs), 

exposure to certain sexually transmitted diseases, 

long-term use of oral contraceptives, high parity, 

obesity, eating a diet low in fruits and vegetables, 

and smoking (Bosch and de Sanjose, 2007). 

Despite major advances in cervical cancer 

prevention worldwide, most cervical cancer deaths 

continue to occur in developing countries with 

poor public health infrastructure for organized 

screening programs. In 2012, there were an 

estimated 265,700 deaths from cervical cancer, 

making it the third leading cause of cancer death 

in developing countries (Torre et al., 2015). In Latin 

America and the Caribbean, there were an 

estimated 28,600 cervical cancer deaths (Torre et 

al., 2015). Cervical cancer incidence rates remain 

high in many developing countries in Latin 

America, disproportionately affecting women who 

are socioeconomically disadvantaged (Lopez et al., 

2017). Recent studies have suggested that in some 

countries, HPV DNA testing might be a more 

effective frontline strategy where screening with 

conventional cytology programs is either 

unavailable or unreliable (Catarino et al., 2015). 

Therefore, there have been concerted public 

health efforts to bolster support for cervical cancer 

prevention in some countries. For example, in 

Peru, researchers described the use of self-

sampling kits to expand the reach of screening 

programs into rural areas and the challenges with 

implementing national cancer control plans 

(Aguilar et al., 2016). Another project 

demonstrated that HPV self-sampling testing was 

a superior method compared to testing by visual 

inspection by acetic acid (VIA) for reaching rural 

populations (Levinson et al., 2013). 

Concurrent with these medical technology 

advancements connecting HPV DNA screening 

and cervical cancer prevention, there is a growing 

body of research to understand barriers and 

facilitators to cervical cancer screening and HPV 

vaccination in special populations experiencing the 

greatest burden of disease (Aharon et al., 2017; 

Ginsburg et al., 2017; Mann et al., 2015; Thompson 

et al., 2014; Vasilevska et al., 2012). Cervical cancer, 

while a relatively rare diagnosis in the US, is a 

disease which persists in poor and marginalized 

communities such as the colonias along the 

US/Mexico border, parts of Appalachia, and other 

areas of the US characterized by high rates of 

poverty, low socioeconomic status, and distrust of 

medical facilities (Scarinci et al., 2010; Smith et al., 

2013). While individual behaviors toward screening 

and vaccination are associated with adherence to 

medical recommendations, there are also 

systematic processes which create conditions 

wherein some population groups are better 

positioned to access preventive health care. In the 

US, what is often termed “cancer disparities” in the 

academic literature has been explained as a 

byproduct of structural vulnerability, or a situation 

resulting from a market-based health system 

which contributes to health disparities by 

increasing financial barriers for poor and 



 
 
 
 
 

 

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disenfranchised populations to access preventive 

health care (Quesada et al., 2011). Disproportionate 

access to health care may in some cases result in a 

late-stage cervical cancer diagnosis in patients 

suffering from a preventable cancer. 

For Hispanic immigrants in the US, an additional 

factor besides socioeconomic status affecting 

health care access is immigration status. Fear 

related to seeking or receiving care and difficulties 

in actually obtaining care linked to immigration 

status was reported in a study almost 20 years ago 

during the time of California’s controversial 

Proposition 187, which prohibited undocumented 

immigrants from accessing non-emergency health 

care, among other public services (Berk et al., 

2000). Since that time, undocumented immigrants 

in the US have been subject to increasingly anti-

immigration policies which have negatively 

affected their ability to access health insurance 

programs and health care more generally 

(Martinez et al., 2015). Undocumented immigrants 

were further excluded from health care coverage 

under the provisions of the Affordable Care Act 

(Alcalá et al., 2017). They often rely on safety net 

programs which accept patients without insurance 

and must use referrals, sometimes on a case-by-

case basis, to provide the array of health care 

services that some patients require to manage 

their health conditions (Castañeda, 2017). 

Moreover, because of language barriers and lack 

of familiarity with US health care systems and 

billing structures, Hispanic immigrants might also 

experience difficulties in securing a regular health 

care provider, finding a trusted provider, accessing 

relevant health education on varied topics from 

prenatal care to diabetes management, and 

understanding payment options for different types 

of medical procedures or office visits (Rhodes et 

al., 2015). 

Medical anthropologists studying cancer 

prevention seek to understand how people’s 

cultural backgrounds might influence their 

knowledge, attitudes, and beliefs around behaviors 

that moderate cancer risk (McMullin, 2016). 

Research which examines whether cervical cancer 

risk factors, and specifically awareness of HPV 

infection risk, are understood and how such 

understandings may reflect a cultural model of risk 

around the disease is the focus of this comparative 

research study. This comparative study seeks to 

understand how models of risk are culturally 

constructed and vary in different US and Latin 

American contexts. 

METHODS 

Participant Recruitment 

For the Georgia study in 2013, a female, native 

Spanish speaker research coordinator 

administered a Spanish-language survey to 

Mexican immigrant women living in rural, 

southeast Georgia. To participate in the survey, 

study inclusion criteria included women who were 

either actively participating in crop agriculture or 

had recently participated in this type of work and 

were between 21 and 65 years of age to align with 

US cervical cancer screening age guidelines 

(Committee on Practice Bulletins—Gynecology, 

2016). To capture a range of acculturation 

experiences, equal numbers of participants had 

lived in the US more than 10 years or for 10 years 

or less. Thirty-nine participants were recruited 

from area farms and a poultry processing plant. 

For the Peru study in 2014, a female, nurse-

midwife research coordinator administered a 

Spanish-language survey to Peruvian women who 

were patients of CerviCusco. CerviCusco is a 

nonprofit clinic in Cusco, Peru which provides 

cervical cancer screening to over 10,000 women 

every year. They have a clinic in the city of Cusco 

but also conduct regular mobile cervical cancer 

screening outreach to serve patients living in 

remote mountain villages. Survey participants had 

either received a Pap test during mobile outreach 

clinic services (n=20) or had received a Pap test in 

the CerviCusco clinic (n=10). Participants were 

between 30 and 49 years old in alignment with 

cervical cancer screening guidelines in Peru (HPV 



 
 
 
 
 

 

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Information Centre, 2016). Participants received 

either a $10 gift card in Georgia or a useful gift 

item in Peru for their research participation. 

Participants in both studies completed a written 

informed consent process before the survey was 

administered. The protocols for these research 

studies were approved by the Institutional Review 

Boards of Georgia Southern University, Augusta 

University, and the Peru Ministry of Health. 

Measures 

Each of the research studies consisted of 

administering a survey questionnaire. The survey 

began with open ended questions about health 

care resources in the community and knowledge 

about cancer and cervical cancer. These questions 

were followed by a section on clinical history of 

Pap tests and results, other health history 

questions, and knowledge of HPV and the HPV 

vaccine. Questions about knowledge and beliefs 

about HPV/cervical cancer were drawn from the 

Health Information National Trends Survey 

(National Cancer Institute, 2016). Next, participants 

were presented with 32 items and asked to agree 

or disagree with whether each item was a possible 

cause or risk factor for cervical cancer. These items 

included both biomedically accepted factors (e.g., 

HPV, multiple sex partners) and other factors 

which may be more ethnomedically defined (e.g., 

abortion, vaginal trauma, stress). Participants were 

also asked to sort 15 index cards of the most 

salient items using a constrained pile sort of no 

more than four piles. In addition, participants were 

asked to agree or disagree with seven belief 

statements related to cervical cancer such as, “I am 

very likely to get cervical cancer sometime in my 

lifetime.” These items and statements were drawn 

from previous structured research questions about 

cervical cancer cultural models with Hispanic 

participants (Chavez et al., 1995; Luque et al., 

2010). Participants also completed the 20-item 

Cultural Cancer Screening Scale (CCSS), which has 

demonstrated good internal consistency (α=0.84) 

with US Hispanics and identifies cultural factors 

related to screening behavior (Betancourt et al., 

2010). The CCSS is comprised of the following five 

constructs: sociocultural deterrents; cancer 

screening fatalism; symptomatic deterrents; 

catastrophic disease expectations; and negative 

beliefs about health professionals. The research 

coordinators administering the survey also 

collected sociodemographic data including age, 

marital status, education, employment status, 

language preference, housing characteristics, and 

health insurance coverage. Participants also 

responded to questions about having a regular 

provider, whether they visited the doctor in the last 

year, and smoking status. 

Data Analysis 

Descriptive statistics for sociodemographic data, 

correlation analysis of cultural competence values, 

and bivariate analysis for between sample analysis 

of CCSS measures were generated using SPSS 

Statistics V. 24 (SPSS, Inc. Chicago, Illinois). For the 

quantitative data from the structured questions on 

risk factor/symptom items, UCINET 6.0 (Analytic 

Technologies, Lexington, Kentucky) was used to 

calculate cultural consensus for the overall sample, 

and each group individually. For the pile sort data, 

each pile sort was analyzed using Visual Anthropac 

1.0 Pilesorts (Analytic Technologies, Lexington, 

Kentucky) to calculate consensus among 

respondents. Nonmetric multidimensional scaling 

(MDS) was used to visualize the results of the pile 

sort analysis and average linkage clustering set to 

five clusters. 

RESULTS 

Sociodemographic and Health Characteristics 

Despite the wider range of participant ages in the 

Georgia sample, the average age in both samples 

was 40 years. The average number of years of 

schooling in the Georgia sample was 8 years, and 

in the Peru sample it was 6.5 years. Places of origin 

for the Mexican immigrant women included 

Campeche, Cardenas, Guanajuato, Guerrero, 

Jalisco, Hidalgo, Michoacan, Queretaro, 



 
 
 
 
 

 

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Tamaulipas, Veracruz, Oaxaca, and San Luis 

Potosi. The two provinces with the highest 

percentage of participants were Guanajuato (36%) 

and Tamaulipas (21%). The Peruvian women were 

multiethnic women from the greater Cusco region, 

and two-thirds were Quechua dominant speakers, 

with the other third either monolingual Spanish 

speakers or bilingual Quechua/Spanish speakers. 

Because the participants in Peru were largely 

covered under the government health insurance 

program, and most Mexican immigrants in 

Georgia did not have access to either government 

or employer provided health insurance, there were 

major differences in responses to the health 

insurance question. However, there were similar 

answers to the question about having a regular 

provider, with only a third reporting having one in 

each sample, yet a smaller percentage of the 

Mexican immigrant women had received a Pap 

test in the last three years compared to the 

Peruvian women (87% vs. 50%), probably since the 

Peru sample was clinic-based. Despite more recent 

contact with health care, a smaller percentage of 

the Peruvian women had heard of HPV (20% vs. 

56%) or the HPV vaccine (17% vs. 41%). Similarly, in 

the Peru sample there was less knowledge about 

some facts about HPV, for example that HPV 

could cause cervical cancer or lead to abnormal 

Pap test results. In the Peru sample, there was 

even less awareness of the purpose of the HPV 

vaccine. Other participant sociodemographic 

characteristics are detailed in Table 1, and HPV 

knowledge questions are listed in Table 2. 

 

Table 1. Sociodemographic Characteristics. 

Characteristics Georgia, US 

(n=39) %  

Cusco, Peru 

(n=30) % 

Age group (years)   

20-29 28 0 

30-39 23 50 

40-49 26 50 

50-64 23 0 

Marital status    

Single/Other  26 13 

Married/living with a partner  74 87 

Education   

 < 11 years 62 67 

 12 years or HS 33 23 

 Some college, tech, or higher 5 10 

Employed   

Yes 87 67 

No 13 33 

Language(s) spoken at home   

English 3 0 

Spanish  74 27 



 
 
 
 
 

 

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Quechua 0 63 

Spanish & Quechua 0 10 

Spanish & English 23 0 

Housing   

Rent 51 70 

Own 49 20 

Other 0 10 

Health insurance coverage   

Yes 3 80 

No 97 20 

Have a regular provider    

Yes 38 30 

No 62 70 

Visited doctor in last year   

Yes 39 100 

No 61 0 

Current smoker   

Yes 3 0 

No 97 100 

Current chronic health condition   

Yes 24 0 

No 73 63 

Don’t know 3 37 

 

Table 2. Cervical Cancer Screening and Knowledge of HPV/HPV Vaccine. 

Characteristics Georgia, US 

(n=39) %  

Cusco, Peru 

(n=30) % 

When was your last Pap test?   

1 year or less 41 80 

> 1 year < 3 years 9 7 

> 3 years < 5 years 19 3 

>5 years 6 0 

Never 22 3 

Don’t know 3 7 

Have you heard of HPV?   



 
 
 
 
 

 

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Yes 56 20 

No 44 67 

Don’t know 0 13 

Do you think HPV causes 

abnormal Pap tests? 

  

Yes 49 17 

No 23 20 

Don’t know 28 63 

Do you think HPV causes cervical 

cancer? 

  

Yes 46 20 

No 15 10 

Don’t know 39 70 

Do you think HPV is a sexually 

transmitted disease? 

  

Yes 51 27 

No 18 3 

Don’t know 31 70 

Have you heard of the HPV 

vaccine? 

  

Yes 41 17 

No 59 83 

Do you think the HPV vaccine is an 

effective way to prevent HPV 

infection? 

  

Yes 87 7 

No 8 13 

Don’t know 5 80 

 

Thoughts and Understanding of Cervical Cancer, 

HPV and the HPV Vaccine 

Participants were asked a series of open-ended 

questions about cervical cancer, HPV and the HPV 

vaccine. In the Georgia study, while more than 

two-thirds of the women had heard about cervical 

cancer and that it was a serious illness, they 

admitted they did not know that much about the 

disease. For example, a participant explained, “it is 

cancer of the vagina, I’m not that sure.” Another 

participant answered, “it is in the uterus, I know 

very little.” There were also some accurate 

explanations such as, “I’ve heard that you have to 

do the Pap after you have relations … you get 

them in private parts of a woman.” There was 

some awareness of the vaccine to prevent it also, 

for example, one participant said, “for this reason, 



 
 
 
 
 

 

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we get checked. They are trying to prevent it with 

thirteen-year-olds who get three shots.” When 

asked what they had heard about HPV, slightly 

more than half of the participants did not offer 

response. Some misconceptions included the 

belief that one could contract cervical cancer in 

lavatories or from using tampons. Those who 

responded to questions about HPV tended to 

have more information, for example participants 

responded with answers such as, “the vaccine 

helps to avoid the high risk of getting the virus,” 

and “that it is important to give to young people 

before they are sexually active.” Participants were 

generally positive about the HPV vaccine and 

responded that sources of motivation to receive 

the vaccine included to be protected, for family 

reasons, to avoid a hysterectomy, to prevent 

cancer, and to prevent the illness so you would be 

able to have sexual relations with other people 

and then be immune from further infection. 

Reasons for not getting vaccinated included 

physical factors such as being pregnant, side 

effects, allergies, or becoming sterile. Other 

reasons for not getting vaccinated listed were 

costs, ignorance, fear, embarrassment and 

religious beliefs. 

In the Peru study, when asked about preventing 

cervical cancer, women responded that personal 

hygiene, cleaning with herbs, receiving Pap tests, 

having only one partner or few partners were all 

important. Women also spoke about living in 

peace and having a good relationship with 

partners. Participants were asked if they had any 

concerns about the Pap test. One participant 

responded, “I got my tubes tied, and I am afraid 

that will cause cancer.” Another echoed this 

concern about tubal ligation and was afraid that it 

could cause an infection or cancer. Another 

woman was concerned about her symptoms by 

expressing, “I have vaginal leakage and am afraid.” 

Regarding the HPV vaccine, motivating factors to 

receive the vaccine included receiving educational 

information and campaigns where the vaccine 

would be available. Reasons for not getting 

vaccinated were lack of financial resources, 

negative beliefs about the effectiveness of 

vaccines, and fear of side effects, such as 

childhood deformities, or pain at the injection site. 

Cultural Consensus Results for Risk Factors and 

Symptoms 

Participants were asked to agree or disagree with 

a list of possible risk factors/symptoms that could 

cause cervical cancer. There was consensus 

amongst all participants (0.4, SD = 0.03), and for 

the Georgia sample independently there was 

marginal consensus with an average cultural 

competence value of 0.49 (SD = 0.28), an 

eigenratio of 5.93, and 5% negative competency 

values. For the Peru sample, there was a lack of 

consensus, with an average cultural competence 

value of 0.30 (SD = 0.24), an eigenratio of 1.83, 

and 10% negative competency scores. The 

convention for consensus, or a shared cultural 

model, is to produce an eigenratio of 3.0 or 

greater. One individual from the Georgia sample 

and two individuals from the Peru sample were 

removed from the analysis because there was no 

variability in their responses since they agreed with 

all risk factors/symptoms (Table 3). After dividing 

the two separate samples by education (primary or 

some secondary, secondary and higher), there was 

a significant difference in the cultural competence 

values for the Georgia sample (t=-2.15, p=0.04), 

and the higher education sample (0.60, SD = 0.27) 

exhibited significantly higher competence in the 

model of knowledge of cervical cancer causes than 

the lower education sample (0.41, SD = 0.26) 

(Figure 1). Analysis of residual agreement also 

showed that higher educated individuals in 

Georgia are a distinct sub-group, meaning they 

have higher within than between-group 

agreement, while lower educated individuals are 

not a distinct sub-group (F=4.515, p<0.05). 

 

 



 
 
 
 
 

 

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Table 3. Cultural Consensus Analysis. 

Measure Agree/ Disagree 

Cusco, Peru 

(N=28) 

Agree/ Disagree 

Georgia, US 

(N=38) 

Pile Sort  

Risk Factors 

Cusco, Peru 

(N=30) 

Pile Sort  

Risk Factors 

Georgia, US 

(N=39) 

Eigenratio
a
 1.8 5.9 2.6 7.1 

Average 

Competence 

0.30 (±0.24) 0.49 (±0.28) 0.30 (±0.19) 0.61 (±0.10) 

aEigenvalue ratios of 3.0 or greater and lack of negative competence values indicate a good fit to the 

consensus model. A competence value of 0.50 indicates an average level of cultural competence. 

Notes. For the agree/disagree questions, two participants from the Peru dataset and one participant from 

the Georgia dataset were removed because of 100% endorsement of all items. 

 

Figure 1. Mean cultural competence by education category, Georgia, US 

 

The average percentage agreement with the items 

was 70% in the Georgia sample and 60% in the 

Peru sample (Table 4). When only considering the 

biomedically defined risk factors, the average 

percentage agreement was 74% in the Georgia 

sample and 76% in the Peru sample. Both samples 

reported high agreement with HPV as a risk factor 

for cervical cancer (>80%). The Peru sample 



 
 
 
 
 

 

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endorsed the following possible cervical cancer 

risk factors significantly higher (>20% difference) 

than the Georgia sample: drinking alcohol, 

smoking, high blood pressure, stress, urinating 

frequently, fate, worry, pelvic rash, and weight loss. 

However, the Georgia sample had higher 

endorsement (>20% difference) of poor feminine 

hygiene and use of birth control pills as risk 

factors.  

 

Table 4. Endorsement of Cervical Cancer Risk Factors/Symptoms. 

Risk factor/symptom Georgia, US (n=39) % Cusco, Peru (n=30) % 

Multiple sex partners* 95 97 

Poor feminine hygiene 92 73 

Spouse with multiple sex partners* 90 87 

Not getting regular check-ups* 90 93 

Gonorrhea* 87 73 

Syphilis* 87 77 

Human papilloma virus (HPV)* 85 83 

Abnormal vaginal bleeding* 82 87 

Sex before age 16 years* 79 80 

Abortion 77 87 

Vaginal trauma 74 77 

HIV infection* 74 87 

Yeast infection 74 87 

Birth control pills* 72 53 

Chlamydia* 72 87 

Sex during menstrual period 69 77 

Family history 67 77 

Many pregnancies 64 80 

Smoking* 56 83 

Drink alcohol 51 93 

Bloody stools 51 63 

Diet* 49 53 

Pelvic rash 49 80 

Chemicals in food 46 67 

Urinating frequently 38 67 

Fate 31 57 

Stress 28 67 

Weight loss 23 60 



 
 
 
 
 

 

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High cholesterol 23 43 

High blood pressure 18 50 

Worry 16 57 

Low income* 13 30 

Average endorsement 70 60 

Average endorsement of biomedical risk factors* 74 76 

*Risk factors/symptoms generally accepted by medical profession. 

Notes. Columns represent % who agreed that the risk factor or symptom was a cause of cervical cancer 

Similar to the agree/disagree task, there was 

consensus for the pile sort data in the Georgia 

sample and no negative competency values (Table 

3). The MDS plot had a stress value of 0.13. The 

MDS plot produced five clusters from the 

constrained pile sort. The first cluster included 

family history and destiny, or unmodifiable factors. 

The second cluster included items about sex and 

infection—HPV, HIV, multiple sex partners, sex 

under 16 years old, and lack of a regular Pap test. 

The third cluster grouped risk factors around 

reproductive factors—birth control pills, abortion, 

and multiple pregnancies. The fourth cluster 

grouped not using condoms and poor feminine 

hygiene. The fifth cluster included environmental 

and behavioral risk factors—smoking, poor diet, 

and chemicals in food. The MDS plot for the Peru 

sample had high stress value of 0.20, and the pile 

sort data did not produce consensus. 

Cervical Cancer Belief Statements 

Study participants responded to seven statements 

about cervical cancer and were asked to agree or 

disagree with each statement (Table 5). There was 

very high agreement in both samples with two 

statements: 1) that cervical cancer was curable if 

found early; and 2) that even if treatment were 

painful, the participant would endure it if it meant 

living longer. The greatest disagreement was 

about not wanting to know about a cervical cancer 

diagnosis, with 63% of Peruvian women not 

wanting to know compared to only 13% of 

Mexican immigrant women. Similarly, only half of 

Peruvian women believed that there was 

something they could do to prevent cervical 

cancer compared to 18% of Mexican immigrant 

women. 

 

Table 5. Endorsement of Cervical Cancer Beliefs. 

Statement of cervical cancer beliefs Georgia, US  

(n=39) % 

Cusco, Peru  

(n=30) % 

I would be afraid to tell my husband or partner if I had cervical cancer 18 37 

I need a Pap smear only when I experience vaginal bleeding other 

than menstruation (or when I experience other symptoms) 

28 53 

I am very likely to get cervical cancer sometime in my lifetime 62 40 

If cervical cancer is found early, it can be cured 95 87 

I would undergo cervical cancer treatment that is unpleasant or painful 

if it would improve my chances of living longer 

97 100 

I would rather not know if I had cervical cancer 13 63 

There is not much I can do to prevent cervical cancer 18 50 



 
 
 
 
 

 

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Notes. Columns represent % who agreed with the statement. 

Cultural Cancer Screening Scale 

The cultural cancer screening scale (CCSS) 

assesses items relevant to cancer screening (Table 

6). In the Georgia sample, the internal consistency 

of the CCSS (20 items) was 0.91, indicating 

excellent reliability. On the 5-point scale (ranging 

from 1 = never to 5 = always), the mean values for 

the subscales were at or below the midpoint on 

the scale: (1) catastrophic disease expectations (2.1, 

SD = 1.5); (2) cancer screening fatalism (2.1, SD = 

1.6); (3) sociocultural deterrents (2.5, SD = 0.9); (4) 

symptomatic deterrents (2.4, SD = 2.4); and (5) 

negative beliefs about health professionals (1.8, SD 

= 0.9). 

 

 

Table 6. Responses from the Cultural Cancer Screening Scale
a
. 

Characteristics Georgia, US 

Mean ±SD 

Cusco, Peru 

Mean ±SD 

P-values 

Catastrophic Disease Expectations 2.1 ±1.5 4.0 ±0.9 <0.001 

Cervical cancer is the worst thing that can happen to a 

woman 

   

Cervical cancer is a deadly disease    

Cancer Screening Fatalism 2.2 ±1.6 3.3 ±0.6 <0.001 

It is not important to screen regularly for cervical cancer 

because everyone will eventually die of something anyway 

   

It is not necessary to screen for cervical cancer regularly 

because it is in God’s hands anyway 

   

Screening regularly is not very important because if you are 

meant to get cancer you will get it no matter what you do 

   

Sociocultural Deterrents 2.5 ±0.9 3.2 ±0.7 0.002 

Having problems making an appointment    

Not knowing where I can get a screening exam    

Not being able to get time off work    

Not having transportation to get to my appointment    

Not receiving a reminder call or text for the screening exam    

Having to take care of my child(ren) of family    

Not having health insurance or the money to pay for the 

exam 

   

Symptomatic Deterrents 2.4 ±1.6 3.3 ±0.8 0.001 

Feeling healthy    

Having several normal screening results    

Not feeling anything abnormal    



 
 
 
 
 

 

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Negative Beliefs about Health Professionals 1.8 ±0.9 2.5 ±0.5 <0.001 

The health care professionals are not compassionate towards 

their patients 

   

Health professionals are always in a hurry and do not have 

time for their patients 

   

I don’t not feel comfortable with health professionals doing 

the screening examination 

   

Some health professionals inappropriately touch their 

patients during the screening examination 

   

Health professionals performing screening examinations are 

not trustworthy 

   

Notes. Values in bold represent summary scale scores for this validated measure. 

aResponse categories for the items in this scale are: 1 = “Never”; 2 = “I don’t think so”; 3 = “Neutral”; 4 = 

“Very sure”; 5 = “Always” 

In the Peru sample, the internal consistency of the 

CCSS was 0.72, indicating acceptable reliability. 

The mean values for the subscales were 

significantly higher than the Georgia sample for 

each construct based on the independent samples 

t-test: (1) catastrophic disease expectations (4.0, SD 

= 0.9); (2) cancer screening fatalism (3.3, SD = 0.6); 

(3) sociocultural deterrents (3.2, SD = 0.7); (4) 

symptomatic deterrents (3.3, SD = 0.8); and (5) 

negative beliefs about health professionals (2.5, SD 

= 0.5). For the Peruvian women, the values were 

above the midpoint value for four of the five 

subscales. The largest difference in average scores 

was for catastrophic disease expectations, 

indicating Peruvian women were more likely to 

endorse the belief that a diagnosis of cervical 

cancer was equivalent to a death sentence. 

DISCUSSION 

To our knowledge, this is only the second study 

comparing knowledge about cervical cancer using 

the same survey instrument between Hispanic 

women in the US and multiethnic women in South 

America. These results suggest that overall, 

women in Cusco held beliefs about cervical cancer 

that are more fatalistic than Mexican immigrant 

women in Georgia. The higher incidence and 

mortality from cervical cancer in Peru might be 

associated with more fatalistic beliefs about 

cervical cancer and by extension, cancer. This 

difference in fatalism scores could also be partially 

attributed to the Mexican immigrant women 

having a higher regard for the quality of health 

services in the US, compared to the Peruvian 

women’s perception of their chances of surviving a 

diagnosis of cancer in Peru. Negative perceptions 

toward the quality and accessibility of government 

health care facilities for the prevention and control 

of cervical cancer were reported in the results of 

other survey projects with women in this area of 

Cusco (Ferris et al., 2015a; Luque et al., 2016). 

The presence of consensus among the Georgia 

sample, and lack of consensus among the 

Peruvian participants, also suggests differences in 

the social distribution of knowledge regarding 

cervical cancer. For while there appears to be a 

general cultural model among Hispanics in 

Georgia, with some variation according to 

education, there is no consensus among the Peru 

sample either in the agree/disagree or the pile sort 

task. Similar to Shiu et al.’s (2010) results among a 

sample of older women in Hong Kong, the lack of 

consensus on questions regarding cervical cancer 

indicates little public or general knowledge on the 



 
 
 
 
 

 

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RESEARCH 

topic. The explanation given in that study was that 

there was substantial disagreement about the 

most highly ranked cervical cancer factors (Shiu et 

al., 2010). Responses may be based more on 

personal knowledge or opinion.  

Our study results are not dissimilar to a previous 

survey study which compared responses to 

cervical cancer knowledge questions between 

women in the Cusco area with women in Augusta, 

Georgia—both English- and Spanish-speaking 

(Han et al., 2012). In this prior comparative study, 

lower levels of knowledge about cervical cancer 

were similarly identified among Peruvian women 

compared to Hispanic women in the US. For 

example, when asked if HPV could cause an 

abnormal Pap test, 69% of US Hispanic women 

answered correctly, compared to 40% of Peruvian 

Quechua speakers, 27% of Peruvian Spanish 

speakers, and 39% of bilingual Peruvians. 

Moreover, in the same study when asked if they 

were embarrassed to receive a Pap test, 38% of US 

Hispanic women answered affirmatively, compared 

to 39% of Peruvian Quechua speakers, 50% of 

Peruvian Spanish speakers, and 39% of bilingual 

Peruvians. In that study the reference group for 

comparison was non-Spanish-speaking women, 

and the survey found significant differences on 

cervical cancer knowledge questions—higher 

knowledge among non-Spanish-speaking 

women— and on belief questions such as fear and 

embarrassment of getting a Pap test—less fear 

and embarrassment among non-Spanish-speaking 

women. 

In our study, in both samples it is possible that 

there was confusion about the difference between 

HIV and HPV, suggested by the grouping of these 

risk factors in the pile sort exercise and the low 

knowledge levels in response to the HPV and HPV 

vaccine survey questions. HIV was endorsed by a 

higher percentage of Peru participants than HPV, 

but in the Georgia sample, HIV was endorsed by a 

lower percentage of participants as a risk factor for 

cervical cancer. Nevertheless, both samples 

endorsed HPV as a risk factor for cervical cancer 

similarly (above 80%).  

Importantly, related to HPV vaccination behaviors, 

previous research in multiple sites in Peru reported 

that even though 59-71% of low-income 25-65 

year old women had low awareness of HPV, the 

HPV vaccine, and cervical cancer, over 90% would 

agree to be vaccinated and 58% would be willing 

to pay some amount for the vaccine (Lee et al., 

2010). Our results about the barriers to screening 

affecting Peruvian women based on the Cultural 

Cancer Screening Scale for the catastrophic 

disease expectations and the responses to the 

belief statements, for example about the 

questionable benefits of receiving cervical cancer 

screening, are similar to another study based on 

focus group discussions with women in four 

Peruvian cities which reported that many women 

cited fear, embarrassment, and lack of knowledge 

as being barriers for not getting a Pap test (Paz-

Soldan et al., 2010). In our work to educate 

gynecologic patients, we have previously 

developed animated videos to educate patients in 

their native languages in Peru and Georgia about 

cervical cancer prevention and treatment 

procedures to increase understanding of HPV and 

HPV vaccination awareness (Ferris et al., 2015b; 

Luque et al., 2017). 

Limitations of this study include a small number of 

questions used in the agree/disagree survey. The 

32 questions may not be enough to accurately 

measure patterns of agreement and variation, 

particularly with small sample sizes. The limited 

number of questions also prevents analysis of 

consensus in any sub-domain (e.g., causes, 

symptoms, or treatments), which would help in 

identifying whether the lack of consensus is rooted 

in specific areas or on the topic in general. 

However, the lack of consensus among Peruvian 

participants in the pile sort task, which is not as 

dependent upon the number of items, may 

suggest that there is limited agreement on risk 

factors for cervical cancer overall. However, the 

pile sort data is limited in terms of the number of 



 
 
 
 
 

 

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RESEARCH 

items participants can negotiate in terms of 

producing piles. Combining pile sort data with 

rank data for the same items can produce better 

understanding of how some clusters of cervical 

cancer risk factors may be perceived as more 

serious than others. For example, it was previously 

reported in a prior analysis of the Georgia survey 

data that the sex-related risk factors were ranked 

higher compared to the genetic and 

environmental risk factors (Luque et al., 2014). 

CONCLUSION 

The comparison of survey studies highlights the 

potential of exploring knowledge in this domain as 

well as revealing the limitations in using this type 

of methodology for a disease which may be poorly 

understood and the diagnosis perceived as 

catastrophic. Cervical cancer is highly curable 

when detected in its early stages, and the goal of 

the Peru clinic CerviCusco is to bring screening 

and more timely treatment to women who have 

unfortunately experienced the burden of the 

disease in their communities (Ferris et al., 2009). 

Future studies are planned in Peru to explore the 

psychological stress produced by screening and 

diagnosis of cervical cancer to benefit patients in 

negotiating their treatment and reduce stigma 

around the disease. 

Ethical approval 

Research for this article was approved by the 

research ethics committees of Georgia Southern 

University, Augusta University, and the Peru 

Ministry of Health. 

Acknowledgements 

In Peru, we acknowledge the collaboration of the 

CerviCusco staff, especially Ms. Wendy Guevara 

Condorhuaman, and the Peruvian Ministry of 

Health in Lima. In Georgia, we acknowledge Mrs. 

Claudia Reyes-Garcia for data collection, Southeast 

Georgia Communities Project and their team of 

promotoras, especially Mrs. Andrea Hinojosa, the 

Vidalia onion farms, and Claxton Poultry. 

Funding 

This paper was supported by funding from the 

National Cancer Institute (R21CA163159, 

R03CA173105). Content presented is solely the 

responsibility of the authors and does not 

necessarily represent the official views of the 

National Cancer Institute. 

Conflict of interest 
The authors declare that no competing or conflict of 

interests exist. The funders had no role in study 

design, writing of the manuscript, or decision to 

publish. 

Authors’ contributions 
Conception and design: JL 

Data analysis: JL, JM 

Literature review and manuscript writing: JL, JM, DF 

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