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Fatalistic Beliefs and Cervical CancerScreening Among Mexican WomenMa. Luisa Marvána, Yamilet Ehrenzweiga & Rosa Lilia Catillo-Lópeza

a Institute of Psychological Research, Universidad Veracruzana,Xalapa, Veracruzana, MexicoAccepted author version posted online: 25 Sep 2014.Publishedonline: 21 Nov 2014.

To cite this article: Ma. Luisa Marván, Yamilet Ehrenzweig & Rosa Lilia Catillo-López (2014): FatalisticBeliefs and Cervical Cancer Screening Among Mexican Women, Health Care for Women International,DOI: 10.1080/07399332.2014.959169

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Health Care for Women International, 0:1–15, 2014Copyright © Taylor & Francis Group, LLCISSN: 0739-9332 print / 1096-4665 onlineDOI: 10.1080/07399332.2014.959169

Fatalistic Beliefs and Cervical Cancer ScreeningAmong Mexican Women

MA. LUISA MARVAN, YAMILET EHRENZWEIG,and ROSA LILIA CATILLO-LOPEZ

Institute of Psychological Research, Universidad Veracruzana, Xalapa, Veracruzana, Mexico

Fatalistic beliefs about cervical cancer were studied in 464 Mexicanwomen, and how such beliefs relate to participation in cervicalcancer screening was evaluated. Rural women were less likely thanurban women to have had a Pap test and more likely to believethat the illness is due to bad luck or fate. These were also the beliefsmost associated with nonscreening among rural women, whereasfor urban women the belief most associated with nonscreening was“there is not much I can do to prevent cervical cancer.”

Cervical cancer (CC) is a serious public health problem and remains a leadingcause of death in developing countries. In recent years, there has beengrowing interest in different disciplines to identify culturally based factors,such as attitudes and beliefs, that may explain differences in participation inCC screening between cultures.

The fact that a woman develops CC may have a particular meaning ina certain culture, but this meaning may vary considerably in other culturalgroups. Thus, it is important to take into account the sociocultural contextwhen studying attitudes and beliefs related to the issue. Some sociocul-tural characteristics of Mexico—such as being a developing country witha machista culture and the prevalence of “magical” thinking—may help toexplain why Mexicans’ health beliefs are similar to those held in some coun-tries but not in others. In the present study, we explored fatalistic beliefsabout CC held by women living in rural and urban areas of Mexico and howthese beliefs affect CC screening. This study is of interest to an internationalaudience and can be used for comparative purposes because some resultsmay be generalized more readily to certain cultures than to others.

Received 7 May 2013; accepted 25 August 2014.Address correspondence to Ma. Luisa Marvan, Institute of Psychological Research, Uni-

versidad Veracruzana, Av. Dr. Luis Castelazo Ayala s/n, Col. Industrial Animas, Xalapa, Ver.91190, Mexico. E-mail: mlmarvan@gmail.com

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Cervical Cancer and Screening

Cervical cancer is the second most common cancer affecting women,and most cases are linked to genital infection with the human papillomavirus (World Health Organization [WHO], 2009). Worldwide, CC is thethird cause of death among women (GLOBOCAN, 2008), and in 2008 itwas responsible for 275,000 deaths, 88% of which occurred in developingcountries (Ferlay et al., 2010). Developing countries have an averagemortality rate of 9.7/100,000 inhabitants, whereas developed nations have arate of 3.2/100,000. In 2008, Mexico’s rate was 9.7/100,000, which is a mostalarming situation because the average rate in Latin America is 6.5/100,000(GLOBOCAN, 2008). These data highlight the fact that in Mexico, CC isa serious public health problem. In the north of the country the mortalityrate is 8.5/100,000, whereas in the south, the region in which the state ofVeracruz is located and where this study was conducted, the rate goes ashigh as 11.96/100,000 (Palacio-Mejıa, Rangel-Gomez, Hernandez-Avila, &Lazcano-Ponce, 2005). This rate is far higher than the average for developingcountries and almost doubles that of Latin America. In fact, Veracruz isone of the states with the highest risk of death due to CC in the country(Sanchez-Barriga, 2012).

Several factors may account for the observed disparity in CC incidenceand mortality, including differences in screening and follow-up rates andpractices. Cervical cancer screening targets the reduction of both cancerincidence and mortality rates. The Papanicolaou or Pap test consists of gentleremoval of exfoliated cells from the uterine cervix, which are then stainedand microscopically examined to detect underlying cancer or its precursors.Thus, the Pap test is important for early diagnosis and treatment of CC. Thistest has been widely used, and deaths from CC have decreased dramaticallysince its introduction in 1943 (Ball & Madden, 2003). In Mexican public healthinstitutions, the Pap test is a service offered free of charge. According to theOfficial Mexican Norm for the prevention, detection, diagnosis, treatment,control, and epidemiological surveillance of CC (Secretarıa de Salud, 2007),CC screening should begin at age 25 or at the initiation of sexual activity. Thenorm recommends that women who have had two normal Pap smears at1-year intervals should decrease the frequency of screening to every 3 years.

Participation in CC screening is related to a variety of psychosocial andindividual factors. Some authors of previous studies of Mexican women havedemonstrated that a woman’s knowledge about CC and about the Pap’s ben-efits, a history of using contraceptives, a previous history of gynecologicalsymptoms, being less than 65 years of age, having had less than five pregnan-cies, being literate, and having her sexual partner’s approval of gynecologicalexaminations have all been associated with the highest levels of CC screen-ing (Aguilar-Perez, Leyva-Lopez, Angulo-Najera, Salinas, & Lazcano-Ponce,2003; Ehrenzweig, Marvan, & Acosta, 2013; Hernandez-Hernandez et al.,2007; Lazcano-Ponce et al., 1999a, 1999b).

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Fatalism and Cervical Cancer Screening 3

Health Beliefs and Cancer

The theory of planned behavior proposed by Ajzen (1991) has been usedto explain some health practices. According to this theory, the intention toperform a certain behavior (health behavior) can be predicted by attitudestoward the target behavior, perceived behavioral control, and subjectivenorms. Attitudes are a function of salient behavioral beliefs, which repre-sent perceived consequences or other attributes of the behavior. Behavioralcontrol is related to factors likely to facilitate or inhibit the performance ofthe behavior. Such factors are referred to as “control beliefs” and includepersonal beliefs regarding both internal (information, personal deficiencies,skills, emotions) and external matters (opportunities, dependence on other,structural barriers). Finally, subjective norms are a function of normative be-liefs, which represent perceptions of specific significant others’ preferencesabout whether one should or should not engage in a behavior (Conner &Spark, 2005). Health beliefs and attitudes acquired through the socializationprocess have been strongly related to health practices (Conner & Norman,2005).

Over time, the belief that a diagnosis of cancer is associated with in-evitable death has been reinforced and perpetuated, often because individ-uals have witnessed the cycle of cancer diagnosis and death. Because of thisbelief, some people may not have integrated into their health care practicesthe benefits of cancer screening and early detection as these technologicaladvances were introduced (Powe & Finnie, 2003).

Participation in CC screening has been related to some psychosocialhealth beliefs including psychological barriers that self-limit a person’s ownhealth practices (Conner & Norman, 2005). In a recent study conducted inMexico in which some barriers related to CC screening were explored, theauthors found that embarrassment was the most frequently reported barrier.They also found that women with basic education, especially those who livedin rural areas, were more likely than urban women with higher education tobelieve that the Pap test was painful, that it was too embarrassing to haveit, and to claim that their partner would not want them to have a Pap test(Marvan, Ehrenzweig, & Castillo-Lopez, 2013).

Another psychosocial health belief is fatalism, but to our knowledge ithas not been studied either in Mexico or in other Latin American countries.Fatalism refers to “the general tendency to believe that events are predeter-mined or caused by external forces and that little, or nothing, can be doneto change their course. Indeed, implicit in this world view is the notion thatindividual will or action exerts little power in changing the course of fate”(Florez et al., 2009, p. 292). When applied to health, fatalism refers to nega-tive or pessimistic attitudes regarding preventive health practices and diseaseoutcomes (Espinosa & Gallo, 2011). If people believe that developing a dis-ease is in the hands of God or that it is a matter of luck and unpreventable,they will not adopt early-detection behaviors (Straughan & Seow, 2000).

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4 M. L. Marvan et al.

This kind of fatalism is related to the concepts of “chance” and of “God”in the health locus of control model proposed by Wallston and colleagues(1999), as well as to the concept of “spiritual” in the model proposed byHolt, Clark, and Klem (2007). Both models were developed independentlyby two groups of researchers who operationalized the locus of control modelof Rotter. These models are research constructs in relation to the predictionof health behavior and refer to the general expectancy that one’s behavioreither is or is not related to one’s health. Perceptions of the source of aperson’s power to control one’s health may be internal or external. Peoplewith an external health locus of control believe that their health is due toexternal forces that may include chance (i.e., fate or luck in the Wallstonet al. model), supreme beings (i.e., God in both models), or both.

Cancer Fatalism

The term cancer fatalism has been used to study fatalistic beliefs regardingmultiple stages of the cancer continuum, from prevention to survivorship(Niederdeppe & Levy, 2007).

The degree to which cancer fatalism influences screening for differentkinds of cancer has been studied, but the data are not consistent. Althoughmany authors have found that people with the highest levels of fatalisticbeliefs have the lowest rates of early-detection tests, other authors have notfound that association. Thus, the evidence supporting fatalism as a barrierto early detection is inconclusive (Baron-Epel, Friedman, & Lernau, 2009).Espinosa and Gallo (2011) analyzed published empirical studies on fatal-ism and Latinas’ utilization of the Pap test or mammogram. The authorsconcluded that although the findings are mixed and additional research isclearly needed, the majority of the results they reviewed were consistent witha relationship existing between fatalism and screening after accounting forstructural barriers such as health care access and socioeconomic status. Theauthors also mentioned that it is not possible to determine whether fatalismoperates differently across Latino subpopulations. Moreover, discussions ofcancer fatalism have often been limited to anecdotal findings from focusgroups or interviews, whereas research to measure cancer fatalism as anindependent or dependent variable has been much more sparse.

Fatalistic beliefs about cancer are largely influenced by several sociocul-tural variables. Women with low levels of education, income, or both tendto have the most fatalistic beliefs (Otero-Sabogal, Stewart, Sabogal, Brown,& Perez-Stable, 2003; Niederdeppe & Levy, 2007; Ramırez, Suarez, Laufman,Barroso, & Chalela, 2000; Russell, Perkins, Zollinger, & Champion, 2006).Moreover, in the United States, Latina immigrants are more likely than U.S.-born Latinas or Anglo women to believe that fate is a risk factor for CC(Chavez, Hubbell, Mishra, & Valdez, 1997). Abraıdo-Lanza, Viladrich, Florez,

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Fatalism and Cervical Cancer Screening 5

Cespedes, Aguirre, and de la Cruz (2007) concluded that fatalism is a culturaltrait among Latinos and a passive response that deters them from engagingin screening behaviors.

The Present Study

Fatalism is a cultural belief widespread across Latin cultures. The objectiveof this study was to examine fatalistic beliefs about CC in Mexican womenfrom urban and rural areas and to evaluate how these beliefs are related toparticipating in CC screening. We expected that fatalistic beliefs would bemore prevalent among rural rather than urban women. We also expected thatfatalistic beliefs about CC would reduce the likelihood that women wouldobtain the Pap test.

METHOD

Participants

We recruited a nonprobabilistic sample of 464 adult Mexican women wholived in the state of Veracruz. Two hundred and thirty-eight of them livedin the city of Xalapa, which is the capital of the state, with a population ofapproximately 650,000 inhabitants, located 315 km northeast of Mexico City.The other 226 participants lived in two rural areas of the state of Veracruz.These areas were Estanzuela and Lencero, where agriculture is the maineconomic activity, and both are located between 14 and 17 km from Xalapa.Estanzuela has a population of approximately 4,130, and Lencero has 1,600inhabitants. The sample size had a confidence level of 95% with a margin oferror of 5%.

Both urban and rural women were recruited by direct solicitation in pub-lic places, such as parks and small shops. A female researcher approachedadult women who were present in these places and asked if they would bewilling to participate in a research project about CC. Once women agreed toparticipate, the researcher asked them to answer a few questions to deter-mine if they fulfilled the eligibility criteria mentioned below for participatingin the study. If the criteria were fulfilled, participant and researcher agreedupon a place, day, and time for the survey to be conducted.

The inclusion criteria to be eligible to participate in the study were thatwomen had never had any kind of cancer, that they had not undergone ahysterectomy, that they had some degree of basic schooling (1 to 9 years),that they know how to read and write, and that they were at least 26 yearsof age. We established the last criterion because the Mexican Official Normstates that women should receive their first Pap examination after they havehad their first intercourse or when they are 25 years old even if they havenot had intercourse. The exclusion criteria were that women had had an

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6 M. L. Marvan et al.

abnormal Pap test result or that they did not completely understand how toanswer the survey.

We invited 640 women to participate in the study, and 615 of them(96%) accepted. Out of those who accepted, 560 (91%) fulfilled the criteriafor participating. We excluded 65 participants because they had had anabnormal Pap test result or because they did not completely understandhow to answer the survey. Thus, the final sample was composed of the 464participants mentioned above, whose ages were between 26 and 59 years(mean age for urban women = 40.4 years, and for rural women = 41.1 years).

Participants’ occupations varied as follows: Twenty percent of urbanwomen and 8% of rural women sold their own merchandise at local markets;34% of the urban women and 15% of the rural women worked as employeesin companies or establishments where most employees have low incomes;33% of the urban women worked in homes doing domestic chores; 6%of the rural women were farmers; and the rest of the participants werehousewives. Their highest educational level was basic education (1 to 9 yearsof schooling).

According to the educational level of the volunteers, as well as theirkinds of employment and the neighborhoods in which they lived, we inferredthat they had a lower- or lower-middle socioeconomic status.

Instruments

Data were collected using a survey created for this study. In the first sectionof the survey, participants completed a basic information sheet that askedgeneral questions such as age, birthplace, neighborhood in which they live,marital status, religion, number of children, schooling, and occupation. Atthe end of this section, women answered whether they had ever receiveda Pap test examination. If so, they were asked two questions: (a) how longago they had had their last Pap, and (b) if any abnormality had ever beendetected by any Pap conducted.

In the second section of the survey, participants rated a list of foursentences regarding fatalistic beliefs about CC. In order to create the list, wecarried out a previous qualitative study with 25 women who shared with ustheir beliefs about CC. Then, these stated beliefs were piloted with 10 urbanand 10 rural women to be sure that women understood them well. The listcontained the following fatalistic beliefs: (a) CC is due to bad luck, (b) If Iget CC, it’s just due to fate, (c) God gives women CC because they have lived abad life, and (d) There is very little I can do to prevent CC . Participants wereasked to indicate if they believed each sentence was true or false.

Procedure

The research protocol for this study was approved by the institutional reviewboard of the Institute of Psychological Research, Universidad Veracruzana.

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Fatalism and Cervical Cancer Screening 7

The surveys were completed between July and November 2012. Signed in-formed consent was obtained from all participants.

A cross-sectional design was used. As mentioned above, women wererecruited by direct solicitation in public places. Urban women were recruitedin neighborhoods where people with lower socioeconomic status usuallylive. Rural women were recruited in local parks and small shops.

After the researcher and a woman agreed upon a place, day, and timefor the survey to be conducted, they met and the survey was individuallyapplied. The participant was told that the information she was going toprovide was anonymous, and the researcher did not put any identifyingmarks on the survey forms. It was emphasized that answers to the surveywere neither right nor wrong. The researcher read each item aloud and thewoman gave her answers orally to the researcher who then recorded them.Each survey took 10–20 minutes to be completed.

Data Analyses

Pearson chi-square tests were conducted to determine any association be-tween the use of the Pap test (number of women who had or had not hada Pap test) and the place in which participants lived (urban or rural area).This test was also used to ascertain any association between fatalistic beliefsabout CC (number of women who showed each of the four fatalistic beliefs)and rural or urban residence.

Two logistic regression analyses were conducted to test whether fatalis-tic beliefs about CC predict the use of the Pap test. In the first, the dependentvariable (DV) was the fact that women had or had not had the Pap test ex-amination; and in the second regression, the DV was the fact that the last Papwas or was not done within the past 3 years. In both cases, the independentvariables were each of the four fatalistic beliefs about CC.

RESULTS

As can been seen in Table 1, there were 339 women (73%) who had hada Pap test, and most of these women were urban (x2(1) = 5.68, p < .017).Among women who had had a Pap examination, there were 64 (19%) whoselast Pap smear was more than 3 years ago, and there were no significantdifferences in the numbers of rural and urban participants who reportedthis.

Results of fatalistic beliefs about CC are shown in Table 2. Twenty-sevenpercent of participants thought CC is due to bad luck and 35% said that ifthey get CC it is due to fate. In both cases, there were more rural than urbanwomen who showed these beliefs.

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8 M. L. Marvan et al.

TABLE 1 Number (and Percent) of Screened Women, and Number of Women Whose LastPap Was Within the Last 3 Years

Question Rural women Urban women Totaland response n (%) n (%) n (%)

Have you ever had a Pap test?Yes 162 (68.1%) 177 (78.3%) 339 (73.1%)No 76 (31.9%) 49 (21.7%) 125 (26.9%)

Was the last Pap within the last 3 years?Yes 128 (79.0%) 147 (83.1%) 275 (81.1%)No 34 (21.0%) 30 (16.9%) 64 (18.9%)

Twenty percent of participants believed that God gives women CC be-cause they have lived a bad life and 31% of women thought there is not muchI can do to prevent CC. In both cases, there were no significant differencesbetween the numbers of rural and urban women who showed these beliefs.

In order to test whether fatalistic beliefs about CC predict the use ofa Pap test, we conducted two logistic regression analyses. In the first, theDV was the fact that women had or had not had the Pap test examination(Table 3). According to the variance inflation factor (VIF) test, there were nocollinearity problems in our data, as all VIF scores were less than 3 (Kennedy,2003). Rural women who thought that CC is due to bad luck were more thanfour times less likely to have had a Pap test than those who did not presentthis belief. Additionally, rural women who thought that CC is due to fatewere more than three times less likely to have had a Pap test than thosewho did not share this belief. Neither belief in luck nor in fate predict Pap

TABLE 2 Number (and Percent) of Women Who Presented Fatalistic Beliefs About CervicalCancer

Rural Urbanwomen women Total

Statement and response n (%) n (%) x2(1) p < n (%)

CC is due to bad luck.Yes 82 (34.5%) 43 (19.0%) 13.25 .0001 125 (26.9%)No 156 (65.5%) 183 (81.0%) 339 (73.1%)

If I get CC it’s due to fate.Yes 99 (41.6%) 64 (28.3%) 8.40 .030 163 (35.1%)No 139 (58.4%) 162 (71.7%) 301 (64.9%)

God gives women CCbecause they have liveda bad life.Yes 54 (22.7%) 40 (17.7%) 1.49 n.s. 94 (20.3%)No 184 (77.3%) 186 (82.3%) 370 (79.7%)

There is not much I cando to prevent CC.Yes 77 (32.4%) 66 (29.2%) .40 n.s. 143 (30.8%)No 161 (67.6%) 160 (70.8%) 321 (69.2%)

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Fatalism and Cervical Cancer Screening 9

TABLE 3 Fatalistic Beliefs About Cervical Cancer That Predict Pap Test Utilization

Rural women Urban women

Statement OR (95% CI) Wald OR (95% CI) Wald

CC is due to bad luck. 4.63 (2.29–9.39) 18.07∗ 2.25 (.97–5.22) 3.61If I get CC it’s due to fate. 3.74 (1.87–7.52) 13.80∗ 2.25 (.94–5.39) 3.28God gives women CC because

they have lived a bad life..50 (.21–1.14) 2.74 1.84 (.76–4.44) 1.85

There is not much I can do toprevent CC.

1.91 (.96–3.78) 3.41 6.57 (2.98–14.49) 21.75∗

∗p < .0001.OR = odds ratio.

test use in urban participants. In contrast with the results of rural women,however, we found that urban participants who believe there is not muchthey can do to prevent CC were more than six times less likely to have hada Pap test than those who did not share this belief.

In the second regression, the DV was the fact that the last Pap was orwas not done within the past 3 years. All VIF scores were less than 3. Noneof the fatalistic beliefs studied predicted whether the last Pap was or wasnot done within the past 3 years regardless of the rural or urban residenceof participants.

DISCUSSION

The present findings indicate that 73% of participants had had at least onePap test. Compared with other cultures worldwide, this percentage is similarto that reported for Turkish women (Reis et al., 2012), slightly higher than thatreported for South Asian women living in New York City (Islam, Kwon, Senie,& Navneet, 2006) or for Somali-born women living in London (Abdullahi,Copping, Kessel, Luck, & Bonell, 2009), and it is dramatically higher than thatpreviously reported for another sample of Turkish women (Esin, Bulduk, &Ardic, 2011). On the other hand, the percentage we found in the current studyis lower than that found by researchers in England (a developed country),although most of the English women surveyed were low-income workers(Waller, Marlow, & Wardle, 2009). Scarinci, Beech, Kovach, and Bailey (2003)conducted a study in the United States (another developed country) andfound that all non-Latinas who were surveyed had had at least one Papsmear, in contrast to only 81% of Latinas.

Other authors who have also studied Latina women living in the UnitedStates found that the percentage of women who had had at least one Pap testis higher than the percentage we found in the current study (Fernandez et al.,2009; Garbers, Jessop, Foti, Uribelarrea, & Chiasson, 2003; Gregg, Centurion,Aguillon, Maldonado, & Celaya-Alston, 2011). A possible explanation of this

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10 M. L. Marvan et al.

difference is that women living in the United States might have greater accessto information about CC, as well as greater access to health care services.

We also found that rural women were less likely than urban womento have had a Pap test. This is consistent with data reported in earlier stud-ies also conducted in Mexico (Marvan, Ehrenzweig, & Castillo-Lopez, 2013;Palacio-Mejıa et al., 2005). These results highlight the need to improve pre-ventive health programs directed toward specific populations of womenliving mainly in rural areas.

Several plausible explanations were considered for the observed differ-ence in Pap test use between rural and urban participants. The first possibilitymay be the greater presence of structural barriers in rural areas, which in-clude factors that limit women’s abilities to actively seek out CC screening,such as accessibility and availability of quality services or lack of knowledgeabout Pap tests as a preventive practice (Menard et al., 2010; Paz-Soldan,Bayer, Nussbaum, & Cabrera, 2012). Second, as has been demonstrated, ru-ral Mexican women are more likely than urban women to have psychosocialbarriers that have been associated with nonscreening (Marvan, Ehrenzweig,& Castillo-Lopez, 2013). A third possibility could be a greater presence of fa-talistic beliefs about CC in rural areas, such as was found in the current study.

Concerning fatalistic beliefs about CC, the percentage of participantswho believed that there is not much they can do to prevent CC was simi-lar to the one reported in a previous study conducted in the United States(Niederdeppe & Levy, 2007). Chavez and colleagues (1997) studied some fa-talistic beliefs similar to those explored in the current study but in a sampleof U.S.-born Latinas, Latina immigrants, and Anglo women. In their study,the percentage of Latina immigrants who claimed that God gives women CCbecause they have lived a bad life was similar to the percentage found inMexican participants in the current study. Chavez and colleagues, however,reported that a lower percentage among U.S.-born Latinas and Anglo womenparticipants maintained this belief. One possible explanation for these dif-ferences is that health beliefs in Latino cultures are greatly influenced byreligious beliefs (Zavaleta, 2006).

Fatalism did not predict usage of the Pap test by rural and urban womenin the same way. Only in the rural areas did belief in fate or luck predictuse of the Pap test. Thus, women who though that CC is due to bad luckor to fate were less likely to have had a Pap test than those who did notshare these beliefs. Additionally, there were more rural than urban womenwho agreed that CC is due to bad luck or to fate. This finding leads thepresent authors to suggest that some “normative beliefs” (as defined in theAjzen theory described in the Introduction section), such as the ideas thatfate or luck have a determinant role in one’s health, may be more deeplyentrenched in rural rather than in urban areas. A possible explanation ofthese results is related to the fact that the “chance” locus of health controlorientation (as defined in the Wallston and colleagues theory described in

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Fatalism and Cervical Cancer Screening 11

the Introduction section) is more prevalent in rural than urban areas (Acosta,2013; Betttencourt, Talley, Molix, Schlegel, & Westgate, 2008).

In contrast with the results of rural women, only in urban areas did thebelief that there is not much one can do to prevent CC predict the use ofPap tests such that women who claimed this statement was true were lesslikely to have had a Pap test than women who did not believe it. Thus, insome population groups certain fatalistic beliefs are important in the decisionto have a Pap test, whereas other beliefs may be more influential in otherpopulations.

An unexpected result was that the belief that God gives women CCbecause they have lived a bad life did not predict use of the Pap test eitherin rural or urban women. Perhaps the participants (most of whom wereCatholic) believe that fate and God are independent external forces, as it isstated in both the Wallston and colleagues and Holt and colleagues modelsregarding external health locus of control. In the Catholic religion, Godrewards or punishes people as a result of their behavior but gives individualsthe opportunity to correct their ways and control their acts.

Some limitations of the present results should be taken into consid-eration, and it is important to state that the decision to participate in CCscreening is so complex that it is difficult to speak of one isolated aspect.First, the participants could have given socially acceptable answers overes-timating their Pap test usage. Additionally, we do not know if our resultscan be generalized to women who declined to participate, who did notfulfill the inclusion criteria for participating in the study, or who were ex-cluded. Finally, this was a quantitative study and hence fatalistic beliefs werenot explored in depth; qualitative research may add to understanding fac-tors affecting CC screening. Further research should include both in-depthinterviews and focus groups.

In spite of these cautions, our results lead us to conclude that womenwith fatalistic beliefs in external forces, such bad luck or fate, may think thatpreventing CC is not possible and therefore there is no point in adoptingany proactive behaviors such as having a Pap test. Taking our results intoconsideration can help practitioners and researchers better understand somepsychosocial factors that may influence the use of the Pap test in the Mexicanculture or in other cultures. In the context of designing and implementingsuccessful preventive CC health programs, it is essential to identify factorsthat deter women from having Pap tests and to assure such programs areefficiently delivered taking into consideration the sociocultural context of thetarget population.

ACKNOWLEDGMENTS

The authors thank Liliana Yepez, who assisted us in the collection of data.

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