Entrega de resultados y (no) adherencia en mujeres VPH+ : perspectivas de mujeres y de profesionales de la salud en la provincia de Jujuy, 2013-2016


Arrossi, Silvina
Pecheny, Mario

Spatial Coverage

Temporal Coverage





266 p.


Atribución-NoComercial-SinDerivadas 2.0 Genérica (CC BY-NC-ND 2.0)




Jujuy (province)


HPV testing as primary screening was included in the Jujuy public healthcare system, earlier than in other provinces of Argentina, with the aim of reducing the high and unequal cervical cancer mortality rates. Such inclusion presents three new challenges: 1) A question about HPV+ women's adherence to follow-up and potential treatment in the healthcare system, considering that implementation can be cost-effective as long as adherence is ensured (the latter can include four stages of contact with the system: screening - HPV testing, Pap test -; diagnosis - colposcopy, biopsy -; treatment; and subsequent follow-up); 2) Being a new diagnostic entity with ambiguous connotations - an asymptomatic, sexually transmitted virus, which can generate lesions and, if left untreated, cancer -, challenges exist in terms of delivery of results; and 3) articulation between delivery of results and the subsequent process is key, since the form of delivery modifies adherence.

The purpose of this thesis is to describe and analyze the delivery of HPV+ test results and (non-) adherence to the follow-up process and potential treatment of women with a positive diagnosis, from the perspective of women and healthcare professionals, in Jujuy between 2013 and 2016. Three moments of possible tension between professional's and patient's perspectives are addressed: the process of delivering HPV+ test results in the public healthcare system, the meanings given by women to such result, and (non-) adherence to the follow-up process. Articulation between these moments is also described and analyzed. The author has sought to make a contribution to the field of healthcare sociology that recovers the conflicting nature of the definitions of health-disease, (non-) adherence and doctor-patient relationships, as well as a contribution to public healthcare.

Based on a qualitative strategy, we have conducted in-depth interviews to 38 women with an HPV+ diagnosis and 27 professionals from the public healthcare system in Jujuy involved in the delivery of HPV+ results. Women with HPV+ / normal Pap test (without lesions) and HPV+ / abnormal Pap test (with low and high risk lesions) are included. For ethical reasons, a counseling interview was implemented for women – providing a space for healthcare conversations based on doubts and misunderstandings - that is taken into account for the analysis. Through the comparison and analysis of interviews and counseling interviews, we have sought to broaden the approaches to adherence beyond technical success, based on a multidimensional approach - which considers the social, programmatic and individual aspects under study as comprehensive interrelated - and Care – wholes - that includes individuals’ projects, even if they conflict or oppose biomedical success.

The perceptions of women and professionals about the delivery of results indicate that both groups make a good assessment. Although the meetings are qualified positively, their descriptions evidence limitations in form and content: use of technical vocabulary, expressions focused on a serious illness rather than on prevention, exclusion of central issues (such as sexual transmission) and conversations focused on "clearing doubts" (while women express difficulties in asking questions). Overrating of delivery responds to a view that understands healthcare from a "charity" and "medical vocation" perspective, and not as a right.

Women do not understand the ambiguity of a positive result, and therefore interpret it from social meanings related to sexually-transmitted infections and cancer. This can lead them to express confusion, and overestimate or underestimate the seriousness of the result. Overestimation predominates in HPV+ / abnormal Pap test women, while underestimation is predominant among HPV+ / normal Pap test women. Each group of women describes differentiating meanings and feelings that can modify their comprehensive health outcomes ("desenlaces de salud"), i.e., generate changes in perceptions about their projects, interpersonal relationships, feelings and bodies, and imply a "biographical rupture" Understanding, and subsequent outcomes, vary both as a result of the information received from various sources and of meetings with health workers.

Professionals' perception individualizes non-adherence factors, and holds non-adhering women responsible and stigmatizes them (combining categories of class, race and gender classification). However, the perceptions of a group of women account for multidimensional reasons for non-adherence: work, economy, gender, healthcare system, geography and mobility, as well as subjective-individual reasons. A second group of women has no notion of the medical indication, or describes an "open" or "in process" temporality. A third group of interviewees expressed not wanting to "return" because they distrust healthcare professionals and institutions and medical interventions, based on "logic of suspicion", according to María Epele's category. Their perceptions include arguments ranging from "doctors hurt" to "they awaken cancer" What professionals identify as "irrational arguments" is expressed in women's accounts as a logic that, rather than "distorting" reality, is related to a dimension of experience, based on situations of abuse and violated rights in healthcare institutions. The logic of suspicion accounts for complex mechanisms of marginalization and exclusion between women in vulnerable sectors and public healthcare institutions. Those who adhere to follow-up also describe violation of rights during biopsies and treatments, where misinformation has important consequences on their comprehensive health outcomes (unwanted pregnancies, deciding not to continue follow-up, perception of "trauma").

Delivery of results - based on biomedical approaches or on Care models - can modify understanding and adherence to follow-up, particularly in those women who do not understand follow-up indications or express underestimation of the result. Among non-adhering women, those who express confusion or underestimate the result (especially HPV+ / normal Pap test women) predominate, rather than those who overestimate it.

Misinformation - related to delivery of results - modifies comprehensive health outcomes because it threatens adherence, but also due to other factors. Outcomes, in turn, account for aspects that exceed lack of understanding of the result. Women can: 1) adhere, but express negative outcomes ("traumatic" experiences or rights violations, perceptions of "biographical rupture" that modify their life projects); 2) not adhere due to multidimensional reasons, but "want" to do so; 3) express a "logic of suspicion" that leads them to distrust healthcare institutions and not adhere. From the point of view of healthcare outcomes, adhering to follow-up does not necessarily mean "success", and not adhering does not necessarily involve "failure". Adherence approaches must be extended in order to modify the functionalist approaches that set the conditions for non-adherence and vulnerability that should be avoided.

Table Of Contents

Lista de siglas y abreviaturas

1. Relevancia para la salud pública
2. Relevancia para la investigación
3. Planteo del problema, objetivos y propuesta teórico-conceptual
4. La prevención del CCU: aspectos técnicos
5. El proceso de prevención del CCU en el contexto argentino y de la provincia de Jujuy
6. Estructura de la tesis

Capítulo 1. Discusiones sobre entrega de resultados y adherencia: marco teórico-conceptual
1.1. Estudios sobre adherencia al seguimiento de la prevención del CCU: enfoques teóricos y límites conceptuales
1.2. El carácter problemático de los procesos de salud-enfermedad-atención
1.3. La (no) adherencia desde una perspectiva multidimensional y de Cuidado

Capítulo 2. Entre investigadora y agente de salud: metodología y reflexividad
2.1. Marco epistemológico
2.2. Estrategia metodológica
2.3. Trabajo de campo
2.3.1. Entrevistas a profesionales
Muestra y características de los/las profesionales
Situación de Entrevista
2.3.2. Entrevistas a mujeres: entre investigadora y agente de salud
Muestra y características de las mujeres
Ingreso y toma de decisiones: de entrevistadora a agente de salud
Situación de la entrevista-consejería en salud
La entrevista-consejería como dato
2.4. Estrategias de análisis

Capítulo 3. Entrega de resultados de un test de VPH+: perspectivas de mujeres y de profesionales de la salud
3.1. Perspectivas y percepciones de las mujeres sobre la entrega de resultados del test de VPH
3.1.1. Modalidad de la entrega de resultados
3.1.2. Contenido de la entrega de resultados: “No estoy ni acá que puede ser malo ni acá que puede ser bueno”
3.1.3. Percepción y evaluación del factor interpersonal en la entrega de resultados: “[…] bien. Por lo menos explican.”
3.2. Perspectivas y percepciones sobre la entrega de resultados del test de VPH
3.2.1. Modalidad de la entrega de resultados
3.2.2. Contenido de la entrega de resultados: “Que no se asusten, que es portadora de un virus, que es precursor de un cáncer”
3.2.3. Percepción y evaluación del factor interpersonal durante la entrega de resultados: “Esa barrera de miedo se rompe”
3. Análisis comparativo

Capítulo 4. ¿Cómo comprender un diagnóstico ambiguo? Significados sociales, fuentes de información y desenlaces en salud
4.1. “Me sentí enfermar, era un bajón para mí”: significados, percepciones y sentimientos de las mujeres sobre el diagnóstico positivo de un test de VPH
4.2. El rompecabezas de la información: encuentros, desencuentros y desenlaces en salud
4.2.1. Una temporalidad incierta: esperar el diagnóstico y la información que no llega
4.2.2. “Lo escuché en la calle”: fuentes de información por fuera de la consulta médica
4.2.3. Armar las piezas del rompecabezas: “Yo misma traté de investigar”
4.2.4. ¿Encuentros que cambian sentidos?

Capítulo 5. Percepciones sobre la (no) adherencia al proceso de seguimiento y posible tratamiento luego de un resultado positivo de test de VPH
5.1. Perspectivas de profesionales de la salud sobre procesos de (no) adherencia
5.2. “[…] enferman a la gente. Yo no quiero ir”: procesos de (no) adherencia desde la perspectiva de las mujeres
5.3. Lógica de la sospecha, (no) adherencia y desenlaces en salud

Referencias bibliográficas

Título obtenido

Doctora de la Universidad de Buenos Aires en Ciencias Sociales

Institución otorgante

Universidad de Buenos Aires. Facultad de Ciencias Sociales

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