The Effect of Educational Program on Increasing Cervical/Cancer Screening Behavior among Women in Hamadan, Iran:/Applying Health Belief Model

The Effect of Educational Program on Increasing Cervical/Cancer Screening Behavior among Women in Hamadan, Iran:/Applying Health Belief Model summarize the two articles and mention each article strength and weaknesses. JRHS 2011; 11(1): 20-25 JRHS Journal of Research in Health Sciences journal homepage: www.umsha.ac.ir/jrhs Original Article The Effect of Educational Program on Increasing Cervical Cancer Screening Behavior among Women in Hamadan, Iran: Applying Health Belief Model Davoud Shojaeizadeh (PhD)a, Seyedeh Zeinab Hashemi (MSc)b, Babak Moeini (PhD)c, Jalal Poorolajal (MD, PhD)d* a Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran b Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran c Research Center for Health Sciences and Department of Public Health, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran d Research Center for Health Sciences and Department of Epidemiology & Biostatistics, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran ARTICLE INFORMATION ABSTRACT Article history: Received: 24 February 2011 Revised: 20 March 2011 Accepted: 3 April 2011 Available online: 6 April 2011 Background: The systematic application of Pap test helps early diagnosis and effective treatment of cervical cancer. This study was conducted to assess the effect of education on health beliefs and practice of women eligible for Pap test using Health Belief Model (HBM). Methods: This quasi-experimental study was conducted in Hamadan City, the west of Iran, in 2010 using before-after design. In this study, 70 women aged 16 to 54 years participated voluntarily who had never done Pap test until the date of the study. The volunteers were divided into several small groups. For each group, 2-hour training session was held twice. The data collection tool was a self-administered multi-choice questionnaire that was developed based on HBM constructs. Health beliefs and practice of the target group were evaluated preintervention and four months later. Results: Our findings indicated that education based on HBM was effective and could enhance the participants' knowledge significantly and improve the HBM constructs including perceived susceptibility, severity, benefits, and barriers. The training program enhanced the practice from zero before intervention to 81.4% after that. The results of the present study revealed that increase in knowledge had effect on the HBM constructs. Furthermore, there was a significant relationship between knowledge and both age and educational level. Conclusion: Health education based on HBM can enhance women's knowledge of cervical cancer, change their health beliefs and improve their behaviors regarding screening programs like Pap test. Keywords: Health Belief Model Knowledge Practice Pap test * Correspondence Jalal Poorolajal (MD, PhD) Tel: +98 811 8260661 FAx: +98 811 8255301 E-mail1: poorolajal@umsha.ac.ir E-mail2: poorolajal@yahoo.com Citation: Shojaeizadeh D, Hashemi SZ, Moeini B, Poorolajal J. The effect of educational program on increasing cervical cancer screening behavior among women in Hamadan, Iran: Applying health belief model. JRHS. 2011;11(1):20-25. Introduction ervical cancer, caused by Human Papilloma Virus (HPV), is the second most common cancer in women worldwide 1. It is also an important leading cause of death from neoplasm among women in low-income countries 2. HPV infection is common and preventable and now widely established as a necessary risk factor associated with the development of almost all cases of cervical cancer 3. C Davoud Shojaeizadeh et al 21 JRHS 2011; 11(1): 20-25 Despite its invasive characteristics, due to having a long incubation period, cervical cancer can be detected in early pre-invasive stage by the systematic application of a screening Pap test 4. A single negative Pap test reduces the risk of cervical cancer to 45% and nine negative tests during lifetime reduce the risk to 1% 5. In developing countries, the knowledge of cervical cancer importance is limited among general population and even among health workers and policy makers. The quality of screening programs and health care is also poor 6. The systematic application of Pap test in women is depended on their knowledge, attitudes, beliefs and behaviors regarding this effective screening program 7. The Health Belief Model (HBM) is one of the most famous frameworks, which are widely used for understanding health behavior. The rationale of HBM is based on that people often take healthrelated actions if they feel those actions can prevent negative health outcomes. HBM consists of various constructs including perceived susceptibility, severity, barriers, and benefits; in addition to self efficacy, cues to action, and health action 8. We conducted the present study to assess the effect of training using the HBM in order to promote women's knowledge and change their health beliefs to do Pap test. Methods This quasi-experimental study was conducted in Hamadan City, the west of Iran, in 2010, using before-after design. One of the 12 urban health centers of the city was selected in which the coverage of Pap test was the lowest. In this study, 70 women aged 16 to 54 years were invited and participated voluntarily who had never done Pap test until the date of the study. In order to find and enroll the eligible women, we searched the household records that were available in the local health centers. Then we invited them to participate in this study. Sample size was calculated at 95% significant level and 90% statistical power. Based on the results of previous studies 9, the value of P was different for various components of HBM. Accordingly, the maximum calculated sample size of 63 was considered for this study. On the other hand, the participants were to be followed for four months. Hence, we increased the sample size to 80 to deal with possibility of lost to follow up. From 80 eligible participants, eight were lost during the follow-up period and two were excluded for other reasons. Thus the number subjects remained for data analysis consisted of 70 volunteers. The volunteers were divided into seven 10- member groups. For each group, 2-hour training session was held twice. In each session, various training methods were used for all groups in the same manner including lectures, question, and answer, group discussion and showing slides. Pamphlets were distributed among the participants as well. Two months later, a follow-up training session was held for all participants. In order to assess the effect of training intervention based on HBM, the knowledge, beliefs, and practice of the participants were evaluated at the beginning of the study and four months later. Data collecting tool was a self-administered multiple choice questionnaire included the following four sections: (a) demographic characteristics (3 questions), (b) knowledge of cervical cancer and Pap test (12 questions), (c) beliefs including perceived susceptibility, severity, benefits and barriers (6 questions for each), and (d) practice (4 questions). Validity of the questionnaire was evaluated and confirmed by experts in health education, epidemiology, and obstetrics. Reliability of the questionnaire was checked through a pilot study using Cronbach's alpha coefficient. The scores of alpha for the questions related to knowledge and perceived susceptibility, severity, benefits and barriers were 66%, 69% 88% 79% and 94% respectively. Questions regarding knowledge and perceived susceptibility were revised in order to increase their internal consistency. Four-choice questions were considered for assessing participants' knowledge of cervical cancer and Pap test. Then, percentage of correct answers to these questions was obtained for each subject. The average score of the correct answers was calculated for all subjects in order to assess the effect of training on participants' knowledge before and after intervention. In ad22 Effect of Education on Cervical Cancer Screening JRHS 2011; 11(1): 20-25 dition, five-choice questions (including strongly agree, agree, neither agree nor disagree, disagree, strongly disagree) were used to assess different components of HBM using Likert scoring method. The score of each component, which, varied from at least five to at most 25 was reported as percentage. Then, average score of each component was calculated for all subjects in order to assess the effect of training on participants' attitude before and after intervention. We used Wilcoxon test for comparing the mean scores of knowledge and attitude before and after intervention, Kruskal-Wallis test for assessing the mean score of knowledge across various age groups and various educational levels, and linear regression model for estimating the extend of changes in mean scores of components of HBM per one unit increase in Knowledge. All statistical analysis was performed at 95% significant level using statistical software STATA 11 (StataCorp, College Station, Texas). Results The mean age of participants was 31.3 years [95% CI: 31.1, 35.6], 59% aged 26-45 years. Most of the participants (93%) did not have academic education (Table 1). The mean difference of scores of knowledge before and after intervention was statistically significant between different age groups (P=0.015) and different levels of education (P=0.027). Table 1: Absolute and relative frequency distribution of the participants by age groups and educational levels Variable Frequency N=70 Percent Mean difference (95% CI) a Kruskal-Wallis test Age group (year) 16-25 19 27.1 48 (42, 54) P=0.015 26-35 21 30.0 47 (40, 54) 36-45 22 31.4 56 (49, 64) 46-54 8 11.5 66 (55, 76) Education Illiterate 16 22.9 63 (56, 69) P=0.027 Primary school 20 28.6 52 (43, 60) Secondary school 14 20.0 46 (40, 53) High school 15 21.4 51 (42, 60) Academic educated 5 7.1 45 (35, 55) a Mean difference of scores of knowledge before and after intervention Table 2: The mean score of knowledge, and perceived susceptibility, severity, benefits, and barriers in pre- and post-intervention using Health Belief Model Items Mean score % Pre-test (95% CI) Post-test (95% CI) Wilcoxon test Knowledge 39 (35, 43) 92 (89, 94) P<0.001 Perceived susceptibility 62 (56, 68) 94 (92, 96) P<0.001 Perceived severity 69 (64, 73) 94 (92, 96) P<0.001 Perceived benefits 75 (70, 79) 96 (94, 98) P<0.001 Perceived barriers 60 (54, 65) 90 (87, 93) P<0.001 As shown in Table 2, the mean score of the participants' knowledge increased significantly after intervention compared to before intervention (P<0.001). In addition, the mean scores of other constructs of the model including perceived susceptibility, severity, benefits and barDavoud Shojaeizadeh et al 23 JRHS 2011; 11(1): 20-25 riers improved significantly after intervention (P<0.001). The most changes were related to the participants' knowledge and the lowest to the perceived benefits. One unit increase in the mean score of knowledge significantly improved the perceived susceptibility, severity, benefits, and barriers (Table 3). The effect of change in mean score of knowledge on perceived susceptibility was higher than the other constructs of the model (P<0.001). From 70 participants, 57 (81.4%) proceeded to do Pap test during the four-month follow-up period. Table 3: The correction between knowledge and different constructs of Health Belief Model based on the analytic results of linear regression model Items MDS a Intercept Coefficient EAI b P-value Knowledge 0.5238095 - - - - Perceived susceptibility 0.3176190 -0.1209871 0.8373391 0.716352 P<0.001 Perceived severity 0.2571429 0.0260372 0.4412017 0.467239 P=0.002 Perceived benefits 0.2133333 0.0441631 0.3229614 0.367125 P=0.014 Perceived barriers 0.3071429 -0.1041488 0.7851931 0.681044 P<0.001 a Mean difference scores of the constructs of the model before and after the intervention b The estimated average increase in the score of each construct associated with one unit increase the score of knowledge Discussion Based on the results of the present study, the intervention based on HBM improved the participants' knowledge of cervical cancer significantly, changed their attitudes and motivated them to do Pap test. The results of the previous similar studies confirmed our findings. Sharifi-Rad et al 10 evaluated the educational effect on the performance of the prevention of smoking in first-year highschool students of Boukan City. They indicated that all constructs of the model inproved significanty after intervention. Papa et al 11 studied the effect of education on the knowledge, concern and desire of 50 women who were eligible to do Pap smear. They reported that 77% of the participants were encouraged to do Pap test after intervention. We found that mean score of knowledge varied across age groups and educational level. This shows that the effect of intervention based on HBM has different effects on different age groups and education level. Tabeshian et al 12 conducted a Knowledge, Attitude and Practice (KAP) study to assess the effect of training on teachers of Isfahan County, but reported no statistically significant relationship between knowledge and both age and educational level. We indicated that the mean score of all components of HBM increased significantly post-intervention compared to pre-intervention. Our findings are consistent with results of previous investigations. Yakhforoushha et al 9 assessed the effect of training on the voluntary health workers' knowledge and attitude regarding Pap test using HBM. Hazavehei et al 13 performed a training program for girl students in Garmsar City and used HBM to investigate the preventive behavior of the participants regarding osteoporosis. Sharifi-Rad et al 14 assessed the effect of health education using HBM on preventive action against cigarette smoking among high school students on preventive health practices of smoking in high school students has examined the results. All these studies revealed that both knowledge and attitude of the participants improved significantly after training program. The main finding of the present study was changing in the participants' health behavior so that majority of them (81.4%) proceeded to do Pap test while they had never done Pap test previously. Park 15 planned a curriculum based on HBM and trained the women and found that tendency of do Pap test and practice was higher in intervention group compared to control 24 Effect of Education on Cervical Cancer Screening JRHS 2011; 11(1): 20-25 group. In addition, an investiagtion conducted by Hazavehei et al 13 revealed that safety training based on the HBM can improve behavior of workers practice in using personal protective equipment. These findings indicate that training based on HBM can motivate and improve the preventive health behaviors. On the other hand, Tabeshian et al 12 used KAP design to improve the health behaviors of teachers in Isfahan County to do Pap test but found no significant differences in the participants' behaviors post-intervention compared to pre-intervention. This study had several limitations including: (a) difficult access to the target group who were eligible to do Pap test but they did not refer to the health center for screening; (b) unwillingness of the participants due to high cost of Pap test; and (c) difficulty in filling out the questionnaire because of low literacy of the participants. Despite its limitations, the results of the current study revealed that education based on HBM could improve the knowledge of general population and change the people's behaviors regarding Pap test even in low educated individuals who had never participated previously in screening programs of the cervical cancer. Conclusion We concluded that health education based on HBM can enhance women's knowledge of cervical cancer, change their health beliefs and improve their behaviors regarding screening programs like Pap test even if they had never participated in preventive programs. Acknowledgments This article is a part of MSc thesis supported by Tehran University of Medical Sciences. We would like to thank Deputy of Education as well as Deputy of Research and Technology of Tehran University of Medical Sciences for financial support of this study. We also wish to thank Deputy of Health Services of Hamadan University of Medical Sciences for their valuable collaboration with this study. Conflict of interest statement The authors declare that they have no conflict of interests. Funding This study was funded by the Deputy of Research and Technology of Tehran University of Medical Sciences. References 1. Armstrong EP. Prophylaxis of cervical cancer and related cervical disease: A review of the costeffectiveness of vaccination against oncogenic HPV types. J Manag Care Pharm. 2010;16(3):217-230. 2. World Health Organization. Cancer fact sheet No. 297. WHO Web Site; [update 1 February, 2011; cited 25 March, 2011]; Available from: http://www.who.int/mediacentre/factsheets/fs297/en/ index.html. 3. Warren JB, Gullett H, King VJ. Cervical cancer screening and updated Pap guidelines. Prim Care. 2009;36(1):131-149. 4. Berek JS. Berek & Novak's Gynecology. 14th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. 5. Wong LP, Wong YL, Low WY, Khoo EM, Shuib R. Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: a qualitative study. Singapore Med J. 2009;50(1):49-53. 6. Cain JM, Ngan H, Garland S, Wright T. Control of cervical cancer: women's options and rights. Int J Gynaecol Obstet. 2009;106(2):141-143. 7. Sach TH, Whynes DK. Men and women: beliefs about cancer and about screening. BMC Public Health. 2009;9:431. 8. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco: John Wiley & Sons; 2008. 9. Yakhforoushha A, Solhi M, Ebadifard A. Effects of education via health belief model on knowledge and attitude of voluntary health workers regarding Pap smear in urban centers of Ghazvin. Faculty of Nrsing of Mdwifery Quarterly. 2009;18(63):25-30. [Persian] 10. Sharifirad Gh, Hazavehie SMM, Mohebi S, Rahimi MA, Hasanzadeh A. The effect of educational programme based on Health Belief Model (HBM) on the foot care by type II diabetic patients. Iranian Journal of Endocrinology and Metabolism. 2006;8(3):231-239. [Persian] 11. Papa D, Moore Simas TA, Reynolds M, Melnitsky H. Assessing the role of education in women's knowledge and acceptance of adjunct high-risk human Papillomavirus testing for cervical cancer screening. J Low Genit Tract Dis. 2009;13(2):66-71. 12. Tabeshian A, Firozeh F. The effect of health education on performing Pap smear test for prevention of cervix cancer in teachers of Isfahan Davoud Shojaeizadeh et al 25 JRHS 2011; 11(1): 20-25 city. Medical Sciences Journal of Islamic Azad University. 2009;19(1):35-40. [Persian] 13. Hazavehei SM, Taghdisi MH, Saidi M. Application of the Health Belief Model for osteoporosis prevention among middle school girl students, Garmsar, Iran. Education for Health. 2007;20(1):1- 11. 14. Sharifi-Rad G, Hazavei MM, Hasan-Zadeh A, Danesh-Amouz A. The effect of health education based on health belief model on preventive actions of smoking in grade one, middle school students. Arak University of Medical Sciences Journal. 2007;10(1):79-86. [Persian] 15. Park S, Chang S, Chung C. Effects of a cognitionemotion focused program to increase public participation in Papanicolaou smear screening. Public Health Nurs. 2005;22(4):289-298. Effect of Health Education About Cervical Cancer and Papanicolaou Testing on the Behavior, Knowledge, and Beliefs of Turkish Women Hatice Bebis, PhD,* Nesrin Reis, PhD,Þ Tulay Yavan, PhD,þ Damla Bayrak, RN,§ Ays¸e Unal, PhD,|| and Serkan Bodur, MD¶ Background: Cervical cancer is the second most common form of cancer observed among women in Turkey. The participation of women in cervical cancer screening programs is strongly affected by Turkish attitudes, beliefs, and sociocultural structure. Aim: This study was conducted to assess the effectiveness of health education that aimed to raise awareness about Papanicolaou testing and to emphasize the importance of the early diagnosis of cervical cancer. Materials and Methods: The study was conducted as a prospective, randomized, controlled trial and was carried out in 148 women. Seventy-five women in the control group were asked to fill out questionnaire forms. A 45-minute conference-style training was given to 73 women in the study group, and all of the subjects were asked to fill out the forms after the training. The sociodemographic characteristics of the 2 groups and the mean ‘‘Health Belief Model Scale for Cervical Cancer and Pap Smear Test’’ scores of the 2 groups were statistically analyzed by Statistical Package of Social Sciences (SPSS), version 15. Results: There was no statistically significant difference noticed between the sociodemographic characteristics of the 2 groups (P 9 0.05). The difference in test scores, which represented knowledge about cervical cancer and Papanicolaou testing, was statistically significant between the control group and the study group (t = 10.122, P G 0.05). In the Health Belief Model Scale for Cervical Cancer and Pap Smear Test, there were statistically significant differences in the following measures: lower levels of susceptibility to cervical cancer score (t = j2.035, P G 0.05), lower levels of perceived benefit from a Papanicolaou test score (t = 3.278, P G 0.05) and lower levels of perceived barriers to Papanicolaou test score (t = j3.182, P G 0.05). Conclusion: Nurses should be involved in educating women about cervical cancer and Papanicolaou testing. By doing so, they can change the attitudes, knowledge, and beliefs of the women. Key Words: Cervical cancer, Health belief model, Health education, Papanicolaou test Received April 17, 2012, and in revised form June 4, 2012. Accepted for publication June 10, 2012. (Int J Gynecol Cancer 2012;22: 1407Y1412) ORIGINAL STUDY International Journal of Gynecological Cancer & Volume 22, Number 8, October 2012 1407 *Public Health Nursing, School of Nursing, GulhaneMilitaryMedical Academy (GMMA), Ankara; †Health Sciences Faculty, Department of Nursing, Ataturk University, Erzurum; ‡Department of Obstetrics and Gynecologic Nursing, School of Nursing, and §School of Nursing, Gulhane Military Medical Academy (GMMA), Ankara; ||Administrative Department of Nursing, and ¶Department of Obstetrics and Gynecology, Maresal Cakmak Military Hospital, Erzurum, Turkey. Address correspondence and reprint requests to Hatice Bebis, PhD, Public Health Nursing, School of Nursing, Gulhane Military Medical Academy (GMMA), Etlik, 06010, Ankara, Turkey. E-mail: hbebis@gata.edu.tr. No funding was received for this work. The authors declare no conflicts of interest. Copyright * 2012 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0b013e318263f04c Copyright © 2012 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited. Cervical cancer is the second most common cancer after breast cancer observed in women, and it is responsible for 10% of all cancer deaths.1,2 It is the most common cancer among women 20 to 39 years of age in developing countries.3 The Papanicolaou test is a systematically used tool in developed countries in the fight against cervical cancer.4,5 Although 80% of all cancers are seen in developing countries, cancer screening in these countries is as low as 5%.6 The Papanicolaou test is the most effective and inexpensive method for early cervical cancer detection, treatment, and slowing down the disease progression.4,6 Studies conducted worldwide and in our country showed that Papanicolaou testing as a method of early cervical cancer diagnosis and cervical cancer screening was not performed at an adequate level.6,7 The factors affecting the behaviors of women in cervical cancer screening programs and how to improve these factors were investigated in several studies.4,8,9 Taking measures against cervical cancer is among the primary concerns of our country because of many risk factors such as having a polygamous spouse, involvement in sexual activity at an early age (G16 years of age), smoking, human papillomavirus history, not being previously screened, low socioeconomic status, and poor hygiene.4,5,10,11 It has been found that lower education, lack of health coverage, and rural location, unorganized health care systems, sociocultural structure, the sex difference of the physician are associated with inadequate preventive cervical cancer screening in Turkey.3,12,13 The Health Belief Model is one of the oldest models used in this regard. According to this model, if an individual understands the screening method and believes that it is an effective method to diagnose the disease, the individual will participate more actively in screening programs.3,7,12Y15 The health belief of an individual is shaped by sociocultural structure but can change with health education. For this reason, health education should take the beliefs of the individuals into account and should create a positive change in the behavior of the individuals.11 There are many studies that show that nurses are the key health professionals who can fill the knowledge gaps of women; it is these knowledge gaps that prevent women from undergoing appropriate screening tests. Thus, nurses could help women to overcome specific situations, such as a fear of pain, anxiety, intimacy, and a sense of shame.7,12,13 This study was conducted to assess the effectiveness of health education on increasing the awareness of cervical cancer, Papanicolaou testing, and cervical cancer screening. MATERIALS AND METHODS Study Population This study was carried out in the city of Erzurum in Turkey. The sample used in the research was comprised of women who live in a public housing neighborhood of 560 apartments and whose name lists and health records were available. The sample size was calculated using the Power and Sample Size software package (http://biostat.mc.vanderbilt.edu/ wiki/Main/PowerSampleSize). In this study, the intention was to reach 140 women for 80% power at a 95% confidence interval. To account for the potential losses during the study, an additional 5 participants were enrolled in both groups. Thus, each group consisted of 75 women. Data The questionnaire consisted of 2 parts. In the first section, sociodemographic questionnaire consisted of 20 multiple choice questions having one correct answer, as well as descriptive questions about age, level of education, marital status, family history of cervical cancer, and history of the Papanicolaou test. Information from studies by Soldan et al,2 Uysal and Birsel,4 and Guvenc et al7 were taken into consideration when preparing questions related to risk factors of cervical cancer, frequency of the Papanicolaou test, how to perform the Papanicolaou test, and who should take the Papanicolaou test. In the second part of the questionnaire, Health Belief Model Scale for Cervical Cancer and Pap Smear Test, which was previously validated and translated into Turkish by Guvenc et al, 35 items in 5 subscales were taken into consideration: susceptibility to cervical cancer (3 items), perceived seriousness of cervical cancer (7 items), health motivation (7 items), benefits of the Papanicolaou test (4 items), and barriers to the Papanicolaou test (14 items). All the items in the subscales have 5-point Likert-type scale response choices: strongly disagree (scores 1 point) disagree (scores 2 point), neutral (scores 3 point), agree (scores 4 point), and strongly agree (scores 5 points). Higher scores indicate stronger feelings regarding that construct. The reliability of these subscales (as used in this study) ranged from susceptibility, 0.68; seriousness, 0.72; health motivation, 0.76; perceived benefits of the Papanicolaou test, 0.83; and perceived barriers to the Papanicolaou test, 0.80. Participants The study was conducted as a prospective, randomized, controlled trial. Only sexually active women 20 years of age and older who did not have a previously diagnosed cervical cancer and who agreed to participate in the study were enrolled in the study, via home visits. The women living in the odd-numbered and even-numbered apartment buildings were randomized into the study groups and the control groups, respectively. A second home visit was made for the women who were not at home during the first visit. The women who were not at home on the second visit were excluded from the study. The aim of the study was explained to all participants, and the forms used in the study were given to the women in the control group. The women in the study group were invited to the training session and informed about the location, time, and duration of the training. Cervical cancer and Papanicolaou test educational training was held as a conference lasting for 45 minutes in October 17. Barcovision was used in the training session, and all the questions from the participants were answered. Data collection forms from each group were collected at a home visit 2 weeks later. At this visit, an informational brochure involving the training contents was given to the participants in the control group for ethical reasons. In this study, the participants’ knowledge and beliefs were the dependent variables; sociodemographic characteristics and educational Bebis et al International Journal of Gynecological Cancer & Volume 22, Number 8, October 2012 1408 * 2012 IGCS and ESGO Copyright © 2012 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited. trainings on cervical cancer and the Papanicolaou test were independent variables. Statistics The W2 test, independent t test, and analysis of variance tests were used to analyze the data. P G 0.05 was considered for statistical significance. Ethical Principles The study was approved by the regional ethical committee of Maresal Cakmak Military Hospital/Erzurum. The participants were informed about the purpose of the study and the length of time required. They were also assured that the answers they shared would be strictly confidential and also that they had the right to withdraw from the study at any time. Written informed consent was obtained on the day of data collection. RESULTS The demographic characteristics of the study group and the control groupwere similar in this study (P9 0.05;Table 1).The mean T SD age of the study group was 31.73 T 5.37 years (range, 20Y53 years), and the mean T SD age of the control group was 32.76 T 8.68 years (range, 20Y68 years). Two patients (2.7%) in the study group and 7 patients (9.3%7) in the control group had a family history of cervical cancer. The women who had a postgraduate degreewere the largest population for both groups, with a 57.5% ratio (42 women) in the study group and 48.0% ratio (36 women) in the control group (P 9 0.05). Whereas, the employment ratewas higher in the study group with a ratio of 53.4% (39 women), the unemployment rate was higher in the control group, with a ratio of 40.0%(30 women). Thewomen who stated that they had knowledge about cervical cancer and Papanicolaou testing were 38.4% (28 women) in the study group and 28.0% (21 women) in the control group. Radio and television was the most encountered source of knowledge in both groups. All of the participants had undergone at least one Papanicolaou test in their lifetime. The 37.8% (56) of all participants had a Papanicolaou test within the last year. Of these 56 women, 37.0% (27 women) were in the study group and 38.7%(29 women) were in the control group (Table 1). When the knowledge levels of women about cervical cancer and the Papanicolaou test were examined, it was found that there was a statistically significant difference between the average knowledge scores of the study group and the control group (P G 0.05). In the study group, the most frequent correct answers were about the female reproductive organs (4.75 T 0.59; Table 2). When subscale mean scores of the health belief model were evaluated, it was found that there was a statistically significant difference between the perception of susceptibility to cervical cancer score (P G 0.05), the perception of benefits of Papanicolaou test score (P G 0.05), and the TABLE 1. Distribution of demographic features Demographical Features Study Group Control Group n % n % Statistics P Marital status Married 71 97.3 72 96.0 W2 = 0.671 90.05 Divorced/widow 2 3.0 3 4.0 No. children, mean T SD 1.14 T 933 1.44 T 017 t = 0.303 90.05 Family history of cervical cancer Yes 2 2.7 7 9.3 W2 = 0.093 90.05 No 71 97.3 68 90.7 Education level Literate 4 5.5 5 6.7 W2 = 0.697 90.05 Primary school 4 55 6 8.0 High school 23 31.4 28 37.3 Collage degree 42 57.5 36 48.0 Employment status Unemployed 34 46.6 45 60.0 W2 = 0.102 90.05 Employed 39 53.4 30 40.0 Prior knowledge about Papanicolaou test and cervical cancer Yes 28 38.4 21 28.0 W2 = 0.181 90.05 No 45 61.6 54 36.5 Papanicolaou test status over the past year Yes 27 37.0 29 38.7 W2 = 0.833 90.05 No 46 63.0 46 61.3 International Journal of Gynecological Cancer & Volume 22, Number 8, October 2012 Cervical Cancer * 2012 IGCS and ESGO 1409 Copyright © 2012 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited. perception of barriers to Papanicolaou test score (P G 0.05) of the study group and the control group (Table 3). DISCUSSION This study was focused on the impact of cervical cancer and Papanicolaou test education on women’s knowledge and beliefs. A number of studies reported that the protective behaviors were more frequently implemented by the women who were familiar with cervical cancer and the Papanicolaou test.15,16 It is known that when the Papanicolaou test was successfully applied, it will result in 80% decrease in the incidence of cervical cancer.10,16Y18 In this study, only one third of all participants declared that they had the knowledge about cervical cancer and the Papanicolaou test mostly gathered by the help of the media. In our country, the Ministry of Health and nongovernmental organizations conduct media campaigns to inform the society.5,8,11,17 In the literature, sociodemographic characteristics are reported to be effective in the behavior of a Papanicolaou testing. We showed that marital status,19 age of women,13 level of education,19 level of income,20 and residential area2 were the demographic characteristics to be effective in behavior of having a Papanicolaou test. In our study, 98% (145) of all participants had a Papanicolaou test at least once in their life. The ratio of the women having a Papanicolaou test within the past year was only one third of all participants. None of the women have had a Papanicolaou test with a screening reason. In fact, all these women were the patients who were seeking an antenatal care or medical care for their gynecological complaints such as infections, pelvic pain, and bleeding after sexual intercourse, at the time of the Papanicolaou test. In addition, none of the participants had an available Papanicolaou test frequency recommended by screening protocols in other studies.2,12,13,15,16,23 In the literature, it was reported that the women’s behavior of having a Papanicolaou test was affected by the distance between the place they live and the place they took health care.2,8 Soldan et al2 reported that women living in the mountainous and forested areas were less eager to have a Papanicolaou test than women living near a coastal city. Contrary to all expectations, Pourat et al23 found that South Asian women living in remote settlements from the health institutions were more eager to have a Papanicolaou test than women living in urban areas. All of our study population was residing in a rural area less than 2 km away from health facilities. We showed that the health behavior of the women in both groups were not in a desirable level, although they were not far away from health facilities. The income level of the women and the status of having a health insurance agreement are the factors that affect the possibility of having a Papanicolaou test. Carrasquillo et al20 reported that one of every 4 women living in the United States on an immigrant status without a health insurance policy had never undergone a Papanicolaou test in their life time. Another study reported that Chinese women with private health insurance had an increased possibility of having a Papanicolaou test, whereas South African women with public health insurance TABLE 2. Mean knowledge score of the participants Health Education Topics Score (n) Study Group Control Group Mean T SD Mean T SD t P Anatomy of the female reproductive organs 5 4.75 T 0.59 2.65 T 1.84 9.281 0.001 Cervical cancer risk factors 5 3.44 T 1.34 2.52 T 1.33 4.164 0.001 Importance of cervical cancer 2 1.29 T 0.58 0.88 T 0.63 j4.044 0.001 Importance of the Papanicolaou test 2 0.96 T 0.20 0.69 T 0.46 j4.499 0.001 Who should take the Papanicolaou test 2 0.85 T 0.36 0.59 T 0.49 j3.679 0.001 Application method of smear 2 0.78 T 0.41 0.44 T 0.50 j1.501 0.001 Frequency of the Papanicolaou test 2 0.71 T 0.45 0.60 T 0.49 j1.438 0.001 Total knowledge score 20 12.78 T 1.78 8.37 T 3.27 10.122 0.001 TABLE 3. Evaluation of participants’ perceptions of health belief model Beliefs Study Group Control Group Mean T SD Mean T SD t P Perception of susceptibility 7.84 T 2.09 8.53 T 2.07 j2.035 0.044 Perceived seriousness of cervical cancer 25.05 T 4.89 25.20 T 4.73 j0.184 0.855 Health motivation 27.97 T 4.27 27.73 T 4.54 0.331 0.741 Perception of benefit from the Papanicolaou test 17.15 T 3.13 15.43 T 3.26 3.278 0.001 Perception of barriers of the Papanicolaou test 31.26 T 8.10 35.32 T 9.62 j3.182 0.002 Bebis et al International Journal of Gynecological Cancer & Volume 22, Number 8, October 2012 1410 * 2012 IGCS and ESGO Copyright © 2012 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited. were less likely to have a Papanicolaou test.23 Long waiting times, significant crowd in the hospitals, absence of screening suggestions, and absence of systematic screening programs were the factors affecting the possibility of having a Papanicolaou test in health care facilities working under public health insurance policy.23 In our study, all participants had health insurance, and most of the subjects were from middle and upper income level of Turkish community. In addition, health care provider in this study was running an appointment system, and there was a low patient intensity in the institution. Besides all these motivating factors, the frequency of having a Papanicolaou test was inadequate in our population. It is stated that education is effective on cervical cancer and Papanicolaou test screening behavior.9 However, it is a hard and complex process to achieve behavioral change. Previous studies conducted to find out the knowledge level of women on the Papanicolaou test and cervical cancer showed that especially young women had the worse and/or insufficient information.24,25 In our study, there was a statistically significant difference between the total knowledge scores on cervical cancer and the Papanicolaou test knowledge scores of the study group and the control group (P G 0.05; Table 2). Reproductive organ knowledge was the most accurately answered question in the study group (P G 0.05). Less and wrong knowledge about cervical cancer and Papanicolaou tests may cause confusion about other gynecological procedures and will let women act in risky sexual behaviors and prevent them from having a Papanicolaou test. If a woman infected by a sexually transmitted disease (STD) assumes that the Papanicolaou test is a diagnostic tool for STD, after having a normal Papanicolaou test result, she could act as if she did not have an STD.24 Head et al25 found that only 6.2% (152) of women at high risk due to sexual activity at an early age and multiple sexual relationships realized the purpose of the Papanicolaou test. Eleven percent and 42.5% of the participants assumed that the Papanicolaou test was done for pregnancy and for diagnosis of STD, respectively.25 Mays et al26 reported that women did not realize the connection between the Papanicolaou test and cervical cancer. In our study, ‘‘multi-partner sexual relations and experiencing sexual relationship at an early age can cause cervical cancer,’’ were the mostly reported risk factor in our study group. Most of the women in the control group gave incorrect answers for the risk factors for cervical cancer (Table 3). When the literature was reviewed, it was found that education also seems to cause positive change in health belief. 11,23 Health and illness-related thoughts and feelings of individuals determine their preventive health behaviors.15,26,27 According to the health belief model, the people susceptible to a disease are more likely to learn and practice protective behaviors.12 We found a statistically significant difference in the perceptions of sensitivity of cervical cancer (P G 0.05) score of the women in the study group. In the literature, the rate of having a Papanicolaou test was reported higher among women believing that the Papanicolaou test is useful in the diagnosis of cervical cancer.16,26,28 We found a significantly positive difference (P G 0.05) on the perception of usefulness of the Papanicolaou test in the study group. There are also studies showing that only knowledge is not enough for taking screening tests. For example, in Nigeria, 18% and 12% of female doctors and nurses, respectively, had not taken a Papanicolaou test in their life.27 In another study, it was shown that only 10% of medical personnel had a Papanicolaou test, although 89% of them knew the purpose of the Papanicolaou test corrrectly.29 Besides the lack of knowledge, recognition of getting the disease as a fate and the sex difference of the physician are also factors affecting women to undergo a Papanicolaou test. For example, it is reported that immigrant women in the United States were associating their health status with their fate and also that they preferred women physicians for gynecological examinations. This situation is also similar with the studies carried out on women from different educational levels and residential areas in our country.4,10,12,20 Particularly, attempts are made to reduce these boundaries by training the population about screening procedures.24Y26 If women accept the Papanicolaou test as a painful procedure and if they feel lack of information about the procedure, they will experience difficulties in having the test.27,30 Nurses can reduce their perception of discomfort and increase their tolerance to pain by notifying andmakingempathy withwomen participating in the screening.12,14,29 In our study, the importance of early detection of cervical cancer and the application of the Papanicolaou test were all described to women in the study group. There was a positive statistically significant difference (P G 0.05) in perception of obstacle of women in the study group. Within 3 months of our study, 12.3% (9) of the women receiving training and 2.6% (2) of the women in the control group were applied to a hospital for a cervical cancer screening with the Papanicolaou test. CONCLUSIONVRECOMMENDATIONS FOR NURSES 1. They can use the ‘‘Health Belief Model Scale for Cervical Cancer and Pap Smear Test’’ as a guide in their health education initiatives. 2. This training should be repeated at regular intervals by using different methods. 3. Effectiveness of the training should also be considered as a behavioral transformation. Limitations of the Study During the evaluation of these findings, it should be considered that there are many groups with different social, cultural, and economic characteristics living in our country, and this study was carried out in only a small group of women. REFERENCES 1. Techakehakij W, Feldman RD. Cost-effectiveness of HPV vaccination compared with Pap smear screening on a national scale: a literature review. Vaccine. 2008;26:6258Y6265. 2. Soldan V, Lee HF, Carcamo C, et al. Who is getting Pap smears in urban Peru? Int J Epidemiol. 2008;37:862Y869. International Journal of Gynecological Cancer & Volume 22, Number 8, October 2012 Cervical Cancer * 2012 IGCS and ESGO 1411 Copyright © 2012 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited. 3. Turkish Cervical Cancer and Cervical Cytology Research Group. Prevalence of cervical cytological abnormalities in Turkey. Int J Gynaecol Obstet. 2009;106:206Y209. 4. Uysal A, Birsel A. Knowledge about cervical cancer risk factors and pap testing behavior among Turkish Women. Asian Pac J Cancer Prev. 2009;10:345Y350. 5. Kurdoglu Z, Kurdoglu M, Kundakci Gelir G, et al. Cervical and breast cancer screening program results of Van cancer early diagnosis, screening and training center. Van Medical Journal. 2009;16:119Y123. 6. McGovern PG, Lurie N, Margolis KL, et al. Accuracy of self-report of mammography and pap smear in a low-income Urban population. Am J Prev Med. 1998;14:201Y208. 7. Guvenc G, Akyuz A, Ac¸ikel CH. Health belief model scale for cervical cancer and pap smear test: psychometric testing. J Adv Nurs. 2011;67:428Y437. 8. Nazlican E, Akbaba M, Koyuncu H, et al. Cervical cancer screening between 35Y40 aged women at Kisecik region of Hatay province. TAF Preventive Medicine Bulletin. 2010:9;471Y474. 9. Dim C, Ekwe E, Madubuko T, et al. Improved awareness of pap smear may not affect its use in Nigeria: a case study of female medical practitioners in Enugu, southeastern Nigeria Transactions of the Royal Society of Tropical. Trans R Soc Trop Med Hyg. 2009;103:852Y854. 10. Andrae B, Kemetli L, Spare´n P, et al. Screening preventable cervical cancer risks: evidence from a nationwide audit in Sweden. J Natl Cancer Inst. 2008;100:622Y629. 11. Unal G, Orgun U. 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Women’s knowledge of pap smear test and human papillomavirus acceptance of HPV vaccination to themselves and their daughters in an islamic society. Int J Gynecol Cancer. 2010;20:1058Y1062. 17. Naki M, Celik H, Api O, et al. Awareness, knowledge and attitudes related to HPV infection and vaccine among non-obstetrician-gynecologist healthcare providers. J Turkish-German Gynecol Assoc. 2010;11:16Y21. 18. McGovern PG, Lurie N, Margolis KL, et al. Accuracy of self-report of mammography and pap smear in a low-income urban population. Am J Prev Med. 1998;14:201Y208. 19. Wellensiek N, Moodley M, Moodley J, et al. Knowledge of cervical cancer screening and use of cervical screening facilities among women from various socioeconomic backgrounds in Durban, Kwazulu Natal, South Africa. Int J Gynecol Cancer. 2002;12:376Y382. 20. Carrasquillo O, Pati S. The role of health insurance on pap smear and mammography utilization by immigrants living in the United States. Prev Med. 2004;39:943Y950. 21. 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