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: [email protected]
E-mail2: [email protected]
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: [email protected]
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. Studying the behaviours of healthy lifestyle
and applying training programs for cancer prevention.
Journal of Inonu University Medical Faculty. 2006;13:31Y35.
12. Ozmen D. Developing a Scale to Examine Attitudes Toward
Early Diagnosis of Cervical Cancer by Using Health
Belief Model as a Theoretical Framework. I?zmir, Turkey:
Ege University Health Science Institution. Doctorate
Dissertation; 2004.
13. Akyuz A, Guvenc G, Yavan T, et al. Determining the women to
have pap smear test and factors affecting to obtain pap smear
test. Gulhane Medical Journal. 2006;48:25Y29.
14. Ertem G. Awareness of cervical cancer risk factors and
screening behavior among nurses in a rural region of Turkey.
Asian Pac J Cancer Prev. 2009;10:735Y738.
15. Lee FH, Soldan VA, Carcamo C, et al. Knowledge and attitudes
of adult Peruvian women vis-a`-vis human papillomavirus
(HPV), cervical cancer, and the HPV vaccine.
J Low Genit Tract Dis. 2010;14:113Y117.
16. Ilter E, Celik A, Haliloglu B, et al. 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. Yucel U. Evaluating the Effectiveness of Training Given to
Women Concerning the Risk Factors of and Prevention From
the Cervical Cancer. I?zmir, Turkey: Ege University Health
Science Institution, Master Dissertation; 2006.
22. Zemheri E, Koyuncuer A. The importance of pap test in early
diagnosis of cervical cancers [in Turkish]. J of Continuing
Medical Education. 2005;14:1.
23. Pourat N, Kagawa-Singer M, Bren N, et al. Access versus
acculturation identifying modifiable factors to promote cancer
screening among Asian American Women. Med Care.
2010;48;1088Y1096.
24. Ramirez JE, Ramos DM, Clayton L, et al. Genital human
papillomavirus infections: knowledge, perception of risk,
and actual risk in a nonclinic population of young women.
J Womens Health. 1997;6:113.
25. Head SK, Crosby RA, Moore GR, et al. Pap smear knowledge
among young women following the introduction of the HPV
vaccine. J Pediatr Adolesc Gynecol. 2009;22:251Y256.
26. Mays RM, Zimet GD, Winston Y, et al. Human papillomavirus,
genital warts, pap smears, and cervical cancer: knowledge
and beliefs of adolescent and adult women. Health Care
Women Intl. 2000;21:361.
27. Tarwireyi F, Chirenje ZM, Rusakaniko S. Cancer of the
cervix: knowledge, beliefs and screening behaviours of health
workers in Mudzi District in Mashonaland East Province,
Zimbabwe. Cent Afr J Med. 2003;49:83Y86.
28. Hoai do H, Taylor VM, Burke N, et al. Knowledge about
cervical cancer risk factors, traditional health beliefs, and
pap testing among Vietnamese American women.
J Immigrant Health. 2007;9:109Y114.
29. Demircier M, Kaya O, Bayrakci A, et al. Measurement
of knowledge and behaviors of health personnel about
breast cancer and cervical cancer. Aksaray Governmental
Hospital, Cancer Early Diagnosis and Screening Center.
Available at: http://www.aksaraydevlethastanesi.gov.tr.
Accessed April 10, 2012.
30. Phongsavan K, Phengsavanh A, Wahlstro¨m R, et al. Women’s
perception of cervical cancer and its prevention in Rural
Laos. Int J Gynecol Cancer. 2010;20:821Y826.