Barriers Non Perform an Pap Smear Test in Women View PDF

Cervical cancer is one of the main health problems in the developing countries and at the same time a preventable disease in women. According to latest findings, 85% of all cervical cancers (annually 493,000 cervical cancer in the world) and also 85% of fatalities of this cancer (273,500 in the world) happen in developing countries [1]. American cancer society predicted that in 2113, about 12341 new cervical cancers will be detected and causes 4131 of deaths [2]. Despite international reports in different types of screening, detecting and curing cervical cancer, because of lacking cancer registry network in Iran, there is no clear statistics about cervical cancer occurrences and fatalities in Iran. According cancer registry report of cancer institute, prevalence of cervical cancer is about 4-7 in every 100,000 [3]. Benefiting current medical knowledge, the best protection possible against cancer is prepared for people by early detection and on-time treatment of cancer, and cancer screening is the main tool for early cancer detection [4]. Pap smear is the most efficient and cost effective method for screening and decreasing the deaths from cervical cancer [5]. Regular implementation of Pap smear test for young and mature women is an essential health behavior [6]. Such that irregular Pap smear increases the risk of cervical cancer by two to six times and the most aggressive cervical cancers are reported from the women who had irregular Pap smear [7]. Its implementation as a public health policy is recommended to all sexually active women; also the price for Pap smear test is trivial than the costs and expenses of cervical cancer which puts a heavy economic burden on a family [8]. With regard to the high prevalence of cervical cancer in women and high diagnostic power of Pap smear test and its ease of implementation, it is expected to refer to the centers; while the rate of referring in the developing countries is not suitable. Some case are introduced as effective factors in lacking effective cover such as information shortage and social and cultural impedes in women and in some cases, while there is awareness, shame and unreliability to health staff for the test.[9] With regard to subject importance and because there is no study about motivational barriers of Pap smear implementation in Iran, this study was performed by the aim of investigating the barriers for performing Pap smear screening test on the women in Jiroft. Thereby, background information for educational interventions of screening program and training women can be provided to be a solution for screening against cancer among women.

This descriptive study was performed on married women referring to health centers of Jiroft. The criteria for entering this study: tendency to participation in study, being married and lack of performing Pap smear test were the output metrics for cancelling participation in the study. According pilot study, the abundance of implementing Pap smear was obtained equal to 10% which considering 95% certainty and accuracy of 4%, sample size was calculated as 225 people; finally 230 were investigated. The samples were selected from urban clinics in Jiroft and were interviewed with sequential method. Before interview, the research goals were descripted and in the case of participation in research, the questionnaire was completed without needing to name and surname. The means for data gathering was researcher-made questionnaire that was regulated in order to reach research goals and included two parts: the first part investigates demographic features and the second part investigates the reasons for non-participation of women in the program of Pap smear test implementation.

These reasons are obtained by investigating papers and researches. The scientific validity of the questionnaire was specified by content validity method.

In order to determine scientific reliability of questionnaire, retest was used which reliability coefficient was obtained ‎86%‎. The data were analyzed by SPSS software version 18. From the central indices to describe quantitative variables, frequency distribution table was used for nominal and ordinal variables.

In this study, 230 married women who referred to health centers of Jiroft were investigated. These women were with average deviation of 31 ± 9.15, 78% of them were jobless, and 12.2% and 54.3% of them had experienced 3 and 2 childbirths respectively.

Table 1: Frequency distribution of the women who referred to health centers of Jiroft town in terms of demographic characteristics.

Table 2: The reasons for non-participation of women in performing Pap smear screening test.

The frequency distribution of the women referred to the health centers of Jiroft is shown in Table 1 in terms of demographic characteristics.

Among the reasons for non-participation in screening program of cervical cancer, from the highest importance are: lack of knowledge about Pap smear (85.3%) and lack of trained health staff for Pap smear implementation (77.8%) and the lowest 17.4% was related to husband’s opposition.

The reasons for non-participation of women in implementing Pap smear screening test is shown in Table 2.

In our study, the most important reason of non-participation in Pap smear implementation was lack of knowledge about the importance of Pap smear (85.3%), while in Larti et al. [10], the main reason for non-implementation of Pap smear was that it wasn’t proposed by doctor or nurse. In a study by Iakhforoshan et al. [11], the most important reason for non-participation in Pap smear implementation was being ashamed of Pap smear.

Hislop et al. [12] reported that some women can’t completely understand that’s what the aim of Pap smear in the screening method of cervical cancer. Only 30% of their case study people knew about the aim of Pap smear test for screening of cervical cancer. This result showed that more education about cervical cancer is effective on its prevention. In Chichang et al. [13] in Kenya, the patients who know about Pap smear often had a Pap smear test in the past. In a study by Lee about the awareness of Korean women in USA which was performed by group interviews, it was reported that the women in the case study had wrong understanding of cervical cancer and this issue caused them to be unaware of cancer prevention methods. [14] All these studies directly or indirectly confirm the necessity of increasing knowledge among women to remove the main reason of non-implementation screenings one of the best strategies that should be recommended by family physicians and nurses ,that as the mission of health education guidelines are to warn against health threats, the requisite for effective training in controlling and preventing of breast cancer is attention to the structure of attitudes of women and proposed approach to encourage health monitoring [15].

According the results from the researches, the reason for not referring is lack of educational stimuli i.e. recommendation of medical staff is the most important factor for non-participation of people for screening; and women mentioned one strong priority for having cervical cancer screening that this case must be implemented by women’s health professionals [16]. According to this, the suggestion of health team including doctor and other staff is the highest stimulus for people referral, as similar researches also confirm this problem [17]. In the study of Lee, doctor’s suggestion and education are robust factors for doing Pap smear test by women. In this study, despite the existence of multiple barriers in the view of women for Pap smear implementation, some women know doctor’s suggestion as a motivational factor for screening test implementation [14]. The participants in this research were also afraid of test method. This issue shows that possibly the more women knowledge is increased, the more these barriers are trivialized in their mind. The feelings of shame, pain and fear during screenings including Pap smear were common in our and others study populations [18]. Mental factors like fear or shame and being embarrassed during inspection are from the important obstacles in screening test implementation [19,15]. Fear, pain and being embarrassed of Pap smear implementation are among other obstacles for women referral for doing diagnostic tests. Therefore, Pap smear as a screening method can be considered as “social event” and women in different groups can share their experiences to others to decrease the barriers like fear, pain and embarrassment and to get them know they are not the only one who must experience this test.

The review study of Sancho Garnir et al. [20] showed that in the countries of north and east Africa, the main obstacle to organize cervical cancer screening was lacking policy and finance.

Also inhibiting factors for women participation in Pap smear implementation is lack of knowledge about cervical cancer, social, cultural and religious barriers, geographical and economic problems of access to Pap smear services.

Among our study population, the older women had more shame than young women. The presenters of health cares must be aware of this difference, especially because higher age causes decrease in cervical cancer screening and occurrence of more cervical cancer [21]. Also, lacking any problem in women was an effective factor for non-referral which indicates the necessity of using education and performing screening methods; people’s believe that they are not susceptible for any serious health problem and lacking the believe to prevention. The data from this study has a great fitness to HBM model structures.

In addition, by looking Cause to Action model we see that action guides such as media, educational materials and the suggestion of trustworthy health staff can be the stimulus for implementing health behavior [22]. In this study, most women of the study don’t know Pap smear as a true health behavior because of incorrect understanding and lack of knowledge. Lack of knowledge and stimulus and insufficient understanding of women causes their neglect than screening and indeed the performed findings and studies in this context indicates that catching cancer causes difficult consequences on family members, family struggle and social and health care system. It is recommended that health education experts can help to remove mental barriers of people preventing actions [23,24]. In the groups with different culture conditions, they can provide appropriate special information with cultural groups. Educational programs must be fitted to the abilities of this group and be prepared as movie and slides and be educated according regular programs.

With regard to the importance of attention to prevention programs and early detection of diseases and also high rate of occurrence and prevalence of cervical cancer in human societies including Iran, educating and receiving information about uterine cancer and its treatment are important. Therefore presenting information about these cases is one of the most important elements for healthcare.

1. Ferlay J, Bray F, Pisani P, Parkin DM. Globocan (2002) Cancer Incidence, Mortality and Prevalence Worldwide. IARC Cancer Base No. 5, version 2.0, Lyon: IARC Press.
2. TheAmerican Cancer Society. What are the key statistics about cervical cancer?
3. Park Ji-VI, un parc (2000) Un cours de médecine préventive et sociale, ShhayTéhéran, Publications Smat Deuxième.
4. Leyva M, Byrd T,Tarwater P(2006) Attitudes Towards Cervical Cancer Screening: A Study of Beliefs. AmongWomen InMexico.California J Health Promot 4: 13-24.
5. Burak LJ, Meyer M (1997) Using the health belief model to examine and predict college women’s cervical cancer screening beliefs and behavior. Health Care Women Int 18: 251-262.
6. El-Hammasi K, Samir O, Kettaneh S, Al-Fadli A, Thalib L (2009) Use of and attitudes and knowledge about papsmears among women in Kuwait. J Womens Health (Larchmt) 18: 1825-1832.
7. Jalalvandi M, Khodadostan M (2005) Knowledge and practice of married women about Pap smear. Iran J Nurs 18: 139-144.
8. Sankaranarayanan R, Budukh AM, Rajkumar R (2001) Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ 79: 954-962.
9. Chirenje ZM, Rusakaniko S, Kirumbi L, Ngwalle EW, Makuta-Tlebere P, et al. (2001) Situation analysis for cervical cancer diagnosis and treatment in east, centraland southern African countries. Bull World Health Organ 79: 127-32.
10. Lartey M, Joubert G, Cronje H (2003) Knowledge, attitudes and practices of rural women in South Africa regarding the Pap smear. Int J Gynaecol Obstet 83: 315-316.
11. Yakhforushha A, Solhi M, EbadifardAzar F (2008) [Effects of education via health belief model on knowledge and attitude of voluntary health workers regarding Pap smear in urban centers of Qazvin] [Article in Persian]. Nurs Midwifery Shahid Beheshti Univ Med Sci 18: 25-30.
12. Hislop TG, Teh C, Lai A, Ralston JD, Shu J, et al. (2004) Pap screening and knowledge of risk factors for cervical cancer in Chinese women in British Columbia, Canada. Ethn Health 9: 267-281.
13. Chang CC, Tseng CJ, Liu WW, Jain S, Horng SG, et al. (2002) Clinical evaluation of a new model of self-obtained method for the assessment of genital human papilloma virus infection in an underserved population. Chang Gung Med J 25: 664-671.
14. Lee MC (2000) Knowledge, barriers, and motivators related to cervical cancer screening American women. A focus group approach. Cancer Nurs 23: 168- 175.
15. Pilehvarzadeh M, Rezie HH, Aflatoonian MR, Rafeti F, Mashayekhi F (2015) Knowledge and Attitude of Women about Breast Self-Examination. Biosciences Biotechnology Research Asia. 12: 209-215.
16. Ogilvie GS, Remple VP, Marra F, McNeil SA, Naus M, et al. (2007) Parental intention to have daughters receives the human papillomavirus vaccine. CMAJ 177: 1506-1512.
17. Lee MC (2000) Knowledge, Barriers and Motivators Related to Cervical Cancer Screening Among Korean-American Women. Cancer Nurs 23: 168- 175.
18. National Advisory Committee on Immunization (NACI) (2007) Statement on human papillomavirus vaccine. An advisory committee statement (ACS). Can Commun Dis Rep 33: 1-31.
19. Peters RK, Bear MB, Thomas D (1989) Barriers to screening for cancer of the cervix. Prev Med 18: 133-146.
20. Garnier SH, Khazraji YC, Cherif MH, Mahnane A, Hsairi M, et al. (2013) Overview of cervical cancer screening practices in the extended Middle East and North Africa countries. Vaccine 6: G51-7.
21. Maxwell CJ, Bancej CM, Snider J, Vik SA (2001) Factors important in promoting cervical cancer screening among Canadian women: findings from the l996–97 National Population Health Survey (NPHS). Can J Public Health 92: 127-133.
22. Rosenstock IM, Strecher VJ, Becker MH (1988) Social learning theory and the Health Belief Model. Health Educ Q 15: 175-183.
23. Foozieh R, Motahare P, Solimani M, Salari S, Pormehr A (2012) Relationship Between BMI and Mental Health in Nursing Students of Jiroft. Iranian Int J Endocrinol Metab 14: 135-141.
24. Pilevarzadeh M (2016) Women’s Perspective of Breast Self-examination. Int J Biomed Sci 12: 115-119.