Barriers to Pap Smear Test for the Second Time in Women Referring to Health Care Centers in the South of Tehran: A Qualitative Approach.

BACKGROUND: Cervical cancer is a preventable disease with a regular screening program. Many studies have reported a large number of barriers that women had for the first time, but this study decided to find other barriers for the second time pap smear.
METHODS: In this qualitative research, data were gathered through in-depth interviews and expressed through conventional content analysis in the form of constant comparison. The participants were 15 women with family profile at 30 health care centers who lived in the south of Tehran and had done Pap smear for one time but didn't do it for the second time.
RESULTS: Three main themes emerged from the analysis of the interviews: negative experiences of the first Pap test were as follows: results of the first time test, readiness for performing the test, getting the test itself, and the site of the first Pap test. Personal barriers to getting the second Pap test were: inattention to time, physical barriers to the second Pap test, and inhibitory beliefs. Perceived social barriers to getting the second Pap test with two sub-themes included social supports and abstract norms.
CONCLUSION: This study provided other barriers about Pap smear including lack of the spouse's support, the role of health care providers and physicians in screening program for early diagnosis in women.

INTRODUCTION

Early diagnosis and prevention of cancer are critical factors to control the disease and increase the survival.[1] Cervical cancer is one of the most common cancers amongst women worldwide and almost more than half a million women contract this cancer.[2] According to the cancer registry in the Cancer Institute, the prevalence of cervical and uterine cancer is about 6-7 per hundred thousand. It is noteworthy that this cancer mainly occurs between the ages of 30 to 55 years; however, recently various reports of affliction in young women have been accessed.[3] Several factors have been considered in the incidence of cervical cancers, amongst which Human Papilloma virus (HPV) has been identified as the major factor.[4] Cervical cancer is a preventable disease whose precancerous lesions can be diagnosed through regular screening before switching to the cancerous stage.[5] Therefore, the morbidity and mortality rates will be reduced through timely prevention and screening of the disease.[6,7]

Pap smear test is a simple, inexpensive and uncomplicated method that is selected for screening cervical cancer in seemingly healthy women[8] and is also considered as a health behavior or health promoting behavior. Economically speaking, cervical cancer imposes enormous expenses on families and society including diagnosis and treatment costs as well as side costs like absenteeism of the patients and their families which are considerable compared with screening costs.[9]

The American Cancer Society (ACS) and American College of Obstetricians and Gynecologists (ACOG) recommends that all the sexually active women and those who age 18 get annual Pap smear test.[10] In Iran, annual Pap test is recommended for all married women aged 20-65 years. If the Pap test is normal and annual pelvic exams are regularly done, screening intervals increases for three consecutive years under a physician’s direction.[11]

Given that there is not any accurate statistics about the frequency of getting Pap smear or not getting Pap test in Iran, the percentage of not getting regular Pap test varies between 20-70% in different areas according to the results of various studies all over Iran. For instance, in a study on women in Rasht in Iran, results revealed that only 27.1% of women had a regular pap smear at least once in their life.[12]

Another KAP study in Tabriz in Iran indicated that 27.1% had got pap test at least once in their life.[13] The same study about pap smear reported that 63.3% of women in Yassoj province in Iran had never done Pap smear test.[14] About getting pap smear in one study, women reported they had never heard about pap smear test.[15] In a study on the cervical cancer screening in nurses who had knowledge about this test, the results showed eighty percent of nurses never did it and did not recommended it to others.[16] Due to the fact that several factors, including cultural, social and economic factors, have a considerable effect on the process of behavior formation, many experiences and beliefs, in this regard, are not quantifiable; thus, they necessitate the use of a more appropriate method to be evaluated. Since qualitative research is an effective method to provide a rich explication in creating a profound understanding of the phenomena, and since few qualitative researches have been done about not doing Pap test, particularly for the second time, amongst women, and with respect to the nature of qualitative research methods, it is possible that the reasons behind not getting the Pap test differs in terms of time, place and health policies at any time. Therefore, the present study intended to explain the barriers, perceived by women, to getting a Pap smear test.

In general, qualitative research seeks to explore the concepts and their relationships in the natural spheres of the incidence of phenomena. The objectives of qualitative research are different based on the research model and methodology. The theoretical framework of the current study, about explaining the reasons of the lack of recourse to Pap test for the second time, is based on the ‘Conventional’ qualitative content analysis. The qualitative approach was selected in this study because it is a beneficial in obtaining an in-depth understanding of the barriers to Pap smear test for the second time in women having a health dossier in the health care centers in the south of Tehran.

MATERIALS AND METHODS

Qualitative content analysis (a method used to express the tenor of the text data derived from the mind of people) was used for data analysis. Content analysis is done after the actual content output derived from the text data. This can help the researchers extract the latent themes, tenors and patterns from the text data elicited from the participants.[17] In this method, a set of codes and themes are acquired through a systematic classification. To this end, semantic units or initial codes are first extracted; then, the codes are classified based on their similarities. Efforts were made to have the maximum uniformity inside each class and minimum non-uniformity between the categories. Therefore, no datum was placed in two categories. Based on the results, main themes and sub-themes were obtained.[18]

Participants, Research Environment and Data Collection Method

The participants were the women, with a family health profile at 30 health care centers in south of Tehran, who had referred once for their first Pap test but had not got the Pap test for the second time during the research period. This study had two parts: quantitative and qualitative. These women took part in the study project for nearly two years (from July 2012 to June 2014) based on protection motivation theory. With this model, we assessed the perceived vulnerability, perceived severity, fear, response cost, self-efficacy, and response efficacy about doing the pap test; the results were perceived vulnerability (3.5=0.94%), perceived severity(3.93=0.94%), fear (2.29=1.38%), response cost (2.96=1.48%), self-efficacy (4.60=0.46%), and response efficacy (4.45=0.49%). According of the study design, if women didn’t do Pap smear for the second time, we interviewed with them in the health center which had their family profile to find its reason. This phase of the study was designed using interview. We thought this phase of the study completed other barriers that were not found using this intervention, and interview was the best way to find them. The research inclusion criteria for the participants included being willing to participate in the study, being married, not having cervical cancer, and not undergoing a total hysterectomy. In addition, if any participant had lost any of the inclusion criteria, for any reason, during the study and follow-up period, she was excluded from the study. The subjects were selected with a wide range of diversity (age, education, occupation, year of marriage, number of pregnancies, number of births (deliveries/labors), number of living children during the research time, incidence of cancer in the family and close relatives). At the end of the first phase of this study, women who had not done Pop test were 19, and 4 of them did not take part in the interview; our data were saturated with 13 and we interviewed with 15 women.

The data were collected based on in-depth semi-structured and unstructured individual interviews. This type of interview is one of the most common methods of collecting data in qualitative research.[19] The purpose of the research, the reasons of recording the interview and voluntary participation in the interview all were accurately explicated to inform the interviewees before any interview. To record each interview, the researchers got permission from the interviewees. The interview started with these questions: “What was your experience about pap smear?”, “Why didn’t you do Pap smear for the second time?”, The rest of questions were formed based on the participants’ answers to these questions. The duration of each interview was not fixed and was determined depending on the situation, participants’ tendency, and trend of the interview. However, each interview usually took 45 minutes to 1 hour in average. To start the interview and have an understanding from the perspective of the participants, each of them were asked to explain their experience of the Pap smear test for the first time. Next, the subsequent questions were set based on the participants’ prior responses. Sometimes, they were asked to elaborate more on their experiences. All the interviews were typed immediately after the recording and read out. The typed texts were adapted to the interviewer’s recorder to verify their validity. One of the researchers listened to each recorded interview carefully and transcribed and typed them all verbatim. Then, the content of each set of transcripts was read and their purport was reviewed over and over. The transcripts of the interviews were typed in MS Word for qualitative analysis. In this method, through a systematic categorization, a number of codes and themes were identified. In this method, firstly, meaning units or primary codes are extracted and then these codes are categorized based on similarities. There was an attempt to maximize intra-category homogeneity and minimize inter-category heterogeneity, so that no datum would go in two categories. Accordingly, the themes and sub-themes were obtained (Graneheim & Lundman, 2004). In order to ensure the validity and reliability of qualitative data, the recommended criteria were selected according to Guba and Lincoln including credibility, reliability (dependability), confirmability and transferability.[20]

The credibility of data analysis was improved by reviewing the data codes, discussing the sub-themes and explicating the decoding process;18 then, the subjects were analyzed with maximum variation.[19] Reliability was reinforced by accurate transcription, and comparison of the audio tapes with correct transcripts and verbal cues. Confirmability was enhanced once the sub-themes were extracted from the data and transcribed on the paper. Finally, to allow transferability of the characteristics of the participants, we used data collection instruments and data analysis methods in this study similar to the examples derived from the speech of the participants.[19]

Ethical Considerations

The protocol of this study was approved by Iran University of Medical Sciences.

RESULTS

The data derived from the in-depth interviews were saturated with 15 housewives. The mean age of the participants was 37.2±6.73. The mean of education years was 8.93±3 and that of the years of marriage was 17.46±7.05 years; the other variables are displayed in Table 1.

Table 1

Socio-demographic characteristics of the participants (N=15)

Participants	number	Age	Age at marriage	Time period of marriage	Number of pregnancy	Number of delivery	Number of alive children	Number of years educated
1	38	15	23	4	3	3	8	rental
2	49	32	18	4	3	3	12	rental
3	42	25	18	0	0	0	8	Real estate
4	41	19	22	3	3	3	8	Real estate
5	43	14	29	5	5	5	5	Public holding
6	28	20	8	2	2	2	12	rental
7	31	25	6	1	1	1	16	rental
8	45	21	24	4	3	3	8	Real estate
9	32	17	15	2	2	2	5	rental
10	35	20	15	3	2	2	8	Real estate
11	26	19	7	1	1	1	12	rental
12	40	15	25	2	2	2	10	rental
13	36	16	20	4	2	2	5	rental
14	33	19	14	2	2	2	12	rental
15	41	21	20	3	1	1	5	Real estate

Three main themes were obtained for the lack of doing Pap smear test as follows:

1.Negative experiences of the first Pap test; 2. Personal barriers to getting the second Pap test; and 3. Perceived social barriers to getting the second Pap test. More details about the themes and sub-themes are presented in Table 2.

Table 2

The main themes and sub-themes

Main themes	Sub-themes
Negative experiences of the first Pap test	Results of the first Pap test
	Readiness conditions for getting the first test
	Process of getting the first Pap test
	Site of the first Pap test
Personal barriers to getting the second Pap test	Inattention to time
	Physical barriers
	Inhibitory beliefs
Perceived social barriers to getting the second Pap test	Lack of social supports
	Abstract norms:

More details about the themes are disclosed below.

Negative Experiences of the First Pap test

The interviewees referred to total negative experiences of women in each stage of the process of the first Pap smear test.

This concept was explained with four sub-themes.

Results of the First Pap test

One of the participants said:

“They told me that the results of my first Pap test is suspicious and I should take medication and visit a doctor, so I was afraid of getting the second test.”(participant 3)

“In my first test, they told me that I’ve got infection or something; the doctor told me the same, so I was afraid to get the second test.”(participant 1)

Readiness Conditions for Getting the First Test

Three of the subjects stated: “Well, there are some reasons that I couldn’t get the second test. For example, one reason was not having sex two days before the test as you recommended.” (participant 1)

“Well, it happens. For example, they told me that we should not have sex; I tried to, but my husband didn’t accept to get the test. That’s why I couldn’t come to get the second test.” (participant 2)

“It takes a long time to get the test after we get ready.” (participant 6)

Process of Getting the First Pap test

One of them said:

“I’m a sort of, let say, shy. I mean I am shy to get the test or such things.” (participant 2)

“You know! I feel something is removed from my body that is why I didn’t get the test.” (participant 5)

Site of the First Pap test

The participants stated:

“I think the personnel, here, were not skillful. It seems they are not experienced enough. They bothered me very much.” (participant 7)

“I personally believe that the private health centers really spend more time for people or patients even though they get more money.” (participant 8)

Personal Barriers to Getting the Second Pap test

Some of the subjects referred to the personal barriers to getting the second Pap test. This theme includes 3 sub-themes which are quoted from participants hereunder.

Inattention to Time

A participant stated:

“I’d like to get the test, but I had no time.” (participant 11)

“I was busy with my sister’s wedding; that’s why, I couldn’t get the test.” (participant 14)

Physical Barriers

The participants expressed their idea as follows:

“I took neuropathic medications by myself. The doctor told me ‘you should take medications to be able to first control yourself and manage your life, so, I didn’t get the test.” (participant 3)

“The cancer test results showed that I had no disease and I’m healthy. Soon, I got pregnant and I couldn’t get the second test.”(participant 15)

Inhibitory Beliefs

The subjects stated:

“I’m very devoted to my life and I like everything goes well. I believe the health of the breadwinner of the family is more important than my health.” (participant 3)

“If I’m destined for a disease, it happens. Thus, why should I do a test?” (participant 5)

Perceived Social Barriers to Getting the Second Pap test

The tenors of this theme referred to the perceived social barriers to getting the second Pap test. This theme includes 2 sub-themes which are quoted from participants hereunder.

Social Supports

The related tenors are:

“My husband had no idea about it. It was not actually important for him. He did not support me to get the test.” (participant 1)

“Yes, it’s very effective. Many do not even know what a Pap smear test is or how many times it should be done. Well, when the TV advertises it, it means it’s certainly something important or influential that is being advertised. Then, women try to get the test.” (participant 12)

Abstract Norms:

The related tenors are:

“My husband did not let me do that. He told me ‘You are healthy; Why to get a test? They will then tell you something and make us sad’.” (participant 3)

“Many others told me ‘come on! You don’t really wanna do that, do you?!’ Many told me that.” (participant 7)

DISCUSSION

The negative experiences of the first Pap test with sub-themes, including results of the first test, readiness conditions for getting the first test, process of getting the first test, and the site of getting the first Pap test made women not undergo the second Pap test. Furthermore, some women declared that the diagnosis of infection, suspicious result of the first test, and fear of affliction with cancer were the reasons for not getting the second Pap smear test. Many researchers found that fear of having a cervical cancer can have a negative effect on women getting a second Pap test.[21-24] Thus, it is necessary to hold interventional programs to increase the perceived susceptibility and reduce the fear in these women. Women’s readiness was another barrier; they might forget the readiness conditions. Providing teaching aids for increase their readiness, explaining that repetition of the test can help women overcome this problem to some extent. In addition, participation of husbands in teaching sessions and Pap smear programs increases the women’s readiness for getting regular Pap test. On the other hand, some women felt shy, embarrassed and ashamed of getting the test. These feelings would have a negative effect on women’s decisions to get a regular Pap smear test. Moreover, unpleasant feelings caused by any examination of the genital system and the waiting time till they could get the test results brought about different feelings in women. The results of the current study were in line with the findings of studies.[25,26] Also, some women claimed that health personnel were not skillful enough in their first Pap test experience and that they were not satisfied with the services given by governmental or public health care centers; this was consistent with another study’s findings.[22] Therefore, it is necessary to hold training courses for the health staff about the process of doing Pap smear test. These factors, altogether, created a negative experience for women and stopped them getting the second Pap test as inhibitory factors.[27] Several studies have reported that accessibility of getting Pap smear test and encouraging the health staff increase the incidence of getting the second Pap test in women.[24,28,29] Additionally, in the present research and another study, women stated that they had not already been recommended that they should get a regular Pap test for three consecutive years by health workers; thus, the question why they had never got the second Pap test was new to them.[25]

Personal barriers to getting the second Pap test was another main reason why women did not get the second Pap smear. Its sub-themes encompassed inattention to time, personal barriers to getting the second test, and inhibitory beliefs. In this regard, some women declared that they were obsessed with other things or events; in other words, lack of time was just a pretext for their absence to get the second test. This was in line with the findings about pap test barriers because they pointed out that lack of time was just an excuse for not getting the test.[30] It is worth noting here the significant role of women as a main pillar of the family because when a woman is sick in her family, the whole family suffers many irreversible changes. Two women declared that they had got pregnant and could not get the second Pap test with respect to their parturition date. Some other believed that the first negative test result would suffice and there is no need to repeat the test even though it was already explained to them that since there is always a risk of getting a false negative test result, it is necessary to get the test for three times; however, they were indifferent to it. Some other women had no belief in preventing the disease; they were indeed indifferent to their health status and gave priority to their husband and children’s health. This was consistent with the findings of a study in Iran; they found that one of the reasons of women’s lack of recourse to second Pap test was the belief that cervical cancer was not preventable.[24,29]

About repeating the Pap test, it was indicated in a study that women did not believe in repeating the Pap smear test while stating that “if it was necessary to get the test, the doctor would have told us”.[31] Some women believed that what is destined to happen, would happen; they believed in the prominent role of fate on occurrence of disease. In fact, these women had external locus of control; they believed that their behaviors did not play any role in the occurrence of the disease and it is the result of fate or fortune or other individuals. According to another study, the belief in the role of fate was an inhibitory factor in women not getting their second Pap smear test.[29] This supposition can be considered and treated in interventional programs on Pap smear test. The personal barriers identified in the present study were consistent with the findings of other studies. [32,33]

The perceived social barriers to getting the second Pap smear test was the third main theme with two sub-themes including social support and abstract norms as the reasons of not getting the second Pap test by women. The former implied that lack of support from husband on the one hand and the lack of media support like TV and Radio to inform and encourage women to get this test, on the other hand, were assumed to be important factors in women’s viewpoint. The latter, i.e. abstract norms, was associated with the disbelief of the spouses and other relatives as inhibitory factors in not getting the second Pap test. This was also found in other related studies.[33-35] For instance, about getting pap smear test it was reported that about 39% of women proceeded in getting or not getting the second Pap smear test as they were recommended by their friends and relatives.[29]

Consequently, since the repetition of getting the Pap smear test by women is influenced by various factors including negative experience of the first test, personal and perceived social barriers, it is necessary to design appropriate interventional programs for these women. In addition, the structure of public health care centers needs to be reformed in order to motivate women to get a regular Pap smear test. Furthermore, attracting the support of husbands in screening programs can increase the provision and coverage of health services. Finally, advertisement and public education through the mass media can bring about positive social norms with respect to getting Pap smear test and repeating it overtime.

We identified several specific barriers and strengths of cervical cancer screening among women. The lack of husbands’ support and the role of health care providers and physicians in screening program for early diagnosis in women were the most barriers to Pap smear. We need to further evaluate our findings from this qualitative study in a larger population based survey. Also, to find these barriers was the strength of this study to prove intervention with models was not enough.

CONCLUSION

The results of the present study indicated that a majority of women expressed all negative experiences of their first Pap test, personal and social barriers for getting the second Pap test as the main barriers to getting Pap smear test. In addition, they considered the advice of the doctors and medical staff very effective on getting this diagnostic method. Therefore, it is recommended that not only doctors but also obstetricians and other health personnel should inform women about the significant role of screening methods on early diagnosis and treatment of cancers in women and the process of giving these screening test to encourage them to get regular and timely screening tests. Furthermore, husbands’ support was identified as one of the influential factors on getting the Pap smear test; thus, in order to promote their support, more training programs should be arranged for men to highlight the effectiveness of their support on their wife’s health. It is recommended in other study more than women men take part and focus on men attitudes by interview.

The results of the present study indicated that a majority of women explained negative experiences of their first Pap test and personal and social barriers for getting the second Pap test as the main barriers to getting Pap smear test