The Pap-Smear Test Experience of Women in Turkey : A Qualitative Study

OBJECTIVE
The study was planned with the purpose of examining the attitude of women who have pap-smear test for the early diagnosis of cervical cancer, factors affecting their decisions and their feelings and experiences during this period.


MATERIALS AND METHODS
A phenomenological method was used. Data were collected between March 2012 and April 2012 using standard and purposive samplings from 17 women. A detailed interview with women were held in their houses and recorded. The data collection tool consisted of two parts, one of which is information form with 17 questions identifying sociodemographic and cervical cancer risk factors of women and the second part is made up of semi-structured interview form with 15 alternative questions taking literature and the pap-smear test into consideration. Collected data were put into a written document. Content analysis was held by loading the documents into NVIVO 8 Statistical Programme.


RESULTS
The study comprised themes such as cervical risk factor, decision of taking pap-smear test, taking pap-smear test, knowledge about pap-smear test, relieving factors during pap-smear test, obstructive factors during pap-smear test, gynecological examination and feelings of women during and after pap-smear test while waiting for the results.


CONCLUSIONS
As women perceive gynaecological examinations differently from other examinations, they have different feelings in each process of the Pap smear test. Medical staff should advise women more clearly on the nature and advantages of the Pap-smear test.


Introduction
Cancer, the second most common reason of death among all other reasons in the world, has been thought to be in the first place until 2030 (Aslan, 2009).Cancer of the cervix is the second most common cancer type amongst women worldwide, as about 500,000 new cases and 250,000 deaths each year indicate (WHO, 2010).Due to its high morbidity and mortality, cancer is a crucial public health problem.A healthy sex life and early diagnose are of great importance to be protected from cervical cancer (Aslan, 2009;Kaya, 2009).Cervical cancer can be detected early by pap-smear test and prognosis can be dramatically recovered.The mean diagnosis age of patients with cervical cancer is 51.There are two peaks in cervical cancer.The first one is about 35-59 and the second one is about 60-64 (Kaya, 2009).A woman who has never taken pap-smear test in her life is exposed to the risk of cervical cancer 1/100 (Özgül, 2007).While 85 % of women in developed countries such as the United States of America (USA) have taken pap-smear test at least once in their life, this rate is about 5 % in underdeveloped countries.With the increasing rate of taking pap-smear test, the incidents of cervical cancer in developed countries have decreased (Kuo and Goldberg, 2003).
The routine cervical cancer screening in the USA is

RESEARCH ARTICLE
The Pap-Smear Test Experience of Women in Turkey: A Qualitative Study Zeynep Arabacı1 *, Suheyla Ozsoy2 recommended to start three years after the first sexual intercourse of women or right before they are 21 years old, and depending on screening data, it is suggested to go on until 65 years old (Ackerson, 2010).According to national standards in Turkey, targeted women aged between 35 and 40 are supposed to have cervical cancer screening at least once.It has been aimed that pap-smear test would be repeated in five-year intervals and screening would be finalized for 65 year old women whose last two tests are negative (Ministry of Health, 2009).Women's taking pap-smear tests depends on their ideas on gynecological examination, sociodemographic characteristics, knowledge about pap-smear test and their cervical cancer risk perception (Akyüz et al., 2006 ;Ak et al., 2010).It has also been found in the study of Smith et al. (2003) that women's economic conditions, health insurance, low personality characteristics and feelings such as being shy have all important effects on taking pap-smear test (Smith et al., 2003).Studies on women with Latin origins have brought out that cultural and economic reason play important roles on women not to take papsmear test (McMullin et al., 2005).Studies on American women with African origins have shown that physical or sexual traumas that they were exposed to before affect the way they take regular pap-smear test (Ackerson, 2010).In the study of Pinar et al. (2008), 73.6 % of nurses have been found not to have regular gynecological examination and 70 % of them have been found not to take pap-smear test before (Pınar et al., 2008).Wong et al. mentioned that women have been found to have insufficient knowledge and conscious about cervical cancer (Wong et al., 2009).In her study, Duran detected women as having insufficient awareness about the prevention and early diagnosis of cervical cancer and having almost no fear of it.Women's knowledge on the prevention or early diagnosis of cervical cancer has been inadequate (Duran, 2011).In the study of Uysal and Birsel on determining the knowledge of women about cervical cancer and their attitudes towards pap-smear test, one third of women have been mentioned to take pap-smear test at least once and their knowledge about cervical risk factor have been found to be in relation with taking pap-smear test (Uysal and Birsel, 2009).Erbil et al. found that women have feelings such as shyness, discomfort and fear during gynecological examination.While having gynecological examination, women expect medical staff to be cheerful, considerate and concerned (Erbil et al., 2008).
The purpose of this study is to examine the attitude of women who have pap-smear test for the early diagnosis of cervical cancer, factors affecting their decisions and their feelings and experiences during this period.

Sample
In the study phenomenological method has been used.The study sample constituted of 17 women who are registered to Number 17 Family Health Center in Bornova, İzmir.Among purposeful samplings, standart sampling has been used and women over 35 years old, who are either married or sexually active and have experienced at least one pap smear test have been included in the study.Interviews that proceeded until the sufficient data were provided included 17 women.

Instruments
Data collection tool consists of two parts one of which is Information Form with 17 questions identifying sociodemographic and cervical cancer risk factors of women and the second part is made up of semi-structured Interview Form with 15 alternative questions taking literature (Ak et al., 2010;Ball and Madden, 2004;Çelik et al., 2009;Farland, 2003;Üner, 1996;Wong et al., 2009) and the pap-smear test into consideration.Before collecting data, a pilot interview was held with three women and some changes were made in the form related to the outcomes of these interviews.

Data collection and analysis
Using an interview form, a detailed interview with women were held in their houses.Interviews were recorded in audio recording device.Interviews were held between March 2012 and April 2012.Data which were collected in 30 days with four-hour work each day, were put into a written document.Content analysis was held by loading the documents into NVIVO 8 Statistical Programme.

Measures Taken for Validity and Reliability
Purposive sampling method was used to increase the reliability and validity of the study.Interviews were also supported by observations.In this study, evaluation was done by seven specialist persons with researcher.To get confirmation of the participants, it was asked to persons whether to add or remove any topics and answers were reviewed again.Detailed description was made and often direct quotations were given.

Ethical considerations
The study was held with women who accepted to be part of it.An oral authorization was taken from these women who were willing for audio recording.Approval of ethics committee was taken in order to conduct the study.A written authorization was taken from the institution where the study was held.

Results
The age of women in the study varies from 36 to 49, all of them are legally married, 13 of them are graduated from primary school, 14 of them are housewives and all of them have social security.The study consists of themes such as; cervical risk factor, decision of taking pap-smear test, taking pap-smear test, knowledge about pap-smear test, relieving factors during pap-smear test, obstructive factors during pap-smear test, gynecological examination and feelings of women during and after pap-smear test while waiting for the results.The numbers at the ends of the statements are the participation numbers given to the women.
Cervical risk factor; marriage age of women in the study varies between 16 and 37, number of pregnancy between 1 and 5 and pregnancy age between 20 and 40.There are three women whose mothers or sisters have been diagnosed as having cervical cancer.No wart or infection has been detected in the genital region of 7 women and 10 of them have been detected to have mycosis and genital wart.12 of women do not smoke, 5 of them have been smoking for more than 5 years, 10 of them do not eat enough fruit and vegetables and 7 of them regularly eat fruit and vegetables.In interviews, women described the cervical cancer risk factors as having more than one partner, lack of genital hygiene, long-term use of intra uterine devive (IUD), genetic predisposition, smoking, consuming hormone-injected food, prevalence of cancer and increasing age.
Decision of taking pap-smear test; women who took part in the interview mentioned reasons of their decision of taking pap smear test.7 of them stated that they take pap smear test "without hesitation", 1 one of them " by getting emotionally ready", 3 of them mentioned to " postpone it", 1 of them "takes the advice of her doctor", 2 of them mentioned to be affected by " people who are cancer", 1 of them by " her friends who have taken the test before" and 2 of them by her "ongoing age"."When they told me to have the test, I had it without thinking about cancer" (11)."Getting emotionally ready in 2-3 days, we decided to take it"(6)."During my examination, my doctor suggested pap-smear test, so I did"(13)."I saw DOI:http://dx.doi.org/10.7314/APJCP.2012.13.11.5687Examination with The Pap-Smear Test Experience of Women: A Qualitative Study many women and neighbors around who had hysterectomy and I was affected by them"(10)."I was willing to go as it is significant for my health.My friends took it, too.So did 1"(16)."I was already 30 years old so I started taking it" (10).Information sources that affect women's decision of taking pap-smear test have been mentioned as medical staff, media and pamphlets.13 of the women in the interview mentioned the information source that affected their decisons as "medical staff"."Nurses; the nurse in the health center told me to take smear test"(4).
Taking pap-smear test; 15 of the women mentioned the reason of their decision of taking pap-smear test as "early diagnose"."I regularly take it to prevent cervical cancer.I know that it has some basic indications (10).3 of the women in the interview mentioned their reason of not taking pap-smear test regularly as "neglecting to go to the doctor" and 7 of them as "having no gynecological problems"."In fact, it is not fear but negiligence.I have taken it once and I felt no pain (5). 3 of the women in the interview mentioned their reason of taking pap-smear test regularly as "religious beliefs"."Everything may happen, God knows.We do not invite illnesses, I mean they happen" (15).13 of the women stated they have taken pap-smear test "once" and 4 of them "more than once".Only 2 of the women who take pap-smear test more than once have it regularly.
Their Knowledge about pap-smear test; women described pap-smear test as carrying out a biopsy , taking liquid swab, having spiral and a usual examination.9 of the women in the interview emphasized the importance of taking pap-smear test "once a year"."It is like a swab and they take it with a long stick" (10)."I think, pap-smear test should be taken once a year.You are healthy today but next year it is possible to have cancer again" (17).
Relieving factors during pap-smear test; Women in the interview emphasized the important relieving factors as follow; 7 of them mentioned the importance of " positive attitudes of medical staff", 2 of them "sufficient information about pap-smear test", 2 of them "selfconfidence of medical staff", 2 of them "being careful about privacy", 2 of them "gender of the doctor", 3 of them "hygienic equipment" and 1 of them "fast treatment"." The nurse was interested and it made me relax.She gave me moral support.I felt so relaxed "(2)." We prefer female doctors more than males.It is not a problem in other examinations but it is of great importance in gynecological examination"(12).
Obstructive factors during pap-smear test; Women in the interview emphasized the important obstructive factors as follow; 3 of them mentioned "shyness", 2 of them "curiosity", 3 of them "gynecological examination", 3 of them "gender of medical staff", 1 of them "her husband's not obeying the sexual abstinence" and 3 of them "the cost of the test"."The examination is very boring so I did not want to go.I have never had my controls since my daughter was born" (14)."Curiosity; it is because I have no idea about it.I do not know how it happens"(7)."You feel relaxed if your doctor is female.Otherwise, you do not want to show the most private part of your body"(10).
Gynecological examination and feelings of women during pap-smear test; 7 of the women in the interview mentioned the feeling of "fear", 6 of them "embarrasment and shyness", 7 of them "boredom"."Lying there for the test makes you feel fear" (7)."You are bored and ashamed.You share your privacy with another person"( 14).
Gynecological examination and feelings of women after pap-smear test while waiting for the results; 5 of the women mentioned the feeling of "fear", 5 of them "worry", 3 of them "anxiety", 1 of them "prejudice" and 1 of them "feeling nothing because of knowing nothing"."You do not know the result.You hear about other cases about cervical cancer and women have to have operations.That's why I was afraid".( 7)

Discussion
Women have not mentioned some of the common cancer risk factors such as the high number of pregnancy, low age level of sexual intercourse, over-aged pregnancy risk and oral contraceptive use.In their qualitative study, Wong et al., (2009) aimed to determine the knowledge and awareness of women who have never taken pap-smear test in Malaysia and in the study women mentioned that having more than one sexual partner and lack of genital hygiene could be crucial risk factors (Wong et al., 2009).Although women were able to define more than one partner and lack of genital hygiene as crucial risk factors, they had no idea about how to protect themselves.
It has been found that women have decided to take pap-smear test without thinking about it.Their main information source to take pap-smear test seems to be mostly medical staff.It has been seen that when the staff advise them to take pap-smear test, they do not hesitate about it, which means they give importance to the information that they get from medical staff.In the study of McMullin et al., (2005), getting information about pap-smear test from medical staff is mentioned to be significant in terms of taking pap-smear test more regularly (McMullin et al., 2005).The importance of getting information from medical staff has also been pointed out in the study of Wong et al., (2009) (Wong et al., 2009).
It is clear that pap-smear test is taken for the early diagnosis of cancer.As women neglect to go to the doctor, they explained the reason of not taking pap-smear test as having no gynecological problems.With a fatalistic approach, 3 of the women in the study have stated that they are not afraid of any illnesses.They do not take papsmear test because of having no gynecological problems and this may show that self-care responsibilities of women have not sufficiently improved.On the other hand, taking the test when they have problems may indicate that they perceive pap-smear test as only a diagnosis test.In their study, Akyüz et al., (2006) brought out that while 51 % of the women in the study have taken pap-smear test before, 49 % of them have never taken it before (Akyüz et al., 2006).In their qualitative study on pap-smear test of immigrant women with Latin origins, McMullin et al., (2005) found that 18 of 20 women in the study have taken pap-smear test at least once (McMullin et al., 2005).In our study, even women with cervical cancer risk have been found not to take pap-smear test and only 2 of them have been found that they do not take pap-smear test regularly.
When women were asked to define pap-smear test, most of them defined it as something like a swab and some of them as carrying out a biopsy, a usual examination or having spiral.Like our study, Wong et al., (2009) has also had similar themes in their study such as "something like a swab" (Wong et al., 2009).In the study of Smith et al., (2003) it has been found that although women do not have regular pap-smear test, they believe the importance of regular screening (Smith et al., 2003).In the study of Wong et al., (2009), some of the women stated that they take pap-smear test once a year or two years while some others have mentioned to take it once every six months (Wong et al., 2009).In our study, women have emphasized the importance of taking pap-smear test once a year.
Positive attitudes of medical staff have been determined to be very important during the pap-smear test.Since women perceive gynecological examination as different from other examinations, they give great importance to positive attitudes of medical staff.Women defined other relieving factors as having sufficient information about pap-smear test, self-confidence of medical staff, being careful about privacy, gender of the doctor, hygienic equipment and fast treatment.In their study, Erbil et al., (2008) mentioned that; women's expectations from medical staff during pap-smear tests are 45 % a cheerful face, 28% interest, 24% consideration, 11 % knowledge and 10% information about their situation.Women in our study also expect medical staff to be cheerful, considerate and concerned (Erbil et al., 2008).In the study of Ackerson (2010), women have mentioned the relieving factors as being informed about what and how things will happen during pap-smear test (Ackerson, 2010).
Women illustrated obstructive factors as shyness, curiosity, gynecological examination, gender of medical staff, not obeying the sexual abstinence and cost of the test.In the study of Ackerson (2010), women's decisions of taking pap-smear test have been found to be affected by lying on the table during the gynecological examination.Women define it as a trauma, that's why they do not take pap-smear test regularly (Ackerson, 2010).In our study, women have also been found to be affected by lying on the table during the gynecological examination which prevents them from having regular controls.
While taking pap-smear test, women defined their feelings as fear, embarrassment, shyness and boredom.Such feelings have bad effects on their decision of taking pap-smear test regularly.It has been seen that, gynecological examination is not similar to other examinations, so it leads to different feelings.Gynecological examination mostly makes women feel embarrassment and shyness.In their study Erbil et al. (2008) mentioned that; 62 % of women feel shyness, 39 % of them feel boredom, 38 % of them feel fear and 21 % of them feel pain during gynecological examination (Erbil et al., 2008).While waiting for the results, women emphasized to feel fear, worry and anxiety and they emphasized their future concern about the possibility of having cancer.
In conclusion, as women perceive gynaecological examination as different from other examinations, they have different feelings in each process of Pap smear test.
When medical staff consult about Pap smear test in an effective way and have a positive communication with the women during the test, number of women who will have Pap smear test will increase.