RESEARCH ARTICLES

Primary health care cervical cancer prevention in nursing consultation

ABSTRACT: This research aimed at analyzing the theoretical and conceptual frameworks of the gynecological nursing consultation at the Primary Health Care (PHC) as well as at discussing the main preventive approaches to Uterine Cervical Neoplasm (UCN). Descriptive and qualitative research, conducted at the University Hospital, in the city of Rio de Janeiro in 2011. Seven nurses were interviewed. Data were treated with thematic analysis. Two thematic units were outstanding: theoretical and conceptual frameworks of gynecological nursing consultation at the PHC; and key actions for primary and secondary prevention of UCN. Consultation complies with PHC guidelines for UC cancer and breast cancer control, with particular emphasis on the syndrome approach. Prevention actions include health education and Pap smear exams. Practice must go beyond those actions, favoring comprehensive care to women. Reality requires interventions that generate impact on the incidence of UCN. That’s a challenge in PHC, which requires investments in various funds and research.

Keywords: Uterine cervical neoplasm; primary prevention; secondary prevention; nursing.

INTRODUCTION

Primary health care (PHC) is one of the structural axes of the Unified Health System (SUS) and plays a strategic role in the constitution of healthcare networks, as it characterized by great proximity with the daily lives of people and groups¹.

As regards the characteristics and possibility of the PHC context in terms of oncologic care, to give an example, actions are aimed at primary and secondary prevention of the main cancer types, particularly uterine colon cancer (UCC). These actions, respectively, focus on the control and eradication of the risk factors for the development of cancer and its early diagnosis.

In PHC, the gynecological consultation, whether by physicians or nurses, is a professional activity in which the woman is individually addressed, considering health promotion, prevention, treatment of precursory lesions/cervical intra-epithelial lesions, of other gynecological conditions and screening of UCC in its initial phase.

In view of nursing professionals’ responsibilities as professionals in PHC, as well as the qualifications established in the law that regulates their professional practice - Law 7.498/19862 – this study was aimed at analyzing the theoretical-conceptual structural axes of the gynecological nursing consultation in PHC; as well as to discuss the pain conducts put in practice to prevent UCC.

LITERATURE REVIEW

UCC figures among the most frequent cancer types. For 2013, 17,540 new cases are expected, with an estimated risk of 17 cases for every 100,000 women3. Among all types of cancer, it displays one of the highest potential prevention and cure rates, close to 100%, when diagnosed early. It is easy to diagnose, using simple technology, and treatment is accessible⁴.

The PHC context should be explored to enhance the access, adherence and return of the women being monitored, promoting health education for the primary prevention of UCC, as well as other orientations towards their wellbeing, besides the possibility of diagnosing this disease early through pap smear testing⁵.

Studies reveal the problem related to women’s inappropriate knowledge and attitude with regard to primary and secondary UCC prevention actions, and also the insufficient coverage of this population in terms of pap smear testing, particularly in less developed areas in the country, and the high morbidity and mortality rates^5-9. Therefore, the importance of nurses’ activities in this context is highlighted, with a view to the accomplishment of nursing consultations that include appropriate health education, as a practice based on comprehensive care delivery to human beings¹⁰.

METHOD

Descriptive research with a qualitative approach. The knowledge produced in this type of research, resulting from opinions, beliefs, values, representations, relations and human and social actions from the perspective of intersubjective actors, involves a theorization process, based on the analytic and systematic course the researchers have followed¹¹.

The research was undertaken at the University Hospital São Francisco de Assis (HESFA), located in the city of Rio de Janeiro – Brazil. It is part of the Hospital Complex affiliated with the Universidade Federal do Rio de Janeiro (UFRJ), and its mission is to deliver high-quality care to the population’s demands in the PHC context.

For gynecological nursing consultations, the HESFA has five consultation rooms and six nurses, who attend to a great daily demand, whether spontaneously or resulting from forwarding. Seven nurses participated in the research, who complied with the following inclusion criteria: being employed at the institution and working or having worked with gynecological nursing consultations for more than six months.

The participants’ socio-professional profile was characterized based on the following variables: gender, age, professional experience at the institution and holding a graduate degree or not.

The data collection technique used was the semistructured interview, guided by the script: how do you develop the gynecological nursing consultation? What conducts do you adopt for primary and secondary UCC prevention? What are the main problems in the development of this practice at your institution?

The participants’ anonymity was preserved and the excerpts from their statements were identified using the letter I for interview and a number indicating the order in which they participated in the study (E.g.: I1, I2, I3...).

The data were collected between September and December 2011. To register the interview data, a digital recorder was used, with the subjects’ agreement. Later, the interviews were transcribed and processed through thematic analysis, according to the most frequent topics in the discourse, characterizing the themes, which served as the base for the construction of the thematic units¹².

The data were discussed based on the literature review and conceptual bases on the theme, and also according to the authors’ critical perspective.

The research project received ethical clearance from the Research Ethics Committee at Anna Nery School of Nursing/HESFA, opinion 60/2011.

RESULTS AND DISCUSSION

As regards the seven nurses’ socio-professional profile, all of them were women. The same prevalence rates were found for the age groups between 41 and 50 and between 51 and 60 years, that is, three nurses each, while one nurse was 33 years old.

Concerning the length of professional experience at the institution, the interval between 20 and 25 years stood out, corresponding to five nurses; two others had worked at the institution for eight years. All of them held a graduate degree, one M.Sc. in Nursing and four held more than one specialist degree.

The analysis of the interviews revealed two thematic units, which are presented next:

Structural theoretical-conceptual axes of the gynecological nursing consultation in PHC

In the research context, the gynecological nursing consultation follows the orientation of the Brazilian Ministry of Health (MH)1 published in the Primary Health Care Terms – Control of Uterine and Breast Cancer, in accordance with the qualifications established in the Law that guides professional nursing practice², and in the following Federal Nursing Council Resolutions: Resolution 381/2011, which regulates the collection of pap smear material by the nurse¹³; and Res 271/2002, which regulates the nurse’s actions during consultations, medication prescription and requisition of tests¹⁴.

The most frequent references to the content of the PHC terms in the statements refer to the instruments, technique and standardization of conducts, in the compliance with the pre-established flowcharts for the syndromic approach.

We follow the manuals, where there is legal support for the activities, like prescribed drugs for example. We also request the necessary additional tests [...]. (I3)

I develop the nursing consultation by using the syndromic approach through the manuals of the Ministry of Health, based on the pre-established flow chart. (I1)

The syndromic approach is based on protocols that guide standardized conducts for physicians and nurses, according to the signs and symptoms the woman presents. This approach is part of the PHC objectives, without ignoring comprehensive and humanized care. Its objectivity and rationalism are strategic, with a view to guiding actions that can influence the treatment of the main clinical syndromes in gynecology in the short term^1,4.

The professionals need technical preparation, as evidenced by each nurse’s commitment in the search for knowledge.

It is wonderful that the nurse can do the pap smear, in the sense that you get autonomy to freely practice your activities [...]. Therefore, I always attempt to remain informed, read a lot, study, so as not to get outdated. (I5)

Besides the individual responsibility, this aspect points towards the need to diagnose the nurses’ training demand in the research context. Continuing education is an institutional responsibility, in which compromised, conscious, active and interdisciplinary practice can lead to favorable results15.

What interdisciplinarity is concerned, the nurses present a prelude to this practice in their testimonies. Interdisciplinarity is an important strategy to achieve goals in PHC and should permeate the institutional work philosophy in order to gain room for discussion^10,15.

I attempt to deliver holistic care [...], I consider the patient as a whole and forward her to other professionals, like the social worker [...]. (I3)

Despite the focus on the syndromic approach and on pap smear testing, the nurse aim for holistic consultations, based on interdisciplinary practice.

I think of the consultation for women. My approach does not depend on what stage of life she is going through. I aim for her wellbeing, physical, biological, social, cultural, emotional and economic. (I5)

The orientations in the PHC Terms in question go beyond the syndromic approach. The range of the actions the nurses need to perform are in accordance with the profession’s humanitarian and social proposal, indicating the need for professional education that includes the development of organizational, cognitive, technical and relational skills and competences¹⁰.

Despite the intentionality of holistic woman’s healthcare actions, consultations based on the syndromic approach can contribute to the fragmentation of care.

[...] our practice is similar to medical practice. That is bad, because the nurses often only focus on the accomplishment of the procedure, the pap smear collection, and forgets about the woman. And the woman is the center, the goal of care, it is the person and not the pap smear collection itself. (I5)

The valuation of the syndromic approach as the only branch has often contributed to care fragmentation, in accordance with the biomedical model.

The nurses acknowledge the negative nature when assuming this model as a reference, in view of its contradiction with the holistic client care discourse, as well as with the theoretical-conceptual axes disseminated by the SUS5. Historically, it is concerning that, for part of the nurses, the similarity with the medical consultation may mean a higher status towards the clients, which raises the discussion about the personal dissatisfaction and lack of identity in many nursing team members.

The great demand for care can contribute to limit the nurse’s time for each consultation, directing the focus to the gynecological complaints, away from the educative activities⁵. In addition, the care agendas are more compromised, as most of the nurses attempt to do the pap smear test each year, due to the woman’s need for care and confidence in that interval.

You tell them to get back to pick up the result of the pap smear, then it was like that, for every two negative results you tell them to get back in three years. But I tell the person that there’s nothing to stop her if she wants to do it every year. Because I’ve already received results that one year are good, and the next there’s CIN [precursor lesion]. (I2)

Most of the women who come here are illiterate and face difficulties to get care in the public network. They feel abandoned, need to talk to someone, be touched, examined. So I schedule them each year. (I6)

Another relevant aspect refers to the nurses’ credibility at the laboratory of the institution they are affiliated with. As a result, tests taken at other institutions the women may bring are considered doubtful and, consequently, are repeated.

Over here I trust the laboratory, now the external labs, from the private network, I don’t know how this smear is read. It has happened that a patient got an excellent result in the private network and presented CIN I or CIN II here. How is this smear read. I have considerable doubts. (I1)

Sometimes it may have been badly collected, the blade was not clean, something interfered in that smear reading and than there’s this result. (I2)

The problem of the professional’s overload may be related, among other factors, to the lack of human resources, and to the way the scheduling of the women’s return is operated, considering that the nurses do not use the interval recommended by the MH for the pap smear testing as the base for orientations. According to the MH, in women between 25 and 60 years, this test should be done once per year and, after two consecutive negative annual tests, every three years. This recommendation is based on the observation of the UCC’s natural and slow history⁴.

It is assumed that the nurses do not manifest their belief in this recommendation, besides better qualitative guarantees of the laboratory analysis of the blades. The nurses’ concern with offering the service to the women should be highlighted, in view of the problem related to health service access.

Main actions for primary and secondary UCC prevention

The focus on the systemic approach indicates that, in most cases, the women visit the health service because of some gynecological complaint, which can prevent the pap smear testing due to the presence of inflammations and discharge¹⁶, so that they need to return to the service. These rearrangements can imply the risk of absence and agendas with higher demand levels.

Besides the possibilities of delay in the pap smear testing and of the women not returning to the service, another consequence relates to the social representations this kind of test produces, such as shame, discomfort, compulsoriness, and some characteristics that refer to the women’s social groups, such as age and marital status (widowed and divorced women) and cultural aspects¹⁷.

The nurse needs to identify the women’s needs, mainly related to the signs and symptoms. As regards the knowledge needed for health promotion and disease prevention, however, some obstacles emerge, such as lack of knowledge, sexual taboos and difficulties to change one’s life habits.

The population is unable to understand uterine colon cancer, because it is invisible [...]. What one cannot see is no source of concern. And many women do not know their own body (I6)

Many people, also due to the kind of upbringing, which is more conservative, think it is shameful to know one’s own body and touch oneself. It is difficult to change some things. (I2)

I think that the dietary habits, the lifestyle, the stressors imposed by society itself: having a child, work, husband, family, lots of things. So I think everything contributes to the development of the cancer, not just the hereditariness. And it’s difficult to change that. (I5)

Thus, the participants’ statements indicate the need to enhance care actions through the women’s involvement in educative processes, so as to enable them to develop a good self-care level. Health education is fundamental in PHC, based on the acknowledgement of individuals as participatory and autonomous subjects, and should address themes related to health promotion, and not just disease prevention and treatment¹⁸.

In view of these problems, the nurse performs fundamental actions in health education, through communication, besides the bonding needed to grant the woman space to present her problems and way of life.

The consultation is the moment the woman has to talk about her problems, she feels welcomed, confident and ends up talking about other problems that affect her daily life. (I3)

We nurses are more patient, we are prepared to educate, talk more, clarify more. I think it’s not just trust, but also more freedom and less shame to ask us, than the physician. (I1)

I am doing the consult with the woman about the problem she is presenting [...] I collect her patient history, ask about her complaints, and work based on these, always promoting an educative action. Then I explain about the test, its importance and why it needs to be done.” (I5)

The nurses highlight the fact that they are nursing professionals as a contributing factor to the establishment of dialogue with the women, that is, they are prepared to develop educative practices, with possible influence from the female gender¹⁹. Nevertheless, the risks inherent in the loss of professional identity and commitment to comprehensive care delivery should be heeded. The need to overcome the biomedical model represents a challenge, which is strongly assumed in the context based on the predominance of the syndromic approach and the valuation of technical procedures.

Concerning the main primary UCC prevention actions, in response to the women’s health needs, keeping in mind the multifactorial causes of cancer, health education should be highlighted. The orientations that permeate the women’s behavior to prevent UCC can be offered individually or to a group of women, like in the waiting rooms of the consultations for example.

Through communication and bonding, the nurses grant the women room to present their problems and way of life.

In secondary UCC prevention, the nurses do the pap smear testing and education permeates all of their actions, as the women need to understand the purpose of the test and value it, so as to return to the service to pick up their results.

Most patients pick up the result, because it’s something I emphasize and repeat until today, it’s no use to come and do the prevention if they don’t pick up the result. Because that’s as if they hadn’t done it. (I7)

All of the nurses mentioned the orientation to pick up the pap smear result, considering that most of the women do not understand or know about its value, as well as the importance of continuing care with the same professional.

I have just received a 17-year-old girl, I did the pap smear in 2008, she was a virgin and didn’t pick up the result. Then she came today, she’s got a four-month-old baby and HPV [...]. That is, it’s not a lack of care, she got help, but she didn’t pick up the result, and says she forgot. (I1)

We ask them to try and continue care with the same professional. It’s better for us and for them, because there’s already that interaction, they feel more at ease to talk [...], they’re not ashamed anymore to talk about things. (I1)

The study reveals, in accordance with other research results, the recommendation of secondary prevention as a form of early diagnosis of UCC or intra-epithelial cervical lesions through the pap smear^6-8. And, in view of the epidemiological profile of the disease, further coverage of the target population is needed, as early diagnosis and treatment are fundamental to reduce the mortality due to UCC²⁰.

In addition, the accomplishment of pap smear testing in PHC often functions as a bureaucratic phase, which the woman needs to go through in order to be included in the referral system among units, according to the complexity level, keeping in mind that, when UCC is diagnosed, she will be referred to institutions that will continue her treatment¹.

In view of problems identified in pap smear testing, the guidelines that are to be followed are described in the test result, following the referral system among institutions that are part of the oncologic care network in the city.

The test result already indicates the day, time and place the patient has to attend for the monitoring. When she is cleared, she returns to the institution of origin where her monitoring started. (I2)

Thus, the referral institution is already mentioned in the test result that indicates intra-epithelial cervical lesions or a tumor, including the appointment the woman is to attend, which facilitates the process.

This care flow may picture a privileged reality, due to the fact that the institution is located at the center of the city of Rio de Janeiro, with a large number of health institutions in the cancer care network²¹.

Despite the problems, it is in PHC that the greatest investments in holistic health care have been observed, as this practice still faces problems related to the way in which the work processes, management, service organization and planning are established.

CONCLUSION

In the gynecological nursing consultation, the nurses indicate that, in the research context, the practice is based on the PHC terms, which serve as the main theoretical-conceptual axis and is based on other SUS publications that are focused on comprehensive care and humanization. Nevertheless, the focus on the syndromic approach is in accordance with the biomedical and medicalization model.

In primary prevention, health education is highlighted, although it is still focused on disease prevention. In view of the epidemiological profile of UCC, the possibility of the early detection of intra-epithelial cervical lesions or UCC is focused on, through pap smear testing.

Gynecological nursing consultations can contribute to enhance the coverage of the target population with regard to pap smear testing, which in the medium and long term can influence the morbidity and mortality rates due to UCC, as the disease evolves slowly and can be diagnosed early, enhancing the chances of cure.

It is fundamental, however, to expand the activities of the consultation beyond the problem-based approach and the testing. In PHC, the gynecological nursing consultation should favor participatory approaches and the formation of citizenship. The challenge is complex and requires investments in human, physical and material resources, besides scientific research, mainly to produce practical evidence.

The main limitation refers to the accomplishment of the research in a single context, in view of the national range of PHC and diversities in the service supply and in the epidemiology of the UCC among the regions of Brazil.

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