ORIGINAL RESEARCH

Nursing interventions in cervical-uterine cancer prevention: clients' perspectives

Jorge Luís Tavares de Oliveira^I; Betânia Maria Fernandes ^II

^I Nurse. Master. Assistant Professor. Faculdade do Sudeste Mineiro. Juiz de Fora, Minas Gerais, Brazil. E-mail: jorgektarin@yahoo.com.br
^II Nurse. PhD. Associate Professor. Federal University of Juiz de Fora. School of Nursing. Juiz de Fora, Minas Gerais, Brazil. E-mail: betaniafernandes@uol.com.br
^III Article extracted from the Master's dissertation of the Graduate Program of the School of Nursing of the Federal University of Juiz de Fora.

DOI: http://dx.doi.org/10.12957/reuerj.2017.26242

ABSTRACT

Objective: to examine nursing interventions to produce changes in behavior, habits and lifestyles with a view to cervical cancer prevention, as seen by clients. Methodology: this qualitative descriptive study was conducted in 2014 with 18 women receiving nursing care for cervical cancer prevention. Data were collected by structured interview with application of a questionnaire. Data were subjected to thematic content analysis. The study was approved by the human research ethics committee (CAAE 32628514.1.0000.5147). Results: three categories emerged: behavioral interventions, cognitive interventions, and social interventions. Conclusion: nurses, jointly with other team professionals, must combine behavioral, cognitive and social interventions, with a view to effecting cervical-uterine cancer prevention actions and promoting women's health.

Keywords: Nursing; women's health; primary prevention; uterine cervical neoplasms.

INTRODUCTION

Cervical cancer (CC) has been a public health problem due to the high rate of morbidity and mortality, despite the implementation of actions and strategies aimed at prevention, screening and control. It is important having knowledge on the magnitude of this problem, and also on the socioeconomic and cultural characteristics of the women affected by this disease, on the identification of risks and on the demand for strategies with planning for prevention and control, through care and/or educational actions^1-5.

The new cases of CC in Brazil have been controlled, but they remain relevant, as high prevalence and incidence rates persist. It is a neoplasm incident in the Brazilian female population, occupying the third position in the estimate for 2014/2015, with 15,590 new cases per year, with an estimated risk of 15.33/100,000 women, disregarding non-melanoma skin tumors^6,7.

CC has a high potential for prevention and cure, as it presents well defined phases, a long period for the development of precursor lesions and easy detection of morphological changes at the onset of the disease ^8-10. The nurse can use the available approaches in the health area, articulating them for the prevention and/or promotion of health, allying assistance to the knowledge about risk factors for CC ^1,8,11,12.

Government actions and programs to control CC are based on four fundamental elements: primary prevention, early detection, diagnosis/treatment and palliative care. Early detection is best indicated due to the effectiveness in reducing CC cases, configured through screening programs and actions, directed at women at all levels of care, especially in primary health care (PHC)^13,14.

Women's lack of knowledge about risk factors prevents them from complying with the recommendations regarding changes in behavior and lifestyle, which is a challenge to be overcome in order to achieve CC control¹⁵.

The objective of this study was to analyze the interventions of nurses that can provide changes in behaviors, habits and lifestyles for the prevention of cervical cancer from the perspective of clients.

LITERATURE REVIEW

Nursing interventions include care provided to individuals, families and the community^16,17. CC interventions can be carried out in isolation or jointly by nurses together with the women, and these interventions are classified as behavioral, cognitive and social ^17,18.

Behavioral interventions are those that stimulate individuals to modify habits and lifestyles, favored by behavior-changes associated with the accomplishment or not of tests for early detection of CC, such as reminders, messages, posters and phone calls^17,18.

Cognitive interventions are those that provide information that can raise women's awareness about the need for behavior changes and guide them to adherence to CC screening and control examinations, promoted through health education^17,18.

Social interventions are implemented with the help of professionals and/or community. Nurses can perform them by using educational activities, offering information or visiting the community, aiming to increase adherence to the CC screening and control examination, or indirectly, through other professionals^17,18.

METHODOLOGY

This is a descriptive study with a qualitative approach¹⁹ carried out in two primary health care units (PHCU) of a municipality in the Zona da Mata Mineira region, in which family health strategy teams (FHS) have been working for 10 and 20 years, whose nurses have promoted CC prevention and screening actions between January and March 2015.

A total of 18 women participated in the study, four of whom were excluded because they did not use the PHCU routinely but, instead, private institutions. The inclusion criteria were: women enrolled and assisted in the FHS, in the age group between 25 and 64 years and assisted by nurses for the prevention of CC.

The users were recruited while awaiting to be seen in the waiting room of the PHCU, and the invitation to voluntarily participate in the study was accepted. After acceptance, they signed the Informed Consent Form, which had clarifications regarding the study.

The research was conducted through the following steps: initially, a semi-structured interview with a questionnaire was applied to the women in the PHCU; after the interviews, the analysis of the collected data was performed, looking for the categories implicit in the testimonials.

Data collection took place in a quiet and private environment in the PHCU. The interviews were recorded in digital recorder and transcribed in full in the Word program for Windows. To safeguard anonymity, the participants were identified by sequential numbers of interviews (P1, P2,..., Pn).

The analysis of the information occurred after the data collection, through the thematic content analysis¹⁹, according to the following steps: pre-analysis, exploration of the material and processing and interpretation of the obtained data. Initially, the floating reading of the interviews was carried out, followed by the identification of the units of records after exhaustive reading, respecting the completeness, representativeness, homogeneity and relevance of the data. The units of records were grouped by means of classification and aggregation of data, thus originating units of meaning (themes) that were then combined to form categories^19,20.

From the testimonies, the categories classified in behavioral, cognitive and social interventions emerged. After the classification, other data collected were analyzed, favoring the investigation of the interventions that modified the behaviors, habits and lifestyles of the women ^19,20.

The recurrence and repetition of the information (nursing interventions) in the transcribed reports and the scarcity of new information in the interviews analyzed are criteria for theoretical saturation ^19,20.

The research project was approved by the Committee of Ethics in Research on Human Beings of the Federal University of Juiz de Fora, under the opinion no. 718.335/2014 (CAAE 32628514.1.0000.5147), in compliance with ethical precepts.

RESULTS AND DISCUSSION

Socioeconomic characterization of clients

The study included women aged between 25 and 61 years, with a mean age of 43 years. Their study time varied from 9 to 11 years, with prevalence of complete and incomplete high school. In relation to family income, the average of three minimum wages predominated. The prevalent self-reported color was white, and most of the women were married.

The care process requires from the nurses skills and knowledge to be applied during care practice through nursing interventions in order to promote the quality of life of individuals and the population ^16,17.

Nursing becomes stronger as a science, profession and social practice as it is constantly challenged to seek new knowledge to promote care for the human being and thus improve the quality of interventions in the health and disease process¹⁶.

The contents of the statements in this study were grouped into three categories, distributed in thematic axes based on the reference adopted in relation to nursing interventions: behavioral, cognitive and social ^17,18.

Behavioral interventions

Behavioral interventions use strategies such as reminders, letters, phone calls and posters that have been shown to be effective, increasing adherence to Pap smears or increasing the number of women with abnormal results. There has also been an increase in the coverage of women in the age range recommended by the Ministry of Health (MoH). Such interventions are based on the assumption that women only need a stimulus to adopt behavior that promotes their health¹⁷.

Participants were asked whether they had received a phone call, letter, note, or message from the nurses to carry out CC prevention. They stated that they were invited only for campaigns, when cervical smear collections were intensified, but not for the routine examination.

Yes. The same as they did the campaign. One week they did it at night. They communicated it to us. (P5)

Participants reported that communicating about the Pap test occurred through community health workers (CHW).

Not from the nurse. The community health worker is always asking me whether I ever did it. [...] I called her and said that I had not done it. [...] She scheduled it for me. (P2)

Professionals working in the PHC must guarantee comprehensive care to the users' health through actions of health promotion, protection and prevention of diseases, and make an active search. Among the attributions of the nurse are the planning, management and evaluation of the actions developed by the CHW¹⁴. So, when the CHW is developing his work with the community, it is understood that nurses are also working indirectly, since they are responsible for these professionals ^12,14.

The invitation and the active search by the CHW should be carried out in order to extend the screening and coverage of the Pap smear to women who do not usually seek this type of care in the PHCU. It is also intended to maintain the assistance to women in routine care^12,17,18.

One strategy that was used in the PHCUs, as a reminder, was the establishment of posters to inform or remember about the Papanicolaou exam.

Whenever there is a campaign, the [nurses] girls put posters on the walls. There are always some poster when they make a campaign. (P4)

The behavioral interventions performed by PHC professionals are related to the encouragement offered to women for the adoption of measures for health prevention and promotion^17,18. The behavioral interventions found in this study were invitations and active search, conducted by CHWs, and posters at the PHCU to remind women of performing the Pap smear. A study showed that the most effective behavioral interventions were those that used as a strategy the reminders (letters or phone calls) and the actual accomplishment of the cytopathological examination¹⁷. Any device that reminds or encourages women to adopt health promotion and prevention measures is considered a behavioral intervention.

Cognitive interventions

The strategies used to provide information about CC prevention and to clarify possible misconceptions are called cognitive interventions ^17,18. Health education is a strategy for changing behaviors and maintaining people's health. It is a social practice developed by professionals to raise critical awareness in people, making them more reflective about their health problems. Therefore, the educational strategies carried out by nurses are valuable resources to meet the health demands of the population^21,22.

In addition to this practice, nurses know the health conditioning factors of a given population that is referenced in the health unit where they work, which enables them to encourage the adoption new behaviors, habits and lifestyles^11,12,21,22.

There are several techniques and methodologies used to carry out health education in PHC, such as collective guidelines in waiting rooms, educational groups, lectures and individual orientations ^17,18,21-23.

In order to identify cognitive interventions in relation to CC prevention ^17,18, the participants were asked whether they had received information from the nurses or another professional at the PHCU receptions while they waited for the care.

It did not happen. [...] How to prevent? It's kind of hard to know; until today I do not know. (P3)

The conduction of educational practices in the waiting rooms is an opportune moment for nurses to inform users about the routines of the service, providing guidelines on the schedule of care and preventive practices¹². Despite being a possibility of nursing intervention in PHC, educational activities in the waiting room have not happened frequently in the two PHCUs surveyed.

Another possibility to develop health education in PHC is the realization of educational groups, which consist of groups of people that have specific objectives, being dependent on the bond to be established among the members and the trajectory to be covered by them until reaching the objectives proposed²³.

The participation of women in educational groups for the prevention of CC and Sexually Transmissible Infections (STIs) was identified.

I have already participated, when I was using contraceptives, in the group of sexual and reproductive rights, which the nurses conducted. (P3)

When conducting educational groups, nurses need to involve women in order to raise awareness to changes in behavior and lifestyle, with a view to adopting safe sex practices (use of condoms) and consolidating information on STI exposure²³. The demand for this educational practice is justified by the participation of women in accessing contraceptive resources offered by the public health system in the researched municipality.

This educational practice is widely used in PHC as an effective device in the dissemination of contraceptive and conception methods and in the prevention of STIs and sexually related diseases, such as CC ^22,23.

The realization of educational groups allows the establishment of bonds, since the members approach the reality of the others involved, with the exchange of experiences and support to the other participants. The professionals of the FHS should offer subsidies and resources for the accomplishment of the groups²³, since nurses in PHC have an important role as educators and teachers of healthy life habits ^2,23,24.

Users were asked whether they had received guidance on STIs, condom use and in which activities they were offered.

Yes. We cannot stop using it [...]. I received these guidelines by talking to the nurses. They talk many things. Also in the group on sexual rights. (P5)

It was verified that the PHCU nurses offered information on this subject when performing groups on sexual and reproductive rights (family planning).

Women's participation in educational groups also focuses on the prevention of STIs and the provision of methods to prevent sexually transmitted diseases. This is a recommendation of public health policies, especially for human papillomavirus (HPV) infection, considered a causal factor for cervical cancer².

Another way to prevent CC is to provide care and information to women about condom use, prevention of STIs and counseling that encourages safe sex. Such cognitive interventions are also performed by nurses ^12,13,16.

The communication process established between nurses and users should be relevant not only to know the woman's complaints, but to establish the interaction, and it should be accessible, allowing women to understand information. This communication should be clear and objective to facilitate the knowledge to be acquired, since a well-contextualized and based orientation, in a relationship of trust between women and nurses, guarantees awareness for health care^24,25.

The provision of advice or counseling by nurses was identified in the report:

I have already been guided by the nurse who does the gynecological exam. [...] Nurses talk a lot about reproductive rights. (P5)

It was evidenced by the report that individual orientations are provided when the users are in the nursing appointments for the accomplishment of CC preventive examination; however, guidelines on this subject are not provided during the awaiting of the women for appointments or even when they are present in the health service. It should be noted that these are missed opportunities for PHC professionals in providing information and clarification to women.

Social interventions

Social interventions suggest the participation of nurses as health promotion workers and changes in the CC screening system, which can be carried out with the help of people from the community. It is up to the nurses to perform them directly, by using educational activities, offering information or visiting the community in order to increase adherence to the CC screening exam, or indirectly through other professionals, such as nursing technicians or community health workers^17,18.

In the investigation, all the women had already participated in a nursing appointments with the Pap smear.

Usually, I do it with the nurses. I do the preventive test with them. (P13)

The nursing appointment is an effective strategy to identify health deviations of the population, being characterized by the nurse's work in an individualized and effective way in front of the users' health demands ^12,24,25. It is a moment of information exchange, of conducting preventive examinations and of strengthening the bond between the user and the professional^24-26.

It was asked which professionals of the FHS team would daily search the women for the CC screening and detection in the community and whether they had received home visits (HV) by the professionals, and whether these professionals, during the visits, reminded or advised users about CC prevention.

The CHW that covers my street always remembers me [...] when the preventive examination is going to happen. Because we like to do it every year. [...]. (P1)

As reported, the CHWs are the professionals who perform the HV and take the opportunity to invite and remind women about the performance of the Pap smear test.

The HVs serve as a screening and clarification strategy, in which professionals perform the active search of women that had not carried out the prevention or that had postponed the examination^27,28. The participants reported that they had not received the HV of nurses inviting, alerting or reminding them of the Pap smear; only the CHWs has been responsible for these activities.

The HV is an interactive technology in health care used by the FHS teams that enables the insertion and knowledge of professionals in the context of users' lives, as well as the establishment of links between them. Therefore, the HV is an activity that gives nurses and CHWs knowledge of the social contexto so that they can identify health needs of individuals and families assisted by the team²⁸.

The information found in the reports corroborate with studies that indicate the CHWs as professionals that actively search actively and follow the population, as opposed to other professionals in the team, who are directed towards the accomplishment of goals and procedures within the primary health care units²⁸.

It is important to emphasize the importance of nurses in social interventions, with the aim of providing information and/or increasing the population's adherence to preventive measures. In this sense, these professionals should actively participate in the community, whether through HVs, active search or nursing appointment^12,17,18.

CC tracking and detection must meet the recommendations of the MoH to achieve goals and increase coverage above 80% with the implementation of the set of actions scheduled, with defined population and periodicity. The occasional demand in the health services for the accomplishment of the CC prevention examination by the women is an opportunistic screening practice, considered not very efficient in reducing the incidence and mortality rates of this type of cancer^3,5,26.

In order to reduce the morbidity and mortality rates of CC, the MoH has adopted the recommendation of the World Health Organization that proposed performing cervical cytopathology examination every three years after two consecutive negative annual tests for women between 25 and 64 years of age or for those who had already had sexual activity, in addition to recommending the improvement of adherence to screening strategies ²⁶.

It is known that women with the highest risk for CC have not been reached by the screening program for the early detection of this neoplasm due to the lack of adherence to the periodicity in the cytopathological examination. Among the factors that imply this non-adherence are the low socioeconomic level, low level of education, fear of accomplishing it and/or receiving a positive result for cancer, embarrassment in the examination, unavailability of time by women, difficulty in accessing the health service and lack of knowledge about the examination²⁶.

It is necessary for professionals, including nurses, to meet these demands by making available unconventional times for care, thus ensuring access and knowing the reality of these women to implement effective health actions ^{11,12,17,18,21}.

The interventions performed by the nurses in the PHC may change the behaviors and life habits of the women regarding the CC prevention and to increase their adherence the cytopathological examination.

I always receive guidelines [...]. And for me, it is good to continue doing the preventive examination. She [nurse] will be following me. [...] I talk to her about preventive examination. (P11)

The individual guidelines and the accomplishment of nursing appointments with cytopathological examination are interventions that make the participants change behavior and life habits, making them healthier and adopting preventive measures for STIs and CC.

Nursing interventions for CC prevention should consider the characteristics of the target population, as well as the environment in which they will be implemented, and should be well designed to achieve the proposed goal. Behavioral, cognitive and/or social interventions have positive results for the early detection of cervical cancer, however, when combined, the results are more effective^17,18.

CONCLUSION

The role of the nurse in the actions for health promotion and disease prevention in PHC is relevant, aiming at the adoption of healthy behaviors, habits and lifestyles, since they exert influences on the health promoting behaviors adopted by the women. It was evidenced the importance of the nursing appointment to the woman, with emphasis on the CC screening, as well as the individual guidelines provided in this care practice, as a valuable opportunity to prevent this type of cancer.

Nurses must combine behavioral, cognitive and social interventions with other professionals of the FHS team, aiming at the implementation of actions for health prevention and promotion regarding CC and women's health.

This work is expected to provide nurses with knowledge and elements to develop care, education and preventive measures in relation to CC by identifying obstacles that prevent or hinder the prevention of this type of cancer and by guiding nursing interventions.

The present study is limited by the small set of participants and by having had only one scenario, elements that prevent the generalization of the findings. However, this research is a starting point in the search for effective ways to prevent CC.

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