RESEARCH ARTICLES

Knowledge and practice on Pap smear tests by women assisted at family health units

Thatiany Rodrigues Santiago^I; Magna Santos Andrade^II; Gilvânia Patrícia do Nascimento Paixão^III

^INurse. Specialist in Obstetrics from the Bahia School of Medicine and Public Health. Bahia, Brazil. E-mail: tathy_1989@hotmail.com.
^IINurse. Master in  Collective Health from the State University de Feira de Santana. Assistant Professor from the Undergraduate Nursing Course at the University of the State of Bahia. Researcher from the Research Group on Nursing Care, Senhor do Bonfim, Bahia, Brazil. E-mail: magnaenf@yahoo.com.br.
^IIINurse. Master in  Nursing from the Federal University of Bahia. Auxiliary Professor from the Undergraduate Nursing Course at the University of the State of Bahia. Researcher from the Research Group on Nursing Care, Senhor do Bonfim, Bahia, Brazil. E-mail: gilvania.paixao@gmail.com.

DOI: http://dx.doi.org/10.12957/reuerj.2014.6368

ABSTRACT: This study aims at describing the knowledge and practice on the Pap smear tests by women between 25 and 59 years assisted at the Family Health Strategy. This is a cross-sectional study. Forty-seven (47) women residing within the area serviced by the Health Unit Family Our Lady of Fatima, Our Lord of Bonfim, Bahia, Brazil were interviewed at home on the basis of application of forms, from August to September, 2012. Data were analyzed on the basis of descriptive statistics. Results show that there are still women who do not receive regular Pap and are mostly unaware of the purpose of the procedure. Conclusions show that women need clarification about the exam and its goal, requiring permanent structure of educational activities in health facilities to sensitize women about the importance of regular Pap smears.

Keywords: Uterine cervical neoplasms; vaginal smear; knowledge; primary prevention.

INTRODUCTION

The cervical cancer (CC) is a serious public health problem due to the high morbidity and mortality rates, with an incidence about two times greater in developing countries when compared to the indicators of developed countries¹.
In Brazil, it is estimated an occurrence approximately 18.000 new cases of cervical cancer a year, with risk of 18 cases per 100 thousand women, which makes it the third most common neoplasm in the female population².

The Pap smear is the main examination for the early diagnosis of the neoplasm of cervical cancer, and it is a low-cost method, easy to accomplish and highly efficient for detecting cervical changes, with a large use in CC control programs³. The effectiveness of the examination and the long pre-clinical detectable phase of this neoplasm turn the early diagnosis, through the procedure, into the best prevention strategy⁴.

Information about the knowledge of women in relation to the purpose of the Pap smear and its accomplishment are indispensable to allow the health teams to know the local reality and use this data for planning and implementing health actions aimed at reducing the current morbidity and mortality rates from this type of cancer⁵.

The study had the aim at describing the knowledge and practice about the Pap smear of women aged between 25 and 59 years living in the coverage area of the Family Health Unit (FHU) Nossa Senhora de Fátima do Alto da Maravilha, located in the city of Senhor do Bonfim, Bahia (BA) 2012.

The importance of this research is to produce knowledge to enable health teams and managers to comprehend the local specificities involving the accomplishment of the Pap smear in the enrolled population and therefore develop suitable planning and implementation of actions for an effective structuring of the prevention of CC.

LITERATURE REVIEW

The CC is characterized by disordered replication of the epithelium of the womb lining, which compromises the underlying tissue (stroma) and may invade neighboring or distant structures and organs⁶. This disordered cell growth and consequent formation of tumors in the uterine cervix can affect young women, but occurs mostly in those aged 35 years or older⁷.

The main factor associated to the occurrence of this neoplasm is the infection with the Human Papilloma Virus (HPV), whose the main transmission route is sexual^1,8. Nevertheless, in addition to the HPV infection, it is necessary the existence of some co-factors for the development of CC: smoking, precarious socioeconomic conditions, multiplicity of sexual partners, inappropriate intimate hygiene, poor diet in vitamin C, beta-carotene and folate and early sexual debut⁹.

The Pap smear examination (oncotic cytology) is a priority for women who already started their sexual lives, mainly those aged between 25 and 59 years, and should be accomplished once a year and, after two consecutive negative annual examinations, for every three years¹. This routine does not prevent the offer of the examination for younger or older women10. The purpose of the examination is the detection of precursory lesions for the early application of therapeutic methods whenever required¹¹.

The full effectiveness of the screening for reducing mortality from CC occurs only if the cytopathological examinations are known and accepted by the population, besides being repeated at intervals recommended for the detection of the disease in early stages^12,13. 

In Brazil, the number of deaths from CC in 2010 was 4.986 cases. Regarding the Brazilian regions, the cervical-uterine neoplasm shows high incidence mainly in the North (24/100 thousand) and Midwest (28/100 thousand) regions, but also shows significant indicators in the Northeast (18/100 thousand), Southeast (15/100 thousand) and South (14/100 thousand) regions².

Low socioeconomic status, cultural issues associated to problems of access, improper operation and precariousness of health services, as well as the lack of knowledge of women about the benefits of the accomplishment of the Pap smear, partly explain because about 70,0% of cases of CC are diagnosed in Brazil at advanced stages, which limits the possibility of healing and entails high morbidity and mortality rates from this neoplasm¹².

METHODOLOGY

This is a quantitative and descriptive study, with cross-sectional cut. It was performed in the coverage area of the FHU Nossa Senhora de Fátima, located in the Alto da Maravilha neighborhood, belonging to the city of Senhor do Bonfim (BA). The FHU includes nine micro-areas and has a total of 1.281 registered families¹⁴.

The study population was composed of women aged from 25 to 59 years living in the coverage area of the FHU. Due to the lack of a list of all women aged from 25 to 59 years for the sample-drawing process in the health unit, we opted to randomly draw a micro-area and, consequently, draw 50% of the families registered in this micro-area that had women aged between 25 and 59 years, in order to obtain women for performing the study from that point onwards.

Among the nine micro-areas that composed the coverage area of the FHU Nossa Senhora de Fátima, the ninth micro area was drawn, and it was identified through the charts A (registration tool of families) of the respective micro-area, with 119 registered families, of which 82 had women aged from 25 to 59 years. Among these 82, 48 families were randomly drawn, which corresponds to approximately 50,0% of families with women in the target age group of the study, resulting in a total of 57 women to be interviewed, since some families had more than one woman with age to participate in the research.

The inclusion criteria were: women members of the families registered in the ninth micro-area; aged from 25 to 59 years; who started sexual activity; who did not suffer from psychic disorders that prevented the provision of answers to the questions raised; who did not undergo total or partial hysterectomy.

Data were collected during the accomplishment of home visits, between the months of August and September 2012, from the application of a semi-structured form, composed of four blocks: sociodemographic data (age, schooling level, race/color, marital status and monthly family income); gynecological and obstetric backgrounds and sexuality (age at first sexual intercourse, number of partners from the beginning of sexual life, use of contraceptive methods, history of sexually transmitted disease (STD), number of children, number of pregnancies and number of deliveries); knowledge about the Pap smear (she already heard about the examination, its purpose, knowledge about the examination in the health unit of the neighborhood); accomplishment of the examination (she already undergone the Pap smear at least once in life, time of accomplishment of the last examination, frequency of accomplishment, reason to have undergone the last examination and reason for not having undergone the cytopathological test in the last three years and having never undergone the procedure).

Up to three visits were conducted in homes in which the person to be interviewed was not at home, but, even with this strategy, some women were not found. That way, 47 women were interviewed in total.

Women who agreed to participate, after being informed of the importance and aim of the study, signed the Free and Informed Consent Form, thereby complying with the ethical aspects advocated by the Resolution nº 466/2012 of the National Health Council/Ministry of Health (MS, as per its acronym in Portuguese), which refers to research involving human beings¹⁵.

The identities of the interviewees were preserved. Each form has been identified with a numbering and it was used for identifying the researched in the database. The project was approved by the Research Ethics Committee of the University of the State of Bahia (Opinion nº 57843) on July 12th, 2012, and it was drafted in accordance with the Resolution nº 466/2012 of the National Health Council/MS.

Concerning the classification of knowledge, the following criteria were used: appropriate knowledge, when the woman had already heard of the examination, and knew that its purpose was to detect cancer in general or, specifically, the cervical cancer; and inappropriate knowledge, when she had never heard of the examination, or had already heard, but did not know that it was used to detect cancer or CC¹⁶.

The assessment of the practice has followed standards set out by the MS¹⁷, and it was considered appropriate when the last examination undergone by the woman had at most three years, and inappropriate when the woman had undergone the last examination for four years or more or had never undergone the procedure.

The collected data were typed into the program Statistical Package for Social Sciences (SPSS), version 9.0, and then the analysis of typing from the lists of simple frequencies of the researched variables to correct possible errors was performed. In order to analyze the item of race/color, the self-reported answers were used.

Subsequently, there was the exploratory and descriptive analysis of the surveyed sample from the simple frequencies of the variables related to sociodemographic characteristics, personal backgrounds, gynecological and obstetric backgrounds and sexuality, knowledge about the Pap smear examination and accomplishment of the examination. Bivariate analysis was also conducted to verify the frequencies of the study variables in relation to the knowledge and practice of the examination.

RESULTS AND DISCUSSION

According to the sociodemographic characteristics of the 47 interviewees, 20 (42,6%) were aged between 25 and 34 years. The data related to schooling showed that 18 (38,3%) women concluded from the 1st to the 3rd year of high school, and four (8,5%) did not attend school (they were unable to read and write, or knew only how to sign their names). Regarding the race/skin color, 32 (68,1%) self-reported having brown color; and, with regard to marital status, 15 (31,9%) were single. Among the researched, 39 (83,0%) had a monthly family income less than or equal to the Brazilian minimum wage (check Table 1).

TABLE 1: Sociodemographic characteristics and gynecological and obstetric backgrounds of women living in the coverage area of the FHU Nossa Senhora de Fátima, Senhor do Bonfim, BA, 2012.

Concerning the gynecological and obstetric backgrounds, only one (2,1%) had a history of STD. As for children, 43 (91,5%) interviewees reported having children, with 37 (86.0%) having a quantity between one and three children. According to the number of pregnancies, including abortion, 31 (66,0%) had up to three pregnancies, and 38 (80.9%) undergone three deliveries or less,  according to Table 1.

Data related to sexuality showed that 29 (61,7%) interviewees started their sexual lives with ages between 12 and 17 years. Concerning the number of partners, from the beginning of sexual activity, 33 (70,2%) had two or more partners. The use of contraceptive methods was reported by 32 (68,1%) women, with 18 (56.3%) that were subjected to sterilization surgery and 8 (25,0%) that made use of combined oral contraceptive.

Regarding the knowledge about the examination, all women have already heard about the Pap smear. When asked about the purpose of the cytopathological test, 38 (80,9%) interviewees did not hold the right knowledge about the procedure; 32 (68,1%) answered that the examination is useful to prevent diseases in general; five (10,7% ) said it is to treat vaginal infections and one (2,1%) did not know, which shows that a significant portion of women did not know the actual purpose of the examination at stake - prevention of CC. In contrast with this finding, a research performed in the city of Juiz de Fora (MG) showed that only 15,0% of the researched people had inappropriate knowledge about the examination¹⁸. However, in the hinterland of Rio Grande do Norte, 53,9% did not know the purpose of the Pap smear test¹⁹.

The survey of the knowledge of women about the examination is of high relevance, since it is an essential factor to assess the strategies adopted in the prevention of CC²⁰.

Among the interviewees, two (4,3%) reported not knowing that the Pap smear was conducted in the health unit of the neighborhood. Accordingly, initiatives should be taken regarding the prevention of CC, thereby strengthening the information and guidance as a way to recruit the population for the accomplishment of the examination²¹.

As regards the practice of the Pap smear, 42 (89,4%) interviewees have undergone the examination at least once in life, as exposed in Table 2. A similar proportion was found in studies performed in the city of São Paulo (SP), where 86,1% of women had undergone the cytopathological test²², and in the city of São Luís (MA), where 82,4% reported having been subjected to the procedure at least once in a life²³.

TABLE 2: Practice of the Pap smear by the women living in the coverage area of the FHU Nossa Senhora de Fátima, Senhor do Bonfim, BA, 2012.

One should observe that, within the coverage area of the FHU Nossa Senhora de Fátima, there is a need to provide clarification and information to the female population with respect to the examination, since five (10,6%) women had never undergone the procedure, and this population should be a topic of active search and target audience in health education.

It is worth highlighting that, 36 (85,7%) interviewees sought the local unit to perform the collection of examination in the last three years, according to Table 2. The index of appropriate practice presented by the women of this study was higher than the one found in the research performed with Argentine women (30,5%)²⁴.

Nonetheless, the data of coverage of this study proves to be similar to the one of the survey performed with women treated by the Family Health Strategy in the city of Feira de Santana (BA), where it was 87,4%²⁵; in the city of Pelotas (RS), it was 83,0%²⁶, and in a research with women treated by the Basic Health Unit (BHU) of Londrina (PR), it was 80,0%²⁷.

The percentage of coverage of the examination of Pap smear of this study was positive, since the World Health Organization considers it as one CC prevention program with good effectiveness, when the appropriate practice of the examination reaches 80,0% of the target population. That is why it has obtained a significant impact on the mortality from this neoplasm¹⁷.

It is worth emphasizing that 22 (52,4%) interviewees were subjected to the examination annually and only one (2,4%) performed it in the period recommended by the MS. The accomplishment of the Pap smear test in different time intervals may be due to the lack of information and knowledge on the part of these women in relation to the frequency recommended by the MS⁶.

The inappropriate frequency of the collection for the cytopathological test may be a reflection of the information given by the health professional, as found in the research performed in the city of Ribeirão Preto (SP), where women had received guidance about the importance of the annual accomplishment of the examination²⁸. Although the health care unit is aware of the frequency advocated by the MS, the collection is still guided annually²⁹.

In addition, one should consider that the annual accomplishment of the examination subjects the woman to an uncomfortable and embarrassing procedure more often, as well as increasing the health system costs because of unnecessary accomplishments of the procedure, in smaller time intervals that the advocated by the MS.

The main causes cited for the accomplishment of the last Pap smear examination were: 14 (33,3%) reported other reasons and, among these, the most cited was the prevention of diseases in general; 11 (26,2%) women reported having undergone the last procedure because they presented gynecological grievances; and 10 (23,8%) because they considered it as a routine examination (check Table 2).

The justifications related with the non-accomplishment of the examination by the interviewees in the last three years, or for having never undergone, were varied: six (54,5%) reported other reasons and three (27,3%) mentioned the absence of grievances, and these conditions have a great influence on the inappropriate practice of the Pap smear and pose a risk for the woman’s health.

One of the reasons that led the women to perform the last Pap smear test was the onset of symptoms, which is a characteristic of the population from developing countries, since they seek health services only when they have some symptomatology. This is due to the understanding that it is not necessary to seek a health professional when a person does not feel anything¹⁶.

This fact may indicate the lack of knowledge of the interviewees about the preventive actions, since they associate the accomplishment of the examination with the presence of some abnormality. Women should be informed by health professionals on the injuries that herald the CC and that these injuries may not have any symptoms. Thus, the test should be conducted with the purpose of early detection.

It is important that the health service performs the active search for women to accomplish the Pap smear, and for that it is essential having the participation of community health agents through the conduction of home visits³⁰. In this context, awareness and attraction of women will be more effective and comprehensive if there is the involvement of the entire BHU team.

In this study, one should observe that the appropriate accomplishment of the Pap smear test was more prevalent among women aged between 40 and 59 years, since 21 (87,5%) interviewees, in this age group, were subjected to the procedure, according to Table 3. This finding corroborates with a study performed in the city of Campinas (SP), where 83,3% of women aged 40 years or older kept an appropriate practice³¹. Nevertheless, these data differ from what was observed by the MS, in which the majority of the cytopathological examinations is held in women under 35 years old, due to the fact that this age group is more inserted in health services and in programs related to the reproductive phase¹².

TABLE 3: Distribution of frequencies of accomplishment (practice) of the Pap smear examination according to Sociodemographic characteristics and other variables, FHU Nossa Senhora de Fátima, Senhor do Bonfim, BA, 2012. (N=47)

One should observe that, even among women with low schooling (non-literate or who attended the Elementary School I), the practice of the examination was appropriate, since 11 (91,7%) women did undergo the examination in the last three years, according to Table 3. A similar outcome was found in a research performed in the city of Ribeirão Preto (SP), where women who finished the Elementary School and the non-literate ones showed a greater adherence to the Pap smear test³⁰.

In contrast, the literature reports that the lower the schooling level, the higher will be the prevalence of women without coverage of the examination for early detection of CC²². A research performed in the city of Feira de Santana (BA) shows that, among women who did not adhere to the examination, 38,5% had never attended school, thereby emphasizing a high prevalence of non-adherence among women with low schooling, and a statistically significant association was unveiled²⁵.

In relation to race/skin color, one should highlight the 11 (27,5%) women who self-reported being black/ brown and held inappropriate practices, according to Table 3. A study developed in the city of Rio Grande (RS) showed that the greatest reasons of prevalence for the non-accomplishment of the examination took place among women with black or brown skin (70,9%)³². This fact is worsened when one considers that the risk of black women contracting the CC is twice as frequent when compared to white women¹⁷.

All interviewees who self-reported being white or yellow/indigenous did undergo the examination properly, thereby highlighting the existence of inequality of race/color with respect to access to the examination to prevent this neoplasm, and this inequality is an important problem to be addressed by health professionals and managers.

By analyzing the marital status, it was found that, among women without a partner, six (27,3%) did not hold appropriate practices of examination and five (20,0%) women married or in a stable relationship held this same behavior. In a study performed in the city of Rio Grande (RS), where 72,6% of single women were more likely to inadequate examination32, concerning the number of partners, from the beginning of sexual life, nine (27,3%) women who had more than two sexual partners revealed an inappropriate accomplishment of Pap smears, according to Table 3.

The early beginning of sexual life and the high number of partners may be considered risk factors for the occurrence of CC, since women become more exposed to the HPV infection, thereby contributing to the development of the neoplasm³³.

Among the interviewed women who make use of some contraceptive method, it is worth emphasizing that none of them reported the use of condoms, eight (25,0%) did not undergo the cytopathological test in a right manner, as shown in Table 3. According to the MS, contraceptives are mainly used by women with active sexual life, who do not make proper use of condoms, which, consequently, increases the risk of contracting HPV¹².

Among the interviewed women who reported having children, 10 (23,3%) did not undergo the Pap smear test properly, according to Table 3.

A research performed in the city of Puerto Leoni, Argentina, showed high proportions of inappropriate practice in women with greater parity. Thus, the high number of children was presented as an obstacle for the accomplishment of the examination in the last three years²⁴. The amount of children influences the self-care of women in relation to their health conditions, since the household tasks and the daily lives of  mothers cause them to leave the care of their health, and they start to be more dedicated to family, thereby contributing to the increase index of late detection of CC³⁴. 

CONCLUSION

The study results show that the majority of women held an appropriate practice in relation to the Pap smear test, i.e., were subjected to the examination in the three years before the research. Nevertheless, the lack of knowledge about the purpose of the collection for the cytopathological examination was prevalent.

The inappropriate practice was observed in greater proportions in women aged between 25 and 39 years, black/brown; who live without a partner; have multiple sexual partners; make use of some contraceptive method without mentioning condoms; multigravida and multiparous.

Although the practice of Pap smear is in line with the MS protocol, there are still women who undergo the examination irregularly, or never were subjected to it, and that are not guided with respect to its frequency.

An important limitation of the cross-sectional study is the recall bias, since not all women have trustworthy memories of past facts, and there may be misunderstandings when reporting situations that occurred in preceding years.

Knowing the reality of a given population with regard to aspects involving the prevention of CC is the first step to define more effective intervention strategies towards the actual community needs, thereby contributing to the reduction of morbidity and mortality indicators for this type of cancer, affecting the quality of life of women in a positive manner.

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