The present study evaluated the effect of an educational intervention developed based on the BASNEF model on promoting CCS behavior. The multivariate regression model (R2 = 0.47) showed that the independent variables integrated within the model (knowledge and BAZNEF constructs) predicted 47% of the variance of the dependent variable (performing CCS).
The present findings showed that the designed educational program managed to significantly increase knowledge, BASNEF model constructs and the CCS behavior in women in the IG. Based on multivariate linear regression analytic findings, attitude, enabling factors and behavioral intention were significant predictors of behavior.
The results showed that, after the educational intervention, a significant difference was observed in the mean knowledge score of the IG compared to the CG. Similarly, in other educational interventional studies, it showed to have a significant effect on the mean knowledge score of the IG compared to the CG [5, 27, 28]. In the present study, women’s knowledge in the IG became twofold, which indicates the success of educational intervention in removing some misconceptions about the causes, risk symptoms and alternatives for preventing and treating cervical cancer. It should be noted that although the mean knowledge score in the IG was increased, this construct was not able to predict CCS behavior. In other words, women did not undergo CCS despite the knowledge. Similarly, in another study, awareness-raising did not manage to predict a higher CCS behavior . Arguably, although awareness-raising is not directly related to the burden of CCS behavior, it indirectly affects the increasing rate of CCS by affecting other constructs. Knowledge has been mentioned as an important factor in the success of disease prevention programs. Familiarizing participants with the cause of a disease along with an early diagnosis of the disease can be an important step in changing patients’ behavior. In this regard, a study in Iran showed that by promoting knowledge about the causes of cervical cancer, and its potential consequences Iranian women can be encouraged to show behaviors that prevent cervical cancer .
The present study showed an increase in the mean attitude score of IG compared to the CG. Another study also confirmed this finding, in which the educational intervention affected women's attitude toward CCS [5, 20, 27]. Unlike the present study, in a work of research, the educational intervention did not manage to affect women's attitude . Demographic characteristics, duration and type of educational intervention can be among the possible reasons for this discrepancy. In our study, attitude was one predictor of CCS behavior. It points to the fact that a theory-based and targeted educational intervention managed to raise awareness (increase women's susceptibility to and understanding of the potential consequences of cervical cancer). Controlling barriers such as the cost of screening and knowing the reliable screening sites can positively affect women's attitude. A qualitative study showed that creating a positive attitude towards screening behavior may encourage Iranian women to engage in cervical cancer prevention behaviors .
The mean subjective norms score of the IG increased significantly compared to the control group. Similarly, in other studies, educational interventions managed to affect subjective norms [20, 27]. Although our educational intervention affected subjective norms, this construct did not predict CCS behavior. Contrary to our research, in another study, subjective norms showed to predict CCS behavior of . One possible reason for this discrepancy could be the study design. Because our research was interventional while Moradi’s research was cross-sectional. Of note is that the participants selected for training (among women's acquaintances) were not the same people as those popular among the participants. Thus, they did not manage to adequately affect women's behavior. It is suggested in future research to ask each participant to choose an influential person in life so that the educational intervention can prove effective.
In the present research, the mean score of enabling factors in the IG was significantly increased compared to the CG. Similarly, another study showed that the educational intervention was able to increase the mean enabling factors score for CCS . In one study, women who were more aware of screening sites and those who were screened for free were more likely to seek screening services . In addition, enabling factors could predict screening behaviors in women, which was somewhat predictable because, in our study, free CCS and raising women's awareness of screening sites and the like were used to control the enabling factors.
As we found, the IG intended more to show CCS behaviors than the CG. The between-group difference was statistically significant. Similarly, a body of research showed the success of educational interventions in increasing the intention to perform CCS [11, 27, 33]. Contrary to our findings, in another study, educational intervention had no effect on intention to CCS . The difference in the type of theory used can be one reason for divergent findings. In our study, the enabling factors, as a construct within the BASNEF model, were used as a catalyst between intention and actual behavior. It can help change intention to actual behavior. It is noteworthy that not all women who intended to undergo screening underwent it actually. Behavior has been considered by researchers in the present study, so in future research, if all barriers are considered and based on those barriers, resources and facilities (enabling factors) are moderated, we will act to a large extent in turning the intention into a successful behavior.
Our findings showed that the CCS rate in the IG was increased significantly compared to the CG. Women in the IG underwent the Pap smear test almost twice as frequently as women in the CG. In agreement with this finding, some other studies showed that educational intervention can improve CCS behavior [5, 27]. Contrary to our finding, in another study, educational intervention had no effect on CCS behavior [20, 28]. Different socio-demographic characteristics of research populations, educational content and types of model used are among reasons for this discrepancy. The success of this study in improving the acceptance of CCS can be attributed to several facts. First, the population had very little previous knowledge of CCS in the prevention of cervical cancer, which increased significantly after the intervention. Freeing up the screening program was one enabling factor and theoretical and purposeful training through peers, gynecologist and experienced health education specialist were among other reasons that can be brought. In addition to success in promoting the acceptance of CCS, it is noteworthy that a number of women in the IG did not undergo screening despite the training. Arguably, the participants’ demographic characteristics may have influenced whether or not they intended to go for the CCS. For instance, one study reported misconceptions about old age and menopause as the potential reasons for reducing women's susceptibility to cervical cancer. It could adversely affect their screening behavior .
Limitations and Strengths
This study had several limitations that need be mentioned. It was quasi-experimental in design and used a convenience sampling method. Because participants were not randomly assigned to the IG and CG, interpretation of the results should be done with caution. The pre-test, post-test and selection of the matched control group partially made up for this limitation.
This research was conducted in a southern province of the country, which may not represent the total population of Iran, but the results can, with caution, be generalized to the southern cities of Iran with similar cultural contexts. Contamination between the two groups was another potential limitation of this study. Possibly, participants in the IG had access to the intervention information through acquaintances and women in the IG. However, the statistically significant between-group differences largely removed this bias. The strengths of this study are the inclusion of a matched control group, interpersonal educational intervention (intervention by important and influential people, empowering resources), and inclusion of a three-month follow-up. The present study, in a short time with minimal facilities, managed to provide important information to policy makers in adopting cervical cancer preventive behaviors. These results could potentially be used in similar settings to increase the rate of low-resource CCS.
Recommendations for further research
In our study, though a number of women in the IG received a type of educational intervention in similar circumstances, they did not perform a Pap smear test as expected. Probably, the barriers to successful CCS may be beyond participants’ and researchers’ control. In another study, from a wide list of reasons for not screening for cervical cancer, the majority of women selected the other option. It shows that the options listed were not comprehensive enough and the barriers were more than already anticipated and enlisted . It seems that more comprehensive and multi-level educational interventions can better manage to change women’s behavior. Thus, it is recommended to assess a research population’s educational and cultural needs before any interventional measures, because behavioral and environmental factors might impede women from the CCS. These factors need to be identified to guide the design of systematic and effective educational interventions at different levels (personal and interpersonal). Qualitative research can help further identify barriers to screening in the target population so as to overcome them. It is also suggested that future research use ecological models that take into account environmental factors in addition to individual factors to further increase the rate of CCS.