This descriptive-analytical, cross-sectional study was conducted in Fasa in 2016. Out of the six healthcare centers in Fasa, two were selected through simple random sampling. Then, based on the lists of the households covered by each center, 350 people were selected from each center via simple random sampling (700 people in total) and were enrolled into the research. In doing so, two researcher’s assistants were present in the healthcare centers, provided the eligible women with the necessary information, invited them to take part in the research, and obtained their written informed consent forms. The inclusion criteria of the study were being married, aging above 21 years, passage of at least three years from marriage, not having the history of cancer and hysterectomy, and not having done the Pap smear test during the past three years. The exclusion criterion of the study was absence in the three-month follow-up.
At first, a cross-sectional study was conducted on 700 participants. The participants were requested to fill out the demographic information and theory of planned behavior questionnaires(14). The results were analyzed and the educational intervention was designed. Then, the educational intervention was conducted in form of a workshop for 50 women as the intervention group, and 50 women were considered as the control group.
The study data were collected using an instrument including three sections, which was prepared based on the previous studies(14). The first part of the questionnaire contained demographic information, such as age, number of children, age at the first pregnancy, history of performance of the Pap smear test, occupation, education level, menopause status, and family history of cervical cancer. The second and third parts of the questionnaire consisted of questions about knowledge and the constructs of the theory of planned behavior. Knowledge was assessed by 15 yes/no questions (yes = 1, no = 0). Attitude was evaluated by six items (e.g., Annual performance of the Pap smear test reduces the probability of cervical cancer) responded via a five-option Likert scale ranging from completely disagree (1) to completely agree (5). Subjective norms of the persuasive person for performance of the Pap smear test were determined by five items (e.g., My husband persuades me to perform the Pap smear test on a regular basis) responded through a five-option Likert scale ranging from very low (1) to very high (5). Perceived behavioral control was measured by two items (e.g., Performance of the Pap smear test is difficult for me) responded using a five-point Likert scale ranging from very low (1) to very high (5). Intention to perform the Pap smear test was also evaluated using two items (e.g., I intend to perform the Pap smear test this year) responded via a five-option Likert scale ranging from very low (1) to very high (5). Finally, screening behaviors and performance of the Pap smear test were assessed via two items whose scores ranged from 2 to 18. The content validity of the questionnaire was assessed by 18 health education specialists, one MSc of midwifery, and one gynecologist. Considering Content Validity Ratio (CVR) and Content Validity Index (CVI), the necessary modifications were applied and the indices were confirmed. Moreover, a pilot study was conducted on 30 eligible women and the reliability coefficients of attitude, subjective norms, behavioral intention, and perceived behavioral control constructs were found to be 0.74, 0.75, 0.65, and 0.76, respectively.
After all, the study data were entered into the SPSS 22 software and were analyzed using Pearson’s correlation coefficient and logistic regression analysis. P < 0.05 was considered to be statistically significant.
The educational intervention was conducted through lecture, group discussion, question and answer, educational pamphlets and posters, movie, and PowerPoint in form of three 45-minute sessions. The educational sessions were held once a week. In the third session, physicians, healthcare staff, and the participants’ husbands were present as subjective norms. The educational content included cervical cancer, importance of performing screening behaviors, probable obstacles against the performance of the Pap smear test, and strategies for overcoming individual and environmental barriers. The intervention was carried out through face-to-face training, group discussion (about beliefs, positive and negative outcomes of the behavior, facilitators, motivation to follow the significant others, and subjective norms), educational pamphlets, and PowerPoint. In addition, an educational movie on how the Pap smear test is done was shown to the participants. The discussions were directed towards the identification of positive beliefs and attitudes so as to promote positive motivation for performance of diagnostic measures, particularly the Pap smear test, and provide the ground for development of a positive attitude or modification of the negative attitude regarding the uncontrollability of the disease. Moreover, common wrong beliefs about the Pap smear test were put into debate so as to reduce the intensity of wrong beliefs by modifying the participants’ beliefs and attitudes. At the end of the educational sessions, the participants were provided with an educational booklet. Besides, a WhatsApp group was created for information sharing. An SMS was also sent to the participants once a week. In the control group, however, the participants were only provided with the educational booklet. All participants were followed up three months after the educational intervention and the theory of planned behavior questionnaire was completed for them again. Furthermore, they were required to send the results of their Pap smear tests to the researcher in case they did the test. After all, the data were entered into the SPSS statistical software and were analyzed via logistic regressions analysis, paired t-test, independent t-test, chi-square test, and McNemar test.
This study was approved by the Research Council (code: 95094) and Ethics Committee (IR.FUMS.REC.1396.187) of Fasa University of Medical Sciences. It was also registered in the Iranian Registry of Clinical Trials (IRCT20160830029608N3).