Cervical Cytological Examination : Perceptions of Women Attended in Primary Health Care

Camila Ferreira da Silva1, Maria Isabelly Fernandes da Costa2, Kamila Ferreira Lima3, Wanderson Alves Martins4, Maria Nilcineide de Sousa Camurça5, Francisca Andrea Marques de Albuquerque5, Viviane Mamede Vasconcelos6, Patricia Neyva da Costa Pinheiro7, Mirna Albuquerque Frota8, Karla Maria Carneiro Rolim9, Raelson Ribeiro Rodrigues10, Izaildo Tavares Luna11, Luiza Luana de Araújo Lira Bezerra12 1 Nurse. Graduated by Faculdade Integrada da Grande Fortaleza (FGF). 2 Nurse. Student of Nursing Postgraduate Program, Master Student level, Federal University of Ceará, Fortaleza, Brazil. 3 Nurse. M.A. Student in Nursing by Universidade Federal do Ceará (UFC). 4 Nurse. Post Graduating in Oncological Nursing and in Health Science Teaching by AVM Faculdade Integrada. 5 Nurse. Specialist in Family Health by Universidade Federal do Ceará (UFC). 6 Nurse. PhD in Nursing by Universidade Federal do Ceará (UFC). 7 Nurse. PhD in Nursing by Universidade Federal do Ceará (UFC). 8 Nurse PhD by Rouen University, France (CHU/ROUEN) and by the Instituto de Saúde Coletiva (ISC) of Universidade Federal da Bahia (UFBA). 9 Nurse. PhD by Rouen University, France (CHU/ROUEN). Professor and Coordinator at Universidade de Fortaleza (UNIFOR). 10 Nursing undergraduate student at Universidade Federal do Ceará (UFC). 11 Nurse. PhD in Nursing in Health Promotion by Universidade Federal do Ceará (UFC). 12 Nurse. Master in Collective Health by Universidade Estadual do Ceará (UECE).


Introduction
Cervical cancer (CC) is the third type of cancer with higher incidence in women worldwide, representing approximately 9% of the cases, and in developing countries it is the most common cancer in this group [1].With estimated 529,000 cases and 275,000 deaths per year in the world, CC load varies considerably among countries, with more than 85% of overall cancer load distributed in low or middle-income countries [2].
In Brazil, for the year 2016, 16,340 new cases of CC are estimated, representing the second most common cancer among women, with calculated risk of 15.85 cases every 100,000.In Ceará, the expected incidence of CC for the same year is of 20.62 cases every 100,000 women [3].
There are several risk factors for the development of this cancer, among which are: infection by human papillomavirus (HPV); smoking; multiplicity of sexual partners; low socioeconomic condition; use of oral contraceptives; multiple births; low intake of vitamins; early sexual initiation; and co-infection by others (HIV) [4].
However, the World Health Organization (WHO) recommends strategies for reduction of cases, as early diagnosis and tracking by means of cytological examination of the cervix in an apparently healthy and asymptomatic population, in order to identify precursor lesions or lesions suggestive of cancer, and forward them to investigation and treatment [5].
The cytological examination of the cervix or Pap smear is available, in Brazil, in Primary Health Care (PHC), due to importance of these units in promoting health and potential to attend women who otherwise have no access to the examination.The test is offered to women aged 25 to 64 years who had had sexual activity, with the recommendation that cytopathological examinations should be performed annually, and after two consecutive examinations with negative results, every three years [6].
In spite of the initiatives to control CC, the high rates represent a challenge for public health.Preventive measures, such as Pap smear offered for free in Family Health Units, have not been sufficient to significantly reduce the morbidity and mortality for the disease in Brazilian women [7].
It is believed that the manner in which the professional receives the patient and how the patient perceives the checkup are factors that are related to the non-participation in smear examination in Brazil, and with consequent increased levels of cervicaluterine cancer.Female perception about the exam, in turn, is influenced by cultural and social factors, values, beliefs, experiences and preconceived ideas built throughout life, impacting on women's adhesion to the examination [8].In this context, it is observed that the ignorance about the disease and the preventive exam, and the communication between the woman and the health professional may influence the woman's decision to take the examination [9].
Thus, increasing knowledge on women's understanding about the cytological examination of the cervix can subsidize interventions aimed at higher adhesion to the procedure, resulting in the reduction of the rates of morbidity and mortality from CC.In this perspective, the objective of this study was to investigate the conceptions of women about the prevention of cervical cancer, to identify the factors that influence the adhesion of women to the exam and to describe the role of the nurse in gynecologic consultation under the optics of the patients.

Methods
This study was descriptive, with a qualitative approach, carried out in a Primary Health Care unit (PHC) in the city of Fortaleza, State of Ceará, Brazil, with 22 women who were waiting for medical attendance.The women attended in the morning and afternoon shifts were included in the study, belonging to the age group of 25 to 64 years and with a history of at least one cervical cytological examination.
Data collection was carried out in October and November 2015, through semi-structured interviews, composed of two stages: demographic data and guiding questions, formulated as follows: What do you know about the Pap exam?In your opinion, what is the importance of preventive examination?What reasons make it difficult to take the preventive examination annually?How do you experience a gynecologic nursing consultation?
The interviews were carried out individually by the interviewer in a private room, recorded and stored in digital recorder.All the empirical material was submitted to the adaptation of content analysis in its thematic mode, which consists of unveiling the nuclei of senses that form the communication, which frequency of appearance can have meaning with the surveyed object.Coding has been applied, the themes were detected and later arranged in categories, which were submitted to analysis based on the literature [10].
The study was submitted to the Research Ethics Committee of the Institute of Health and Hospital Management -ISGH in Portuguese, having been approved according to paragraph 1,241,804, complying therefore with national and international standards of ethics in research involving humans.To preserve the anonymity, the answers were codified by the letter E, plus an Arabic number.

Results and Discussion
Regarding the characterization of the interviewed, the average age was 45 years, ranging from 25 to 60 years, with medium level education, and subtle difference between those who were attending school and those who had concluded their education.With regard to civil status, the majority were married or widowed, in stable relationships and performing remunerated activity.
The low educational level is considered a risk factor for the development of CC; however, this was not the case in this study, in which there was a considerable education level among the participants, when considering that the average educational level of the Brazilian population of 10 years of age or more, for the year 2009, was 7.2 years of study [11].
From the reports, it was possible to recognize three categories of analysis: Meanings attributed to cervical cytological examination and access to the exam; Barriers to the realization of periodic preventive examination of cervical cancer; Role of the nurse in the prevention of cervical cancer.

Meanings assigned to cervical cytological examination and access to the exam
About the participant's knowledge on cervical cytological examination, the reports revealed that they had some information, although incipient, about the purpose of the examination, as a measure for prevention of CC.However, they recognized the examination as a means of detection of other diseases.

It's for prevention of cervical cancer. It's very important, because it helps you discover some diseases, the sooner you can treat them, the better. You can find lumps, any contagious disease.
E5.

The exam detects any infectious disease and cervical cancer.
E12.
Similar findings were reported in a study with 250 women attended at PHCU in Brazil, where it was found that 40.4% of these women had adequate knowledge about Pap smear.Only 54.8% knew that the exam was performed to prevent CC and only 10.0% cited the prevention of CC as reason for its realization [12].
Another study conducted in Northeastern Brazil with 493 women showed that 94.5% of them had heard about the preventive examination of CC, though only 36.7% presented adequate knowledge about it.The health professional was cited by 44.2% of the participants as the main source of information about the examination [13].Thus, performing health education activities is a matter of urgency, in order to clarify women on preventive examination of CC.
The deficiency in knowledge about the smear examination was revealed in the statements of the participants, who associate the relevance of the exam as a measure of prevention of diseases related to the reproductive system, with mention of sexually transmitted infections (STIs): It is important to detect venereal diseases ... it is good to prevent ourselves against certain types of diseases.

E12.
Findings of a survey conducted in Southern Brazil PHCU corroborate this study, with the fact that women seek, through the examination, other diagnoses, for believing that prevention of CC can confirm the existence of diseases as HIV and STIs [14].Although HPV is the main factor for the development of CC, only one of the participants noted the importance of the examination for its detection: Several risk factors can be associated with HPV and can influence the persistence or regression of the virus, as early sexual initiation, multiplicity of sexual partners, multiple births, use of oral contraceptives, smoking, immunosuppression, inadequate hygiene and low socioeconomic condition [15].
Therefore, in addition to offering only the exam, it is necessary to recognize that women need clarification as to the importance of early detection of CC, as well as information regarding the etiology of the disease, focusing on the risks of exposure to STIs, including HPV.Health guidelines that allow decision-making must reach beyond the surface, which requires professional training and knowledge to carry out efficient actions in health education [16].
It is essential that health professionals responsible for conducting preventing examination of CC undertake the role of educators in health [17].It is worth noting that despite the incipient knowledge, women stressed the importance of early diagnosis and its relation with greater chances of cure.
To prevent early some kind of cancer, because if I detect it early, I have more chances to be healed, the chances are greater. E3.

It is... because cancer is much in evidence and with the preventive examination the doctor can detect it.
E15.
Tracing in asymptomatic women through Pap smear is the most used and highly effective strategy that results in the control of CC.This strategy of early detection allows to obtain the cure in 100% of cases diagnosed at early stage [6].It was observed that most women sought Basic Health Units annually for examination: I take it every year, I do not put prevention aside.

E20.
The frequency of preventive examination is an event that can be associated with various cultural, social and political factors, which may or may not contribute to the implementation of health care for women in various levels of health care and promotion, especially in basic attention [18].
On this subject, a qualitative study carried out in a School Health Center has detected that there are many reasons that influence women not to perform the Pap smear, which include: lack of knowledge about cervical cancer, the technique and the importance of the preventive examination, fear of the examination and the result, sense of shame and embarrassment and, finally, difficulties to take the examination, being highlighted both the difficulty of access to the service and the reasons related to the role of women in caring for the house and the children [19].
Thus, for prevention of CC, in addition to the examination, it is necessary to understand its importance and to return to the health unit to follow up each case.In addition, monitoring, completing and continuing the process of prevention are considered fundamental to combat CC effectively [20].

Barriers to periodic preventive examination of Cervical Cancer
The main difficulties identified for the preventive examination of CC were the lack of time availability related to the inclusion of women in the labor market and the lack of vacancies in health services.

Lack of time and because there are no vacancies when I come.
E1.

I was careless, you forget to care and also because of work ... you think since you're not feeling anything, you don't have to come anymore, so I decided to come, I'm not feeling anything, but it's because I must do it.
E4.

I try to come to the unit, but I have to miss work and so it is difficult… I have to explain to my boss, who sometimes don't want to give me leave.
E15.
The inclusion of women in the labor market, in addition to the domestic activities of the daily life, can suppress the health needs, which are placed in the background.As a result, the preventive exam is no longer carried out periodically due to the absence of symptoms, being taken eventually or with the appearance of signs and symptoms characteristic of CC, which constitutes harm to women's health [21].
The periodicity of this examination, according to the recommendations of the Brazilian Ministry of Health is important because performing it irregularly or due to an abnormality is worrisome, since cervical cancer do not show symptoms in its early stages.Furthermore, it is stated that the early diagnosis and timely treatment increase the chances of curing CC [22].
The difficulty of access to health services was also considered to hamper preventive examination.Women stated that it was difficult to get an appointment in the PHCU and, when they were able to do it, the time was incompatible with their availability: It is a little complicated to get an appointment, and I have a job... when I arrived here they said: next month.But when I returned, there were no vacancies, and I returned again, and they also had no vacancies.

E3.
The timetables offered by basic health units to conduct gynecological collection are often incompatible with the working hours of women and, in addition, the amount of vacancies is insufficient, contributing to the non-accession to the examination [23].
They were supposed to offer vacancies until the evening so we could take our examination.

E15.
A survey conducted in a city in Northeast of Brazil, with women attended in primary health care, found that the difficulty in scheduling for lack of vacancies reveals itself as an institutional barrier to accessing the examination [20].Therefore, there is a deficiency in the service offered to users seeking the UAPS for quality assistance for prevention and early detection of CC, often causing low adhesion to preventive examination and the distancing of those who had already taken it.
Difficulties in accessing the service may be assigned both to problems in the management of local units and to the managers of each sphere of government, with regard to the establishment of a suitable assistance flow, since the manuals prepared by the Ministry of Health are not specific for each health unit, but to the national reality [24].

Role of the nurse in the Prevention of Cervical Cancer
When questioned about the experiences regarding gynecology nursing consultation, it became evident through the reports the importance of the role of the nurse as educator in health regarding the prevention of the CC.
At least with the nurse to whom I'm used to take the exam, she gives us a great deal of information.She likes to say that we take an examination for prevention, but that syphilis, sometimes is not detected, but when we do a blood test it is identified.

When I take it with the nurse, she guides everything, I shouldn't miss the consultations, because in my family my aunt died of breast cancer and another one of uterine cancer [...] we must return to get the result, she tells us precisely what we have.
E8.
The nurse, as a health professional, has a vital role in health education actions, therefore, elaborating educational strategies helps the prevention and improves the care provided to the patients [25].Furthermore, the guidelines held during the gynecologic consultation contribute to the empowerment of women in relation to the preventive examination of CC.
In addition to educating the public on how to prevent CC, clarifying the actions that must be performed by women before undergoing the examination becomes relevant, as not using creams or intravaginal showers, avoiding sex for 48 hours before the exam and not be menstruating, since the negligence of these cares interfere both in the examination and the result [26].
The most of the informers revealed positive aspects about the information given by the nurse during the gynecological examination.However, it was in evidence in the speech of one of the participants, a deficiency of information supply in previous examinations.
They could improve the information, because I'm full of doubts, when I was examined by the nurse, she was all about collecting the liquid, don't know where she puts it, I think she sends it to the lab.

E11.
The discomfort at the time of examination, the shame and the fear are recognized as factors that can lead some women not to take the examination [27].Other elements, such as carelessness, fear of going to the doctor, the absence of symptoms and lack of time were presented as individual components that may interfere with the adhesion to the examination [28].The guidelines made given during the consultations may reduce the development of misguided thoughts, which may interfere with the behavior of patients in relation to Pap smear.Some factors that interfere in nurse-patient communication are: the absence of exchange of information, being these verbal and non-verbal exchange, lack of transmission of feelings and emotions during consultation, usage of inappropriate language to the patient, inappropriate consultation time and excessive use of technical terms.The communication is relevant not only to meet the complaints, but also to establish a form of interaction between nurse and patient [29].

But my first appointment was deficient because she went straight for the exam and almost didn't talk to me.
E6.

InternatIonal archIves of MedIcIne sectIon: Global health & health PolIcy
ISSN: 1755-7682 An efficient communication requires interpersonal skills that go beyond the transmission of technical knowledge.Thus, the way the professional nurse communicates with the patient may influence the personal motivation to change behavior [30].
With respect to the importance of the habit of returning to the health unit to receive the Pap smear result, most participants showed positive knowledge, due to the guidelines received during gynecologic consultation.

E21.
A study on primary health care, which aimed to understand the knowledge, attitude and practice of women in relation to preventive examination of CC, found that 67.6% were classified as adequate practice, because they knew the correct time to perform the test and return to get results, corroborating the findings of the present study [12].
Poor guidelines may result in low awareness about the relevance of the Pap smear and in restricted access to health care.Therefore, it is due to Primary Care professionals, especially nurses, the coordination of services and the longitudinal tracking of users who are accompanied in the unit.Among the actions taken concerning the attention directed to CC control, those aimed at the prevention of STIs are of utmost importance, as well as those directed towards early detection of this neoplasy, including the dissemination of information to public about tracing [31].
It should be noted that difficulties in health are a complex issue that surpasses many aspects related not only to individual lives, but also the social aspects of the individual that are related to behavior and lifestyle [32].

Conclusions
The preventive examination of CC, despite being considered the gold standard for the prevention of this neoplasy, when isolated, proves to be insufficient, in particular regarding the co-responsibility of women in performing it in a timely manner.
The women attended at PHCU presented primary knowledge in relation to preventive examination of cervical cancer.In addition, it was noted the importance of the role of the nurse on the prevention of cervical cancer.The women's limited availability of time related to their inclusion in the labor market and the lack of vacancies in health services were obstacles to the realization of Pap smear.
It is concluded that health professionals, who work in primary health care must know the context in which women are included, as well as understand the meanings that they attach to the examination, so they can adopt effective interventions that increase access to preventive examination of CC and, therefore, reduce the mortality rates related to this neoplasia.
In order to improve the assistance of professionals working in primary care, it is suggested the conducting of researches aiming at the production and validation of educational technologies that can enhance knowledge and empower women and the professionals who work on preventive examination of CC.Finally, as a limitation of the present study, it is worth pointing out the analysis of women attended in only one health unit, making it impossible to generalize the results to other contexts.
She explains it properly, says to get the test results in about 40 days.It is important to guide us, she gives a cream if you get any injury, says people should use condoms, take proper care of themselves. E4.