Introduction
A Papanicolaou (Pap) test is used in the prevention of cervical cancer as a simple and inexpensive cervix cytological examination. The test allows the lesions to be detected in the early stages [1, 2]. The basic condition to take material from the cervix is to report to the specialist and voluntarily undergo the medical examination. In order to obtain tangible effects, the screening test in the cytological examination should be repeated regularly. The frequency of having a Pap test depends on the individual assessment of a woman’s health situation and meeting specific eligibility criteria.
In Poland, despite the implementation of the programme of cervical cancer prevention, currently funded with public funds in the form of three stages [3], satisfactory results are not achieved [4]. According to the specialists, still too low a percentage of Polish women have a Pap test [4–6]. This situation results from various reasons; one of them is insufficient knowledge of cervical cancer and low attendance in the programme [4]. To understand the behaviour of women and their lack of recommended attitudes in the scope of cervical cancer prevention is a valuable source of information which should be taken into consideration in making some revision to the programme in the future. It is believed that an important factor in increasing women’s participation in prevention programmes can be achieved by improving their health awareness [7–10].Aim of the research
The aim of the study was to analyse the behaviour of women in the scope of cervical cancer prevention. Material and methods
The research was conducted with 210 women, aged 18 to 73 years. The average age for all respondents was 45.5 years. In connection with the low rate of interest of respondents in individual years of age, four age groups were used. Percentages of women in particular age classes were as follows: 1: ≤ 35 years (21.9%); 2: 36–45 years (24.8%); 3: 46–55 years (37.6%); and 4: ≥ 56 years (15.7%). Among the respondents, 52.4% of women had secondary education and post-secondary education. The percentages of women who had a higher education (23.8%), and primary or vocational education were the same (23.8%). According to place of residence, respondents were divided into three groups: 1 – living in country areas (36.7%); 2 – living in a city of up to 100 thousand inhabitants (≤ 100 thousand inhabitants) – 27.6%; 3 – living in a city of over 100 thousand inhabitants (> 100 thousand inhabitants) – 35.7%. The research used the diagnostic poll method, using the author’s original questionnaire form. The research was carried out in four gynaecological wards in hospitals in Kielce. In the research the following criteria were used to select respondents: 1) hospitalization due to illness or diseases of reproductive organs (pregnant women and those who had a miscarriage were excluded from this analysis); 2) the age of 18 (lawful age); 3) staying in the ward for at least three days; 4) getting consent to participate in the research.
Statistical analysis
Statistical Package for Social Sciences (version 12.0) was used to compute statistical analyses. The significance of differences between categorized groups (according to place of residence, age and education) was evaluated with the chi-square test of independence (c2). A level of p < 0.05 was considered statistically significant. Results
From the analysis of given answers as shown in Table 1, it follows that 83.3% of women had a Pap test. 16.2% of respondents by the time of diagnosis had never received a Pap test. In the research significant differences among participants were found depending on education (p < 0.05) and place of residence (p < 0.001). Women with the lowest level of education (primary, vocational education) and respondents living in the country more rarely had a Pap test than women with a higher education and living in big cities (> 100 thousand inhabitants). Detailed data are shown in Table 1.
The group of respondents was asked for any reasons why the material from the cervix was never taken for a Pap smear. The analysis showed that 88.2% of women had not reported to a specialist to have a smear test (Table 2). 11.8% of participants were referred to a doctor for taking a Pap test but did not report to the specialist. In the analysed group were women living in country areas, aged 46–55, and women with primary, vocational and secondary school education. The numbers were small in percentage terms and did not allow for a statistical assessment in the above-mentioned group.
Of the women who participated in the research, 35.7% had received a Pap test regularly, once a year or once every 2 years (Table 3). 33.3% had difficulties to describe when they had a Pap test (did not remember). The third group of 16.2% consisted of women who have never had a Pap test. Every 3 years or less than that, 14.8% of women reported to the gynaecologist for a smear test. In terms of the analysed feature the differences in the proportion of respondents by age class were not significant. Statistically significant relations occurred between respondents who were divided depending on education (p < 0.01) and place of residence (p < 0.001). Women with a higher education more often and on a more regular basis had a Pap test, i.e. once a year or once every 2 years, than women with the lowest education (primary, vocational) – 16%. Similar results were achieved between occupants of villages (18.2%) and big cities (> 100 thousand inhabitants) – 50.7%.
The majority of women who had had a Pap test were those who reported to the doctor for a smear test on the doctor’s initiative (64.8%), especially the gynaecologist (61.4%) (Table 4). The family physician or nurse was mentioned only by 3.4% of respondents. On their own initiative 35.2% of women had a Pap test. The proportion of respondents did not differ with regard to age and place of residence, while significant differences were found between participants depending on education (p < 0.05). It was found that the higher the category of education the higher was the percentage of women who had a pap test on their own initiative.Discussion
According to the Central Statistical Office (GUS) in 2009 6,147 Polish women died because of malicious tumours of reproductive organs, among which cervical cancer caused the death of 1,748 women [11]. Compared with 2008, indicators mentioned above were at a similar level [12]. Although intensive prevention has been conducted for many years against cervical cancer, performed in accordance with the rules at a specific period of time [3, 13, 14], radical improvement of the epidemiological situation of cervical cancer was not achieved. Still the number of deaths per 10 thousand population due to cervical cancer for several years has remained at a high level (2000 – 1.0; 2005 – 0.9; 2008 – 0.9) [11].
The benefits and advantages of cytology in the prevention of cervical cancer are confirmed by many specialists [15–17]. It is necessary to remember that to have a Pap test a woman has to report to the doctor. The research showed that by the time of diagnosis of the reproductive organ disease 16.2% of women had never had a smear test. Similar results were obtained by Binkowska and Dębski. In a group of 1,083 Polish women, aged 45–54 (chosen at random), almost one out of four tested women (24%) for more than
10 years had not had a Pap test, or some declared that they had never had one in their life [18]. Also Kozimala et al. mentioned low attendance of women towards the prevention of cervical cancer [19]. Two thousand two hundred and two women were invited for a smear test and only 577 of them (26.2%) had this test. The remaining 73.8% of women did not take advantage of having a Pap test [19]. Other authors in their reports also confirmed the lack of regular and satisfactory reporting to a doctor by Polish women to take material from the cervix [10, 20, 21].
Detailed data concerning the frequency of reporting to the doctor for a smear test showed the real picture of women’s attitudes towards cervical cancer prevention. The research showed that 35.7% of women, once a year or once every 2 years, had reported to the doctor for a Pap test and that it depended on education and place of residence of respondents. However, according to estimates of Filip et al., in Poland, after several years of the regular screening programme only 12% of women are having a Pap test [22].
The presented data have to be recognized as unsatisfactory; thus the functioning programme needs to be urgently modified. It should be noted that only implementation of a long-term nationwide and population survey system of screening tests can decrease the incidence of cancer in women [21–23]. In many countries, as a result of a well-functioning screening programme, morbidity and mortality rates of women with cervical cancer have been radically reduced [2, 9, 10, 16, 23–25]. However, in many countries where due to numerous obstacles and restrictions women rarely or never participate in prophylaxis, the factors mentioned above remain at a high level [1, 7].
Based on material gathered in the research it must be noted that the actions taken by the respondents and attitudes towards cervical cancer prevention were insufficient. It would appear that if the methods which give a woman freedom of choice failed, other ways of increasing women’s behaviour in cervical cancer prevention should become widespread. Considerable mobilisation of Polish women for regular health checks of reproductive organs can be obtained by introducing an obligation to undergo gynaecological examinations at the periodic physical examination of employees. At least in the subpopulation of working women 100% attendance can be gained. It should be noted that each examination may also be an opportunity for health education, because improvement of the health situation of girls and women in Poland should be carried out to increase the level of health awareness.
Developing specific skills in the scope of health prophylaxis and motivation to take responsibility for women’s own health could be introduced to the curriculum of secondary schools. The implementation of this plan can be effective and girls can improve their knowledge, education, self-control and individual activity in the scope of prophylaxis and therapy. These activities and other recommendations have already been proposed by experts [21, 26].
It is important to conduct a sustained information campaign and various forms of health education [1, 2, 7–9, 26]. The aim of these actions is to increase the participation of women in prophylaxis and to prevent the morbidity and mortality caused by cervical cancer.
In conclusion, this study should also provide opinions of specialists, which should be regarded as a warning and a challenge for people deciding on the implementation of prophylactic programmes in Poland. Considering the above problems, according to Didkowska et al., if intensive action is not taken, women’s health may be jeopardized, as it was in Finland 25 years ago [27]. Also Spaczyński et al. in the Report of the Realisation of the Population Program of Cervical Cancer Early Detection evaluated the effectiveness of action taken in the scope of this programme. According to the authors, obtaining effective screening methods in Poland requires many years of work [4].Conclusions
The effort made by the women towards the attitudes of cervical cancer prevention was insufficient; still too many women had not reported to the specialist for taking material from the cervix, or did not do so regularly. A significant relation in the behaviour of women was found depending on their level of education and place of residence. Greater activity of nurses, midwives and family physicians in stimulating Polish women to participate in prevention programmes for cervical cancer is advisable. To increase the health awareness of girls and women, it is important to include in the curriculum, especially in secondary schools, the issues of prevention of female reproductive system cancer.References
Mupepi SC, Sampselle CM, Johnson TRB. Knowledge, attitudes, and demographic factors influencing cervical cancer screening behavior of Zimbabwean women. J Women Health 2011; 20: 943-952.
1. Hansen BT, Hukkelberg SS, Haldorsen T et al. Factors associated with non-attendance, opportunistic attendance and reminded attendance to cervical screening in an organized screening program: a cross-sectional study of 12,058 Norwegian women. BM Public Health 2011; 11: 264.
2. Rozporządzenie Ministra Zdrowia z dnia 18 lutego 2011 r. zmieniające rozporządzenie w sprawie świadczeń gwarantowanych z zakresu programów zdrowotnych. Dz.U. nr 52, poz. 271, 3301.
3. Spaczyński M, Michalska M, Januszek-Michalecka L. Raport z realizacji Populacyjnego Programu Profilaktyki i Wczesnego Wykrywania Raka Szyjki Macicy za okres 01.01.2008 do 31.12.2008. Ginek Pol 2009; 80: 220-226.
4. Nowakowski A, Nowakowska H, Kotarski J. Profilaktyka raka szyjki macicy. Możliwości i ograniczenia postępowania ginekologów oraz lekarzy POZ. Lek Rodz 2007; 12: 76, 78-80, 84-85.
5. Rekomendacje Polskiego Towarzystwa Ginekologicznego dotyczące diagnostyki, profilaktyki i wczesnego wykrywania raka szyjki macicy. Prz Menopauz 2006; 4: 198-201.
6. Nwankwo RC, Aniebue UU, Aguwa EN et al. Knowledge attitudes and practices of cervical cancer screening among urban and rural Nigerian women: a call for education and mass screening. Eur J Cancer Care 2011; 20: 362-367.
7. Hislop TG, Teh Ch, Lai A et al. Pap screening and knowledge of risk factors for cervical cancer in Chinese women in British Columbia, Canada. Ethnicity Health 2004; 9: 267-281.
8. Hawkins NA, Cooper CP, Saraiya M et al. Why the Pap test? Awareness and use of the Pap test among women in the United States. J Women Health 2011; 20: 511-517.
9. Nowicki A, Borowa I, Maruszak M. Zachowania zdrowotne kobiet w zakresie zapobiegania, wczesnego wykrywania stanów przedrakowych i raka szyjki macicy. Ginek Pol 2008; 79: 840-849.
10. Rocznik demograficzny. GUS, Warszawa 2011.
11. Rocznik demograficzny. GUS, Warszawa 2010.
12. Rozporządzenie Ministra Zdrowia z dnia 21 grudnia 2004 r. w sprawie zakresu świadczeń opieki zdrowotnej, w tym badań przesiewowych oraz okresów, w których te badania są przeprowadzane. Dz.U. 2004 nr 276, poz. 2740.
13. Rozporządzenie Ministra Zdrowia z dnia 30 sierpnia 2009 r. w sprawie świadczeń gwarantowanych w zakresie programów zdrowotnych. Dz.U. 2009 nr 140, poz. 1148.
14. Malarewicz A. Cytologiczne badania przesiewowe raka szyjki macicy u kobiet i ich znaczenie w okresie po menopauzie. Prz Menopauz 2003; 5: 27-30.
15. Monsonego J. Screening and prevention of cervical cancer. Future directions and new stakes. Kolposkopia 2001; 2: 1-6.
16. Syrjanen K, Erzen M, Syrjanen S. Cervical cancer control by organized screening. Issues to be considered in designing a national programme control. Kolposkopia 2001; 1: 95-116.
17. Binkowska M, Dębski R. Profilaktyka raka szyjki macicy w populacji kobiet polskich w wieku od 45 do 54 lat. Ginek Pol 2005; 76: 863-870.
18. Kozimala M, Mrozowicz A, Ciechaniewicz W. Program badań profilaktycznych ukierunkowanych na zdrowie kobiet – ocena realizacji w powiecie lubaczowskim. Zdr Pub 2007; 117: 462-465.
19. Barnaś E, Borowiec-Domka E, Kądziołka J et al. Czynniki wpływające na zgłaszalność kobiet z Podkarpacia na badania cytologiczne w ramach Ogólnopolskiego Programu Profilaktyki Raka Szyjki Macicy. Probl Hig Epidemiol 2008; 89: 482-486.
20. Spaczyński M, Nowak-Markwitz E, Januszek-Michałecka L et al. Profil socjalny kobiet a ich udział w Programie Profilaktyki i Wczesnego Wykrywania Raka Szyjki Macicy w Polsce. Ginek Pol 2009; 80: 833-838.
21. Filip R, Ciurysek M, Schabowski J. Rola lekarza rodzinnego w profilaktyce raka szyjki macicy. Fam Med Prim Care Rev 2009; 11: 595-596.
22. Łoś J. Skryning cytologiczny raka szyjki macicy. Ginek Prakt 2006; 88: 10-14.
23. Roland KB, Larkins ChTL, Benard VB et al. Content analysis of continuing medical education for cervical cancer screening. J Women Health 2010; 19: 651-657.
24. Adamczyk-Gruszka O, Niziurski P, Gruszka J. Rola badań cytologicznych w profilaktyce raka szyjki macicy. Stud Med 2012; 25: 31-36.
25. Rekomendacje Polskiego Towarzystwa Ginekologicznego i Funduszu Ludnościowego Narodów Zjednoczonych (UNFPA) w sprawie zdrowia reprodukcyjnego. Racot, 26-28 marca 2004. Ginek Dypl wyd. specjalne 2005, 20-23.
26. Didkowska J, Wojciechowska U, Zatoński W. Nowotwory szyjki macicy w Polsce – epidemiologiczny bilans otwarcia i perspektywy. Ginek Pol 2006; 77: 660-666.
Address for correspondence:
Aleksandra Słopiecka MD
Department of Psychology and Medical Pedagogy
Institute of Public Health
Faculty of Health Sciences
Jan Kochanowski University
al. IX Wieków Kielc 19, 25-317 Kielce, Poland
E-mail: aleksaonet@op.pl
