Conceptions of women on cervical cancer screening

Despite the high prevalence and incidence of cervical cancer, this disease can be avoided and has great healing potential when detected at early stages. Cervical cancer screening is used in monitoring programs for early diagnosis and is considered safe and effective. This study aimed to analyze the conceptions of women on cervical cancer screening. A qualitative study was carried out with 30 women assisted in primary care, in Teresina, Piauí, Brazil. The Discourse of the Collective Subject was obtained from interviews carried out from August to October 2016. The speeches expressed the notions that women have about the significance of the screening test, the importance of undergoing the test, and prevention of cervical cancer. The conceptions of the interviewed women revealed that the test prevents diseases, including cervical cancer. However, the discourses left clear the lack of knowledge on HPV, its forms of prevention and cervical cancer. The analysis revealed that women have superficial or insufficient knowledge about the significance of the screening test and cervical cancer.


Introduction
Among the different types of neoplasia that affect women, cervical cancer (CC) has been prominent as a Public Health problem due to the high frequency of new cases, especially in developing countries.In Brazil, nearly 16,340 new cases were reported in 2016, with an estimated risk of 15.85 cases per 100,000 Brazilian women.In the northeastern Brazilian region, CC is the second most incident cancer in the female population (19.49/100 thousand women), second only to non-melanoma skin cancer (National Cancer Institute [INCA], 2016).Therefore, Brazil follows the pattern of other countries, with high CC incidence in states that have lower socioeconomic conditions that lead to large inequalities in access to prevention and control measures (Negrin, 2015).
Human Papillomavirus (HPV) infection necessarily precedes CC.Genital contamination by this virus is common and, most of the times, does not develop the disease.However, factors related to immunity and sexual behavior influence the mechanisms that determine the persistence of the infection and also the evolution to lesions that precede the cancer.Thirteen types of HPV have the potential to cause cancer, with a greater potential of Acta Scientiarum.Health Sciences, v. 40, e35898, 2018 inducing persistent infections.Types 16 and 18 are among the ones with highest oncogenic risk and are present in 70% of CC cases (Silveira et al., 2016).
HPV transmission occurs through the direct contact of genitals in the sexual intercourse.The interruption of the chain of transmission of the virus is indispensable.Several factors contribute to viral contamination, including multiple sexual partners, prolonged use of oral contraceptives, multiparity, sociodemographic aspects, inadequate intimate hygiene, early onset of sexual activity, smoking, early age of first sexual relation, low vitamin intake and co-infection with agents such as HIV and Chlamydia trachomatis (Barasuol & Schmidt, 2014).
Although CC is a neoplasm with high international and national prevalence and incidence, it can be avoided and has great healing potential when detected at early stages.Diagnosis and screening are among the strategies for early detection according to the World Health Organization.The Pap smear screening or cytological examination of the cervix is used in monitoring programs for early diagnosis of CC, being considered safe, effective, and low cost (Souza, Oliveira, Stevanin, Sousa, & Almeida, 2013).
The Pap smear testing performed by means of cytological collection is indispensable for identification of inflammatory and infectious alterations of the female genital tract.It is one of the most used tests to detect precursor lesions of CC, increasing the possibility of success of the treatment and reducing the occurrence of possible complications (Neri et al., 2013;Silveira et al., 2016).Therefore, the Pap smear is the screening method recommended as the preventive strategy worldwide.In Brazil, the target population corresponds to women between 25 and 64 years of age who have already initiated sexual activity.The test should be performed once a year, and after two consecutive annual examinations, every three years (National Cancer Institute [INCA], 2011).
Although Brazil was one of the pioneer countries to incorporate the Pap smear testing as a preventive strategy, there are still several factors that hinder its realization.Feelings of shame or embarrassment at the moment of collection, difficulty in scheduling a collection in the Unified Health System, fear of a positive result for CC or misinterpretation of the results are among these factors (Teixeira, 2015).In general, studies have shown that cultural, social, economic and behavioral factors are determinant for the non-adherence to the Pap smear test (Silva, Santos, Silva, & Amorim, 2013;Silva, Teixeira, Ferrari, Cestari, & Cardelli, 2015).
At the international level, a study carried out by the Ministry of Education of Greece showed that 60% of sexually active adolescents lacked knowledge about HPV infection, its forms of transmission and prevention, as well as of the risk of developing cervical cancer (Vaidakis et al., 2017).Similar results have been also found in other studies in Canada (Kiely, Sauvageau, Dubé, Deceuninck, & De Wals, 2011) and Europe (Hilton & Smith, 2011).
In this sense, it is very important that primary care professionals directly act in the promotion, prevention and health education of the population, considering the lack of knowledge of women about the HPV infection.The lack of awareness can lead to neoplastic lesions and CC, non-adherence to the preventive examination and the increase in the prevalence and incidence of CC, with relevant impact on Public Health.
In view of this need, it is relevant to investigate the knowledge that these women have about cervical cancer screening.Primary health care professionals are fundamental in this process of enlightenment, acting not only to prevent and/or avoid the neoplasia, but also to reinforce the self-care of the target public.
To that end, the research question that guided the development of this study was: What are the conceptions of women about cervical cancer screening?Thus, this study aimed to analyze the conceptions of women about cervical cancer screening.

Material and methods
This is a descriptive study with qualitative approach selected as a result of the nature of the focused object, namely: the conceptions of women on cervical cancer screening.
The setting of this research was the Basic Health Units (BHU) of the South, Center/North and East/Southeast Regional Health Directories of the Municipal Health Foundation, located in the city of Teresina, Brazil.Teresina, the capital of the state of Piauí, is located in the center-west of the state and midnorth of the Brazilian Northeast.It has an approximate area of 1,756 km².The population is 844,230 (380,612 men, 40.6%, and 433,618 women, 59.4%), with 767,557 people living in the urban area and 46,673 in the rural area (Brasil, 2012).The structure of the assistance offered at the BHUs in the city of Teresina is based on the Family Health Strategy (FHS), which currently operates with 260 Family Health teams of professionals, including physicians, nurses, nursing technicians and community health agents and oral health professionals.The FHS is considered the main strategy for the structuring of primary care, the main entry point to the Unified Health System (SUS) (Fausto, Giovanella, Mendonça, Seidl, & Gagno, 2014).
To select the participants of this study, the following inclusion criterion was established: women aged between 25 and 64 years (according to the recommendation of the Ministry of Health for the Pap smear screening test) undergoing the preventive examination at the FHS Basic Health Units in the period of data collection.Women who had not started sexual activity and those who had disabilities preventing them to participate in data collection, such as hearing and/or visual impairment, were excluded.
The number of women participating in this study was not previously established due to the nature of the qualitative approach, which seeks to address the depth of the meanings present in the speeches, the recidivism and saturation of the information collected (Minayo, 2017).The sample size was determined by the accumulation of conceptions of women on cervical cancer screening acquired during their life-time experiences; thus, the sampling ended when the objective of the study was reached and the questions of the researchers were answered.Thus, 30 women participated in the study.
In order to obtain the empirical material, interviews were carried out and recorded in a reserved room in the BHU, with closed door, good lighting and ventilation, and the presence of researchers only, on Tuesdays and Thursdays, 2:00 p.m. to 5:00 p.m., from August to October 2016.These interviews were transcribed in full-length and guided by a semi-structured script composed of three questions to meet the objective of this research: "1.In your opinion, what does the Pap smear test mean?","2.What reasons led you to go to the health facility to do this test?""In your opinion, how does cervical cancer is prevented?"In order to characterize the participants, a form was applied to collect socioeconomic and reproductive data.Among the 30 participants, 14 were married, with an average age of 30 years, 22 were Catholic and 16 declared to be "housewives".Regarding the schooling level, 12 had completed high school and six had incomplete elementary education.In relation to family income, 20 reported having an income between one and two minimum wages.With regard to reproductive characterization, twelve full years were the age of first menstruation reported by seven of the women interviewed, 23 reported having children (20 of these had the first pregnancy over 15 years of age).Regarding contraceptive pills, 18 used them at present or had already used in the past, and among these, five have been using them for less than five years.
The Discourse of the Collective Subject (DCS) was used as methodological strategy for analysis of the empirical material.This method consists of a qualitative way of representing the collective thought, adding to a synthetic discourse the discursive contents with similar sense emitted by different people.Thus, each participant interviewed, chosen based on criteria of social representativeness, contributes with a fragment of thought to the collective thought.The DCS technique consists in selecting, from each individual answer to a question, the central ideas (CI), which are the synthesis of the discursive content manifested in the synthetic discourses, which are the DCS, where the thought of a collective group appears as an individual discourse (Lefevre, Lefevre, & Marques, 2009).The following steps were followed for construction of the DCS: 1) reading of the interview transcripts; 2) identification of key expressions related to each of the interviews; 3) identification of three major themes; 4) identification and association of key expressions in the three themes identified; 5) reading of the key expressions in each of the three themes; 6) identification of CIs in each of the three themes to obtain three respective tables containing the CIs, the coding of the interviewed women (letter W followed by a sequential Arabic number corresponding to the interview, W1, W2, W3... W30) and absolute frequency (number of women interviewed in each CI); 7) identification of CIs of equal, similar or complementary meaning with their respective key expressions; 8) elaboration of the three DCSs; 9) analysis of the three DCSs for each of the three themes and association of equal, similar or complementary themes; 10) re-elaboration of the three DCSs to obtain coherent and consistent collective discourses.
The inclusion of participants in this study was performed obeying the ethical and legal recommendations that rule research with human beings (Brasil, 2013)

Results
The analysis of the transcripts of the interviews allowed the organization of frequency Acta Scientiarum.Health Sciences, v. 40, e35898, 2018 tables of the identified central ideas and the discourses of the collective subject according to the three themes that emerged from the guiding questions during the interviews.Next, the three themes with their respective central ideas, the frequency tables (Table 1, 2 and 3) and the discourses of the collective subject (DCS 1, DCS 2 and DCS 3) are presented.This test is done to find out if there is any disease in the cervix, whether something is happening to a woman's health, and to prevent cancer.It also serves to know if there is any sort of inflammation; this examination is very important, that is why I do it every year, it prevents various types of diseases (DCS 1).
The speech denotes that the Pap smear screening serves for preventing cervical diseases, especially cancer.Knowledge about the presence of inflammations was also reported by women.Although they spoke about the importance of performing the preventive examination and the concern to do it every year, discourse does not reveal depth about the meaning of the examination.It is very important because it prevents several diseases; if a myoma, or cyst, appears, the person will be aware of it, promptly prevents herself, and treats the problem as soon as possible, makes a surgery if necessary, if you have a history of cancer in the family, especially.By the way, I have a myoma, and I have been following up for more than 10 years that I live with it and it is ok, normal, no change, it appeared because of the menopause.We always have to undergo the Pap smear test, take care of ourselves; because there some women who do not want to do it, and they have those discharges that come out yellowish, so we always have to do it, to avoid other diseases too.I think it's important and I always do it, but my friends pass two or three years without doing it, they say they do not like it, they think it is inconvenient (DCS 2).In this discourse, the women once again emphasized the importance of taking the Pap smear for preventing diseases, diagnosing them at early stages and treating them.Contrastingly, some interviewees expressed a misconception about the belief in the association between the appearance of a myoma and the menopause.However, they also stated that the presence of yellowish discharges may be an indicator of disease, besides mentioning that they delay to take the examination because it causes discomfort.I've heard about it, what I know is that it is very serious and dangerous, but I do not know much about it, I don't know exactly how it can be prevented.I have at least heard of it, but there are a lot of people who have never even heard of it!One day I was talking to my friends, they did not even know what it was, let alone how to prevent it.What I can also say is that it is a disease that we get from that HPV virus, I also think that by taking the Pap smear test we can discover the cancer, that's why it's good to do it.Oh yeah, you have to use a condom and know the person is with you too, be careful to do the test every year because you may find out the cancer early, in the beginning; thus, it is important to do it frequently, it is very important every woman (DCS 3).
Many interviewees stated that they were not aware of what cervical cancer is and how it can be prevented.Only one woman claimed to know that HPV contamination can lead to cervical cancer.However, they mentioned the use of condoms as a protection during the sexual practice, the importance of knowing the partner, and taking the test with the proper frequency.

Discussion
In Brazil, the Pap smear screening is a low-cost, highly accurate and effective test in primary health care capable of detecting precursor lesions of CC.This test is considered an effective diagnostic tool for prevention and health promotion; it is highly specific, and reduces the chances of unnecessary treatments and interventions (Tomasi et al., 2015).Primary health care professionals are responsible for instructing the population about the importance of the screening as an important tool for preventing and detecting CC at early stages (Cunha, 2015).
The population needs knowledge about the meaning of the test.In this study, the discourses revealed that the Pap smear test is important for preventing CC, but were superficial when it comes to its significance.Research carried out with women aged 18 to 50 years about knowledge on the Pap smear test showed that all the interviewed women claimed to know the test (Silva et al., 2015).However, a study carried out in the city of Teresina/PI showed that the women had insufficient knowledge about the significance of the test; the majority stated that they needed to take the test but they could not explain why they should do it (França, França, & Moraes, 2013).
Another research carried out in the city of Toledo, Paraná State on the perception of women about the Pap smear test showed that they attributed to it more often a curative rather than a preventive characteristic.The women also related the examination to gynecological problems only, showing lack of knowledge (Maeda, Alves, & Silva, 2012).In this context, another study revealed that, when questioned about the real meaning of the Pap smear test, doubts arose as to whether it was related to the prevention and/or detection of CC and other diseases (Peretto, Drehmer, & Bello, 2012).
Regarding the frequency of the preventive examination, the discourses revealed the concern of some interviewees to do it in annual basis.The recommendation in Brazil, according to the Ministry of Health, is do the Pap smear screening test every three years, after two consecutive normal results, with an interval of one year.The repetition one year after the first examination aims to reduce the possibility of a false-negative result in the first round of screening (Brasil, 2016).Women who do not undergo the test regularly compromise the prevention of diseases and the possibility of early diagnosis.Thus, interventions in health services to reduce the incidence and prevalence of cervical cancer are necessary (Simões, Silva, & Teixeira, 2014).
The discourses of the collective subject showed that some women sought the test as a way to take care of their health and or to receive assistance due to the appearance of symptoms.They recognize the importance of the test for the diagnosis of any sort of inflammation, but did not mention the preventive character of the test, which should be performed also by asymptomatic women.In this perspective, a research found that the participants referred to the Pap smear test as a means of diagnosis for certain diseases or prevention of others, such as STD/AIDS, revealing a lack of knowledge about the real purpose of the Pap smear test.This ignorance is, in fact, one of the reasons for not doing the test with the proper periodicity (Moura, Silva, Farias, & Feitoza, 2010), justifying the condensation around this idea in the discourses presented in the present study.
Gynecological problems, either malignant or benign, may require surgical treatments.Among the benign problems are, for example, uterine myomatosis, ovarian cysts, endometriosis, dystopias, salpingitis and problems associated with childbirth.Among the malignant, there are several types of cancer that may require surgery, often requiring a long and complex treatment (Primo, Plaster, Bravin, Leite, & Lima, 2012).A research presented a case study of a woman with uterine leiomyoma submitted to a non-conservative treatment.The study showed that, despite the fact that the interviewee had performing the Pap smear test in annual basis, the myoma had not been identified (Almeida, Barbosa, Marques, Heitmann, & Neves, 2015).
The presence of neoplasms in family history was also highlighted in the discourses, being one of the factors of susceptibility to develop CC.The study also linked the importance of the Pap smear testing to family history of cancer (Matão, Miranda, Campos, Machado, & Ornelas, 2011).
It is important to emphasize that women are also motivated to perform the Pap smear test by the presence of risk factors.The search for health care occurs when women identify factors that may trigger gynecological symptoms (Silva, Silveira, & Gregório, 2012), such as the presence of discharge, as observed in the discourse of this research.
It was also revealed in the speeches that, although women recognized the importance of taking the examination, this is hindered by the discomfort of exposing the female intimacy.Another study also showed that women face several barriers that hinder the performance of an effective prevention exam, because the exposure of the body and the sexuality makes them feel embarrassed.Thus, the expressed feelings compromise the preventive character.Many women avoid undergoing the test periodically because of the embarrassment that they feel during its realization.In this case, more sensitivity and understanding of basic health care professionals during the Pap smear screening test is necessary (Barreto et al., 2016).
An important aspect to be considered is the lack of knowledge about CC.Some women in the discourses of the present study admitted to know nothing about the disease.Researchers have shown that ignorance about this neoplasia, its risk factors, its evolution to an invasive carcinoma and its possible consequences may contribute to the lack of awareness regarding the importance of the Pap smear screening test (Silva, Santos, Silva, & Amorim, 2013).
It is interesting to note that despite the implementation of programs by the Ministry of Health and the widespread dissemination of information on the Pap smear test in primary care, women have superficial or insufficient knowledge about the significance of CC prevention (Aguilar & Soares, 2015, Souza et al., 2015).
Researchers have shown that women have limited knowledge about CC, leading to misperceptions of the disease, including about the risk and preventive factors.Knowledge about CC is critical for sharing in preventive behaviors, as greater adherence to the Pap smear test among women who have more information about the test (Ports, Reddy, & Rameshbabu, 2014).This lack of knowledge results in low awareness of the population of the significance of the Pap smear test and restricted access to health care.
Regarding the relation between HPV and CC, this association was expressed in one of the discourses.Researchers found that the knowledge of 202 healthy Indian women relating HPV to CC was low because they did not know the most coherent method to prevent CC (Montgomery, Dune, Shetty, & Shetty, 2015).This confirms that low knowledge about HPV is associated with less ability to correctly prevent this oncogenic agent by performing the Pap smear screening test.
HPV infection has been recognized as a risk factor for the development of CC.HPV is transmitted primarily through sexual contact, by direct contact with infected skin or mucosa.Despite the magnitude of this problem, this infection is little discussed among women either because of the space just recently gained in the media and campaigns for information about the disease, or even due to the focus on other types of STDs, such as AIDS (Andrade, Almeida, Araújo, & Santos, 2014).
A study conducted in the city of Teresina/PI with 126 women showed that 71.4% self-declared to know the HPV, but 63.5% were unaware of the form of transmission and prevention and 89.7% were unaware of viral reactions in the body; 96.8% reported to have knowledge on CC, but 88.9% did not know how to associate it with HPV (França, França, & Moraes, 2013).
The discourses of the collective subject of the interviewed women revealed that periodic realization of the Pap smear test is fundamental to the effective prevention of CC.A research revealed that 90% of the participants were aware that screening can prevent CC, accurately identifying changes in the cells that can trigger the disease (McCarey et al., 2011); the study emphasized the need to perform the test periodically.
Thus, primary prevention of CC is characterized by the health promotion through lifestyles and behaviors that minimize the risks to develop the disease.Counseling and guidance should be offered to incentive the adoption of safe lifestyles and sexual behaviors.The main behavior to reduce risk is the use of female and male condoms during sexual intercourse, as they reduce the risk of contamination by more than 80% (National Cancer Institute [INCA], 2012).However, a research showed that the use of condoms do not offer total protection against HPV infection because they may present limitations such as perforation, slippage, rupture, or inadequate placement (Costa & Goldenberg, 2013).
It is noticed that, despite advances in primary and secondary prevention of CC, there is still a lack of knowledge among the target public.Educational actions should aim at the participation and joint questioning of health professionals and women about the different aspects related to prevention, education, diseases and control actions, seeking to raise awareness of the adoption of attitudes and behaviors compatible with healthier lives (Dias, Santos, Dias, Alves &, Soares, 2015).In general, recruitment, active search and self-care education are strategies that can be used to increase women's conception of the importance of the Pap smear screening test associated with CC prevention (Silva et al., 2015).

Final considerations
Considering the main questions raised in the study, it was possible to analyze the conceptions of women on cervical cancer screening, associated with the significance and the importance of conducting the screening test, and knowledge about prevention of cervical cancer.The discourses evidenced that the Pap smear test is intended to prevent diseases in the cervix, especially CC, in addition to early diagnosis and treatment.The discourses also revealed the need to take the exam on a regular basis if changes are detected.However, it was also noticed in the discourses that the non-adherence of women to the preventive examination may be related to the discomfort of exposing the female intimacy.
The discourses further revealed misconceptions, such as the belief that the appearance of a myoma and the menopause were related.Guidance and educational practices of self-care aimed at the health of women who have already started sexual activity and who attend the Basic Health Units is recommended.Furthermore, it is necessary to raise women's awareness on the need to undergo the Pap smear testing periodically not only for preventing diseases, but also for the early detection, treatment and cure of CC.
A central idea that was highlighted was that HPV contamination can cause CC, but this was mentioned by only one interviewee.Little information regarding the relationship between HPV and CC may be related to the development of risk factors for HPV as well as reduced adoption of strategies to prevent cervical cancer.
Thus, the actions of the health professionals of Basic Health Units should be broader, contemplating the reduction of risk factors for contamination and/or transmission of HPV, such as the use of condoms during sexual practice, reduction of sexual partners and regular realization of the Pap smear screening test.This would promote greater engagement of the entire female population and their partners, as well as individual and collective well-being.Here we highlight the possibilities of developing health promotion initiatives based on health education rather than encouraging self-care for women's health.
This study has as limitation the peculiarities of the interviewed women and of the local political aspects of the northeastern region of Brazil.However, the study contributes to the scientific community, insofar as it endorses the demands in the area of women's health, which require political interest, especially by local health managers.This would enable the promotion of better practices of health professionals linked to the Basic Units, favoring the adoption of educational actions to facilitate the adhesion of women to the Pap smear screening test.It would also guide and increase the awareness of these women on the importance of regularly undergoing the Pap smear testing, for early detection, treatment and cure of cervical cancer.

Theme 1 .
Significance of the Pap smear screening test Central ideas: -Prevention of diseases -Diagnosis of inflammation -Cancer prevention -Woman's health -Importance of the exam -Annual testing Discourse of the Collective Subject 1

Theme 2 .
Importance of conducting the Pap smear screening test Central ideas: -Prevention of diseases -Diagnosis and early treatment of myomas and cysts -Presence of discharges -Discomfort during the examination -Family history of cancer Discourse of the Collective Subject 2

Theme 3 .
Knowledge and prevention of cervical cancer Central ideas: -Lack of knowledge about cervical cancer -Severe and dangerous -Do not know how it can be prevented -Disease acquired through the HPV -Pap smear creening test detects cancer at early stages -Use of condoms for prevention -Annual testing Discourse of the Collective Subject 3 . All participants were informed about the purpose and methods of the study and signed the Informed Consent Form.

Table 1 .
Central ideas, interviewees and frequency of the first theme.Teresina,PI, Brazil, 2016.
*W = woman; Source: Direct Search

Table 2 .
Central ideas, interviewees and frequency of the second theme.Teresina,PI, Brazil, 2016.
*W = woman; Source: Direct Search
*W = woman; Source: Direct Search