Telephone interventions for adherence to colpocytological examination 1

ABSTRACT Objective: to test the effects of behavioral and educational intervention by telephone on adherence of women with inappropriate periodicity to colpocytological examination. Method: quasi-experimental study with a sample of 524 women, selected with the following inclusion criteria: be aged between 25 and 64 years, have initiated sexual activity, have inappropriate periodicity of examination and have mobile or landline phone. The women were divided into two groups for application of behavioral and educational intervention by telephone. It was used an intervention script according to the principles of Motivational Interviewing. Results: on comparing the results before and after the behavioral and educational interventions, it was found that there was a statistically significant change (p = 0.0283) with increase of knowledge of women who participated in the educational intervention. There was no change in the attitude of women of any of the groups and there was an increase of adherence to colpocytological examination in both groups (p < 0.0001), with greater adherence of women participating in the behavioral group (66.8%). Conclusion: the behavioral and educational interventions by phone were effective in the adherence of women to colpocytological examination, representing important strategies for permanent health education and promotion of care for the prevention of cervical cancer.

moment in the healthcare unit, without greater efforts to reach the population considered to be at higher risk.
Most healthcare services are restricted to younger women seeking primary healthcare, prenatal care or family planning, in which the examination is performed aiming at treating or preventing other health problems (6) .
In this context, the nurse, as a health professional, has a fundamental role in the development and practice of interventions aimed at changing this reality, considering that the focus of this profession should be the healthcare in general. Interventions should take into account the individuals and subjectivities of each region, and must be performed differently, considering the individuality and the way of living of each woman (5) . Therefore, the telephone intervention arises as a potential tool for the integral health care and means an expansion of the action in health, representing an advance in the traditional nursing care, emerging as potential strategy in the holistic care (7) . In telephone counseling, a standardized protocol must be used to identify the barriers that prevent the individuals from having a good attitude in relation to their health, and provide information to help them to address and overcome these barriers (8) .
Given the above, there is a need to introduce new behavioral and educational interventions that increase the adherence to colpocytological examination and aim at women's empowerment. Thus, it has been questioned: What will be the effects of an educational intervention and a behavioral intervention, by telephone, on the adherence to colpocytological examination by women who have inappropriate periodicity? The aim of this study is to test the effects of the behavioral and educational interventions by telephone on the adherence of women with inappropriate periodicity to colpocytological examination.
Such studies are important because they aim to propose and assess the use of interventions to minimize the absenteeism rates to the regular consultations for colpocytological examination and, thus, improve the healthcare of women; reduce the unnecessary health system expenditures and stimulate nurses to undertake new interventions, which are essential for success in the control of CC.

Method
This is a quasi-experimental study with pre-test and post-test design, developed in the city of Fortaleza, at the Family Development Center (CEDEFAM), from June to December 2014.
The study population consisted of women who underwent examination for prevention of cervical cancer at that healthcare unit, and did not show the periodicity to examination in accordance with the recommendations of the Ministry of Health, i.e., they did not undergo the annual colpocytological examination or any examination in the last three years, after two consecutive negative tests (3) . The sample selection met the following inclusion criteria: women aged between 25 and 64 years, who have initiated sexual activity, with inappropriate periodicity of examination and who had their mobile or landline phones numbers registered in the medical Lima TM, Nicolau AIO, Carvalho FHC, Vasconcelos CTM, Aquino PS, Pinheiro AKB.
records. To classify them as "inappropriate periodicity", the amount of previous examinations was also assessed.
The sample size calculation was performed using the formula for comparative studies of groups and the following values were adopted: Zα = 95%, Zβ = 80%, p = 18.6%, d = 10%. Thus, by substituting the values, it was found that 239 women would be needed for each group. However, a 10% safety percentage for possible telephone losses was added, with 262 women for each group, totalling 524 women.
The women composing the sample were randomly allocated into two groups: The study design involved the random assignment of subjects to groups. By means of randomization, or random selection for groups, all participants had an equal chance of being included in either group.
It was predicted from the beginning of the study that the randomly assigned groups were similar, in general, in relation to the infinite number of biological, psychological and social features (11). The random selection was performed by means of a table created by using a random allocation software. Each number on the lists of the two groups (educational and behavioral) was inserted into an opaque envelope, which was numbered and sealed. Individuals unaware of the study performed these steps.
In this study, women who were part of the sample were blinded with respect to the group to which they belonged. Besides them, two professionals were chosen -one of them performed the behavioral telephone interventions and the other performed the educational telephone interventions. These trained professionals were also blinded, because they were not aware of the goals of the study and they did not know the schedule and the existence of groups.
The educational telephone intervention was divided into two phases: the first phase consisted of the introduction of the professional, research on the examination performed in other healthcare services and questions about the intention to participate in the study; if the answer was affirmative, the second phase was started.
In the second phase, information on the sociodemographic characteristics and knowledge and attitude of women on the prevention of CC were collected. Subsequently, the intervention started, which addressed: a brief explanation on CC and its risks, the purpose of the colpocytological examination, the importance of the periodicity of examination, preexamination care and return to receive the result of the colpocytological examination (3,9) .
The evoke-provide-evoke model was used, supported by the MI, because it involves a collaborative mindset, proper for interventions aiming at behavior changes. This model seeks not only to transfer information, but also to insert the patients into the context and enable them to make their own decision about the change (10) .
The two phases were carried out in a single telephone call, lasting about fifteen minutes, because this is the recommended time for intervention (12) .
Finally, the examination was scheduled according to the availability of women to attend the healthcare unit.
The behavioral intervention used in this study aimed to serve as a reminder to the colpocytological examination. This telephone intervention was divided into two phases -the first phase consisted of the introduction of the professional, research on the examination performed in other healthcare services and questions about the intention to participate in the study; if the answer was affirmative, the second phase was started.
In the second phase, information on the sociodemographic characteristics and knowledge and attitude of women in relation to prevention of CC were collected. Subsequently, they received a reminder for the examination without any information about it. In addition, the examination was scheduled according to the availability of women to attend the healthcare unit.
These two phases were carried out in a single telephone call, lasting about five minutes.
The second phase of data collection was carried out on the day of consultation, which was scheduled to perform the colpocytological examination.    There was a prevalence higher than 60.9% of the inappropriate attitude before and after intervention in both groups, but this association was not statistically significant in the behavioral group (p = 0.631) and in the educational group (p = 0.681). In the educational group, there was a slight reduction in the inadequacy of attitude before (61.5%) and after (60.9%) intervention.
In the behavioral group, there was a small increase of inappropriate attitudes, when it was compared before (60.7%) and after (62.9%) intervention.  leading to decrease of prevention practices in the age period in which the incidence and severity of cancer are higher (14) .
Added to the above, non-adherence to appropriate periodicity to the colpocytological examination is related to some social factors such as be part of the younger age group, be single and have low education or low socioeconomic status (15) .
There was a large time gap since the last colpocytological examination, with an average of 31.7 months. The periodical examination is essential, since the late diagnosis of CC can cause not only physical injury, but also emotional and psychosocial problems (16) .
Women undergoing examination at a periodicity exceeding three years also have higher proportion of no returning to receive the final results of examination, and they do not show the results to a professional, featuring discontinuity of this health care (17) .
When asked about the reason for not undergoing what was HPV or reported -erroneously -that it was the "same as" AIDS, cancer, some kind of bacteria and so on (18) .
In assessing the knowledge before and after Investing in prevention practices and awareness of the population is less costly than the curative treatment of various types of diseases, especially in the public health system, by reducing the costs of hospitalization, surgeries and treatments (19) .
In a case study of a chemically dependent patient, the use of MI by telephone enabled the codependency to be reduced, and modified the observed permissive behavior. Moreover, the authors noticed the expansion of self-perception of the patient on his personal needs and limits with regard to chemical dependency. Thus, it is emphasized that an intervention focused on motivational approaches and in MI represents a helping strategy (21) .
The educational intervention based on principles of MI was able to arouse the interest of participants to change their demotivation in relation to self-care and caused changes that favored the prevention of diseases, in this case, the undergoing of colpocytological examination. It is emphasized that no person is completely unmotivated and the motivation to change is quite malleable and formed especially within the context of relationships.
Great results are achieved when patients are interested and show an active role, making the intervention more effective and with a lasting influence on the patient's health (10) .

Conclusion
It was found, in the view of the observed changes, that the different telephone interventions were effective in promoting the adherence of women to colpocytological examination. For this reason, it is considered relevant the permanent healthcare education, with actions that aim at promoting the prevention of CC and are comprehensive, prioritizing interventions for the screening of both the asymptomatic and symptomatic women, besides ensuring access to methods for proper diagnosis and treatment.
It is recommended conducting future studies to assess the long-term effectiveness of the educational and behavioral interventions on adherence to colpocytological examination, in order to check, after a year, if women remain seeking the healthcare service to undergo the examination within the recommended periodicity.