That so-called papanicolaou: women's social representations about the screening test for cervical cancer

Abstracts

Esta pesquisa teve como objetivos identificar as representações sociais de mulheres sobre o câncer do colo do útero, e descrever a relação dessas representações sociais para o cuidado preventivo. A abordagem utilizada foi do tipo qualitativo-exploratório, adotando a teoria das representações sociais como suporte teórico-conceitual. Duas técnicas de coleta foram utilizadas para obtenção dos dados: a livre associação de palavras e a entrevista semidirigida com perguntas abertas. Para a interpretação dos dados foi utilizada a técnica de análise temática. A pesquisa teve como resultado duas unidades temáticas: câncer cérvico-uterino - uma ferida tratável e o preventivo - o fazer por temer. Observou-se que as mulheres temem muito o câncer cérvico-uterino e, por esse motivo, admitem a importância da realização do exame preventivo, considerando-o como um ato de cuidado com a própria saúde.

Neoplasias do colo do útero; Esfregaço vaginal; Saúde da mulher; Enfermagem

ORIGINAL ARTICLE

Sílvio Éder Dias da Silva^I; Esleane Vilela Vasconcelos^II; Mary Elizabeth de Santana^III; Ivaneide Leal Ataide Rodrigues^IV; Dayse Farias Mar^V; Francilene da Luz Carvalho^VI

^IMaster in Nursing by Anna Nery Nursing School, Federal University of Rio de Janeiro. PhD. in Nursing by Programa DINTER at Federal University of Pará and Federal University of Santa Catarina. Assistant Professor at the College of Nursing at Federal University of Pará. Member of the Study Group História do Conhecimento de Enfermagem (Nursing Knowlegde History) and ofd the Research Group Pesquisa Educação, Políticas e Tecnologia em Enfermagem da Amazônia (Education, Policies and Technologies in Nursing in the Amazon). Belém, PA, Brazil. [e-mail]

^IINurse. Speciliat in Surgical Nursing and Intensive Care. Nurse of the Eye Bank at Hospital Ophir Loyola de Belém, PA and of the State Coordination for Oncology Care at the Pará State Public Health Department. Member of the Researh Group Educação, Políticas e Tecnologia em Enfermagem da Amazônia. Belém, PA, Brazil. [e-mail]

^IIIPhD. in Fundamental Nursing by Ribeirão Preto College of Nursing, University of São Paulo. Adjunct Professor at the Faculty of Nursing, Federal University of Pará. Local Operational Coordinator of Programa DINTER at Federal University of Pará and Federal University of Santa Catarina. Member of the Research Group Educação, Políticas e Tecnologia em Enfermagem da Amazônia. Belém, PA, Brazil. [e-mail]

^IVMaster in Nursing by Anna Nery Nursing School, Federal University of Rio de Janeiro. Doctoral Student in Nursing by Programa DINTER at Federal University of Pará and Federal University of Santa Catarina. Assistant Professor of the Nursing Course at Pará State University. Belém, PA, Brazil. [e-mail]

^VNurse graduated by College of Nursing, Federal University of Pará. Belém, PA, Brazil. [e-mail]

^VINurse graduated by College of Nursing, Federal University of Pará. Belém, PA, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This research aims to identify women's social representations of women regarding cervical cancer and describe the relationship of these social representations with preventive care. The study used a qualitative-exploratory approach, with the theory of social representations as the theoretical-conceptual support. Data collection was performed using two techniques: the free association of words and the semi-directed interview with open questions. The thematic analysis technique was used for data interpretation. The research resulted in two thematic units: cervical cancer: an early treatable wound and the screening test: taking because of fearing. It was observed that women have great fear of having cervical cancer and, therefore, recognize the importance of the screening test and see it as an act of self-care towards their health.

Key Words: Uterine cervical neoplasms. Vaginal smears. Women's health. Nursing.

RESUMEN

Esta investigación tiene como objetivo identificar las identificar las representaciones sociales de mujeres sobre el cáncer del cuello uterino; y describir la relación de esas representaciones sociales para el cuidado preventivo. El abordaje utilizado fue cualitativa - exploratoria, adoptando como soporte teórico conceptual la teoría de las representaciones sociales. Para obtención de los datos se utilizaron tres técnicas de recolección: la asociación libre de palabras, la entrevista semi dirigida con preguntas abiertas y la observación libre. Para la interpretación de esos datos, fue utilizada la técnica de análisis de contenido temático. La investigación tuvo como resultado de las unidades temáticas: cáncer cérvico-uterino: una herida tratable y el preventivo: El hacer por temer. Durante toda la investigación, se observo que las mujeres temen mucho tener cáncer cérvico - uterino, y por ese motivo, admiten la importancia de la realización del examen preventivo y lo consideran como un acto de cuidado con la propia salud.

Descriptores: Neoplasias del cuello uterino. Frotis vaginal. Salud de la mujer. Enfermería.

INTRODUCTION

The object of this study was women's social representations about cervical cancer and their relationship with preventive care. There are approximately 500,000 new cases of cervix cancer per year in the world. This is the second most common type of cancer in women, and it is responsible for close to 230,000 deaths per year. It is estimated that the incidence is twice as large in less developed countries, and this disease is more evident among women aged between 20 and 29 years. The risk gradually increases with age, reaching the peak in the age range of 45 to 49 years. In Brazil, there were approximately 18,680 cases in the biennial 2008 and 2009, with an approximate risk of 19 cases for 100,000 women⁽¹⁾.

Regarding etiology, it is currently known that the necessary condition for cervical cancer to appear is the presence of infection by the human papillomavirus (HPV). In general, cervix cancers are caused by one of the 15 oncogenic types of HPV, with HPV 16 and HPV 18 being the most common types. Other factors, besides the HPV contribute to the etiology of this tumor: smoking, insufficient vitamin intake, multiple sexual partners, early sexual initiation and use of oral contraceptives⁽¹⁾.

The screening test was discovered by studies initiated by Dr. George Nicolau in 1917, after analyzing cellular alterations in the cervix and vagina, besides alterations presented in the different phases of the menstrual cycle. After several studies, the screening test became effective in the 1940's, being referred to as Papanicolau, or Pap-smear, due to the dying system used, which consists on collecting cellular material from the posterior wall of the vagina, cervix and endocervix⁽²⁾. In Brazil, the test consists of a screening strategy recommended by the Ministry of Health, and is considered a priority among women aged between 25 and 59 years⁽¹⁾.

In the state of Pará, cervical cancer has the second highest incidence, following breast cancer. In 2008 the state had 790 new cases of cervical cancer, of which 400 occurred in the capital city⁽¹⁾. This situation remains as a result of the low rate of women that take the screening test, either because it is not offered at some locations, or due to a lack of structure to perform the test, or owing to cultural problems, such as embarrassment of the women or husbands not allowing their wives to collect the material⁽²⁾. Regarding cultural aspects, women from Pará hold a number of beliefs, which should be considered and worked on, as they may influence on their compliance or not to a determined health practice, in the case of this study, their performing the Pap-smear test. It should be stressed that cultural values without any correlation with the reality may represent a great obstacle for professionals who work with health promotion and with the prevention of diseases⁽²⁾.

Epidemiological data permit to confirm the importance of the health team, specifically the nursing team, to develop prevention actions. With this study, emerges a need to learn the social representation that cervical cancer has for women and in what way that representation influences or not their performing the screening test, emphasizing that their identification would favor the implementation of preventive care strategies.

For a long time, care was seen as always associated with performing some nursing procedure, emphasizing only a well-performed technique, always associated with a medical prescription and some kind of disease. However, with time the technique was no longer considered the main aspect and importance was also given to social and psychological interventions. From there on, emphasis has been given to the concept of self-care and humanization in the act of caring, aiming at the wellbeing of those needing that care⁽³⁾. Hence, we can affirm that care and prevention have an important meaning in the current context, and, with time, is becoming essential for working in the health area, especially in public health, where the professionals are more and more assuming the responsibility of educating, orienting, and caring towards prevention.

Nursing has been standing out in the task of preventive care, seeking to develop strategies that motivate and encourage the professionals involved towards performing that care. One of these forms is to provide orientation about the importance of performing preventive screenings, which can be done by means of information and orientations; seeking to make the process interactive, and promoting self-knowledge, developing trust among the participant of the process and respect for an efficient work.

OBJECTIVES

To identify the social representations that women have about cervical cancer and describe their relationship with preventive care.

MÉTODO

This exploratory study used a qualitative approach, and adopted the Theory of Social Representations as framework (TSR). This theory has been disseminated in Brazil, especially in the areas of collective health and nursing, and is being employed to answer questions that concern beliefs, values and attitudes of individuals regarding self care ⁽⁴⁾. The TSR shows the interface of an individual's particular attribute in his or her constant inter-relation with the social environment. The social representations occur between the psychological and the social environments, and may be understood as a form of practical knowledge aiming at orienting the subject towards his or her understanding of the world and developing their ability to communicate.

Participants were twenty women who had come to the Municipal Health Center located in the Telégrafo neighborhood in the city of Belém to perform the screening test for prevention. This number of respondents considered the saturation criterion that consists in the knowledge formed by the researcher who was able to understand the internal logic of the studied group and that moment emerges when the researcher understands the homogeneity, diversity and intensity of the information necessary for the study⁽⁵⁾. The women were selected to participate in the study based on the following criteria: they should be oriented in time and space, aware about the purpose of the study and provide their statements after signing the free and informed consent form.

The research project was submitted to the Research Ethics Committee at Universidade do Estado do Pará (UEPA) in Belém, and was approved in the meeting performed on 06/30/2006. To guarantee the respondents' anonymity an alpha-numerical system was used to identify their statements.

Data collection was performed from January to December 2007, using two techniques: free word association and a semi-directed interview with open questions, applied in the same sequence. A questionnaire was used to identify the sociodemographic profile of the study subjects, and it was found that: age, color/ethnicity, nationality, marital status, initiation of sexual life, parity, smoking, education level, income, social security for health, religion, housing conditions and basic sanitation.

Free word association is a technique that favors the interviewees' spontaneous accessibility to the material, free from any previous contamination from the researchers' speaking, it consists of the application of words of encouragement for the respondents to associate with the ideas that go through their minds⁽⁶⁾. Free association was part of the following questions: what comes to your mind when I say cervical cancer? What comes to your mind when I say preventive screening? What comes to your mind when I say care? What comes to your mind when I say prevention?

After applying the free word association, the semi-directed interview was performed, which consisted of flexible open questions, allowing for both interviewer and interviewee to determine its direction. This alternation occurs naturally as a form of providing a better construction of the ideas being exposed⁽⁷⁾. It is emphasized that during the application of this technique the researcher was careful to conduce but not induce the respondents' reports. The script of the semi-directed interview consisted of the following questions: For you, what is cervix cancer? For you, what is preventive screening? For you, what is going to a Health Center for the preventive screening?

The data were analyzed and interpreted using the thematic analysis technique, which is a variant of the classic content analysis technique, frequently used in quantitative studies. This type of analysis helps to find core meanings that compose communication and their frequency, thus contributing for a better understanding of the report⁽⁸⁾. The themes that emerged from the analysis are defined as register units that permit the researcher to study opinions, attitudes, values and beliefs besides other aspects. The theme is the meaning unit that stands out from the analyzed text, and may be cut into ideas that compose statements that bear meanings.

Three steps were followed to perform the thematic analysis: pre-analysis, exploration of the material and result analysis. Pre-analysis is the first contact with the content to be analyzed and helps to organize the material and the process of reading the interviews, so the ideas that emerge become impregnated. The following step was to comprise the corpus that followed the phases of: exhaustiveness, which consists in reading the material as a whole, not prioritizing or disregarding any data; representativeness, which consists in prioritizing the material as a whole; and homogeneity, which is the act of identifying the pertinence and adherence to the material⁽⁸⁾.

In the material exploration stage, the interviewees' answers were grouped by according to the questions of the script, making the answers easier to visualize and thus identify the repetition of words and phrases, observing the pertinence and saturation of the meanings that emerged from the respondents' reports. As of this moment, the thematic units were elaborated, which will be discussed in the next section of this manuscript. It should be emphasized that, to support the units that emerged in the reports, the number of women who mentioned the addressed themes was mentioned by their respective percentages, as a form of providing a better view of the social groups that reported the theme⁽⁸⁾.

RESULTS AND DISCUSSION

After completing the analysis of the material it was possible to identify core meanings that helped to capture the respondents' social representation about cervix cancer, as well as the psychosocial contextualization that surround this object. In addition, it was possible to describe the relationship between the captured social representations and preventive care practice. The core themes were created based on the repetition of the themes present in the interviewees' answers, leading to data saturation, thus helping to consolidate two theme units, which will now be discussed:

Cervical cancer: a treatable wound

Cervical cancer is considered one of the most serious diseases affecting women. The word cancer comes from Latin, and means crab. This name is related to the similarity between the legs of the crustacean and the tentacles of the tumor, which infiltrate into healthy body tissues. Tumors occur when some cells from an organism multiply with no control due to some abnormality⁽⁹⁾.

The disease is known by several names: uterine-cervical cancer, cancer of the uterine cervix or simply cervical cancer. Among the different cancers, this form has high cure rates, reaching close to 100% if early detected, with the possibility of ambulatory treatment in about 80% of the cases⁽¹⁾. In general, it groups with greater social vulnerability, which group the larger hindrances of accessibility to health services for early detection and treatment, caused by financial and geographical difficulties, insufficient services and cultural issues, such as fear and prejudice from their partners⁽²⁾.

It was found that sixteen (80%) women considered cervical cancer a wound that evolves in a way that, if not treated early, has no chance of cure, as observed in the reports:

[...] I know it appears like when you get it, for example, a disease, then it becomes a wound, [...] then there's no more cure and that's it (E14).

[...] It's a wound you get [...] it starts little and then if you don't get it cured it becomes a big wound at that's it. It goes on until you die (E15).

[...] It is a disease that can kill, if not treated in time, it becomes a really serious wound can kills the person. It starts small and grows and grows [...] (E13).

The respondents used objectivation as a form of changing cervical cancer from an abstract concept into something concrete, a wound that, if not treated, becomes incurable and causes death. This thought process mechanism was used to transfer what is in one's mind to something that exits in the physical world. We gave evidence that the things that the mind perceives appear to be distant from out physical eyes and an imaginary being starts assuming the reality of something that is visible, something tangible⁽¹⁰⁾. This process of forming a social representation changed the unfamiliar, the act of suffering from cervical cancer, into a familiar reality, having a wound that must be treated.

Another aspect present in the social representations of the respondents concerns the evolution of cervical cancer, which begins as a small wound that must be detected and treated early, because if that does not happen the disease will develop until causing death. This representation evidenced how the reified knowledge about cervical cancer has converted into a consensual knowledge that made it possible for the women in this study to adopt a practice of preventive care, which is submitting themselves to the Papanicolau test.

The phenomenon of social representations may be understood as a form by which social life has adapted to decentralized conditions of legitimacy, and it is important to phrase that science, in addition to being an important source for the emergence of new forms of knowledge in the modern world, is also responsible for the genesis of common sense⁽¹¹⁾. In this context, it was made evident that health education is important in nursing as a strategy for presenting the academic knowledge to the female audience, considering it will later convert into a social representation that will be essential for the appearance of a behavior of adherence to preventive screening.

People's behavior, regarding health, is quite complex because it depends on opinions, beliefs, attitudes, and values that each individual has about health. Therefore, it is the duty of health professionals, through their work, to encourage and strengthen behavioral changes that would contribute to improving the health of the population⁽¹²⁾.

During the interviews, it was observed that, when talking about cancer, the women showed disbelief regarding the cure of the disease, because some of them had had some sort of experience with cancer. This became clear when they stated that cervical cancer surely killed women, because once a women was affected, there was no way of surviving, as observed in the reports of ten (50%) interviewees:

[...] Cancer is a disease that has no cure, you can prevent it, but there is no cure [...] (E07).

[...] A serious disease, practically if the woman doesn't take care of herself its death. We see that so much and there is no cure. There is no cure for cancer[...] (E10).

Social representations are complex and exist within the framework of a preexisting thought. They depend of belief systems that are anchored on values, traditions, and images o the social world. They are, above all, the object of a permanent social work, which, through discourse, incorporates new phenomena in explanatory and justification models that are familiar, and, therefore, acceptable⁽¹⁰⁾. Based on this context, it is highlighted that cancer is associated with the social imaginary as an incurable disease, and its manifestation is expressed in the communication of the respondents as a death sentence, and should, therefore, be prevented.

Preventive: the doing for fearing

At this unit, it was observed that women fear being affected by cervical cancer; this was evidenced in fourteen (70%) respondents, which performed the screening test not only because they were aware of its importance, but also because of their fear of getting cancer. This fact was present because many women had already been through serious cervical problems, or because they knew someone close who had cancer. Their experience contributes to forming their social representations and defined their way of thinking and acting towards the preventive screening, as observed in the following reports:

[...] There was a neighbor who started feeling pain. When she came to do the test that the doctor requested, she had this disease and it was very advanced and it took her down, I think everyone should do it [...] (E02).

[...] I had a wound in my uterus that I found out in the screening test [...] because I felt something coming from inside me, like some sort of water and I didn't know what it was. Then I went to do the preventive test and I took an x-ray and it was a myoma, but I also had a wound in mu uterus and the doctor said that if I didn't take care it would turn into cancer [...] (E13).

Fear is defined as a feeling of constant inquietude in view of the idea of a real or imaginary danger, of threat, terror, fright⁽¹³⁾. It was possible to notice the fear of interviewees that had had some kind of contact or experience with cervical cancer. It should be emphasized that in the social imaginary, cancer is considered a disease that kills many women, and fear is, therefore, understandable among them, which is observed in the report of one of the women:

[...] I know it is very dangerous, that it is scary, it scares me to death, did you see how I was when I arrived here? I didn't sleep at night because I was worried [...] (E11).

Still today, many women receive the diagnosis of cervical cancer as if they were receiving a death sentence, because for many of them, it is related to death. It is currently known that if early detected it can be eliminated, because medicine has made many advancements in cancer treatment, using a specific conduct for each case, depending on the stage of the disease and the patient's overall condition.

It is known that learning something through pain is certainly not one of the most pleasant ways of learning, but, unfortunately, that is what happened to those women, who, somehow, only earned about the importance of doing the screening test and about the type of changes in their lives implied by the disease when they realized the how serious cancer is.

Denying the disease may have multifactor causes, of which the most relevant is the fear of prolonged suffering, which occurs during the treatment and throughout the stages of the disease. Depressive feelings and reduced self-esteem also may occur⁽¹⁴⁾.

The diagnosis for cancer directly affects the integrity of the patient's ego, which finds herself extremely fragile and vulnerable⁽⁹⁾. This situation causes much suffering because of the fear of pain, separation and death, as observed in the following reports:

[...] To me, just the word cancer is scary [...] (E17).

[...] It is a disease that shocks women. It is very big suffering [...] (E3).

Initial denial has the purpose to adapt to the new situation, where the patient, by using a defense mechanism, tries to dodge despair and the loss of control, also protecting her family⁽⁹⁾. This fact is observed in one of the reports:

[...] It is a disease that wears you out little by little, [...] it is a disease that not everybody accepts [...] (E9).

This attitude of denial, of unacceptability, is related to the cancer/death association. That association is clearly shown in some reports:

[...]A serious disease, practically if the woman doesn't take care of herself its death. [...] (E10).

[...] It is a disease that destroys our life, takes it away, leads us to death[...] (E12).

[...] I know that it is a terrible disease and that it kills if you don't take care [...] (E14).

It would be ideal that women did not need to have this experience to learn to value health, and that this awareness would develop from the information provided by Health Services and educational campaigns that could be disseminated through the media, not only about cervical cancer, but also about other types of cancer and other diseases that affect women's health.

Unfortunately, the biomedical model is still present, which focuses only on curing diseases, without considering that many of them may be avoided if the health team takes preventive measures. These measures are referred to as preventive medicine, which are sought to be made effective through the Ministry of Health by means of Public Policies that have implemented action plans to control cervical and breast cancers as a strategy for diagnosing and treating the disease ⁽¹⁵⁾.

It is evidenced that it is possible to change this condition. To do that, it is necessary for health professionals to become fundamental parts of this change, not permitting that women seek medical care only when they feel something is wrong with their health. Rather, health professionals should teach women to seek care as a form of prevention, and always encourage self care.

CONCLUSION

This article addressed women's social representations about cervical cancer. The techniques used permitted to understand their social representations and to analyze their relationship and implications on preventive care, as the reports were rich in information about women's practice towards the screening test.

During the interviews, the central theme suffered several ramifications that made the present study rewarding because several points were addressed to reach a common denominator: how women see the screening test as a form to avoid the appearance of the disease. After completing the interviews, the collected material was analyzed. Based on the analysis, next step was the development of two large theme units: Cervical cancer: a treatable wound and preventive: the doing for fearing.

In the first theme unit, it is possible to identify the social representations that many interviewees have about cancer: that is a disease characterized by a wound that if not treated evolves to a more serious form that is difficult to cure, and may cause death, and they recognize that if it is treated early, the chances are much greater.

In the second unit it was observed that women consider the preventive test important based on the fear they have of getting cervical cancer. That is the reason for many women to seek Health Centers for the screening. It was identified that most women reported having someone close who had been affected by the disease, by the simple fact that they did not seek a form of prevention.

The knowledge that most respondents have about cases in their family, at work, or in their neighborhood increases their awareness of the importance of doing the screening. Unfortunately, many must go through a difficult situation so that people close to them become aware, and avoid the occurrence of similar cases.

It may, therefore, be stated that primary care is important and necessary, and should reach all women integrally, but, sadly, it is seen on the media and confirmed in professional practice that health care, especially to the unprivileged population, is not as quick, efficient and simple as it should be.

Cervical cancer is considered a public health issue, thought, apparently the authorities do not take any measures that truly allow reversing the condition. Fortunately, at the Health Center where the present study was performed, the program for preventing cervical cancer is efficient, but we know that this is not true for many other Units, especially in the interior cities of the state, for multiple reasons, such as: insufficient qualified professionals and, often, even material to collect the exam.

In view of the emerged representations it is concluded that there is still much to be done by health professionals in terms of preventing the diseases that most affect women's health. This practice should begin with a simple routine appointment, where women can be encouraged to do the screening, such as the clinical breasts exam and the pap-smear.

It was found that, unfortunately, many women only seek health care when they are already sick, because in our country it is not the custom to work with the prevention of diseases, the focus is more on treating rather than preventing, by influence of the biomedical model.

During the research it was concluded that the interviewees, despite considering the screening test an act of self care, they were there only to do the test and because they feared getting cancer, because they were aware of the consequences, and of how the disease could change their lives, considering they know the importance of their role in the family.

Nursing has a significant role in health promotion, helping women to become more and more informed, improving their quality of life. Encouraging these women to seek medical care in case they discover any abnormality is a challenge that nurses must acknowledge and deal with in their daily practice.

Nurses hold a great part of the responsibility along with other health professionals regarding the prevention, early detection, diagnosis and treatment of a disease. Nurses are responsible for orienting the community about programs for the prevention and management of cervical cancer. To do this, is important for nursing staff to know about the women's social representations regarding cervical cancer, thus, facilitating a more efficient continuing education - an education in health.

The authors hope this study will contribute to the advancement of the measures involved in cervical cancer management, especially by offering support to nurses, considering that the objective of the measures proposed by the National Cancer Institute Coordination for Prevention and Surveillance are to reduce the incidence and improve women's quality of life. Despite the present study having been performed with a specific population, which poses limitations in terms of generalization, it contributes to the analysis of the situation at the Municipal Health Center in the neighborhood of Telégrafo, regarding the strategies that should be adopted for cervical cancer management.

One of the responsibilities of health professionals is that of contributing to the issue of how women see the act of being submitted to the preventive tests and searching for a means of prevention. Health professionals should be concerned with that responsibility in their daily practice and also when performing research, which are certainly not limited to this or previous studies. Their concern should reach the whole academic community, in the sense of searching for alternatives that would, at least, reduce the problems that public health has currently been dealing with.

It is known that much has been done until today: studies have resulted in the discovery of a vaccine that prevents the HPV, the virus related to cervical cancer, but further advancements are called for. It is important to know about the social representation that women have regarding cancer and the screening test, because through that knowledge it is possible to create new interventions, seeking to work more based on the importance of self care so women can have quality health.

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That so-called Papanicolaou: women's social representations about the screening test for cervical cancer

Ese tal nicolau: representaciones sociales de mujeres al respecto del examen preventivo del cáncer cérvico-uterino

Publication Dates

• Publication in this collection
  07 Oct 2010
• Date of issue
  Sept 2010

History

• Received
  25 Sept 2008
• Accepted
  06 May 2009