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This is to certify that the

thesis entitled
HEALTH BELIEFS AND
CERVICAL CANCER SCREENING PRACTICES OF

OF WOMEN 50 YEARS AND OLDER
presented by

JUDITH FLEISHMAN

has been accepted towards fulfillment
of the requirements for

MASTERS OF SCIENCE NURSING

 

degree in

ﬂu MW)

Major professor I!” 3%)
DR. RACHEL SCHIFFMAN

 

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

 

LIBRARY
Michigan State
University

 

 

' 1
PLACE iN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU is An Affirmative Action/Equal Opportunity Indituiion
smarts-o:

 

HEALTH BELIEFS AND CERVICAL CANCER SCREENING PRACTICES OF
WOMEN AGED 50 YEARS AND OLDER

By

Judith Fleishman

A THESIS

Submitted to
Michigan State University
in partial fulﬁllment of the

requirements

for the degree of

MASTER OF SCIENCE

College of Nursing

1993

ABSTRACT

HEALTH BELIEFS AND CERVICAL CANCER SCREENING PRACTICES OF
WOMEN AGED 50 YEARS AND OLDER

By

Judith Fleishman

The purpose of this study was to explore the relationship between health beliefs
and cervical cancer screening practices in a group of older women. The Health Belief
Model adapted by Given et a1. (1989) was used as a conceptual framework. The
correlational study utilized a non-probability convenience sample (N = 109) of women
50 years of age and older. Six health belief variables were measured using a ﬁxed
alternative format questionnaire. Perceived barriers to cervical cancer screening and
the intention to be screened for cervical cancer in the future were found to signiﬁcantly
correlate with screening practices. The results of this study provide useful information
for the clinical nurse specialist to utilize in counseling and educating older women

about Pap smear screening issues in the primary health care setting.

To Thomas Henry Parker

iii

ACKNOWLEDGMENTS

I would like to thank the chairperson of my thesis committee, Rachel Schiffman,
for guiding me through the research process, and for her continuous encouragement
throughout this project. I would also like to thank the other members of my thesis
committee, Barbara Given, Barbara Sparks, and Brigid Warren, for their ongoing

support and for the time they devoted to reviewing the many drafts of this thesis.

Special thanks to Barbara Given for permission to adapt and use her questionnaire

and to Chiung Ying Cheng for assistance with data analysis.

iv

TABLE OF CONTENTS

LIST OF TABLES ........................................................... vii
LIST OF FIGURES .......................................................... viii
INTRODUCTION .............................................................. 1
STATEMENT OF THE PROBLEM ............................................ 5
Research Question ................................................... 6
Study Relevance ..................................................... 6
THEORETICAL FRAMEWORK .............................................. 6
Health Belief Model ................................................. 7
Conceptual Deﬁnition of Study Variables ............................ 10
Role of the Clinical Nurse Specialist ................................. 15
Critique of the Health Belief Model ................................. 15
REVIEW OF LITERATURE ................................................. 16
Age in Relationship to Screening Frequency ......................... 18
Psychosocial Aspects of Screening ................................... 19
Multivariate Studies ................................................ 20
Health Needs of Older Women ...................................... 24
Rationale for Proposed Study ....................................... 25
METHODS ................................................................... 27
Study Questions .................................................... 27
Sample Procedures ................................................. 28
Operational Deﬁnition of Variables .................................. 29
Instrumentation .................................................... 31
Scoring Procedures ................................................. 35
Data Collection Procedure .......................................... 37
Data Analysis ...................................................... 37
Study Limitations .................................................. 38
Protection of Human Subjects ...................................... 38

FINDINGS .................................................................... 39

Sociodemographic Characteristics ................................... 39
Health Characteristics .............................................. 39
Screening Characteristics ........................................... 39
Description of the Variables ......................................... 42
Analyses of Research Questions ..................................... 44
The Effects of Age and Hormonal Replacement Therapy on Pap
Smear Frequency ................................................... 45
DISCUSSION ................................................................ 47
Research Questions ................................................. 48
The Effects of Age and Hormonal Replacement Therapy on Pap
Smear Frequency ................................................... 57
Implications for Advanced Nursing Practice ......................... 58
Future Research .................................................... 64
SUMMARY .................................................................. 67
REFERENCES ............................................................... 69
APPENDICES ............................................................... 72
Appendix A: Cover Letter .......................................... 72
Appendix B: Questionnaire ......................................... 73
Appendix C: Reminder Postcard .................................... 84
Appendix D: U.C.R.I.H.S. Approval ................................. 85
Appendix E: C.T. Union Approval .................................. 86

vi

 

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

Table 8:

LIST OF TABLES

Sample .............................................................. 29
Reliability of “Cervical Cancer Screening Practices” Questionaire ..... 34
Sociodemographic Characteristics of Sample ........................... 40
Health Characteristics of Sample ..................................... 41
Screening Characteristics of Sample .................................. 43
Range, Mean and Standard Deviation of the Variables ................ 44
Correlations between Pap Smears and Health Beliefs .................. 45
Two Way ANOVA: The Effects of Age and Hormonal Replacement

Therapy on Pap Smear quuency .................................... 46

vii

 

LIST OF FIGURES

Figure 1: Health Beliefs of Older Women Regarding Pap Smears ............... 11

Figure 2: Health Beliefs of Older Women Regarding Pap Smears (Revised) ..... 59

viii

 

Introduction

One of the central goals of the Clinical Nurse Specialist in the primary health care
setting is the promotion of optimal client health by routinely screening for diseases
for which no prevention methods exist. Preventive screening has been deﬁned as
improving the health outcomes of individuals by the early detection of disease in
order to identify potentially serious conditions prior to the onset of any signiﬁcant
symptom development (Stoeckle, 1987).

Currently no method of preventing cervical cancer exists and therefore it is an
appropriate disease for screening in the primary health care setting. Cervical cancer
meets the criteria delineated by Shields, Daunter, and Wright (1987) for large scale
population screening: it poses a signiﬁcant health threat to adult women, has a nat-
ural history which is long enough to allow for successful early detection and therefore
optimal treatment, and the screening method, the Papanicolaou (Pap) smear, is a
reliable and cost effective procedure.

The natural history of cervical cancer enables successful screening to occur because
it is a slow growing disease with a lengthy natural growth period, commonly taking
anywhere from eight to twenty years to fully develop (Peters, Duncan, Skultin, &
Henderson, 1988). This type of cancer often exhibits no apparent signs and symptoms

for an extended period of time and ﬁrst manifests clinically as cervical intraepithelial

neoplasia (CIN). CIN is a condition in which a woman’s normal cervical epithelial
cells, the cells lining the outer layer of the cervix, are found to have been gradually
replaced by atypical cells (Gray & Heuther, 1990). Unlike normal cells, atypical cells
are poorly differentiated, proliferate more rapidly than normal cells, and have the
potential to become increasingly malignant as they multiply (Rubin & Lauver, 1990).

CIN progresses along a continuum and is classiﬁed according to three categories:
CIN I, CIN II, and CIN III. These classiﬁcations provide a method for describing
the degree to which atypical cellular growth has occurred. The ﬁrst phases of the
continuum, CIN I and CIN II, precede any cancerous conditions whereas the last
phase, CIN III, signiﬁes the beginning of microscopic malignant changes.

CIN 1, or mild dysplasia, is characterized by the appearance of a few cervical
cells exhibiting atypical changes. CIN II, or moderate dysplasia, occurs when ap-
proximately half the endocervical cells show abnormal changes. CIN III encompasses
severe dysplasia and carcinoma in-situ. When CIN III develops the majority of cells
exhibit atypical changes. Carcinoma in-situ occurs once the majority of the atypical
cervical epithelial cells have become malignant on a microscopic level but have not
yet penetrated the deeper cell layers of the cervix (Gray & Heuther, 1990; Rubin &
Lauver, 1990).

If cervical cancer is detected during the CIN III phase, prior to the deeper layers
of cervical tissue being invaded by malignant cells, the chances of surviving this
disease are excellent, close to 100 percent (Mandelblatt, 1989). However, after the

carcinoma in-situ stage the chances of surviving cervical cancer for ﬁve years or more

substantially decreases. When the malignant cells have invaded the deeper tissue of
the cervix and the upper portion of the vagina the long term survival rate drops to
approximately 80 percent. These chances are further reduced, to roughly 30 percent, if
the cancer spreads as far as the lower vagina or pelvic wall. If the cancer metastasizes
to the bladder, kidneys, or rectum, and also perhaps to other distant organs, the
chances of survival over a ﬁve year period are as low as 15 percent (Gray & Heuther,

1990; Mandelblatt, 1989).

 

Major risk factors for cervical cancer include early menarche, multiple sexual part-
ners, smoking, antepartal exposure to diethylstilbestrol, advancing age, and presence
of human papillomavirus (HPV) (Eddy, 1990; Mandleblatt, 1989; Rubin & Lauver,
1990). HPV signiﬁcantly increases the risk of cervical cancer because it has been
found that the virus accelerates the atypical cellular growth pattern along the CIN
continuum, thereby shortening the usual lengthy natural history of this disease (Rubin
& Lauver, 1990).

Over the last several decades there has been a steady decrease in the morbidity
and mortality due to cervical cancer, largely because of the widespread use of the
Pap smear screening technique with its ability to detect cervical cancer in its earliest
stages (Eddy, 1990). The Pap smear, ﬁrst developed by Dr. George Papanicolaou
in the 1930’s, involves obtaining a sample of superﬁcial ectocervical and endocervical
cells from the squamocolumnar junction of the cervix in order to examine these cells
for possible abnormalities along the CIN continuum (Eddy, 1990).

Considering that cervical cancer is nearly 100 percent curable if successfully detected

early with the Pap smear, the morbidity and mortality rates from this disease remain
high. It is estimated in 1991 as many as 13,000 American women were diagnosed
with invasive cancer of the cervix and up to 4,500 died as a result of complications of
this disease (American Cancer Society (ACS), 1991).

Many factors affect the extent to which women receive routine Pap smear screen—
ing. The following categories have been identiﬁed in the recent literature: (1) demo-
graphic factors such as advancing age, being Black or of Hispanic origin, having a low
income and lack of a high school education; (2) health care system factors such as
type of health care setting, health care provider characteristics, degree of contact with
the health care system, and differing screening recommendations; and (3) psychoso-
cial factors or health beliefs, that is, the perceptions, attitudes, and behaviors of the
women themselves toward Pap smear screening (Celentano, 1988; Celentano, Klassen,
Weisman, & Rosenshein, 1988; Elkind, Haran, Eardley, & Spencer, 1988; Harlan,
Bernstein, & Kessler, 1991; Peters, Bear, & Duncan, 1989; Teitelbaum, Weisman,
Klassen, & Celentano, 1988).

Cervical cancer is not preventable and currently regular screening with the Pap
smear remains the most effective way of eliminating morbidity and reducing the mor-
tality of this disease. Therefore, if the prevalence of this disease is to be reduced it
is of the upmost importance to target those women who do not receive regular Pap

smear screening.

Statement of the Problem

Advancing age is considered a risk factor for many types of cancers and cervical
cancer is no exception. Women of advancing age do not receive Pap smears as fre—
quently as do younger women and therefore constitute a high risk group for cervical
cancer due to both advancing age and under—screening. (Celentano, 1988; Hayward,
Shapiro, Freeman, & Corey, 1988). It has been found that, as a result of less fre—
quent screening, older women are typically diagnosed with cervical cancer at a more
advanced stage of disease, usually already invasive, making successful long-term re-
covery less likely (Blesch & Prohaska, 1991). In contrast, when younger women are
diagnosed with cervical cancer, because they are screened more regularly, their dis-
ease is more likely to be still localized, in the in-situ stage, a condition associated
with complete recovery (Gusberg & Runowicz, 1991).

Because it appears that older women are at increased risk for cervical cancer
due to both increasing age and consistent under—screening, and because it has been
hypothesized that psychosocial factors exert a primary inﬂuence over health behavior
(Janz & Becker, 1984), it is of interest to closely examine how the health beliefs of
older women affect their cervical cancer screening practices. Therefore, the purpose of
this study is to determine, using a descriptive survey, what health beliefs signiﬁcantly

inﬂuence the cervical cancer screening practices of older women.

Research Question

 

The following research question will be asked: What is the relationship between
health beliefs and cervical cancer screening practices in a group of women aged 50

years and older?

Study Relevance

 

The results of this investigation have the potential to contribute to the nursing
profession in two ways. First, information from this study will expand theoretical
knowledge on preventive health behavior. Second, it will aid the Clinical Nurse Spe-
cialist in developing speciﬁc clinical management strategies to promote appropriate
Pap smear screening schedules in older women. These strategies can be based on
what the study reveals about their perceptions, attitudes and knowledge of screen-
ing. Phture research on cervical cancer screening can be conducted to evaluate the

effectiveness of these clinical management strategies.

Theoretical Framework

The variables used to study the psychosocial aspects of Pap smear screening in
women of advancing age were derived from the Health Belief Model (HBM). The HBM
is a theoretical framework that was developed in response to the needs of researchers to
explain and predict why and how individuals engage, or do not engage, in certain types

of health behaviors (Janz & Becker, 1984). The model, whose central assumption is

that cognitive, perceptual and psychosocial factors strongly influence health behavior,
hypothesizes that health behavior is dependent on the occurrence of the following
three circumstances: (1) the existence of sufficient motivation, or health concern, on
the part of the individual to make health issues salient or relevant; (2) the perceived
threat, or belief, that one is susceptible to a serious health problem or illness; and,
(3) the belief that following through on a particular health recommendation would
be beneﬁcial in reducing the perceived threat of an illness or condition (Rosenstock,

Strecher, & Becker, 1988).

Health Belief Model

The HBM is composed of several interrelated concepts designed to measure sub-
jective beliefs. When ﬁrst introduced the model contained four concepts: perceived
susceptibility, perceived seriousness, perceived beneﬁts and perceived barriers. Exten-
sive research examining health behavior demonstrated that other factors accounted
for the variation in health behavior and three additional concepts were added to the
model: health motivation, self—efficacy and social influence.

The HBM divides these seven concepts into three categories: individual percep-
tions, modifying factors and the likelihood of action. The ﬁrst category, individual
perceptions, contains the concepts perceived susceptibility and perceived seriousness.
Perceived susceptibility is a person’s subjective view of the likelihood of experiencing
a potentially harmful condition or illness and perceived seriousness is how threatening
a particular illness or condition is to that person (Champion, 1984; Janz & Becker,

1984)

The second category, modifying factors, contains the concept of social influence.
This concept is deﬁned as the influence that one’s support system or social network,
that is, one’s family, friends, or physician, have on an individual’s health behaviors
(Champion, 1991; Zapka, Harris, Stoddard, & Costanza, 1991).

The remaining four concepts, perceived beneﬁts, perceived barriers, health motiva-
tion, and self—efficacy make up the third category, the likelihood of action. Perceived
beneﬁts are deﬁned as an individual’s view of how effective a speciﬁc behavior or
action would be in reducing a particular threat or condition (Champion, 1984; Janz
& Becker, 1984). Perceived barriers are deﬁned as the potential negative effect—
pain, cost, unpleasantness—that undertaking a recommended behavior would cause
(Champion, 1984; Janz & Becker, 1984). Health motivation represents the individ-
ual’s generalized state of intent which results in engaging in behaviors that maintain
or improve health (Champion, 1984). Self-efﬁcacy is the degree of self-conﬁdence or
conviction that an individual possesses in order to successfully perform or execute
a given behavior required to produce a desired health outcome (Rosenstock et ‘al.,
1988)

The HBM has been particularly successful in predicting sick—role behaviors, the
actions taken after diagnosis of a medical problem in order to restore good health or
to prevent further disease process, and preventive health behaviors, the actions taken
to avoid illness or injury. (Janz & Becker, 1984; Nemcek, 1990).

The HBM has been adapted by Given, Given, and Dimitrov (1989) to speciﬁcally

reflect preventive health behavior pertaining to breast cancer screening. The Given

model (Given et al., 1989) has been revised for use in this study on cervical cancer
screening. Since many cancer related issues are similar it is felt that this model
provides an appropriate conceptual framework to measure the perceptions of older
women toward cervical cancer screening.

Given’s HBM (Given et al., 1989) combines the concepts of perceived severity and
perceived susceptibility into a single variable: perceived susceptibility. Given et a1.
(1989) use the concept efficacy instead of self—efficacy, deﬁning it as the conﬁdence
that the individual has in a particular intervention as opposed to the degree of self—
conﬁdence an individual has in performing a particular health related activity. Given
et al. (1989) utilize the term intentions instead of health motivation but deﬁne the
concept very similarly. The Given HBM combines the two concepts perceived barri-
ers and perceived beneﬁts into one variable: perceived barriers and facilitators. The
Given HBM (Given et al., 1989) is therefore comprised of six variables: perceived sus-
ceptibility, knowledge, social influence, perceived barriers and facilitators, perceived
eﬂicacy, and intentions.

For the purposes of this study Given’s six variables will be considered the inde-
pendent variables and will be correlated separately with the dependent variable, the
number of Pap smears the respondent has had in the last 10 years. It is possible
to deﬁne the variables in this manner because the Given HBM (Given et al., 1989)
proposes that the extent to which an individual participates in preventive health be-
haviors is dependent on health beliefs. For the purposes of this study health beliefs

are deﬁned as the cognitive, perceptual and psychosocial factors that inﬂuence an

individual’s preventive health behaviors. The next section provides conceptual deﬁ—
nitions of the Given HBM variables (Given et al., 1989) and their application to this

study.

Conceptual Deﬁnition of Study Variables

 

As illustrated by the model in Figure 1, the ﬁrst variable, perceived susceptibility,
is considered part of an older woman’s individual perceptions toward cervical cancer.
Perceived susceptibility to an illness or, potentially harmful condition, is deﬁned as
a person’s subjective view of the likelihood of experiencing that potentially harmful
condition or illness (Champion, 1984). Perceived susceptibility to cervical cancer
reﬂects a woman’s feelings about the chances of developing cervical cancer herself
sometime in her lifetime and her perceptions about how serious a threat cervical
cancer is.

The second and third variables in the model, knowledge and social inﬂuence, are
classiﬁed as modifying factors. Knowledge is determined by the amount of information
an individual has about a particular disease; this is in part dependent on prior contact
one has had with the disease (Pender, 1987). Knowledge of Pap smears includes being
aware of the cervical cancer screening schedule, understanding the role that the Pap
smear plays in the early detection of cervical cancer, and understanding the particular
nature of the cervical cancer disease process. Prior contact with cervical cancer would
inﬂuence awareness of the screening schedule, disease process, and treatment.

Social inﬂuence is the inﬂuence that the external environment has on an individual

10

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION

 

#2 KNOWLEDGE

of Pap Smears

1

#1 SUSCEPTIBILITY Perceived Threat #4 BARRIERS

to cervical cancer of cervical cancer to screening

#3 INFLUENCE

of important others
concerning Pap smears

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#5 EFFICACY
of the Pap smear

l

#6 SCREENING INTENTION S

1

Pap smear
SCREENING
FREQUENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: HEALTH BELIEFS OF OLDER WOMEN REGARDING
PAP SMEARS

(Adapted from the Breast Cancer Screening Health Belief Model (Given et al., 1989))

11

 

in regard to their health behaviors. The external environment is deﬁned as one’s
social support network: family, friends, or physician, as well as mass media such as
newspapers and billboards (Champion, 1991; Pender, 1987). Inﬂuence in the context
of Pap smear screening of older women refers to any advice or discouragement that
an older woman receives from a member of her social network about screening, or any
discussion about screening that an older woman holds with a member of her social
network. Social inﬂuence also depends on the degree to which a woman perceives the
opinions about Pap smear screening of members of her social network to be important.

As illustrated by the direction of the arrows in Figure 1, the combination of the ﬁrst
three variables perceived susceptibility, knowledge, and social inﬂuence, account for an
older woman’s generalized perception of threat toward cervical cancer. The perceived
threat of cervical cancer is visually depicted in the model in order to illustrate the
relationship that the ﬁrst three variables have to each other but does not represent a
speciﬁc HBM variable. The extent to which a woman feels a threat of cervical cancer
inﬂuences the action that she is likely to take in order to prevent cervical cancer from
occurring.

The fourth, ﬁfth, and sixth variables shown in Figure I, perceived barriers and
facilitators to Pap smear screening, perceived efficacy of the Pap smear, and screening
intentions, measure factors that inﬂuence the likelihood of action. In the context of
Pap smear screening, the likelihood that a woman will participate in screening for
cervical cancer on a routine basis depends on what she believes the facilitators and

the barriers of the Pap smear screening process to be, whether or not she believes

12

that the actual Pap smear screening procedure is efficacious, and what her intentions
are to have Pap smears in the future.

Perceived barriers and facilitators are the factors that either promote or deter
participation in preventive health screening behaviors. For the purposes of this study
participation in preventive health screening will be measured by only the factors that
deter screening. Therefore, this concept will be deﬁned as perceived barriers to Pap
smear screening. Perceived barriers to Pap smear screening are deﬁned as feelings
of fear, physical discomfort, embarrassment, or anxiety caused by the Pap smear
procedure that may discourage a woman from participating in routine screening.
Barriers to screening also include practical considerations such as lack of time, money,
or transportation. If few factors deter the individual from receiving routine Pap
smears then the lack of barriers is then viewed as a facilitator of the screening process.
However, in this study facilitators to cervical cancer screening will not be measured.

As illustrated by the direction of the arrow in the model (Figure 1), perceptions
of efficacy of the screening process are formed by the individual once barriers to the
screening process have been established. Perceived efficacy refers the individual’s
conﬁdence in the ability of a given clinical intervention or health recommendation
to successfully accomplish a desired health outcome (Given et al., 1989). Perceived
efﬁcacy of the Pap smear is deﬁned as the conﬁdence a woman has that the Pap smear
screening procedure will be able to detect cervical abnormalities.

Screening intentions or, health motivation are deﬁned as an individual’s general-

ized state of intent, toward engaging in behaviors that maintain or improve health.

13

This concept assumes that the individual feels a given health action is relevant and
important and is therefore motivated to participate in it (Champion, 1984). An in-
dividual’s screening intentions for cervical cancer are deﬁned as the likelihood of a
woman receiving a Pap smear within the next year and the extent to which receiving
a Pap smear on a regular basis is a priority for her.

The six previously described health belief variables all interact to inﬂuence the
degree to which a woman will participate in routine screening for cervical cancer. The
extent of this inﬂuence is represented by the dependent variable screening frequency,
which is deﬁned by the number of times an older woman has participated in Pap
smear screening in the last 10 years.

One would like to compare Pap smear screening frequency observed in this study
with previously established guidelines for routine screening. However, the most recent
guidelines of three national organizations that set screening standards, the American
College of Obstetricians and Gynecologists, the American Cancer Society, and the
National Cancer Institute, do not explicitly recommend a speciﬁc time frame for
screening. These three organizations jointly recommend that asymptomatic women
who are 18 years or over or, who have been sexually active, have three consecutive
annual Pap tests and pelvic examinations. After three or more consecutive normal
examinations, the Pap test may be performed less frequently at the discretion of
the physician (American College of Obstetricians and Gynecologists (ACOG), 1989;
Fink, 1991; National Cancer Institute (NCI), 1990). Therefore, for the purposes of

this study, the deﬁnition of routine Pap smear screening was derived from selected

14

current research investigations on Pap smear frequency which have included a speciﬁc
time frame and will be deﬁned as a Pap smear every three years (Celentano, 1988;

Harlan et al., 1991; Hayward et a1. 1988).

Role of the Clinical Nurse Specialist

 

In the clinical setting the CNS is in an ideal position to have a direct inﬂuence
the screening behaviors of older women. It is likely that Pap smear screening fre-
quencies in older women differ. Differing frequencies will therefore require different
management strategies. By incorporating health belief concepts into an organizing
framework for planning nursing care all the aspects of a woman’s screening behavior,
individual perceptions, modifying factors, and likelihood of action, can be assessed.
With this information the CNS is then able to plan counseling and educational inter-
ventions for her clients accordingly. The role of the Clinical Nurse Specialist (CNS)
in relationship to Pap smear screening frequency of older women will be discussed in

a later section.

Critique of the Health Belief Model

 

As discussed earlier, health belief concepts have proven to be successful in explain-
ing a variation of health behaviors. However, Janz and Becker (1984) have identiﬁed
two important conceptual limitations of the HBM. First, the HBM is based on the as—
sumption that the individual perceives health as a highly valued state; consequently,
the model may be limited to measuring only those individuals who view their health

in this manner. Second, the HBM is primarily a psychosocial model and is, therefore,

15

mostly limited to accounting for the variance in individual health—related behaviors
as can be explained by attitudes and beliefs.

The HBM is a dynamic theoretical framework, that is, the variables occur in
sequence with each concept relating to the following one, creating movement in one
direction as illustrated by the arrows in the model. Multivariate statistical techniques
are often employed when analyzing this model in order to accurately reﬂect the overall
direction and close conceptual relationship that these variables have to each other.
However, for the purposes of this study the variables will be analyzed separately and
will not be examined in relationship to each other. Therefore the dynamic quality
of the model and the relationship that the variables have to each other will not be

accounted for.

Review of Literature

In recent years extensive research examining the factors that inﬂuence the fre-
quency of Pap smear screening has been conducted. There appear to be three major
perspectives on the subject: (1) those that primarily deal with epidemiological factors
such as incidence of cervical cancer in the population and the extent to which Pap
smear screening occurs; (2) those that address the psychosocial issues surrounding
the screening and disease process such as subjective perceptions, cognition, and at-
titudes of women toward screening and cancer; and (3) those that investigate health
care system variations including type of doctor, type of health insurance, and degree

16

of contact with the health care system.

These differing perspectives provide a broad view of the issues that are relevant
to Pap smear screening and contribute much valuable information that is relevant to
this study. However, comparison of these investigations of differing perspectives and
different study purposes is difficult because consistent terminology and deﬁnition of
variables and concepts under study are lacking.

For example, several studies (Elkind et al., 1988; Harlan et al., 1991; Peters et
al., 1989) utilize HBM concepts such as attitude, beliefs, and cognition, to discuss
factors that deter or enhance the Pap smear screening process. But because the main
intent of these investigations is not exploring health beliefs these variables are not
clearly deﬁned, placed into a conceptual framework or, strongly emphasized as health
belief constructs. Only two recent studies (Hill, Gardner, & Rassaby, 1985; Hennig &
Knowles, 1990) utilize the HBM as a conceptual framework and deﬁne their variables
clearly in these terms.

The goal of this literature review, therefore will be to review and synthesize the
various types of investigations on Pap smear screening and cervical cancer in order
to identify research ﬁndings that are relevant to this study. The following types of
investigations on cervical cancer and Pap smear screening will be discussed: those
that discuss the relationship between advancing age and cervical cancer screening
frequency, those that use the HBM as a conceptual framework a basis for study,
those which have simultaneously addressed a broad combination of factors that affect

Pap smear frequency such as demographic, structural and psychosocial variables, and

17

those which address how the health care needs of women of advancing age affect the

frequency of Pap smear screening.

Age in Relationship to Screening Frequency

 

The relationship between age and cervical cancer screening frequency has been
found to be signiﬁcant. In a large telephone survey of 1200 middle aged and el-
derly women (Celentano, 1988) that investigated the relationship between age and
frequency of Pap smear screening, a direct negative linear relationship between ad-
vancing age and obtaining a routine Pap smear was found. Routine Pap smear was
deﬁned as a Pap within the last three years. Results from this survey revealed that
as many as 90 percent of the women aged 45—54 years reported having at least one
Pap smear in the last ﬁve years. These ﬁgures dropped to 72 percent in women aged
55—64 and to 56 percent in women 65 and older.

In another national telephone survey of 4629 women that also examined age in
relationship to cervical cancer screening, Hayward et a1. (1988) obtained results
similar to those of the Celentano study (1988). The proportion of women who had
received routine Pap smears decreased signiﬁcantly with advancing age. The survey
indicated that, in the 20—39 age group, 91 percent of women had received a routine
Pap smear. Whereas by the time women were 65 and older this ﬁgure dropped to as
low as 59 percent. Hayward et al. (1988) deﬁned routine screening as a Pap smear
within the last three years for women up to age 65 and within the last ﬁve years for

women over the age of 65.

18

Psychosocial Aspects of Cervical Cancer Screening

 

Psychosocial factors have been found to have an inﬂuence on the frequency of Pap
smear screening. There are only two recent investigations which focus entirely on the
psychosocial aspects of Pap smear screening. These investigations, both Australian,
were conducted by the social scientists Hill, Gardner, and Rassaby (1985) and Hennig
and Knowles (1990). The Hennig and Knowles study (1990) is a partial replication
of the Hill et a1. study (1985). Both studies utilized the HBM as a conceptual frame-
work, utilized the same questionnaire and stated that the purpose of the study was
investigate health behavior in order to plan more effective health education programs.

Hill et a1. (1985) had a sample of 123 women over the age of 18 with a median
age of 34. The independent variables derived from the HBM included the following:
social influence of important others, attitude toward Pap smears, perceived barriers
to screening, perceived beneﬁts to screening, perceived seriousness of cervical cancer,
perceived susceptibility to cervical cancer, and health motivation, the degree to which
women thought they would be screened for cervical cancer in the future. Hill et a1.
(1985) correlated their independent variables with the dependent variable future Pap
smear behavior. Future Pap smear behavior was deﬁned as the intention of having a
Pap smear in the next two years and was measured using the scores from two Likert
scale items. The Hennig and Knowles study (1990) had a slightly older aged sample
which included 144 women whose mean age was 54. Hennig and Knowles (1990)
correlated the same independent and dependent variables as in the Hill et al. study

(1985)

19

The two studies obtained similar results for four of the six health belief variables.
Both investigations reported that attitude toward cervical cancer, perceived barriers
to screening, perceived susceptibility, and health motivation signiﬁcantly accounted
for the intention to have a Pap smear in the future.

In addition, Hill et al. (1985) found social inﬂuence was able to signiﬁcantly
predict the intention to be screened for cervical cancer in the future, whereas in the
Hennig and Knowles study (1990) the concept of social inﬂuence was not found to
signiﬁcantly affect future Pap smear behavior. Two explanations given by Hennig and
Knowles (1991) for the lack of signiﬁcance of social inﬂuence were that, in general,
older women have less social contact than younger women, and that older women are
less apt to discuss their personal concerns with others.

The Hennig and Knowles study (1991) described past cervical cancer screening
practices of their sample according to age, whereas the Hill et al. study (1985) did
not. Hennig and Knowles (1991) divided their sample into three age groups (40—49,
50—59, 60—82). The 40-49 age group reported having had signiﬁcantly more Pap
smears in the last 10 years than either of the other two age groups. This was the only
reported analysis in either study done according to age group. All other statistical
analyses in both studies were done on the samples as a whole. Neither study deﬁned

the term routine Pap smear.

Multivariate Studies
Two recent studies exist which have investigated a combination of factors that
affect the frequency of Pap smear screening (Harlan et al., 1991; Peters et al., 1989).

20

Even though there is no consistent conceptual deﬁnition of the variables under study
and methods differ substantially in each investigation, these studies both found sim-
ilar psychosocial, demographic, and health care system factors to exert a signiﬁcant
inﬂuence in the frequency of Pap smear screening.

Peters et al. (1989) investigated a group of Caucasian and Hispanic women up to
age 76 in order to determine the barriers to participating in cervical cancer screening.
The sample (N = 400) was divided into ﬁve groups according to Pap smear screening
frequency in the last ﬁve years. Barriers to screening were grouped into six categories:
(1) cognitive barriers, (2) emotional barriers (fear), (3) emotional barriers (hate), (4)
economic barriers, (5) logistic barriers, and (6) social barriers. Demographic, health
history, and health care system variables were also analyzed. Peters et al. (1989)
found that cognitive and emotional (fear) barriers were signiﬁcantly more apparent
in the group of women who had been screened the least in the last ﬁve years. Cognitive
barriers were deﬁned as statements from subjects indicating a lack of understanding
of the screening nature of the Pap smear and not knowing when or why a Pap smear
was necessary. Emotional (fear) barriers were deﬁned as fear of pelvic exams, doctors,
and abnormal ﬁndings.

Other factors differed between the ﬁve frequency—based screening groups. The
group of most frequently screened women had signiﬁcantly greater incomes, were more
highly educated, had resided in the United States for longer periods of time, had a
regular doctor, had a health insurance policy, and were familiar with the appropriate

Pap smear screening interval. Whereas women in the group who had received little

21

to no screening were mainly of Latin descent and were signiﬁcantly older than those
women who received the most frequent screening. Peters et al. (1989) did not do any
speciﬁc analyses according to age, nor did they deﬁne the term routine Pap smear
screening or report the use any type of conceptual framework to guide their study.
However, many of the variables used in the Peters et al. study (1989) are very similar
to those that have been deﬁned in the context of the HBM.

Harlan et al. (1991) examined a sample of 12,686 African—American, Caucasian,
and Hispanic women aged 18 years and older to discover the variables that affect
compliance to routine Pap smear screening. Compliance to routine screening was
deﬁned as having had a Pap smear in the last three years. Attitudinal, demographic,
and health care system variables were examined.

Attitudinal reasons for noncompliance were categorized into seven groups: (I)
thinking that the Pap smear was unnecessary; (2) having had a hysterectomy; (3)
cost of the Pap smear as a consequence of not having health insurance; (4) not
having a physician; (5) not having had a Pap smear recommended by physician; (6)
embarrassment or fear; and (7) other or unknown reasons. The two groups which
had signiﬁcantly decreased screening compliance were those that thought that the
Pap smear was unnecessary and those that had not had a Pap smear recommended
by a physician.

Demographic variables examined were: ethnicity, education, income, and age. It
was found that Latina women had had signiﬁcantly fewer Pap smears than either

Caucasian or African—American women in the last three years, and were less likely to

22

have ever heard about the Pap smear technique. This was especially apparent in the
Latina population whose primary spoken language was Spanish. In addition, having
less than a high school education, being of low income status, and being of older age
all correlated with decreased screening compliance.

When examining health care system variables, Harlan et al. (1991) discovered
that a factor that signiﬁcantly affected screening compliance was the type of health
care setting. Harlan et al. (1991) found that women who belonged to prepaid health
plans or health maintenance organizations were more likely to have been screened
in the last three years than women who received care from a private doctor’s oﬂice.
While the authors do not state why this is so perhaps it is because of the emphasis
prepaid health plans put on the early detection and the prevention of disease.

Factors that correlated with reduced Pap smear screening frequency which were
common to both the Harlan et al. study (1991) and the Peters et al. study (1989)
were: lack of knowledge about the necessity of routine Pap smears, low income status,
low level of education, Hispanic origin, and advancing age.

A third study (Elkind et al., 1988) examined several factors that inﬂuence Pap
frequency. This was a qualitative study conducted in Britain that interviewed 56
women, the majority under the age of 50, which was designed to explore reasons for
low attendance at government—run cervical cancer screening programs. Elkind et al.
(1988) classiﬁed reasons for not attending screening programs into three categories:
organizational barriers, logistical barriers, and subject characteristics. Although com-

paring most of these variables to the variables in the two previous studies is difficult

23

because of different health care systems, it is of interest that. subjective beliefs of the
women interviewed and the barriers that prevent their routine screening are similar
to those found in the two previous studies discussed.

Subject characteristics which were found to account for low screening attendance
were grouped into two categories: attitudinal barriers and invalid beliefs. Attitudinal
barriers were deﬁned as embarrassment due to having an internal exam, having a
male doctor, fear about test results, previous unpleasant experiences with screening,
and fatalism (described as preferring not to know or think about Pap tests or their
results). Invalid beliefs were deﬁned as thinking that the test was inappropriate, being
unaware of the preventive nature of the Pap smear, or not believing that the test was
needed. Elkind et al. (1988) did not deﬁne the term routine Pap smear. Because of
the small number of older women in the study Elkind et al. (1988) were unable to
determine whether or not older women were less likely to be screened because of their

attitudes and beliefs.

Health Needs of Older Women

The health care needs of women of advancing age have an impact on the frequency
of Pap smear screening (Blesch & Prohaska, 1991; Teitelbaum et al., 1988; Warren &
Pohl, 1990). In a discussion about cervical cancer screening in older women Blesch
and Prohaska (1991) describe Pap smear screening as an incidental procedure done
primarily in the larger context of reproductive health care. Reproductive health
care centers around birth control and childbearing issues. When women no longer

require this type of health care they tend to drop out of the pool of women receiving

24

reproductive health care and therefore receive fewer Pap smears.

Differing health care needs of older women affect. the type of health care provider
they receive care from. Warren and Pohl (1990) investigated cancer screening prac-
tices of nurse practitioners and state that middle-aged and older adults often receive
their health care from specialists due to chronic medical conditions such as diabetes
and hypertension. As a consequence, primary health care issues such as Pap smear
screening for early detection of cervical cancer and other health promotion issues are
often not the main concern of a specialty practice and therefore not addressed at
these types of visits.

A study by Teitelbaum et al. (1988) examined two aspects of Pap smear screening:
women’s reported Pap screening practices in relationship to type of physician from
whom they received care, and the recommendations of 400 health care providers
(obstetrician—gynecologists, family practitioners and internists) regarding cervical
cancer screening for middle aged and older women. Teitelbaum et al. (1988) found
that while the majority of providers in all specialties recommended annual screening,
Obstetrician / Gynecologists were consistently more likely to recommend annual Paps
to their clients than the other two specialties surveyed. However, older women were
more likely to receive their health care from internists or family practice physicians,

thus decreasing their opportunity to be screened.

Rationale for Proposed Study

 

Literature relevant to cervical cancer and Pap smear screening has been reviewed
with an attempt to explain the numerous factors that inﬂuence the frequency of Pap

25

smear screening in older women. The studies have revealed that several factors are
required for cervical cancer screening to take place on a regular basis. Optimal cervical
cancer screening is promoted if: (1) psychosocial barriers such as embarrassment, fear,
discomfort or lack of understanding are minimized; (2) a woman is well educated, of
high income status and is English speaking, and (3) a woman has regular contact
with the health care system and adequate health insurance.

Few studies have speciﬁcally examined the relationship between health beliefs
and cervical cancer screening practices of older women and therefore one area of in-
quiry which is signiﬁcantly lacking in the literature on cervical cancer is a detailed
description of how psychosocial factors affect the Pap smear screening practices of
older women. The two recent studies that have exclusively examined the relation—
ship between health beliefs and Pap smear screening (Hill et al., 1985; Hennig &
Knowles, 1990) have included a broad age range of women in their samples and have
not reported the data according to age. Consequently, these study results can only
be applied to women in a general context and cannot be used to draw conclusions
speciﬁcally about how health beliefs affect cervical cancer screening practices of older
women.

Women of advancing age have health care priorities and needs that differ from
those of younger women. Perceptions on cervical cancer and Pap smear screening
may therefore also differ. Those aspects of preventive health behavior described in
the HBM, individual perceptions, attitudes and level of knowledge, clearly have an

important impact on cervical cancer screening practices. Therefore, a study that

26

examines how health beliefs inﬂuence the cervical cancer screening practice of older

women is needed.

Methods

The methods utilized in this study are presented in this section. Study questions,
sample procedures, instrumentation, scoring, data collection and data analyses are
outlined. This is followed by a discussion on study limitations and the protection of

human subjects.

Study Questions

 

The aim of this study was to determine, utilizing a correlational design, what
health beliefs were signiﬁcantly related to the cervical cancer screening practices in a

group of women 50 years old and older. Six study questions were asked:

(1) Is there a signiﬁcant relationship between knowledge about Pap smear

screening and frequency of Pap smear screening?

(2) Is there a signiﬁcant relationship between perceived susceptibility to

cervical cancer and frequency of Pap smear screening?

(3) Is there a signiﬁcant relationship between social inﬂuence and fre-

quency of Pap smear screening?

(4) Is there a signiﬁcant relationship between perceived barriers to Pap

smear screening and frequency of Pap smear screening?

27

(5) Is there a signiﬁcant relationship between perceived efﬁcacy of the Pap

smear as a screening procedure and frequency of Pap smear screening?

(6) Is there a signiﬁcant relationship between the intention to be screened

for cervical cancer and frequency of Pap smear screening?

Sample Procedures

 

This investigation utilized a non—probability convenience sampling method. The
target population was the membership of the Clerical—Technical Union (CTU) of
Michigan State University (MSU). Permission from the union board was obtained to
contact all women in the union who were 50 years of age or older (see appendix E).
This included actively employed female members of the CTU as well as 29 female re-
tirees. These women were identiﬁed by their birth year according to Human Resource
records at MSU. Returned questionnaires were subject to the following eligibility cri-
teria: returning the questionnaire in the designated period of time and not having
had a hysterectomy.

As illustrated in Table 1, a total of 361 women 50 years old or older were identiﬁed
and sent questionnaires. Out of a total of 361 questionnaires sent, 175 were returned
prior to the cutoff date of September 10th, 1992 (a response rate of 48%). Out of
these 175 returned questionnaires, 66 subjects reported having had a hysterectomy
and were subsequently excluded from the study. The remaining 109 subjects reported
that they had not had a hysterectomy and were therefore eligible for the study. The

ﬁnal sample consisted of 109 subjects.

28

Table 1

 

 

Sample

Questionnaires n %
Questionnaires Sent 361 100
Questionnaires Not Returned 186 52

Questionnaires Returned:
Questionnaires returned but subjects ineligible 66 18

Valid questionnaires 109 30

 

Operational Deﬁnition of Variables

 

The variables were operationalized by the self—report of each subject completing
the questionnaire (see appendix B). The independent variables were operationalized
as follows:

Knowledge of Pap smear screening—(Questions 11, 12, 13, 28, 30, 31). This vari-
able measures the knowledge subjects have about Pap smear screening and cervical
cancer. Included are questions that assess understanding about the preventive nature
of the Pap smear, when one needs a Pap smear, and whether one can have cervical
cancer without exhibiting signs and symptoms of the disease.

Perceived susceptibility to cervical cancer—(Questions 23, 24, 25, 26, 27). This
variable measures concerns women have about getting cervical cancer. Included are

questions about the likelihood of developing cervical cancer, the seriousness of the

29

disease, and the possibility that one could have cervical cancer without being aware
of it.

Social inﬂuence—(Questions 18, 19, 20, 21, 22). This variable measures the inﬂu-
ence that “important others” such as health professional, friends, and family, have on
a woman’s decision to get a Pap smear. Included are questions measuring the reported
advice, discussion, or discouragement on the practice of cervical cancer screening from
“important others”. The perceived importance of the opinions of “important others”
about Pap smear screening is also included.

Perceived barriers to Pap smear screening—(Question 34: a 16 item subscale).
This variable measures what subjects perceive as the barriers to Pap smear screen-
ing. Included are questions assessing both the emotional and physical discomfort
of the subject during procedure, the perceived importance of having a Pap smear,
the perceived efficacy of the Pap smear procedure, the Pap smear in relationship to
control of one’s health, and cost and time issues.

Efﬁcacy of the Pap smear screening process—(Questions 10, 14, 15, 16, 17, 29).
This variable measures the degree to which subjects feel that the Pap smear is a
worthwhile procedure. The questions measure perceptions about whether Pap smears
are effective in detecting cervical cancer and improving chances of survival.

Intentions to be screened for cervical cancer—(Questions 32, 33). This variable
measures the extent to which cervical cancer screening is a priority for the subject

and the likelihood of participating in immediate and long—term screening.

30

The dependent variable was operationalized as follows:
The number of Pap smears the subject received in the last 10 years—(Question 8).
Measurement of this variable was done using one question which asked the respondent

to check the number of times she had had a Pap smear in the last 10 years.

Instrumentation

The instrument for this study consisted of an adapted version of the question-
naire,“Breast Cancer Screening Practices” developed by Given et al. (1989). (The
original questionnaire was developed for use in “Assessment of Barriers and Facilita-
tors to Screening for Breast Cancer: A Worksite Approach” (Given et al., 1989). This
was an investigation (N21632) funded by the Michigan Department of Public Health
whose purpose was to explore the barriers and facilitators to breast cancer screening
in the workplace.) The adapted instrument “Cervical Cancer Screening Practices
Questionnaire” (see appendix B) contained a total of 42 questions; 24 measuring
health beliefs and the remaining 18 items asking about the subject’s background and
health history. The background and health history questions provided information
on the similarities and differences in demographic characteristics, preexisting medical
conditions, and current health practices.

The majority of items in the “Cervical Cancer Screening Practices Questionnaire”
were arranged in a ﬁxed alternative format, the remainder required a yes / no response.
The ﬁxed alternative items required the respondent to pick the most appropriate
answer out of a choice of three to ﬁve alternatives. Each alternative was assigned
a numerical value for purposes of analysis. Several background and health history

31

items requested that the respondent pick as many items in the questions that were
applicable. The adapted instrument was pilot tested by three female volunteers, all
over the age of 50, in order to judge for clarity and completion time. Revisions were
then made based on their comments.

Modiﬁcations to the Breast Cancer questionnaire (Given et al., 1989) were nec—
essary in order to more accurately reﬂect health beliefs pertaining to cervical cancer
screening practices. The breast cancer screening process has three dimensions: mam-
mography, breast self exam (BSE), and clinical breast exam (CBE). In contrast, the
cervical cancer screening process only has one dimension: the Pap smear. There-
fore, only one set of questions, those that measured CBE, were adapted for use in
this study. The CBE dimension was chosen because this procedure is most similar
to the Pap smear in that both are performed in the office setting and both require
direct client / provider interaction. Because breast cancer and cervical cancer differ in
terms of incidence and signiﬁcance of known risk factors questions pertaining to these
categories were omitted in the adapted questionnaire.

Given et al. (1989) reported Cronbach’s alpha coefficient of reliability for the
barriers scale. The barriers scale was factor analyzed and four subscales and their
alpha coefﬁcients were reported: perceived importance of the CBE procedure (.86),
perceived efficacy of the CBE (.87) procedure, perceived discomfort of the CBE pro—
cedure (.88), perceived control of health (.75). Each subscale yielded a high alpha
correlation indicating a high degree of internal consistency for the barriers scale. The

present study did not use the subscales of barriers to report alpha coefﬁcients.

32

The “Cervical Cancer Screening Practices Questionnaire” was a newly adapted
instrument and therefore no information on the validity and reliability was available
prior to questionnaire administration. Reliability studies were performed after the
data collection was complete. These results will now be reported.

The reliability of each of the six scales on the adapted instrument “Cervical Can-
cer Screening Practices Questionnaire” was tested using the Cronbach’s alpha corre-
lational analysis of internal consistency. Internal consistency determines the extent
to which all items on a particular scale consistently contribute to the overall mea-
surement of a concept by correlating the individual items on a scale with each other
and with the overall score (Brink & Wood, 1988).

Table 2 reports the mean inter—item correlations and the alpha coefﬁcients. As
illustrated, four out of the six health belief scales, inﬂuence, barriers, efﬁcacy, and
intentions had correlations of .70 or higher. This is considered an acceptable corre-
lation for this type of analysis (Polit & Hungler, 1987) and indicates that the items
contained in these four scales were consistently measuring the same concepts.

Three items on the barriers scale (see question #34, items j, o, and s, appendix
B) were omitted after the initial reliability analysis was performed because they de—
creased the alpha correlation coefﬁcient. Once these items were eliminated the alpha
correlation coefﬁcient rose from .70 to .79 indicating that these three items were not
effectively contributing to the ability of the overall scale to consistently measure the

concept.

33

Table 2

Reliability of “Cervical Cancer Screening Practices Questionnaire”

 

 

 

Variable Mean Inter-Item Correlation Alpha
Knowledge .06 .27
Susceptibility .15 .44
Inﬂuence .19 .73
Barriers .20 .79
Efﬁcacy .40 .79
Intentions . 70 .82

 

The knowledge and susceptibility scales both had considerably lower alpha correla-
tions, 7‘ = .27 and r = .43 respectively, indicating that the responses from individual
subjects to these questions showed considerable variation and therefore the items
within these scales were not consistently measuring the concepts.

Extensive analyses to determine the validity of the “Cervical Cancer Screening
Practices” instrument were not performed in this study. However, the instrument was
reviewed by four nurses in advanced practice who specialize in the area of women’s
health and cancer screening. Further validity studies would have helped to determine
the degree to which the scales were accurately representing the abstract concepts

under investigation but were beyond the scope of this study.

34

Scoring Procedures

 

The dependent variable (the number of Pap smears that the sub ject has received
in the last 10 years) was measured using a range that consisted of 11 possible alter-
natives, assigned a numerical value, from “can’t remember how many Pap smears in
the last 10 years” to “more than 10 Pap smears in the last 10 years”. The respondent
chose one alternative.

Fixed alternative scales were used to measure the items representing the inde-
pendent variables. All items had a range of three to ﬁve responses. Each possible
response was assigned a numerical value. Scoring on ﬁve of the six scales (knowledge,
susceptibility, inﬂuence, efﬁcacy, and intentions) was arranged so that signiﬁcant pos-
itive correlations would reveal a positive relationship between health beliefs and Pap
smear frequency. That is, an increase in the scores on any of the ﬁve scales was
expected to be accompanied by an increase in the number of Pap smears that the
individual had had in the last 10 years.

The knowledge scale contained six ﬁxed alternative three or ﬁve-point items.
The highest possible score for the scale was a total of 26 points on a range of 6—26
points. High scores on the scale reﬂected that respondents were knowledgeable about
the nature of cervical cancer and Pap smear screening recommendations, low scores
reﬂected less knowledge.

The susceptibility scale contained ﬁve ﬁxed alternative four or ﬁve-point items.
The highest possible score was 24 points on a range of 5—24 points. High scores re-

ﬂected that subjects perceived themselves to be susceptible to cervical cancer, whereas

35

low scores indicated a low degree of susceptibility.

The inﬂuence scale contained four items. Three items had a total of 27 yes/ no
alternatives. The fourth item was a. scale with eleven four—point items. The highest
possible score was 62 points on a range of 0—62 points. Subjects who reported that
their Pap smear practices were inﬂuenced by “important others” obtained high scores,
whereas subjects not inﬂuenced by “important others” obtained the low scores.

The efﬁcacy scale contained six ﬁxed alternative ﬁve—point items. The highest
possible score for the scale was 30 points on a range of 6—30 points. Those who scored
high on the scale reported that they perceived the Pap smear to be an efﬁcacious
procedure whereas those with lower scores felt the Pap smear to be less efﬁcacious.

The intentions scale contained two ﬁxed alternative four or ﬁve—point items. The
highest possible score for the scale was nine points on a range of 2—9 points. Those
for whom getting a Pap smear in the future was a high priority received high scores
as opposed to those who felt that getting a Pap smear in the future was less of a
priority.

Scoring on the barriers scale was arranged so that signiﬁcant negative correlations
would reveal that a negative relationship exists between past Pap smear practices
health beliefs. That is, an increase in the scores on the barrier scales was expected
to be accompanied by a decrease in the number of Pap smears in the last 10 years.

The barriers scale contained nineteen four—point items (this was reduced to sixteen
after the reliability analysis). The highest possible score was 64 points on a range

of 16—64 points. High scores on the scale reﬂected that the subject perceived many

36

barriers to cervical cancer screening, low scores reﬂected few perceived barriers.

Data Collection Procedure

Data was collected between August 13, 1992 and September 10, 1992. With the
permission from the CTU the names and addresses of potential participants were
made available from the Human Resources department at MSU. The questionnaire
with an accompanying cover letter (see appendix A) and return envelope were mailed
to the 361 subjects who met the age criterion on August 13, 1992. Two weeks after
the initial mailing of the questionnaire a follow—up thank-you / reminder postcard (see
appendix C) was sent to all recipients of the questionnaire regardless of whether or

they had returned the questionnaire.

Data Analysis

 

Data analysis was done with the SPSS/PC+ computer program. Demographic
and health history characteristics were categorized using descriptive statistics: percents,
frequency distributions, and measures of central tendency. Pearson’s correlational
analysis was utilized to determine the relationship of the six independent variables to
the dependent variable. For the purposes of statistical analysis and application of the
study results to nursing practice, the six independent health belief variables derived
from Given’s HBM (Given et al., 1989) (knowledge, susceptibility, social inﬂuence,
barriers, efﬁcacy, and intentions) were correlated separately with the dependent vari-
able (the number of Pap smears the respondent has had in the last ten years) as

reﬂected by the six study questions posed.

37

Study Limitations

 

There are three limitations to this study. First, although only minor alterations
to the Given questionnaire (Given et al., 1989) were made, this is a newly adapted
instrument and the reliability was not established prior to data collection, nor were
any validity issues explored. Second, this was a correlational study and it would have
been preferable to use a random sampling method. Because a convenience method
was utilized the sample did not accurately represent the larger population. Therefore,
results could only be discussed in terms of this study. Finally, data collection was
self—reported by participants. No attempt was made to verify information through

other sources.

Protection of Human Subjects

 

The rights of the individuals who participated in this study were protected accord-
ing to the guidelines developed by the University Committee on Research Involving
Human Subjects (UCRIHS) at Michigan State University. Approval to conduct this
survey was received from UCRIHS prior to data collection (see appendix D).

The identity of all study participants remained conﬁdential. The list of partici-
pants names and addresses was used for mailing purposes only and no further records
were kept after mailing. The responses of all study participants remained anonymous.
The questionnaires were not coded in any way to identify participants nor were ques-
tionnaire responses reported in such a way as to link them to individual subjects.

All study results are reported in aggregate form.

38

Findings

The results described in this section are compiled from the self—reported question-
naires returned by 109 subjects who were eligible for this study. Included are tables
showing the sociodemographic, health, and Pap smear screening characteristics of the

sample; and tables giving results of the data analyses.

Sociodemographic Characteristics

 

The 109 subjects in the sample were between the ages of 50 and 71 years; their
mean age was 56.2 years. 'As illustrated in Table 3, the majority were white (93.5 %),
employed full-time (80.7%), and married (68.5%). Over half the sample, 61 subjects
(56%), reported that they had gone to college for one year or more. At least 56
subjects (45.5%), reported a combined household income of $41,000 or above. All

subjects reported having health insurance.

Health Characteristics

As reported in Table 4 the majority of the sample, 90 subjects (84.1%), had
reached menopause and approximately one quarter of the sample, 27 subjects (24.8%),
reported that they were on hormonal replacement therapy. The most frequently

reported chronic medical conditions were hypertension (28.4%) and arthritis (19.3%).

Screening Characteristics

 

As can be seen in Table 5 the entire sample (100%) reported having had at least one

Pap smear in the past 10 years. The mean number of Pap smears in the last 10 years

39

Table 3

Sociodemographic characteristics of sample

 

 

 

Characteristic n %
Age
50-54 years 42 38.1
55-59 years 33 30.2
60—64 years 27 24.5
65—69 years 5 5.4
70 years and above 2 1.8
Race
White 101 93.5
Hispanic 4 3.7
Chinese 1 0.9
Other 3 2.8
Employment Status
Fulltime 88 80.7
Part-time 12 11.0
Retired 9 8.3
Marital Status
Married 74 68.5
Divorced 27 25.0
Widowed 4 3.7
Never married 2 1.9
Missing 2 1.9
Highest grade Completed
8 - 11th grade 3 2.8
High school graduate 28 25.9
Post high school 14 13.0
1 - 3 years of college 43 39.8
College graduate 14 13.0
Graduate school 6 5.5

 

40

table continues

Table 3 continued

 

 

 

 

 

 

n %
Combined Household Income
<$10,000 1 0.9
$10,000 - $20,000 9 8.6
$21,000 - $30,000 29 26.8
$31,000 - $40,000 14 12.1
$41,000 - $50,000 24 22.3
> $50,000 32 29.6
Health insurance
Yes 109 100
Table 4
Health characteristics of sample
Characteristic n %
Menopause
Yes 90 82.6
No 13 11.9
Don’t Know 4 3.7
Missing 2 1.8
Hormonal replacement
Yes 27 24.8
No 50 45.9
Missing 32 29.4
Co-morbidity ‘1
Hypertension 31 28.4
Heart disease 3 12.8
Diabetes 7 6.4
Arthritis 21 19.3
Cancer 10 9.2
Other 11 10.1

 

“ Respondents were asked to check all answers that applied.

41

for the sample was 8.83. When asked how many Pap smears they had had in the last
10 years as many as 70 subjects (74.3%) reported that they had at least nine Pap
smears in the last 10 years. When asked what prompted their most recent Pap smear
102 subjects (93.6%) reported that their most recent Pap smear was part of a routine
check-up. A total of 26 subjects (23%), reported that they had had an abnormal
Pap smear in the past and 2 subjects (1.8%), reported these abnormal results were
positive for cervical cancer. When asked who usually performs their Pap smear, 62
subjects (56.9%) reported that they had had their routine Pap smears done by a
family practice physician and 64 subjects (62.1%) reported that the procedure was

usually performed by a male provider.

Description of the Variables

 

Several characteristics of the sample are apparent from the statistics reported in
Table 6. The knowledge and intentions scales, and to a lesser extent the efﬁcacy
scale, have means near the top of their range and relatively low standard deviations.
This indicates that most subjects in this study were quite knowledgeable about Paps
smears, intended to get regular Pap smears in the future and felt the Pap smear
procedure was efﬁcacious. The statistics for the Pap smear frequency scale clearly
indicate that most woman in this study had received yearly Pap smears for the last
decade, reﬂecting the fact that the sample was drawn from a homogeneous population
which had health insurance and readily accessible health care. The possible reasons
for the sample characteristics and their implications for the study will be discussed

in the next section.

42

Table 5

Screening characteristics of sample

 

 

 

Characteristic n %

Number of Pap smears in last 10 yrs
about 1 3 2.8
about 2 2 1.9
about 3 2 1.9
about 4 7 6.5
about 5 6 5.6
about 6 6 5.6
about 7 5 4.6
about 8 6 5.6
about 9 44 40.7
10 or more 26 24.1

Reason for last Pap smear "

Due to a previous problem 7 6.4
Part of routine check-up 102 93.6
Recommended by provider 5 4.6
Recommended by friend 2 1.8
Abnormal Pap
Yes 26 23.9
No 81 74.3
Missing 21 1.8
Results of abnormal Pap
Positive for cancer 2 8.0
Negative for cancer 19 72.0
Positive for other disease 2 8.0
Don’t know results 3 12.0

Pap smear usually performed by a

Family practice doctor 62 56.9
Internist 18 16.7
Obstetrician / Gynecologist 36 33.0
Nurse practitioner 10 9.2
Physician’s assistant 2 1.9

Gender of provider who usually performs Pap “
Male 64 62.1
Female 39 37.9

 

a Respondents were asked to check all answers that applied.

43

Table 6

Range, mean and standard deviation of the variables

 

 

 

Variable Possible Range Observed Range Mean SD. 11
Knowledge 6 - 26 17 - 25 21.8 2.0 105
Susceptibility 5 - 24 8 - 19 13.1 2.2 104
Inﬂuence 0 - 62 24 - 51 36.9 4.7 65
Barriers 16 - 64 16 - 42 29.7 3.9 95
Efﬁcacy 6 - 30 9 - 29 23.4 3.5 108
Intentions 2 - 9 3 - 9 8.4 1.0 108
Pap frequency 1 - >10 1 — >10 8.8 2.5 109

 

Analysis of Research Questions

 

The six research questions described earlier were analyzed using Pearson’s cor-

relation coefﬁcient. As shown in Table 7, two out of the six variables: perceived

barriers to cervical cancer screening and intentions to be screened for cervical cancer

in the future yielded signiﬁcant correlations at the .001 level. The remaining four

variables: knowledge about cervical cancer, perceived susceptibility to cervical can-

cer, perceived efﬁcacy of the Pap smear, and intentions to be screened for cervical

cancer in the future did not yield signiﬁcant correlations.

44

Table 7

Correlations between Pap smear frequency and health beliefs

 

 

 

 

Variable Correlation n
Knowledge .05 105
Susceptibility .21 104
Inﬂuence .05 65
Barriers —.31* 95
Efﬁcacy .19 108
Intentions .60* 108

* pg .001.

The Effects of Age and Hormonal Replacement Therapy on Pap Smear Frequency

 

After the initial descriptive analysis of demographic and health history variables a
two way analysis of variance (ANOVA) was performed in order to examine the effects
of hormonal replacement therapy (HRT) and age on Pap smear frequency. HRT was
chosen because approximately one fourth of the sample (24%) reported that they had
taken HRT. Age was chosen to observe whether or not screening frequency declined
with advancing age as had been documented in the literature.

The sample was ﬁrst divided into three age groups (Group 1 = 50—55 years,
Group 2 = 55-59 years, Group 3 = 60 years and over). As illustrated in Table 8, age
did not signiﬁcantly affect Pap smear frequency, that is, in the last 10 years there

45

was no signiﬁcant difference in the mean screening frequency between the three age
groups (Group 1: Y: 8.58 , Group 2: 7: 8.71, Group 3: K: 8.06). However, HRT
did signiﬁcantly affect Pap smear frequency, that is, those who reported taking HRT
had received signiﬁcantly more Pap smears in the last 10 years than those who were
not taking HRT (HRT yes : 729.52, HRT no: 727.96).

There was no signiﬁcant interaction between variables when HRT and Pap smear
frequency were examined simultaneously. That is, the overall variation in Pap smear
frequency for the sample could not be accounted for when the combined effects age

and HRT were examined.

Table 8

Two way ANOVA: The effects of age and hormonal replacement therapy on

 

Pap smear frequency

 

 

 

 

Source of Variation S.S. D.F. M.S. F. Sig. of F.
Age 3.01 2 1.5 .23 .793
HRT 40.99 1 41.0 6.33 .014“
Age x HRT 18.06 2 9.0 1.39 .254
Explained 63.66 5 12.7 1.96 .094
Residual 459.58 71 6.5 — —
Total 523.24 76 6.9 — -

* pg .05.

46

Discussion

Study ﬁndings are interpreted in this section. First, an overview of ﬁndings is
given; this is followed by a discussion of the results of the six research questions and
the effects of age and hormonal replacement therapy on screening frequency. Second,
implications of study ﬁndings in terms of the HBM and the CNS’s roles in the primary
health care setting are presented. Finally, topics for future research are suggested.

This study utilized a convenience, or non-probability, sampling method. As often
occurs with this sampling technique, the resulting sample was fairly homogeneous.
Sociodemographic characteristics of the subjects in this sample were very similar:
the majority were white (93.5%), married (68.5%), and employed full-time (80.7%).
At least 45 percent reported a combined household income of $41,000 or more. All
reported having health insurance.

Because this was a correlational study it would have been preferable to use a prob-
ability, or random, sampling method. Random sampling assures that each member
of a chosen study population has an equal chance of being included in the study.
This increases the likelihood that the sample will be diverse and will, as accurately as
possible, represent the natural variability that exists in the overall population (Brink
& Wood 1988).

The more variability in a sample the easier it is to detect correlations that may
exist. In this study four out of the six correlations between the health belief variables

and Pap smear frequency were not signiﬁcant. This is perhaps due to the homogeneity

47

of the sample. Therefore, the convenience sampling procedure used in this study is a
study limitation.

Nearly all the women in the sample (95.3%) had had routine Pap smear screening,
which in this study was deﬁned as a Pap smear every three years. In fact, 70 subjects
(74.3%) reported having at least nine Pap smears in the last. 10 years (7 = 8.8, SD. =
2.5). Thus, many of these woman seem to be receiving Pap smear screening annually
and it is felt that perhaps these women were screened more often than is necessary.
Current recommendations do not explicitly advocate annual screening (Fink, 1991;
NCI, 1990; ACOG, 1989). Furthermore, there is no scientiﬁc data to suggest that
asymptomatic women who are screened annually are at signiﬁcantly lower risk for
developing invasive cervical cancer than those who are screened every three to ﬁve
years (Fisher & Eckhart, 1989).

Often screening schedules are based on a woman’s personal risk factors for cervical
cancer and at the discretion of the health care provider, and in individual cases there
may be sound medical reasons for more frequent Pap smear screening. Questions
dealing with these issues would have had to be asked before drawing the conclusion

that screening was being done too often.

Research Questions

 

The six research questions posed in this investigation were based on the the Health
Belief Model adapted by Given el al. (1989). Two out of six variables, barriers and
intentions, yielded signiﬁcant correlations with the dependent variable the number
of Pap smears in the last 10 years. The remaining four variables: susceptibility,

48

knowledge, inﬂuence, and efﬁcacy did not yield signiﬁcant correlations.

Alpha correlation coefﬁcients provided information about the internal consistency
of the scales used to measure the variables. Four scales had relatively high degree
of internal consistency, (inﬂuence: alpha 2.73, barriers: alpha 2.79, efficacy: alpha
2 .78, and intentions: alpha 2.82), indicating a high probability that the results
derived from the scales were accurate. However, the knowledge and susceptibility
scales both had considerably lower alphas, alpha 2 .27 and alpha 2 .43, respectively.
With the low degree of internal consistency of these two scales, the conﬁdence that

the signiﬁcant results, had they been found, were accurate would be low.

Question #1. Is there a signiﬁcant relationship between knowledge about Pap
smear screening and frequency of Pap smear screening in the last 10 years?

This study did not ﬁnd that knowledge about Pap smear screening inﬂuences Pap
smear frequency. This is in contrast to the ﬁndings of other investigations (Peters
et al. 1989; Harlan et al. 1991; Elkind et al. 1988) who all found that lower levels
of knowledge about Pap smear screening were associated with decreased screening
frequency.

In this study the correlation between knowledge and Pap smear frequency was not
signiﬁcant (r 2 .05). Therefore, the study failed to show that knowledge inﬂuenced
Pap smear frequency. The failure to get a signiﬁcant correlation was most likely the
result of the homogeneity of the sample: the subjects nearly all had a high level of
knowledge and a high level of screening frequency. In order to yield a signiﬁcant
correlation, if one in fact existed, and conclude that knowledge did indeed inﬂuence

49

screening frequency, would require a sample that also included subjects with low levels
of knowledge and low levels of screening frequency.

A majority of 69 subjects (62.3%) scored 22 points or above out of a possible 26
points (7 2 21.8, SD. 2 2.0). These scores reﬂected that subjects were generally
knowledgeable about Pap smear screening; they understood the preventive nature of
the Pap smear, its ability to detect cancer early and the asymptomatic nature of the
disease.

The low reliability of the knowledge scale (alpha 2 .27) revealed that this was not
an effective measure. This was possibly because the questions assessing knowledge
were broad. They dealt with a wide range of issues: the symptoms of cervical cancer,
the medical effectiveness of the Pap smear technique, and the recommended screening
frequency. Furthermore, they were phrased using general terms such as “a woman”
and “ a person” and did not speciﬁcally address or account for the personal health

situation of the individual.

Question #2. Is there a signiﬁcant relationship between perceived susceptibility
to cervical cancer and frequency of Pap smear screening in the last 10 years?

The correlation between the susceptibility scale and Pap smear frequency was not
signiﬁcant (7‘ 2 .21) and therefore the study failed to show that perceived suscepti-
bility to cervical cancer inﬂuenced Pap smear screening. Again, the failure to get a
signiﬁcant correlation was most likely the result of the homogeneity of the sample:
the subjects nearly all had low levels of perceived susceptibility toward cervical cancer

and high levels of Pap smear screening frequency.

50

About two thirds of the subjects (68.6%) scored 14 points or below out of a
possible 24 points (7 = 13.1, SD. = 2.2). The consistently low scores reflected
that most respondents did not believe they were at high risk for developing cervical
cancer and did not believe that being over 50 years old affected the likelihood of their
developing cervical cancer. Neither did they think it likely that they would develop
cancer sometime in their lifetime.

The low reliability of the perceived susceptibility scale (alpha = .27) revealed that
this was not an effective measure. Similar to the questions measuring knowledge
most of the questions on the susceptibility scale were general; they assessed global
susceptibility issues rather than relating susceptibility speciﬁcally to the individual.

A high level of perceived susceptibility to disease or illness is usually associated
with a high level of participation in preventive health behavior (Janz & Becker, 1984;
Nemcek, 1990). It is of interest to observe that in this study different results were
found. The subjects had a consistently low level of perceived susceptibility to cervical
cancer but a consistently high frequency of screening. The low level of perceived
susceptibility toward cervical cancer of subjects in this sample may be the net result
of their high level of knowledge about screening issues, their high conﬁdence that the
Pap smear is able to detect cervical cancer if present, and their history of frequent
screening over a long period of time. In addition, it would appear that Pap smear
screening is considered a regular part of the health care of these subjects regardless

of their particular concerns about cervical cancer.

51

Question #3. Is there a signiﬁcant relationship between social influence and fre-
quency of Pap smear screening in the last 10 years?

The correlation between the social influence scale and Pap smear frequency was
not signiﬁcant (1" = .05) and therefore the study failed to show that social influence
affected Pap smear screening frequency. Again, the weak correlation can be attributed
to the lack of variability in the sample. The total possible score on the social influence
scale was 62 points and the results showed scores rather tightly concentrated around
the mean (7 = 36.9, SD. = 4.7).

The subjects had similar feelings about the advice or opinions of important others
concerning screening. Nearly all the subjects felt that the opinions and advice of
their doctor was most important, followed by the opinions and advice of their nurse
or a family member. Most sampled women felt that opinions and advice of friends,
co-workers and the media were only somewhat important. Virtually no one in the
sample reported having been discouraged from obtaining a Pap smear.

The questions on the inﬂuence scale had a high reliability (alpha = .73), showing
that this scale was consistently measuring the inﬂuence concept. However, only about
half of the sample completed the questions on this scale (n = 65). It is felt that
this happened because either the items on this scale lacked sufﬁcient alternatives for
respondents to choose from, or the format was not appealing to respondents.

Social inﬂuence is a complex concept to measure. To examine its full dimensions,
one must measure not only negative and positive inﬂuence, but also the absence of

inﬂuence. The questionnaire used in this study did not provide any alternatives that

52

clearly signiﬁed the absence of inﬂuence. Having this choice would have allowed fuller
measurement of the concept.

Although social inﬂuence did not signiﬁcantly affect Pap smear screening in this
study it should be considered an important component of the HBM. Other studies
have found that social inﬂuence signiﬁcantly inﬂuences health behavior, including Pap
smear practices. Hill et al. (1985) found that the inﬂuence of a physician, mother,
sister, or close friend correlated signiﬁcantly with the intention to have a Pap smear
in the future. In a study that examined breast cancer screening behavior Champion
(1989) found a signiﬁcant relationship between social inﬂuence and performance of
breast self-exam (BSE). Speciﬁcally, Champion found that women who were taught
BSE by their physicians scored higher on proﬁciency scales, performed the exam more
frequently, and had higher intentions of performing it in the future than those who

had not been taught by their physicians.

Question #4. Is there a signiﬁcant relationship between perceived barriers to Pap
smear screening and frequency of Pap smear screening in the last 10 years?

A signiﬁcant negative correlation (r = —.31) was found between perceived bar-
riers and frequency of Pap smear screening in the last 10 years. Therefore in this
study perceived barriers to cervical cancer screening did inﬂuence Pap smear screen-
ing frequency. However, only 9.6% of the variance in Pap smear screening could be
explained by barriers.

The inﬂuence was in the direction one would expect; subjects who perceived the
fewest barriers to the Pap smear screening process, as reﬂected by lower scores on

53

the barriers scale, had received signiﬁcantly more screening in the last 10 years. In
contrast, those subjects who perceived more barriers to the screening process, as
reﬂected by higher scores on the barriers scale, had received signiﬁcantly fewer Pap
smears in the last 10 years. The reliability of the barriers scale was high (alpha 2
.79) showing that this scale was an effective measure.

The total score possible on the barriers scale was 64 points (7 = 29.7, SD. =
3.9). About a third of the items on the barriers scale had a high rate of variability
in the scoring; such variability in data generally makes the detection of signiﬁcant
correlations easier. These items distinguishing the women who perceived a high level
of barriers to screening from those who didn’t. Items with a high rate of variability
were: forgetting to arrange a Pap smear, feeling that the Pap smear was an embar-
rassing and unpleasant procedure, feeling physical and emotional discomfort when
having a Pap smear, and anxiety and fear about abnormal Pap smear results.

The remainder of the items on the barriers scale showed little variability in the
scoring and were not considered barriers by most women in the sample. The majority
of women felt that they knew when they needed a Pap smear and knew how to ask
for one, felt that the Pap smear was convenient to arrange, was worth the effort, and
would improve their chances of detecting cancer early. In addition, the majority of
women did not feel that arranging a Pap smear was a hardship due to cost, lack of
time, or too many other worries.

These results are in agreement with other investigations which have also found

that barriers to screening inﬂuenced Pap smear practices. Hill et a1. (1985) and

54

Hennig and Knowles (1991) correlated perceived barriers to Pap smear screening with
intentions to be screened for cervical cancer in the future and found that women who
perceived more barriers to the screening process reported that they were signiﬁcantly
less likely to participate in Pap smear screening in the future. Both investigations
found that embarrassment, indignity of the exam, discomfort, fear of abnormal re-
sults, and not having the procedure recommended by a physician were the items that

correlated most signiﬁcantly with Pap smear screening frequency.

Question #5. Is there a signiﬁcant relationship between perceived eﬂicacy of the
Pap smear as a screening procedure and frequency of Pap smear screening in the last
10 years?

The correlation coefﬁcient between efﬁcacy and Pap smear frequency was not
signiﬁcant (7" = .19). Therefore, perceived efficacy of the Pap. smear did not inﬂuence
Pap smear frequency in this study. Again, the weak correlation was due to the lack
of variability in the sample. Approximately two thirds of the subjects (67.9%) scored
23 points and above out of a possible 30 points (7(— = 23.4, SD. = 3.5). Most
believed that the Pap smear was an efﬁcacious procedure and were conﬁdent that
the Pap smear could detect abnormalities likely to be cervical cancer. In addition,
the majority agreed that if cervical cancer was found early with the Pap smear the
chances of complete recovery were improved.

The reliability of the perceived efficacy scale in this study (alpha 2 .79) revealed
that this was an effective measure and that the questions on this scale were con-
sistently able to measure the efficacy concept. However, it may have been more

55

appropriate in this study to more closely measure the concept of self—efﬁcacy in rela-
tionship to cervical cancer screening practices (see page 9).

The questions on the efﬁcacy scale dealt only with the effectiveness of the Pap
smear as a cancer detection procedure. Whereas the the self—efﬁcacy concept also
deals with subjective feelings such as self—mastery and personal ability to carry out
certain health related behaviors which both strongly pertain to personal perceptions
about Pap smears. To measure the self—efﬁcacy concept the questionnaire could have
included questions asking more speciﬁcally about perceived degree of control over
health attained by getting the Pap smear, the ability to arrange a Pap smear, and
the conﬁdence that one’s health care practices provide adequate protection from, or
warning about, the possibility of cervical cancer. Items measuring self—efficacy as
well as efficacy of the Pap smear would have provided a broader interpretation of the

concept and may have yielded more signiﬁcant results in the context of the HBM.

Question #6 Is there a signiﬁcant relationship between the intention to be screened
for cervical cancer and frequency of Pap smear screening in the last 10 years?

The correlation between intentions and Pap smear frequency was signiﬁcant (7‘ =
.60). Therefore, in this study future intentions to be screened for cervical cancer did
inﬂuence Pap smear screening frequency. The variance in Pap smear frequency that
could be explained by intentions was 36%.

The inﬂuence of intentions on Pap smear frequency was in the expected direction.
Subjects who strongly agreed that having a Pap smear in the next two years was a
high priority and those who felt that it was highly likely that they would be having a

56

Pap smear in the next year had received signiﬁcantly more Pap smears in the last 10
years than those who thought that it was less of a priority and less likely. The total
number of points possible on the intentions scale was 9 points (3(— = 8.4, SD. = 1.0).
The reliability of the intentions scale was was high (alpha 2.82), although there were
only two questions measuring this concept.

Although the standard deviation for the intentions scale was relatively low, the
data for this scale was not homogeneous. As shown in Table 6, the mean for the
intentions scale was at the very top of the range (2? = 8.4 on a 2-9 range). This
indicates a highly skewed distribution, with most scores near the top of the range.
However, there were a signiﬁcant number of scores lower in the range. These scores
lower in the range made the data inhomogeneous. Therefore, a signiﬁcant correlation

with Pap smear frequency was found because the women with low levels of intention

generally had received fewer Pap smears.

The Effects of Age and Hormonal Replacement Therapy on Pap Smear Frequency

 

An ANOVA was performed to examine the effects of age and use of HRT on Pap
smear frequency. While advancing age had no signiﬁcant effect, the use of HRT was
found to signiﬁcantly affect Pap smear screening frequency. Results revealed that
women who reported taking HRT (regardless of age) had received signiﬁcantly more
Pap smears in the last 10 years than women who did not take HRT.

The health history collected on HRT practices was not sufﬁcient to explain this
ﬁnding. However, it is presumed that taking hormones increases the need of women
to contact their health care providers, and therefore increases the likelihood of their

57

receiving regular Pap smears. Furthermore, some sources have recommended that
women on HRT have annual Pap smears (Gambrell, 1992). These recommendations
appear to be precautionary because, while HRT is a known risk factor for endometrial
cancer and a possible risk factor for breast cancer, it has not been shown to affect
cervical cancer rates (Gambrell, 1992). Nevertheless, these recommendations (and
possibly other considerations) could be prompting health care providers to advise

their HRT patients to have annual Pap smears.

Implications For Advanced Nursing Practice

 

Cervical cancer screening is an integral part of advanced clinical practice and
in the primary health care setting the CNS manages all aspects of screening care.
This requires the expertise of the CNS as clinician, counselor, and advocate. As
clinician, the CNS judges the necessity of screening, performs the Pap test, interprets
lab results, and plans follow-up care on a long term basis. As counselor, the CNS
advises clients about the importance of regular Pap smear screening as an ongoing
health promotion behavior and works with the client to achieve this as a lifetime
goal. As advocate, the CNS is accountable for being aware of current screening
schedules and cervical cancer research issues and relaying this information to clients
in an objective manner so that they may make informed decisions about their care.
The HBM provides a framework to implement these roles and to plan cervical cancer
screening strategies for older women in the primary health care setting.

The results of this study identify, in the context of the HBM, two areas where the

CNS can have a signiﬁcant impact on the cervical cancer screening practices of older

58

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION

 

#2 KNOWLEDGE

of Pap Smears

l

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

#1 SUSCEPTIBILITY Perceived Threat #4 BARRIERS
to cervical cancer of cervical cancer to screening
#3 INFLUENCE #5 EFFICACY

of important others

. of the Pap smear
concerning Pap smears

l

#6 SCREENING INTENTIONS

l

Pap smear
SCREENING
CNS FREQUENCY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2: HEALTH BELIEFS OF OLDER WOMEN REGARDING
PAP SMEARS (Revised)

(Adapted from the Breast Cancer Screening Health Belief Model (Given et al., 1989))

59

women. These are shown in Figure 2.

The CNS can play a vital role in inﬂuencing what women perceive as barriers to
screening. Study ﬁndings indicate that the fewer barriers women perceived to the
screening process the more frequently they had been screened for cervical cancer in
the past. For the most part women in this study were well informed about Pap
smear issues and did not perceive a high level of barriers to screening. However, the
emotional aspects of having the procedure: embarrassment, fear, anxiety, forgetting
to schedule the test, and the physical and emotional discomfort of the test itself
revealed high rates of variability. Nursing interventions to decrease these types of
barriers should be aimed at making the procedure as physically and emotionally
comfortable as possible. This can be accomplished by acknowledging the fear, anxiety
and embarrassment that older women may experience when having a Pap smear and
by ensuring that client privacy will be provided.

Giving straight forward information can also decrease perceived barriers. By clar-
ifying any misconceptions about cervical cancer and Pap smears that may exist for
the older client, anxiety, fear and embarrassment can very possibly be diminished.
Information can include discussing the factual aspects of the disease such as its natu-
ral history, the ability of the Pap smear to detect abnormalities, and the wide success
of treatment for the early stages of cervical cancer.

In different populations of women perceived barriers to screening may be quite
different. For instance, women of low socioeconomic status, of ethnic origins other

than Caucasian, with little or no health insurance may also perceive ﬁnancial, time

60

and transport issues as major barriers to screening. Nursing interventions for these
women would need to be directed at locating facilities that perform these services
at reduced costs and assisting the client with time management and transportation
strategies.

Study ﬁndings indicate that women who had participated more frequently in Pap
smear screening in the past had signiﬁcantly higher intentions of being screened for
cervical cancer in the future. It is likely that this ﬁnding is most relevant to this
study and therefore, it is particularly important that initial client assessment focuses
on motivation to participate in future screening. This data will provide the CNS with
information about the degree to which the client perceives future Pap smear screening
as a priority and will provide a general framework for planning future care.

Again, in a different population women may not consider Pap smear screening a
high priority and therefore will not intend to participate in future Pap smear screen-
ing. In this case nursing interventions would have to be directed at motivating clients
to participate in screening by emphasizing the value of routine lifetime screening.

It is possible that an interrelationship between barriers and intentions exists but
was not uncovered because a univariate technique was used to analyze the data. For
example, it is possible that women who perceive fewer barriers to screening are sig-
niﬁcantly more likely to be motivated to participate in screening in the future. There
is also the issue of the relative strength of the barriers and intentions variables. It is
possible that only one of these variables, intentions for example, accounts for a sig-

niﬁcant amount of variation in screening frequency when all variables are considered

61

at once. Both of these issues would have been clariﬁed by performing a multivariate
analysis of the data.

The efficacy concept did not yield signiﬁcant results in this study. However,
the overall efﬁcacy/self—efﬁcacy concept provides a valuable framework for planning
and implementing nursing interventions pertaining to Pap smear screening. Nursing
interventions enhancing self—efﬁcacy can be used as a method to bring about a long
term change in Pap smear screening behavior. Such interventions should be designed
to affect behavioral change through personal mastery, self—motivation and increasing
of knowledge.

For clients who have not been previously motivated to participate in routine
screening nursing interventions should be directed at educating clients about Pap
smear issues and setting mutually acceptable and achievable goals concerning screen-
ing schedules. The CNS can increase the likelihood that future client appointments
will be made and kept by coordinating the scheduling of follow—up exams and the
calling or sending out of reminder. postcards when appointments are due.

For clients who are motivated and well educated about Pap smear screening is-
sues nursing interventions should be directed at reinforcement of present behaviors.
Women who realize that routine Pap smears are necessary throughout the lifespan
will need ongoing support, encouragement and reinforcement to maintain their present
practices.

Study ﬁndings did not indicate that social inﬂuence signiﬁcantly affected screen-

ing frequency. However, complete assessment of how this concept inﬂuences client

62

perceptions of Pap smear screening still constitutes an important component of nurs-
ing care. The practicing CNS should ascertain the type and degree of social inﬂuences
affecting each client. Nursing interventions assessing the extent of social inﬂuence
would include exploring client perceptions about the opinions of signiﬁcant others
about Pap smear screening. Interventions would also include asking about past health
care provider’s recommendations about screening frequency and asking whether the
client knows someone who has been diagnosed with cervical cancer. When negative
inﬂuences are found, the CNS should try to alleviate the client’s apprehensions and
misimpressions by educating her about the purposes and procedures of routine Pap
smear screening.

The results of this study found that quite possibly this population of women were
being screened more often than is necessary. The CNS would need to ascertain reasons
as to why this is so. Nursing interventions would include taking a client health history
in order to review personal risk factors, signs and symptoms of disease, past abnormal
test results and client perceptions of the necessity of such frequent screening. After
this information is obtained the CNS will be able to judge each client individually,
on a case by case basis, and decide whether such frequent screening is warranted.

The CNS is responsible for informing her clients about the complexity of screening
issues. The CNS needs to be aware of both the advantages and disadvantages of
annual screening for asymptomatic, low risk women both within her own practice
and in the context of the health care system. The beneﬁts of annual Pap smear

screening include increasing the possibility of detecting cancers at their earliest stage,

63

compensating for past clinical errors, and client reassurance. These beneﬁts need to
be carefully weighed in relationship to the disadvantages such as the extra cost to
the health care system over time, unnecessary clinical time spent performing the test,

and lack of scientiﬁc proof of the efficacy of annual screening.

Future Research

This study leaves open several avenues for future research. These include access-
ing a more diverse population of women, providing further information about the
HBM as a conceptual framework, reﬁning the “Cervical Cancer Screening Practices
Questionnaire”, and more sophisticated analysis of data.

The sample in this study was homogeneous and lacked variability. The problem of
homogeneity was compounded by the probable self—selection of study participants. It
is reasonable to assume that there was a degree of self-selection in this study. Women
who were motivated to complete and return the questionnaires were perhaps the type
of individuals who are likely to schedule and keep regular doctor’s appointments. On
the other hand, nothing is known about the screening practices of the women who
did not return the questionnaires. It is quite possible that these women do not par-
ticipate in Pap smear screening to the same extent as the women who returned the
questionnaires. Future research should therefore work with a broader, more heteroge-
neous sample, and should attempt to minimize the self-selection problem by including
strategies, such as phone interviews, to recruit those who are not apt to voluntarily
return written surveys.

The sample used in this study contained virtually no older women from minority

64

groups, women of low socioeconomic status, women who lacked a high school education,
or women who didn’t have health insurance. More information is needed about the
health beliefs and Pap smear screening behavior of individuals with these character-
istics because these types of women are very likely to have screening practices that
differ from the subjects who participated in this study. An investigation that gained
access to this population would provide valuable further information about health
behavior to the nursing profession. Strategies to locate these women could include
targeting non health related facilities such as churches and social service institutions.
It is possible that the HBM is not an appropriate conceptual framework for cer-
vical cancer screening in some populations. For instance, a known limitation of the
HBM is that it may only be effective in measuring the health behaviors of those who
believe that their health is a valued state. Similarly, it may only be effective in mea-
suring perceptions of individuals who are well educated about their health or those
who have faith the health care system. Women of low socioeconomic status may
not view their own health care as a priority because of difﬁcult economic or life cir-
cumstances. Women with certain cultural backgrounds may have fatalistic attitudes
and perceive health and preventable illnesses as something that cannot be controlled
by the individual. Women without a high school education may not understand the
necessity of routine lifetime screening. A study that drew from a large diverse popu-
lation, or one that focused on a special population (such as minority or rural woman)
would provide further testing of the HBM’s ability to accurately measure perceptions

and beliefs regarding Pap smear screening.

65

Revisions of the “Cervical Cancer Screening Practices” questionnaire would in-
clude designing questions to more speciﬁcally ﬁt cervical cancer screening and reﬁning
the scales that had a low reliability or did not yield signiﬁcant results, namely the sus-
ceptibility, knowledge, efficacy, and inﬂuence scales. Reﬁnement of these scales would
be directed at improving their construct validity, that is, the extent to which the
questions developed are accurately reﬂecting the broader theoretical concepts under
investigation. The “Cervical Cancer Screening Practices” questionnaire could also be
adapted for use in the clinical setting. For example, by incorporating the items used
to measure barriers into a written history form the barriers scale could successfully
be used as a client assessment tool.

Revision of the perceived susceptibility scale would include developing questions
addressing cervical cancer risk factors relevant to older women. These questions would
assess life-style factors such as sexual practices and smoking history in relationship
to developing cervical cancer. Questions would also include items dealing with past
abnormal Pap smear results. Revisions of the knowledge scale would entail further
development of items measuring cognition about the cervical cancer disease process,
screening schedules, and the role that the Pap smear plays in early detection of cervical
cancer. Revisions of the efﬁcacy scale would focus on adapting questions to reﬂect the
self-efﬁcacy concept. Questions would include items that measured perceived control
over health, motivation and ability to arrange for routine screening and the degree of
self—conﬁdence the individual had in being able to control their health. Revisions of

the inﬂuence scale would include broadening the concept to include all dimensions of

66

social inﬂuence: positive, negative and the lack of inﬂuence.

In this study the data associated with the six health belief concepts was studied
using separate univariate correlational analyses. Future research would include more
sophisticated data analysis using a multivarate regression technique, which would si-
multaneously examine of the effects of all six independent variables on the dependent
variable. This would allow one to assess the relative importance of each of the in-
dependent variables. Because the study variables are closely related conceptually a
multivariate technique would more accurately reﬂect the HBM’s conceptual frame-

work.

Summary

The results of this study have several implications for the clinical practice of the
CNS involved with Pap smear screening. Two variables, barriers and intentions,
were found to signiﬁcantly inﬂuence Pap smear screening frequency. The analysis of
these scales led to the conclusion that effective nursing management should include
efforts to reduce perceived barriers to cervical cancer screening by making the Pap
smear procedure as comfortable as possible, alleviating fear and anxiety, and clarifying
misconceptions about the test. These interventions should be linked with efforts
to increase intentions to be screened in the future through motivational strategies
that establish realistic screening schedules and emphasize the importance of regular
lifetime screening. The remaining four variables studied, knowledge, susceptibility,
efficacy, and inﬂuence, were not found to affect screening frequency.

67

The signiﬁcance of the ﬁndings was limited because the study used a convenience
sample of restricted diversity, consisting mostly of middle class women with health
insurance and access to health care facilities. The majority of subjects had received
annual Pap smears for the last 10 years and were well educated about cervical cancer
screening. Because there are no current guidelines that explicitly advocate annual
screening it is felt that these women were screened more frequently than is necessary.
The data also showed that subjects who were taking hormone replacement therapy
had a higher rate of screening than those who were not, even though HRT has not
been found to be a risk factor for cervical cancer.

This study has increased the knowledge base available to the CNS about the
cervical cancer screening practices of older women. However, it was not able to address
several other important issues related to Pap smear screening in this age group. The
homogeneous sample used in this study did not involve minority woman, women of
low socioeconomic status, or woman without health insurance. It is important that
the CNS in clinical practice understand the needs and attitudes these woman have
concerning cervical cancer screening. A worthwhile avenue for future research would
be to apply the HBM to study Pap smear screening in a diverse population that

included woman at the margins of the health care system.

68

LIST OF REFERENCES

List of References

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Blesch, K. S., & Prohaska, T. R. (1991). Cervical cancer screening in older women:
Issues and interventions. Cancer Nursing, 31, 141—147.

 

Brink, P. J., & Wood, M. J. (1988). Basic steps in planning nursing research. Boston:
Jones and Bartlett.

 

Celentano, D. D. (1988). Updated approach to screening for cervical cancer in older
women. Geriatrics, 43(4), 37—42, 48.

Celentano, D. D., Klassen, A. C., Weisman, C. S., & Rosenshein, N. B. (1988). Cervical
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Champion, V. L. (1984). Instrument development for health belief model constructs.
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Champion, V. L. (1989). Effect of knowledge, teaching method, conﬁdence, and social in-
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Champion, V. L. (1991). The relationship of selected variables to breast cancer detection
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Eddy, D. M. (1990). Screening for cervical cancer. Annals of Internal Medicine, 113,
214—226.

 

Elkind, A. K., Haran, D., Eardley, A., & Spencer, B. (1988). Reasons for non-attendance
for computer-managed cervical screening: Pilot interviews. Social Science
Medicine, 27; 651-660.

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Fink, D. J. (1991). Guidelines for the cancer-related checkup: Recommendations and
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Fisher, M., & Eckhart, C. (Eds). (1989). Guide to clinical preventive services: An
assesment of the effectiveness of 169 interventions. Baltimore: Williams and Wilkins.

 

Gambrell, R. D. (1992). Hormone replacement therapy. Durant: Essential Medical
Information Systems, Inc.

 

Given, 8., Given, C., & Dimitrov, N. (1989). [Assessment of barriers and facilitators to
screening for breast cancer: A worksite approach]. Unpublished ﬁnal report: Michigan
Department of Public Health. Lansing, Michigan.

Gray, D. P., & Heuther, S. E. (1990). Structure and function of the reproductive system.
In McCance, K. L. & Heuther, S. E. (Eds), Pathophysiology: The biological basis
for disease in adults and children (pp. 693—696). St. Lewis: G. V. Mosby.

 

Gusberg, S. B., & Runowicz C. D. (1991). Gynecologic cancers. In A. I. Holleb, D. I.
Fink, & G. P. Murphy (Eds), American Cancer Society textbook of clinical oncology
(pp. 481—496). Atlanta: American Cancer Society.

 

Harlan, L. C., Bernstein, A. B., & Kessler, L. G. (1991). Cervical cancer screening:
Who is not screened and why? American Journal of Public Health, 8L 885—890.

 

Hayward, R. A., Shapiro, M. F., Freeman, H. E, & Corey, C. R. (1988). Who gets
screened for cervical and breast cancer? Archives of Internal Medicine, 148, 177—
1181.

 

Hennig, P., & Knowles, A. (1990). Factors inﬂuencing women over 40 years to take pre-
cautions against cervical cancer. Journal of Applied Social Psychology, 22 1612—
1621.

 

Hill, D., Gardner, G., & Rassaby, J. (1985). Factors predisposing women to take
precautions against breast and cervical cancer. Journal of Applied Psychology, 1i
59—79.

 

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A decade later. Health
Education Quarterly, _1_1_, 1— 47.

 

Mandelblatt, J. (1989). Cervical cancer screening in primary care: Issues and recom-
mendations. Primary Care, 16, 133—155.

 

National Institute of Health. (1990). What you need to know about cancer of the
cervix (NIH Publication No. 90-2047). Bethesda, Maryland: US. Department of

Health and Human Services.

 

70

Nemcek, M. A. (1990). Health beliefs and preventive behavior: A review of the literature.
American Association of Occupational Health Nursing, 3_8_, 127—138.

 

Pender, N. J. (1987). Health promotion in nursing practice. Norwalk: Appleton and
Lange.

 

Peters, R. K., Bear, M .B., 85 Duncan, T. (1989). Barriers to screening for cancer of the
cervix. Preventive Medicine, _1_(18), 133—146.

 

Peters, R. K., Duncan, T., Skultin, G., & Henderson, B. E. (1988). Invasive squamous
cell carcinoma of the cervix after recent negative cytologic test results — A distinct
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Polit, D. F. & Hungler, B. P. (1987). Nursing research: Principles and methods. Phila-
delphia: J. B. Lippincott.

 

Rosenstock, I. M., Strecher, V. J ., & Becker, M. H. (1988). Social learning theory and
the Health Belief Model. Health Education Quarterly, 15, 175—183.

 

Rubin, M. M., & Lauver, D. (1990). Assessment and management of cervical intraep-
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Shields, P. W., Daunter, B., & Wright, R. G. (1987). The Pap smear revisited. _Tlie
Australian and New Zealand Journal of Obstetrics and Gynaecology, 27, 269—282.

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Teitelbaum, M. A., Weisman, C. S., Klassen, A. C., & Celentano, D. D. (1988). Spe-
cialty differences in physician’s recommendations in relation to women’s Pap testing
behavior. Medical Care, 26, 607-618.

 

Warren, B., & Pohl, J. P. (1990). Cancer screening practices of nurse practitioners.
Cancer Nursing, 1_3 (3), 143—151.

 

Zapka, J. G., Harris, D. R., Stoddard, A. M., & Costanza, M. E. (1991). Validity and
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71

APPENDICES

Appendix A

Cover Letter

Michigan State University
College of Nursing

Life Sciences Building

E. Lansing, MI. 48824

August 8, 1992

Dear CTU member,

I am a registered nurse graduate student at Michigan State University and I am
conducting a survey for my Masters of Science in Nursing thesis. I received your
name and address from the Clerical Technical Union, and, with their permission, I
am sending you the enclosed questionnaire.

I am interested in knowing your views about Pap smear screening for cervical
cancer. The information you provide may be important in helping nurses and other
health care professionals.

In addition to your feelings toward Pap smears the questionnaire includes some
items about your background and personal health history. It should take you about
20 - 25 minutes to ﬁll out. After completion please mail the questionnaire back to
me at the College of Nursing in the self addressed stamped envelope provided.

Your responses will remain anonymous. Your name will never be placed on the
questionnaire and no attempt will be made to link your name to any returned ques-
tionnaire. Results of this survey will be reported as a whole and therefore will not be
associated with you as an individual in any way.

Participation in this study is strictly voluntary. Your completion and return of
this survey will serve as an indication that you understand the study and that you
consent to participate.

The completed study results will be reported in the Clerical Technical Union
newsletter in early 1993. If you have any concerns please write to me at the above
address or call and leave a message for me at the college of nursing and I will return
your call (telephone no. 355 - 6523). I would be happy to answer any questions.
Thank you very much for your interest and participation in this survey.

Sincerely,

Judith Fleishman

72

Appendix B

Questionnaire

 

PERSONAL HISTORY

The ﬁrst set of questions ask you about your personal health history as well as your
Pap smear screening history.

1.

2.

Please write in the date of your birth. (WRITE IN)
Month/ Date/ Year/

 

Have you reached menopause? (CHECK ONE)
YES (1)_ NO (2)_ DON’T KNOW (3)_

If YES, at what age did you begin menopause? (WRITE IN AGE) .

3.

era-99's

Have you ever taken hormones such as: (Check one for each)
Estrogen YES (1)_ NO (2)_ DON’T KNOW (3)_
Premarin YES (1)_ NO (2)___ DON’T KNOW (3)_
Provera YES (1)_ NO (2)_ DON’T KNOW (3)_
DES YES (1)_ NO (2)___ DON’T KNOW (3)_
Other (PLEASE SPECIFY)

 

Have you ever been diagnosed with: (CHECK AS MANY AS APPLY)
High Blood Preassure ( 1)
Heart Disease (2)

Diabetes (3)

Arthritis (4)

Cancer (Please specify; ) (5)

Other (Please specify; ) (6)

 

Have you ever had a hysterectomy (uterus removed)? (CHECK ONE)
No (1)

Uterus only (2)

Uterus and ovaries removed (3)

Don’t know (4)

Other (Please specify; ) (5)

 

73

6. Have you ever had an abnormal Pap smear? (CHECK ONE)
YES (1) NO (2) (If NO, go to next section)

If YES, what were the results? (CHECK ONE)
Positive for cancer (1)

Negative for cancer (2)

Positive for other cervical disease (3)
Negative for other cervical disease (4)
Don’t know results (5)

 

If you were diagnosed with cervical cancer, what treatment did you receive? (CHECK
ALL THAT APPLY)

_ Hysterectomy ( Removal of uterus and cervix) (1)

_ Radiation (X—Ray treatment) (2)

_ Chemotherapy (Cancer drugs) (3)

_ Cone Biopsy (Removal of part of the cervix) (4)

 

_ Other (Please specify) (5)
What year were you diagnosed? (Write in year)
PAP SMEARS

A Pap smear is a procedure to screen for cervical cancer. Cells from the outer layer
of the cervix are obtained during a pelvic exam. These cells are then checked under
a microscope to look for any changes which may be pre-cancerous or cancerous.

7. Have you ever had a Pap smear? (CHECK ONE)
YES (1) (go to question 8) NO (2)

8. If YES to question 7, about how many Pap smears have you had in the last 10

years? (CHECK ONE)

don’t know (1)

about 1 (2)

about 2 (3

about 3 (

about 4 (
(
(

 

about 5
about 6
about 7 (
about 8 (9)

about 9 (10)
more than 10 (11)

)
4)
5)
6)
7)
8)

74

9. Which of the following best describes what prompted you to have your most recent
Pap smear? (CHECK ALL THAT APPLY)

To follow up a problem on a previous Pap smear (1)

It was part of my routine check-up (2)

A health professional recommended it (3)

A friend or relative has recently had an abnormal Pap smear (4)
A relative or friend recommended that I have Pap smear (5)
Other: Please Specify: (6)

_—
_—
_—
_—
_—
_—

DETECTION

The following set of questions focus on early detection of cervical cancer. Early
detection means ﬁnding an abnormality in the early stages. For cervical cancer this
means when the cancer is still conﬁned to the cervix and has not spread to other
areas of the body.

10.If found early enough, cervical cancer can be cured. (CHECK ONE)
Strongly agree (5)
Agree (4)
Disagree (3)
Strongly disagree (2)
Don’t know (1)

11. Unless she has symptoms, a woman doesn’t need a Pap smear. (CHECK ONE)
Don’t know (1)
__ Strongly agree (2)
Agree (3)
Disagree (4)
Strongly disagree (5)

12. Pap smears can detect early abnormalities likely to be cervical cancer. (CHECK
ONE)

Strongly agree (5)

Agree (4)

Disagree (3)

Strongly disagree (2)

Don’t know (1)

75

13. Once a person develops cancer, it is usually too late to do anything about it.
(CHECK ONE)

Don’t know (1)

Strongly agree (2)

Agree (3)

Disagree (4)

Strongly disagree (5)

14. Early detection of cervical cancer with a Pap smear would improve a woman’s
chances of recovery. (CHECK ONE)

Strongly agree (1)

Agree (2)

Disagree (3)

Strongly disagree (4)

Don’t know (5)

15. How conﬁdent are you that a Pap smear gm detect an abnormality likely to be
cervical cancer? (CHECK ONE)
Don’t know (1)
Not at all conﬁdent (2)
Somewhat conﬁdent (3)
Quite conﬁdent (4)
Extremely conﬁdent (5)

 

16. Early detection would improve one’s chances for cure of cervical cancer. (CHECK
ONE)
Strongly agree (5)
Agree (4)
Disagree (3)
__ Strongly disagree (2)
Don’t know (1)

17. If you had abnormal cells in your cervix, how conﬁdent would you be that a Pap
smear would be able to detect these changes? (CHECK ONE)

Extremly conﬁdent (5)

Very conﬁdent (4)

Somewhat conﬁdent (3)

Not very conﬁdent (2)

Not at all conﬁdent (I)

 

76

INFLUENCE

The next series of questions ask you about the inﬂuence that others might have on
your decision to to have a Pap smear.

18. Do you have any close friends that have been diagnosed with cervical cancer in
the last ﬁve years? If yes, please write in the number

19. Have any of the following persons discussed Pap smears with you? (CHECK
ONE FOR EACH)

DISCUSSED: PAP SMEAR
YES NO

 

 

 

Family doctor
OB / GYN doctor
Internist
Surgeon

Nurse

Family

Friend
Co—worker
Other: specify

 

 

 

 

 

 

 

 

 

 

 

 

 

20. Have any of the following persons advised you to obtain a Pap smear? (CHECK
ONE FOR EACH)

ADVISED: PAP SMEAR
YES NO

 

 

 

 

Family doctor
OB / GYN doctor
Internist
Surgeon

Nurse

Family

Friend
Co-worker

Other: specify

 

 

 

 

 

 

 

 

 

 

 

 

 

77

21. Have any of the following persons discouraged you from obtaining a Pap smear?
(CHECK ONE FOR EACH)
DISCOURAGED: PAP SMEAR
YES NO

 

 

 

 

Family doctor
OB/GYN doctor
Internist
Surgeon

Nurse

Family

Friend
Co-worker
Other: specify

 

 

 

 

 

 

 

 

 

 

 

 

 

22. With regard to cervical cancer screening, how important to you is the opinion
and advice of the following? (CHECK ONE FOR EACH)

very somewhat not at all
important important important important

 

 

Family doctor
OB / GYN doctor
Internist

Surgeon

Nurse

Family

Friend

Co-worker

Radio / T.V.
Literature / Pamphlets
Other: specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONCERNS

The following questions explore concerns women have about getting cervical can-
cer. We want you to answer these questions in the way that you generally think about
these issues. Let us know your usual feelings.

23. As compared with other women of your age, what do you think the chances are
that you will develop cervical cancer in the next ﬁve years? (CHECK ONE)

Much less than other women (1)

Somewhat less than other women (2)

About the same as other women (3)

Somewhat higher than other women (4)

Much higher than other women (5)

 

78

24. What is the chance that someone like yourself will develop cervical cancer some-
time during your lifetime ? (CHECK ONE)

Much less than other women (1)

Somewhat less than other women (2)

About the same as other women (3)

Somewhat higher than other women (4)

Much higher than other women (5)

25. How serious do you think the risk of cervical cancer is for women in the U.S.A.?
(CHECK ONE)

Extremely serious (5)

Very serious (4)

Somewhat serious (3)

Not very serious (2)

Not at all serious (1)

 

26. If you were to develop cervical cancer, how probable do you think it is that it
would have spread before it was discovered? (CHECK ONE)

Can’t predict (1)

Not at all probable(2)

Somewhat probable (3)

Very probable (4)

Extremely probable (5)

27. Who do you think is more likely to get cervical cancer? (CHECK ONE)
Women over age 50 (4)
Women under age 50(3)
Age makes no difference (2)
Don’t know (1)

28. Could a woman have cervical cancer without having any symptoms or feeling ill?
(CHECK ONE)

Yes (3)

No (2)

Don’t know (1)

79

29. If the Pap smear showed no signs of cervical cancer, how conﬁdent would you be
that it is correct? (CHECK ONE)
Don’t know (1)
Not at all conﬁdent (2)
Somewhat conﬁdent (3)
Quite conﬁdent (4)
Extremely conﬁdent (5)

 

30. If a woman didn’t have any symptoms but was 50 years of age or older, how often
should she have a Pap smear?(CHECK ONE)

At least every three years (4)

Every year (3)

Only when she had a problem/ symptom (2)

Don’t know (1)

 

31. If you do not have any symptoms/ problems, how sure can you be that you don’t
have cervical cancer? (CHECK ONE)

Not at all sure (4)

Somewhat sure (3)

Quite sure (2)

Extremly sure (1)

32. In the next year, how likely are you to have a Pap smear? (CHECK ONE)
Deﬁnitely (5)

Very likely (4)

Somewhat likely (3)

Not very likely (2)

Not at all likely (1)

33. To what extent is getting a Pap smear on a regular basis a priority for you?
(CHECK ONE)

Not at all (1)

To a small extent (2)

To some extent (3)

To a great extent (4)

 

80

34. How much do you agree or disagree with each of the following statements about
Pap smears? (CHECK ONE BOX FOR EACH QUESTION)

 

A PAP SMEAR : Strongly
Disagree Disagree Agree

Strongly
Agree

 

. is an embarrassing procedure

 

. is an unpleasant procedure

 

. is a hardship due to cost

 

 

. would make me feel anxious

 

is convenient to arrange

 

a
b
c
d. is painful/ physically uncomfortable
e
f.
h.

is not worth the effort

 

i. makes me feel uncomfortable

 

j. is able to detect abnormalities early

 

k. I don’t know when I need exams

 

l. I have too many other worries

 

m. I’m afraid something abnormal would be found

 

n. improves my chances of early detection

 

I want to keep control of my health

 

. I’m just too busy to have a Pap smear

 

. I forget when I’m supposed to have a Pap smear

 

I don’t really know how to ask for an exam

 

I am conﬁdent the exam will be done correctly

 

 

 

 

VHT’Q'UO

my doctor has never suggested having an exam

 

 

 

Other comments: (Please write in)

 

BACKGROUND

This ﬁnal series of questions asks for background information about you, including
your employment and occupation. We remind you that all the information you provide
will be held in the strictest conﬁdence and will not be linked to you as an individual.

35. What is your current employment status? (CHECK ONE)
Work full-time (1)

Work part-time (2)

Volunteer (non-salaried)(3)

Retired (4)

On leave or disability (5)
Other (please specify) (6)

 

36. Do you have health insurance? (CHECK ONE)
YES (1)___ NO (2)__

81

37. Is this insurance coverage provided by: (CHECK ALL THAT APPLY)
Your employer (1)

Your spouse (2)

Other family member’s employer (3)

Self Pay(4)

Medicare (5)

Medicaid (6)

Not insured (7)

Other (please specify) (8)

 

 

38. Does your health insurance pay for routine Pap smears ? (CHECK ONE)
YES (1) NO (2) DON’T KNOW (3)

 

39. What is your ethnic background? (CHECK ONE)

White (1)

Black (2)

Hispanic (3)

American Indian/ Alaskan native (4)

Chinese (5)

Japanese (6)

Filipino, Hawaiian, Korean, Veitnamese (7)

Other (please specify) (8)

 

 

40. What is your marital status? (CHECK ONE)

Single - never married (1)

Widowed (2)

Married or living as married (3)

Seperated (4)

Divorced (5)

Other (please specify) (6)

 

41. What is the highest grade (or level) of education that you completed? (CHECK
ONE)

Less than 8th grade (1)

8th grade to 11th grade (2)

High school graduate/ GED (3)

Post high school, trade or technical school(4)

One to three years of college (5)

College graduate (6)

Graduate and/ or professional school (7)

 

82

42. Which catagory best. describes your total combined household income last year
(from all adult sources living in your household)? (CHECK ONE)
Less than $10,000 (1)
$10,000 $15,000 (2)
$15,000-$20,000 (3)
$21,000-$25,000 (4)
$26,000-$30,000 (5)
$31,000-$35,000 (6)
$36,000-$40,000 (7)
(8)
(9)

 

$41,000-$45,000
$46,000-$50,000
More than $50,000 (10)

43. Who USUALLY does your Pap smear screening procedure? (CHECK ALL THAT
APPLY)

Never had a Pap smear screening procedure done (1)

Family practice physician (2)

Internist (3)

Obstetrician-gynecologist (4)

Nurse practioner or clinical nurse specialist (5)

Other (6) (Please specify )

 

Is the person who USUALLY does your Pap smear screening procedure male or
female? (CHECK ONE)
Male (1) Female (2)

 

THANK YOU FOR YOUR TIME AND INTEREST IN COMPLETING THIS
QUESTIONNAIRE. PLEASE PLACE IT IN THE SELF-ADDRESSED STAMPED
ENVELOPE AND MAIL BACK WITHIN TWO WEEKS. IF YOU HAVE ANY
ADDITIONAL COMMENTS PLEASE FEEL FREE TO NOTE THEM BELOW.

PLEASE RETURN WITHIN TWO WEEKS.

83

Appendix C

Reminder Postcard

Michigan State Univ.
College of Nursing
Life Sciences Building
E. Lansing, MI. 48824
355-6523

Your participation in the CERVICAL CANCER SCREENING
PRACTICES survey is greatly appreciated. If you have already
mailed back the questionnaire, thank you very much. If you have
not completed the questionnaire and would like another copy, or if
you have any questions, please contact me at the above address.

Sincerely,

Judith Fleishman

84

Appendix D

U.C.R.I.H.S. Approval

 

MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE PRESIDENT FOR RESEARCH EAST LANSING 0 MICHIGAN 0 «8244046
AND DEAN Of THE GRADUATE SCHOOL

June 30, 1992

Judith Fleishman
4161 Mariner Lane
Okemos, MI 48864

RE: HEALTH BELIEFS AND CERVICAL CANCER SCREENING PRACTICES OF WOMEN AGED 50-
65, IRB #92-323

Dear Ms. Fleishman:

The above project is exempt from full UCRIHS review. The proposed research
protocol has been reviewed by a member of the UCRIHS committee. The rights and

' welfare of human subjects appear to be protected and you have approval to conduct
the research.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate UCRIHS approval one month prior to June 25, 1993.

Any changes in procedures involving human subjects must be reviewed by UCRIHS
prior to initiation of the change. UCRIHS must also be notifed promptly of any
problems (unexpected side effects, complaints, etc.) involving human subjects
during the course of the work.

Thank you for bringing this project to my attention. If I can be of any future
help, please do not hesitate to let me know.

Sincerely,

  

Chair
Research Involving

Human Subjects (UCRIHS)
DEH/pjm

cc: Dr. Rachel Schiffman

85

Appendix E

C.T. Union Approval

Clerical -Technica| U nion of Michigan State U niversity
Phone: 355-1903 PO. Box 025 East I.“ W 48826

Hatch 31, 1992

Ms. Judith Fleisman
4161 Mariner Lane
Okemos. RI 48864

Dear Ms. Fleismen:

It was a pleasure to see you at our'uarch 17. 1992, Executive
Board meeting and to hear more of the details involved with your
thesis project.

The CT Union would be happy to grant your request for labels to be
used in a mailing targeting female 01s and retirees from the ages
of 50-65. Please contact my secretary, Debbie Wells. to arrange
ordering of the labels as well as details regarding costs involved
($50.00 or less), etc.

Board members Becky Hicks (3-3944), Barbara Reeves (5-8447) and
Josselyn Carrasco (3-9016) are available to help in reviewing the
questionnaire to be used in the mailing.

The Board looks forward to offering our assistance as needed. on
this project.

Sincerely, -
(f%’dﬂ (Mi:

Randy Sc idt

President

RS/dw

86