Increasing cervical cancer screening in Iran: effectiveness of a theory-based educational intervention

Study design and population

The present quasi-experimental study was conducted with an experiment group. It was carried out in 2019–2020 to assess the effectiveness of an educational intervention based on the BASNEF model in promoting CCS behavior among 202 women between 20 and 49 years of age (101 in the IG and 101 in the CG). It was conducted in the south of Iran.

Setting

The present study was conducted in Deir County in Bushehr Province in the south of Iran. This place is located on the coastal areas of the Persian Gulf, and the capital city is Bandar-Deir.

Eligibility criteria

The inclusion criteria were: 20–49 years of age, being sexually active, not being pregnant, being literate (i.e., being able to read and write, to jot down their ideas themselves to reduce any bias) and full consent to participate in the training sessions. The exclusion criteria were: absence at more than two training sessions, absence at the post-test, history of uterine cancer, hysterectomy and other sexually transmitted diseases such as Chlamydia infections, Neisseria gonorrhoeae, Herpes simplex virus, Trichomonas vaginalis diagnosed by a gynecologist assistant in this project, unwillingness to continue participation in the study, and incomplete questionnaires.

Sample size estimation

The sample size was estimated using the following formula:

$$n = \frac + z_ )^ \sigma^ }} }} = \frac *(12)^ }} }} = 91$$

The sample size in each group was calculated as 91. With an attrition rate of 10% in each group, the final sample size was decided to be 101 (for each group).

Sampling

There are only two comprehensive healthcare centers in Deir County. In order to prevent the information exchange between the intervention and control groups, one of these centers was randomly selected as the intervention group and the other as the control. Thus, healthcare center #1 was selected as the IG and #2 as the CG. Then, women who met the inclusion criteria were assigned to each group.

Content of the survey instrument and scoring system

The questionnaire used in this study contained closed-ended questions to be rated on a Likert scale, true, false, or do not know. This questionnaire was divided into three main parts.

The first part contained questions exploring the participants’ demographic information including age, education, husband’s education, residence, occupation, history of the Pap test.

The second part consisted of questions about knowledge of causes of the disease, risk factors, prevention and therapeutic measures. This part included 15 three-choice questions. The choices were True, False, and do not know. Every true answer received 1, and a false or don’t know received 0.

The third part included the BASNEF constructs as summarized in Table 1.

Table 1 Description of the research instrument

All items of the subscales were rated on a five-point Likert-scale: strongly agree (1 point), agree (2 points), undecided (3 points), disagree (4 points), and strongly disagree (5 points). Each subscale was assessed separately, and the total score was not calculated. Subscale scores were calculated for each participant. Higher scores indicated stronger feelings for a construct.

Data quality assurance

The data collection instrument was developed based on a review of the related literature. The questions were pretested and well-organized. All were to be rated as self-reports. Before the main data collection phase, the questionnaire was piloted on 23 women who were similar to the research population on all aspects. Their feedback was used to revise the content and facilitate its comprehension and organization. These participants were excluded from the main phase of study. Also, the initial draft of the questionnaire was sent to a panel of experts to evaluate the readability, simplicity, relevance, and importance criteria. Their opinions were used to improve the organization and content of the questionnaire. To determine the reliability of the instrument, a test–retest method was used. The questionnaire was given to 20 individuals who had the same conditions as the subjects at a two-week interval and on two occasions. Then, to calculate the test agreement with the retest, the ICC index was estimated. The estimated ICC value was 0.86; thus, the reliability of the questionnaire was substantiated.

Data collection

The data were collected using self-administered questionnaires. A written consent form was completed in two copies. One remained with the researcher and the other with the participant. After obtaining the written consent, complete explanations were provided to the two groups (control and intervention) about the procedure. Then the pre-test questionnaires were submitted to the two groups. Three months after the training, to assess the effectiveness of the educational intervention, the two research groups completed the post-test questionnaires again.

At the interpersonal level, the research participants included the women’s family members and health care workers accessed by the corresponding author through a snowball sampling. The purpose of the training at this level was to strengthen the social skills (the effect of women’s friends on increasing their motivation to perform the screening test). Therefore, no questionnaire was distributed among these participants before and after the training.

Of note is that the questionnaires were distributed by the same member of the research team (the corresponding author) in the morning shift in the training room of each health center. In order to tell apart the pre-test and post-test questionnaires, each participant entered the last 4 digits of the mobile phone number and their age on the questionnaire. Each questionnaire took 20–25 min to complete.

Intervention activities and follow-up

In the present study, the educational intervention was carried out at both personal and interpersonal levels. For the former, the training was held for the women. The relevant questionnaires (awareness and constructs of BAZNEF model) were used as the pre-test for the women of the IG. Then according to the results obtained from the pre-test, an educational needs assessment was done to decide on the educational materials and methods and the number of sessions needed. The teaching methods included lectures, collaborative discussions, Q&As, brainstorming, role models, peer education. The educational content of each session was tailored to the comprehension level of the learners, use of reliable scientific sources, inclusion of experts’ as well as participants’ opinions, and the Baznef model constructs. A total number of 10 training sessions were held in 6 groups, each session lasting for 40–60 min, and a 10-min break included.

At the interpersonal level, the training was held for family members, patients and health care workers. At this level, 4 training sessions were held for 6 groups, each session taking 40–60 min with a 10-min break.

It should be noted that in order to adjust the enabling factor, the sampling and testing were made free of charge for the participants of the IG. The cost of the above tests was paid from the budget provided by the supporting organization.

In the CG, pre-test questionnaires were completed at the same time as the intervention group. Then, a one-hour training session was held on the significance of the CCS in 6 training groups of 15–20 members. Three months after the training, the post-test questionnaires were distributed among the participants. The CG did not attend the training specifically held for the IG (based on the BAZNEF constructs, making the pap test free to adjust the enabling factors, etc.). For example, making the test free (for the effect of the enabling factor, which is one of the components of the BEZENF model) was implemented only in the IG. The reason was to assess the real effect of the educational intervention on the screening behavior of cervical cancer in women.

It is noteworthy that all educational interventions were designed by the research team and implemented in the training room of the relevant health center.

In order to ensure minimal contamination of groups, the women of the IG and CG were selected from two comprehensive health service centers that were far from each other, so that the chances of exchanging information between the two groups were minimized. Also, during the intervention program, no training was held by other organizations. Nor was any other relevant public training held in the whole city. It was attempted to reduce the attrition rate using telephone follow-ups once a week. Thus, after three months, there was no attrition in the intervention and control groups (Fig. 2). Details of the educational intervention are provided in Additional file 1.

Fig. 2figure 2Post intervention activities

Three months after the training, the questionnaires were completed by both groups to assess the effectiveness of the educational intervention.

The educational intervention covered the following topics.

1.

General issues with cancers and more specifically the cervical cancer, detailed description of cervical cancer (how people can prevent the risk of cervical cancer, etc.), factors affecting cervical cancer

2.

Symptoms of the disease, prevention and therapeutic measures

3.

Benefits of early diagnosis of cervical cancer, introduction of cervical cancer screening test

4.

Teaching the benefits of CCS, time of cervical cancer screening, place of cervical cancer screening.

Interventionist training

The educational intervention was instructed by (1) SD (a health promotion/education researcher experienced in the field of educational interventions based on models of health education and health promotion), (2) A gynecologist with more than 15 years of educational experience (3) A group of peers.

Output evaluation

Knowledge, Attitude, Subjective norms, Enabling factors, Behavioral intention.

Outcome evaluation

Cervical cancer screening (whether or not a woman has the Pap test).

Ethical considerations

For data collection, we visited the comprehensive healthcare centers with an official introduction letter from the deputy of research. First, we introduced the research objectives in full and in a simple and clear manner. All details of the research were explained and the participants were asked for a voluntary participation. They were then asked not to mention their names. They were also assured of the confidentiality of the information they provided. The research project was approved by the ethics committee of Hormozgan University of medical sciences (#IR.HUMS.REC.1398.112).

Data management and analyses

When the data collection was over, descriptive statistics (frequency, relative frequency, mean and standard deviation) were used to describe participants’ age, education, husband’s education, and occupation. Kolmogorov–Smirnov test and Levene’s test were run to check the normality of distribution and equality of variances. For inferential statistics, the independent-sample T test was run to compare model constructs and the performance of CCS in the IG and CG. Paired-samples T-Test was run to compare the scores of the model constructs before and after the educational intervention within each group. ANCOVA was used to control and adjust for the effect of pre-intervention scores on post-intervention scores. Also, to evaluate the effect of each model construct on behavior in the IG, multiple linear regression analysis was used, in which the behavioral constructs were considered as dependent variables and knowledge and the model constructs as the independent variables. All analyses were done in SPSS 22.

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