Cognitive determinants of cervical cancer screening ...

Health Care for Women International

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Cognitive determinants of cervical cancer screening behavior among housewife women in Iran: An application of Health Belief Model Towhid Babazadeh, Haidar Nadrian, Hamed Rezakhani Moghaddam, Elaheh Ezzati, Reza Sarkhosh & Shahin Aghemiri To cite this article: Towhid Babazadeh, Haidar Nadrian, Hamed Rezakhani Moghaddam, Elaheh Ezzati, Reza Sarkhosh & Shahin Aghemiri (2018) Cognitive determinants of cervical cancer screening behavior among housewife women in Iran: An application of Health Belief Model, Health Care for Women International, 39:5, 555-570, DOI: 10.1080/07399332.2018.1425873 To link to this article: https://doi.org/10.1080/07399332.2018.1425873

Accepted author version posted online: 17 Jan 2018. Published online: 09 Feb 2018. Submit your article to this journal

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HEALTH CARE FOR WOMEN INTERNATIONAL 2018, VOL. 39, NO. 5, 555–570 https://doi.org/10.1080/07399332.2018.1425873

Cognitive determinants of cervical cancer screening behavior among housewife women in Iran: An application of Health Belief Model Towhid Babazadeha, Haidar Nadrian b, Hamed Rezakhani Moghaddamb, Elaheh Ezzatic, Reza Sarkhoshd, and Shahin Aghemirie a Department of Health Education and Promotion, Health Faculty, Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; bSocial Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran; cDepartment of Health Education and Promotion, Health Faculty, Hamadan University of Medical Sciences, Hamadan, Iran; dStudent Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran; eSchool of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran

ABSTRACT

ARTICLE HISTORY

Our aim in this cross-sectional study was to assess the cognitive determinants of Cervical Cancer Screening Behavior (CCSB) among housewife women in Islamabad County, Iran. Through multistage random sampling we recruited and interviewed 280 housewife women. The women who perceived more benefits of performing the Pap test (OR D 1.11), and perceived fewer barriers (OR D 0.915), and higher self-efficacy to perform the test (OR D 1.12) were more likely to have a CCSB in the previous three years. Our findings are informative for the development of targeted interventions to foster CCSB among housewife women.

Received 6 June 2017 Accepted 6 January 2018

Cervical cancer is the seventh most common cancer worldwide and the fourth most common cancer among women (Ferlay et al., 2013). This cancer, as an easily detected cancer in the pre-malignancy period, is also one of the most common cancers among women in the developing countries World Health Organization [WHO], (2016). In other words, about 90% of the cervical cancer deaths occur in developing parts of the world like the sub-Saharan Africa, Latin America, and the Caribbean (Siegel, Miller, & Jemal, 2015). According to a report, in Iran the incidence rate of cervical cancer is 2.4 per 100,000 per year (Khorasanizadeh et al., 2013). Currently, Pap test is one of the most important measures for prevention and early detection of cervical cancer (Meggiolaro et al., 2016). Beside the low cost, this diagnostic test is an effective method to detect cervical cancer in early stages among apparently normal women (Chen, Lee-Wen, Bai, & Chin-Cheng, 2016;

CONTACT Haidar Nadrian [email protected] Department of Health Education and Promotion, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran. © 2018 Taylor & Francis Group, LLC

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Keshavarzian & Barzegari, 2014). Pap test has been reported as successful in reducing the incidence rate of cervical cancer to 79% and the mortality rate up to 70% (Keshavarzian & Barzegari, 2014). Therefore, Pap smear test may be considered as a key to early detection and prevention of cervical malignancies (Ghahramani-Nasab, Farshbaf-Khalili, & Ghanbari, 2014). In Iran, a national cervical cancer screening program is conducted since 1989 (Khodakarim et al., 2014), based on which all 20–65 years old women have to be included in the program after their first time marriage. Although this screening service was omitted from the list of Iranian free of charge healthcare services in 1999, the screening is conducted per request of the women or recommendation of healthcare providers (Allahverdipour & Emami, 2008). However, since then, Pap smear testing is covered under the complementary insurance of the most of Iranian insurance companies (Allahverdipour & Emami, 2008; Khodakarim et al., 2014). As the test is now available in all urban healthcare centers in Iran, the women have the least problem in accessibility to the screening units. However, the rate of participation in the program among the Iranian women is still low (Dehdari et al., 2014; Majdfar et al., 2016). For instance, Dehdari et al., in an interventional study on 240 women (data collection year D 2014) in Tehran, reported none of the women referred to the primary health care clinics with the history of Pap smear uptake (Dehdari et al., 2014). In two previous Iranian studies in Tabriz city (n D 440, data collection year D 2015) (Farshbaf-Khalili, Salehi-Pourmehr, Shahnazi, Yaghoubi, & Gahremani-Nasab, 2015) and Gilan-e-gharb county (n D 355, data collection year D 2015) (Ashtarian, Mirzabeigi, Mahmoodi, & Khezeli, 2017), about 50% of the participants reported no history of pap smear test throughout their lives. Farzaneh et al., in a study in Ardabil, Iran, reported the level of conducting Pap test to be 28.1% (n D 1134, data collection year D 2016) (Farzaneh, Heydari, Shekarchi, & Kamran, 2017). Majdfar et al., in another current study investigating the level of Pap test uptake by self-efficacy among 442 women in Tehran, found that the rate of test uptake among those with low and moderate/high levels of self-efficacy were 30.8% and 69.1%, respectively (Majdfar et al., 2016). In general, the rate of participation in cervical cancer screening test in Iran is mostly reported to be moderate (41.6% to 87.6%) (Abedian & Dormohammadi, 2012; Ashtarian et al., 2017; Farshbaf-Khalili et al., 2015; Ghahramani-Nasab et al., 2014; Jalilian, Emdadi, Barati, Nasirzadeh, & Hatamzadeh, 2011), while in the developed countries like the U.S. this rate is up to 90% (Ercoli et al., 2009). Ashtarian et al. in the study conducted on 18–49 years old women in Gilan-egharb county, reported the lack of Pap-test screening awareness and/or cognitive factors among women as one of the reasons for their low rate of participation in Pap smear screening programs (H. Ashtarian et al., 2017; Shobeiri, Javad, Parsa, & Roshanaei, 2016). Increasing the awareness of women and introducing the importance and effectiveness of early diagnosis in cervical cancer are important steps in

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promoting the level of participation in this program at the country level. However, before an early detection intervention for Pap smear uptake, there is a need for identifying the factors related to and the barriers associated with the behavior. In comparison with the non-theoretical approaches, theory-based interventions are more effective in influencing health-related behaviors, as they provide a reasonable framework to develop the intervention and a guide for its evaluation (Babazadeh, Nadrian, Banayejeddi, & Rezapour, 2017; Plotnikoff, Trinh, Courneya, Karunamuni, & Sigal, 2009). One of the most applicable theories in the field of health education is the Health Belief Model (HBM). The HBM (Figure 1) was developed initially to explain the widespread failure of people to participate in the early detection and disease prevention programs and has now been applied in a wide range health behavior change studies (Haghighi et al., 2017; Mehri, Nadrian, Morowatisharifabad, & Akolechi, 2011; Shirzadi, Jafarabadi, Nadrian, & Mahmoodi, 2016). This model is based on people’s motivation for health action and focuses on the ways that an individual percepts, motivates toward and performs a healthy behavior (Glanz, Rimer, & Viswanath, 2008). HBM is composed of six structures including: (a) Perceived Susceptibility: refers to beliefs about the likelihood of having a disease or condition; (b) Perceived Severity: feelings about the seriousness of having an illness or leaving it untreated which includes the evaluations of possible clinical (for example death, disability, and pain) and social consequences (such as effects of the conditions on work, family life, and social relations); (c) Perceived Benefits: refers to belief in the efficacy of the advised action to reduce the risk or seriousness of the impact; (d) Perceived Barriers: refers to the potential negative aspects of a particular health action. The perceived barriers may act as impediments to undertaking recommended behaviors; (e) Self-Efficacy: which is defined as “the conviction that one can successfully execute the behavior required to produce the outcomes”; (f) Cues to Action: is accelerating forces for prompting engagement in health-promoting behaviors. Cues to action can be internal or external. Physiological cues (e.g., pain, symptoms) are examples of internal cues to action. External cues include events or information

Figure 1. Schematic presentation of Health Belief Model (Glanz et al., 2008).

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from close others, the media, or health care providers which may promote the engagement in health-related behaviors (Glanz et al., 2008). The HBM-based studies carried out in Iran have shown that the level of cognitive determinants of Pap smear test among women is not favorable (Mahdavifar, Sabzevari, & Harandi, 2015; Mohebi, Sharifirad, Gharlipour, & Kamran, 2016). For example, in a study conducted in Ghom county (Mohebi et al., 2016), the levels of perceived susceptibility and perceived severity for cervical cancer among women were only 20.94% and 32.81%, respectively. In another study conducted in Bandarabbas city, Southern Iran, (Mahdavifar, Sabzevari, & Harandi, 2015) the levels of perceived susceptibility for cervical cancer and perceived barriers to Pap test uptake were less than moderate. Ashtarain et al. also reported poor knowledge of women on the disease and Pap smear test as a main barrier to perform cervical cancer screening test (Ashtarian et al., 2017). We conducted a review on the literature and found no study with specific focus on the determinants of Pap test uptake among housewife women. As women’s identity as housewives may provide a basis for their collective action (Asthana, 1996) in the family, we can presume that the housewife women, especially in developing countries, are at a high risk for ill-health due to such collective actions in a variety of roles including wife, mother, housekeeper and even girl (for their parents). In the other hand, the level of Pap test uptake among women in developing countries like Iran has been reported as unfavorable (Dehdari et al., 2014; Nojomi, Modarres, Erfani, Mozaffari, & Mottaghi, 2007). Therefore, this question bore in our mind that, how is the status and what are the cognitive determinants of Pap test uptake, as a disease prevention behavior, among housewife women. In a previous study in Mashhad (Abedian & Dormohammadi, 2012), another Iranian city, the frequency of CCSB was reported to be higher among the women with a history of uterine infection compared to those without such a history. As an assumption, the women with the history of uterine infection may perceive the severity of disease more in proportion to those without the infection. Also, fear of the disease and its consequences may be considered as predictors for perceived severity (Karimy, Gallali, Niknami, Aminshokravi, & Tavafian, 2012). Therefore, investigating this history may be helpful in justifying the associations between the HBM constructs and CCSB. Finally, we conducted this study to examine the determinants of Cervical Cancer Screening Behavior (CCSB) among housewife women in Islamabad County, Iran, utilizing the HBM model. Identifying cervical cancer influential factors in such studies may be helpful in designing interventional efforts aiming at CCSB promotion among housewife women. The questions guided the study were as follow: (a) what is the status of performing CCSB among the housewife women? (b) To what extent do the HBM constructs (perceived susceptibility, severity, benefits and barriers, as well as self-efficacy) and knowledge may predict CCSB among the housewife women? (c) What are the main barriers to perform Pap test among these women?


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Methods Study design and participants

We conducted this cross-sectional study from March to May 2015 among the housewife women referring to the health centers of Islamabad County, Kermanshah province, Iran. We employed multistage cluster sampling to recruit 280 women in the study. Among the initially three health centers, we randomly selected two centers from which the respondents were randomly elected based on their records in the health centers. The first researcher found phone number of the women in their health records, and dialed and invited them on the phone to participate in the study. He requested the women to refer to the health center whenever they can at the business times of business days in the scheduled weeks. He was present at the health center all days of the weeks, and was prepared to explain the respondents about the research objectives. As the women were familiar with the healthcare providers in the health centers, we suggested the healthcare providers to introduce the interviewer to the women. So, it was assumed that the women provided the research team with honest information. The respondents were assured of confidentiality of data. The respondents signed a written informed consent form when presented in the health center. The respondents, then, completed the questionnaires in a consultation room in the health center. The literate respondents completed a self-administered HBM-based questionnaire. The illiterate women were interviewed by the first author to complete the questionnaire. All the interviews with illiterates/those with elementary education were conducted by the first author of the study. In order to alleviate gender sensitivity between the interviewer (male) and the interviewed women in our study, the interviews’ process was facilitated by a female healthcare provider from the health centers. The inclusion criteria for this study were housewife and non-pregnant women, with at least one year of married life, and consent to participate in the study. Instruments

Demographic data included age, level of education (Illiterate/Elementary, High school/Diploma, University), and economic status of the family (Weak, Fair, Good), history of urinary infection (Yes/NO). We applied a reliable and valid HBM-based questionnaire and a knowledge scale (Karimy et al., 2012) for data collection. These questionnaires were developed in Persian by Karimi et al. aiming to assess the HBM-based cognitive constructs related to CCSB among women referring to health care centers in Zarandieh County, Iran. In their study, the Cronbach’s alpha for the HBM-based questionnaire (as a unite instrument) and knowledge scale were 0.82 and 0.85, respectively. In the present study, the Cronbach’s alpha coefficients for the HBM-based

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questionnaire and knowledge scale were found to be 0.76 and 0.70, respectively. A brief description of the scales is as follows. Knowledge scale

The knowledge on cervical cancer scale, including 12 items, was used to measure the level of knowledge on cervical cancer signs and symptoms, severity, and preventive behaviors among the respondents. An example of the items was: “Early marriage (at the ages lower than 17) increases the risk of developing cervical cancer”. The respondents should select Yes (2), I don’t know (1), or No (0) for each item.

Subscales of the HBM-based questionnaire Perceived susceptibility and perceived severity scales

Perceived susceptibility toward cervical cancer was measured applying a five-item scale. An example of the items included: “I am worried about being diagnosed with cervical cancer”. Perceived severity towards cervical cancer was also measured using a 5-item scale. One of the items, for instance, was: “The name of cervical cancer causes fear and panic in my mind”. The items for perceived susceptibility and severity scales were rated on a five-point Likert-type scale ranged from 1 to 5 (1 D totally disagree through 5 D totally agree). The higher the score, the more susceptibility and severity toward cervical cancer were concluded. Perceived benefits and perceived barriers scales

Perceived benefits and perceived barriers of performing CCSB comprised 12 items (6 items per a scale). The items, “Having a Pap test will increase the chance of early diagnosis of a possible tumor in my cervix”) and “I am too busy to find enough time to go for Pap smear test” were two examples of the items included in the perceived benefits and barriers scales, respectively. For the scales of perceived benefits and perceived barriers, the items were rated on a five-point Likert-type scale ranged from 1 to 5 (1 D totally disagree through 5 D totally agree). The higher the score, the higher benefits from and the lower the score, the lower barriers for performing CCSB were concluded. Perceived self-efficacy scale

The self-efficacy to perform CCSB scale comprised 10 items. An example of the items was: “I am confident that I can encounter with unexpected problems, effectively”. For this scale, the items were rated on a four-point Likert-type scale ranged from 1 to 4 (1 D totally confident through 4 D totally unconfident). The higher the score, the more self-efficacy was concluded.


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Cervical Cancer Screening Behavior Scale (CCSBS)

Finally, the CCSB was measured applying one item: “Have you had a Pap smear test in the previous three years?” To answer the question, the respondents should select Yes (1) or No (0). Statistical analysis

We used summery statistics and frequency distributions to describe and interpret the meanings of data. As the distribution of data was normal, one-way ANOVA and independent t-test were used to analyze the differences in the HBM constructs by the demographic variables. We analyzed the associations between HBM structures and CCSB using Pearson correlation coefficient test. Moreover, Logistic Regression analysis with Enter method was applied to illustrate the variations in CCSB by the HBM constructs. We analyzed the data applying SPSS, version 20.0 for windows. In all the analyses, the level of significance was considered less than 0.05.

Results We conducted the analyses on the data provided from 280 housewife women. The respondents’ age ranged from 30 to 40 years with the mean age of 38.9 § 6.21 years. About less than half of the respondents (44.3%) were illiterate. The history of urinary infection was reported by 3% of the participants. About 44% reported their economic status as weak (Table 1). Also, 45.7% reported having Pap smear test in the previous three years. The frequency and relative frequency of the CCSB by demographic characteristics are presented in Table 1. We found significant differences in CCSB by the history of urinary infection (p D 0.019) and economic status of the family (p < .001). Table 2 shows the means and standard deviations (SD) of knowledge and the HBM constructs by having/not having the Pap smear test in previous three years. Table 1. Comparison of Cervical Cancer Screening Behavior (CCSB) by demographic characteristics. Not Having Pap test in previous 3 years Variables Level of Education

N (%)

Illiterate/Elementary 148 (44.3) High school/ Diploma 6.1) University 31 (11.1) History of Yes 8 (2.9) Urinary Infection No 272 (97.1) Economic status Weak 124 (44.3) of the family Fair 92 (32.9) Good 64 (22.9)

Chi-square test

having Pap test in previous 3 years

N

%

N

%

p-value*

79 56 17 1 151 94 44 10

52 36.8 11.2 0.7 99.3 64.5 28.9 6.6

69 45 14 7 121 26 48 54

53.9 35.2 10.9 5.5 94.5 20.3 37.5 42.2

0.948 0.019 0.000

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Table 2. Mean and Standard Deviation of HBM constructs among housewife women with/without the history of Pap smear test. Not Having Pap test in previous 3 years

having Pap test in previous 3 years

Variables

Mean

SD

Mean

SD

p-value*

Knowledge Perceived Susceptibility Perceived Severity Perceived Benefits Perceived Barriers Perceived Self-efficacy

14.36 15.81 20.55 22.71 20.74 22.07

3.30 4.21 7.13 5.31 6.71 6.40

15.78 16.08 18.51 26.54 16.24 26.45

2.32 4.73 3.98 3.47 5.65 6.14

P < .001 P D 0.614 P D 0.003 P < .001 P < .001 P < .001

Independent t-tests; SD D Standard Deviation.

The differences in CCSB by knowledge and all the constructs of the HBM were statistically significant, except for perceived susceptibility. Women with at least a Pap smear test in previous three years had higher levels of knowledge, perceived severity, perceived benefits, and perceived self-efficacy and lower level of perceived barriers to perform CCSB. Table 3 presents the bivariate correlations between CCSB and the HBM constructs. Applying Pearson correlation coefficient test, statistically significant positive correlations were found between CCSB and knowledge and all the HBM constructs, except for perceived severity and perceived barriers that were negatively associated with CCSB. We applied logistic regression analysis to predict factors related to having CCSB (Table 4). The results of analysis showed three variables with significant odds ratios. The housewives who perceived more benefits of performing Pap test (OR D 1.11, 95% CI D 1.02, 1.21), and perceived fewer barriers (OR D 0.915, 95% CI D 0.87, 0.96), and higher level of self-efficacy (OR D 1.12, 95% CI D 1.04, 1.19) to perform the test were more likely to have a CCSB in the previous three years. Table 5 presents the frequency of barriers to perform CCSB. According to the results, the main barriers to perform Pap test among the women were “I hate such an examination and sampling procedure” (46.1%),” If I were to have cervical Table 3. Bivariate correlations of the HBM variables and knowledge with Cervical Cancer Screening Behavior (CCSB). Variable 1D Knowledge 2D Perceived susceptibility 3D Perceived severity 4D Perceived benefits 5D Perceived barriers 6D Perceived self-efficacy 7D CCSB

1

2

1 0.126* 0.076 0.535 * ¡0.412 * 0.152 * 0.238 *

1 0.089 0.023 ¡0.058 0.030 0.013

p < .05; p < .01; SD D Standard Deviation.

3

1 0.206 * ¡0.032 ¡0.216 * ¡0.170 *

4

1 ¡0.319 * 0.336 * 0.390 *

5

1 ¡0.199 ** ¡0.338 **

6

1 0.333 *

7

Mean § SD

1

15.01 § 2.97 15.93 § 4.45 19.62 § 5.98 24.01 § 4.90 18.68 § 6.63 12.37 § 5.01 1.45 § 0.49


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Table 4. Logistic Regression analysis to predict Cervical Cancer Screening Behavior (CCSB). Confidence Interval 95% Variables Knowledge Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Perceived self-efficacy

p-value

Odds Ratio (OR)

Lower

Upper

0.817 0.629 0.142 0.015 0.001 0.001

0.986 1.015 0.945 1.11 0.915 1.12

0.879 0.954 0.876 1.02 0.873 1.04

1.10 1.08 1.02 1.21 0.960 1.19

cancer, I prefer not to be aware of” (38.6%), and “I am too busy to go for having Pap smear test” (37.5%).

Discussion Our aim in this study was to investigate the cognitive predictors of CCSB among housewife women referring to the healthcare centers in Islamabad County, Iran, based on the HBM. Our findings showed that only about 45% of the women reported having Pap smear test in the previous three years. In another study in Tabriz, Iran, (Farshbaf-Khalili et al., 2015), 50.6% out of all the participants have never had a Pap smear test throughout their lives. In a study conducted in Hamedan County (Jalilian et al., 2011), the frequency of performing regular Pap smear test among women was reported to be 28.3%. In Botswana, McFarland (McFarland, 2013) reported that about half of the participants (52%) had one to two Pap tests in the past 5 years. In general, previous studies in developing countries have indicated lower levels of Pap smear uptake (Ranabhat, Tiwari, Dhungana, & Shrestha, 2014; Shivanthan, et al., 2014) among different populations of women compared to those reported in the Iranian studies. For instance, Ranabhat et al. (Ranabhat et al., 2014) reported that only 15.7% of Nepali women had undergone Pap smear uptake for at least one time throughout their lifetime. In the other studies conducted in Saudi Arabia (Sait, 2009) and Nigeria (Idowu, Olowookere, Fagbemi, & Ogunlaja, 2016), the frequencies of performing regular Pap smear test Table 5. The frequency of barriers to perform Pap test among the housewife women.

Variables I hate such an examination and sampling procedure I am too busy to go for having Pap smear test If I were to have cervical cancer, I prefer not to be aware of. Such cancers are the results of fate I am afraid of being diagnosed with cervical cancer I am in doubt with the efficacy of Pap smear test in detecting cervical cancer.

Totally agree N (%)

Agree N (%)

No idea N (%)

Totally disagree N (%)

Disagree N (%)

129 (46.1) 105 (37.5) 108 (38.6)

24 (8.6) 30 (10.7) 30 (10.7)

1 (0.4) 9 (3.2) 5 (1.8)

49 (17.5) 43 (15.4) 59 (21.1)

77 (27.5) 93 (33.2) 78 (27.9)

104 (37.1) 69 (24.6)

35 (12.5) 35 (12.5)

47 (16.8) 20 (7.1)

37 (13.2) 75 (26.8)

57 (20.4) 81 (28.9)

76 (27.1)

14 (5.0)

12 (40.0)

33 (11.8)

45 (16.1)

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among women were reported to be 16.8% and 8%, respectively. These findings may show the moderate implication of the Iranian cervical cancer screening program implemented in 1989 (Khodakarim et al., 2014). Although this screening service was omitted from the list of Iranian free of charge healthcare services after 10 years (in 1999) and the screening is now conducted per request of the women or recommendation of healthcare providers (Allahverdipour & Emami, 2008), it seems that implementing the policy has been moderately successful in promoting Pap test uptake among Iranian women in comparison with those in the developing countries. Such a presumption may draw attentions to the need for cervical cancer screening within the context of an organized program, especially in developing countries, that has the means to invite community-wide women to participate. Our results showed significant difference in CCSB by age, in a way that by increasing age among women the level of adopting CCSB was decreasing. This finding was similar to those reported by Onsori et al. in Parand and Robat Karim Counties, Iran (Onsori, Abdollahi, & Siri, 2013). Troconis et al. (Troconis, Tulliani, Martınez, & Fernandez, 2013), in another study in Venezuela, reported that the frequency of performing Pap smear test among the women younger than 45 was significantly higher compared to the women older than 45, which may be due to the age of menopause and its related issues. Women at the age of menopause may consider this test as unnecessary and thus may not perform CCSB as recommended in the guidelines of prevention and early detection of cervical cancer (Schlichte & Guidry, 2015). In the present study, we found that the frequency of CCSB among the housewife women with a history of uterine infection was significantly higher than those without such a history, which was similar to those reported by Abedian et al. (Abedian & Dormohammadi, 2012). Therefore, compared to the women without the history of uterine infection, women with such history may have a better perception on the severity of the disease and consequently perform CCSB with a higher possibility. Also, fear of the disease and its consequences may predict perceived severity (Karimy et al., 2012). Women with the history of urinary infection may have previously been informed and/or warranted on the disease by the healthcare providers. But, those without such history may have not referred to receive prior urinary and vaginal care services and, thus, may not understand the importance of the issue. The CCSB was significantly differed by the economic status of the family in our study. The housewife women with better economic status of the family performed CCSB more in comparison to those with worse economic status. Previous studies have also showed the women with low socioeconomic status as prone to not adopt Pap test (Onsori et al., 2013). Considering these findings, it is essential to pay more attention to the women with low socioeconomic status and particularly those living in marginal settings. For instance, providing complementary insurance may be helpful as a financially supportive strategy to promote CCSB adoption among these women.


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In our study, the differences in all the constructs of HBM were statistically significant by performing CCSB, except for perceived susceptibility. Statistically significant relationships were also found between all the constructs of the model and CCBS, except for perceived susceptibility. In studies conducted by Namdar et al. (Namdar, Bigizadeh, & Naghizadeh, 2012) and McFarland (2013), no statistically significant relationship was found between perceived sensitivity and performing Pap test behavior. These findings suggest that the women may not consider themselves as susceptible for having cervical cancer. A reason for this low level of perceived susceptibility toward the disease may be the low level of health literacy among these women, considering that about 45% were illiterate or with elementary education. Therefore, particular attention to the housewife women while designing and implementing Pap test promotion campaigns as the first stages of cervical cancer screening programs in such communities may be helpful in promoting the level of perceived susceptibility among these women. Further studies on the health literacy of housewife women regarding cervical cancer are also recommended. Similar to the findings of previous studies (Namdar et al., 2012; Tanner-Smith & Brown, 2010), the strongest associations were found between perceived benefits and barriers with CCSB among the women in our study. The more the women perceived the benefits of CCSB and the less they perceived the barriers to perform the behavior, the more possibility to adopt the behavior. Similarly, Jalilian et al., in another study showed perceived barriers as a strong predictor to perform regular Pap smear test among women (Jalilian et al., 2011). Hyacinth et al., also reported that the lack of awareness and belief on this fact that cervical cancer is preventable may be a barrier to perform Pap smear test among women (Hyacinth, Adekeye, Ibeh, & Osoba, 2012). Our further analysis of the barriers to perform Pap test in the present study showed that the three main barriers to perform Pap test among the women were being hated with the examination and sampling procedure, preference to be unaware from being with the disease, and being too busy to go for CCSB. Our findings in the present study and those of previous studies (Hyacinth et al., 2012; Jalilian et al., 2011; Namdar et al., 2012; Tanner-Smith & Brown, 2010) show the significant role of perceived barriers in predicting CCSB. It may therefore be concluded that in the behaviors such as CCSB, which requires the active participation of the target group, one of the most powerful HBM-based determinants of the behavior is perceived barriers. As long as such barriers are perceived among women, voluntary effective participation of women in this regard may not be expected. In the study of Shakibazadeh et al., the most important barrier was lack of awareness on the causes of cervical cancer, fear of being diagnosed with the cancer, pain of sampling procedure, and costs of the test (Shakibazaeh, Ahmadnia, Akbari, & Negarandeh, 2008). Such perceived barriers should be considered while planning CCSB promotion programs with the hope to promote the level of participation among women. As a major finding in our study, perceived self-efficacy, perceived benefits, and perceived barriers were the main determinants for performing CCSB among the

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housewife women. In other words, compared to the other women, the women who perceived more benefits of and fewer barriers to performing Pap test, and had higher level of self-efficacy to perform the test were more likely to adopt CCSB in the previous three years. In line with these findings, Mahdavifar, Sabzevari, Harandy, and Fasihi (2015 reported perceived benefits and barriers as the most important determinants of Pap smear screening uptake among women. Do (Do, 2015), also, highlighted the important role of perceived barriers in the frequency of participation in screening behaviors. The strong associations of perceived self-efficacy and perceived barriers with screening behaviors have been shown in previous studies (Majdfar, Khodadost, Majlesi, Rahimi, Shams, & Mohammadi, 2015; Miller et al., 2017; Shirzadi, Nadrian, Asghari-Jafarabadi, Allahverdipour, & Hassankhani, 2017). In our study, perceived self-efficacy was the strongest predictor for CCSB among the women. When individuals perceive themselves as confident to conduct a healthy behavior, they may consider themselves with greater abilities to have control over and to reduce the barriers of a health-related behavior (Glanz et al., 2008).

Limitations As a limitation for our study, data collection method may be noted which was based on self-report by the housewife women. Therefore, recall bias is warranted. Also, the subjectivity of measuring the economic status may be another limitation. In the questionnaire, we asked the respondents to rate the economic status of their families as Good, Fair, or Weak, which may be differently understood by different women. Another limitation of the present study may be the age range of participants. Although we elected the women in a random manner, the age of all the participants was at the range of 30 to 40 years. This limitation may be due to the large number of women at this age range who have active health records at the health centers. In Iran, a majority of women refer to health centers only when they are going to have a child. Therefore, they refer to the centers to receive pregnancy healthcare and, after childbirth, to receive maternal (postnatal healthcare) and child healthcare (e.g. vaccination, child development care and nutritional care). As the majority of Iranian women with such healthcare needs are at the range of 30 to 40 years of age, and considering that we recruited the women based on their heath records in the health centers, we unintentionally missed out those who were not at this range of age.

Conclusion Our findings showed that the frequency of performing Pap smear test in the last three years among the housewife women in Islamabad County was somewhat low. We found perceived self-efficacy, and perceived benefits and barriers of adopting the behavior as the most significant cognitive factors contributed to CCSB among the housewife women. The HBM was found to be helpful in determining the cognitive predictors of CCSB among these women. Therefore, designing


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interventional programs aiming to promote the level of CCSB among these women and to early detection of cervical cancer applying promising frameworks like HBM is recommended. Healthcare providers should have a specific focus on perceived self-efficacy, perceived barriers, and perceived benefits of CCSB while designing such interventions.

Ethical approval Ethical approval for the study was provided from ethical committee in Tabriz University of Medical Sciences. The project Code: 94-02-132. Informed consent form was completed and signed by all respondents.

Acknowledgments The researchers appreciate the officials of the deputy and the women participated in the study.

Funding This article was supported by research committee in Tabriz University of Medical Sciences (grant number: 94-03-201).

Disclosure of potential conflicts of interest No potential conflicts of interest were disclosed. Competing Interest.

ORCID Haidar Nadrian

http://orcid.org/0000-0003-3129-2475

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