The Effect of Educational Intervention Based on the Theory of Planned Behavior on The Performance on Pap Smear Test Screening in Iranian Women


 Background: Cervical cancer is the second most common cancer and the fifth deadly cancer among women in Iran. Educational interventions based on proper behavior promoting models can lead to early diagnosis of cervical cancer. The theory of planned behavior pays attention to social factors and motivation for following the significant others. The aim of this study was to determine the factors related to performing regular Pap smear test based on the Theory of Planned Behavior (TPB) among the females living in Fasa, Iran.Methods: A cross-sectional study was conducted on 700 participants. Then the educational intervention based on the results of cross-sectional study was conducted in form of a workshop for 50 women as the intervention group, and 50 women were considered as the control group. After all, the data were entered into the SPSS statistical software and were analyzed via logistic regressions analysis, paired t-test, independent t-test, chi-square test, and McNemar test.Result: According to the results, 45.7% of the patients had a history of undergoing a Pap smear test, and 20.7% of them performed this test regularly. The knowledge, attitude, subjective norms, and perceived behavioral control were the predictors of intention and behavior of Pap smear test among the women (P<0.05). These components accounted for 57.4% and 31.6% of the intention and behavior variance, respectively. After the intervention, a significant increase was observed in the mean scores of attitude, subjective norms, and perceived behavioral control in the intervention group compared to the control group. The results revealed no significant difference between the two groups concerning the behavioral intention (p=0.41) and performance of the Pap smear test (p=0.583). The number of the participants who had undergone the Pap smear test increased from 10 to 26 in the intervention group three months after the intervention. The results of McNemar test indicated that this difference was statistically significant.Conclusion: The results indicated an increase in the women’s performance of the Pap smear screening test by appropriate planning, provision of educational packages based on the women’s needs, and using effective subjective norms.This clinical trial is registered in the Iranian Registry of Clinical Trials (IRCT20160830029608N3).


Abstract
Background: Cervical cancer is the second most common cancer and the fth deadly cancer among women in Iran. Educational interventions based on proper behavior promoting models can lead to early diagnosis of cervical cancer. The theory of planned behavior pays attention to social factors and motivation for following the signi cant others. The aim of this study was to determine the factors related to performing regular Pap smear test based on the Theory of Planned Behavior (TPB) among the females living in Fasa, Iran.
Methods: A cross-sectional study was conducted on 700 participants. Then the educational intervention based on the results of cross-sectional study was conducted in form of a workshop for 50 women as the intervention group, and 50 women were considered as the control group. After all, the data were entered into the SPSS statistical software and were analyzed via logistic regressions analysis, paired t-test, independent t-test, chi-square test, and McNemar test.
Result: According to the results, 45.7% of the patients had a history of undergoing a Pap smear test, and 20.7% of them performed this test regularly. The knowledge, attitude, subjective norms, and perceived behavioral control were the predictors of intention and behavior of Pap smear test among the women (P<0.05). These components accounted for 57.4% and 31.6% of the intention and behavior variance, respectively. After the intervention, a signi cant increase was observed in the mean scores of attitude, subjective norms, and perceived behavioral control in the intervention group compared to the control group. The results revealed no signi cant difference between the two groups concerning the behavioral intention (p=0.41) and performance of the Pap smear test (p=0.583). The number of the participants who had undergone the Pap smear test increased from 10 to 26 in the intervention group three months after the intervention. The results of McNemar test indicated that this difference was statistically signi cant.
Conclusion: The results indicated an increase in the women's performance of the Pap smear screening test by appropriate planning, provision of educational packages based on the women's needs, and using effective subjective norms.
This clinical trial is registered in the Iranian Registry of Clinical Trials (IRCT20160830029608N3).

Background
Cervical cancer is the second most common cancer and the fth deadly cancer among women in Iran(1).
It is also the most common cancer in developing countries. Each year, one out of every 123 women is infected with cervical cancer, with the mortality rate of 1 per 100,000 (2). The World Health Organization (WHO) has estimated that cervical cancer will be responsible for 474,000 deaths by 2030, with 95% of the deaths occurring in low-and middle-income countries (3). Nonetheless, considering the long pre-invasion period, accessibility of appropriate screening programs, and effective treatment of the primary lesions, cervical cancer has been known to be a preventable cancer (3). Since the utilization of Pap smear test as a screening technique, the prevalence of cervical cancer has reduced by 79%(4). Therefore, performance of this test should be considered as a health policy for sexually active women (5). Benedet et al. maintained that the women who had undergone the Pap smear test more than three years ago and those who had not undergone the test at all were at the highest risk of cervical cancer (6).
Educational interventions based on proper behavior promoting models can lead to early diagnosis of cervical cancer, eventually decreasing the resultant mortality. Among the models aiming at perception and prediction of health behaviors, the theory of planned behavior has been successful. The theory of reasoned action has been designed for predicting and explaining behaviors based on the assumption that individuals select their behaviors in accordance with the logical investigation of the available information and consider the results of their performance prior to decision making. According to this theory, the best predictor of behavior is the individual's intention for involvement in the behavior. Intention is predicted by two variables; i.e., attitude related to the behavior (overall positive or negative evaluation of the behavior) and subjective norms (overall perception of social pressure for doing the behavior). The success of this theory in explaining the behavior depends on the extent the behavior is controlled by the individual. In fact, individuals normally act according to their perception of what others think they should do. Besides, their intention to accept the behavior is potentially affected by the individuals with whom they have close relationships. In this theory, subjective norms are obtained through multiplying normative beliefs by the motivation to do the target behavior in spite of expectations. In addition, perceived behavioral control has been de ned as the extent to which an individual believes in the controllability of a behavior (7). In the present study, the theory of planned behavior was selected to create and improve the Pap smear screening behavior among women in Fasa. This model has been employed in numerous studies. For instance, Saberi et al. (2018) conducted a study on 140 married women aged 20-49 years in order to explore the impact of education using the theory of planned behavior on promotion of breast self-examination. The results revealed a signi cant increase in the mean scores of knowledge, attitude, perceived behavioral control, behavioral intention, and breast self-examination behavior in the intervention group after the educational intervention. However, no signi cant changes were observed in the control group. These results con rmed the effectiveness of the educational intervention in promotion of breast self-examination behavior as a screening method for breast cancer (8). Similarly, Taghdisi et al. attitude, perceived behavioral control, and subjective norms compared to the control group six months after the intervention. After the intervention, 78% of the women in the intervention group were willing to do mammography and 74% did the test. These measures were respectively obtained as 19% and 7% in the control group. Hence, the educational intervention based on the behavioral theory was effective in improvement of the performance of mammography among the women(10). The theory of planned behavior pays attention to social factors and motivation for following the signi cant others. Hence, various studies have found it to be an important factor in the acceptance of desirable behaviors, such as performance of the Pap smear test (11)(12)(13).

Methods
This descriptive-analytical, cross-sectional study was conducted in Fasa in 2016. Out of the six healthcare centers in Fasa, two were selected through simple random sampling. Then, based on the lists of the households covered by each center, 350 people were selected from each center via simple random sampling (700 people in total) and were enrolled into the research. In doing so, two researcher's assistants were present in the healthcare centers, provided the eligible women with the necessary information, invited them to take part in the research, and obtained their written informed consent forms.
The inclusion criteria of the study were being married, aging above 21 years, passage of at least three years from marriage, not having the history of cancer and hysterectomy, and not having done the Pap smear test during the past three years. The exclusion criterion of the study was absence in the threemonth follow-up.
At rst, a cross-sectional study was conducted on 700 participants. The participants were requested to ll out the demographic information and theory of planned behavior questionnaires (14). The results were analyzed and the educational intervention was designed. Then, the educational intervention was conducted in form of a workshop for 50 women as the intervention group, and 50 women were considered as the control group.
The study data were collected using an instrument including three sections, which was prepared based on the previous studies (14). The rst part of the questionnaire contained demographic information, such as age, number of children, age at the rst pregnancy, history of performance of the Pap smear test, occupation, education level, menopause status, and family history of cervical cancer. The second and third parts of the questionnaire consisted of questions about knowledge and the constructs of the theory of planned behavior. Knowledge was assessed by 15 yes/no questions (yes = 1, no = 0). Attitude was evaluated by six items (e.g., Annual performance of the Pap smear test reduces the probability of cervical cancer) responded via a ve-option Likert scale ranging from completely disagree (1) to completely agree (5). Subjective norms of the persuasive person for performance of the Pap smear test were determined by ve items (e.g., My husband persuades me to perform the Pap smear test on a regular basis) responded through a ve-option Likert scale ranging from very low (1) to very high (5). Perceived behavioral control was measured by two items (e.g., Performance of the Pap smear test is di cult for me) responded using a ve-point Likert scale ranging from very low (1) to very high (5). Intention to perform the Pap smear test was also evaluated using two items (e.g., I intend to perform the Pap smear test this year) responded via a ve-option Likert scale ranging from very low (1) to very high (5). Finally, screening behaviors and performance of the Pap smear test were assessed via two items whose scores ranged from 2 to 18. The content validity of the questionnaire was assessed by 18 health education specialists, one MSc of midwifery, and one gynecologist. Considering Content Validity Ratio (CVR) and Content Validity Index (CVI), the necessary modi cations were applied and the indices were con rmed. Moreover, a pilot study was conducted on 30 eligible women and the reliability coe cients of attitude, subjective norms, behavioral intention, and perceived behavioral control constructs were found to be 0.74, 0.75, 0.65, and 0.76, respectively.
After all, the study data were entered into the SPSS 22 software and were analyzed using Pearson's correlation coe cient and logistic regression analysis. P < 0.05 was considered to be statistically signi cant.
The educational intervention was conducted through lecture, group discussion, question and answer, educational pamphlets and posters, movie, and PowerPoint in form of three 45-minute sessions. The educational sessions were held once a week. In the third session, physicians, healthcare staff, and the participants' husbands were present as subjective norms. The educational content included cervical cancer, importance of performing screening behaviors, probable obstacles against the performance of the Pap smear test, and strategies for overcoming individual and environmental barriers. The intervention was carried out through face-to-face training, group discussion (about beliefs, positive and negative outcomes of the behavior, facilitators, motivation to follow the signi cant others, and subjective norms), educational pamphlets, and PowerPoint. In addition, an educational movie on how the Pap smear test is done was shown to the participants. The discussions were directed towards the identi cation of positive beliefs and attitudes so as to promote positive motivation for performance of diagnostic measures, particularly the Pap smear test, and provide the ground for development of a positive attitude or modi cation of the negative attitude regarding the uncontrollability of the disease. Moreover, common wrong beliefs about the Pap smear test were put into debate so as to reduce the intensity of wrong beliefs by modifying the participants' beliefs and attitudes. At the end of the educational sessions, the participants were provided with an educational booklet. Besides, a WhatsApp group was created for information sharing. An SMS was also sent to the participants once a week. In the control group, however, the participants were only provided with the educational booklet. All participants were followed up three months after the educational intervention and the theory of planned behavior questionnaire was completed for them again. Furthermore, they were required to send the results of their Pap smear tests to the researcher in case they did the test. After all, the data were entered into the SPSS statistical software and were analyzed via logistic regressions analysis, paired t-test, independent t-test, chi-square test, and McNemar test.

Results
The two groups were homogeneous with respect to age, education level, and occupation at baseline ( Table 1). The results showed no signi cant difference between the two groups regarding the constructs of the theory of planned behavior before the educational intervention. After the intervention, however, a signi cant increase was observed in the mean scores of attitude, subjective norms, and perceived behavioral control in the intervention group compared to the control group (Table 2).  The results revealed no signi cant difference between the two groups concerning the behavioral intention (p = 0.41) and performance of the Pap smear test (p = 0.583) (Tables 2 and 3). The number of the participants who had undergone the Pap smear test increased from 10 to 26 in the intervention group three months after the intervention. The results of McNemar test indicated that this difference was statistically signi cant (p < 0.001, Table 3).  review. Among the investigated articles, seven were conducted using health education theories and models, while ve were performed without these theories and models. The ndings demonstrated that utilization of multifaceted educational methods and application of health education and health promotion theories and models were highly effective in improvement of individuals' behavioral performances.
As mentioned above, health education and health promotion interventions play a critical role in elimination of problems and promotion of behaviors, such as performance of the Pap smear test. When these interventions are carried out based on models and theories, nding the constructs under the in uence of the theories and models can help design interventions for promotion of the behavior. This can, in turn, play a key role in evaluation and documentation of change strategies(15) (15).
The results of the meta-analysis conducted by Saei et al. (2018) revealed the effectiveness of educational interventions based on health behavior change theories in improvement of women's behavior regarding the performance of cervical cancer screening around the world. In this respect, the theory of planned behavior was found to be a bene cial model for determining the women's tendency to perform cervical cancer screening. Overall, theory-based educational interventions could increase the women's knowledge and promote their performance of the cervical cancer screening test (17). The ndings of the metaanalysis by Steinmetz et al. (2016) also proved the effectiveness of the interventions based on the theory of planned behavior in behavior change (18). These results were in agreement with those of the current investigation.
Innocentia Ebu et al. (2019) assessed the impact of planned interventions based on the health belief model on breast cancer and cervical cancer screening as well as performance of the Pap smear test among 870 women. The results indicated an increase in the performance of Pap smear test after the intervention. Although the utilized method was different from that employed in the present study, the results con rmed the positive effect of educational interventions on promotion of cancer prevention methods among women (19).
Molaei et al. (2019) reported that education based on the theory of planned behavior (either in person or in groups) was effective in the women's attitude, subjective norms, perceived behavioral control, and behavioral intention regarding the performance of mammography. In fact, the educational intervention improved the breast cancer screening behavior, which was in line with the present study results (20).
Kocaöz (2017) investigated the impact of education on the women's attitude and behavior regarding breast cancer and cervical cancer screening. The results showed that 28.4% of the women did mammography, 69.9% did breast self-examination, and 33.6% did the Pap smear test six months after the intervention. Hence, the training was found to be effective in promotion of the women's attitude and behavior regarding the performance of screening. Although the used educational method was not similar to that utilized in the current study, the results indicated the women's need for a professional educational program for improvement of their attitude and behavior regarding screening programs (21).
One of the limitations of the present study was data collection via self-report questionnaires. On the other hand, the strong points of the research included the creation of the WhatsApp group, continual repetition of the trainings, and reception of the Pap smear test results in addition to the women's report of performance of the test.

Conclusion
Based on the study ndings, knowledge, attitude, perceived behavioral control, and subjective norms were the predictors of the women's intention and Pap smear screening behavior. In addition, the physician, husband, and friends were the major subjective norms. The results indicated an increase in the women's performance of the Pap smear screening test by appropriate planning, provision of educational packages based on the women's needs, and using effective subjective norms. Thus, it seems that regular execution of educational programs based on the theory of planned behavior emphasizing attitude change, subjective norms, and increase of women's skills in performance of screening behaviors can be considered as an effective method in promotion of their health in healthcare centers. In fact, women have to be provided with the information through simple and understandable concepts by healthcare providers and mass media. Moreover, healthcare providers have to be aware of the effective factors in preventive and health promoting behaviors in order to design and execute useful educational programs for women.

Consent for publication: Not applicable
Availability of data and material: The data of this article is the personal information of the participants, so the research team has concluded that their publication is not ethical.