Women ’ s Perceptions and Attitudes about Cervical Cancer in Turkey : Kato ’ s Device as an Alternative to the Pap Smear

Cervical cancer is the third most common cancer in women, and the seventh overall, with an estimated 530,000 new cases in 2008. More than 85% of the global burden occurs in developing countries, where it accounts for 13% of all female cancers. Overall, the mortality: incidence ratio is 52%, and cervical cancer is responsible for 275,000 deaths in 2008, about 88% of which occur in developing countries: 53,000 in Africa; 31,700 in Latin America and the Caribbean; and 159,800 in Asia. The incidence of cervical cancer is estimated to be 4.2/100.000 in Turkey according to the data from Globocan, 2008. Based on these data, 1443 women were diagnosed with cervical cancer in 2008 in Turkey, with almost 556 women dying of cervical cancer within the same year (IARC, 2013). The risk factors known to increase the incidence of cervical cancer are early marriage (child marriage) and sexual practice, delivery of the first baby before the age of 20, too many or too frequent childbirths, multiple


Women's Perceptions and Attitudes about Cervical Cancer in Turkey: Kato's Device as an Alternative to the Pap Smear
Mustafa Kursat Sahin, Gulay Sahin, Mustafa Fevzi Dikici, Fusun Artiran Igde, Fusun Yaris* sexual partners, poor personal hygiene practice, low socio-economic status, Human Papilloma Virus (HPV), Herpes Simplex Virus type II, HIV positivity, use of oral contraceptive pill, and smoking. (Raychaudhuri et al, 2012). Most cervical lesions do not progress to cancer, and those which do, progress slowly, making cervical cancer largely preventable through effective screening (Tran et al., 2011). The Pap smear test, developed by Papanicolau and Trout, is a very notable screening method for not only being cheap and easy-to-use, but also for being easily applicable to and accepted by different target populations in the community screenings, with a resulting noteworthy decrease of deaths from cervical cancer (Chew, et al., 2004).
Low coverage rate for Pap smear test is one important factor for the outcome of the screening program not only in the normal population but also among health personnel (Pengsaa, et al., 1989 ;. Those who do not cooperate and comply when adviced to take the test often state that shyness is one reason for not having a pelvic examination, while some indicated that they do not have time to come to the health offices because of work responsibilities . To cope with these problems, a self-administered device has been advised, known as the Kato method, and found to give 100% sensitivity and 99.6% specificity in detecting abnormal cells suspicious for malignancy (Pengsaa, et al., 2003). The acceptance and feasibility of a selfadministered device for cervical cancer screening of rural women in Northeast Thailand have already been tested (Pengsaa, et al., 1997). The results obtained from testing the so-called Kato device (Noguchi, et al., 1982) have been promising. The device was found to be suitable for mass screening campaigns (Sanchaisuriya, et al., 2004).
In this study, we aimed to determine women's perception and attitudes about cervical cancer, and we wanted to learn their thoughts on using Kato's selfscraping device in our family medicine clinic.

Materials and Methods
This descriptive research was conducted between July 1 st -December 31 st , 2012. The study population comprised married women older than 18 years of age, who visited the Family Medicine Central Outpatient Clinic of Ondokuz Mayıs University in Samsun, for any reason other than gynecological problems. During the dates of this study, all married women, who were admitted to the clinic and who agreed to participate and who supplied the study conditions, were included in the research. A total of 246 women were included in the research. The study was approved by the Ethical Commission of the Medical School of Ondokuz Mayis University.
Data were collected by the researcher, applying face-toface structured interview techniques with a questionnaire developed after a relevant literature review. The time allocated for a woman to complete the questionnaire was approximately 10-15 minutes. The questionnaire consisted of two sections. The first section included the sociodemographic characteristics of women, and the second included questions about their knowledge of Pap smears, their status of taking the test, and associated factors, as well as their risk perceptions of cervical cancer.
We provided information about how to use the instrument for Kato's self-scraping method. This easyto-use examination instrument is specially designed for at home use for early detection of cervical cancer (Pengsaa, et al., 2003). Then, we gave them brochures for informational purposes.
All the data were entered and analyzed using SPSS version 16.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics and Chi-square tests were used to analyze the data. P values <0.05 were accepted as statistically significant.

Results
Socio-demographic characteristics of women who participated in the study are summarized in Table 1 Of the group in the last year, 128 (52.0%) had been examined by a gynecologist for either control of an existing  condition or to address a complaint. Of the 118 (48.0%) women who had not had a gynecological examination, 31 (26.3%) said they had not had an exam because they had no gynecological problems, 50 (42.4%) they were negligent, 10 (8.5%) indicated they were shy about such examinations, 10 (8.5%) feared the examination itself, and 17 (14.4%) feared that they might receive bad news as a result of the examination.
Of all of the women, 86 (35.0%) stated that they had information about cervical cancer, and 100 (40.7%) had heard about the HPV vaccine. However, the women indicated that no one in their families had had an HPV vaccine. Of the 82 (33.3%) women who had heard about a Pap smear, 43 (52.4%) received this information from a doctor. A total of 53 (53. 0%) got information about the HPV vaccine from the television, Internet, or a newspaper ( Table 2).
The likelihood of having a gynecological examination significantly increases with income, use of oral contraceptives, smoking, a family history of gynecological cancer or cervical cancer, having information about the HPV vaccine and Pap smears, having had a Pap smear, and the desire to use Kato's device (Table 3).
Our study shows that being informed about cervical cancer increases with age and income, having a family history of gynecological cancer, having had a gynecological examination in the last year, having information about Pap smears and the HPV vaccine, having had a Pap smear test, and having a desire to use Kato's device (Table 4).
Having had a Pap smear had a statistically significant   None of the women had heard about Kato's device; however, once the women were informed about Kato's device, 181 (73.6%) wanted to use it. The reasons stated by the women for wanting to use Kato's device include: 94 (51.9%) said she would not be embarrassed to use it, 56 (30.9%) stated that there was no need to see a doctor, and 31 (17.1%) indicated the convenience of being about to take a smear whenever she wants. Of the women, 39 (60.0%) said that she would not be able to use Kato's device to take the smear herself, and 26 (40.0%) thought that only doctors should take a smear.
After the interview, we gave the patients brochures for informational purposes and all of them read the brochure.

Discussion
Studies show that the women's attitudes about gynecological examinations affect whether they have examination and Pap smears. In a study in Turkey (Karaca, 2008), 92.8% of women had had at least one gynecological examination. In a study by Bekar (2011) 79.1% and in a study by Erbil (2008) 66.3% indicated that they had had at least one gynecological examination. Based on previous gynecological examination experience, the women indicated that they did not have a gynecological examination because of the following: 67.1% indicated anxiety around privacy, 39.6% were irritated by the doctor's attitude, and 62.5 % stated they were shy, 38.8% were anxious, 37.9% were scared, and 21.7% were concerned about pain during the examination (Bekar et al., 2011). In our study, 128 (52.0%) of the women had a gynecological examination in the last one year. The reasons given for not visiting the gynecologist were similar across the studies.
It was established that women's opinions affecting their frequency of having gynecological examination was also effective in taking the Pap Smear Test, and a significant relationship was found between having gynecological examination and taking Pap Smear Test. In many studies, it was determined that the socio-demographic characteristics of women had an influence on the rate of having Pap testing (Akyuz et al., 2006;Jun et al., 2009;Uysal et al., 2009). The rate of taking the Pap Smear Test among women in Turkey according to their socio-demographic characteristics has been investigated in various studies conducted by Turkish researchers. For example, Akyuz et al. (2006) noted that the rate of taking the Pap smear test was highest among women who were between 30-39 years and who were secondary school graduates, unemployed, married for 11-20 years, and had given birth four or more times. Kalyoncu et al. (2003) reported that this rate increased in women older than 35 years and who had been married for a longer period. On the other hand, Ak et al. (2010) reported this rate to be low among women with a low level of education and who lived in rural areas. Karaca (2008) indicated that having social insurance and availability of gynecological examinations in university hospitals had a positive effect on the rates of hearing about and taking the Pap smear test. According to Gurel et al. (2009), the average age was higher among women who took a Pap smear test. These women had more gynecological examinations, lived in the city center, and had a higher socio-economic level as well as a higher level of knowledge Pap smear testing, and a higher education level. In our study, the rate of taking Pap smear test was observed to be higher among women who had middle socio-economic level, had gynecological examination and as higher level of knowledge about Pap smear. Matin and LeBaron (2004) examined the utilization of preventive health care by immigrant Muslim women against breast and cervical cancer; they determined that the religious and cultural values of these women, such as virginity and bodily privacy, play a preventive role in their health care. Among the factors that affect the Pap test are having a male doctor and the feeling of embarrassment. Women in Turkey according to the research by Guvenc et al. (2010) preferred to see a female physician, and they were embarrassed to have a smear test. The reasons for the barrier to having a Pap smear test are reported here and in some other studies (Allahverdipour and Emami, 2008;Reis et al., 2012), to be caused by religious and cultural factors. Wong et al. (2008) reported, for example, that due to religious affiliation and cultural beliefs, Muslim women in particular felt most comfortable with female health care providers. Research has shown that easy access to female doctors contributed to the increased likelihood of receiving a Pap smear test (Reis et al., 2012). Therefore, accurate health care information and communication by health providers may be important to close the gap between women's subculture and that of health professionals, thereby eliminating the stigma and pain perception associated with cervical screening. From the literature review, the most common reasons given by patients who avoid Pap smears are fear of vaginal examination, embarrassment, lack of any symptoms, carelessness, male doctor, never heard about it, and the physician does not request (Coughlin et al., 2005;Imam et al., 2008;Oranratanaphan et al., 2010;Reis et al., 2012;Thippeveeranna et al., 2013;Demirtas et al., 2013). Lack of a physician recommendation contributes to under-use of Pap screening by many eligible women. (Coughlin DOI:http://dx.doi.org/10.7314/APJCP.2014.15.2.905 Women's Perceptions andAttitudes about Cervical Cancer in Turkey: Kato's Device as an Alternative to Pap Smear et al., 2005) In our study, the most common reasons for avoiding a Pap smear test were: lack of any symptoms, no reason/never thought about it, fear of pathological result, and fear of vaginal examination, embarrassment/male doctor and carelessness.
As observed in the previous survey, acceptance of the Kato's device by women was generally good. However, a larger proportion of women with a higher educational background were somewhat more skeptical towards the device than their counterparts from the villages. The higher educated women were more suspicious of the device and thought that it might be harmful to use it or that it might carry the risk of infection. A greater proportion of the higher educated women tended to put their trust more in Pap smear tests done by medical doctors, and many of them would prefer to be screened again by a doctor. From the results of this survey (Pengsaa et al., 1997), it might be concluded that the use of the Kato device is justified in situations where resources for mass screening with the conventional Pap smear is limited. Efforts need to be made to lower the women's suspicions that the device is unsafe or not accurate. Especially the higher educated females must be convinced of the usefulness and safety of the device, if the intention is to integrate them into a scheme where the Kato device is used. It seems that, especially women in the villages could be persuaded to volunteer for mass screening using the device. Suitable health facilities to help distribute the device to women in villages might be the health centers and district hospitals (Sanchaisuriya, et al., 2004). In our study, embarrassment and being scared of the examination were the causes for avoiding a Pap smear, which is similar to the literature. Kato's device may be good alternative for those women.
Most of the women found the device to be convenient to use. However, most of them were not convinced that the method was safe or accurate. The participants were divided almost in half over the question of what screening method they would prefer to use the next time and what method they would recommend to a friend or neighbor, if there were a choice. Almost 24% of them found no difference in the application of the two methods, but 38% considered the Kato device to be less harmful (Pengsaa et al., 1997). In our study, most of the women wanted to use Kato's device.
In conclusion, the attitude of a health professional before and during a gynecological examination is very important. It is important that physicians and nurses understand women's attitudes towards gynecological examinations because this affects their willingness to have gynecological examination and take the Pap smear test, so that they can adopt the appropriate approach in informing and educating women on this subject.
This study also showed that the women readily accepted training to prevent cervical cancer and that their knowledge of the benefits of screening and the risk factors improved.
The Kato method seems to offer a suitable alternative to improve the coverage and frequency of cervical cancer screening in developing countries like Turkey. Females have to be trained on how to use the device, and they have to be convinced that the device is safe and acceptable as a tool for screening.