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International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 333
www.internationaljournalofcaringsciences.org
Original Article
Evaluation of Women Having Pap Smear Test by
Health Belief Model Scale
Eda Cangol, PhD, MSc
Assistant Professor, Canakkale Onsekiz Mart University, Faculty of Health Sciences, Midwifery
Department, Canakkale, Turkey
Seda Sogut,
PhD, MSc
Assistant Professor, Canakkale Onsekiz Mart University, Faculty of Health Sciences, Midwifery
Department, Canakkale, Turkey
Ufuk
Berberoglu, PhD
Associate Professor, Usak University, Faculty of Medicine, Department of Public Health, Uşak, Turkey
Ilknur Dolu, PhD, MSc
Assistant Professor, Bartın University, Faculty of Health Sciences, Department of Public Health Nursing,
Bartın, Turkey
Correspondence:
Eda Cangol, PhD, MSc, Assistant Professor, Canakkale Onsekiz Mart University,
Faculty of Health Sciences, Midwifery Department, Canakkale, Turkey e-mail: edacangol@comu.edu.tr
Abstract
Background: Cervical cancer is the most important type of gynecologic cancer that can be prevented by early
detection by screening test. Screening and early diagnosis with pap smear test are secondary prevention
measures.
Aim: The aim of this study was to evaluate the women’s beliefs about having Pap smear test.
Study Design: This study was conducted as a descriptive study with 620 women between April and June 2016,
who applied to gynecology out patient clinics of a state hospital and agreed to participate in the study.
Method: The data were collected using the "Data Collection Form" and the "Health Belief Model Scale". The
evaluation of the data was analyzed using descriptive statistics (such as mean, number, percentage) and chi-
square test, kruskal wallis test in the SPSS for Windows 16.0 statistical package program. The ethics committee
of Usak University approved the ethics committee and obtained the institutional permission.
Results: The average age of the women participating in the study is 37,66 (SS: 9,43 Min: 19,00, Max: 59,00).
90.32% of the participants were married, 45.32% were primary school graduates and 58.23% were housewives.
49.3% (n = 306) of women participating in the study had had a pap smear test at leastonce. A statistically
significant difference was found between age, menopause, pregnancy, abortion, childbirth, number of births and
number of childrenandstatus of getting information about cancer by pap smear test (p <0.05). When women's
scores were analyzed, the highest score was found to be related to health motivation, pap smear utility / health
motivation and cervical cancer severity perception subscales. A statistically significant relation ship was found
between participants' education status and pap smear utility/ health motivation perceptions, and it was found that
pap smear benefit / health motivation perceptions of non-illiterate women were lower than other groups (X2 =
41,843; SD = 4; p = 000). A statistically significant relation ship was found between the income status of the
participants and the pap smear utility / health motivation perceptions. As the income status increased, the pap
smear utility / health motivation perceptions were higher (X2 = 28,599; SD = 2; p = .000).
Conclusion: As a result of this study, it was found that pap smear test rate of women is still below the desired
level. It was identified that there was a significant relationship between the status of pap smear test and many
variables, and it was understood that the low pap smear benefit / health motivation perception, which
significantly affected the pap smear test status, was particularly low among the education level and the women in
the income group.
Keywords: Pap smear test, cervical cancer, Health Belief Model
International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 334
www.internationaljournalofcaringsciences.org
Introduction
Cervical cancer is the most common cancer type in
women following breast cancer in the developing
countries worldwide (Addawe et al., 2018; Leyva et
al., 2006). Its estimated worldwide prevalence was
84% in 2012 (WHO, 2018). In the United States of
America, cervical cancer is also the leading cause of
deaths among women. However, there has been a
considerable decrease in the number of cases with
cervical cancer and the number of deaths caused by
cervical cancer for the last 40 years. This decrease is
associated with the fact that many women have pap
smear screening tests (CDC, 2018). In Turkey, on the
other hand, the prevalence of cervical cancer is
estimated to be approximately 4.5 in 100 thousand. It
is the 10th most prevalent cancer type (T.R. Ministry
of Health Public Health Institution of Turkey, 2017).
Cervical cancer is the most important type of
gynaecologic cancer that can be diagnosed early and
prevented with the screening test. It is highly treatable
and is associated with a high life quality (CDC, 2018).
In the protection, the pap smear test screening and
early diagnosis are among the secondary preventive
precautions (Cetin et al., 2014). The pap smear test is
a test based on collection and examination of the
cervical cells. (T.R. Ministry of Health Public Health
Institution of Turkey National Standards of Cervical
Cancer Screening Program). In the study conducted by
Sun et al., (2005) to examine the prevalence of the
cervical HPV in women with abnormal pap smear
results, it was determined that while 75% of them had
low-risk HPV types, 84% had high-risk HPV types
(Sun et al., 2005). In Turkey, national population-
based cervical cancer screenings are conducted by
Early Diagnosis, Screening and Training Centres for
Cancer (EDSTCC) within the body of Family Health
Centres (FHCs) and Community Health Centres
(CHCs). In the Screenings, it is aimed to repeat the
pap smear test in women aged between 30-65 years
every five years and interrupt the screenings in women
aged 65 years whose last two pap smear test results
are negative (T.R. Ministry of Health Public Health
Institution of Turkey National Standards of Cervical
Cancer Screening Program). ACOG recommends
performing the screenings along with the pap smear
test being applied every three years in women aged
21-29 years regardless of the type of cytology and the
screenings in women aged 30-65 years when the HPV
test is applied with cytology every five years (ACOG
cervical cancer screening, 2017; New screening
Guidelines for cervical cancer, 2012). In the study by
Kessler (2017), it was stated that the increase of risk in
cervical cancer cases was associated with the
countries’ lack of prevention and screening programs
for cervical cancer and access to treatment services
(Kessler, 2017). Healthcare professionals have an
important role in informing women about the
objective, frequency and importance of the pap smear
test and spreading health education (Akyuz et al.,
2006).
Low knowledge levels and wrong attitudes and beliefs
about the pap smear test cause women to develop
negative behaviours and attitudes regarding the
protection and development of health. In this case, it is
important to understand the perceptions, barriers,
decision making processes and behaviours of
individuals in relation to their health needs. For that
purpose, the Health Belief Model (HBM) is frequently
used (Bal, 2014). The model was developed by
Hochbaum, Kegeles, Leventhal and Rosenstock in
1950 for the purpose of explaining why some people
display health protection behaviours and others show
an inadequate participation in prevention and
screening programs (Aydogdu and Bahar, 2011;
Champion and Skinner, 2008). HBM components
assert that the relevant health behaviour will emerge if
individuals perceive the disease as a sensitivity for
themselves, believe in results concerning the severity
of the disease, are aware of both benefits and barriers
of the screenings and there are positive cues to action
(education, media, reminders of health control, and
sickness of a friend or a family member) in taking
action for the screenings. It is stated that the most
powerful separatrix of the model is the perceived
barriers (Champion and Skinner, 2008; Tuzcu and
Bahar, 2012). Beliefs about the reasons of the disease
may vary from person to person and may be affected
by a person’s culture, socio-economic condition,
educational level and personal experience about the
disease. Beliefs may considerably affect women’s
decision of taking protective precautions against
cervical cancer (Mcfarland, 2009). If beliefs and
attitudes are detected, more convenient health
education or treatment methods will be determined for
a particular person (Gozum and Capık, 2014).
In this sense, the aim of the study was to evaluate
women’s beliefs about having the pap smear test.
Material-method : The study was a descriptive study.
The population of the study consisted of women who
applied to gynaecology outpatient clinics of a public
hospital between April- June 2016. On the other hand,
the sample included 620 women who applied to
gynaecology outpatient clinics of a public hospital
between the same dates and agreed to participate in
the study. An ethics committee approval (Ethics
Committee no: 2016-09) from the Ethics Committee
of Usak University for the ethical convenience of the
study and an institutional permission from the public
hospital were obtained in order to collect the data. The
women who were voluntary to participated in the
study were informed about the study and their verbal
and written consents were received. The data were
collected using an information form which was
prepared by the researchers upon the literature review
and consisted of a total of 33 questions including 16
questions about women’s socio-demographic
characteristics, 9 questions about their conditions
International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 335
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concerning pregnancy and birth and 6 questions about
knowledge about cervical cancer and state of having
the pap smear test as well as “Health Belief Model
Scale” including attitudes and beliefs about cervical
cancer and the state of having the pap smear test. The
scale was developed by Champion for breast cancer
and mammography and adapted into Cervical Cancer
and Pap Smear Test (Champion, 1993). The Turkish
validity and reliability study of the scale was
conducted by Güvenc, Akyüz and Acıkel in 2010
(Guvenc et al., 2011). The scale consists of 35 items
as susceptibility (3 items), severity (7 items), pap
smear benefits and motivation (8 items), health
motivation (3 items), pap smear barriers (14 items)
and five subscales. The scale is evaluated using the 5-
point likert scale ranging from 1 to 5 – “strongly
disagree” (1), “disagree” (2), “neutral” (3), “agree”
(4), and “strongly agree” (5). Each subscale of the
scale is evaluated separately and cannot be combined
in only one total score. The scores are obtained as
much as the number of subscales for every individual.
High scores signify that susceptibility, regard, and
motivation increase, benefits are perceived highly for
the benefit perception, and barriers are perceived
highly for the barrier perception. Subscales except for
the subscale of barrier perception are positively
associated with the pap smear screening behaviour.
High score of an individual for barrier perception
signifies highness of barriers of having the pap smear
test. Before starting the data collection, the women
were informed about the purpose of the study. The
women who agreed to participate in the study filled in
the information form and the scale for approximately
30 min. The data were assessed and analysed in the
SPSS for Windows 16.0 statistical packaged software
using descriptive statistics (such as mean, number,
percentage), chi-square test, and Kruskal Wallis test.
Results
The age average of the women who participated in the
study was 37.66 years (SD: 9.43 Min: 19.00, Max:
59.00). Among the participants, 90.32% were married,
45.32% were primary school graduate, and 58.23%
were housewives. Among the study participants,
73.71% got married at the age of 18-24 years and
67.02% of them gave birth for the first time in the
same age range. 16.94% of the women in the study
group went through the menopause and majority of
these women (73.33%) were older than 45 years
(Table 1). Almost half of the women who participated
in the study had the pap smear test at least once. When
examining the correlation between the variables
examined in the study and the state of having the pap
smear test, it was determined that there was a
statistically significant difference between age,
menopause, pregnancy, miscarriage, abortion, parity,
number of children and the state of obtaining
information about cancer and the state of having the
pap smear test (Table 2). When examining the scores
of subscales of the Cervical Cancer (CC) and Pap
Smear Test Health Belief Model Scale in women; the
highest score was observed in the subscales of health
motivation, pap smear benefit/health motivation and
CC severity perception (Table 3). The correlation of
the scores obtained by the women from the subscales
of Cervical Cancer and Pap Smear Test Health Belief
Model Scale with the variables examined in the study
was examined. It was determined that the
susceptibility perception was only affected by the state
of having cervical cancer in family; whereas, the
severity perception was only affected by the state of
having miscarriage. It was found that the women who
had the history of cervical cancer in their family were
more susceptible than those who did not (F=.324;
p=.001) and the women who had miscarriage had
higher severity perceptions than those who did not
(F=1.409; p=.001) (Table 4).
Table 1: Demographic Characteristics of the Women (n: 620)
Age Group n %
15-21 years 20 3.23
22-28 years 126 20.32
29-35 years 208 33.55
36-42 years 172 27.74
43-49 years 94 15.16
Marital Status
Married 560 90.32
Widow 32 5.16
Divorced 28 4.52
Educational Background
Illiterate 19 3.06
Literate 44 7.10
Primary school 281 45.32
International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 336
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High school 153 24.68
University and higher education 123 19.84
Working Condition
Housewife 361 58.23
Employee/Retired 259 41.77
Income Status
Income less than expenditure 134 21.61
Income equal to expenditure 374 60.32
Income more than expenditure 112 18.06
Health Insurance
Available 556 89.68
N/A 64 10.32
Age of Marriage
13-17 years 69 11.13
18-24 years 457 73.71
25-29 years 85 13.71
30-35 years 9 1.45
Age of menarche
11 years and younger 48 7.74
12-14 years 482 77.74
15-20 years 90 14.52
Age of First Pregnancy*
14-17 years 32 5.64
18-24 years 380 67.02
25-34 years 150 26.46
35-37 years 5 0.88
Age of Menopause**
26-35 years 5 4.76
36-45 years 23 21.90
46-55 years 77 73.33
*Percentages were calculated over 567 people. ** Percentages were calculated over 105 people.
Table 2: Distribution of Women’s State of Having the Pap Smear Test According to Age Groups and
Some Other Characteristics (n: 306)
Variables The State of Having the Pap Smear Test
Yes No Chi-Square
p
n % n %
Age
15- 21 years 3 1.00 17 5.40
38.742
0.000
22- 28 years 39 12.70 87 27.70
29- 35 years 105 34.30 103 32.80
36- 42 years 106 34.70 66 21.00
43- 49 years 53 17.30 41 13.10
Menopause
Available 68 22.20 40 12.70 9.689
0.002
N/A 238 77.80 274 87.30
Conception
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Yes 290 94.80 277 88.20 8.517
0.004
No 16 5.20 37 11.80
Miscarriage
Yes 87 28.40 67 21.30 4.177
0.041
No 219 71.60 247 78.70
Abortion
Yes 61 19.90 44 14.00 3.863
0.049
No 245 80.10 270 86.00
Birth
Yes 287 93.80 272 86.60 8.973
0.003
No 19 6.20 42 13.40
Parity
N/A 19 6.20 42 13.40
19.521
0.001
1 58 19.00 77 24.50
2 146 47.70 111 35.40
3 66 21.60 56 17.80
> 4 17 5.60 28 8.90
Number of Children
N/A 19 6.20 43 13.70
18.435
0.001
1 57 18.60 78 24.80
2 153 50.00 116 36.90
3 61 19.90 56 17.80
> 4 16 5.20 21 6.70
Information about
Cancer
Yes 243 79.40 112 35.70 121.161
0.000
No 63 20.60 202 64.30
Table 3: Test Scores Obtained by the Women from the Subscales of Cervical Cancer and Pap Smear Test
Health Belief Model Scale
Subscales of the Scale The highest score of the scale
Mean Standard
Deviation
Minimum
Maximum
CC Susceptibility Perception 15 7.801613 2.373316 3.00 15.00
CC Severity Perception 35 24.38226 5.125628 7.00 35.00
Health Motivation 15 12.57097 1.973114 3.00 15.00
Pap smear Barrier Perception 70 35.31452 9.859241 14.00 70.00
Pap smear Benefit/Health
Motivation 40 29.61129 4.493636 8.00 40.00
In the study, it was determined that there was a statistically significant correlation between individuals’ state of menstruating
regularly, the state of getting information about cancer, state and frequency of having the pap smear test, age, educational
background, age of first pregnancy and income status and the pap smear barrier perception. The pap smear barrier
perceptions were higher in the participants who did not menstruate regularly (F=6.715; p=.027), had no information about
cancer (F=.002; p=.000), did not have the pap smear test (F=4.176; p=.000) or did not have the test regularly (F=.049;
p=.004) compared to the others. As the women’s educational levels increased, their pap smear barrier perceptions decreased
(F=12.299; p=.000). The pap smear barrier perception was higher especially in illiterate participants than all other
educational levels. The pap smear barrier perceptions also varied according to the women’s age of first pregnancy (F=3.224;
p=.022) and the barrier perceptions were higher in women who gave birth at the age of 18- 24 years than those who gave
birth at the age of 25- 34 years (p=.014). The pap smear barrier perceptions were higher in the participants who stated that
they had an income more than expenditure (F=5.045; p=.007) (Table 4).When comparing the test scores obtained by the
women from the subscales of Cervical Cancer and Pap Smear Test Health Belief Model Scale with some variables, it was
determined that there was a significant correlation between many variables (Table 4).
International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 338
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Table 4: Comparing the Test Scores Obtained by the Women from the Subscales of Cervical Cancer and Pap Smear Test Health Belief Model Scale with
Some Variables
Variables
Subscales of the Scales
Susceptibility Severity Perception PapSmear Barrier
Perception Health Motivation PapSmear Benefit/Health
Motivation
Mean ±
SD F
p Mean ± SD
F
p Mean ± SD F
p Mean ±
SD U
p Mean ± SD U
p
Health Insurance
Yes 7.76 ±
2.39 1.547
.170
24.35 ±
5.17 0.325
.689
35.06 ± 9.97 2.167
.054
12.63 ±
1.90 15684.0
.111
29.90 ± 4.40 11584.5
.000
No 8.19 ±
2.16 24.63 ±
4.78 37.56 ± 8.55 12.06 ±
2.46 27.09 ± 4.52
Miscarriage
Yes 7.81 ±
2.50 1.200
.953
23.15 ±
5.19 1.409
.001
35.63 ± 8.99 4.386
.627
12.23 ±
1.94 29936.0
.002
29.02 ± 4.03 31736.0
.031
No 7.80 ±
2.33 24.79 ±
5.04 35.21 ± 10.14
12.68 ±
1.97 29.81 ± 4.62
The state of obtaining information
about cancer
Yes 7.83 ±
2.46 2.077
.722
24.19 ±
5.21 1.603
.277
32.59 ± 9.54 .002
.000
12.88 ±
1.68 37944.0
.000
30.75 ± 4.15 30059.5
.000
No 7.76 ±
2.25 24.64 ±
5.00 38.97 ± 9.09 12.15 ±
2.24 28.09 ± 4.50
The State of having PapSmear Test
Yes 7.85 ±
2.46 .950
.643
24.09 ±
5.38 3.598
.154
31.67 ± 8.84 4.176
.000
12.82 ±
1.86 40908.0
.001
30.77 ± 4.47 32468.5
.000
No 7.76 ±
2.29 24.67 ±
4.86 38.87 ± 9.51 12.33 ±
2.05 28.48 ± 4.23
Age group
14- 17 years 8.00 ±
2.09 .421
.738
23.38 ±
4.67 .928
.427 36.13 ± 8.19 3.224
.022
12.15 ±
3.47 16.366
.003 27.25 ± 5.95 16.094*
.003
18-24 years 7.73 ± 24.60 ± 36.20 ± 9.92 12.80 ± 28.60 ± 4.57
International Journal of Caring Sciences January – April 2020 Volume 13 | Issue 1| Page 339
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2.45 5.07 2.17
25-34 years 7.96 ±
2.28 24.11 ±
5.25 33.29 ± 10.10
12.69 ±
1.59 30.26 ± 4.66
35-37 years 7.80 ±
2.38 25.80 ±
2.28 33.60 ± 5.94 12.33 ±
1.42 29.61 ± 3.71
Educational Background
Illiterate 8.47 ±
2.27
1.007
.403
24.42 ±
3.61
.296
.881
45.26 ± 6.72
12.299
.000
11.42 ±
1.12
53.985
.000
27.26 ± 3.14
41.843*
.000
Literate 7.32 ±
2.79 23.72 ±
5.04 38.68 ± 9.08 12.11 ±
1.34 27.84 ± 3.93
Primary school 7.74 ±
2.31 24.52 ±
5.13 36.37 ± 9.08 12.36 ±
1.97 29.29 ± 4.27
High School 7.89 ±
2.35 24.49 ±
5.12 33.98 ± 10.44
12.59 ±
2.15 29.48 ± 4.86
University and higher education
7.91 ±
2.40 24.17 ±
5.39 31.83 ± 9.86 13.37 ±
1.77 31.51 ± 4.49
Age of Marriage
13-17 years 8.04 ±
2.53
.648
.585
24.01 ±
5.96
.851
.467
36.49 ± 9.09
.721
.540
11.87 ±
2.46
11.118
.011
27.85 ± 5.05
16.378*
.001
18-24 years 7.74 ±
2.35 24.57 ±
4.87 35.34 ± 9.63 12.63 ±
1.86 29.62 ± 4.29
25-29 years 7.84 ±
2.38 23.71 ±
5.64 34.16 ± 11.86
12.71 ±
2.06 30.84 ± 4.78
30-35 years 8.56 ±
2.19 23.89 ±
5.99 35.78 ± 9.86 12.57 ±
1.97 29.61 ± 4.49
Age of First Pregnancy
14-17 years 8.00 ±
2.09
.421
.738
23.38 ±
4.67
.928
.427
36.13 ± 8.19
3.224
0.022
11.87 ±
2.46
20.397
.000
27.86 ± 5.05
22.085*
.000
18-24 years 7.73 ±
2.45 24.60 ±
5.07 36.20 ± 9.92 12.63 ±
1.86 29.62 ± 4.29
25-34 years 7.96 ±
2.28 24.11 ±
5.25 33.29 ± 10.10
12.71 ±
2.06 30.83 ± 4.78
35-37 years 7.80 ±
2.38 25.80 ±
2.28 33.60 ± 9.92 13.56 ±
1.24 31.00 ± 4.49
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Income status
Income less than expenditure 7.98 ±
2.26 .530
.589
25.04 ±
4.47 1.398
.248
37.69 ± 9.03
5.045
.007
12.39 ±
1.68 12.211
.002
28.78 ± 3.99
28.599*
.000
Income equal to expenditure 7.73 ±
2.45 24.20 ±
5.24 34.65 ± 10.08
12.49 ±
2.07 29.34 ± 4.50
Income more than expenditure 7.82 ±
2.26 24.21 ±
5.44 34.70 ± 9.71 13.04 ±
1.93 31.52 ± 4.49
*Kruskal Wallis Test
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Discussion
Papanicolau (pap) test is a reliable test for early
diagnosis of cervical cancer and plays a vital role
in preventing and reducing the deaths caused by
cancer (Gumus and Cam, 2011). In the study,
almost half of the women had the pap smear test
for at least once. In similar studies conducted in
different groups and regions in Turkey, these
rates are around 29%, 30%, 34%, 51% and 52%,
which shows a parallelism with the study (Akyuz
et al., 2006; Bal, 2014; Esin et al.,2011; Duman
et al., 2015; Gokgoz and Aktas, 2016). The
results indicate that the rates of having the pap
smear test in Turkey are not at desired level, yet.
Behaviours of having the pap smear test vary
according to women’s age, education, race,
socio-economic condition and cultural
characteristics (Juon et al., 2006). As a matter of
fact, in the study, it was also determined that
there was a statistically significant difference
between age, menopause, pregnancy,
miscarriage, abortion, parity, number of children
and the state of obtaining information about
cancer and the state of having the pap smear.
Health motivation is a component of Health
Belief Model which shows the general intention
and desire of forming behaviours in the health
maintenance and promotion (Bal, 2014). In the
study, when the scores obtained by the women
from the subscales of Cervical Cancer and Pap
Smear Test Health Belief Model Scale were
examined, it was determined that the highest
scores were obtained in the subscales of health
motivation, pap smear benefit/health motivation
and CC severity perception. In the study, as the
educational level increased, individuals’ health
motivation increased. Similar results were
determined in studies (Bal, 2014; Gokgoz and
Aktas, 2016).
Barriers perceived by women concerning the pap
smear test were reported as lower health
perception, lack of health insurance, fear of
cancer, transportation insufficiency, remoteness
of health institution, lack of information about
cancer and early diagnosis, culture and traditional
practices (Addawe et al., 2018; Aydogdu and
Bahar, 2011; Markovic et al., 2005; Wong et al.,
2009). In the study, it was determined that there
was a statistically significant difference between
women’s state of menstruating regularly, the state
of getting information about cancer, the state and
frequency of having the pap smear test, age,
educational background, age of first pregnancy
and income status and the pap smear barrier
perception. The results of the study support the
literature.
Conclusion and suggestions
As a result of the study, it was found that
women’s rates of having the pap smear test were
not at desired level, yet. It was determined that
there was a significant correlation between the
state of having the pap smear test and several
variables and it was concluded that low pap
smear benefit/health motivation perception
significantly affecting the state of having the pap
smear test was common especially among
women with low educational and income levels.
It is recommended to increase the information
and susceptibilities of women concerning
cervical cancer and pap smear test screening with
repetitive trainings and media support.
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