Table 2: Distribution of FHW sbased on their Last Pelvic Examination or Pap Smear Screening Test Experience.

The distribution of FHWs based on their latest pelvic examination experience reveals that while 48.3% of FHWs underwent pelvic examination, 51.7% have never had a pelvic examination; among the examined FHWs 48.8% had the pelvic examination for pregnancy- and birth-related purposes and33.8% were diagnosed with normal findings; 80.6 % between the unexamined participants stated that they did not feel the need for pelvic examination and 10.6% were sexually passive as summarized in Table 2.

The distribution of FHWs based on their latest pap smear screening test indicates that 19.5% of FHWs had pap smear screening test, 80.5% have never had the test before; among the screened FHWs 36.8% had the test when requested by their doctor, 44.3% stated that they had been screened with the sole reason that such procedure had been requested by their doctor; 68.6% of the FHWs were diagnosed with normal findings while 19.5% were diagnosed with urinary tract infection, 58.5%between the unscreened FHWs stated that they did not feel the need for having Pap smear screening test and 22.6%were sexually passive as summarized in Table 2. In addition, 77.3 % of the participants declare that they do not advise people about cervical cancer; 22.7 % state that they instruct others on cervical cancer of which while 52.9 % inform public and patients, 21.2% inform relatives and acquaintances.

Table 3: The Distribution of FHWs based on their Pap Smear Screening Status according to their Demographic Characteristics and Knowledge Transfer Status on Cervical Cancer.

A significant statistical difference was found between Pap smear screening status and of FHWs in terms of their age, occupation and marital status (p<0.05).

A significant statistical difference was found between knowledge transfer status of FHWs about cervical cancer in terms of their age, occupation and marital status (p<0.05).

Table 4: The Distribution of FHWs based on their Responses to Knowledge Statements on the Risk factors for Cervical Cancer, Pap Smear Screening and HPV.

5. Discussion

While the three highest rates of correct responses to the knowledge statements on the risk factors of cervical cancer, Pap smear screening and HPV by FHWs were “Early diagnosis and treatment of cervical cancer is possible”(92.9%), “Gynecological examination shall only be performed when a gynecological problem occurs” (87.3%) and “Every sexually active woman must have pap smear testing” (83.5 %), the lowest rate of correct response was obtained on the statement “HPV causes pain during sexual intercourse” (7.6%).

The most significant characteristics of cervical cancer are that it is preventable and has good prognosis when diagnosed early. Therefore, if and to what extent cervical cancer and pap smear test are known and up taken by the public pose an important health problem [6, 8, 19].

The awareness of the risk factors that cause cancer is important for taking precautions to avoid the cervical cancer. In this respect, health awareness must be raised among all women especially among the ones who are under risk [20,21]. The studies in the literature indicate that the opinions of women about gynecological examination affect their attitude towards having gynecological examination and Pap smear screening test [18, 22]. The study by Gülen shows that one-third of the midwives and nurses (33.2 %) have never had gynecological examination and that a large portion of those who have been examined had the test only when they are obliged to so in cases such as pregnancy (46.1 %) and RIA (43.6 %). A similar study also shows that women are shy about having gynecological examination and do not have periodic health check-ups in healthcare institutes unless they suffer from a health problem [22,23]. In our study, 51.7 % of FHWs have never had pelvic examination and almost half of those who have been examined (48.4%) had the test due to pregnancy- and birth-related issues and bleeding and menstrual irregularities (17.2 %). The fact that only 10.2 % of FHWs have had pelvic examination for regular health check-ups (Table 2) and majority of them did not feel the need to be examined because they did not have any health problems (Table 3) evokes the idea that health-protective approaches are inadequate and FHWs may not represent a role model for women. It is well known that in our country, women do not have routine health check-ups for protecting or preserving their health [6,17]. Our study indicates that, despite being a healthcare worker, the percentage of them having a pelvic examination is lower (10.2 %) compared to the other studies in the literature. Therefore, they do not pay attention to protect or enhance their own health and may not be considered as a role model.

Gynecological problems are known to increase with age [14,19, 24]. In our study, almost half of the participants (45.4 %) who have never had pelvic examination are in the age range of 25-29 years old. This means that, despite their advanced age, the other half have not undergone a pelvic examination which poses a risk for their health. In addition, both our study and a similar study in the literature indicate that the percentage of FHWs having gynecological examination increases with advancing educational level [11,17,18]. In terms of their marital status, while a large portion of married FHWs had undergone pelvic examination with a percentage of 84.1, 71.3 % of single women have never had pelvic examination. Thus, one may conclude that single FHWs overlooks to the fact that pelvic examination may also be performed without vaginal examination.

In Europe, the mortality rate related to cervical cancer is reduced gradually thanks to the effective screening programs. In fact, the disease can be diagnosed at an early stage via the Pap smear screening [2,25,26] In a study, 51.3 % of women were found to have undergone pap smear screening and this percentage increases proportionally with age, marriage duration, number of births, knowledge level on Pap smear screening and perception of cervical cancer risk factors [17]. The relevant studies in the literature indicate that, opinions of women about gynecological examination affect their attitudes towards having gynecological examination and pap smear screening [22,27,28,29]. While 85 % of the women living in developed countries such as USA have undergone pap smear screening test at least once in their lifetime, in less developed countries it is only 5% [2,11,16,30,31]. In our study, 80.5 % of the women have never had the Pap smear screening before. The fact that the majority of healthcare professionals have never undergone Pap smear screening test is an important significant finding in terms of cervical cancer screening. As almost half of the FHWs have undergone Pap smear screening test upon doctor's request and one-fourth of them have had the test for screening purposes, this practice may be considered to be insufficient. Even though the ratio of the screened FHWs may 

seem high, it actually is insufficient as they are healthcare professionals. Thus, one may conclude that the FHWs are not sensitive about the importance of screening and early diagnosis.

Even though cancer can be identified at an early stage via periodic examination and the pap smear screening, relevant studies show that, FHWs are able to point out neither the group of women that should have Pap smear screening nor the frequency of the screening. This finding indicates that healthcare professionals are not extensively informed on the importance of the issue [29,32].

It is rather striking that approximately one-fifth of FHWs were diagnosed with infection. Because untreated long-term infections are significant risk factors for cervical cancer [12]. Raising awareness of FHWs on pap smear screening test is of great importance to ensure early diagnosis and treatment through examining genital infections before the onset of serious illness such as cervical cancer. 58.8 % of FHWs report that “the reason for them not to be screened is that they did not feel the need for having Pap smear screening test since they did not have any health problems”. The fact that FHWs have not been screened just because they did not feel the need for it might be interpreted as they did not develop the necessary skills to take on self-care responsibility and that they only have had Pap smear screening when they have a complaint may be explained as they perceive it as a diagnostic test only. In similar studies, the women expressed that they have not undergone Pap smear screening because they did not feel under risk, were unaware of symptoms of the disease, had a fear for vaginal examination, were embarrassed, had pain, did not have sufficient interest, perceived discomfort during the test and were not in the at-risk age group [22,29].

Protection against risk factors that may cause cervical cancer is essential in preventing it and this is only possible if one is knowledgeable on the issue [4,13,14]. In a study, awareness of cervical cancer and Pap smear screening is found to increase the rate of being screened [20]. In another study, women are found to be more knowledgeable on HPV and cervical cancer if they have undergone Pap smear screening [30]. Therefore, FHWs have an essential role in raising awareness among women. In our study, we find that 77.3% of FHWs did not acknowledge others and half of those did provide information only to patients and public. This finding might arouse the idea that healthcare professionals are not fulfilling their educational role to a sufficient extent. In similar studies this can be explained with the fact that healthcare professionals and especially midwives and nurses do not comprehend their role to deliver health education, which is of great importance in early diagnosis, or that their institutions have no expectations from them in this regard [18,29,31].

The present study indicates that the percentage of FHWs having Pap smear screening increases with age and advancing education level. In a similar research, the group of participants who received in-service training (IST) has a higher percentage of undergoing Pap smear screening (58.4 %) than that of the group of participants who are not given IST (35.7 %) [11,29,32]. When the status of FHWs to have Pap smear screening test based on their professions is analyzed, doctors and midwives-nurses are expected to be different in this context compared to the other two groups. As technicians and dieticians-physiotherapists-biologists-pharmacists are also healthcare professionals, their low percentages on undergoing Pap smear screening leads to the impression that they definitely need to have in-service training (IST). In a study conducted among health department students, 87 % stated that they had never undergone Pap smear screening and did not consider themselves to be under risk [29]. It has been found that almost half of the population have never had Pap smear screening when the results are reviewed according to the marital status of FHWs. Pap smear screening should definitely be performed as a part of pelvic examination within three years following the first sexual intercourse as is done in developed countries [18-20,24,33].

The status of FHWs on informing others about cervical cancer increases with advancing education. In a similar study it has been found that the knowledge level of women about cervical cancer, risk factors and HPV vaccination also increases with advancing education. It is both important and necessary to instruct women, who are responsible for protecting their own health and the health of family members, about the aforementioned topics to ensure a more conscious and a healthy future generation [17,30,34,35,36].

According to the form with 34 knowledge statements on the Risk factors for Cervical Cancer, Pap Smear Screening and HPV (Table 4) the proportion of correct answers on Risk factors for Cervical Cancer and Pap Smear Screening was found to be higher compared to the ones on HPV. Therefore, one may conclude that comprehensive and well-planned trainings on the risk factors for cervical cancer and Pap smear screening and in particular on HPV are necessary in order to raise awareness of FHWs and to strengthen their perception about the significance of this issue.

6. Conclusion

In our study we found that the knowledge of FHWs on risk factors for cervical cancer, Pap smear screening and HPV is insufficient and that the percentage of them having pelvic examination and Pap smear screening is quite low. It is recommended that the content of the occupational training should be modified and extended (especially for technicians) to cover both theoretical information and practices necessary to meet the demands on pelvic examination and Pap smear screening. In addition, for more detailed information on these subjects, IST may be given. Moreover, FHWs were identified not to be proficient in informing others and in health education. Therefore, it is proposed that the importance of the role of healthcare professionals in health education should be explained to them and health education should be made more widespread. As the nurses are easily accessible within the healthcare team and they are responsible mainly of instructing others, they are suggested to be more active and to function as role models in this context. It is also proposed that risk groups should be identified through country-wide cervical cancer screenings, protective measures should be taken and that diagnosis and treatment modalities should be explained in detail.