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Reducing women's fears and anxieties about smear tests

Gayle Allen
Practice Nurse
Waterfield Practice
Bracknell, Berks

Each year it is estimated that over 2,000 women die in the UK from cervical cancer.(2) These statistics may indicate inadequate testing methods, or an overall increase of cervical cancer in society. However, one of the main reasons for the high number of cervical cancer cases is women not attending for a cervical smear test.(3)
Research shows that the two main reasons for noncompliance with the cervical screening programme are increased anxiety and a lack of knowledge about the procedure.(1-5) This article explores the factors that influence women's anxiety about the smear test, and discusses techniques that can be used by the nurse to ensure that these fears and misapprehensions are significantly reduced. Published research predominately focuses on environmental, educational and personal factors that influence the amount of anxiety about the smear test. Therefore these factors will also be analysed.

Reducing anxiety over the smear test

The smear test involves a very intimate examination that most woman find uncomfortable.(6) One factor that can affect the nurse-client communication is the setting for the test. It is therefore very important to create an environment within which the client feels comfortable and safe.(7)
To reduce anxiety, the room used for the procedure must be clean, quiet and private.(2) To create privacy during the consultation, and with the patient's consent, the door should be locked, a screen provided for the client to undress behind, and the telephone left unanswered (or switched off during the consultation). Face-to-face contact without physical barriers (such as furniture) is very important, as physical barriers can have the effect of distancing the interviewer and thus creating a hostile environment.(8) Efficiency also decreases anxiety levels, and hence all necessary equipment should be prepared for use before the test begins.(1)

Communication and education
Positive nonverbal communication skills such as maintaining eye contact, appropriate smiling, a relaxed open posture, equal seating status, a professional appearance, comfortable close proximity, moderate tone of voice and rate of speech are all important when reducing anxiety levels.(9,10) To gain a necessary and complete account of the client's menstrual and sexual health, the nurse should use open questions, listen and empathise with the patient. To ensure that effective communication has taken place, the nurse should clarify and explain the procedure in simple terms throughout the smear, giving reassurance wherever necessary.(10)
A women's level of anxiety over smear examinations tends to be influenced by her educational background,(11) which highlights the importance of the client being given appropriate information so they can give their "informed" consent for the procedure or treatment to take place.(12) This informed consent is crucial - studies have found that women believe that a greater amount of information, both in spoken and written form, would have significantly reduced their anxiety levels before and after their cervical screening test.(3,13)
From these findings it could be proposed that the nurse is responsible for educating women about cervical cancer, the smear test and what the results mean. Nonetheless, one piece of conducted research demonstrates how little patients are informed about cervical screening and its implications.(14)
Several studies have found that the main reason that women give for not having a smear is their fear of the test showing cancer and their inability to understand the term "precancer".(3,15) Misconceptions, such as the belief that a positive smear test is caused by promiscuous behaviour and therefore carries the same stigma as a sexually transmitted infection, have also prevented women from participating in the smear test and increased their anxiety about the result.(16) The challenge is to get the message across that only rarely does a positive screening test mean significant disease - the majority of the time, the test just triggers a routine recall.(17)
Educational aids such as leaflets and videos can be provided for the client to use in their own time. These aids should be clear, concise and relevant, to ensure that they do not confuse the client and possibly increase their anxiety.(18) Furthermore, it must be recognised that these aids should not be used as a substitute for one-to-one sessions with the client, ensuring that any relevant questions or concerns can be addressed.(19) The nurse must also ensure that s/he is aware of the content of these aids and be competent in answering any questions.(17)

Inadequate results
Inadequate smear results that could have been avoided are another cause of anxiety in women.(20) This further stresses the importance of nurses receiving appropriate training to carry out the procedure. Inadequate smears can occur due to several factors, such as problems in locating the cervix and infections present at the time that may hide the necessary cells. However, some of the reasons are due to the practitioner's inadequate technique, for example using the incorrect speculum, spatula and method to fix the cells onto the slide for adequate examination in the labs. The sample must also be taken during the middle of the women's menstrual cycle to ensure that hormonal changes do not affect or obscure the view of the cells that need to be examined.(21)
Nurses are accountable practitioners and must acknowledge their limitations by carrying out activities only if they are competent.(12) The nurse's tuition should include a recognised course and assessment by a qualified professional. It is very important for the nurse to regularly update this knowledge by attending suitable study days.

Liquid-based cytology
Liquid-based cytology offers a new way to prepare the smear sample for examination. With this technique, a special spatula device gently brushes cells from the neck of the cervix, causing the cells to lodge themselves at the head of the spatula. The head of the spatula is then broken off into a small tube containing preservative fluid, which is sent to the laboratory. The laboratories mix and treat the sample to remove unwanted material and therefore improve the quality and appearance of the necessary cells. A thin layer of the resulting cell suspension is deposited onto a slide for the usual examining technique.
Research suggests that liquid-based cytology could provide significant benefits in reducing inadequate smear tests and therefore will be the future technique used in the cytology screening programme.(22)

"Health Belief Model"
The "Health Belief Model" looks at health-related behaviour that could also influence individual compliance with the cervical screening programme. The concept of "health" can be referred to as the "locus of control", which is defined as the level at which each person believes his or her own life and health is under their own control.(23) Research suggests that those who take responsibility for their own health are more likely to comply with preventive health screening programmes. Equally, those who believe that fate and chance have control of their health, and give the responsibility to health professionals, show less compliance with such schemes.(15) Furthermore, social groups classed under IV and V (the lower socioeconomic classes) are more likely to disassociate themselves from the responsibility for their own health and to fail to have regular smears.(24)

Due to the intrusive nature of the smear test procedure, embarrassment is often cited as a reason for noncompliance with the system.(25) Many women are reluctant to show a stranger a very private and personal area of their body, and this is particularly prevalent in certain ethnic and religious groups. The nurse must be sensitive to these issues and treat each client as an individual, respecting all their beliefs and anxieties. It is also important that women who have any problems or cultural issues with the test itself are followed up if they do not respond to a smear invitation.

The first-time experience and past history
A woman's first-ever smear examination is critical to how they will react to further necessary examinations throughout their life. In addition, previous bad experiences of the smear test, childbirth, gynaecological problems and sexual difficulties can all have a psychological impact on women.(11) A smear test also provides an ideal opportunity for the nurse to discuss any sexual problems and recognise any sexual abuse.

Time and energy
The roles that women play in society - as mothers, wives and employees, for example - all affect the amount of time available to attend for a smear appointment. Researchers have found that women place very little emphasis on their own health, and give their time and priority to their children's health.(14) Inaccessibility of the surgery and a lack of facilities such as a crèche may all affect compliance.(26) Flexible opening times and more and better facilities could increase attendance to smear invitations.

Clients with disabilities
Facilities should also be available for those clients with physical disabilities: for example, the nurse may require assistance and additional appointment times. This will reduce anxiety by ensuring that the patient can be held in a comfortable manner and the procedure is not rushed.
Evidence exists that cervical smears are rarely offered to women with learning disabilities.(27) A study carried out on 389 women with learning disabilities found that coverage of the screening programme in these women was markedly lower than for the general district population.(28)
In the general population, cervical cancer is mainly related to sexual activity; assumptions, however, that people with learning disabilities are sexually inactive may be wrong. Consequently, these women should be invited for a smear test, and if they are unable to attend the surgery a domiciliary service to the patient's home should be considered.

Anxiety is responsible for reduced uptake of the cervical screening programme. It is evident that anxiety can be caused by a hostile environment, lack of communication, lack of understanding and psychological fears. To increase compliance with the smear test, the author believes that health professionals who carry out smear screening should adjust their practice to incorporate education, counselling and appropriate communication skills. Furthermore, the improvement of facilities and accessibility to the surgeries should be addressed to ensure that women can receive the best possible preventive care from this ever-increasing disease.

Practice pointers

  • Practice nurses have a huge ­influence over compliance with the cervical screening programme and must ensure that they provide the most comfortable and informative ­environment for every woman attending for a smear test
  • Surgeries should ensure that they invite all women within the specified age ranges for a ­cervical smear, including those with learning disabilities and those unable to get to the surgery
  • Surgery ­opening times should be adjusted to meet the needs of all women
  • Nurses must ensure that they are adequately trained in cytology
  • The nurse must ensure that the smear is as comfortable as possible for the client, to ­encourage their return for ­necessary recalls and ultimately to reduce the ­incidence of ­cervical cancer



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