Document Type : Original Article


1 Department of Public Health, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Department of Health Promotion and Education, School of Health, Alborz University of Medical Sciences, Alborz, Iran


BACKGROUND: The cancer is uncontrolled growth and spread of cells that affect almost all parts of
the body. One of the most prevalent cancers in the female genital system is cervical cancer. The aim
of present study was to determine the effect of educational intervention using the Precaution Adoption
Process Model (PAPM) on cervical cancer screening behavior (Pap smear test) among women.
MATERIALS AND METHODS: In this interventional study that was done in Karaj health centers (2016),
women (aged 15‑49 years) were in the third stage of behavior change process based on PAPM
randomly assigned to experimental and control groups. The data collection tool was a PAPM‑based
questionnaire whose validity and reliability were confirmed. Gathered data were analyzed using
statistical software SPSS 16 and statistical tests (t‑test, repeated measures analysis of variance,
and Wilcoxon, Chi‑squared, Fisher’s exact, and Mann‑Whitney tests).
RESULTS: The result showed that the stages of the decision‑making process between the two groups
were significantly different at the time immediately and 2 months after the intervention (P > 0.001). Also
the results of the intervention based on the health belief model health belief model (HBM) components,
regarding variables of knowledge, perceived susceptibility, perceived benefits, perceived barriers,
and subjective norms, the mean scores in the experimental group were significantly different between
the three sections before, immediately, and 2 months after the intervention (P > 0.001).
CONCLUSIONS: This study provides hints how persons could be influenced to move from the
“Deciding about action” positions into to the stages of decided to act, adoption, and maintenance
for promoting cervical cancer screening behavior.


1. World Health Organization. Cancer 2014. Available from: http://
2. Novak ER, GS Jones H. Novak’s Textbook of Gynaecology. 13th ed.
USA: Williams & Wilkins; 1965.
3. Rakhshanderou S, Maghsoudloo M, Safari-Moradabadi A,
Ghaffari M. Theoretically designed interventions for colorectal
cancer prevention: A case of the health belief model. BMC Medical
Education. 2020;20(1):1-8.
4. Mohebbi B, Tol A, Shakibazadeh E, Yaseri M, Sabouri M,
Agide FD. Testing psychometrics of healthcare empowerment
questionnaires (HCEQ) among Iranian reproductive age women:
Persian version. Ethiopian J Health Sci 2018;28:341-6.
5. Karimi N, Saadat-Gharin S, Tol A, Sadeghi R, Yaseri M,
Mohebbi B. A problem-based learning health literacy intervention
program on improving health-promoting behaviors among girl
students. J Educ Health Promot 2019;8:251.
6. Musa J, Achenbach CJ, O’Dwyer LC, Evans CT, McHugh M,
Hou L, et al. Effect of cervical cancer education and provider
recommendation for screening on screening rates: A systematic
review and meta-analysis. PloS One 2017;12:e0183924.
7. Krivak THC MJ, Elkas JC. Cervical and vaginal cancer. In: Berek JS,
editor. Novak’s Gynecology. 13th ed. Philadelphia: Williams and
Wilkins; 2002.
8. Gibbs RS KB, Haney AF, Nygaard IE. Danforth’s Obstetrics and
Gynecology. 10th ed. USA: Lippincott Williams & Wilkins; 2008.
9. Asgary R, Cole H, Adongo P, Nwameme A, Maya E,
Adu-Amankwah A, et al. Acceptability and implementation
challenges of smartphone-based training of community health
nurses for visual inspection with acetic acid in Ghana: mHealth
and cervical cancer screening. BMJ Open 2019;9:e030528.
10. Azizi F, Hatami H, Janghorbani M. Epidemiology and Control of
Common Diseases in Iran. Tehran: Eshtiagh Publications; 2013.
p. 602-16.
11. Safari-Moradabadi A, Alavi A, Eftekhaari TE, Dadipoor S. The
reproductive behavior of families with Thalassemic children in
Hormozgan. Journal of reproduction & infertility. 2015;16(3):167.
12. Dadipoor S, Moradabadi A, Esmaeelion F, Eftekhaari TE, Alavi A,
Fallahi S, et al. Prevalence of legal abortions and correlated causes
in a central women’s hospital in south of Iran (2009-2012). Life
Sci J. 2013;10(12s):91-4
13. Keshavarzian K, Barzegari Z. The knowledge of Herisian female
about the cervical cancer and pap smear in. Med J Tabriz Univ
Med Sci Health Serv 2014;36:70-3.
14. Enjezab B, Mojahed S, Bokaee M. Barriers and motivators related
to cervical and breast cancer screening. J Shahid Sadoughi Univ
Med Sci 2004;12:78-84.
15. Green LW. Health education models. Behavioral Health:
A Handbook of Health Enhancement and Disease Prevention.
John Wiley & Sons, New York, 1984. p. 181-98.
16. Saffari M, Shojaeizadeh D, Ghofranipour F, Heidarnia A, A
Pakpour. Health Education and Promotion Theories and Models.
Tehran: Sobhan Press; 2012.
17. Glanz K, Rimer BK, Viswanath K. Health Behavior and Health
Education: Theory, Research, and Practice. John Wiley & Sons;
San Francisco, 2008.
18. Anderson CA. Abstract and concrete data in the perseverance
of social theories: When weak data lead to unshakeable beliefs.
J Exp Soc Psychol 1983;19:93-108.
19. BrocknerJ, Rubin JZ. Entrapment in Escalating Conflicts: A Social
Psychological Analysis. Springer Science & Business Media;
Cambridge University Press, 2012.
20. NisbettRE, Ross L. Human Inference: Strategies and Shortcomings
of Social Judgment. Englewood Cliffs, NJ, USA: Prentice-Hall;
21. Weinstein ND, Sandman PM. The Precaution Adoption Process
Model and Its Application. San Francisco: Jossey-Bass; 2002.
p. 16-39.
22. Clemow L, Costanza ME, Haddad WP, Luckmann R, White MJ,
Klaus D, et al. Underutilizers of mammography screening today:
Characteristics of women planning, undecided about, and not
planning a mammogram. Ann Behav Med 2000;22:80-8.
23. Costanza ME, Luckmann R, Stoddard AM, Avrunin JS, White MJ,
Stark JR, et al. Applying a stage model of behavior change to colon
cancer screening. Prev Med 2005;41:707-19.
24. Glanz K, Steffen AD, Taglialatela LA. Effects of colon cancer
risk counseling for first-degree relatives. Cancer Epidemiol
Biomarkers Prev 2007;16:1485-91.
25. Bahmani A, Baghianimoghadam MH, Enjezab B ,
Mahmoodabad SSM, Askarshahi M. Factors affecting cervical
cancer screening behaviors based on the precaution adoption
process model: A qualitative study. Glob J Health Sci 2016;8:211.
26. Weinstein ND, Sandman PM. A model of the precaution adoption
process: Evidence from home radon testing. Health Psychol
27. Weinstein ND, Sandman PM. The precaution adoption process
model and its application. Emerging Theories in Health
Promotion Practice and Research. San Francisco: Jossey-Bass;
2002. p. 16-39.
28. Dadipoor S, Mehraban M, Ziapour A, Safari-Moradabadi A.
Causes of maternal ortality in Iran: a systematic review.
International journal of pediatrics. 2017;5(12):6757-5770.
29. Fang CY, Ma GX, Tan Y, Chi N. A multifaceted intervention to
increase cervical cancer screening among underserved Korean
women. Cancer Epidemiol Biomarkers Prev 2007;16:1298-302.
30. Delara M, Ghofranipour F, Azad Fallah P, Tavafian S,
Kazemnejad A. Premenstrual syndrome: Reliability and validity
of a new developed diagnostic criteria in a sample of Iranian
adolescents. J Res Med Sci 2013;3:55-62.
31. Hazavehei S, Sharifirad G, Mohabi S. The effect of educational
program based on health belief model on diabetic foot care. Int J
Diabetes Dev Ctries 2007;27:18-23.
32. Sabouri M, Shakibazadeh E, Mohebbi B, Tol A, Yaseri M, Babaee S.
Effectiveness of an educational intervention using theory of
planned behavior on health care empowerment among married
reproductive-age women: A randomized controlled trial. J Educ
Health Promot 2020;9:293. doi: 10.4103/jehp.jehp_751_20.
33. Dignan M, Michielutte R, Blinson K, Wells HB, Case LD, Sharp P,
et al. Effectiveness of health education to increase screening for
cervical cancer among eastern-band Cherokee Indian women in
North Carolina. J Natl Cancer Inst 1996;88:1670-6.34. Karimy M, Gallali M, Niknami S, Aminshokravi F, Tavafian S.
The effect of health education program based on Health Belief
Model on the performance of Pap smear test among women
referring to health care centers in Zarandieh. J Jahrom Univ Med
Sci 2012;10:53-9.
35. Austin LT, Ahmad F, McNally M-J, Stewart DE. Breast and
cervical cancer screening in Hispanic women: A literature
review using the health belief model. Womens Health Issues
36. Asgharnia M, Mirbolouk F, Oudi M, Shakiba M, GhaforiPoor B.
Frequency of pap smears test and attitude about it among post
partum women referred to Alzahra hospital in Rasht (2009).
J Health 2010;1:57-65.
37. Park S, Chang S, Chung C. Effects of a cognition‐emotion focused
program to increase public participation in Papanicolaou smear
screening. Public Health Nurs 2005;22:289-98.
38. Yakhforoushha A, Solhi A, Ebadiaza F. The effect of health
education via health belief model on knowledge and attitude of
healthy voluntaries about pap smear in urban centers Gazvin.
J Nurs Midwifery Sci 2008;18:24-31.
39. Pirzadeh A. The effect of health education based on health belief
model on performance of women regarding Pap smear test in
Kouhdasht health centers in 2010. J Health Syst Res 2010;6:356-72.
40. Mandelblatt JS, Yabroff K. Breast and cervical cancer screening
for older women: Recommendations and challenges for the
21st century. J Am Med Womens Assoc (1972) 2000;55:210-5.
41. Chavez LR, Hubbell FA, Mishra SI, Valdez R. The influence of
fatalism on self-reported use of Papanicolaou smears. Am J Prev
Med 1997;13:418-24.
42. Dadipoor S, Alavi A, Safari-Moradabadi A. A survey of the
growing trend of caesarian section in Iran and the world: a review
article. Iranian Journal of Obstetrics, Gynecology and Infertility.
43. Akbari F, Shakibazadeh E, Pourreza A, Tavafian S. Barriers and
facilitating factors for cervical cancer screening: A qualitative
study from Iran. Iran J Cancer Prev 2010;3:178-84.
44. Jalilian F, Emdadi S. Factors related to regular undergoing
Pap-smear test: Application of theory of planned behavior. J Res
Health Sci 2011;11:103-8.