Predicting the factors related to cervical cancer screening in secondary school female teachers in Shahrekord: Application of PEN-3 model factors about cervical cancer screening in female teachers

Background and aims: Cervical cancer is one of the most common cancers in women. Cervical cancer screening is one of the essential measures for preventing this disease, and its purpose is to detect lesions in the premalignant stage and reduce the risk of death from this cancer. This study aimed to predict the factors related to cervical cancer screening in secondary school teachers using the PEN-3 model in Shahrekord, southwest Iran. Methods: This descriptive-analytical study was conducted on secondary school female teachers in the academic year 2019-2020. The samples were 228 individuals who were selected by convenience random sampling. The research tools were a demographic information checklist, uterine screening performance information, and a questionnaire based on PEN-3 model constructs (perceptual, enabling, and reinforcing factors). Data analysis was done using SPSS version 22. Results: Regarding cervical cancer screening (Pap smear test), 59.82% of the teachers had a history of undergoing Pap smear tests, of which 35.43% had performed the test regularly. Pearson’s correlation coefficient showed a direct and significant correlation between PEN-3 model constructs (perceptual, enabling, and reinforcing factors) and a history of cervical cancer screening ( P < 0.001). In the regression analysis of demographic variables and PEN-3 model constructs, the predictive value of these variables for cervical cancer screening was obtained at 0.57%. Conclusion: Based on the findings of the study and given the role of PEN-3 model constructs (perceptual factors, enabling factors, and reinforcing elements) in predicting cervical cancer screening behavior, comprehensive planning for intervention and use of this educational model and gaining knowledge about the cultural and socioeconomic factors for cervical cancer screening seems useful.

lesions in the premalignant stage and reduce the risk of death from this cancer (9). As a simple, cheap, and uncomplicated method, the Pap smear test is still the choice in cervical cancer screening (10).
According to the National Cervical Cancer Program, screening should be done for all women after marriage, and after three normal Pap smear samples (once a year), this test should be repeated every three years. This screening is done for free in comprehensive healthcare centers, but unfortunately, the related statistics could be more satisfactory (6).
The research shows that women face many cultural, emotional and functional, social, religious, geographical, and economic barriers to accessing services to perform the pap smear test.
Among the reasons for not referring to take this test can be factors such as lack of knowledge about the necessity of taking the test, lack of doctor's recommendation, stress, feeling ashamed at the time of taking the test, high cost, low age, old age, busyness, unethical behavior of health care workers, the lack of respect for patient privacy, the fear of a positive test result, and the aggressiveness of the follow-up methods in case of a positive test (11,12).
Based on the studies carried out in Iran and other countries, the strategies to control cervical cancer at the first level of the health service delivery system are: identifying and removing cultural and social barriers, planning to correct beliefs and attitudes about cervical cancer, and adopting of health behaviors as well as health education through designed and targeted health communication.
It is better to investigate the factors of not conducting screening among meaningful educational occupations such as professors, teachers, health workers and doctors, nurses, and paramedics because these people play an essential role in the education of society. For example, the part of teachers as educators and the role of students as a bridge of communication with the family is crucial and straightforward (13)(14)(15).
The PEN-3 model is one of the models for studying behavior in education and health promotion, and the factors that influence a person's behavior are examined in this model. This model has different structures: perceptual factors, enabling factors, and reinforcing factors, which are associated with positive, negative, and ineffective selfbeliefs. Identifying these factors is very important for the use of interventions (16). The role of the PEN-3 pattern in other diseases has also been demonstrated (17).
This pattern consists of three dimensions, each indicated by one of the letters P, E, and N. These three dimensions are internally related and dependent. The first dimension, health education, includes the following PEN: P (Person): Health education should sensitize and commit the person to improve healthy behaviors. E (Extended Family): Health education should be directed not only to the individual's immediate family but also to the individual's extended family or relatives. N (Neighbourhood): Health education should be directed towards improving the health of the neighborhood and society. Engaging community leaders in culturally appropriate health planning is essential (18).
In the second dimension, the PEN-3 model refers to the educational diagnosis of health behavior: P (Perception): Perception is related to knowledge, beliefs, attitudes, and values that can facilitate or prevent motivation to change a specific behavior. E (Enablers): These are regular social forces that can increase health behaviors or prevent them from occurring by creating barriers. Enablers include available resources, accessibility, referral points, and types of services. N (Nurturers): These are reinforcing factors that a person may receive from others who are important to them, such as extended family members, peers, employers, health workers, religious leaders, or government officials (19).
The third dimension of the PEN-3 model is called the cultural fit of health beliefs; P (Positive): Positive perceptions, enablers, and nurturers that help engage the person, family, or community in positive health practices. These positive health practices lead to individual, family, and social empowerment. E (intermediate): They include functions that are neither good nor bad and therefore do not need to be changed. N (Negative): These include negative perceptions, enablers, and nurturers that involve the person, family, and/or community in negative practices that cause harm to health (20).
Few studies with this model have been conducted in Iran; therefore, because the context for health and preventive behaviors of people in the society is provided in comprehensive health service centers, women's culture, beliefs, and opinions significantly impact the acceptance of cancer screening methods. This study investigates whether the PEN-3 model has a role in identifying the factors related to cervical cancer screening among secondary school teachers in Shahrekord, southwest Iran.

Materials and Methods
The study population of this descriptive-analytical study included all female teachers of the first-and second-grade secondary schools across Shahrekord in the academic year 2019-2020. According to the report from the Department of Planning and Statistics of the General Education Department of Shahrekord, the total number of female secondary school teachers working in Shahrekord in the academic year 2019-2020 was drawn. Then, the sample size was decided to be at least 190 using the sample size calculation formula × , and given a 20% probability of dropout due to not answering all the items.
Finally, simple random sampling selected the minimum sample size according to the table. To carry out the study in the specified academic areas, the researcher referred to the schools chosen after obtaining Application of PEN-3 model factors about cervical cancer screening permission from the Research and Technology Deputy of the Shahrekord University of Medical Sciences and the General Department of Education of Shahrekord, coordinating with the Education Departments of the 1st and 2nd Districts and then with the school principals, and encouraging the teachers to cooperate with the study after presenting necessary explanations about the objectives and procedure of the study to them. The inclusion criteria were working in selected schools, married, and volunteering to participate in the study. The exclusion criteria were suffering from cervical cancer and lack of volunteering to participate in the study. To comply with ethical considerations, before completing the questionnaires, verbal consent was obtained from the participants. They were also ensured that the questionnaires would be anonymous and that their information would be kept confidential. The questionnaires were collected in person by the researchers.
Based on the research questions, an appropriate research instrument and a demographic characteristics checklist were used to collect data. The research tool was a researcher-made questionnaire consisting of 28 items based on the PEN-3 model and literature review, whose content validity was theoretically confirmed by consultation with ten experts.
To determine the reliability of the questionnaire, it was administered to 30 participants. Cronbach's alpha (α) was obtained at 0.72 for perceptual factors, 0.70 for enabling factors, and 0.76 for reinforcing elements (21).
To measure the performance of the cervical cancer screening method, items with yes and no answers (scored 0 and 1) were used.
To measure the perceptual factors, a 5-point Likert scale [Absolutely agree (score 5), agree (score 4), neither agree nor disagree (score 3), disagree (score 2), and disagree (score 1)]. Items with yes and no answers (scored 0 and 1) were used to measure enabling and reinforcing factors.
Finally, the data were analyzed using correlation, simple regression, and descriptive tests in SPSS software (22).

Results
The mean and standard deviation of the age of the teachers participating in the study was 41.83 ± 11.30. The mean age at first pregnancy was 23.44 ± 9.67, the mean number of teachers with a history of genital tract infection was 26.76 ± 8.93, the mean number of miscarriages and stillbirths was 2.97 ± 0.73, the mean parity was 2.44 ± 1.47, and the mean regular menstrual cycle was 217.84 ± 12.35.
For performance regarding cancer screening, among the perceptual factors in the positive beliefs, the belief that cancer can be prevented by screening (85.96%) and belief in the timely detection and control of cancer (74.13%) were drawn as the most frequently reported beliefs. Among the negative thoughts, the unpleasant experience of the previous test (41.22%) and feeling ashamed of screening (36.84%) were the most frequently reported reasons for the lack of undergoing screening tests. Among the enabling factors mentioned in the positive characteristics of screening, the attention and follow-up of healthcare center personnel to perform the test (75.76%) and free screening services (56.58%) were drawn. Among the negative and inhibiting factors of screening, busy work and lack of time were expressed by 80.71%. Among the reinforcing elements, the wife's encouragement (77/63%) was mentioned as the reason for screening, and the wife's opposition (40/78%) was said among the negative factors (Table 1).
Pearson's correlation test showed that there was a direct correlation between the history of cervical cancer screening and demographic variables (P < 0.05) and also between PEN-3 model constructs (perceptual, enabling, and reinforcing factors) and history of cervical cancer screening (P < 0.001) ( Table 2).
In the regression analysis between demographic variables (age at first pregnancy, parity, regular menstrual cycle, history of genital infection, history of abortion and stillbirth) and the constructs of the PEN-3 model (perceptual, enabling, and reinforcing factors), the predictive value of these variables was obtained at 0.57%. Among these variables, the predictive value of perceptual factors, enabling factors, and history of genital tract infection was higher (Table 3).

Discussion
This study was conducted to use the PEN-3 model for predicting the factors related to cervical cancer screening among secondary school teachers in Shahrekord. The study's findings showed that 47.82% of the teachers had a history of performing Pap smear tests, of which 31.43% had performed the screening test regularly. In this regard, a study in Hamadan, western Iran, showed that 53.6% of the samples still needed to be screened (21). In Mohebi and colleagues' study, 36.88% of women in Qom had never undergone this test, 11.25% of women used Pap smear tests regularly, and 51.87% irregularly participated in cervical cancer screening (22).
Morowatisharifabad et al also surveyed cervical cancer screening in women of Chaharmahal and Bakhtiari and reported that 36.3% of women had undergone this test once and 6% twice (23). Ruzigana and colleagues' study showed that only 13.3% of women without symptoms had been referred for screening, and out of 84% of women with symptoms, more than a third had never undergone a speculum examination (24). In a study by Rositch et al, although 69% knew that a Pap smear aims to detect cervical cancer, 14% had done it only once (25). In this regard, it is argued that one of the main reasons for women's unfavorable performance in doing cervical cancer screening tests regularly is caused by their poor awareness and insufficient knowledge of the disease because awareness is a necessary prerequisite for changing attitude, behavior and making the right decision about adaptation to behavior (26).
Among the perceptual factors in the positive beliefs section, the belief that cancer can be prevented by screening and the belief in timely detection and control of cancer had the most cases.
In the study by Lee et al in Singapore on cervical cancer screening, 58.9% of women did not consider themselves susceptible to cervical cancer, and 48.7% believed that cancer could not be prevented (27). Parikh et al also pointed out in his study that part of the spread of this cancer is due to the lack of appropriate screening tests. Among the causes of such behavior (not performing tests), he points to the lack of information and economic, cultural, and belief system problems (28).
The results showed that there were some perceptions of some types of eating habits that were part of their culture, and there was no feeling of requiring behavior change (29) which is in line with the findings of the present study and cultural, religious, and economic factors are influential in screening behavior.
Among the negative beliefs, the unpleasant experience of the previous test and feeling ashamed of screening were the most critical factors that prevented screening. In the study of Mohebi et al, fear of the test result and feeling ashamed were the essential obstacles to performing a Pap smear test (22). Among the enabling factors mentioned in the positive screening factors, the attention and followup of healthcare center personnel to perform the test and free screening services were mentioned. In the negative and inhibiting factors of screening, busyness and lack of time were mentioned. Among the reinforcing elements, the wife's encouragement was drawn as the reason for screening, and the wife's opposition was a negative factor. The study of Fitzgibbon and Beech on the role of nutritional culture in children's education using the PEN-3 model showed that dietary problems in society are caused by the culture of the community and the way parents view obesity as a reinforcing factor in society (30). Also, in the study of Pakseresht et al, which was conducted on women's viewpoints about cervical cancer, three main results were obtained, including weak health information, neglect of the disease, and the need for treatment and support, among which neglect of the disease was divided into three subclasses: inattention to the risk of cervical cancer, negligence in screening, and lack of selfcare motivation (26). This finding is in agreement with the present study.
Also, the study's findings showed a direct correlation between the constructs of the PEN-3 model (perceptual, enabling, and reinforcing factors) and the history of cervical cancer screening. In the regression analysis of demographic variables and PEN-3 model constructs, the predictive value of these variables for cervical cancer screening was drawn at 0.57%.
In this regard, Moradi and colleagues' study in Sanandaj high school students in which the PEN-3 model was used for analysis showed low nutritional knowledge, beliefs, and values. The influence of peers, the role of parents, the media, and the accessibility of some concepts were obtained that are not only dependent on the individual and are also influenced by factors outside the individual; therefore, all influential factors should be taken into account in designing interventions to improve fruit and vegetable consumption (31), which is consistent with the findings of the present study. Factors such as knowledge, beliefs, and values, the influence of colleagues, the role of the spouse, the media, and access to healthcare centers are among the contributing factors to screening behavior. Therefore, attention should be given to the individual's internal and external factors for behavioral change in educational interventions.
Because part of the model was used in this study, it is recommended to use it to identify the cultural, social, and economic factors influencing cervical cancer screening.

Conclusion
Based on the findings of the study and given the role of PEN-3 model constructs (perceptual factors, enabling factors, and reinforcing elements) in predicting cervical cancer screening behavior, comprehensive planning for intervention and use of this educational model and gaining knowledge about the cultural and socioeconomic factors for cervical cancer screening seems useful.