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Factors related to failure to attend the consultation to receive the results of the Pap smear test1

Objective to identify the factors related to the failure of women to attend the follow-up consultation to receive the results of the Pap smear test. Method a cross-sectional study, carried out with 775 patients who underwent the Pap smear test in the Centro de Saúde da Família of Fortaleza, between September 2010 and February 2011. Results the majority of the women studied were young (≤35 years), had low levels of education (≤7 years of study), and commenced sexual activity early (≤20 years), with 17.0% of them failing to return to receive the test results. Statistically significant results for the failure to return were related to: young women (p=0.001); early onset of sexual activity (p=0.047); and inadequate knowledge about the Pap smear test (p=0.029). Conclusion the fact that the women failed to return for the result is a problem for the control of cervical cancer and must be addressed through educational strategies that reinforce the importance of the return for the early detection of this cancer.


Introduction
Despite showing high cure potential when diagnosed early, cervical cancer (CC) still remains a serious public health problem, especially in developing countries, where screening tests are conducted opportunistically, and for women below the age group at risk for this cancer (1) . The incidence and mortality resulting from CC can be reduced through screening for the detection and treatment of invasive cancer precursor lesions.
According to the World Health Organization (WHO), with Pap smear test coverage of between 80 and 100% of the target population and an organized network for adequate diagnosis and treatment, it is possible to reduce the cases of invasive cancer in the population by an average of 60 to 90% (2) . However, a recent study revealed that the provision of the test in Brazil is still found to be below the requirements of Brazilian women (3) .
Numerous interventions to improve the adherence of women to the Pap smear test have been described in the literature. These interventions focus on improving the information provided by the professionals about the exam, reducing the barriers for the women to have access to the exam, or both (4)(5) . Despite the magnitude of these interventions, the high cure potential for CC, and the increase in the provision of services for prevention and treatment of the cases, the control of this condition will be limited if these women do not return to receive the test results (6) .
This situation is complex, because a financial and professional investment is made by the service with each examination performed, however, the ultimate impact is impaired. Graduate and technical professionals are involved, as well as various expenses, in the sample collection process, reading the slide, and printing the result. When a woman does not return to the service to receive this result, there is a waste of time and resources, both for the service provider and for the woman, because the purpose of the examination, i.e. the prevention of cervical cancer, is not achieved (6) . Some studies (6)(7)(8) have already addressed the issue of women failing to return for the Pap smear test result, however, they are characterized as descriptive studies that only aimed to discover the reasons why the women failed to return and to identify their characteristic profile, without establishing any statistical relationship between the variables. Furthermore, another factor that prompted the realization of this study was the finding, in a preliminary study performed in a primary health unit (PHU) of Fortaleza, of a high rate (24%) of Pap smear tests not received by the users (6)  The identification of the profile of the women who fail to return may support the development of interventions, with emphasis on cognitive, behavioral and social aspects, by the primary healthcare professionals to improve the quality of the care provided to combat CC.

Method
This was a cross-sectional study carried out in a Family Health Center (CESAF) of Fortaleza, composed of four teams. In this institution the tests are performed exclusively by nurses, in four periods per week, with ten women attended per period. This institution was selected because, in a previous study, it presented a rate of approximately 24% of exams that were not received by the women. One hypothesis for the high number of retained tests is that, in the unit, the followup consultation was not scheduled. Furthermore, despite making use of an active search, a significant percentage of exams were not getting into the hands of the women (6) .
The study population was composed of women who sought the performance of the examination in this institution. The sample size was calculated using a confidence interval of 95%, power of 80%, and a percentage of eventual losses of 10%, amounting to a total of 699 women. The sample included only the women who had commenced sexual activity; excluding those who, for any reason, left the unit without performing the Pap smear test.
As the data were collected while the women waited to perform the test, only later was it realized that some of the women who had been interviewed left the office without carrying out the examination, which determined their exclusion. Thus, it was decided to expand the sample beyond the estimated 699 women, in order to ensure that, if it was necessary to exclude anyone, this value would be obtained. Therefore, at the end of the study, a sample of 775 women was achieved.
Identification data were collected for all the women who agreed to participate in the study and a validated instrument, called a KAP survey, was applied to assess

Results
Throughout the study 802 questionnaires were During the study period, of the 775 women in the sample, the majority (83%) attended to receive the test results, although 28% (n=181) of these came after the date scheduled for the return (Figure 1). Although all the women who attended the study unit after the scheduled date received their results, for the calculation of the factors related to failure to attend the follow-up consultation it was necessary to define the interval limit of sixty-five days to consider that the woman had returned. This deadline was adopted because it was the maximum number of days given for the last patient that underwent the test to return. That is, the women who attended within sixty-five days to receive the test results were classified as "Returned", the women who attended after sixty-five days from the performance of the examination and those who did not attend were classified as "Failed to return". Thus, with 132 women who did not attend and 58 who attended after 65 days, a total of 190 women was obtained.
Higher proportions of non-attendance of the followup consultation were found to be related to the following  in the public services, and 3.2% in the health insurance or private services (12) . Among the studies in which the percentage of non-returns has been studied, the rates are much lower than that found in this study, however, the methodology used makes comparisons difficult.
A study carried out in a primary health unit in to the others (7) .
It is noteworthy that the women's apparent lack of interest in receiving the results, represented by the justifications for personal reasons, is not always unilateral (7) . The low quality of the care provided, the difficulty in arranging a new consultation when the woman can not attend on the scheduled date, the long waiting list for service or to schedule a consultation, and the lack of effective communication between the user and service professionals also contribute to hinder women's access to the test results (6-7) .
The problem of failing to return is present in various contexts, although in varying proportions, indicating the need for the healthcare professionals responsible for CC prevention to use cognitive type strategies to increase women's knowledge related to the fight against cervical cancer, emphasizing the importance of the return consultation. Behavioral type strategies should also be used to reinforce the behavior of returning, using reminders (graphics, visual or telephone calls), as well as social strategies, which might include changes in the current healthcare system in order to optimize the dynamics of the care with the aim of reducing these numbers. Therefore, it is necessary not only to know the reasons why women fail to return, but also who these women are and whether there are characteristics related to the non-return behavior.
In a study also performed in Fortaleza, in order to assess the knowledge, attitudes and practices of 250 women regarding the Pap smear test, it was found that 67.6% of the respondents were classified as having inadequate practice concerning the test. The women who reported performing the exam at intervals of more than three years showed higher proportions of failure to return for the result of the last examination (10) .
In this study, age was the factor most strongly  (Table 1).
Although low levels of education were not statistically associated with failure to return (mean years of schooling of the women who returned=7.0/ mean years of schooling of the women who failed to return=7.2: p=0.888), another study (12) demonstrated that the percentage of women who did not know the result of their examinations increased with decreased schooling: the proportion was approximately three times greater among those with less than four years of schooling compared to women with twelve or more years of education (10.7% versus 2.9%) (linear trend p value=0.000). Just over a third (35.6%) of the women with up to four years of schooling believed that CC is incurable, while among the women with twelve or more years of education, the percentage was 9.9% (12) .

Inadequate knowledge regarding the Pap smear test
is described in the literature (10) as a risk characteristic for not performing the examination and, in this study, for failing to return. These data show that gaps in knowledge influence the adoption of healthy behaviors, especially, in the case of this study, regarding the attitude of the women related to returning for the result.
In this sense, it is necessary to apply a health education strategy, which should be performed by a multidisciplinary team of healthcare professionals, especially nurses. To adequately fulfill the role of educator, the professional should identify the information that the learners need and consider their motivations and learning styles. However, to only provide information to the learners does not guarantee their learning (13) . Learning needs are defined as gaps in knowledge between the actual performance level and desired performance level. Such gaps exist due to lack of knowledge, attitude or ability.
It is important to note that not all the individuals perceived their own need to obtain knowledge about a particular subject. Therefore, it is up to the educator to help them identify, clarify and prioritize their needs and interests. After this, the information gathered could, in turn, be used to establish goals and plan appropriate and effective approaches in the teaching-learning process so that the education begins at an appropriate point for the learner, and not from a unknown or inappropriate level (13) .
Despite all the dangers posed by the woman failing to return, highlighted in this article, it can still be

Conclusions
There are several intervention needs in the combat against CC, however, adequate knowledge regarding the Vasconcelos CTM, Cunha DFF, Coelho CF, Pinheiro AKB, Sawada NO.