Knowledge, familiarity and perceived quality of care : midwives' knowledge of and women's experience with population-based cervical screening programme in Stockholm

Abstract

The current study is part of an interdisciplinary project on population-based screening for cervical cancer, entitled "Between Sickness and Health: A Multidisciplinary Study of a Population-based Cervical Screening Programme in the Stockholm-Gotland Region". This interdisciplinary research project commenced in 1995 in order to generate a multi-facetted overview of cervical cancer screening. In this part of the research project, an investigation was made into midwives' knowledge of and familiarity with cancer and cancer prevention (subsidiary study I) and how women participating in screening evaluate the health care received at follow-up appointments with midwives (subsidiary study II).

Subsidiary study I. The purpose of this article was to investigate how midwives describe their work with cervical cancer screening, their familiarity with the disease and it prevention. Twenty-one midwives from seven gynaecological clinics participated in a qualitative interview study. A semi-structured questionnaire was used to examine the attitudes of the midwives in regard to the risks and benefits of the screening programme, the at-risk factors for cervical cancer, test reliability, "sources" of information/knowledge relevant to cervical cancer and screening, and how the midwives describe their roll in the screening programme. The results showed that the midwives saw themselves as having an important role in regard to women's health, and their own confidence in their ability to receive patients also reflected a sense of having a central and important role within the screening programme. In regard to the midwives' assessment of risks and benefits of the work with cancer screening, it was revealed that they felt there were gaps in their knowledge of gynaecological cancer, the processes surrounding the test and that they lacked feedback. The midwives stated that they lacked relevant knowledge about cancer and cancer prevention, but felt they were very familiar with the testing technique. They felt that there was a lack of further professional development in these areas after completion of their midwifery training.

Subsidiary study II. The purpose of this article was to describe the quality of care and patient satisfaction in a population-based cervical cancer screening programme for women with documented cell abnormality. The women in the screening programme whose pap-smear tests revealed varying degrees of cell abnormality were referred directly from the pathology/cytology lab to a gynaecological clinic. The women were then given an appointment for examination and further investigation. Many women had to wait for the test results and an appointment with the gynaecologist, the wait being anything from a couple of weeks to six months. In 1996, the Stockholm-Gotland Oncology Centre initiated a pilot scheme in which women with abnormal cell tests were contacted by a midwife at the maternity clinic. The midwife had an additional meeting with the women to give them information about their abnormal test results and they were given the opportunity to ask questions and continue to discuss health care. In order to evaluate the women's perceptions of this care, a follow-up survey was conducted using the questionnaire QPP (quality from a patient perspective). The model describes quality of care in four dimensions: medical-technical competence, physical-technical competence, identity-orientation in attitudes and actions, and socio-cultural atmosphere. In this study, questions related to physical-technical competence were excluded as they were not relevant. One context-specific factor with four questions was added. In total, the questionnaire contained twenty six questions measuring eight factors in three dimensions, plus the four context-specific questions. Seventy-five women with cell morphology answered the questionnaire. Thirty-seven of these women (the intervention group) had received one additional meeting with a midwife to enhance but not replace the information provided by the gynaecologist The remaining thirty-eight women (control group) only received standard appointments for examination and discussion with the gynaecologist.

The results for the whole group of women showed that the most highly rated aspects of perceived reality were medical care, information prior to intervention, respect and privacy. The aspects of perceived reality that were most poorly rated were involvement, interest, empathy and post-intervention information. The factors that were most highly rated in relation to perceived reality also had the highest quality index, whereas those that were most poorly rated had the lowest quality index. The greatest difference between the groups (intervention and control groups) lay in the personal quality index, and only for the context-specific statement: "I had the opportunity to discuss my health with the midwife". The personal quality index for the intervention group indicated moderate satisfaction with care whilst for the control group, the index indicated less satisfaction. The women who had been offered an additional meeting with a midwife were more satisfied with the information received from the gynaecologist, their own level of self-care, the physical environment of the gynaecological clinic and the gynaecologist's knowledge of the test. The results also indicate that more attention can be given to psycho-social aspects such as participation in decision-making, empathy and being in control.