Qom University of Medical Sciences Journal

Introduction
Cervical cancer is the fourth most common cancer in women. In many developing countries where screening programs are not properly implemented, the prevalence of this malignancy is higher than in developed countries. Cervical cancer screening can be associated with a reduction in cancer mortality in women. This cancer is a detectable cancer in the early stages and can be prevented due to having a long pre-invasive period, availability of the affected organ for sampling, valid screening test and also the possibility of effective treatment of precancerous lesions. Unfortunately, women's performance in this screening is not satisfactory and they usually refer when the cancer is in its advanced stages. Numerous factors such as awareness level, fear, shame, lack of privacy, behaviors of healthcare staff, test costs, and worry about the positive test result can affect the tendency of women towards cervical cancer screening. Today, due to changes in lifestyle, increased rate of smoking and drug use, especially among women, and the high-risk sexual behaviors, the increase in the prevalence of cervical cancer in Iran is expected. Social support is another factor that can affect the cervical cancer screening behavior of women, which has various dimensions, including instrumental and emotional support. Social support is an important factor in maintaining health and is one of the most important forms of interpersonal relationships which affects the physical and mental health of people. Among the dimensions of social support, the role of emotional support is more prominent. Emotional support refers to providing love and care, and acceptance, reassurance, and understanding of our loved one, and can significantly encourage women to perform cervical cancer screening. This study aims to design an instrument to measure the emotional support of Iranian women for cervical cancer screening and assess its psychometric properties.
Methods
This methodological study was conducted in two phases, Item generation and instrument design, and psychometric assessment of the designed instrument. For item generation, a review was conducted on related articles and scales in online databases. From 25 articles found, 14 eligible articles were selected, from which 28 items were adapted. Then, semi-structured interview with women of reproductive age (20-65 years) referred to health centers in Karaj city was conducted to survey their perceptions of emotional support for cervical cancer screening which was continued until data saturation which was reached after conducting 20 interviews. The interviews were transcribed and underwent qualitative content analysis using directed approach proposed by Hsieh and Shannon. The protection motivation theory was used to survey women’s beliefs about cervical cancer screening, which is one of the effective theories in predicting health-related behaviors.
After coding and categorization of materials, finally 5 items were extracted. Considering the 28 items extracted in the previous step, a total of 33 items were prepared. Using the Delphi method, the opinions of 12 experts in various fields of health such as health promotion and education, health psychology, reproductive health, social determinants of health, and social medicine, were asked about the designed items. After three Delphi rounds, a consensus was reached among the experts regarding the items, based on which 24 items were removed and the initial draft of the instrument was designed with 9 items. Then, its face validity, content validity and construct validity were assessed. In face and content validity assessments (qualitative and quantitative methods), one item was removed and the number of items was then reduced to 8. Then, the construct validity of the instrument using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) was assessed on data from 630 women, of which 330 participated in EFA and 300 in CFA. The mean age of participants was 42.46±9.96 and 41.78±9.48 years for the two groups in EFA and CFA, respectively, who were selected by a convenience sampling. Being at the reproductive age, literacy, having a health record, no history of hysterectomy and cervical cancer, and not being pregnant were considered as the inclusion criteria. The reliability of the scale was assessed using Cronbach's alpha coefficient (internal consistency) and intra-class correlation coefficient (test-retest reliability). The EFA was conducted in SPSS version 24 and CFA was conducted in AMOS version 24 applications.
Results
Based on the results, the content validity index and intra-class correlation coefficient and were reported 0.92 and 0.93, respectively and the value of Cronbach's alpha coefficient for the overall scale was 0.79, indicating the acceptable validity and reliability of the scale. By the EFA, two factors of positive effects and negative effects of emotional support for cervical cancer screening were identified. The first factor had 6 items and the second factor had 2 items. All items were preserved and together explained 61.866% of the total variance. The results of CFA confirmed the two-factor solution of the designed questionnaire.
Discussion
The designed emotional support scale for cervical cancer screening has 8 items and two subscales of positive effects and negative effects of emotional support. It has good internal consistency and reliability, and can be used as a valid and reliable tool to measure the emotional support for cervical cancer screening in Iranian women of reproductive age.
Ethical Considerations
Compliance with ethical guidelines
The present study included ethical principles such as obtaining informed consent, the confidentiality of participants keeping their information confidential. The study also provided sufficient information on how to conduct the research. In addition, participants were free to leave the study at any phase of this study.
Funding
This article was extracted from a PhD thesis in Health Psychology of the first author, in the Department of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran. No financial support has been received from any organization for this research.
Authors contributions
Data collection and analysis and drafting of the manuscript: Mona Khalednejad; the main supervisor, directed the research team and contributed to research design and data analysis. Sara Pashang contributed to research design and drafting and review of the manuscript: Leili Salehi; contributed to data analysis and revision of the manuscript: Abbas Moghimbeigi and Atefeh Nezhadmohamad Nameghi.
Conflicts of interest
The authors declare no conflict of interest.