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The Precaution Adoption Model (PAM) has been proposed by Weinstein in 1988. It is a theoretical paradigm of preventive behavior. It defines an orderly sequence of cognitive steps that individuals must complete in order to modify behavior. The stages given in some sort of order. Hence, people in the same stage will experience similar barriers to behavior change. In contrast, people in different stages will experience difference barriers and need some sort of different intervention to encounter each stage. The PAPM has seven stages. The first three stages address an individuals belief about his or her susceptibility to harm. A person in the first stage is unaware of the hazard. In the second stage, the person has heard of the hazard, but does not necessarily apply it to himself. This stage may include the incorrect belief that one's own risk is less than that of others. Due to unclear information, obtained from mass media or peers, people may fail to personalize their own risk. In the third stage, additional hazard messages have convinced the person that the risk is personally significant. Personal experience, education about specific risk factors, and witnessing of precautions taken by peers can all help move a person to this stage. According to the PAPM, once a person perceives a significant personal threat, he or she will examine the severity of the hazard, look at the effectiveness of precautions, and calculate the cost (money and effort) involved before deciding whether to act. This process leads to the next three stages of the PAM, the decision to act or not to act and the action itself. Finally, if the person takes action and then chooses to continue the behavior he has started, he may reach a seventh stage, maintenance of the behavior. PAPM is applied in variety preventive behavior in health including the protection of osteoporosis, radon gas and uptake of Pap smear. Application of PAPM in the uptake of Pap smear screened test among housewives.

STAGE 1 Never heard of Pap smear

STAGE 2 Aware of the test, not engaged in issue

STAGE 3 Deciding about getting Pap smear

STAGE 5 Have decide to get Pap smear

STAGE 6 Action on screening test

STAGE 4 Decided not to get Pap smear

Completed and maintainence

In Malaysia, cervical cancer was the second commonest cancer among women after breast cancer. Pap smear screening is an effective method of preventing cervical cancer. It was acceptable worldwide as effective screening tools for precancerous states and control of cervical cancer. In Malaysia, despite the high incidence of cervical cancer, only 26% of eligible women had Pap smear screening (NHMS, 1996). By applying PAPM, the lack of Pap smear screening test uptake by housewives in Malaysia will be analyzed and specific intervention will be provided in each stages to promote behavior change. Stage 1: Unaware of the cervical cancer testing In this stage, the woman does not have any awareness and knowledge on cervical cancer and the purpose of doing Pap smear test. Majority of women have lack of knowledge about risks of cervical cancer and it reduces participation in the cervical cancer screening. There are many factors why women are unaware of this issue. The primary factor is Pap smear is a very intimate procedure that can cause embarrassment as many women are not aware that such procedure exist were among the reason deterring women from undergoing Pap smear screening. A study done in Kota Bahru, Kelantan that, lack of knowledge and embarrassment is the main factors reducing the uptake of Pap smear test (Asmani & Aziah, 2006). The culture obviously effecting ones perception towards a treatment. In Malaysia, Chinese women are the highest group who practice Pap smear test regularly compared to Malay women. Because of the women is unaware of the cervical cancer and risk of not doing Pap smear, they just take for granted regarding the issue. The individual belief that she will not getting the cancer and never aware of the issue. As to cater this issue, the mass media play a crucial role in increasing the women awareness towards this serious issue. Mass media such as television, radio and other printed materials must be used in order to disseminate the information about the cervical cancer and the importance of Pap smear test to prevent form cervical cancer. The use of advertisement in the television will publicize the important of Pap smear test and the risk if the women do not get any screening and how it would affect her. The content of the advertisement must define what is cervical cancer, the importance of do Pap smear test to prevent the cancer the benefit and risk if the women do not pap smear test. Besides that, advertisement in radio, internet and other new technology medium such as mms, sms and blog also important and can introduce such awareness and give information to the women. The timing of the advertisement must be suitable for the housewives. For example, the advertisement must be shown in the morning and in the

evening where housewives rest at home and not busy cooking and cleaning the house. The message must suitable and use emotional sense in order to persuade the housewives to do Pap smear test. Use of experience and the consequences of not the Pap smear test to the children would make the message more effective. Besides that, printed material such as newspaper, magazines, books, poster, pamphlets, booklets, T-Shirt and banner on cervical cancer and its prevention must be distribute nationwide. The distribution of the printed material must take place in a location that housewives are always gone. For example in the market, shopping complex, in school and distribute at housing area. The message must be clear, concise and the words use must in line with the level of their education. The explanation on Pap smear test must be cleared, not against the religious and not painful. The knowledge of the cervical cancer and its preventive treatment is the far most important to induce the awareness. With full of knowledge and positive attitude toward the screening procedure, can increase the uptake. Stage 2: Aware of test, not engaged in the issue After seen much advertisement in television, heard about the cervical cancer in the radio and read it in the pamphlets, the women already has the knowledge about cervical cancer and Pap smear procedure. She knows that cervical cancer is a serious health issue and could bring death and she understand that Pap smear test is the most valuable test to diagnose the cervical cancer. At this stage, the women start to find more information about Pap smear test especially from doctors and nurses in health clinic (Jamsiah, 2009). Most women believed that, the best method of receiving information regarding Pap smear test and cervical cancer is from medical staff (Quek, Abdul Rashid & Lingam, 2005). In addition, effective communication along with a comfortable discussion on the issue would be a stepping stone to undergone Pap smear test. On the same time, if the women encounter to have the cancer at that time or have an experience to take care other significant people around her who have the disease might trigger her to do Pap smear test. Most of the study claimed that having personal experience on the cervical cancer would bring a huge impact on ones attitude towards getting Pap smear test. If she had sign and symptoms of having the cancer as been shown from the advertisement, then, this situation would change her attitude towards Pap smear test. The wrong belief, attitudes and norms must be corrected at this time. The messages on the benefit of Pap smear, the right of doing it in religious context, and tell the women that the procedure is not as painful as they believe. Because the women is still healthy, she perceived that she wont get that disease, the message transferred must be strong enough to change her

intentions. The role of peers in this stage is also important. If the woman sees her friend do the test without any side effects and shown positive attitude towards it, the women belief about the preventive treatment will change. Stage 3: Deciding about getting screened In this stage, the women are deciding about getting screened. She is deciding whether to do Pap smear test or not. In this period, interpersonal communication is very important. The use of persuasion technique to persuade the women on getting the Pap smear done especially by their husband would bring succeeds. Husband is the most important person for married women and with their strong support and encouragement, the women might start to think about getting the screening test or not. This is a crucial time to encounter. The health care provider should provide a through explanation and guideline on Pap smear test to the women. Bring the women to meet the doctor and get a fully understanding about the procedure. Explained the benefit that she will get if she does the Pap smear test. The doctor and nurses should use persuasion communication and be a good listener while talking to the individual. The women now perceived the severity and the susceptibility to get cancer if she does or does not do the Pap smear test. She also will evaluate the barrier that she must overcome if she decides to do the Pap smear. The restriction in terms of money to pay for the Pap smear test and time waste to go to clinic to do the test. As conclusion, verbal education and counseling can influence ones behavior on getting Pap smear test. Stage 4: Have decided not to get screened The women now have decided not to get screened after she evaluate the susceptibility of her not getting the cervical cancer, the severity of the disease, and the barriers that she will overcome later. At this time, the women behavior is still can be changed. Bring the women to go for other consultation with another doctor. Have another discussion and try to use her children as way to persuade her to change her mind. The interpersonal communication such as counseling and in depth discussion is really important to make the women induce her intention to change her behavior. Stage 5: Have decided to get screened The woman now is decided to get the Pap smear test done. After she analyzes the barrier and benefit doing the test, she is now ready to do the screening test. At this time, she

need fully support from the doctor, nurses and especially her family. Give fully information, motivation to support her intention and empowered her to do make decision on her own. With the present of cues of action such as availability of health clinic, easy assess to health clinic in terms of transportation and able to choose the health clinic will make she implement her action. This is important to develop high self efficacy towards the new behavior change. On the other hand, involvement of husband, religious leaders, parents and other influential adult may increase the woman self efficacy. Stage 6: Acting The woman now is doing the Pap smear test. Health care provider should give fully support for her. Give guideline on when and where the Pap smear will be done. If she does the Pap smear successfully give positive reinforcement and appreciate her for doing that. But if she unable to do the test due to fear or pain gives moral support and always be with her if possible. Encourage her to do the test again and ask family member especially husband to accompany and motivate their wife. If the encountered some problem on the money and time, discuss with her on the alternatives and refer her with the right person. Stage 7: Completed screening and maintaining The woman is accomplishing the first Pap smear test. Remind her that there will be another test next year and ask her to come for follow up. Do follow up with her annually. Give a call whenever the date is near. Continually support the women and guide her family to give fully support the women. Individual in this stage have a chance to relapse. They tend to relapse due to the social interaction. So, the community itself needs to play their role to maintain the individual behavior on doing Pap smear test. Group support on Pap smear screening must be established in order to strengthen the community support especially with the people who share same experiences and problems regarding Pap smear screening test. Community agencies such as NGOs and community leaders can play an important role in maintaining the Pap smear uptake behavior.

References Asmani, A, R. & Aziah, D. (2006). Effect of intervention on pap smear screening among rural women in Kota Bahru. Malaysian Journal of Public Health Medicine. Vol 6(1): 38-43. Retrieved on 21st December, 2011 from Jamsiah, M. (2009). Determining factors on level of knowledge regarding pap smear among married women in Hulu Langat district, Selangor. Journal of Community Health. Vol 15(1). Retrieved on 20th December, 2011 from Ministry of Health Malaysia. National Health Morbidity Survey 1996. Quek, K, F., Abdul Rashid, M. & Lingam S, S. (2005). Astudy of knowledge, attitude, and practice (KAP) of pap smear screening among warded female patients in Hospital Teluk Intan, Perak. Retrived on 20th December, 2011 from