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Study Women Verbal and Nonverbal Response, during Their First Gynecological Examination

Somaia Ragab Eid, Hanan Elzeblawy Hassan*, Walaa Fathy, Kamilia Ragab Abou-Shabana

Maternal and Newborn Health Nursing, Faculty of Nursing, Beni-Suef University, Egypt

Abstract: Aim: study women response during and post their first gynecological examination. Setting: The study was conducted at the gynecological clinic at Αin-Shams University Maternity Hospital. Subjects and methods: Α descriptive study design. Sampling: Sample size was 199 from females who attended to the previously mentioned study setting for the first time. Sample type: Α purposive sample. Tools: four tools of data collection were used. (I): Α Structured interviewing questionnaire; (II): The emotional situational nonverbal response questionnaire; (III): The situational verbal response checklist; (IV): The visual analogue scale to assess pain level. Results: The present study results had revealed that majority of the studied sample had incorrect knowledge. Also 76% among studied sample reported that gynecological examination was а stressful event, majority of women said that it is immoral to expose intimate part, furthermore 63% of the studied sample complain of moderate pain during gynecological examination, also 59% among the studied sample was irritable and completely correspond and most of the women were cooperative and completely correspond during gynecological examination, also 63% among the studied sample recommend female, not male gynecologist. Additionally, the main barriers self-reported by the women were No pre and post gynecological instruction 29% and the presence of male gynecologist 14%, and difficulty in transportation. Conclusion: the present study concluded that the majority of the studied sample had incorrect knowledge. Also, most of them corresponding with negatively verbal and nonverbal emotional response as well as the majority were an embarrassment, first gynecological examination was а stressful event, and it was immoral to expose intimate part. Recommendation: design purshors, guideline, and poster concerning the importance and technique of female gynecological examination.

Keywords: verbal, nonverbal, response, gynecological examination

Received August 02, 2018; Revised November 19, 2018; Accepted December 29, 2018

Citation: Somaia Ragab Eid, Hanan Elzeblawy Hassan, Walaa Fathy, Kamilia Ragab Abou-Shabana, Study Women Verbal and Nonverbal Response, during Their First Gynecological Examination. American Journal of Nursing Research, 7 (1). 1-7. January 2019. doi:10.12691/ajnr-7-1-1

1. Introduction

Regular gynecological examination (Gyne. Ex.), done many times in every woman’s life-cycle, is essential attempts used in the estimation of women’s reproductive health. Also, gynecological examination is an essential part in practice and very commonly widely method. However, gynecological examination means the examination of the genital organs which needs to be covered, hide and protected for most of the women. [1]

Furthermore, the importance and advantage of gynecological examination are to give accurate information and confidential answer to any question concerning sex, changing body, prevention through checking the internal and external reproductive organ for any health problem and finally, treatment for experience missed period, pain, and other reproductive disorders. Gynecological examination involved, external vaginal examination, internal vaginal examination, bimanual examination, and Pap smear. [2]

Response is an answer or replies as in words or in some action. However, gynecological examination is а stressful event that is the women may respond negatively as consequence to no orientation before the examination (stress either impels or may lead and exacerbates anxiety and in turn, seems to have a negative effect on women). [3] Gynecological examination anxiety poses an obstacle for women to get the best healthcare which is possible. The most important reasons of anxiety experienced during gynecological examination are; sex, attitudes, professional profile of health personnel, embarrassment about dressing, examination position, used equipment, previous negative experiences of gynecological examination, inattention to confidentiality, religious beliefs, pain, pathological diagnosis, fear about personal hygiene, negative first pelvic examination experience, and socio-cultural value. [4].

Moreover, this intimate physical examination may provoke many negative feelings such as embarrassment, shame, anxiety, and awkwardness. The first pelvic examination in women’s life and the attitude of health providers may lay the basis for subsequent pelvic exams. Addition, women during adulthood may be experienced strong discomfort during pelvic examinations but find it necessary to confirm their health. Many women have negative experiences of gynecological examination. Women receive insufficient information about how the examination is conducted. Therefore, gynecological examination utilization can lead to traumatize impacts that result in the reactions such as avoidance of being examined, light anxiety and feeling of Shame. [5] Consequently, а part from the physical discomfort, psychological factors are important, as gynecological examination included exposure of intimate parts of the body in а vulnerable situation with loss of control. Women experience many feelings such as worries about cleanliness, qualms about vaginal odor, а concern that the gynecologist might discover something about sexual practices, fear of discovery of а pathological condition, and fear of pain. [4]

Finally, nurse is the key person in healthcare delivery system. [5] Maternity nurses play а crucial part in gynecologic examination; before examination women should be given а complete explanation of the procedure and how they conducted and also specific instructions necessary for adequate preparation during examination. The nurse must assess complete history, reassure the woman during the procedure, perform steps of nursing procedures, while after examination; the nurse must discuss the results of the exam, arrange for any follow up or consultation needed, instruct women regarding laboratory investigation, and finally ask women for any further explanation needs. [7]

1.1. Justification of the Problem

Gynecological examination is one of the physical examination which is essential for assessing female (internal & external) reproductive system. In the Egyptian, there are many traditions and concepts related to gynecological examination. Some women were usually in а culture rejecting to perform any gynecological examination in the first time. [5] They pay little attention and may absolutely refuse gynecologist counseling for а female reproductive system. [8] So, when the women face this exam, they become very anxious, stressed and fearing from а situation, because she considered it is immoral issues to expose her intimate part to another person. So, it was important to assess their response regarding their first gynecological examination. [5]

Gynecological examination was а nursing concern because the nurse is expected to be beside female pre, during and post gynecological examination, the nurse had а very important role in preparing women before an examination. Additionally, preparing equipment, women during an examination, instruct women about comfort and suitable position for gynecological examination, instruct women about laboratory investigation, medical treatment as well as follow up visits to the clinic to enhance women positive response to attend regularly to gynecological clinic.

1.2. Operational Definition

Gynecological examination (Gyne. Ex.): is any procedure performed to the female genital tract where instrument is inserted directly into the vagina.

Response: is an answer or reply as in words or in some action.

2. Aim of This Study

To study women’s verbal and non-verbal response during their first gynecological examination.

3. Research Questions

1. What is women's knowledge concerning their first gynecological examination?

2. How women response verbally and nonverbally to their first gynecological examination?

3. What are the barriers that facing women during their first gynecological examination?

4. What was the relation between women knowledge and nonverbal response concerning their gynecological examination?

4. Methodology (Material and Methods)

4.1. Design

Α descriptive study design was utilized in this research.

4.2. Setting

The study was conducted at the gynecological clinic at Ain-Shams University Maternity Hospital.

4.3. Sampling

4.3.1. Sample Size

199 from females who were attended to the previously mentioned study setting for the first time were included in the study for six months.

4.3.2. Sample Type

Α purposive sample was used in this study.

4.3.3. Inclusion Criteria

Age ranges from 20 to 35 years, Firstly admitted to the gynecological clinic.

4.3.4. Exclusion Criteria

Amenorrhea, Complaining of the following: Dyspareunia, dysuria, Leucorrhea, offensive vaginal discharge, and vulvar itching.

4.4. Tools of data collection:

4.4.1. Interviewing Questionnaire

It was included two parts:

The first part: To assess female general characteristics (age, occupation, area of residence, and level of education).

The second part: To assess women’s knowledge concerning gynecological clinic as definition of examination, Importance of the examination, Position during examination, Complication due to gynecological examination

Scoring system for evaluating women’s knowledge was developed as the following:

• Knowledge was scored as correct and incorrect answer for each knowledge question.

• Each question was given 2 scores for the correct answer and 1 score for an incorrect answer.

4.4.2. The Emotional Situational Nonverbal Response Questionnaire (Larsson, 2011) [9]

It was modified by the researcher to assess women’s response during all gynecological examination. It contains a list of words describing different emotions as (irritable, cover her eyes, afraid, attentive co-operative, frustrated). Under each word are three response choices. Each woman asked to circle the choice which best describes Respond as follow:

1) The word does not correspond to how she felt right then

2) The word partly corresponds to how she felt right then

3) The word completely corresponds to how she felt right then

4.4.3. The Situational Verbal Response Checklist

It was designed by the researcher to assess women’s response post gynecological examination. It had consisted of eight positive verbal response statements and eight negative verbal response statements. Each statement was checked as (yes) or (no). It was written in Arabic language.

4.4.4. The Visual Analogue Scale to Assess Pain Level (Gillian A., et al., 2011) [10]

Α Visual Analogue Scale (VΑS) is a measurement instrument that tries to measure a characteristic or attitude that is believed to range across а continuum of values and cannot easily be directly measured. It is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end, as illustrated in the figure below.

Level of pain associated with gynecological procedures was measured by asking the participants to place а line perpendicular to the VΑS line at the point that best indicates their pain at the present time. The score was considered as the following: 0=no pain, 1-3=mild pain 4-6=moderate pain, 7-10=sever pain.

4.5. Validity of the Tools

All tools of data collection were sent to three specialized University Professors, according to their comments modification were considered.

4.6. Ethical Considerations

Letter of approval to conduct the study was obtained from the head of the department of maternity and gynecological nursing partner. Then approval from the ethical committee at Αin-Shams faculty of nursing was obtained to conduct the study. Another letter of approval was sent to Αin-Shams University Maternity Hospital director included the title and the aim of the study.

Oral Informed consent was obtained from each participant in the study; the aim of the study was explained before starting the study for each participant. Each woman had the right to withdraw from the study at any time. Tools of data collection were not touching women dignity, culture, and ethical issues. The participants were interviewed individually in a private room to maintain confidentiality of data collection. After data collection and statistical analysis, all tools of data collection were burned to maintain confidentiality of the study.

4.7. Field Work

The study was conducted through three phases:

4.7.1. Phase 1 (preparation phase)

The researcher collected the relevant literature related to the study then designed and prepared tools of data collection then the pilot study was conducted. Pilot study was conducted on 10%of the study subjects for one month to assess applicability, practicability, and the clarity of the study tools then any necessary modifications would be done.

4.7.2. Phase 2 (implementation phase)

The Study was conducted at the previously mentioned study setting. The researcher visited the study setting from 10 pm to 1 pm to interview women for three days per week, the researcher interviewed three females per day for six months, during this period the sample size reached 199 women. Women were interviewed according to their sequences from clinic registration book, firstly aim of the study was explained to each female to gain her confidence and trust and obtained the oral consent to participate in the study. Pre gynecological examination; each woman was interviewed for 20 minutes using interviewing questionnaire schedule.

4.7.3. Phase 3 (evaluation phase)

During examination observational situational nonverbal response scale was applied for each woman to assess nonverbal (emotional) response during examination and visual analogue scale (VAS) was utilized to assess pain level during examination while post examination verbal emotional response checklist was applied for each woman to assess verbal response post gynecological examination.

5. Analysis of Result

Table 1.a. had illustrated that 48.0% of the study sample with age 20-26, while 33.8% of the study sample with age 27-32 and 17.9% aged from more than 33 years old. Table 1.b. had revealed that 43.2% of the study sample from rural area, while 56.7% from urban area. Table 1.c. had illustrated that 13.9% of the study sample were illiterate, while 16.3% from the study sample were primary educated also 47.8% were had secondary educated and 21.9% were had university educated. Table 1. d. had illustrated that 95.4% of the study sample were married while 0.5% were divorced. Also, 4.0% were widow. Table 1.e. had illustrated that 18.9% of the study sample were working women while 81.1% of the study sample were housewives.

Table 2 had illustrated that 42.8% of the studied sample had the correct knowledge about the definition of gynecological examination, furthermore, 18.9% of the study sample had correct knowledge about the technique of gynecological examination and 81.1% had incorrect knowledge. Also, 59.2% of the study sample had correct knowledge about importance of gynecological examination, furthermore 32.8% of the study sample had the correct knowledge regarding parts of gynecological examination. Furthermore, 69.7% of the study sample had correct knowledge regarding preparation before gynecological examination.

Table 3: had illustrated that 76.0% among the studied sample reported that the gynecological examination is а stressful event, furthermore, 37.8% of the studied sample reported that the gynecological examination touches their dignity, moreover, 77.1% among the studied sample reported that there is no orientation before the examination.

Table 4: had illustrated that 62.7% of the studied sample was cooperative and completely correspond while 7.0% of the studied sample doesn't correspond and frustrated. Furthermore, 61.7% of the study sample completely correspond and were attentive while 30.8% partly correspond and cooperative, furthermore, 60.6% of the studied sample was afraid and completely correspond.

Table 5: had illustrated that more than quarter among the studied sample 29.3% self-reported that no pre and post gynecological instruction. Furthermore, 22.4% among the studied sample self-reported that no barriers facing her during gynecological examination, also 14.4 % among the studied sample self-reported that long waiting time before examination, and presence of male gynecologist. Moreover, 7.5% of the study sample self-reported that presence of too much medical and nursing student during examination, also, 6.0% of the study sample self-reported that there is no privacy during examination.

Table 6: show that there was a significant statistical relation between studied sample knowledge and their non-verbal response regarding afraid emotional response, 56.8% among the studied sample had a correct knowledge and completely correspond with afraid (chi-square = 4.701, p-value = 0.056). Furthermore, no relation regarding irritability (chi-square = 3.848, p-value = 0.146)

Table 1. Frequency according to studied sample general characteristics (N=199)

Table 2. Frequency according to studied sample knowledge concerning gynecological examination (N=199)

Table 3. Frequency according studied sample verbal response post gynecological examination (N=199)

Table 4. Frequency according to studied sample nonverbal response during gynecological examination (N=199)

Table 5. Frequency according to studied sample self-reported to barrier that facing her during gynecological examination (N=199)

Table 6. Relation between studied sample knowledge and there non-verbal response (N=199)

6. Discussion

The aim of significantly approved within the framework of the present study research questions. The first research question which was What are women's knowledge concerning their first gynecological examination? this question was significantly answered by the present study research finding. It was observed that the majority among studied sample had incorrect knowledge regarding meaning, importance, parts of gynecological examination, so present study research stated that increasing knowledge about gynecological examination was one factor motivated women to seek and continue gynecological exam, and this agrees with Hassan (2018), who had revealed that majority among the present studied sample had incorrect knowledge concerning definition, importance, complication & preparation. [11] This disagrees with Norrell et al. (2016), who found that approximately one-half of the participants stated that they knew the examination's purpose. [12] Similarly, Freyens et al. (2017), who reported that that the majority of women in Egypt had incorrect knowledge regarding reproductive issue because culture and tradition prevent them from to discuss this issues of reproductive and gynecological health. [13] The present study had illustrated that majority of corresponding among studied women had incorrect knowledge which consequently had reflected upon their positive and negative verbal and non-verbal reaction concerning their Gyne. Ex. This may be due to differences in culture, tradition, and education.

Moreover, the second research question was How women response verbally and nonverbally to their first gynecological examination? This research question was significantly answered through present study finding concerning their verbal response, most women among the studied sample reported that the gynecological examination was a stressful event and the majority of the studied sample reported that it was immoral to expose intimate part and felt embarrassing and frustrated. Furthermore, the majority of the studied sample was frustrated and completely correspond with their emotion during vaginal examination. This agreed with szymoniak, et al. (2012) and Nappe (2010), who reported that the most among their studied sample reported that the gynecological examination embarrassing and stressful according to women and the most unpleasant moment during to their visit to gynecologist was time spent on examination table, whereas the least embarrassing moment was the gynecological examination itself. However, the most embarrassing moment of the examination was vaginal examination. [14,15] Also, in the present study the majority of the women refused gynecological examination by a male physician. Furthermore, more than half of the studied sample found that gynecological examination damage internal sexual organ and most of the studied sample women fear of losing their femininity and this agreed with Nappi (2010) who found that the majority of women didn’t prefer to be examined by a male doctor. [15] pelvic examination leads to a feeling of lost dignity and shyness and agreed with Adekunle, Julius (2010) and Williams, Hettie (2013) who stated that women who prefer a female physician were asked about the reasons, the majority of the studied sample reported that they felt comfortable with female physician women who wish examined by female physician provide causes such as, religious, beliefs, unwillingness to discuss sensitive and confidential situation with a male physician. In addition, studied young female reaction of embarrassment & shame. While exposing the intimate part of their body, worries about cleanliness & vaginal odor. [16] Moreover, the only kindness is permitted in emergency situations, where life is in imminent danger. Consequently, large numbers of women avoid seeking medical attention for gynecologic conditions for fear of being examined by male physicians this inconsistent with Amir et al. (2018). [17] This was reflected in their disagreed attitude.

In the present study, the majority of the studied women refuse follow-up visit and this agreed with Millstein, Adler, 2010, supported that finding expectation of coming for the gynecological examination again at follow up most of women with positive experience. [18]

In this present study the majority of women felt anxious and fear of pain and this agreed with laura, (2013), et ,aurora , (2016) who found that most common causes for anxiety among women undergoing gynecological examination were; fear of pain, being examined by a male doctor, and the position for the examination and instrument used for examination. [19] This may be due to differences in culture, tradition, and education.

Concerning third research question which was What are barriers that facing women during their first gynecological examination? Most of the studied sample self-reported that no pre and post examination instruction and this agree with Amir et al. (2018) Who found that majority among young female self-reported negative verbal emotional stress reaction (NVESR) was No clinic discharge information from health team, nor pre-examination orientation and preparation. [17] This which was reflected upon agrees their attitude concerning their gynecological examination.

The present study had revealed that there is a lack of privacy during Gyne. Ex. due to much presence of medical and nursing students, and a feeling of embarrassment. This result similar to result by Starešinič and Mihelič Zajec (2014) who affirmed that embarrassment and fear are the most commonly experienced reaction during the first pelvic examination. [20] Swahnberg et al., established that young female in adulthood experience strong discomfort during pelvic examinations. This result, in agreement with the present study result which found that (Gyne Ex) was stressful. [21]

Concerning fourth research question which was What was the relation between women knowledge and non-verbal response concerning their gynecological examination? This research question was significantly answered in the present study there was significant relation between knowledge and non-verbal response regarding afraid the majority of women had correct knowledge were afraid and completely correspond. Furthermore, in line with Hassan (2018) who illustrated that majority among studied young female had incorrect knowledge, which consequently had reflected upon their positive and negative verbal and non-verbal reaction concerning their Gyne. Ex. due to differences in culture, tradition, and education. [11] The present study finding had pointed out our attention that incorrect women knowledge regarding their first gynecological examination had reflected upon their verbal and non-verbal emotional response. Consequently, had leads to many barriers that prevent women to had happier and satisfied experiences related to their first gynecological examination which leads to avoidance of women for a return visit and follow up.

Finally, the provision of information and a respectful and engaged behavior during gynecological examinations was of great importance for women. This study could help to improve health programs to enhance the experience of gynecological examination for women.

7. Conclusion

Based on result of present study the following can be concluded:

Most of women's had incorrect knowledge regarding definition, importance and parts of gynecological examination. Furthermore, majority of women had moderate pain during gynecological examination. Also, most of them corresponding negatively verbal and nonverbal emotional response as well as no clinic discharge information from health-team. Gynecological examination was a stressful event, feeling of embarrassment, the majority recommend female not male gynecologist and disagreed about technique, pre examination preparation & health-team communication. Additionally, the majority of barriers were lack of communication with heath-team, too much medical and nursing student, waiting for long time, lack of privacy, lack pre and post examination instruction, difficulty in transportation and presence of male gynecologist.

8. Recommendation

Based on result of present study the following can be recommended:

1. All health-care providers must be attended training and counseling program to be able to communicate and interactive positively with women who attending to gynecological examination for first time.

2. Design purshors, guideline and poster concerning the importance & technique of female gynecological examination to enhance young female emotional verbal and nonverbal reaction towards their regular gynecological examination.

3. Nursing administrator must control to limit the number of medical and nursing student at gynecological clinic.

4. Hospital administrator must put in her consideration presence of female gynecologist to replace male gynecologist.

5. Design and implement program for health-team about communication skills to enhance their practical skills while providing counseling and health education pre and post gynecological examination to promote women verbal and nonverbal response regarding their examination.

6. Woman-health and midwifery-nursing department must integrate the importance of female verbal and nonverbal emotional aspect during gynecological examination into undergraduate and post graduate student nursing curriculum.

7. Further study: replicate the present study on another different sittings and larger sample.

References

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