Investigate Young Female Reaction Concerning Their Gynecological Examination

The aim of this study was to investigate young female reaction concerning their gynecological examination. Design: descriptive study. Setting: This study was conducted at obstetrics and gynecology outpatient clinic at Mansoura university hospital, Egypt. Subjects: two hundred and three young female. Sample type: purposive sample. Tools: An interviewing questionnaire schedule, emotional stress reaction questionnaire, visual analogue scale and immediately post gynecological examination assessment. Results: The present study results had revealed that, majority among young female had incorrect knowledge. Also, 90.1% of young female complain from pain during bimanual examination &insertion of instrument, It was observed that majority among young female had totally correspond negative nonverbal reaction during (Gyne Ex) were feeling of embarrassment (92.1%), while (84.2%) closed& tight her thighs during (Gyne Ex). In addition negative verbal emotional stressful reaction during (Gyne Ex) was no clinic discharge information from health team (88.7%). Moreover most of young female were disagreed about technique, pre-preparation (Gyne Ex). Furthermore 71.4% refused to repeated future (Gyne Ex). Additionally the main barriers by self reported by young female were stressful event (88.2%), lack of communication with health team (85.2%) & taking long time for waiting (79.3%). Conclusion: the present study concluded that the majority of the young female had incorrect knowledge. Also, most of them corresponding with negatively verbal and nonverbal emotional reaction as well as the majority were embarrassment and (Gyne Ex) hurted the dignity, Recommendation: design purshor, guideline and poster concerning the importance & technique of female gynecological examination to enhance young female emotional verbal and non verbal reaction towards their regular Gyne Ex).


Introduction
Gynecological examination is an essential part of gynecological care and is vital to get checked regularly to ensure that women have a good health and prevent or diagnose any disease in time and some may repeated it during their lifetime. Additionally this intimate physical examination may provoke much negative reaction, such as embarrassment, shame, anxiety and awkwardness among young female [1]. Meanwhile the first pelvic examination for young female years and the attitude of health providers may lay the foundation for subsequent pelvic exams [2]. Similar results are obtained in the research by Starešinič and Mihelič Zajec [3] who affirmed that embarrassment and fear are the most commonly experienced reaction during the first pelvic examination. In addition Swahnberg et al., [4] reported that women in adulthood experience strong discomfort during pelvic examinations, but find it necessary to confirm their health Furthermore pelvic examination is a routine part of physical examination in obstetrics and gynecology. It is very important in the diagnostic work-up of gynecologic cancers, gynecologic infections (including sexually transmitted diseases), bleeding disorders, sexual function disorders, infertility, and family planning services. However, many women declare reaction or experiences of fear and anxiety about pelvic examination [5].
Moreover (Gyne Ex) is crucial for promoting young female reproductive health. A large number of women in the world will have a gynecological examination at some time in their lives, and some may repeated examinations during their lifetime [6].
Minimal gynecological invasive examination(MGIE) can be done in outpatient clinic, this examination may be for diagnosis or treatment, included, pelvic examination, speculum examination, Transvaginal Ultrasonography, pap smear, cryotherapy, coloscopy. Also, the pelvic examination includes three components: inspection of the external genitalia (vulva, urethral meatus, vaginal introitus, perineal region); speculum examination of the vagina and cervix; and bimanual examination of the uterus, cervix, and adnexa [7].
Furthermore apart from the physical discomfort, the psychological factors are important as gynecological examination involves exposure of intimate parts of the body in a vulnerable situation with loss of control. Women experience many feelings, such as embarrassment about undressing, worries about cleanliness, qualms about vaginal odour, concern that the gynecologist might discover something about sexual practices, fear of discovery of a pathological condition, and fear of pain [8], or even the history of psychological, physical or sexual abuse [4].
Additionally cold instruments, lack of information about the procedure and lack of gentleness from the examiner are also perceived as barriers contributing to discomfort [8]. Also, an important barrier in the perception of the exam is also the gender of the examiner. Additionally Racz et al., [9] conclude that increasing experience with intimate examinations over time results in greater comfort with these examinations and a greater willingness to be examined by doctors of either gender. Another barrier to be considered in association with a patient's perceived level of discomfort is the premises and technical equipment used in gynecology [10].
Additionally American College of Obstetricians and Gynecologists(ACOG) suggests that the annual visit has value, and recommends annual (Gyne Ex) for asymptomatic adult young female [11]. Moreover during the pelvic examination the vaginal wall is assessed for rugae, texture and weak spots [12]. In addition to a thorough pelvic exam, other tests may order to further determine the cause of symptoms that are concerning [13]. However during the pelvic exam, samples of vaginal fluids may be taken to screen for sexually transmitted infections or other infections [14]. Some clinicians combine a routine pelvic exam along with other preventative procedures like a breast examination and pap smear [15]. Therefore many obstacle factors facing young female concerning their (Gyne Ex) such as lack of privacy & communication with health team, taking long time for waiting examination also, long distance to reach the clinic. Therefore caution that the examination room should ensure intimacy and sense of safety during the examination. A separate place must be provided to prepare for the examination [10]. The metal instruments should be warmed up before insertion to alleviate discomfort. In addition there are special preparations should be done for performing Invasive (Gyne Ex) procedure. Pre-examination, the woman lies in the lithotomy position. Then, use KY jelly over an examination instrument before inserted into the vagina to facilitate insertion. During examination presence of good light is important to clear observation and help in diagnoses [16].
Nurses have an essential role toward young female counseling, education, orientation and management through (pre, during and post) (Gyne Ex) in addition has a supportive role pre, during and post examination consequentially nursing role can promote and enhance young female experience and emotional reaction leading to happier and satisfied experience with (Gyne Ex). Similarly it is reported that the acceptance by health care providers and the patients is widespread, but it has many advantages includes greater clinical competence, increased performance, and efficiency as well as reduced costs [17].

Significance of the Study
Despite (Gyne Ex) is an essential examination of the female's pelvis. The pelvic exam is part of the physical examination in obstetrics and gynecology. It is very important and one of the primary screening modality in the diagnosis of gynecological cancers, gynecological infections (including sexually transmitted diseases), bleeding disorders, disorders of sexual function, infertility and family planning services. However, many women report reaction or experiences of fear, anxiety and embarrassment about the pelvic exam [5].
Consequentially it may be uncomfortable for most women. It can be physically and psychologically stressful for young female patients, mainly in the examination of the pelvic region. Some young female patients may be anxious about the procedure; some may have feared that it might be a painful procedure [18]. Moreover, after the young female has perceived (Gyne Ex), she may develop an attitude and reaction concerning the procedure that could be positive or negative based on the patients' perception. Consequently, it is very important to investigate women's reaction towards the invasive gynecological examination and its effect on female level of pain and satisfaction among the young female.

Operational Definition
Gynecological examination: is any procedure performed to the female genital tract where instrument is inserted directly into the vagina.
Reaction: feelings and response to a situation or event.

Aim of the Study
This study aimed to investigate young female reaction concerning their gynecological examination

Study Questions
-What was the young female's knowledge concerning their Gyne Ex?
-What was the young female emotional stressful reaction during their Gyne Ex? -What was young female level of pain during their Gyne Ex?
-What were barriers that facing young female concerning their Gyne Ex?
-What was young female attitude concerning their Gyne Ex?

Subjects and Method
Study Design: Descriptive design. Study Setting: The study was conducted at obstetrics and gynecology outpatient clinic at Mansoura university hospital, Egypt.

Subjects of the Study
Study type: A purposive sample consisted of 203 young female patients who attended the previously mentioned study setting, selected according to the following inclusion and exclusion criteria.

Inclusion Criteria
-Firstly registered to previous mention study setting. -Age ranged from 18 to 25 years -Able to read and write.

Exclusion Criteria
-Pregnant women.

Sample Size
Calculating sample size for the study, according females admitted to gynecological outpatient, through surveysystem.com/sscalc. Sample size calculator software, at confidence level 95.0% and confidence interval 2.5 of the study). The calculated sample size is 183 female and adding 10 % for better quality of data. So the number of study women was 203 female.
Tools of Data Collection (TODC): Data was collected through the following tools: Tool I: A Structured Interviewing Questionnaire Schedule: It was designed by the researchers after reviewing the related literatures to be filled from each woman. It consisted of three parts: The first part: A: assessed young female general characteristics (age, occupation, area of residence).
The first part: B: assessed young female reasons for visited gynecological clinic.
The second part: assessed young female knowledge concerning their gynecological examination as: (definition -Importance -pre examination preparation-Complication) Knowledge was scored as correct and incorrect answer for each knowledge question: Scoring system for evaluating women's knowledge was developed as the following: Each question was given 2 score for correct answer and 1 score for incorrect answer.

Tool 2 The emotional stress reaction questionnaire
It was adapted from Larsson and Wilde, [19] to assess women's reaction during all gynecological examination. It was modified as categories into positive and negative nonverbal emotional stress reaction, also excluded 4 items for giving the similarity of meaning, in addition excluded 4 items which are not appropriate and added another 7 items such as feeling of embarrassment, cry, afraid, irritable and changing her position, closed & tight her thighs during Gyne Ex, closed her eyes during Gyne Ex and attentive and cooperative to be appropriate for assessing women's reaction during all gynecological examination and for cultural religious aspect. Furthermore the scoring system was modified into totally correspond, partial correspond and not correspond.

Tool 3 The visual analogue scale to assess pain level adopted by Jensen, Chen &, Brugger, [20] A Visual
Analogue Scale (VAS) is a measurement instrument of pain intensity in adults. It is usually a horizontal line, 100 mm in length, anchored by word descriptors at each end, as illustrated into no pain(score of 0) and pain as bad as it could be" or "worst imaginable pain" (score of 100). (VAS) Score interpretation, a higher score indicates greater pain intensity. Based on the distribution of pain VAS scores pain intensity as none, mild, moderate, or severe, the following cut points on the pain VAS have been recommended: no pain (0-4 mm), mild pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm). Tool 4-Immediately post gynecological examination assessment Part A: checklist to assessed emotional stressful verbal reaction: It was designed by the researcher to assess women's reaction post gynecological examination. It was consisted of five positive verbal response statements and ten negative verbal response statements. Each statement was checked as (yes) or (no) for each statement. It was written in Arabic language.
Part B: Self reported barriers through open ended questions concerning barriers facing young female during their gynecological examination Part C: Likert scale was used to assess post gynecological examination attitude among young female. It was consistent of three items and it was evaluated as agreed, uncertain and disagreed regarding each item.

Validity of the Tools
Tools were reviewed by three specialist university professor at obstetrics& gynecological nursing field tested, according to their comments it was considered.

Reliability
Ferraz et al, [21] stated that visual analogue scale test-retest reliability has been shown to be (r = 0.94, P < 0.001). Non verbal emotional stressful reaction and verbal emotional stress reaction, Cronbach's alpha was calculated on a pilot of 23 young female. Its value for both tools was 0.901 and 0.842 respectively, while the test re-rest was (=0.884 and 0.861 respectively). These tools are valid and reliable.

Ethical Considerations
• The researchers obtained approval to conduct the study was obtained from the head of department of woman's health and midwifery nursing. • Then approval from the ethical committee at Mansoura university faculty of nursing (MUFN) was obtained to conduct the study. • Approval was from director of outpatient clinic Mansoura University Hospital. • Written informed consent was obtained from each young female who participate in the study • Each woman had the right to withdraw from the study at any time. • Tools were not touch women dignity, culture, and ethical issues. • Young female participant was interviewed individually in a private room to promote confidentiality of data collection

Pilot Study
It was conducted on 23 women (10% of the sample size) for three weeks to test the applicability, relevance of the research tools and the clarity of the designed questionnaire. They were excluded then all the required modifications were considered.

Field Work
The study was conducted through three phases:

Phase 1: Preparation phase
The researcher collected the relevant literature related to the study then designed and prepared tools of data collection finally the pilot study was conducted.
Phase 2: Implementation phase -Study was conducted at the previously mentioned study setting, at January 2014 to December 2014. The researcher visited the study setting from 9:00 am to 1:00 pm to interview young female for three days per week, each young female was interviewed according to their sequences from clinic registration book, firstly the researcher introduced their self to each young female then explain the aim of the study to each female to gain her confidence and trust and obtained written informed consent from each young female to participate in the study.
-Pre gynecological examination; each young female was interviewed individually at the private room for 20 minutes using interviewing questionnaire schedule to collect required data about general basic characteristic & their knowledge about Gyne Ex.
-All young female was instructed by the nurse to lie on dorsal recumbent position and expose the genital area. Also, young female was examined by the same gynecologist.
Phase 3: Evaluation phase -During examination observation of nonverbal emotional stress reaction was applied for each women to assess non verbal emotional stress reaction by using observational checklist, then assess pain level among young female during their examination by using visual analogue scale (VAS) and at the end of Gyne Ex each young female verbal emotional stress reaction was assessed. Finally each young female barriers and attitude regarding their Gyne Ex was assessed by using likert scale. Then, the collected data are coded then stored and the results were analyzed.

Statistical Analysis
Collected data were coded, computed and analyzed by using SPSS version 20.0. Data were presented using descriptive statistics in the form of frequencies & percentages. Quantitative variables were presented as means ± standard deviations.       Table 1 had illustrated that the majority among studied sample had incorrect knowledge about preparation before gynecological examining (87.2%), importance of (Gyne Ex) (75.9%), definition of (Gyne Ex) (70.4%), and complication due to gynecological examining (59.2%)  Table 2 had revealed that majority of positive verbal emotional stress reaction (PVESR) among studied sample was recommend female not male gynecologist for examination (81.3%). While about one quarter (rewarding Gyne Ex experience, health team answer her all questions during & after the (Gyne Ex). Furthermore negative verbal emotional stress response (NVESR), the majority of studied sample refused future Gyne Ex (83.3%) and it is immoral to expose my intimate part to male gynecologist(92.1%), No clinic discharge information from health team about three quarter had reported bimanual exanimation and insertion of instruments (88.7%), also, (Gyne Ex) may be damage internal sex organ(82.3%) and more than three quarter had no pre-examination preparations.   Figure 6. Frequency distribution among studied sample according to their self reported barriers concerning their gynecological examination Table 3 had illustrated that young female was totally correspond with attentive & co operation (19.7%), while partial correspond was (39.4%) additionally not correspond was (40.9%). Also, (15.3%) among young female was totally correspond with Concentrated with interest to gynecologist instructions, while partial correspond was (41.9%) and not correspond was (42.8%). Additionally more than one tenth had happy relaxed facial expressions totally correspond, more than one third was partial correspond and not correspond. While the majority of young female negative non verbal emotional stress reaction (NNVESR) totally correspond had embarrassment (92.1%), partial correspond was (3.4%) and not correspond was (4.5%) also, totally correspond with irritable and changing her position was (70.4%), partial correspond and not correspond was (14.8%), furthermore young female totally correspond closed& tight her thighs (84.2%), partial correspond & not correspond was (7.9%). Regarding indifferent among studied sample was (29.6%) totally correspond, while partial correspond & not correspond more than one third.

Discussion
The present study aimed to investigate young female reaction concerning their gynecological examination. This aim was achieved within the frame work of the present study research questions Concerning to1 st study research question which was about (what was the young female's knowledge concerning their Gyne Ex?). The present study result had revealed that majority among present studied sample had incorrect knowledge concerning (definition, importance, complication & preparation). This is in agreement with Norrell et al., [22] who found that approximately one-half of the participants stated that they knew the examination's purpose. Similarly Freyens et al., [23]. The study result had illustrated that the majority of young female in Egypt had incorrect knowledge regarding reproductive issue because culture and tradition prevent them from to discuss this issues of reproductive and gynecological health. Also may be due to educational level and nature of study sample that are from rural area also, and nature of silent symptoms of complain The present study had illustrated that majority of corresponding 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).
Concerning to the 2 nd study's research question which was about (what was the young female emotional stressful reaction concerning Gyne Ex?). The present study finding had revealed that majority among studied young female self reported positive verbal emotional stress reaction (PVESR) was recommend female not male gynecologist for examination, because our Egyptian culture, tradition and religious prevent female from exposing her intimate part to male gynecologist or obstetrician. This stressed the importance of female gynecologist or obstetrician at any health setting to enhance female to regularly visited health services. This consistent with Amir Alshiek et al., [24] who had reported that Nowhere is the gender of the health professional as crucial to the choice and adherence of young female as to the intimate nature of obstetrics / gynecology. Furthermore Arab female's preference for a female obstetrician/gynecologist in intimate procedures was due to feeling more comfortable with a female obstetrician/ gynecologist, [24,25]. Likewise, Rizk et al. found that the reason given for same gender preference of religious was "embarrassment during intimate examinations" [26].
Regarding to positive verbal emotional stress reaction (PVESR) about more than quarter among studied young female self reported of health team answering all questions during & after the Gyne Ex this finding due to most of examiner is male doctor which lead to avoidance of this service among young female.
Furthermore concerning to positive non verbal emotional stress reaction(PNVESR) among studied young female the present study finding had revealed that few was attentive and cooperation, also, very few was pleased and happy relaxed facial expression. This interrelated to nature of Egyptian female in endure the pain with silent. It was evident from the present study that there were the finding of (PVESR) it was reflected upon (PNVESR) of the present study.
Otherwise (NNVESR) it was reflected upon (NVESR) of the present study. As 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, This which was reflected upon their attitude concerning their (Gyne Ex) because most of them disagreed with health team communication and disagreed with preparation. Moreover majority among young female refused to be repeated future (Gyne Ex) again by a male doctor, (Gyne Ex), immoral expose intimate parts to male gynecologist, hurts the dignity this is could be related to exposure of intimate parts of their bodies in a vulnerable situation with loss of control and nature also, Arab who are viewed as being highly traditional, especially when it comes to rules of behavior for females, with an emphasis upon modesty. In addition, studied young female reaction of embarrassment & shame. While exposing the intimate part of their body, worries about cleanliness & vaginal odour. 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 Hilden et al., and Amir et al., [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. This was reflected upon their disagreed attitude.
Concerning feeling of unknown regarding the finding of (Gyne Ex), the current study had revealed that near to half among studied young female had this concern, some of female fear about the gynaecologist might discover something abnormal because female tolerate pain and discomfort or use traditional measure to relive paint without consultation of medical care so when presence of tumor or malignance discover at late stage also other female may be embarrassment due to previous sexual practices and fear of pain.
Additionally majority of young female state that (Gyne Ex) may damage internal sex organ(ISO), this pointed our attention to female reluctance towards attending gynecologic examinations, due to the nature of the examination, to young female's fear about damage (ISO) or perforation or to attitudes of the gynecologists, may result in delay or avoidance of gynecologic examinations with potentially harmful health effects. This is in agreement with Damico, and Hoffman, Barbara [12,13,14,15] who sate that pelvic examination can be part of the assessment of sexual assault. The American College of Physicians published guidelines against routine pelvic examination in adult women who are not pregnant and lack symptoms in 2014. [28].
As regards painful bimanual examination & insertion of instrument about three quarter of self reported among young female, may be related to use cold instrument. Furthermore the present study had revealed that more than three quarter reported that there's no pre-examination preparation which affect negatively the young female, this inconsistent with Hilden et al., [8] whom emphasis that discomfort during the (Gyne Ex) is strongly associated with a negative emotional contact with the examiner, therefore it is important to establish a rapport, offer a sense of safety, express empathy and build a trusting professional relationship to diminish the discomfort of the situation. This was reflecting upon their disagreed attitude regarding (Gyne Ex).
Furthermore the majority of young female (NNVESR) negative non verbal emotional stress reaction was embarrassment, afraid, irritable and closed & tight her thigh during (Gyne Ex). While few cry this interrelated to nature of Egyptian female character of shy and endure the pain with silent.
In relation to 3 rd study's question which was about (what was the effect of gynecological examination on the young female level of pain?). It was illustrated from the present study around half self reported had moderate level of pain, during (Gyne Ex) while few self reported sever pain during (Gyne Ex). Also, about one tenth reported no pains this result reflect upon the nature of Egyptian female about pain tolerance with calm &silent try to mange by traditional methods.
It was evident from the present study finding that the negative verbal and non verbal female reaction of (Gyne Ex) had reflected upon their attitude.
Regarding to the 4 th study's question which was about (what was young female attitude concerning their gynecological examination?). The result of present had illustrated that more than half among the studied young female disagreed with (Gyne Ex), technique, pre examination preparation and with health team communication. This result may be interrelated with specific examination position, lack of privacy from presence of medical and nursing staff, limited number of health team, so there's no enough time for giving information and pre preparation this result congruent with [29].
Concerning to 5 th study's research question which was about (What were barriers that facing young female during their gynecological examination?). The main barriers concerning (Gyne Ex) was stressful event then cold utilization of instrument, lack of communication with health team, long distance between home and hospital, taking log time for waiting examination. While more than half reported lack of privacy during examination due presence of medical and nursing students, these barriers had reflected upon their attitude where disagreed to repeated (Gyne Ex).
The present study had revealed that there's a lack of privacy during (Gyne Ex), due to much presence of medical and nursing students, and feeling of embarrassment this result Similar to result by Starešinič and Mihelič Zajec [3] who affirmed that embarrassment and fear are the most commonly experienced reaction during the first pelvic examination.
Swahnberg et al., [4] 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 event may be due to painful sensation, expose the intimate part, young age. The noted result lies in young female didn't receive any preparation and explanation about the (Gyne Ex) procedure. Additionally, there was a gap of communication between the young female and the health team.
Furthermore one of the common obstacles is the personnel's behaviour in the situation of (Gyne Ex) which may result in poor or ineffective communication. If the health personnel do not obtain the necessary information to tailor their approach to the woman's needs and preferences, the procedure may be even more unpleasant for the examinee [29]. This in agreement with the study result revealed that majority reported that lack of communication with health team.
Regarding to (Gyne Ex) taking long time for waiting examination this consider a barrier due to effect on female psychological status. In the same line Sarah et al., [30] reported that adverse psychological symptoms in women awaiting gynecological procedure. Also Ulker and Kivrak [5] stated that the major complain of the patients visiting an outpatient clinic was the waiting time before the clinical interview and examination. In addition long distance between home and hospital play a role in hindering to be checked and follow up by (Gyne Ex), because majority from rural area.
Additionally one barrier to be considered in association with a young female perceived level of discomfort is cold instruments, the premises and technical equipment used in gynaecology, this result congruent with [10].
Finally the present study 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). Additionally, had reflected upon their attitude to Gyne Ex, because the majority was disagreed about technique, preparation and communication with health team.

Conclusion
The present study concluded that the majority among the young female had incorrect knowledge. Also, most of them corresponding negatively verbal and nonverbal emotional reaction as well as no clinic discharge information from health team and (Gyne Ex) hurts the dignity, 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 (Gyne Ex) is stressful event, use cold instrument and lack of communication with heath team.

Recommendations
-Design purshor, guideline and poster concerning the importance & technique of female gynecological examination to enhance young female emotional verbal and non verbal reaction towards their regular gynecological examination.
-Nursing administrator must control and regulate number of students at gynecological clinic.

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-Hospital administrator must stress the importance of female gynecologist to be present at gynecological clinic to enhance female cultural, religious and emotional reaction.
-Design and implement program for health team about effective communication skills to enhance their positive reaction with their patients.
-Woman health and midwifery nursing department must integrate the importance of female verbal and non verbal emotional aspect during gynecological examination into undergraduate student nursing curriculum. Further study: replicate the present study on another different sittings and larger sample.