Introduction

Among malignant neoplasms, cervical cancer (CC) is an important public health concern, being one of the main causes of death among women [1,2]. It is characterized by the abnormal growth of cells, generated especially by persistent infection with oncogenic Human Papillomavirus (HPV) of various groups. These viruses have the ability to specifically infect epithelial cells and replicate in the nucleus of squamous cells, particularly those located in the genital region [3–5].

The prevalence of HPV infection can vary significantly depending on the population studied and the methods used to detect the virus. Studies have shown high rates of this infection among women living in the Amazon region of Brazil [6–12], a context in which a meta-analysis showed an average prevalence of 25.41% for cervical HPV in Brazilian regions, with particularly high rates in populations with less access to health services [6] and in women aged 25 or younger [7–9].

In riverside populations in the state of Pará, one of the federative units of this country, the prevalence of HPV was estimated at 16.4%, with 2.3% of cases attributed to HPV-16 and 1.4% to HPV-18, both with high oncogenic risk, and approximately 70% of women had never had a Pap smear (PS) [7,8]. Low screening coverage, combined with the existence of viral types with high oncogenic risk, indicates increased vulnerability to the development of cervical lesions in these populations [9].

In the context of traditional communities and peoples, epidemiological analyses also highlight a high prevalence of HPV infection among indigenous people in the Amazon region, with an estimated rate of 34.2%. This highlights the need for culturally appropriate public health actions and strategies to reduce the occurrence of this infection and its biopsychosocial repercussions among these communities [9], whose vulnerabilities tend to be as severe as those found in the daily lives of riverside populations.

Among the ways to prevent HPV infection and, consequently, the risks of becoming ill from CC, using condoms and anti-HPV vaccination stand out. Furthermore, the pathology is directly linked to smoking, prolonged use of oral contraceptives, early onset of sexual activity and a sexual lifestyle with multiple partners. Usually, signs and symptoms are not evident in the initial phase of the disease, but, as it worsens, manifestations such as intermittent vaginal bleeding or bleeding after sexual intercourse, abnormal vaginal discharge and abdominal pain may occur [13,14].

With PS, early diagnosis can be made and possible worsening can be prevented [4,5,15]. It is worth highlighting that, in addition, other strategies can be used to detect HPV early, such as innovative self-collection methods combined with molecular diagnosis, which have been shown to be an effective strategy for screening for CC among women in rural and hard-to-reach communities, such as riverside populations [16–18]. Studies conducted in the Northern region of Brazil, especially in the states of Amazonas and Pará, showed high acceptability of cervicovaginal self-collection among women who participated in these studies, in addition to significant agreement between self-collected samples and samples collected by health professionals to detect HPV and high-risk HPV [16–18].

According to global estimates, this type of cancer ranks fourth in the highest incidence in the female population, presenting more than 604,000 new cases in 2020, which corresponds to 3.1% of all types of cancer, accounting for the seventh most common in the world [19]. In Brazil, from 2023 to 2025, more than 17,000 new cases are expected, with an estimated risk of 15.38 cases for every 100,000 women [20].

Unequally distributed among Brazilian regions, CC has a higher prevalence in the North, Northeast and Central-West due to the peculiarities of these regions. In the North region, according to national estimates for the 2023–2025 period, CC ranks third among the most common types of cancer [20]. It mainly affects women aged 25 and older, and is associated, in most cases, with challenging sociodemographic and epidemiological conditions, such as low income, reduced access to health promotion and illness prevention actions, in addition to a low level of education [21].

In the context of the groups that inhabit the Brazilian territory, riverside populations constitute a segment exposed to social vulnerabilities that are characterized by sociodemographic and epidemiological conditions similar to those already mentioned. This reflection is made considering the assistance initiatives that are insufficiently received from the Brazilian State through its public policies, contributing to reduced or unfeasible access to health services [22,23]. Furthermore, it is necessary to consider the scenario in which riverside women experience certain restrictions in their own healthcare due, for instance, to a low level of knowledge about the importance of certain services or preventive procedures [7].

Therefore, the issues at hand indicate the need to better assist this population, considering that CC represents a concern in women’s daily lives, mainly in developing countries and among vulnerable groups, such as riverside populations, as prevention and control measures have not yet achieved encouraging results [24].

Given the relevance of the topic, this study aimed to analyze riverside women’s knowledge about preventive measures against CC and its influence on the adoption of these measures.

Methods

Results

Among the participants, the age ranged from 23 to 64 years, with the age group from 23 to 32 years prevailing (n = 7; 35%). Regarding color/race, 14 (70%) declared themselves to be brown and, in relation to the level of education, those who reported having completed high school (n = 7; 35%) and incomplete elementary school (n = 6; 30%) predominated. There was a predominance of Catholics (n = 9; 45%) and Evangelicals (n = 6; 30%), in addition to singles (n = 8; 40%), self-employed (n = 7; 35%) and housewives (n = 6; 30%).

For monthly family income, the minimum wage in force in Brazil during 2023 (R$ 1,320.00) was used as a reference, in which 14 (70%) participants had an income lower than or equal to one minimum wage. All were mothers, and the number of children varied from one to four per woman, with those who had two children prevailing (n = 9; 45%). Regarding sexual life, 17 (85%) reported having an active sexual life (Table 1).

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Table 1. Sociodemographic and clinical profile of participants (n = 20). Belém, Pará, Brazil, 2023.

https://doi.org/10.1371/journal.pone.0347609.t001

In the case of data generated by IRaMuTeQ^®, the corpus consisted of 20 texts, corresponding to the set of interviews. Furthermore, 262 TS were identified, with 222 being used, making up 84.73% of the corpus. A total of 9,126 occurrences (forms or words) emerged, of which 1,320 were distinct words and 651 hapaxes (words whose frequency is equal to one), with an average of 34.83 occurrences per TS.

IRaMuTeQ^® dimensioned and classified TS based on DHC, generating six lexical classes using a dendrogram. To present the results, the classes were analyzed in two subcorpora: the first subcorpus was composed of classes 2, 4 and 6; and the second was composed of classes 1, 3 and 5 (Fig 1). Thus, it was possible to organize three thematic axes. The first axis, consisting of classes 2, 4 and 6, brings together TS that demonstrate perceptions about CC, behaviors regarding gynecological signs and symptoms and opinions about access to information about the disease. The second axis, with classes 1 and 5, demonstrates experiences related to cancer and the adoption of preventive measures in the face of risk factors for the disease. Represented by class 3, the third axis presents ideas that come from social thinking about HPV.

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Fig 1. Descending Hierarchical Classification dendrogram of the “Riverside women’s knowledge about preventive measures against cervical cancer” corpus. Belém, Pará, Brazil, 2023.

https://doi.org/10.1371/journal.pone.0347609.g001

Based on this organization, thematic axes were named, respectively: “Riverside women’s perceptions, behaviors and access to information about cervical cancer”; “Knowledge about preventive measures against cervical cancer”; and “Knowledge about the human papillomavirus and its relationship with cervical cancer” (Fig 1). The axes are presented below, highlighting the contents and main lexical characteristics of their classes as well as some emblematic excerpts.

Discussion

The results of this study demonstrate that, although women recognized the severity of CC, they had limitations in describing its basic characteristics, demonstrating a deficient level of knowledge regarding the disease. Limitations like these were also highlighted in research with women who lived in rural communities in Malawi [37], demonstrating the lack of basic understanding about cancer in general and CC screening among participants, a reality also verified in a study with women from a traditional population in northeastern Brazil [38]. In view of this, it is important that women understand aspects related to preventive measures, as knowledge helps them to make informed decisions about screening tests and necessary care, having a positive impact on their health.

The elements related to lack of knowledge about the disease are related to several determinants, such as level of education, socioeconomic status, availability of access to health services, and women’s beliefs and perceptions about concepts of health, disease and preventive measures, as pointed out in research with women from rural Indian communities of Jaipur, state of Rajasthan [13], and Javarnahalli, state of Karnataka [39]. Thus, riverside populations’ low education level, their low socioeconomic level and territorial barriers they face in accessing essential services, especially health services, can have a significant impact on the way they perform self-care and reflect on their health, as evidenced by the results of this study.

A literature review on decision-making actions based on knowledge about CC identified knowledge related to signs and symptoms and preventive measures, showing reasonable knowledge of women, but restricted attitudes in seeking health services in a timely manner, despite understanding the need to carry out tests to diagnose CC early [40]. Partially differing from the findings of this review, it is important to highlight that, in the reports of this study, participants demonstrated positive attitudes that allude to the search for professional guidance and carrying out test for signs and symptoms that may make them suspect an abnormal gynecological condition, even though they did not specify the most important clinical manifestations of CC, such as pain or vaginal bleeding, highlighted in the scientific literature on the subject [40,41].

Hence, it is emphasized that the search for care in health services, without regularity and driven only by a suspected condition of abnormality or existing pathology, characterizes fragmented preventive care, with insufficient or ineffective health promotion actions, given that, in this case, the search does not occur, primarily, with the objective of preventing pathological changes in gynecological health. This context was identified in the health education experience carried out in an indigenous community with Tabajara women, in which the search for PS was found in situations of suspected bacterial or fungal genital infections, a fact that may limit the identification of lesions with carcinogenic potential by the same test [42].

Despite the positive attitudes, this highlights an important gap in the study participants’ reports. This weighting is made considering that PS, with its potential to prevent and screen CC early, was rarely mentioned by women when they reported the care taken to prevent the disease, a context in which imaging tests stood out, especially transvaginal ultrasound.

Reports that indicate changes in participants’ attitudes based on their experiences with people affected by CC stood out so that, with the identification of gynecological abnormalities, they are soon encouraged to seek care at a health service. From this perspective, we reflect on the repercussions of these experiences in encouraging self-care practices, emphasizing the importance of scientific knowledge so that subjects can perform them appropriately, through which they are aware of the aspects surrounding the topic, such as risk factors for illness, prevention strategies and ways to diagnose CC. This knowledge is essential as it favors women’s autonomy in caring for their own bodies, avoiding conflict of information from dialogue with third parties, when this is the main source of knowledge about diseases such as CC [43].

Participants reported that, in some circumstances, they heard something about the disease, but still knew about it superficially, which is why they said they knew little about its causes and preventive measures. Other studies found a similar result, made up of a considerable number of women who had already heard about the disease and/or knew something about it, but did not know how to adequately inform a sign or symptom, preventive measures or the cause related to HPV [44,45]. Furthermore, the lack of broad and disseminated information about HPV can encourage negligent behavior, implying greater risk for the female population, since HPV infection is one of the most common STIs in the world [46].

Thus, the role of healthcare professionals in sharing information and clarifying doubts effectively is reaffirmed, taking full responsibility for promoting health and preventing illness. As strategies for this purpose, health education actions can be carried out to provide women with knowledge about the causes of CC, preventive measures and the importance of carrying out PS regularly [42,47], with the aim that such knowledge supports conscious decision-making regarding the management of their own health.

However, it is not enough to simply inform; it is necessary to pay attention to the quality of information shared. It is known that this quality is influenced by healthcare professionals’ sensitivity in enabling understanding for riverside women, with educational actions in which they use accessible vocabulary on topics of individual and collective interest, valuing their geographic and sociocultural context [48,49].

Therefore, based on the statements presented here, it is understood that language adequacy to enable communication between professionals and users constitutes an aspect to be considered in the healthcare of these women. This was also highlighted by an experience report that complementarily investigate indigenous women’s knowledge about CC, demonstrating that their understanding was limited and that the scenario in which they lived was not conducive to effective communication with professionals, as, in the health unit that assisted the indigenous community, this aspect was little valued in educational practices [42].

As reiterated in the literature, important limitations related to access to information about the disease include geographic and social aspects, since the main sources of information for many people, in the context of health issues, refer to what is broadcast on television media and/or appointment with healthcare professionals to whom they have access. However, not all social realities are covered by routine access to health services to obtain information about CC, due to difficulties in accessing means of maritime transport and, often, long distances between places of residence and health units, as often occurs with riverside populations, since the river dynamics and forest imposition spawn these difficulties [50].

Participants demonstrated that they understood that preventive measures are necessary in the context of the disease, but they did not know enough about which measures they should adopt, because, when asked about barrier methods, they quickly said that they would possibly not fit into this condition. Therefore, it is important to highlight that the lack of scientific knowledge about such measures means that they are not adequately prevented, a fact that can increase risk factors due to length of exposure to HPV, organism aging, sexual behaviors, among others [51].

To encourage self-care practices, this highlights the need to share, with contextualized and accessible language, that CC is a condition caused by changes in the tissue that covers the cervix due to uncontrolled proliferation of cells that deteriorate the underlying tissue. Despite having repercussions on the structure and/or functionality of adjacent organs or even more distant regions of the body, it is a slowly evolving disease that is subject to early identification, effective therapeutic intervention and adequate monitoring, resulting in a favorable prognosis and possibility of cure [13,14,52].

As vulnerable groups, in addition to being marginalized in the provision of effective public policies, it is appropriate to highlight that riverside populations are still rarely seen in health research, as evidenced by a bibliometric study that measured scientific production on these populations’ health in Brazilian territory. To this end, different databases and electronic libraries were used, covering national and international literature, without choosing a time frame, study designs and languages, so as not to reduce the acquisition of materials. However, only 35 documents were included, whose first publication took place in 2007, indicating growth in production only in the four-year period from 2019 to 2022 [53].

Conclusions

This study analyzed riverside women’s knowledge about CC and measures to prevent the disease, identifying gaps in this knowledge. Furthermore, we observed particularities of thought and attitude when adopting these measures, making it possible to reflect on how such aspects had or could have an impact on women’s daily lives in order to strengthen or weaken their health.

Considering the importance of healthcare professionals, this knowledge can give them the opportunity to rethink and redirect strategies, especially with regard to educational activities with vulnerable groups, such as riverside populations. It is understood that, in a special way, this applies to nursing professionals in Primary Health Care (PHC), given their closeness to communities and their relevant contributions to healthcare.

Therefore, in addition to supporting possible reflections on care, care management and educational activities that value the peculiar contexts of these populations, the results can encourage the proposition of new objects of study to thus develop research that makes it possible to understand or clarify aspects not covered here as well as deepen evidence about riverside women’s knowledge and practices about CC.

Supporting information