Methods:
The present qualitative study was conducted based on the conventional
content analysis approach to understand the reproductive concerns of
HPV-positive women by exploring their feelings, experiences, and
perceptions (15).
This study was carried out from September 2018 to December 2019 at the
referral gynecology-oncology outpatient clinic of Valiasr (located in
Imam Khomeini hospital complex, a large, busy, university-based, and
geographically accessible complex in Tehran) serving a large population
of women from across the country. The clinic is equipped with colposcopy
and directed by oncologist-gynecologist SHSH and her colleagues.
A coordinator of Valiasr clinic sent all women tested positive for HPV
(either only high-risk HPV or both high-risk/low-risk strains) to the
interviewer (KQ-female- no relationship with participants) in the calm,
convenient room to provide them information about the purpose and
methods of the study. Women were eligible for interview if they were
over 18 with a heterosexual partnership; had no severe disease
(including cervical cancer) and were willing to share their experiences.
A maximum variation purposive sampling was used to recruit
information-rich candidates with diverse age, marital status, education,
and socioeconomic status. In total, 20 Persian-speaking women with
different ethnic, cultural, and religious backgrounds were included. Two
invited women refused to participate because they prefer not to discuss
HPV. Since the clinic is crowded, all participants interviewed during
their waiting hours. Semi-structured one-to-one interviews were
conducted using an interview guide (Appendix 1) started with the
demographic background and reproductive and screening history. Three
pilot-interviews were done (included in the study) to improve questions.
Memos aided to design the next questions of the subsequent interviews.
Besides, field notes were written during the interviews. Face-to-face
in-depth interviews with participants’ consent were recorded (lasted
between 35 and 90 minutes), transcribed verbatim, and collected until
data saturation was reached over fifteen months.
The data analysis was performed concurrently with data collection, using
a qualitative content analysis approach described by Burnard et al.
(16) using MAXQDA 10 software. Initially,
interview transcripts, memos, and field notes were integrated, and two
coders (KQ and STM) read the transcriptions multiple times to formulate
a general understanding of the whole data. Open coding was based on this
approach. Primary codes were then reduced by constant comparison and
combination. The extracted codes were then brought together in terms of
similarities and differences. The sub-categories with similar content
were interpreted in a higher level of abstraction into the main
categories.
The accuracy of this qualitative research was ensured according to the
four criteria proposed by Guba and Lincoln, namely credibility,
dependability, confirmability, and transferability
(17, 18).
The credibility criterion was achieved through prolonged engagement and
member checking, by which, the transcript and extracted codes from the
interview were returned to each interviewee to approve their accuracy.
Confirmability and dependability of the results were ensured by peer
debriefing and external checking. Therefore, two observers reviewed and
rechecked all transcripts, codes, and themes. Finally, this process
completed with numerous discussions among the research team about areas
of disagreement until reaching a final consensus. To enhance the
transferability of the results, we tried to consider the maximum
variation during sampling. We interviewed women with diversity in age,
relationship status, education, socioeconomic status, and cultural
background. In qualitative research, generalizability labeled as a full
description of the setting, the participants, and the themes in rich
detail through the lens of the outside reader. To attain dependability,
the process within the study was described in detail.
This study was undertaken as a part of a Ph.D. thesis in Reproductive
Health, which was reviewed and approved by the Ethics Committee of
Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1397.139).
Moreover, Valiasr hospital managers willingly facilitated the study.
Written informed consent was obtained from all the participants. Direct
quotes that are representative of the participants have been presented.