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.