Advances in Cancer Prevention
Open Access

I was crippled with fear and apprehension when at the beginning of the semester we when told that the end of semester’s term paper is on concept analysis. I was anxious because I did not know what concept analysis was and how I will be able to do it. The fear vanished gradually after we were taught about concept, how to analyze it and also when I read a lot of articles on concept analysis.

Hoffman [1] said that humans have always been scared of the unknown. This explains why most clients become frightened and anxious when they are diagnosed of a condition for the first time and especially when they don’t know anything about that condition. Some also become terrified when they are told they will be going through a procedure at the hospital without giving them enough information about the procedure.

Being afraid of the unknown is not a new concept [2]. Fear according to scientists is a negative emotional state elicited by the presence of an external stimulus that is possible of causing harm, and anxiety [3]. Fear affects the day to day activities of a person as well as ability of a person to make decisions [3]. According to Lovecraft [4], fear is said to be the oldest as well as the strongest emotion of man and he identified the unknown to be the greatest of all fears. The unknown is said to be lack of information at one’s consciousness level [5]. The fear of the unknown is said to cause more worry than when one is aware of an impending danger [6].

This also explains why a patient after being told of an impending surgery feels more anxious and psychologically distressed especially when he/she doesn’t know about the surgery itself, pre-operative preparation procedures, intra operative activities as well as what will happen after the surgery. Patients become relieved of anxiety and signs consent form after they are enlightened on the surgery, its outcome and the need. Surgical fear is described as tomophobia and is termed as an intense fear which is associated with impending surgery or any medical intervention [7].

This severe fear arises from several factors such as fear of the surgical procedure, fear of the anesthesia, having to undergo blood transfusions, being stung by an insect, being pricked with needles, losing dignity or even dying as well as well as being informed about impending surgical procedure (Th eunissen, 2014). Lack of understanding was again found as one of the things that will cause patients to postpone surgery [8]. Emotions of Anxiety, fear and shock were reported among women receiving HPV cervical cancer screening in England [9].

Cervical cancer is said to be of concern Globally [10], affecting women worldwide [11] and causing more than 270,000 deaths worldwide each year. Out of 20 countries that have the highest incidence of cervical cancer worldwide, 16 of them are African countries [12]. It is the principal source of cancer deaths among women in Ghana [13], the commonest gynecological malignancy seen at the Korle Bu teaching hospital [13-15].

Cervical cancer screening is used to control and prevent cervical cancer worldwide. Cervical cancer screening using Pap smear test has led to decline in death rates from cervical cancer in the United States [16]. Papanicolaou smear or ‘Pap test is recommended for women who are sexually active, thus from 18-20 years to 69-70 years [17]. Pap smear test is recommended every 3 years among women beginning at the age of 21-29 years and every 5 years among women between 30-65 years (American Cancer Society, 2014; CDC, 2017). A higher patronage in cervical cancer screening examination, is important in preventing cervical cancer especially the Pap smear test since it gives the possibility of early cervical cancer detection (Labeit & Peinemann, 2017).

Despite the benefits of cervical cancer screening in prevention of cervical cancer among women, the patronage of cervical cancer is low. Screening coverage in developing countries is low ranging from 2.0% to 20.2% in urban areas and 0.4% to 14.0% in rural [18]. This results is not different from Ghana, since out of the 1193 population studied in the capital of Ghana (Greater Accra Region), 2.1% had never done Pap smear screening [13].

This is attributed to lack of awareness of cervical cancer screening since it was found by [10] that about, 93.6% of the respondents are not aware of the risk factors of cervical cancer and 97.7% had never heard of Pap smear test in a research done in Elmina, Ghana. [19] also said that not much is known concerning Ghanaian women's knowledge and beliefs about cervical cancer screening.

The results is also is said to be similar in other countries like Nigeria where it was revealed that only few 37.2% of respondents studied have ever heard of cervical cancer thereby influencing the screening (thus only 8.5% had undergone pap smear screening [18]. Also in Di et al. [20] identifying lack of knowledge as leading cause to poor patronage of screening among women in China leaving in rural areas. Again [21] also identified lack of information as one of the barriers to cervical cancer. Ashtarian et al. [22] also identified unawareness about the Pap test was the main barrier to performing the test.

Other researchers have found other obstacles to cervical cancer screening which are embarrassment, fear of pain and worries about what the test might reveal [23]. It was further revealed by Ebu [10], that majority of the respondents were with a negative belief that the Pap smear test was embarrassing and painful. Again, it was found in a study by Ekane [24] that 45.3% of its respondents were of the fear that, something wrong might be detected if they went for a Pap smear test. Moreover, fear was the first factor detected among Hispanic women in the year [18] as a perceived barrier towards cervical cancer screening. According to these researchers, to overcome this issue and other barriers, the following were recommended: physician recommendation, community outreach programs with the use of Hispanic lay health leaders, Spanish print material, and use of culturally specific media.

In addition, Fear was listed as the first among the main psychosocial barriers to cervical cancer screening among women in Korean- American [25]. They recommended that medical advice and education would influence participants to undergo a Pap smear test. Some respondents of a study done by Crista, et al. [26] were of the belief and fear that cervical cancer screening could break their virginity thereby preventing them for partaking in cervical cancer screening. Fear of bleeding or abortion was identified among pregnant and postpartum women in Fortaleza, Ceará, Northeastern Brazil as one of the reasons why the will fail to go for cervical cancer screening [27].

Similar to the above results, findings from a study done by Anaman [11] revealed lack of knowledge about cervical cancer and Pap smear, the absence of warning signs, embarrassment, fear, concern about the gender of the service provider, lack of privacy, cultural and religious beliefs, and healthcare system factors as barriers to screening and finally, misconceptions about Pap tests, fear of diagnosis of serious illness, perceived pain, embarrassment, bodily modesty, and limited access to female health care providers were identified as reason for low cercal cancer screening patronage [28].

It can be deduced from the above discussion that the poor patronage of cervical cancer screening in Ghana and other countries could be attributed to lack of knowledge about cervical cancer screening, and fear about the screening. It is therefore necessary to explore the concept of “Fear of the unknown” in relation to cervical cancer screening.

A concept is defined as something perceived in the mind [29]. According to Bousso [30] here are no definite ways or common grounds for defining a concept. Concepts are defined as something that is abstract or formulation of words that symbolize mental pictures [30]. Analysis is defined as careful explaining or describing the mental picture to get understanding (Collins English dictionary, 1819). According to Cronin [31] concept analysis refers to the process of identifying concept, and distinguishing it from other concepts to help resolve gaps of a particular discipline [31].

Methods

There are several methods that have been identified by researchers for analyzing a concept which includes Wilson’s method 1963, Schwartz-Barcott & Kim’s 1993, 2000 Hybrid model, Rodgers’ method 1989, 2000 - Evolutionary approach, Näsi; Takala & Lämsä, (2001) in business studies, Walker et al. [32]. The concept of fear of the unknown was analyzed using Walker [33] methodology. Walker & Avant’s method was selected because it is said to be the most frequently used method [34]. Also, according to Duncan et al. (2007) they are regarded as one of the first to theoretically discuss concepts of the nursing science, their method even though criticized and modified it is still being used in large number of studies [34]. This method is made of 8 steps which are: Selecting/identifying a concept, determining the aims or purpose of analysis, identify all uses of the concept, determining the defining attributes, identifying a model case, constructing borderline and contrary cases, identifying antecedents & consequences, and defining empirical referents.

After critical analysis of the topic “Assessment of cervical cancer screening among women” several concepts were drawn from “assessment” which are perceptions, practices, barriers, beliefs, knowledge etc. After careful reading articles on cervical cancer screening in Ghana, it was deduced that patronage towards cervical cancer screening in Ghana is poor (thus 2.1% patronage in cervical cancer screening in Accra, Ghana [13]. This was attributed to lack of awareness on the screening [10].

In other countries it was also found that barriers to cervical cancer screening include lack of information on cervical cancer screening as well as embarrassment, fear of pain and worries about what the test might reveal [23]. Considering the fact that the lack of awareness might bring about fear and cause women to be anxious about a lot of things including what the test might reveal, fear that it might be painful, fear of been exposed, fear that it will be costly etc. the appropriate concept chosen is “Fear of the unknown” in relation to cervical cancer screening.

The aim of the concept is to identify the meaning of fear of the unknown, to explore the concept of fear of the unknown in nursing, also to identify the defining attributes of fear of the unknown as well as the relationship between the two, and to find the operational definition for fear of the unknown. This will help to better understand this concept and its relation to cervical cancer screening

A literature search included Science direct, CINAHL, and Google scholar. Terms like “Fear”, “Unknown,”, and “Fear of the unknown” was used to help retrieve some of the relevant journals and articles available.

Dictionary definitions

In the searches for data through encyclopedias and dictionaries, the combined words “Fear of the unknown” was not found. Hence “Fear” and “unknown” was searched separately.

Fear has several definitions from dictionaries’ point of view but few will be considered. According to Dictionary.com (2002) fear as a noun is defined as “distressing emotion aroused by impending danger, evil, or pain”. Cambridge English dictionary (2017), also defines fear as an unpleasant emotion or thought that when you are frightened or worried by something dangerous, painful, or bad that is happening or might happen and fear as a verb as “to be frightened of something or someone unpleasant”.

Fear as a noun is also defined by oxford English living dictionary as “An unpleasant emotion caused by the threat of danger, pain, or harm” and as a verb as to be afraid of something or someone that can be perceive as dangerous, harmful or painful. Similarly Collins English dictionary also defined fear as the unpleasant feeling experienced by a person towards an impending danger. Furthermore Merriam-Webster defined fear as “an unpleasant emotion caused by being aware of danger: a feeling of being afraid.

Unknown has several synonyms in thesaurus Dictionary.com as unexplained, unexplored, new, secret, unrecognized, unrevealed, unidentified, unfamiliar, undiscovered, strange etc. and defined as “not known; not within the range of one's knowledge, experience, or understanding; strange; unfamiliar”. Cambridge English dictionary defined it as “not known or familiar”. Merriam Webster dictionary also defined unknown as a place, situation, or thing that you do not know about or understand Cody & Alvin, said that the Unknown can take the form of anyone, anytime, or anyplace, that feeling you get that makes you uncertain about your future, is fear. Everyone of conscious mind has a fear of putting the two words together, fear of the unknown is shortened as “FOTU” [5]. Holland also cited in Peng [35] said that everyone has fear for the unknown within his or her deepest psyche. With this reason we stay in situations that are not good for us being afraid to change even though the unknown is packed with potential for possibility and personal growth [36,37] said that a very big part of fear is lack of knowledge and supported it with the fact that a person becomes terrified when an unknown thing falls beside him or her until that thing is identified and it is realized that it is not even harmful as they had thought. And he added that lack of knowledge is the foundation of most fears.

Popvich [38] a psychologist says that even if what we are afraid of actually happens, it can still be used to one’s advantage. This means that those who are afraid of cervical cancer screening because of the fear that they might be diagnosed of cervical cancer will still be at advantage even if it happens so. This is because it can be detected early, so treatment can be started early and prevents serious complications.

According to Hadjicostis there is greater power in what is not yet known since it exposes us towards new life experiences, new knowledge, and new human relationships – a renewed and revitalized life. Despite the advantages of the unknown, we either accept or object the unknown but Hadjicostis added that, the Unknown must be embraced since everything that belongs to the Known of today was once unknown. The unknown is therefore, defined the as the name we give to the experiences and knowledge we are yet to gain.

Fear of the Unknown in Nursing

Andrew Rosen, director of The Center for Treatment of Anxiety and Mood Disorders in Delray Beach, Florida said fear of the unknown is the biggest fear among patients. One nursing diagnosis formulated for client to help relieve anxiety of patient in nursing is fear/Anxiety related to new or strange environment; lack of knowledge about one’s diagnosis, diagnostic investigations, treatments; financial concerns; and feelings of confinement [39]. This show how important this concept is in nursing.

A research done by Bahrami et al. [40] among Iranian nurses concerning their fears revealed the following results “fear of pain and punishment,” “fear of losing worldly involvements,” “religious transgressions and failures,” and “parting from loved ones”. Another fear that has been identified among nurses is anxiety towards clinical practice especially during their first exposure [41].

Percival [42] defined fear of the unknown as feeling uncomfortable with a situation we are unsure of, trying to make it known and understood. He added that the fear is experienced even if we know for sure that the change is positive. Fox [43] gave one example to this as “Mary Jones even though smokes two packs of cigarettes refuses a mammogram because, as she so bluntly puts it, "I don't want no x-ray on my boobs x-rays cause cancer." Fox [5,43] also identified that clinicians have several fears they are trying to overcome ranging from acquiring new skills, marketing themselves and making the transition from being a paid provider in a clinic to running their own clinic and paying others. Below are some definitions on fear of the unknown elicited from professional nurses and student nurses. Akayuure MPhil nursing student at the University of Ghana, defined fear of the unknown as a patient who has been diagnosed of a problem/condition and doesn’t know the outcome of the condition. Kappiah also defined it as a psychological state where an individual is afraid of something that may or may not be exist.

Determining defining attributes

Walker and Avant [33] defined attributes as the features that are used to describe a concept to give more meaning. It was also defined by Walker and Avant as a characteristic that is used to differentiate one related concept from another to help in understanding of a concept as cited Gültekin et al, [44]. The attributes that were identified are stimulus, anxiety and education or creation of awareness.

Stimulus

A stimulus is defined as anything that encourages activity in people or things (Collins English Dictionary, 1819). Farlex also defined stimulus in the free dictionary as any agent, act, or influence that produces functional or trophic reaction in a receptor. Narrowing it to this topic, stimulus is anything that will cause patient to be anxious, and bring about fear and apprehension. There are a lot of situations that can cause someone to be anxious, some of which are: seeing dangerous animals and insect that one fears, an accident scene, been diagnosed of a chronic condition, death of a loved one, going for an interview, preparing for xams, some medical procedures like injection, impending surgery. In relation to the topic the stimulus is cervical cancer screening since some people have the fear that the screening might reveal cervical cancer [45], hence they will prefer not to go for the screening to even find out at first place.

Anxiety

From my personal experience, I’m always filled with fear whenever we stop at a filling station to purchase fuel due to the gas explosion that befell the country at gas station at Madina atomic junction. Middleton [46] said that everyone at a point in time experiences anxiety that rises from stimulus like preparing for an examination, having a medical test or job interview. Feeling anxious towards a situation could be normal or abnormal Middleton [46] Anxiety is defined as a vague and discomforting feeling, or dread, followed by autonomic answer (the source is frequently not specified or unknown for the individual); apprehension feeling caused by the anticipation of danger.

One’s a person is exposed to or anticipating a dangerous stimulus it brings about anxiety. Individuals anticipating cervical cancer screening (stimulus) becomes anxious and worried about several things. One of these stimuli is fear of getting to know that they have cervical cancer [47] to the extent that some women equated cervical cancer to be death sentence [48], anxiety that is painful Armstrong et al. [49] it will cause damage [50], and fear of embarrassment or being screened by male health professionals etc.

Because of these fears and anxieties about cervical cancer screening, most women prefer rather not know about diseases due to the fact that it has no cure and can lead to death have no cure [7]. In solution to this, one research found that playing music during the test can help relieve women anxiety [50]. Also the results from Marteau [50] shown that women can experience high levels of anxiety towards cervical cancer screening even higher than anxiety levels in women before surgery.

Education

One way that has been shown by researchers to relieve fear and anxiety associated with cervical cancer screening is through creation of awareness about cervical cancer disease and screening. Gele found out that one way to increase cervical cancer screening uptake is disseminating information through different channels. Teng [36] also found out that increasing knowledge and creation of awareness can help women to overcome embarrassment and other psychosocial barriers associated with cervical cancer screening. Again, Abiodun, Fatungase, and Olu-Abiodun [51], in conclusion of their research said that improving access to screening services is crucial to the success of a cervical cancer screening programme.

Six categories of case studies have been analyzed to help expand the concept of fear of the unknown. These are model case, borderline case and contrary case.

Model case

Analyses of the case: From the above scenario, it can be concluded that this is an example of a model case since it contains all the defining attributes of the concept. The, first defining attribute (the stimulus) in this scenario is cervical cancer screening. Hearing of the screening made her anxious (second defining attribute) about the fact that it will be painful and that she might be diagnosed of cervical cancer and this resulted to her having insomnia and finally the last defining attributed came to play when she received education by her family physician and decided to go.

Additional cases

Borderline case: According to Walker and Avant [32,33], a borderline case contains most of the defining attributes but not all of them. Scenario Miss Akua serwaa’s mother informed her to go for cervical cancer screening after she was present during a health presentation given by a nurse in her church in Accra. Even though she was anxious about the screening since her mother was not able to explain it better to her understanding and it was her first time hearing of it she still decided to go because she didn’t want her mother to be offended.

Analyses

Analyzing this scenario, it could be deduced that this person was anxious about cervical cancer screening since it was the first time hearing of it, she still went for the screening without getting to know much about it.

Analysis of the scenario

The above scenario does not contain any attribute of the concept. Since she was not afraid of the screening, never received any education on it and hence didn’t go because she didn’t see the need to.

Related case

It has a relation with the concept been analyzed but doesn’t have the critical attributes of the concept.

Scenario Akua Manu was passing by Komfo Anokye hospital last Sunday when she saw a queue of women going for free cervical cancer screening. She was curious to know what the screening is about so she went for the screening.

Analysis: The above scenario shows curiosity concept that is related to fear of the unknown but does not contain all the defining attributes.

Invented case: Invented case scenarios do not exist in real life.

Scenario: Kwame 34 years old was watching a movie and saw a ghost appear from the screen. Kofi became afraid run and locked himself in the room.

Analysis: Fear was captured in this case but the scenario does not exist.

Illegitimate case: This case is used out of authors’ research context.

Scenario: Kwame a second year student saw Yaa a first year student in her department and was afraid to approach her so he employed his friend Kwaku a final year student to assist him.

Analysis: This has fear but does not have any relation to cervical cancer screening which the researcher is interested in.

Antecedents

Walker and Avant [32,33] define antecedents as the events or attribute that precedes concept’s occurrence. Things that bring about fear are impending danger, unknown source. Fear of the unknown can be preceded by several situations in life including: going into marriage [52-55], Fear of medical illness [55], Fear of medical screening, cervical cancer screening.

Consequences

Consequences included a greater sense of satisfaction and wellbeing for the patient and for the nurse. Most people are relieved of fear and feel confident to face a given situation been it relationship, marriage, screening, exams etc. after been counseled, and received enough information on it. Likewise increasing awareness on cervical cancer and its screening will help relieve fear and increase the patronage of cervical cancer screening [56].

Empirical referents

Empirical referents are measurable ways to demonstrate the occurrence of the concept [32,33]. Determining empirical referent answers the question, “How will we know if we see it?” [57]. Empirical referents make concepts measurable as compared to attributes [35]. Freud suggested that individual differences make some people more likely to experience fear or anxiety [5]. Anxiety towards anesthesia was studied in a research done by Kindler using visual analog scales (VAS). Results revealed that participants with no previous anesthetic experience had higher anxiety scores. Fear of been embarrassed during the screening andanticipated shame might contribute to explaining lower cervical screening coverage for some ethnic groups [58,59]. Agnes Bukirwa findings highlight the need for client-centered counseling and support to overcome fears and misconceptions.

Implication to nursing practice

Analysis of the concept of fear of the unknown in relation to cervical cancer will inform nurses about the anxieties women go through in relation to seeking cervical cancer screening. This will help nurses to strengthen education on cervical cancer screening as well as ensure a positive interpersonal relation with women seeking cervical cancer screening to help relieve their fears and anxiety. Patient will also feel confident to go for the screening and will encourage friends and other females who had fear concerning the screening to also go for it.

Concept on fear has been explored, concept of unknown has been done but through literature search, no concept was found on fear of the unknown. Fear of the unknown is a general issue that cut across all facets of life as described above. Addressing this issue will give people the courage and confidence to go through situations that one fears. It is anticipated that this analysis will help increase patronage to cervical cancer screening and inform nurses to educate women on cervical cancer screening