A Systematic Review of Intervention on Improving Cervical Cancer Screening Rates

DOI: http://doi.org.10.35654/ijnhs.v3i4.340 Abstract. Cervical cancer is a disease that can be prevented through early detection. However, cervical cancer is the fourth leading cause of death for women globally due to the low coverage of cervical cancer screening. An intervention is needed to increase the coverage of cervical cancer screening. This study aimed to provide current evidence of effective interventions to improve cervical cancer screening coverage, especially with low socio-economic conditions. This study uses a systematic design review to review the literature that has been evaluated in a structured, classified, and categorized based on evidence-based previously. The study's inclusion characteristics are as follows: all article searches are limited to those in English or Indonesian only, and scan bibliography to identify relevant articles, method design is RCT studies, or quasi-experiments. The study results found the characteristics of the article as follows: the majority of studies were conducted in the Americas, two studies in Asia, and one in Europe. The respondents' age varied from> 18 years to 75 years; the number of samples ranged from 102 to 12,061 respondents. Interventions were grouped into three types, namely: health education, self-testing, and reminders of the screening schedule. Among the three types of interventions most recommended is counseling with video media, because providing information with exciting media will increase knowledge which will increase women's interest in screening. Independent screening interventions can also increase the coverage of cervical cancer screening in women with low socioeconomic conditions because this method allows more savings in funding.


INTRODUCTION
Cervical cancer is the fourth leading cause of death in women globally; as many as 528,000 cases were diagnosed in 2012. About 87% of all cases and 90% of all deaths from cervical cancer occur in developing countries (1). Cervical cancer is a disease that can be prevented by early detection with a Pap smear. Early detection using a Pap smear has been used worldwide to detect and treat dysplasia before it develops into cancer (2). Early detection has been recognized to reduce cervical cancer rates in developed countries with high incomes, especially states that have implemented early detection programs nationally (3). It has been accepted that cervical cancer screening as a public health intervention to reduce the incidence and death from this disease (4).
Women's socio-economic conditions can influence women's involvement in cervical cancer screening. This study will examine the effect of interventions to increase cervical cancer screening coverage in the low socio-economic population. Based on reviews (5) found that interventions to increase the coverage of cervical and breast cancer screening would be useful by combining knowledge with theoretical models. The results of his research suggest that economic and geographical problems must be addressed. In addition, health workers play a significant role in promoting women's awareness about cervical cancer. Another thing is that the invitation for cervical cancer screening by mail should be avoided because this method can reduce the interest in screening women with high incomes and prevent women with low economies from participating in cervical cancer screening.

OBJECTIVE
This study aims to provide current evidence of interventions to improve cervical cancer screening rates, especially in the low socio-economic population.

METHOD
This type of research is a systematic review. This reviews the literature that was evaluated in a structured, classified, and categorized manner based on previous evidence-based (6).
This study is fit to be used as a preliminary study and to provide direction on nursing interventions. This study's reporting follows the recommendations of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes). The first stage of PRISMA is the identification of articles based on keywords. Then articles are screened based on titles, abstracts, and keywords. The next article is filtered based on criteria. At this stage, the article is viewed as worthy by reading the contents of the article to ensure that the article is suitable for review. The next step is data extraction, which is poured into the PRISMA checklist (7).
Data based, which is used to search literature, is MEDLINE and CINAHL. This strategy's procedure starts from searching for articles in each data based beginning from January 2005 to May 2020.
The keywords were used: "cervical cancer," "cervical cancer screening," "cervical screening," "perceived risk," and "risk perception." To identify search keywords using PICO where, P (Population): women of age range who have to screen for cancer cervical; I (Intervention): Interventions were grouped into three types namely: health education, self-testing, and reminders of the screening schedule; C (Comparison): -; O (Outcome): an increase in cervical cancer screening rate. The keywords were used: "cervical cancer," "cervical cancer screening," "cervical screening," "health education," "self-testing," and "reminders of the screening schedule." In addition, the literature search strategy uses inclusion criteria. The inclusion criteria for article search are as follows: all article searches are limited to those in English or Indonesian only, and scan bibliography to identify relevant articles, design RCT studies or quasi-experiments, populations in studies of women of age range who have to screen for cancer cervical, research is carried out in developing or underdeveloped countries, and the outcome of the study is an increase in cervical cancer screening coverage.
The division makes an article selection of tasks between the primary author and the members. The main author is tasked with selecting and reviewing all titles and abstracts obtained from the database to determine eligibility. The member's task is to get the full text and determine the eligibility of each article.
The lead author carried out data extraction using the inclusion and exclusion criteria format, the intervention and control groups, and the research outcomes. The contents of the form in each article include the respondent's age and the location of the study. Rating the quality of articles was used Jaddad's score. Jaddad's rating independently assesses methodological quality. The components evaluated are randomization, double-blinding, and withdrawals and dropouts (8). How to give a scoring to Jaddad "s score, the first question is whether the study was conducted randomly, if yes, then given a value of 1, if not given a value of 0. The second question whether the method used to generate the randomization sequence, if explained and accordingly, was given a value of 1 and if not given a value of 0. The third question is whether the study was conducted double-blind, if yes then it was given a value of 1, and if not given value 0. The fourth question is whether the double-blinding method is explained and appropriate (use of identical placebo, active placebo, dummy, etc.), if yes, given a value of 1, if not given a value of 0. The fifth question explained the description of withdrawal and dropped out of the sample. If yes, then assigned a value of 1 and if not given a value of 0 (9).

RESULTS
The total of articles searches through the data based article to produce 500 articles. After going through the duplication, title, and abstract selection by the primary author, 40 articles are left. Of these, only 14 articles met the inclusion criteria. The 14 articles are then analyzed ( Figure 1).
The characteristics of the 14 articles reviewed are as follows: 11 studies were conducted in the American continent, two studies were carried out in the Asian continent, and 1 in the European continent, no research was conducted in Indonesia. Age in this study varies significantly from the youngest age> 18 years to the oldest 75 years, while the number of samples at least amounted to 102 respondents to the most numbered 25,061 respondents. The duration of intervention also varies but generally starts from a few months to several years.

Articles after review based on keywords and abstracts (N = 500)
Article excluded (N = 446) because it did not fit the purpose of the study Articles after duplicates remain (54) articles.

Articles according to inclusion criteria (N = 14)
The article was reviewed (N = 14) because it was following Systematic Review.
Inclusion criteria: -All article searches are limited to those in English or Indonesian only, and scan bibliography to identify relevant articles. -Method design are RCT studies or quasi-experiments -Populations in studies of women of age range who have to screen for cancer cervical -Research is carried out in developing or underdeveloped countries. -The outcome of the study is an increase in cervical cancer screening coverage.

Health education
Health education is divided into two methods: those that provide information directly (face to face) and through the media.

a. Providing Direct Health Education
Health education is carried out by cadres, with the consideration that cadres are closer to women. The study was conducted in America for his health education regarding cervical and breast cancer screening. Health education in this study is carried out individually and in groups. The Pvalue in this group is significant, which is <0.001.
Other research was conducted by using cadres as educators about screening and facilitating screening examinations. The analysis showed that the two were not very significant between the health education group and those combined with reminders. This study has the potential for contamination in the control group (13).
Research also uses cadres as providers of education, combined with the procurement of community screening activities. The analysis showed a significant difference between the intervention and control groups of 14% (18).
A study then uses cadres as providers of education by comparing education to individuals or small groups that are more effective. The results of the analysis showed post educational intervention individually experienced a higher increase (45.5%) than in the group (39.4%) (15) Three articles provide health education in packages based on cadres' health promotion (12; 16;17). Research by Chalapati and Chumworathayi (11) includes information about Pap smear screening using leaflet media as reading. While a study Mishra (16) conducted on American Samoa women by using the concept of healthy behavior to influence knowledge, communication of patients with health professionals, individual trust, and self-efficacy (16). The study using cadres to provide health education to Hispanic women based on a social cognitive theory with the hypothesis that knowledge of the benefits and risks of screening will make women screen (17) Research in this group also seeks to help women overcome obstacles in obtaining health (17) and skills for making contracts for screening (16). All three studies show a significant increase in screening coverage.

b. Provision of Health Education with video media
The four studies in this review provide health education using video as a teaching medium. Health professionals give the two studies' interventions as education providers on cervical cancer screening (10,12). Both of these studies showed significant improvement in cervical cancer screening. Whereas two other studies by cadres as educators about screening (14,19).
A study used cadres as providers of educational material to increase awareness of the benefits of screening. The analysis showed that more intervention groups participated in cervical cancer screening (15%) (14).
Other researchers use cadres as providers of education about cervical cancer and screening through audiovisuals at respondents' homes. Cadres also recommend doing sports (19). The analysis showed that the intervention only affected women who had had Pap smears twice during their lives.

Self-screening
Two studies in this review used a tool to take HPV samples themselves (self-screening) to increase cervical cancer screening coverage (3,22). Both of these studies showed a significant increase in cervical cancer screening coverage.
A study in France on 18,730 women who had never been screened as an intervention group while the control group received an invitation to screen for cervical cancer, the results of the analysis showed that more intervention groups participated in cervical cancer screening (18.3%) than in the control group (2%) (3).
A study was conducted in Mexico on 25,061 respondents. The intervention group increased by 98%, which is due to nurses visit their homes to be given their sampling equipment. Then nurses brought the results compared to the control group, which only increased by as much as 87% where respondents were visited at home to be invited to screen for cervical cancer in the clinic the closest (22).

Screening schedule reminders
In this review, two studies use a screening schedule reminder to remind women of cervical cancer screening (20,21). Both of these studies showed a significant increase in cervical screening schedule.
A study was conducted in America in 1,413 women aged 40 to 69 years. At the same time, the control group made three telephone calls and an additional two phone calls to recommend discussions with health workers. The analysis showed that the intervention group more participated in the cervical cancer screening schedule (19.4%) than the control group (13%) (21).
A study in Thailand on 320 respondents. There was an increase in the intervention group (44.67%) where the respondent sent a letter containing the date of examination by health workers to take a screening test then the results were brought by health workers compared to the control group which only increased by (25.68%) where the respondent was not given an intervention (20)

Discussion
This study reinforces the previous intervention findings to increase the coverage of cervical cancer screening in low socio-economic groups. The new thing in this review is the existence of cervical cancer screening using HPV sampling methods independently. This study also reinforces cadres' use in providing health education about cervical cancer and screening to women.
Two experimental studies found that independent screening can increase cervical cancer screening coverage in women with low socio-economic status. This can reduce the need for health workers to screen for Pap smears or IVA tests. And this seems acceptable to women, with women twice as likely to do screening if offered this method (23). This method allows more savings also in financing (22). However, the disadvantage of this independent test is that there are many false positives compared to the Pap smear test (22). Therefore, it can cause anxiety in women who use the test with this method and the high number of colposcopy referral rates, raising other challenges related to follow-up on women who get positive screening results.
In addition, this group intervention uses the theory of behavior change by empowering women by increasing their knowledge and skills related to cervical cancer screening. Various studies suggest that the factor that causes women not to screen is the level of knowledge. This is in line with the research conducted (24) in Tuban, which states that there is a significant relationship between women's knowledge and interest in screening, in this case, the IVA test. In this group, it was also found that the intervention would be more effective if added with assistance to women to access screening services such as face-to-face, or telephone communication, or cadres accompanying women to do the screening.
In addition to the method of HPV sampling independently, other interventions that can increase the coverage of cervical cancer screening in women with low socio-economic, namely the method of providing health education/counseling with the help of video media that has been proven from the three experimental studies examined. As previously stated, knowledge is a factor that can influence a woman's interest in screening (24). One effort to increase public awareness is by using counseling or health promotion. According to (25), counseling methods are considered more effective than other methods to improve community knowledge and maintain and improve health.
The information provided at the time of counseling certainly needs to be conveyed interestingly so that students easily understand it. Interesting advice can be done by adding interactive discussions and using media tools. The media can represent what is not able to be said by the giver of information. Through certain words or sentences, even the abstractness of the material can be concretized with the presence of the media. Visual media for concertizing health promotion material is audiovisual aid (AVA) or known as video. The advantages of using video in counseling include information delivered to be more realistic. There are features in the video that can add a more attractive appearance so that the interest of students to receive information increases (26).
In addition to video, the media that is often used in providing health education is leaflets. But in fact, video media is more effective than brochures. This is evident from research (26), which shows that video administration in the control group was 2.13 times more influential during IVA examination visits compared to leaflet administration. The research is in line with the previous study (27), which states that health education uses effective audiovisual media (p-value = 0.007) in improving the behavior of respondents in conducting IVA screening.
The provision of health education is indeed considered effective in increasing knowledge. However, differences in age, level of education, and experience can affect individual perceptions in receiving information. We cannot generalize all individuals who are given health education interventions to understand all the material presented. This is the weakness of the health education intervention. Therefore, a personal approach is needed to provide health education interventions.
From the various studies discussed, the majority of interventions were carried out by cadres. Interventions using cadres as health education providers show significant results to increase cervical cancer screening coverage. That is because the material presented is related to culture and is very sensitive for women. Thus, cadres need to be equipped with proper knowledge so that they can transfer their knowledge to women within their reach. This can be seen in research conducted (25) in Bantul, which mentioned an increase in women's desire to undergo screening after previously being given health education.
The two studies with intervening reminders of the screening schedule for cervical cancer screening were carried out (20,21). Both studies showed a significant increase in the cervical cancer screening schedule. A previous study (28) shows that the visit of facility users will double by simple notification (reminder), both by mail and by telephone. Thus, the goal of detecting precancerous lesions can be achieved. But in Indonesia itself, it seems complicated to apply a reminder by mail or phone, but the approach should be made even though it is differently (29).
Limitations on the number of articles reviewed as many as 14 articles with different research locations. The majority of research is conducted in America with nine articles. The rest are in France, Thailand, Mexico, London, and Samoa (USA). The weakness in this review literature is the limited area of research in which the USA region is more numerous than other areas. 7 of the 14 articles that have been reviewed there are several articles that use respondents more than women of productive age, namely 20-35 year.