Fakultas Kedokteran, Universitas Udayana, Denpasar,
Bali, Indonesia1,2,3,4,5,6,7
Email: bgliyis@gmail.com
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KEYWORDS |
ABSTRACT |
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cervical cancer, early detection, women of
childbearing age |
Background: Cervical cancer is one of the most common cancers in
the world and Indonesia, with a low rate of early detection. Cervical
screening is an important intervention, especially for women of childbearing
age (WUS). Objectives: This literature review aims to summarize effective
interventions in increasing WUS participation in the early detection of
cervical cancer. Methods: A total of 20 studies with 10,396 WUS were
included. These studies were grouped based on intervention methods, namely
Self-Sampling, SMS Reminders, Health Counseling, Family Support, Cervical
Cancer Cadres, and Motivational Interviewing. The analysis was carried out
with a PICO (Population, Intervention, Comparison, Outcome) framework.
Results: Health counseling was the most common intervention (8 studies, 1,053
interventions). Self-sampling, evaluated in 3 RCTs (1,953 WUS), showed a
significant improvement in screening, especially in developed countries. SMS
reminders, which were tested in 4 RCTs (4,905 WUS), also increased participation,
with one study reporting a five-fold improvement. Family support, which was
studied in 3 studies in Indonesia, emphasized the importance of the role of
husbands in encouraging screening. The Cervical Cancer Cadre method in
Cameroon shows that community workers can mobilize WUS for screening.
Motivational Interviewing in one study in Iran increased the screening of
women who were motivated face-to-face or over the phone. Conclusion: Six
intervention strategies have been proven to be effective in increasing WUS
participation in the early detection of cervical cancer. The support of
facilities and resources is critical to the effectiveness and sustainability
of the program. |
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DOI: 10.58860/ijsh.v3i8.229 |
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Corresponding Author: Bryan
Gervais de Liyis *
Email: bgliyis@gmail.com
INTRODUCTION
Cancer, a
non-communicable disease, is the leading cause of death globally, with the
number of cases and deaths expected to rise significantly. In 2018, there were
18.1 million cancer cases and 9.6 million deaths, with projections reaching
over 13.1 million deaths by 2030 (GLOBOCAN). Cervical cancer, one of the most
prevalent cancers worldwide, particularly in Indonesia, is a malignant neoplasm
originating from uterine cervical cells. Despite being preventable, it remains
a top gynecological cancer, ranking fourth among all cancers affecting women.
In 2018, an estimated 570,000 cases and 311,000 deaths occurred globally, with
these numbers rising to 604,127 cases and 341,831 deaths in 2020. Cervical
cancer is most commonly diagnosed between ages 35 and 44, often in individuals
who do not undergo regular screenings. In Indonesia, cervical cancer is the
second most common cancer in women, with 36,633 cases and 21,003 deaths
reported in 2021, reflecting a twofold increase since 2008.
Central to
this process is persistent infection by high-risk human papillomavirus (HPV)
strains, especially HPV-16 and HPV-18, which subtly integrate their genetic
material into the host genome
The increasing
prevalence and high incidence of cervical cancer in developing countries can be
caused by the lack of awareness among women to immediately check themselves.
Most cervical cancer patients come when they are at an advanced stage, so they
do not get effective treatment. Interventions for cervical cancer focus on
primary and secondary prevention. Primary prevention and early screening are
the best methods to reduce the burden of cervical cancer and reduce mortality
METHOD
Search Techniques
In preparing this systematic review, a
meticulous literature search process was conducted to ensure that the most
relevant studies were included. This process, aimed at addressing the research
questions and achieving the review’s primary objectives, took place on October
9-10, 2023. During this period, research articles were carefully selected based
on predetermined inclusion and exclusion criteria. The review focused on
studies published between 2019 and 2023 that explored strategies or efforts to
enhance women's participation in cervical cancer screening. To ensure a broad
and comparative analysis, articles written in both Indonesian and English were
considered, allowing the authors to gain a comprehensive perspective on the
approaches used in Indonesia and other countries. Additionally, these language
choices were intended to enhance the authors' ability to analyze and interpret
diverse findings. Further criteria were applied to evaluate the studies'
relevance and quality, ensuring that only the most pertinent research was
included in the review, which can be found in more detail in Table 1.
Table 1.
Inclusion and Exclusion Criteria
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Inclusion Criteria |
Exclusion Criteria |
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Written in Indonesian or
the United Kingdom |
Full text is not
accessible |
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Year of publication last
5 years (2019-2023) |
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Performing interventions
for women of childbearing age to increase participation in early detection of
cervical cancer |
Involves other cancers
other than cervical cancer |
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The average age of the
study subjects was women of childbearing age (15-49 years old) |
Review or case report |
The literature search process is carried out by
entering keywords into the Google Scholar, Cochrane, and Pubmed search engines,
with the use of Boolean operators such as AND and OR. The purpose of this step
is to collect journals that will then be compared and adjusted to the focus of
the discussion in the literature review. The authors have set publication
restrictions in the last five years as a search guideline. When using Google
Scholar, search involves using synonyms of relevant keywords. On the other
hand, searches in Cochrane and Pubmed rely on the term MeSH (Medical Subject
Headings) as a guide in finding appropriate literature.
Keywords
The author utilized sources from Google
Scholar, Cochrane, and PubMed to gather relevant information. Keywords were
carefully selected and translated into both Indonesian and English to optimize
the search process. Using these keywords, the author conducted comprehensive
searches across the mentioned databases. The study selection was then guided by
the criteria outlined in the PRISMA chart. During the initial screening, the
author reviewed the titles of the top 280 articles from Google Scholar, 133
articles from Cochrane, and 30 articles from PubMed. This process was followed
by a detailed assessment of the literature's relevance and quality through
full-text reviews.
RESULT AND DISCUSSION
Summary of Study Results
Based on the
results of the literature search, there were 20 articles involving 10,396 women
of childbearing age (WUS) who met the inclusion criteria in this literature
review. From the 20 articles, the author then grouped the intervention methods
to increase WUS participation in the early detection of cervical cancer into 6
methods in general, namely the Self-Sampling method, the SMS Reminder method,
the Health Counseling method, and the Family Support method. Cervical Cancer
Cadre method, Motivational Interviewing method. Each of these articles is then
summarized based on population, intervention and comparison, and outcome
(PICO).
The
self-sampling method was carried out on 3 RCT studies
The SMS
reminder method was studied in 4 RCTs in the United Kingdom, Nigeria, and
Tanzania involving 4,905 WUS
The health
counseling method was carried out in 8 studies, making it the most widely used
method to increase WUS participation in the early detection of cervical cancer ;
The family
support method was carried out in 3 cross-sectional analytical studies covering
425 WUS in Indonesia. Found that there is a relationship between family support
and women's intention to undergo cervical cancer screening. Research from
Juwitasari et al
The cervical
cancer cadre method was investigated by 1 quasi-experimental study in Cameroon
involving 1,940 WUS. This study involved 4 sub-regions in the Dschhang area.
The researchers recruited 52 cadres who had major jobs in their respective
areas to be educated for two days. After the education program, they were
released to their respective areas to invite women of childbearing age in their
areas to take part in cervical cancer screening. The study found that cadres
were able to invite 584 WUS to do screening.
The
motivational intervewing method involved 120 Iran WUS in 1 prospective cohort
study
Cervical cancer remains the main
focus of educational efforts to raise awareness in the community, especially
for individuals who are already sexually active. Regular check-ups are highly
recommended for early detection of cervical cancer. In the early stages,
cervical cancer often shows no obvious symptoms. By the time symptoms begin to
appear, the disease has usually reached the pre-cancer or cancer stage, thus
confirming the need for regular early detection. Available cervical cancer
screening methods include visual examination with IVA, Pap smear test, and HPV
DNA testing. The high incidence of cervical cancer in Indonesia is greatly
influenced by the low rate of cervical cancer screening. In 2021, only about
6.83% of women aged 30-50 years have undergone IVA screening
Self-Sampling Method
HPV
self-sampling is a process in which a person uses a kit to take a sample of the
vagina by himself or herself and then send it for analysis in a laboratory.
Sampling uses lavage, brushes, swabs, and vaginal patches. HPV self-sampling
cannot diagnose (pre-)cervical cancer but only identify a person who is at high
risk (World Health Organization, 2022). If the laboratory results are positive
for HPV or cannot be interpreted, then the participant will be referred for a
pap smear.
The
self-sampling method as a primary screening has the opportunity to expand the
scope of screening, especially in low-resource conditions, where infrastructure
and labor are very limited. The implementation of self-sampling can save time
and lower the cost of cervical screening because patients do not need to go to
the clinic for smear collection
Based on the
results of the research of Scarinci et al.
SMS Alert Method
(Reminder)
The most
common obstacle to a person not getting screened for cervical cancer is
forgetting and procrastinating
The SMS alert
method has been shown to increase the coverage of screening tests, but a 2-way
SMS is needed for more effective results
Health Counseling Methods
The main
strategy to reduce the incidence of cervical cancer is education about primary
and secondary prevention for women and their families. Education through
counseling can use verbal, written, and video communication media. Thus, the
woman and her family will be motivated to do cervical screening for themselves
and vaccinate their daughters against HPV
Counseling,
both using leaflets and videos, is known to increase knowledge about cervical
cancer. If looked at further, video media has proven to be more effective than
leaflets because there is a significant increase in knowledge. A narrative
online video style with a storyline according to the local culture can be one
option because it helps to increase the psychosocial variables of participants
Family Support Methods
The low number
of women of childbearing age who undergo cervical cancer screening is
influenced by several factors including a lack of awareness regarding cervical
cancer, fear of cervical cancer screening, and diverse beliefs and cultures.
This is despite the wide opportunity to access adequate healthcare for cervical
cancer screening. Related to this, the World Health Organization states
that men's involvement in the prevention of cervical cancer is often an opening
of access to health services for wives and girls in the family. The support of
a husband or father in the family is considered necessary for women of
childbearing age to undergo cervical cancer screening. When families better
understand the risk factors associated with cervical cancer and how cervical
cancer screening can benefit them, they are more likely to be motivated to
support cervical cancer screening for their female partners
One of the
many cervical cancer examinations, the Visual Inspection of Acetic Acid (IVA)
is a simple and adequate examination. Family support and family knowledge are
thought to be related to the intention of women of childbearing age to carry
out cervical cancer prevention with IVA. In addition to the level of education
and distance from health services, a person who does not receive support or
approval from his family will tend to be reluctant to undergo such screening
Cervical Cancer Cadre Method
Many levels of
society do not have enough knowledge regarding the prevention and early
detection of cervical cancer. One of the efforts in cervical cancer prevention
that can be done is to involve the role of cadres in the community so that
there is an increase in knowledge related to early detection of cervical
cancer. Cadres are placed in the community to increase cultural legitimacy,
trust, and public acceptance of cervical cancer screening interventions in
their areas. Cadres are also trained to hold community-based programs in
conducting cervical cancer screening and treatment.
Cadres can
play a role in increasing public knowledge, behavior, and awareness in the early
detection of cervical cancer through examination. The cadres formed also need
to be trained first before going into the community to provide education
related to early detection and prevention of cervical cancer
The
application of cadres is not only influential and used in Indonesia. In some
countries such as El Salvador, cadres identify women of childbearing age who
have not been screened and conduct home visits to convey education to the
community, including examination and treatment methods for cervical cancer, to
find out the reasons why people have not been screened. In another area, namely
Iran, cadres are trained to convey information to women regarding the
importance of screening and how to carry out self-detection using a pap test.
Even in Nigeria, cadres are trained to conduct direct screening using IVA under
supervision. In positive cases that are found, they are directed to do therapy.
The roles of these cadres certainly show that cadres play an active role in
increasing the screening rate of cervical cancer in various countries in the
world.
Motivational Interviewing Method
Motivational
interviewing or motivational interview is a method of approach that is centered
on the purpose of increasing motivation in behavior change. Motivation is
considered a source of change that can last for a long time. Motivational
interview is an intervention that aims to change health-related motivations and
behaviors. Motivational interviewing strategies can improve and facilitate
decision-making related to change among women and women of childbearing age.
Motivational interviewing (MI) is considered to play a role in community
compliance with cervical cancer screening. In an experimental study of 150
women of childbearing age, divided into 3 groups based on the face-to-face call
group, telephone group, and control group where the women of childbearing age
will receive 3 face-to-face and telephone calls 3 times in one week, with the
results that through the intervention the results were obtained that both
methods had an effective impact in motivating WUS to carry out early detection
in the form of pap smears.
This method is
considered effective in increasing motiation in performing a pap smear. This
suggests that MI can help reduce cervical cancer screening barriers and may
improve cervical cancer screening rates. MI-based interventions are considered
effective for increasing the number of cervical cancer screenings and related
studies recommend using this type of MI intervention to increase the frequency
of regular screening in addition to early detection. MI involves a strategy
that increases a person's motivation to switch from the stage of
pre-contemplation and contemplation to the stage of continuous action
CONCLUSION
To optimize
cervical cancer screening rates among women of childbearing age, this research
will compare the effectiveness of six intervention strategies self-sampling
methods, SMS warnings, health counselling, family support, cervical cancer
cadre methods, and motivational interviews to identify the most impactful
approaches. It will also explore strategies for ensuring the long-term
sustainability of these interventions, examining the necessary support for
facilities and resources. The study will assess barriers and facilitators to
screening across different demographic groups, considering socio-economic
status, education, and geography, and explore how these interventions can be
integrated into existing health services. Additionally, the role of technology
in enhancing screening rates through digital tools for self-sampling,
reminders, and motivational support will be evaluated, alongside cultural and behavioural
factors influencing participation in screening.
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