Effect of Cervical Cancer Education and Provider Recommendation for Screening: A Systematic Review

The incidence of cervical cancer in the world is still high as well as in Indonesia. This cancer affected women's physically, psychologically, socially, sexually functionally, and spiritually. The purpose of this review literature was to determine the effect of cervical cancer education and to identify the effects of provider recommendations for screening to eligible women, as a basis for developing new interventions for nurses. We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework to develop our search strategy. Searching for articles was done through four English databases namely CINAHL, Science Direct, Pubmed, and Proquest to identify articles published between 2009 2,665 filtered research reports, 14 articles were found th requirements. The data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Results, there were eight randomized control trials, five quasi and one mix method involved in the analysis step. The interventions were cervical cancer screening methods (1 article), interventions to increase participation in cervical cancer screening (10 articles), postoperative cervical cancer nursing interventions (1 articles), and intervent handling symptoms or problems due to cervical cancer (2 articles). Our findings supported the implementation of cervical cancer educational interventions to increase women's participation in cervical cancer screening programs. Nurses and midwifery have the opportunity to innovate interventions related to nursing, through research in order to improve the quality of nursing care for patients. This open access article is under the CC–BY-SA license.


Effect of Cervical Cancer Education and Provider Recommendation for Screening: A Systematic Review
Devita Madiu 3 ; Cecep Eli Kosasih 4 ; Yanti Hermayanti A B S T R A C T The incidence of cervical cancer in the world is still high as well as in Indonesia. This cancer affected women's physically, psychologically, socially, sexually functionally, and spiritually. The purpose of this review literature was to determine the effect of cervical cancer education and to identify the effects of provider recommendations for screening to eligible women, as a basis for developing new interventions for nurses. We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework to develop our search strategy. Searching for articles was done through four English databases namely CINAHL, Science Direct, Pubmed, and Proquest to identify articles published between 2009 2,665 filtered research reports, 14 articles were found th requirements. The data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Results, there were eight randomized control trials, five quasi and one mix method involved in the analysis step. The interventions were cervical cancer screening methods (1 article), interventions to increase participation in cervical cancer screening (10 articles), postoperative cervical cancer nursing interventions (1 articles), and intervent handling symptoms or problems due to cervical cancer (2 articles). Our findings supported the implementation of cervical cancer educational interventions to increase women's participation in cervical cancer screening programs. Nurses and midwifery have the opportunity to innovate interventions related to nursing, through research in order to improve the quality of nursing care for patients. This open access article is under the CC-BY-SA license.

Effect of Cervical Cancer Education and Provider Recommendation
Hermayanti 5 ; cervical cancer in the world is still high as well as in Indonesia. This cancer affected women's physically, psychologically, socially, sexually functionally, and spiritually. The purpose of this review ncer education and to identify the effects of provider recommendations for screening to eligible women, as a basis for developing new interventions for nurses. We used the PICO (Problem or Population, Interventions, Comparison and Outcome) elop our search strategy. Searching for articles was done through four English databases namely CINAHL, Science Direct, Pubmed, and Proquest to identify articles published between 2009-2019. Of the 2,665 filtered research reports, 14 articles were found that met the requirements. The data synthesis and reporting was guided by the Preferred analysis (PRISMA). Results, there were eight randomized control trials, five quasi-experiment, in the analysis step. The interventions were cervical cancer screening methods (1 article), interventions to increase participation in cervical cancer screening (10 articles), postoperative cervical cancer nursing interventions (1 articles), and interventions handling symptoms or problems due to cervical cancer (2 articles). Our findings supported the implementation of cervical cancer educational interventions to increase women's participation in cervical cancer e the opportunity to innovate interventions related to nursing, through research in order to license.

Introduction
Cervical cancer is a disease that causes morbidity and mortality in women. Although cervical cancer can largely be prevented through screening, it remains one of the leading causes of cancer morbidity and mortality globally al., 2017). The incidence of cervical cancer in the world is still quite high, as well as in Indonesia. Based on GLOBOCAN (2018) cervical cancer ranks fourth in cancer incidence and mortality in women in the world (Bruni et al., 2018(Bruni et al., al., 2015. Whereas in Indonesia, cervical cancer ranks second after breast cancer which causes death in women (Kemenkes, 2019). The high rates of cervical cancer morbidity and mortality must be a concern for women and health workers.
Cervical cancer is a malignant cancerous cell that grows in the cervix caused by Human Papilloma Virus (HPV). There are 100 types of HPV that can infect humans and 2 of them are often the cause of cervical cancer namely HPV16 and HPV18 ( Dunleavey, 2008;Harlianty, R., & Paramastri, I. 2020). Persistent HPV infection can cause cervical pre cancerous lesions which if left untreated can develop into cancer 10 to 20 years later ( WHO, 2014). Symptoms of cervical cancer appear after the cancer develops. Patients with cervical cancer initially complain of sometimes smelly vaginal discharge, bleeding after sexual intercourse, and irregular bleeding (Smeltzer & Bare, 2009). Whereas in the early stages the patient does not experience symptoms of cervical cancer so that the patient does not check his health and does not immediately seek treatment.
A woman with cervical cancer will experience various changes, both physical, psychological, social and sexual function, as well as spiritual. Changes experienced physically, such as body shape such as vaginal atrophy, stenosis and abnormal bleeding (Cohen, Jhingran, Oaknin, & Denny, 2019;Thapa et al., 2018). Psychological changes, where women with cervical cancer will experience psychological distress and threaten changes in marital status (Isaka, Inada, Hiranuma, & Ichikawa, 2017). In addition, the emergence of bad stigma from the environment related to cervical cancer that can have an impact on social relations (Bae & Park, 2016;Bjelic-Radisic et al., 2012;Wenzel, Mechanic, & Penner, 2015).
To prevent morbidity and mortality, it must be treated with appropriate interventions. Nurses have a role to develop or innovate nursing interventions in order to improve the quality of nursing care in cervical canker patients. The purpose of this review literature was to determine the effect of cervical cancer education and provider recommendations for screening for cervical cancer, as a basis for developing appropriate interventions or nurses in cervical cancer patients.

Method
Searching for articles was carried out through four databases namely Pubmed, CINAHL, Science Direct, and Proquest. An electronic data search was conducted in September 2019. The keywords used in the search were (cervical cancer) AND (nursing care OR nursing intervention). To prevent morbidity and mortality, it must be treated with appropriate interventions. Nurses have a role to develop or innovate nursing interventions in order to care in cervical canker patients. The purpose of this review literature was to determine the effect of cervical cancer education and provider recommendations for screening for cervical cancer, as a basis for developing appropriate interventions or nurses Searching for articles was carried out through four databases namely Pubmed, CINAHL, Science Direct, and Proquest. An electronic data search was conducted in September 2019. The keywords used in the search were g intervention).
A total of 2,665 articles were taken based on year criteria. A total of 8 articles were duplicates. A total of 48 articles met the inclusion criteria, namely articles in the form of interventions (randomized control trials, cluster randomi control trials, Mixed methods, and quasi designs of relevant interventions to cervical cancer), primary studies, not protocol studies, in English, published from 2009 -2019, fulltext. Then we read the title of the article and filter the articles in accordance with the theme of the article, namely early detection of cervical cancer. We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework in developing the focused question of the article selected (Higgins & Green, 2011 abstracts of all studies taken from electronic database searches were stored in EndNote X5. After removing the duplicates, the remaining titles / abstracts were filtered, study reports that did not meet the review criteria were excluded, eventually 14 articles were included in the analysis. Figure

Results and Discussion
Our search yielded 2,665 published articles (705 in Pubmed, 1,033 in Science Direct, 36 in CINAHL, and 891 in Proquest). After variable screening filter, we have 1,638 study. We removed 8 duplicate publications, we had 1630 study reports for screening. After screening study titles / abstracts and inclusion criteria we found 48 potentially relevant studies for full-text review and consideration for inclusion, and 1,582 were eliminated because they did not meet the inclusion criteria for further review of full After completing a full-text review, 14 articles were found to be eligible for inclusion in a randomized controlled trial of 8 articles, quasy experiment 5 articles, and 1 research mix method. The study participants in this article consisted of 559 cervical cancer patients, 451 women of cervical cancer who were infected with HIV and as many as 24,658 women of childbearing age.
Literature search results found, one artic cancer screening methods, ten articles on interventions to increase cervical cancer screening participation, one article on postoperative cervical cancer nursing interventions, and two articles on interventions handling symptoms or problems due to cervical cancer. Table 1  A total of 2,665 articles were taken based on year criteria. A total of 8 articles were duplicates. A total of 48 articles met the inclusion criteria, namely articles in the form of interventions (randomized control trials, cluster randomized control trials, Mixed methods, and quasi-experimental designs of relevant interventions to cervical cancer), primary studies, not protocol studies, in English, published from 2009 2019, fulltext. Then we read the title of the article and filter ticles in accordance with the theme of the article, namely early detection of cervical cancer. We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework in developing the focused question of Higgins & Green, 2011). The titles and abstracts of all studies taken from electronic database searches were stored in EndNote X5. After removing the duplicates, the remaining titles / abstracts were filtered, study reports that did not meet the review criteria were entually 14 articles were included in the 1 explained the process of selecting articles. The synthesis of our findings was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Moher, Liberati, Tetzlaff, & Altman, 2009). The risk ias for each study was assessed using the Cochrane Higgins & Green, 2011).
Our search yielded 2,665 published articles (705 in Pubmed, 1,033 in Science Direct, 36 in CINAHL, and 891 in Proquest). After variable screening filter, we have 1, 638 We removed 8 duplicate publications, we had 1630 study reports for screening. After screening study titles / abstracts and inclusion criteria we found 48 potentially text review and consideration for minated because they did not meet the inclusion criteria for further review of full-text.
text review, 14 articles were found to be eligible for inclusion in a randomized controlled trial of 8 and 1 research mix method. The study participants in this article consisted of 559 cervical cancer patients, 451 women of cervical cancer who were infected with HIV and as many as 24,658 women Literature search results found, one article about cervical cancer screening methods, ten articles on interventions to increase cervical cancer screening participation, one article on postoperative cervical cancer nursing interventions, and two articles on interventions handling symptoms or ms due to cervical cancer.

Cervical Cancer Screening Method
Based on the literature, cervical cancer screening can be done by the IVA / VILI method, Pap smear and HPV DNA testing. Visual inspection method with acetic acid (IVA) was carried out to determine the development of pre-cancerous lesions before becoming cancerous. In addition, IVA tests have several advantages over other methods, which can be done easily, the results are accurate and fast. For the VILI method, use lugol iodin for cervical examination. The sensitivity level was also good, which is 57% -98%, but depends on the quality of staff competence, experience, supervision and quality tools (Cholli et al., 2018).
Another method of screening for cervical cancer is the pap smear, which has become a national screening program in various developed countries, such as Australia. The pap smear method was aimed at women aged 18-70 years. Pap smear tests were carried out regularly, proven effective in reducing mortality from cervical cancer (Kwok & Lim, 2016).
In addition to IVA / VILI and pap smears, there are cervical cancer screening methods with HPV DNA testing. HPV DNA testing is done by examining genetic material (HPV DNA) on cervical cells. The advantages of HPV DNA testing, namely sampling can be done independently by women with the help of tools, as has been done in various developed countries such as America (Murphy et al., 2016).

Interventions to Increase Cervical Cancer Screening Participation
Based on the results of a literature search, found various interventions that are used to increase women's participation in cervical cancer screening. The most common intervention is to increase women's knowledge and awareness of cervical cancer screening. The study of Hidago, revealed that strategies to increase screening participation, can be done by providing information about cervical cancer screening, by mail, telephone and coming to group meetings (Lopez-Torres Hidalgo et al., 2016). In addition, the letter and telephone media can be used as a reminder for cervical cancer screening schedule ( Kolutek et al., 2018). Other studies that in line was Han, that the method of health education through brochures, followed by training and counseling by telephone, was effective for increasing cervical cancer screening participation (Han et al., 2017). The study of Ersi, also proved that training and continued by evaluating information obtained through a model based on the health belief model and health promotion model can also increase participation in early detection of cervical cancer compared to just training ( Ersin & Bahar, 2017). Provision of information can not only increase the participation of women who possess that information. However, people around such as their daughters can also increase participation for early detection of cervical cancer (Odunyemi et al., 2018). Various studies to increase knowledge have been carried out proven effective for increasing cervical cancer screening participation. Other studies using leaflets and online were less effective in increasing cervical screening uptake compared to the sampling method itself (Kitchener et al., 2018). There were also studies that use effective cultural and language approach strategies to increase women's knowledge and awareness about breast cancer screening and cervical cancer succeed in increasing the intention and participation in screening mammographs and pap smear tests (Kwok & Lim, 2016).
In addition to health workers, students can also be involved in strategies to increase participation in cervical cancer screening. This has been proven by research of Weston, where nursing students worked closely with family nursing students to conduct assessments, planning and home visits (Weston et al., 2018). Through this method, the public expresses satisfaction with the services provided and was compelled to screen for cervical cancer.  of: education about medicine, nutrition, health education about cervical cancer and further education by telephone. · The NLHP-HB intervention package consists of: forming a family care team, physiological rehabilitation, emotional release management, an informal support system, monitoring follow-up at home. · The intervention was carried out for 6 months.
Participants took the pre-test 7 days after surgery, and the post-test was done 6 months after the intervention.
There was a significant improvement in the quality of life of patients, after the intervention (p = 0,000). ) At the first visit and provided an explanation of how to use it. In accordance with the protocol for biohazard safety and labeling specimens, participants are recommended to the nearest bathroom to conduct self sampling and return it to the researcher in the specimen bag. Furthermore counseling is completed by telephone The results showed that there was no significant difference in the completion of the cytology test within six months from the baseline between the control group and the intervention group (p = 0.59). However, in the intervention group, positive HPV testing increased the threat of cervical cancer significantly in Self sampling for HPV testing is feasible, because it can increase the threat of cervical cancer. Allen, 2016. Amerika about 2 weeks after the first visit. 3-5 weeks after the first visit, participants were interviewed to complete the modified HBM instrument. · Participants in the control group were only given a reminder at the first visit to do the screening. Two weeks later, a reminder call was made to control and the last call was made 3-5 weeks after the first visit, to complete the modified HBM instrument. · The main outcome was the completion of a cervical cytology test within 6 months of the baseline. The secondary outcome is the perceived threat of women developing cervical cancer.
the completion of the cytology test within six months of the baseline between the control group and the intervention group (p = 0.59). However, in the intervention group, positive HPV testing increased the threat of cervical cancer. The IVA "training of trainers" (ToT) program is conducted for 3 days for nurses. The participants did an IVA test illustration during the training. Mobilization activities will then be carried out, by providing health education to several maternal and child health centers about the burden of cervical cancer, risk factors, early signs and the importance of screening. The next activity was carried out in the clinic, cervical images were taken 1 minute before and after the application of Acetic Acid 5%. Pictures are taken using a smartphone with a 16 megapixel camera and built-in flash. The total procedure is around 15 minutes per patient. The compiled IVA images must be shown to the gynecologist every two weeks at the health institute.
Nurses report that there were 25 (13.8%) IVA-positive cases, but only 19 accessed the referral service. Image capture and quality have an effect on expert evaluation. The results also showed that awareness was still low for screening and access to referral services The "Happy and healthy life in Sydney" program is a culture and language sensitive breast and cervical cancer education program, which focuses on the promotion of knowledge. The education program is delivered in the form of PowerPoints lasting 35 to 40 minutes in the spaces provided. At the end of the program, participants were given an information package to take home, in the form of an information booklet using simple language and pictures, a calendar containing reminders about the date of mammography and Pap smear tests, contacts for booking appointments, and souvenirs.
The results showed increased intention and participation in screening mammographs and pap smear tests over a 6-month period (all p <0.05). Nursing care intervention packages on sexuality, consisting of 3 sessions, namely: information on cervical cancer, solving of sexual problems, practices and exercise. The nursing intervention was carried out for 6 weeks, which was divided into 2 sessions.
Nursing care intervention packages on sexuality can reduce symptoms of dyspareunia (p = 0,000), increase vaginal lubrication (p = 0,000), increase sexual satisfaction (0,000) increase sexual arousal (p = 0.002), sexual desire (p = 0.012) and orgasm between cervical cancer patients and their partners (p = 0.002) Nursing care intervention packages on sexuality can be used as supportive care and important aspects in the nursing standards of cancer patients in Indonesia. Another intervention to improve cervical cancer screening was done by self-sampling HPV DNA. The study of Murphy, tested the effectiveness of HPV self-sampling to promote cervical cancer screening, compared to standard services via reminders and telephone reminders (Murphy et al., 2016). The results showed that there was no significant difference in the completion of the cytology test within six months from the baseline between the control group and the intervention group (p = 0.59). Although there were no significant differences, the results of the study indicate that self-sampling for HPV testing was feasible. While the research of Kitchener, revealed different results, that the self-sampling method showed a significant increase in cervical cancer screening participation ( Kitchener et al., 2018). It can be concluded, that self-sampling was feasible as a strategy to improve cervical cancer screening.
Based on the results of the literature, also found intervention using a smartphone. The research of Sharma, tested the feasibility of a cervical cancer screening program using smartphone images, taken by nurses (Sharma et al., 2018). Previously, the IVA "training of trainers" (ToT) program was conducted for 3 days for nurses, and nurses also did IVA test illustrations during the training. The IVA pictures taken by the nurse will later be shown to the gynecologist every two weeks at the prepared health institute. From nurses' reports, 25 (13.8%) IVA cases were found positive, but only 19 accessed the referral service. This showed that women's awareness was still low for screening and access to referral services. In addition, image capture and image quality taken have an effect on the evaluation of gynecologists. Thus, high-quality smartphone devices were needed in this intervention. This shows that there were still weaknesses of this smartphone image intervention.

Intervention Handling of Symptoms in Cervical Cancer Patients
The results of our literature review found two interventions used to treat symptoms or problems that arise from cervical cancer. The research of Afiyanti, evaluated the effectiveness of nursing care intervention packages on sexuality, which consisted of 3 sessions, namely: information on cervical cancer, solving of sexual problems, practices and exercise. The nursing intervention was carried out for 6 weeks, which was divided into 2 sessions (Afiyanti et al., 2016). The results showed that the package of nursing care interventions on sexuality can reduce symptoms of dyspareunia (p = 0,000), increase vaginal lubrication (p = 0,000), increase sexual satisfaction (0,000) increase sexual arousal (p = 0.002), sexual desire (p = 0.012) and orgasm among cervical cancer patients and their partners (p = 0.002). Thus, the nursing care intervention package on sexuality can be used as supportive care and an important aspect in the nursing standards of cancer patients in Indonesia.
Another research conducted by Zhang, which showed that mindfulness-based stress reduction had a positive effect on subjective sleep parameters (p <0.01) (Zhang et al., 2019). Subjective sleep parameters (CNS) were used, including sleep diary and insomnia severity index (ISI), while objective sleep parameters (OSP) including polysomnography (PSG) and wrist actigraphy are used as baseline data for the intervention group (MBSR) or control group. It was concluded that mindfulness-based stress reduction has a definite impact on patients with insomnia that was secondary to cervical cancer after the intervention, but there is no long-term effect.

Nursing Interventions Post Cervical Cancer Surgery
Based on the results of the literature review, there is a postoperative nursing intervention.
Post-operative intervention was demonstrated by research Li, that the home-based program, nurse-led health promotion (NLHP-HB) improves the quality of life, sexual function and family function in post-operative patients with early-stage cervical cancer (Li et al., 2016). The NLHP-HB intervention package consists of: forming a family care team, physiological rehabilitation, emotional release management, an informal support system, monitoring follow-up at home. It can be concluded that, nurses can implement these interventions, to improve the quality of care for post-operative patients with cervical cancer.

Conclusions and Recommendations
Cervical cancer education and providers have proven effective in dealing with problems related to cervical cancer. Nurses can develop new interventions for nurses. Nurses have a role in the management of cervical cancer. However, there are still few interventions developed by nurses. Nurses can play a role in strategies to increase cervical cancer screening participation, such as providing education through various media, remembering screening and counseling schedules and home visits. In addition, it can also be done through HPV self-sampling. For the post-operative stage of cervical cancer, nurses can use evidence-based practice, such as home-based, nurse-led health promotion (NLHP-HB). For handling symptoms or problems caused by cervical cancer, can be done with a package of nursing interventions on mindfulness and stress reduction with mindfulness.
The article is useful for improving the Nurses to develop interventions the management of cervical cancer. This review is beneficial for health provider as an evidence base in order to increase knowledge and healthy behavior of women.