Is an Educational Level Affect Women’s Participation on Cervical

Cancer Screening?

A Systematic Review

Rafika Rosyda

, Budi Santoso

, Esti Yunitasari

Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Faculty of Medicine, Universitas Airlangga, Surabaya

Keyword: Cervical cancer, Cervical cancer prevention, Screening, Early detection, Education.

Abstract: Cervical cancer became fourth most common cancer case among women in the world. There were

approximately 528.000 new cases in 2012. Screening is the most proven method to prevent cervical cancer.

Level of education seems to be an important predictor of cancer screening participation. Nowadays, there is

a little strong evidence of this specific association. Therefore, a systematic review is necessary. This review

was guided by PICO framework to identified appropriate resources for relevant study. Search of the studies

were carried out by Pro-Quest and Medline, with keywords: “cervical cancer screening”, “Pap smear”,

“VIA” “screening program”, “socioeconomic factors”, “educational level” and “screening participation”.

From 904 studies found, 13 included for review. 11 of 13 (84,6%) reported that level of education were

positively associated with women’s participation on cervical cancer screening, and only 2 studies reported

that there is no association. This review conclude that women with higher educational level are more likely

to participate cervical cancer screening.

1 BACKGROUND

Cervical cancer became fourth most common cancer

among women and seventh in all cancer all over the

world. There were approximately 528.000 new cases

in 2012. In Western counties, cervical cancer

prevention effort was done by increasing HPV

vaccination (Cullen, Stokley, & Markowitz, 2014).

However, screening is the most proven method for

reducing rates of cervical cancer (de Blasio, Neilson,

Klemp, & Skjeldestad, 2012). There were some

evidences that Pap Smear, and VIA are associated

with decreasing mortality of cervical cancer

(Meggiolaro et al., 2016; Sankaranarayanan et al.,

2007).

There are some recommendations for cervical

cancer screening (Schwaiger, Aruda, LaCoursiere,

Lynch, & Rubin, 2013). In general, cervical

screening interval may once in 3 to 5 years

(Schwaiger et al., 2013). Screening policy could

affect screening participation. Other than that, there

are more various factors as well as the characteristic

of health system, sociocultural factors,

environmental factors, invitation method, and

individual factors such as age, occupation, and

education. Notably, level of education is one of

health determinant that could be an important

predictor of cancer screening participation (Damiani

et al., 2012).

Although there were a lot of studies had found

positive relationship between level of education and

participation on cervical cancer screening, some of

the results did not find statistically significant.

Nowadays, the strong evidence for this relationship

is still low. Therefore, this systematic review is

necessary. This systematic review assessed the

impact of educational level on women’s

participation on cervical cancer screening.

2 METHODS

The PICO framework was used to guide this

systematic review, with P: sexually active women,

with no symptom and history of female cancers, I:

higher level of education, C: lower level of

education, O: have ever done cervical cancer

screening in their lifetime.

482

Rosyda, R., Santoso, B. and Yunitasari, E.

Is an Educational Level Affect Women’s Participation on Cervical Cancer Screening?.

DOI: 10.5220/0008327204820488

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 482-488

ISBN: 978-989-758-336-0

2.1 Search Strategy

Search of the studies were carried out by ProQuest

and Medline, with keywords: “cervical cancer

screening”, “Pap smear”, “VIA” “screening

program”, “socioeconomic factors”, “educational

level” and “screening participation”.

2.2 Assessment of the Studies

2.2.1 Eligibility

The inclusion criteria for this review:

- Studies published between 2008 – 2018,

- Articles published in English,

- The result section reported the relationship

between level of education and cervical cancer

screening participation.

The exclusion criteria for this review:

- Participants were women with history or family

history of cervical cancer,

- Participants with other disease (e.g. diabetes).

Methodological Quality:

The quality assessment consisted:

- The design of the study,

- Data collection,

- Selected bias,

- Statistical analysis conformity.

Quality assessment was done by rating each item

above as “strong”, “moderate”, or “weak”. As

consequence, the study would be “high quality” if

three of them were strong, with no weak. If there

was only one weak, study would be “moderate

quality”, and if there were more than one item rated

weak, the study would be “low quality”.

2.2.2 Data Extraction

These following items were collected from each

study:

- Author, years of publication

- Design of the study

- Population size and targeted age

- Outcome

- Educational level

- Relationship between educational level and

screening participation

3 RESULTS

3.1 Included Studies

Twelve from Thirteen studies are cross sectional,

and one is case control. Studies selected for this

review obtained by the Swedish National Cervical

Screening Registry (Broberg et al., 2018),

Morehouse School of Medicine (Miles-Richardson,

Allen, Claridy, Booker, & Gerbi, 2017), The

KNHNES (Chang et al., 2017; Lee et al., 2013),

WHO’s Study on Global Ageing and Adult Health

(Akinyemiju, Ogunsina, Sakhuja, Ogbhodo, &

Braithwaite, 2016), GPMSSP (Gyulai et al., 2015),

University of Pittsburgh (Alfaro et al., 2015),

Karolinska Institutet (Östensson et al., 2015), New

Americans Community Services, and University of

Minnesota (Harcourt et al., 2014), European Health

Interview Survey for Spain (Martín-López et al.,

2012), ISTAT (Damiani et al., 2012), BRFSS and

ARF (Coughlin, Leadbetter, Richards, & Sabatino,

2008), and the JCUSH (Blackwell, Martinez, &

Gentleman, 2008).

Two studies were conducted in Sweden (Broberg

et al., 2018; Östensson et al., 2015), four studies in

US (Blackwell et al., 2008; Coughlin et al., 2008;

Harcourt et al., 2014; Miles-Richardson et al., 2017),

two studies in Korea (Chang et al., 2017; Lee et al.,

2013), and the other respectively in Canada

(Blackwell et al., 2008), El Salvador (Alfaro et al.,

2015), Spain (Martín-López et al., 2012), Italy

(Damiani et al., 2012), Hungary (Gyulai et al.,

2015). Twenty two different populations were

identified. Specifically, 10 studies analyzed one

population, and 3 studies analyzed more.

3.2 Quality Assessment

Based on the design of the study, twelve studies

rated “weak” due to cross sectional, and one study

rated “moderate” due to case control. Based on their

data collection, all studies rated “moderate” because

obtained by surveys. Based on selection bias, ten

studies rated “strong” (Akinyemiju et al., 2016;

Blackwell et al., 2008; Broberg et al., 2018; Chang

et al., 2017; Coughlin et al., 2008; Damiani et al.,

2012; Gyulai et al., 2015; Lee et al., 2013; Martín-

López et al., 2012; Miles-Richardson et al., 2017)

because conducted nationwide and enrolled

representative sample. Then, based on statistical

analysis conformity, all studies rated “strong”.

Overall, all studies are in moderate quality.

Is an Educational Level Affect Women’s Participation on Cervical Cancer Screening?

483

Figure 1: Review method.

3.3 Study Characteristic

Table 1: Study Characteristic.

Author, Year of

Publication

Design

Populations,

Targeted Age

Outcome

Educational Level

Relationship

(Broberg et al.,

2018)

Case

control

Sweden;

Case; n=314.302

Control;

n=266.706

30-60 years old

Attended

pap smear

test

1. ≤ 9 years

2. 10-12 years

3. > 12 years

Women with lower

education were more

likely to not attend

cervical screening

(Chang et al.,

2017)

Cross

sectional

Korea; n=3.734

15-39 years old

Had pap

smear test

1. < 6 years

2. 6-9 years

3. 10-12 years

4. >12 years

Higher educational

levels associated with

participation in

cervical cancer

screening

(Akinyemiju et

al., 2016)

Cross

sectional

China; n=8.002

India; n=7.489

Mexico; 1.689

Russia; n=2.676

South Africa;

n=2.427

21-65 years old

Had pap

smear test

1. No formal

education

2. Primary

3. Secondary

4. University/

college

education,

significantly

increased cervical

cancer screening

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

484

(Alfaro et al.,

2015)

Cross

sectional

El Salvador;

n=409

30-49 years old

Had

cervical

cancer

screening

1. < Elementary

2. Middle school

3. > High school

There was no

association

between screening

participation and

educational level

(Östensson et

al., 2015)

Cross

sectional

Sweden; n=1.510

23-60 years old

Attended

cervical

cancer

screening

1. < High-school

2. High-school or

equal

3. > High-school

Educational levels

positively associated

with cervical cancer

screening

participation

(Harcourt et al.,

2014)

Cross

sectional

USA; n=421

≥ 18 years old

Had

cervical

cancer

screening

1. ≤ High school

2. > High school

There was no

association between

educational level and

cervical cancer

screening

participation

(Martín-López

et al., 2012)

Cross

sectional

Spain; n=7.634

25-64 years old

Had Pap

smear test

1. Primary

2. Secondary

3. University

Undergoing cervical

cancer screening

positively associated

with higher

educational levels

(Damiani et al.,

2012)

Cross

sectional

Italy; n=35.349

25-64 years old

Had 1 pap

smear test

1. < Primary

2. Secondary

3. > high-school

Education level were

positively associated

with attendance to

cervical cancer

screening

(Coughlin et

al., 2008)

Cross

sectional

USA; n=97.820

≥18 years old

Had Pap

smear test

1. < high-school

2. High-school

graduate/ GED

3. Some college/

technical school

4. College graduate

higher educational

levels related to

having cervical

cancer screening

(Blackwell et

al., 2008)

Cross

sectional

Canada; n=1.895

US; n=2.959

18-69 years old

Had Pap

smear test

1. < High-school

2. High-school

Diploma/ GED

3. Vocational

certificate

4. University

Educational levels

predict compliance

with cervical cancer

screening in Canada

(and nearly

did in the US)

(Gyulai et al.,

2015)

Cross

sectional

Hungary; n=

1539

25-65 years old

Had pap

smear test

1. Primary

2. Some Secondary

3. Secondary

4. Post-secondary

without diploma

5. College /

university

higher education

increases

participation

(Miles-

Richardson et

al., 2017)

Cross

sectional

USA; n=272.692

≥ 18 years old

Had pap

smear test

1. ≤ high school

2. Some college

3. College graduate

women with higher

level of education

were more likely to

be screened

(Lee et al.,

2013)

Cross

sectional

Korea; N=17.105

[1998]; n=2725

[2001]; n=1622

[2005]; n=2596

[2008]; n=2944

[2010]; n=2737

≥30 years old

Participat

cervical

cancer

screening

1. ≤ elementary

2. Middle – high

school

3. ≥ university

Educational levels

influenced screening

participation. lower

educational levels

were less likely to be

screened

Is an Educational Level Affect Women’s Participation on Cervical Cancer Screening?

485

4 DISCUSSION

This review found that 84,6% studies reported that

women with higher level of education are more

likely to participate cervical cancer screening

compare with women with lower level of education.

Overall, this review confirms that the risk of

participating cervical cancer screening is affected by

education.

Similar review found that there was positive

association between educational level and some

health-related behavior, one of them is screening

participation (Cutler & Lleras-Muney, 2010). The

reason is Well-educated women may have better

interest, and better access to resources and

information, so they have better knowledge about

health issue and behavior to improve their health.

Also, they have greater awareness of risks (Adams,

2010; Hahn & Truman, 2015). Simply, sufficiency

of current knowledge has a positive influence on

health-promoting behavioral options.

The argument of this finding is health literacy

has positive association with level of education.

Health literacy is an individual capacity to get,

process, and figure out the necessary information

and basic health service to determine health-related

decisions. One of the important factor that can

determine health literacy is level of education.

People with higher educational level were found to

demonstrated higher health literacy skill. (van der

Heide et al., 2013). Well-educated people are more

likely to completely understand the information and

instructions. Furthermore, people with higher level

of health literacy can increase the likelihood of

communication to health care providers that can lead

to better outcomes. Simply, low health literacy skill

can be a barrier in access health information, health

service, and disease prevention.

People with high capacity of health literacy also

have a higher capacity to be informed that screening

is necessary to prevent cervical cancer. This means

that the association between educational level and

some health behaviors – in this case cervical cancer

screening participation – is affected by health

literacy skill.

Cervical cancer screening participation is also

affected by the type of health care system and its

accessibility, screening policy, environmental,

sociocultural, and factors at individual level such as

age, race, insurance coverage and occupation

(Blackwell et al., 2008; Coughlin et al., 2008;

Damiani et al., 2012). In addition, cultural factors

can predict cervical cancer screening participation

and may be related with educational level. Some

studies reported that low cervical cancer screening

participation was caused by low knowledge about

screening guideline, along with various cultural

factors, such as negative attitudes toward illness and

misunderstanding about risk factors and screening

practices (Cadet, Burke, Stewart, Howard, &

Schonberg, 2017; Luque et al., 2015; Madhivanan,

Valderrama, Krupp, & Ibanez, 2016). Furthermore,

there is a correlation between cervical cancer

screening and some of the health-related behaviors,

including unhealthy diet, obesity, lack of physical

activity, and tobacco and alcohol consumption

(Damiani et al., 2012; Martín-López et al., 2012).

All factors above should be considered as they

may lead to be confounders in the evaluation of the

role of education level on cervical cancer screening

participation. Nevertheless, all included studies

conformed their analysis to those possible

confounding factors.

5 CONCLUSIONS

Women with higher educational level have a higher

risk to participate cervical cancer screening. This

finding can be considered in decision-making

processes to reduce the inequalities and increase

women’s participation on cervical cancer screening.

Overall, this review confirms that more educated

women are more likely to have cervical cancer

screening.

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