Intervenciones educativas para la prevención del cáncer cervicouterino: revisión del alcance

Mariño, Josiane Montanho; Nunes, Lailah Maria Pinto; Ali, Yasmin Cardoso Metwaly Mohamed; Tonhi, Leonardo do Carmo; Salvetti, Marina de Góes

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Revista Brasileira de Enfermagem

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Brasil

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Sumário

REVIEW • Rev. Bras. Enferm. 76 (5) • 2023 • https://doi.org/10.1590/0034-7167-2023-0018 copiar

Intervenciones educativas para la prevención del cáncer cervicouterino: revisión del alcance

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivos:

identificar, mapear y describir las características de las intervenciones educativas para la prevención del cáncer de cuello uterino en mujeres adultas.

Métodos:

revisión de alcance, realizada en once bases de datos y en la literatura gris, incluyendo estudios que describían intervenciones educativas dirigidas a la prevención del cáncer de cuello uterino en mujeres adultas.

Resultados:

se analizaron 33 artículos con 151.457 participantes. Las estrategias educativas más utilizadas fueron las discusiones participativas y los folletos educativos. La mayoría de las intervenciones se realizaron en una sola sesión, con una duración de 40 a 60 minutos. El modelo teórico más utilizado en las intervenciones para mejorar la adherencia de las mujeres al Papanicolaou fue el Modelo de Creencias de Salud.

Conclusiones:

las discusiones grupales, las conferencias y los folletos educativos pueden aumentar el conocimiento y reducir las barreras para la prevención del cáncer de cuello uterino. Las intervenciones basadas en teorías y culturalmente sensibles pueden tener un impacto positivo en la salud de las mujeres.

Descriptores:
Neoplasias del Cuello Uterino; Tamizaje Masivo; Prueba de Papanicolaou; Educación en Salud; Atención Primaria de Salud.

Code/author/year/country	Design/sample/theory	Population characteristics	Intervention characteristics
A1(⁴⁰40 Mboineki JF, Wang P, Dhakal K, Getu MA, Chen C. The effect of peer-led navigation approach as a form of task shifting in promoting cervical cancer screening knowledge, intention, and practices among urban women in Tanzania: a randomized controlled trial. Cancer Control. 2022;29:10732748221089480. https://doi.org/10.1177/10732748221089480 https://doi.org/10.1177/1073274822108948... ) Mboineki, et al. 2022 Tanzania	RCT n=88 Theory of Planned Behavior, HBM and Diffusion of Innovation Theory	Women aged 21 to 50, who have never had a preventive exam, without a previous history of cancer. Never received health education about CC and not being pregnant.	Peer-Led Navigation (PLNav), a single session lasting two hours over 6 months. The intervention included health education about CC and CC screening, advice to women who did not undergo screening according to scheduled appointments, navigation care.
A2(⁹9 Hosseini Z, Mohseni S, Momeni R, Aghamolaei T, Alavi A. Increasing the prevalence of cervical cancer screening in Iran: effectiveness of a theory-based educational intervention. Reprod Health. 2022;19(1):1-13. https://doi.org/10.21203/rs.3.rs-1311063/v1 https://doi.org/10.21203/rs.3.rs-1311063... ) Hosseini et al. 2022 Iran	Quasi-experimental study n=202 BASNEF Model	Women aged 20 to 49, sexually active, not pregnant, with at least elementary school education.	Educational program about CC applied in 14 sessions of 40-60 minutes, with lectures, participatory discussion, questions and answers, brainstorming.
A3(²⁸28 Lima TM, Nicolau AIO, Carvalho FHC, Vasconcelos CTM, Aquino PS, Pinheiro AKB. Intervenções por telefone para adesão ao exame colpocitológico1. Rev Latino-Am Enfermagem. 2017;25. https://doi.org/10.1590/1518-8345.1683.2844 https://doi.org/10.1590/1518-8345.1683.2... ) Lima 2017 Brazil	Quasi-experimental study n=524 Motivational Interviewing: Evoke-Provide-Evoke Model	Women between 25 and 64 years of age, who have started sexual activity, inadequate frequency of examinations and have their mobile or landline telephone numbers in their medical records.	Telephone intervention in a single 15-minute session. Brief explanation about CC and its risks, purpose of Pap smear test, importance of Pap smear test frequency, pre-examination care and the return for the result.
A4(¹²12 Mirzaei-Alavijeh M, Karami-Matin B, Jalilian F, Rakhshan F, Mahboubi M, Emdadi S. Pap smear test promotion among women: an educational intervention based on theory of planned behavior. J Biol Today’s World [Internet]. 2014 [cited 2023 Jan 17];3(4):100-3. Available from: https://oaji.net/articles/2014/598-1398623374.pdf https://oaji.net/articles/2014/598-13986... ) Mirzaei-Alavijeh et al. 2014 Iran	RCT n=120 Theory of Planned Behavior	Women aged 35 to 64, married and attending health centers	Intervention in four weekly sessions lasting 45-60 minutes each (one lecture and three group discussions) on CC, related factors and the role of Pap smear.
A5(³⁵35 Abu SH, Woldehanna BT, Nida ET, Tilahun AW, Gebremariam MY, Sisay MM. The role of health education on cervical cancer screening uptake at selected health centers in Addis Ababa. PLoS One. 2020;15(10):e0239580. https://doi.org/10.1371/journal.pone.0239580 https://doi.org/10.1371/journal.pone.023... ) Abu et al. 2020 Ethiopia	RCT n=2203 HBM	Women aged 30 to 49 who sought care at maternal and child health clinics but who were never screened for CC.	The intervention consisted of a brief individual conversation about CC and benefits of screening lasting 5 to 10 minutes provided by nurses. At the end, the participants received a leaflet containing information on the topics addressed.
A6(¹⁴14 Ramaswamy M, Simmons R, Kelly PJ. The development of a brief jail-based cervical health promotion intervention. Health Promot Pract. 2015;16(3):432-42. https://doi.org/10.1177/1524839914541658 https://doi.org/10.1177/1524839914541658... ) Ramaswamy et al. 2015 USA	Pilot study n=7 Bourdieu’s Theory of Social Transformation and Feminist Theory	Women aged ≥18 years, incarcerated, who have never had a Pap smear and who have not been diagnosed with cancer.	Educational intervention on sexual empowerment consisted of five two-hour sessions, over the course of a week, including group discussions and delivery of health agency leaflets by a nurse and physician.
A7(⁸8 Ernawati, Oktaviana D, Mantasia, Yusuf RA, Sumarmi. The effect of health education based on the health belief model about pap smear test on women in rural district Indonesia. Medico-Legal Updat. 2021;21(2):1-6. https://doi.org/10.37506/mlu.v21i2.2636 https://doi.org/10.37506/mlu.v21i2.2636... ) Ernawati et al. 2021 Indonesia	Quasi-experimental study n=100 HBM	Married women, aged ≥18 years, able to communicate in Indonesian (national language), regardless of whether they can read or not.	Educational intervention with one session lasting one hour, including lecture, space for questions and answers, group discussions and booklets on CC and CC screening.
A8(³⁰30 Luque JS, Tarasenko YN, Reyes-Garcia C, Alfonso ML, Suazo N, Rebing L, et al. Salud es vida: a cervical cancer screening intervention for rural Latina Immigrant Women. J Cancer Educ Off. 2017;32(4):690-9. https://doi.org/10.1007/s13187-015-0978-x https://doi.org/10.1007/s13187-015-0978-... ) Luque et al. 2017 Georgia	Quasi-experimental study n=90 SCT and Popular Education Theory	Women ages 21 to 65, rural immigrants, Latinas who have not had a Pap smear in 2 years or more.	Salud es Vida group intervention, with an introduction to CC with video and flipchart as well as dialogue to explore barriers to health care. Sessions of approximately 3 hours, with an average of 7 participants per session.
A9(⁴³43 Thompson B, Carosso EA, Jhingan E, Wang L, Holte SE, Byrd TL, et al. Results of a randomized controlled trial to increase cervical cancer screening among rural Latinas. Cancer. 2017;123(4):666-74. https://doi.org/10.1002/cncr.30399 https://doi.org/10.1002/cncr.30399... ) Thompson et al. 2017 USA	RCT n=443 SCT	Women age 21 to 64 of Latino ethnicity residing in the Yakima Valley who have not had a Pap smear in the past 3 years and have not had a prior hysterectomy.	Low-intensity intervention: culturally appropriate video in Hispanic language. High-intensity intervention: educational session with a health worker at home (watching the video with the health worker, appointment to perform or schedule a Pap smear).
A10(¹³13 Pirzadeh A, Mazaheri MA. The effect of education on women’s practice based on the health belief model about pap smear test. Int J Prev Med [Internet]. 2012 [cited 2023 Jan 17];3(8):585-90. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3429807/ https://www.ncbi.nlm.nih.gov/pmc/article... ) Pirzadeh et al. 2012 Iran	Quasi-experimental study n=70 HBM	Married women who have never had a Pap smear.	Group interventions with three sessions of 45 to 60 minutes in one week. Information about CC and films of cancer patients. Group discussion on the benefits and barriers to having Pap smear with films about the steps of the test.
A11(¹¹11 McDonough AM, Vargas M, Nguyen-Rodriguez S, Garcia M, Galvez G, Rios-Ellis B. Mujer sana, familia fuerte: the effects of a culturally-relevant, community-based, promotores program to increase cervical cancer screening among Latinas. J Health Care Poor Underserved. 2016;27(2):568-79. https://doi.org/10.1353%2Fhpu.2016.0094 https://doi.org/10.1353%2Fhpu.2016.0094... ) McDonough et al. 2016 USA	Quasi-experimental study n=5211 HBM and SCT	Participants had to be 18 or older and identify as Latinas.	Intervention in a single two-hour session, offered over four years. Lectures with group discussions using flipchart and bilingual educational brochures listing local resources where participants could obtain a free or low-cost Pap smear test.
A12(¹⁰10 Koç Z, Özdeş EK, Topatan S, Çinarli T, Şener A, Danaci E, et al. The impact of education about cervical cancer and human papillomavirus on women’s healthy lifestyle behaviors and beliefs: using the PRECEDE Educational Model. Cancer Nurs. 2019;42(2):106-18. https://doi.org/10.1097/ncc.0000000000000570 https://doi.org/10.1097/ncc.000000000000... ) Koç et al. 2019 Turkey	RCT n=156 PRECEDE-PROCEED Conceptual Model	Women taking courses at the community training center, literate with no history of cancer and no previous training in CC or HPV.	Focus group discussions with 6 to 10 individuals on quality of life, CC history, behaviors, lifestyle and beliefs. The women received 3 sessions of 60 minutes on cancer, HPV infection, healthy lifestyle and behaviors, including healthy nutrition, physical activity and weight management.
A13(²¹21 Daryani S, Shojaeezadeh D, Batebi A, Charati JY, Naghibi A. The effect of education based on a health belief model in women’s practice with regard to the Pap smear test. J Cancer Policy. 2016;8:51-6. https://doi.org/10.1016/j.jcpo.2015.11.001 https://doi.org/10.1016/j.jcpo.2015.11.0... ) Daryani et al. 2016 Iran	Quasi-experimental study n=120 HBM	Women aged 20 to 65 years, married for at least 6 months.	The group intervention was carried out in two sessions of 1 hour and 30 minutes. The first session included understanding CC, risk factors, symptoms and prevention. The second session included understanding the Pap smear. The teaching methods involved practical exhibitions, films, lectures, questions and answers, and a pamphlet based on the content of other media.
A14(²⁷27 Lee HY, Koopmeiners JS, Rhee TG, Raveis VH, Ahluwalia JS. Mobile phone text messaging intervention for cervical cancer screening: Changes in knowledge and behavior pre-post intervention. Obstet Gynecol Surv. 2015;70(1):26-7. https://doi.org/10.1097/OGX.0000000000000142 https://doi.org/10.1097/OGX.000000000000... ) Lee et al. 2015 USA	Quasi-experimental study n=30 Fogg Behavior Model	Korean American women aged 21 to 29 without prior receipt of a Pap smear.	Intervention in seven sessions, with questions and answers about information about CC, Pap smear, accessibility to health care, cultural barriers, availability of local clinics, cost of Pap smear, testimony from a Korean American woman who experienced Pap smear, and testimony from a CC survivor.
A15(²⁹29 Love GD, Mouttapa M, Tanjasiri SP. Everybody’s talking: using entertainment-education video to reduce barriers to discussion of cervical cancer screening among Thai women. Health Educ Res. 2009;24(5):829-38. https://doi.org/10.1093/her/cyp019 https://doi.org/10.1093/her/cyp019... ) Love et al. 2009 USA	Quasi-experimental study n=498 SCT	Thai women aged 18 and over.	Single session. 7-minute video for small groups of participants and discussion about their knowledge, attitudes and beliefs regarding Pap smear and CC.
A16(⁴¹41 Mishra SI, Luce PH, Baquet CR. Increasing Pap Smear Utilization among Samoan Women: results from a community based participatory randomized trial. J Health Care Poor Underserved. 2009;20(2):85-101. https://doi.org/10.1353%2Fhpu.0.0160 https://doi.org/10.1353%2Fhpu.0.0160... ) Mishra et al. 2009 USA	RCT n=398 Structure of Health Behavior and Freire’s Pedagogy of Empowerment	Samoan women, age 20 years or older, no self-reported history of obtaining a Pap smear within the last two years, no history of CC, no history of hysterectomy, and staying in the territory for the duration of the study (about six months).	Three two-hour weekly educational sessions, with hands-on exhibits, CC lectures and space for questions and answers. A total of 20 groups with 8 to 14 women were assisted.
A17(⁷7 Samami E, Seyedi-Andi SJ, Bayat B, Shojaeizadeh D, Tori NA. The effect of educational intervention based on the health belief model on knowledge, attitude, and function of women about Pap smear test at Iranian health centers: a randomized controlled clinical trial. J Educ Health Promot. 2021;10(1). https://doi.org/10.4103%2Fjehp.jehp_33_20 https://doi.org/10.4103%2Fjehp.jehp_33_2... ) Samami et al. 2021 Iran	RCT n=120 HBM	Women aged 21 to 65 years, with no history of uterine surgeries and hysterectomy.	Group intervention with two 90-minute sessions. Practical presentation, film, lecture, questions and answers. The first session was about CC, prevention methods and how to perform Pap smear. The second session was about women’s attitude, knowledge and role towards Pap smear.
A18(³⁸38 Calderon-Mora J, Alomari A, Shokar N. Comparison of narrative video and flipchart presentation to promote cervical cancer screening among Latinas along the border. Health Educ Behav. 2022. https://doi.org/10.1177/10901981221074918 https://doi.org/10.1177/1090198122107491... ) Calderón-Mora et al. 2022 USA	RCT n=500 HBM, Theory of Planned Behavior and SCT	Women ages 21 to 65, who have a Pap smear, are uninsured or underinsured, have no history of CC or hysterectomy, and have a Texas address.	Single-session group intervention (17-minute video on Pap smear, discussion of barriers to screening, followed by narration of infographics with guidance on screening and overcoming barriers). A 20-minute flipchart presentation was also used to reinforce the information.
A19(²³23 Fang CY, Ma GX, Tan Y, Chi N. A multifaceted intervention to increase cervical cancer screening among underserved Korean women: Cancer Epidemiol Biomarkers Prev. 2007;16(6):1298-302. https://doi.org/10.1158/1055-9965.EPI-07-0091 https://doi.org/10.1158/1055-9965.EPI-07... ) Fang et al. 2007 Korea	Quasi-experimental study n=102 HBM and SCT	Korean women from two community organizations, aged 18 years or older, without a diagnosis of CC and a Pap smear in the past 6 months.	Two-hour educational session with lectures, discussions, navigation training, exhibition of cultural videos, role-play use and behavioral skills test. The educational session focused on CC and tips for action and strategies to overcome barriers.
A20(³³33 Thompson B, Vilchis H, Moran C, Copeland W, Holte S, Duggan C. Increasing cervical cancer screening in the United States-Mexico border region. J Rural Heal Off J Am Rural Heal Assoc Natl Rural Heal Care Assoc. 2014;30(2):196-205. doi: https://doi.org/10.1111/jrh.12044 https://doi.org/10.1111/jrh.12044... ) Thompson et al. 2014 Mexico	Quasi-experimental study n=162 Principles of Mapping Intervention	Hispanic women, residents of border counties in New Mexico, ages 29 to 80, who have not had a Pap smear in the past 3 years.	The activity was individual, delivered by a CHW at home and consisted of one session. The intervention period was for 12 months. Intervention materials included a PowerPoint presentation that illustrated and described Pap smear, CC, and HPV. Color images and a video of a Pap smear were included in the presentation.
A21(²⁵25 Guvenc G, Akyuz A, Yenen MC. Effectiveness of nursing interventions to increase pap smear test screening. Res Nurs Health. 2013;36(2):146-57. https://doi.org/10.1002/nur.21526 https://doi.org/10.1002/nur.21526... ) Guvenc et al. 2013 Turkey	Quasi-experimental study n=2,500 HBM	Women at least 21 years of age, not having a previous diagnosis of gynecological cancer, literate, sexually active currently or in the past, not having a Pap smear in the last 12 months, not being in the second or third trimester of pregnancy, nor in the postdelivery of 3 months and available for telephone contact.	Educational flyers with invitation to Pap smear; telephone interview: information on the topics in the booklet and invitation to perform the Papanicolaou test; face-to-face interviews: conducted at home to inquire about the reason(s) related to not participating in the free CC screening after two invitations.
A22(²⁴24 Ghahremani L, Harami ZK, Kaveh MH, Keshavarzi S. Investigation of the Role of Training Health Volunteers in Promoting Pap Smear Test Use among Iranian Women Based on the Protection Motivation Theory. Asian Pac J Cancer Prev. 2016;17(3):1157-62. https://doi.org/10.7314/APJCP.2016.17.3.1157 https://doi.org/10.7314/APJCP.2016.17.3.... ) Ghahremani et al. 2016 Iran	Quasi-experimental study n=420 Protection Motivation Theory	Married, non-pregnant women, who had never had a Pap smear, did not have CC, had no history of hysterectomy surgeries.	CHWs trained the women under their cover in person using educational pamphlets during 3 sessions over 21 days.
A23(²²22 Drokow EK, Effah CY, Agboyibor C, Sasu E, Amponsem-Boateng C, Akpabla GS, et al. The impact of video-based educational interventions on cervical cancer, Pap Smear and HPV Vaccines. Front Public Health. 2021;9:681319. https://doi.org/10.3389/fpubh.2021.681319 https://doi.org/10.3389/fpubh.2021.68131... ) Drokow et al. 2021 Africa	Quasi-experimental study n=600 HBM and Transtheoretical Model	Ghanaian residents over 18 years of age, mentally healthy, not deaf or mute, with no previous history of HPV vaccination, cell phone or tablet carrier.	Three 3 sessions lasting 15 minutes. Educational videos about CC, HPV, Pap smear delivered by a nurse and a CHW. The video has been played twice for clarity. This was done every 2 months until the end of the 6-month intervention period.
A24(³⁴34 Wang X, Fang C, Tan Y, Liu A, Ma GX. Evidence-based intervention to reduce access barriers to cervical cancer screening among underserved Chinese American women. J Womens Health (Larchmt). 2010;19(3):463-9. https://doi.org/10.1089/jwh.2009.1422 https://doi.org/10.1089/jwh.2009.1422... ) Wang et al. 2010 USA	Quasi-experimental study n=134 HBM and SCT	Asian Chinese women, low-income, uninsured, no history of CC.	Two small group sessions led by trained Chinese community health educators. Specific syllabus focused on CC risk factors, prevalence and benefits of screening and early detection. Participants received help from the health professional to schedule appointments (nurse navigator). Handouts on CC and Pap smear and a video in Chinese on the subject were also presented.
A25(³⁶36 Byrd TL, Wilson KM, Smith JL, Coronado G, Vernon SW, Fernandez-Esquer ME, et al. AMIGAS: a multicity, multicomponent cervical cancer prevention trial among Mexican American women. Cancer. 2013;119(7):1365-72. https://doi.org/10.1002/cncr.27926 https://doi.org/10.1002/cncr.27926... ) Byrd et al. 2013 USA	RCT n=613 Mapping intervention, SCT, HBM, Transtheoretical Model and Rational Choice Theory	Self-declared women of Mexican origin aged 21 years or older, with no previous history of cancer, no hysterectomy, and no CC screening in the past 3 years.	AMIGAS intervention included a video drama using models to discuss barriers and facilitators to CC screening, a flipchart reviewing video information, games and activities, including a set of cards to understand a woman’s stage of change, in addition to a contract sheet titled “my promise”.
A26(⁴⁴44 Fleming K, Simmons VN, Christy SM, Sutton SK, Romo M, Luque JS, et al. Educating hispanic women about cervical cancer prevention: feasibility of a promotora-led charla intervention in a farmworker community. Ethn Dis. 2018;28(3):169-76. https://doi.org/10.18865/ed.28.3.169 https://doi.org/10.18865/ed.28.3.169... ) Fleming et al. 2018 USA	Pilot study n=60 SCT and HBM	Hispanic/Latino women, able to speak and read Spanish or English, aged 21-70.	Intervention with six 75-minute meetings. Group discussions, average of 10 participants per meeting. Community educators provided education using the CC educational resource as a structured and organized way of delivering content.
A27(²⁶26 Kurt G, Akyuz A. Evaluating the effectiveness of interventions on increasing participation in cervical cancer screening. J Nurs Res. 2019;27(5):e40. https://doi.org/10.1097/jnr.0000000000000317 https://doi.org/10.1097/jnr.000000000000... ) Kurt 2019 Turkey	Quasi-experimental study n=134.704 HBM	Women aged 30-65 (based on national CC screening age group), are or have been sexually active, able to speak, read and understand the Turkish language.	Brochure + education group: individual training on the importance of CC and Pap smear; leaflet only group: participants were asked to read the educational leaflet; Invitation-only group: Participants in this group were invited to receive a screening without additional training or an educational brochure.
A28(³²32 Shobeiri F, Shobeiri F, Javad M, Parsa P, Roshanaei G. Effects of group training based on the health belief model on knowledge and behavior regarding the pap smear test in Iranian Women: a quasi-experimental study. Asian Pacific J Cancer Prev. 2016;17(6):2871-2876. https://doi.org/APJCP.2016.17.6.2871 https://doi.org/APJCP.2016.17.6.2871... ) Shobeiri et al. 2018 Iran	Quasi-experimental study n=330 HBM	Women over 18 years old, attending premarital education classes, wanting to get married for the first time, or divorced women wanting to remarry.	Intervention with two group sessions of 45-60 minutes/week. The sessions were led by a professor of medical sciences, including lectures on Pap smear, group discussions, questions and answers. Educational leaflets were handed out to participants at the end.
A29(⁴⁵45 Jeihooni AK, Jormand H, Harsini PA. The effect of educational program based on beliefs, subjective norms and perceived behavior control on doing pap-smear test in sample of Iranian women. BMC Womens Health. 2021;21(1):290. https://doi.org/10.1186/s12905-021-01419-w https://doi.org/10.1186/s12905-021-01419... ) Khani et al. 2021 Iran	Interventional and prospective experimental study n=300 HBM and Theory of Planned Behavior	Women married for at least 6 months, not pregnant and without a history of cancer and/or hysterectomy.	Eight 50-minute educational sessions, once a week, with group discussions, brainstorming, Q&A and film screenings. At the end, a booklet and an educational CD were delivered. An educational message about the importance of CC prevention and screening behaviors was sent to the subjects each week and a telegram group was formed.
A30(⁴²42 O’Brien MJ, Halbert CH, Bixby R, Pimentel S, Shea JA. Community health worker intervention to decrease cervical cancer disparities in Hispanic women. J Gen Intern Med. 2010;25(11):1186-92. https://doi.org/10.1007/s11606-010-1434-6 https://doi.org/10.1007/s11606-010-1434-... ) O’Brien et al. 2010 USA	RCT n=120 HBM	Hispanic women aged 18 to 65.	Intervention applied by CHW with two 3-hour sessions. Presentation of information about CC, delivery of pamphlets and educational booklets to groups of 4 to 10 women.
A31(³¹31 Parsa P, Sharifi F, Shobeiri F, Karami M. Effects of group counseling based on health belief model on cervical cancer screening beliefs and performance of rural women in Kaboudrahang, Iran. Asian Pacific J Cancer Prev. 2017;18(6):1525-30. https://doi.org/10.22034%2FAPJCP.2017.18.6.1525 https://doi.org/10.22034%2FAPJCP.2017.18... ) Parsa et al. 2017 Iran	RCT n=80 HBM	Married women, aged between 18 and 60, residing in the village for at least 2 recent years, no hysterectomy, no history of CC.	Group counseling intervention applied by rural CHWs in three sessions of 45-60 minutes with an interval of one week and a capacity of 10 people per session, using posters and pamphlets.
A32(³⁹39 Malmir S, Barati M, Jeihooni AK, Bashirian S. Effect of an educational intervention based on protection motivation theory on preventing cervical cancer among marginalized women in West Iran. Asian Pac J Cancer Prev 2018;19(3):755-61. https://doi.org/10.22034/apjcp.2018.19.3.755 https://doi.org/10.22034/apjcp.2018.19.3... ) Malmir et al. 2018 Iran	RCT n=152 Protection Motivation Theory	Age over 20 and residing on the Kermanshah bank, not having a CC diagnosis and being married or sexually active.	Intervention with lectures on CC, group discussions and question-answers, pamphlets and a booklet were delivered by women from the region to participants, after each educational session. The activity took place in five sessions lasting 45 minutes for four weeks.
A33(³⁷37 Calderón-Mora J, Byrd TL, Alomari A, Salaiz R, Dwivedi A, Mallawaarachchi I, et al. Group versus individual culturally tailored and theory-based education to promote cervical cancer screening among the underserved Hispanics: a cluster randomized trial. Am J Health Promot. 2020;34(1):15-24. https://doi.org/10.1177/0890117119871004 https://doi.org/10.1177/0890117119871004... ) Calderón-Mora et al. 2020 USA	RCT n=300 HBM, Rational Choice Theory and SCT	Women between 21 and 65 years old, who have not had a Pap smear in the last 3 years, residents of El Paso or Hudspeth County, uninsured, no history of hysterectomy and/or CC, income >200% of the federal poverty level, or not enrolled with the Texas State Department of Health Services.	Intervention with group and individual discussions about barriers to screening and interactive dialogue. Participants received education with identical content from the AMIGAS project, with 75 minutes in the individual arm and 90 minutes in the group arm. Flipchart, message cards, body diagrams, action plan worksheet, resource sheet and information leaflets were used.

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[1] Corresponding author: Josiane Montanho Marino, E-mail: enf_josiane@yahoo.com.br