Global Health Action

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Facilitators and barriers for the delivery and

uptake of cervical cancer screening in Indonesia: a
scoping review

Gianna Maxi Leila Robbers, Linda Rae Bennett, Belinda Rina Marie
Spagnoletti & Siswanto Agus Wilopo

To cite this article: Gianna Maxi Leila Robbers, Linda Rae Bennett, Belinda Rina Marie
Spagnoletti & Siswanto Agus Wilopo (2021) Facilitators and barriers for the delivery and
uptake of cervical cancer screening in Indonesia: a scoping review, Global Health Action, 14:1,
1979280, DOI: 10.1080/16549716.2021.1979280

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 GLOBAL HEALTH ACTION
2021, VOL. 14, 1979280
https://doi.org/10.1080/16549716.2021.1979280

REVIEW ARTICLE

Facilitators and barriers for the delivery and uptake of cervical cancer
screening in Indonesia: a scoping review
Gianna Maxi Leila Robbers a, Linda Rae Bennett a
, Belinda Rina Marie Spagnoletti a

and Siswanto Agus Wilopob

a
Nossal Institute of Global Health, The University of Melbourne, Melbourne, Australia; bCenter for Reproductive Health, Faculty of
Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia

ABSTRACT ARTICLE HISTORY

Background: Cervical cancer (CC) is the second most common female cancer. In Indonesia, Received 19 March 2021
national CC screening coverage is low at 12%, highlighting the need to investigate facilitators Accepted 6 September 2021
and barriers to screening.
RESPONSIBLE EDITOR
Objective: This review synthesises research on facilitators and barriers to the delivery and Julia Schröders
uptake of CC screening; analyses them in terms of supply- and demand-side factors and their
interconnectedness; and proposes recommendations for further research. KEYWORDS
Methods: Medline Ovid, CINAHL, Global Health, Neliti, SINTA and Google Scholar were Gynaecological cancer;
searched, applying a search string with keywords relevant to screening, CC and Indonesia. female cancer; secondary
In total 34 records were included, all were publications on CC screening in Indonesia (2000- prevention; sexual and
2020) in English or Indonesian. Records were analysed to identify findings relevant to the reproductive health and
categories of barriers and facilitators, supply-and demand-side factors. rights; visual inspection with
Results: Demand-side facilitators identified included: husband, family or social/peer support acetic acid
(14 studies); information availability, knowledge and awareness (12 studies); positive attitudes
and strong perception of screening benefit and the seriousness of CC (12 studies); higher
education and socioeconomic status (11 studies); having health insurance; and short distance
to screening services (4 studies). Evidence on supply-side was limited. Supply-side facilitators
included counselling and support (6 studies), and ease of access (6 studies). Demand-side
barriers identified focused on: lack of knowledge/awareness and lack of confidence in screen­
ing (14 studies); fear, fatalism and shame (10 studies); time and transportation constraints (8
studies); and lack of husband approval and support (6 studies). Supply-side barriers included:
lack of skilled screening providers (3 studies); lack of advocacy and health promotion (3
studies); resource constraints (3 studies); and lack of supervision and support for health care
providers (3 studies).
Conclusions: Facilitators and barriers were mirrored in the supply- and demand-side findings.
The geographical scope and population diversity of existing research is limited and further
supply-side research is urgently needed.

Background
Cervical cancer (CC) is the fourth most common can­ interventions [5]. Many LMICs also struggle with
cer in women worldwide and one of the most common inadequate and fragmented health systems ill-
cancers in low- and middle-income countries (LMICs) equipped to attend to the screening needs of all
[1]. In 2018, 84% of all new CC diagnoses as well as women, further reinforcing the disadvantage and
90% of CC-related deaths affected women in LMICs cycle of poverty already experienced by vulnerable
[2]. Reproductive cancers contribute to the rising bur­ women [5].
den of chronic diseases worldwide, which dispropor­ A data analysis of 185 countries from the
tionally affect LMICS in particular Southeast Asia [3,4]. Global Cancer Observatory (Globocan) 2018 data­
In addition, three times more women die from repro­ base, showed that Africa accounts for the highest
ductive cancers than women die from childbirth com­ CC incidence and mortality rates worldwide due
plications every year [5]. In Indonesia, chronic diseases to high rates of HIV, followed by South-eastern
including cancer dominate the country’s mortality rates Asia [1,8]. Within Asia, Indonesia accounts for
and contribute to 73% of all deaths [6,7]. Women in one of the highest CC age-standardised incidence
LMICs die disproportionally from reproductive can­ (approx. 24 per 100,000 women-years) and mor­
cers compared to women in high-income countries tality rates (approx. 15 per 100,000 women-years)
due to lack of access to cost-effective and life-saving [1]. Moreover, Indonesia’s reported CC incidence

CONTACT Gianna Maxi Leila Robbers [email protected] Nossal Institute of Global Health, The University of Melbourne, Level
5, 333 Exhibition Street, Melbourne, 3000, Australia
Supplemental data for this article can be accessed here.
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 G. M. L. ROBBERS ET AL.

doubled between 2012 and 2018 [9]. This jump For low-income women, CC screening is available
may reflect the Government of Indonesia’s (GoI) for free at primary health centres (puskesmas) or
introduction of universal health coverage (UHC) during outreach mass screening programs conducted
through the National Health Insurance Scheme within low-income communities [22]. While reliable
(JKN) in 2014, which resulted in CC treatment data on health care coverage in Indonesia is scarce,
becoming free of charge and subsequently more some estimates from 2014 indicated that govern­
women are presenting for diagnosis and treatment ment-run screening programs were only available in
[10]. The introduction of UHC indicates the GoI’s eight out of 34 provinces [21,23,24]. The CC screen­
commitment towards realising its citizens’ right to ing coverage reached only 12% of women in the
health. However, women’s fulfilment of their right target population (30–50 years) in 2020 [25]. There
to comprehensive sexual and reproductive health is also great variance between provinces with the
care in relation to the prevention and early detec­ lowest CC screening coverage reported in Papua
tion of CC remains insufficient. At present, 70% (0,9%), while the highest coverage was in Bangka
of Indonesian women are diagnosed at advanced Belitung (25%) [25,26]. This indicates widespread
stages of CC and 50% of all Indonesian women inequality in access to the government-run CC
diagnosed die from the disease [11,12]. Fifty screening covered by the National Insurance
Indonesian women are now dying daily from CC Scheme and significant shortfalls in capacity in public
[13]. As a result of the significant burden of CC, screening service delivery.
Indonesia has signed the World Health Indonesia faces manifold challenges in CC screen­
Organization (WHO)’s Global Strategy to ing program implementation and uptake and
Accelerate the Elimination of CC launched in a detailed assessment of existing literature is needed
2020. The GoI has committed to screen at least to inform improvements in CC screening program
70% of women between the ages 35 and 45 and to delivery and uptake by 2030. No comprehensive ana­
enable 90% of women diagnosed with CC to lysis of prior research on the range of barriers and
receive treatment by 2030 [14,15]. While our facilitators influencing both the delivery and uptake of
focus in this review is on Indonesia, the review CC screening has been undertaken. This is a crucial
contributes to the larger global project of devel­ gap, as improvements in screening coverage cannot be
oping and interpreting a sufficient evidence-base realised without a comprehensive understanding of the
to tackle the vast inequity in access to life-saving underlying dynamics and challenges from both the
cervical cancer screening among women living in demand and supply sides. This scoping review analyses
LMIC. existing research on CC screening in Indonesia to
synthesise what is currently known about factors that
impede and facilitate uptake of CC screening, and to
Cervical cancer screening in Indonesia identify the strengths and weaknesses of current
CC prevention includes primary and secondary preven­ research findings and gaps in knowledge
tion and should engage women across their life-course. A scoping review approach has been applied in
For women who are sexually active,1 the World Health this article to investigate the extent of heterogenous
Organization (WHO) recommends a screen-and-treat knowledge on the topic, to identify knowledge gaps,
program that prioritises women aged 30–49, and repeat and to guide future research [27]. For the purpose of
screening every 3–5 years [16]. For lower-resource set­ this scoping review we define the demand-side of the
tings such as Indonesia, the visual inspection with acetic supply-demand nexus as including people requiring
acid (VIA) screening method is recommended. access to or influencing access to CC screening ser­
Indonesia adopted the WHO-recommended model and vices. The demand-side includes women who are
introduced the Cervical and Breast Cancer Prevention potential or actual consumers of such services, and
Project, which was first piloted in Karawang district, their partners and family members who may influ­
West Java in 2007 [17]. From 2014 the full cost of certain ence their engagement with screening services.
CC screening services was covered by the National Supply-side factors refer to components of the health
Health Insurance Scheme. Indonesia’s national CC system necessary for the delivery of CC screening.
screening program provides free services to married While consumers of health care are increasingly con­
women aged 30–50 years, including VIA or cytology sidered an integral part of the health system, this
[18]. CC screening is performed every 3–5 years. For review separates the supply- and demand-sides
women who are screened positive for precancerous because this delineation is apparent in the literature
lesions, repeat exams are recommended yearly [19–21]. reviewed. The supply-side components identified as

1
Since 2015, there also have been efforts to implement a school-based HPV vaccination program for adolescent girls before sexual debut. However, due
to logistical issues in vaccine availability and administration changes within the Ministry of Health in late 2019, the program has been temporarily
stalled [11,78].
 GLOBAL HEALTH ACTION 3

influencing facilitators and barriers to screening determine that the research was re-producible
mainly refer to: health service delivery; health service and unbiased. A search string with relevant key­
coverage; health workforce capabilities; and capacity words consisting of three sub-searches was devel­
to provide quality CC screening. Barriers to screening oped and included the following terms: a)
refer to obstacles, including beliefs and attitudes, that screening terms (pap smear* or papanicolaou* or
impede women from accessing CC screening. papanicolaou test or pap test* or visual inspec­
Barriers to screening relate to obstacles to both initial tion* or VIA test*), b) cervix uteri terms (cervix*
and repeat screening. Facilitators of CC screening or cervical or cervix uteri); c) Indonesia*. Search
relate to enabling conditions or actions that support terms for the Indonesian database Neliti and
and encourage women to be screened or to partici­ SINTA included: deteksi dini kanker serviks or
pate in screening. Facilitators typically create condi­ kanker serviks or leher Rahim or deteksi dini kan­
tions which are responsive both to the individual, and ker leher rahim or IVA kanker or pelayanan deteksi
to the social, cultural, geographic and economic con­ kanker leher rahim. GMLR is studying Indonesian
texts of women’s lives. Facilitators support women to and SAW, LRB and BRMS speak and read
engage in initial screening or repeat screening, and Indonesian fluently, SAW is Indonesian, ensuring
also support women to follow the recommended clarity in comprehension of the Indonesian lan­
treatment if screening results are positive for pre- guage articles. All sub-searches were combined to
cancer. However, this scoping review focuses solely yield the most relevant results (Supplement 1).
on screening and does not extend to a discussion of
facilitators and barriers for the provision of and
Data analysis
access to CC primary prevention or treatment for
women with pre-cancerous lesions. The objectives of Included literature was analysed according to the cate­
this scoping review are three-fold. We first synthesise gories of barriers, facilitators, supply- and demand-
relevant research on facilitators and barriers to the side as demonstrated in Figure 1. Below, with common
delivery and uptake of CC screening in Indonesia. themes identified within each of these categories.
Second, the facilitators and barriers identified are The database search initially yielded 551
analysed in terms of supply- and demand-side factors records and was conducted in December 2020;
and their interconnectedness. Finally, we identify 323 records remained after duplicates were
knowledge gaps and recommend how future research removed. The 323 records were screened by
can address these gaps. GMLR for their eligibility, with Indonesian
sources cross-checked by BRMS to ensure appro­
priate inclusion of research published in
Methods
Indonesian. Evaluation and selection of records
The scoping review followed the PRISMA scoping based on inclusion criteria was conducted by
review guidelines and included peer-reviewed GMLR and BRMS in consensus. Disagreements
research articles and grey literature as defined by over the inclusion of individual records were
Auger (1998) [28], published between 2000 and resolved via consultation with LRB. Citations that
2020, in English or Indonesian, and which reported included published abstracts only, poster presenta­
on the national CC screening program of Indonesia tions, commentaries, opinion pieces, editorials,
[27]. The time period was chosen as the national CC guidelines, methodology reports, case reports and
screening program was trialled and introduced in the grey literature without description of research
early 2000s. The following five databases were used to methodology was removed. Review articles were
search for eligible studies: Medline Ovid, CINAHL, also excluded and reference lists were scanned
Global Health, Neliti, SINTA and Google Scholar for any missed eligible studies. All other records
(first 10 pages of results). The Indonesian databases were considered, provided they met the inclusion
SINTA and Neliti were included on advice of SA to criteria. The Prisma flow chart shows the process
ensure the inclusion of research published only in of study selection and inclusion (Figure 2). Of 323
Indonesia. records, 216 were excluded after a title, keywords
and abstract screening and 107 records remained
for full-text screening. After full-text screening, 34
Inclusion criteria and screening process
were found to be eligible for data abstraction.
Inclusion criteria for records included those Citations were imported into Endnote and key
that: 1) explicitly discussed barriers and/or facil­ data was summarised in a table (Supplement 2).
itators to the delivery or uptake of CC screening The table in Supplement 2 was developed and
in Indonesia; 2) were published in either English piloted with six records by the authors. GMLR
or Indonesian; and 3) included a description of and BRMS then independently extracted and
research methodology that enabled us to cross-checked for consistency the following data
4 G. M. L. ROBBERS ET AL.

•health service •enabling

delivery condions and
•health care acons
providers
Supply-side Facilitators

Demand-
Barriers
Side

• Challenges •women
and obstacles •husbands
•family
members

Figure 1. Nexus between barriers, facilitators, supply- and demand-side factors.

Figure 2. Prisma flow chart [27].

for each included record: details on author, pub­ barriers. A deductive thematic analysis approach
lication date, data collection date, study type, was applied, by identifying key themes based on
applied research methods, study sample, research pre-existing knowledge of the topic and repetitive
location and setting, identified facilitators and reading of the texts to enable dominant themes to
barriers on the supply- and demand-side for each emerge across the body of research. The emerging
included publication and recommendations given themes of this approach are then used as cate­
by the respective authors. The data analysis of the gories for further analysis [29,30]. A narrative
34 included records included the identification of synthesis approach was then applied to describe
common themes among both barriers and facilita­ key themes across the categories of barriers and
tors, and analysis of how both supply- and facilitators, from both supply- and demand-side of
demand-side factors influence facilitators and the health system.
 GLOBAL HEALTH ACTION 5

Results data analysis of the fifth Indonesian Family Life

Survey (2014–2015) and analysed survey answers in
In total 34 records met the inclusion criteria, all of which
13 out of 27 provinces [23]. Twenty-three articles
were articles that reported on published studies from
reported on studies conducted on the island of Java,
peer-reviewed journals. Table 1 provides an overview of
indicating the historical bias toward what is known
the included literature. Out of 34 articles, 29 articles
as ‘inner Indonesia’ [32]. Most articles reported stu­
discussed studies analysing primary data (n = 29),
dies that were conducted in urban settings (n = 23),
three articles discussed studies that analysed secondary
two articles reported on studies that were conducted
data,2 and three articles discussed studies that analysed
in peri-urban setting [33,34] and six articles reported
both, primary and secondary data.3 Of the included
on studies that took place in a rural setting [35–40].
articles, almost two thirds were in English (n = 22); the
Two articles discussed studies in Yogyakarta and
remainder were in Indonesian (n = 12). The included
Central Java were undertaken in both rural and
articles reported on studies which primarily applied
urban communities [41,42]. One article analysed
quantitative methodologies (n = 27), while six articles
secondary data of a national survey, but did not
discussed studies that applied a qualitative methodology.
disaggregate responses by area [23]. The majority
One of the included articles discussed a study that
of articles (n = 29) was published between 2015
applied a mixed methodology [31]. The sample sizes of
and 2020. Most included articles were about studies
the various studies ranged from 12 to 5,397 participants.
that used health care settings to recruit participants,
The 34 articles discussed studies that were clus­
with 17 conducted via primary health centres (pus­
tered in ten of Indonesia’s 34 provinces (of which
kesmas) [22,34,36,39,43–55]. One article reported on
six are located on the island of Java): Central Java
a study that recruited participants via a hospital in
(n = 13), East Java (n = 5), West Java (n = 4),
Jakarta [31]. Four articles discussed studies that were
Jakarta (n = 3), Yogyakarta (n = 3), North
conducted in a community setting [33,40,56,57], one
Sumatra (n = 1), Riau (n = 1), South Sulawesi
in a workplace setting [58] and remaining articles
(n = 1), Banten (n = 1) and Bali (n = 1). One
reported on studies (n = 11) that did not specify the
study conducted in 2018, conducted a secondary
types of research sites where data was collected
[23,35,37,38,41,42,59–63].
Table 1. Description of included articles. The majority of included articles (n = 25) dis­
Characteristics of research n* References cussed facilitators and barriers [22,23,33,34,36,39–
Quantitative methodology 27 [23,34–38,41–43,45–50,52–63] 42,44–48,50–52,54–58,60,61,63], two articles explored
Qualitative methodology 6 [22,33,39,40,44,51] barriers exclusively [31,59] and seven articles focused
Mixed- methodology 1 [31]
Primary Data 29 [22,33–44,46,47,50–63] only on facilitators [35,37,38,43,49,53,62]. Articles
Secondary Data 3 [23,49,63] exploring the demand-side of CC screening predomi­
Primary & Secondary Data 3 [31,45,48]
Population Sample nately focused on women, with 29 articles reporting
Women only 29 [23,33–38,41–43,45–63] on studies having women participants only. Three
Health Care Providers** 4 [22,31,39,44]
Men** 3 [22,31,40] articles reported on studies with both women and
Location men as participants [22,31,40]. Four articles reported
Rural 6 [35–40]
Peri-urban 2 [33,34]
on studies that also included health care providers
Urban 23 [22,31,43–63] (HCPs), health officers or primary health clinic man­
Urban & Rural 2 [41,42] agers [22,31,39,44]. Research that evaluated the sup­
National (13/27 provinces) 1 [23]
Provinces ply-side of CC screening mainly focused on: health
Central Java 13 [35–38,40,42,44,45,52,53,56,61,62] worker training or skills; CC screening service cover­
East Java 5 [33,46,49,54,55]
West Java 4 [22,47,50,57] age; health service capacity; and resource constraints
Jakarta 3 [31,51,63] leading to poor implementation and CC screening
Yogyakarta 3 [34,41,43]
North Sumatra 1 [59] service delivery. The included research predominately
Riau 1 [39] focused on married women, with seven articles
South Sulawesi 1 [48]
Banten 1 [58]
reporting on studies that analysed women’s CC
Bali 1 [60] screening uptake among married women exclusively
Timeframe of Publication [36,41,45,50,51,56,58]. Another five articles reported
2000–2010 1 [31]
2015–2020 29 [22,23,33–55,57,59–63] on studies that analysed answers of women with
**Studies counted more than once per category a majority of them being married, ranging between
*Number of studies 65% and 93% of the total study sample

2
Secondary data based on the Indonesian Family Life Survey (2014–2015) [23], health data from the Ministry of Health Research and Development
Agency RI collected for the cohort study of non-communicable disease risk factors 2011 [63] and medical records [49].
3
Primary data was collected via questionnaires and secondary data was based on medical records/health data regularly collected by participating health
centres. The included time period of secondary data was only specified by Susanti et al. (2003): year 2000–2001 [31]. Time origin of secondary data for
Nordianti et al. (2018) [45] and Nuryana et al. (2019) [48] was not indicated.
6 G. M. L. ROBBERS ET AL.

[23,31,33,43,47]. Therefore, unmarried women’s socioeconomic status. Ten articles discussed studies
experiences of screening are almost entirely absent conducted across West Java, Java and East Java,
or only present in small percentages of the included Yogyakarta, Jakarta and Riau province addressed sup­
population sample of the individual studies.4 ply-side facilitators. The following four supply-side
facilitator themes emerged from our analysis:
Counselling and support; ease of access; health
Facilitators of CC uptake and delivery promotion and advocacy; HCPs gender; and clear
supervision and support of HCPs and ensuring
Two included articles discussed supply-side facilita­ quality of services.
tors [39,44], 19 articles discussed demand-side facil­
itators [34–36,43,45,46,48–50,52,54–58,60–63], and
eleven discussed demand and supply-side facilitators Demand-side facilitators
[22,23,33,37,38,40–42,47,51,53]. Table 2 provides an
overview of the identified themes within the included One of the most significant demand-side facilitators
literature. Five main demand-side facilitators identified across the literature was husband, family
emerged from our analysis, these are: husband, or social/peer support – referring to the support of
family or social/peer support; information avail­ women received from their husbands, family mem­
ability, knowledge and awareness; positive attitude, bers, and their friends and peers. This type of support
motivation and perception of benefit of screening was commonly characterised as any emotional or
and seriousness of CC; having health insurance and tangible support such as active encouragement to
short travel distance to CC screening service; and seek CC screening, assistance to attend services or
women having higher education and to access information or to provide an open and
positive communication about the topic. Fourteen
publications discussed the positive impact of such
Table 2. Identified themes.
support on women’s CC screening uptake and were
Theme n* References
Demand-Side Facilitators:
conducted in West, Central and East Java [22,23,35–
Husband, Family or Social/ 14 [22,23,35–38,40,45,49,53,55– 38,40,45,49,53,55–57,62]. Husband support was sta­
Peer Support 57,62] ted as a significant facilitator for increasing CC
Information availability, 12 [34,36,40,45,46,48,49,51–53,55–
knowledge and awareness 58,61,62]
screening uptake in multiple studies across West,
Positive attitude, motivation 12 [37,38,43,49,51–54,58,60–62] Central and East Java (n = 6) [22,35–37,49,55].
and perception
Having health insurance and 4 [23,41,42,45]
Husband support included gaining permission from
short travel insurance spouses to access CC screening services, being
Higher education and 11 [23,38,47,50,52,55,57,58,61–63] encouraged or advised by spouses to seek CC screen­
socioeconomic status
Supply-Side Facilitators: ing services and being accompanied to CC screening
Counselling and Support 6 [22,33,37–39,47] services by one’s husband. In a study in Central Java
Ease of access 6 [22,33,41,42,51,53]
Health Promotion and 2 [22,39] (n = 80), women whose husbands supported them to
Advocacy access CC screening were three times more likely to
HCPs gender 2 [40,41]
Clear supervision, support and 1 [44]
access CC screening services than women who did
ensuring quality of services not have their husband’s permission [35]. Five arti­
Demand-Side Barriers: cles described family support as an important facil­
Lack of knowledge, awareness 14 [22,23,31,33,34,36,40,48,51,55,57–
and lack of confidence 59,62] itator to encourage women to attend CC screening
Low-risk perception 3 [40,50,51,55] [22,38,45,53,55]. Family support included the support
Lack of husband’s permission 6 [22,31,41,47,50,56,59]
and general support of other relatives in terms of encouragement and
Fear, fatalism and shame 10 [22,33,34,39–41,47,50,51,55] tangible support to access information and services
Time and transport 8 [22,31,41,42,46,50–52,57]
constraints related to CC screening [22,38,45,53,55]. However,
Low education 4 [45,58,59,63] while family support was observed across multiple
Supply-Side Barriers:
Limited access/coverage and 2 [22,31] studies as important, husband support was estab­
operating hours lished as being of critical importance in terms of
Lack of skilled CC screening 3 [36,39,44] influencing women’s CC screening uptake [55].
providers
Lack of advocacy and health 3 [22,44,52] Social or peer support was discussed in eight arti­
promotion cles and was defined as the provision of information,
Inadequate implementation & 2 [40, 45]
coordination encouragement and support with respect to learning
Resource constraints 3 [23, 40] about CC screening and seeking services provided by
Lack of communication and 3 [23, 40, 45]
support for HCPs friends or community members [22,23,36–
38,56,57,62]. A study in Central Java (n = 100)
4
While some studies aggregated their population sample according to marital status incl. married, single, widowed, not all included studies provided
this information.
 GLOBAL HEALTH ACTION 7

described how advice and support of a close friend 22.33 times (OR) [42,49,53,61]. Perceived benefits of
can encourage women to attend outreach screening CC screening were also found to increase women’s
events [36]. Another study in Central Java (n = 99) participation in CC screening between 1.61 and 5.21
found that women who had strong social support are times [49,61]. However, attitudes and perceptions are
up to ten times more likely to attend CC screening also influenced by other external factors, such as trust
than women without significant social or peer sup­ in screening services and by observing behaviours of
port [56]. An evaluation of the fifth Indonesian peers and their experiences with CC screening. The
Family Life Survey data (2014–2015) (n = 5,397) reviewed studies indicated that women whose peers
asserted that women who regularly participated in undergo CC screening are up to 4.3 times (OR) more
social activities and interacted with peers and com­ likely to access screening themselves [53]. Perceived
munity members were more likely to be exposed to seriousness of CC was also observed to increase
CC screening information and to access screen­ women’s motivation and likelihood by 1.17 times to
ing [23]. access screening [61].
Twelve studies described the importance of Four studies conducted in Central Java and
information availability, knowledge and aware­ Yogyakarta discussed having health insurance and
ness of CC and screening services as facilitators of a short travel distance to CC screening services as
screening uptake, these studies were conducted a demand-side facilitator. Among those, three studies
across West, East and Central Java, South discussed in particular that women having health
Sulawesi, Yogyakarta, Jakarta and Banten insurance was found to be a facilitator for accessing
[34,36,40,45,46,48,49,51–53,55–58,61,62]. Another CC screening across Yogyakarta and Central Java
study tested the significance of a health education [23,41,45]. Having insurance increased women’s like­
intervention on improving women’s knowledge of lihood to access screening by 9.15 times5 [45]. Short
CC screening and the CC screening behaviour of travel distance to screening services was a facilitator
study participants (n = 79) [46]. The intervention identified by two studies in Central Java [23,42]. In
used audio-visual material and information book­ these studies, living within 8 km of a service increased
lets on CC screening, and found that women in the the likelihood of accessing screening by almost four
intervention group were more likely to know the times [23,42].
benefits of screening and to participate in CC Eleven studies conducted in the provinces of West,
screening post-intervention than women in the Central and East Java, Banten and Jakarta discussed
control group (90% vs. 73%) [46]. Four studies the influence of education and socioeconomic status
identified information availability, such as informa­ on CC screening uptake [23,38,47,50,52,55,57,58,61–
tion provided via social media on CC screening, as 63]. Women with high school and post-secondary
an important facilitator for women’s CC screening education were up to 1.8 times more likely to access
uptake [33,36,48,53]. Notably three of these four CC screening than women with lower education
studies were situated in urban settings where [47,58]. Moreover, women with an occupation or
women’s use of social media is typically higher a monthly income of more than 2 million rupiah
than that of women living in rural areas are also more likely to access CC screening. Other
[33,36,48,53]. One study in South Sulawesi facilitators for CC screening uptake identified in the
(n = 350) found that women with sufficient CC reviewed studies included being aged between 30 and
knowledge and who have good general access to 42 years [55,58], being married [47,58], and having
information about CC screening are between 4.5 a family history of CC [33].
and 6 times more likely to undergo CC screening
than other women [48].
Supply-side facilitators
Twelve studies reported on attitudes, motivations
and perceptions of women as facilitators for CC Counselling and support provided by screening pro­
screening and were conducted in Yogyakarta, viders, typically via pre- and post-screening or by
Central and East Java, Banten and Bali encouraging women to access CC screening, was
[37,38,43,49,51–54,58,60–62]. These studies demon­ identified as a supply-side facilitator in six studies
strated that women’s positive attitude, their percep­ and was found to have a positive impact on screening
tions of both the benefits of screening and the uptake [22,33,37–39,47].
seriousness of CC influenced their motivation and Six studies set in West, East and Central Java,
uptake of CC screening. A positive attitude towards Yogyakarta and Jakarta found that ease of access in
CC screening was found to increase women’s like­ of geographic convenience and availability of free CC
lihood to undergo CC screening between 2.04 and screening services were important facilitators for

5
As Indonesia has a decentralized healthcare system not all regencies (kabupaten) provide reimbursement for the government-run CC screening even
though national policies state that CC screening is intended to be covered by the National Health Insurance Scheme [79,80].
8 G. M. L. ROBBERS ET AL.

women’s uptake of services [22,33,41,42,51,53]. The on demand-side barriers: lack of knowledge, aware­
availability of mobile outreach or mass screening ness and lack of confidence in screening outcome
events was also identified as a facilitator in two stu­ or quality; low-risk perception; lack of husband’s
dies in West and Central Java [22,40]. These events permission and general support; fear, fatalism and
improved access to CC screening especially for rural- shame; time and transportation constraints; and
dwelling women in areas with limited health care low education. Six themes of supply-side barriers
coverage [22]. Women in three studies in related to the delivery CC screening were identified
Yogyakarta, Jakarta and East Java also stated that in our analysis, including: limited access/coverage
they would attend CC screening if it is available free and operating hours; lack of skilled CC screening
of charge [33,41,51]. providers; lack of advocacy and health promotion;
Two studies in Central Java and Yogyakarta found inadequate implementation and coordination;
that the gender of HCP predicts women’s comfort resource constraints; and lack of communication
during CC screening services. Therefore, the avail­ and support for HCPs.
ability of a female HCP had an impact on women’s
CC screening behaviours, as it reduced their discom­
Demand-side barriers
fort related to modesty, embarrassment or shame
during CC screening. Employing more female CC Fourteen studies set identified women’s lack of
screening providers was hence concluded to be an knowledge and awareness, and lack of confidence
important facilitator to CC screening acceptability in screening as crucial barriers to their uptake
and uptake [40,41]. [22,23,31,33,34,36,40,48,51,55,57–59,62]. Twelve out
Health promotion and advocacy were discussed of 14 studies focused on women’s lack of understand­
as facilitators in two studies conducted in West Java ing or awareness of either CC prevention and/or
and Riau [22,39]. Health promotion and advocacy where CC screening is available
were found to be particularly useful when the health [22,23,31,33,34,36,40,48,50,51,58,59]. Additionally,
office collaborates with the community level such as having a negative attitude towards screening with
community leaders in a joint health promotion effort. respect to outcome expectation, trust in services and
It was argued that this due to the fact that the envir­ perceived quality was identified as a barrier in three
onment of women can influence their health beha­ studies [31,57,59]. A qualitative study with men
viours. Consequently, community leaders can serve as undertaken in Central Java (n = 15) identified their
important role models and advocates for CC screen­ lack of knowledge about CC as a barrier to screening
ing [39]. HCPs are also a common source of health uptake [40].
promotion and advocacy and hence those two facil­ Four studies conducted in East Jakarta, Central,
itators were commonly linked [22,39]. West and East Java identified low-risk perception
One study in Semarang, Central Java evaluated the as a demand-side barrier to CC screening
CC screening program in 13 primary health care [40,50,51,55]. Limited knowledge about CC can con­
clinics and showed how clear supervision and sup­ tribute to low-risk perception among women because
port of HCPs and ensuring quality of services at CC it is asymptomatic until it reaches later stages of the
screening services is essential to the delivery of CC disease [40,55]. Misconceptions among women about
screening [44]. Hence, the study concluded that the being at risk for CC was identified as a barrier as
following factors are important facilitators for the women understood themselves as being outside of
smooth delivery of quality CC screening: clear com­ ‘high-risk’ groups [40,50,51].
munication between midwives and clinic managers; Six studies conducted in Central and West Java,
positive attitudes, motivation and commitment North Sumatra, Jakarta and Yogyakarta identified
among screening providers; regular supervision and lack of husband’s permission and general support
provision of feedback to midwives who provide as a barrier to women’s decision to access CC screen­
screening; ensuring the availability and comprehen­ ing [22,31,41,47,50,56,59]. The requirement of
sion of screening guidelines for midwives; and ensur­ a husband to consent to undergo screening was iden­
ing the availability of functional screening equipment. tified as a barrier in three studies [22,41,50]. A related
barrier to women accessing CC screening identified
in two studies was the need to explain the procedure
Barriers to CC uptake and delivery
to husbands and lack of available educational mate­
Twenty studies identified demand-side barriers rial for this purpose [22,41]. Another study in West
[23,33,34,36,40,42,45–48,50,54–56,58–61,63], one Java found that lack of support by HCPs prevents
study identified supply-side barriers [44], while five some women from attending regular or repeat
studies discussed both supply-and demand-side bar­ screening [47].
riers [31,39,41,52,57]. Seven key themes of barriers Ten studies conducted in West and East Java,
were identified in our analysis of included literature Riau, Yogyakarta and Jakarta, identified the issues of
 GLOBAL HEALTH ACTION 9

fear, fatalism and shame to be demand-side barriers Another supply-side barrier identified in three
to screening [22,33,34,39–41,47,50,51,55]. Women studies [36,39,44] was the limited training on CC
feared experiencing pain undergoing screening, screening available for HCPs leading to a lack of
based either on their own prior experiences or those skilled HCPs who could perform CC screening.
of their peers [33]. Fear of receiving a positive result According to an evaluation in Riau province in
of cancer or pre-cancer was also reported as a barrier 2018 for example, only 31 out of 956 eligible HCPs
to screening in three studies [40,50,55]. Fear of (3.14%) working at public health centres were trained
a positive test result was also linked with fatalism in in CC screening [39]. Another evaluation at a health
three studies, which related to women’s belief that if care centre in Central Java also showed that only
cancer was brought about by preordained destiny, it three midwives were trained and permitted there to
could not be altered or cured [22,41,51]. In five conduct CC screening, which was also reflected in
studies in Yogyakarta, Riau, West Java, Central and a low coverage of CC screening among women of age
East Java, shame or embarrassment resulting from 30–50 years (5%) attending the same healthcare cen­
having a pelvic exam during screening, was reported tre [36].
as deterring women from accessing screening or The lack of advocacy and health promotion in
returning for repeat screening [33,39–41,47]. Having the forms of community mobilisation and counsel­
a male doctor as a screening provider was also iden­ ling regarding the importance and availability of CC
tified as a deterrent for women’s screening uptake, screening was identified as a barrier to CC screening
and was linked directly with women’s desire to avoid in three studies in West and Central Java [22,44,52].
feelings of shame or embarrassment [40,41]. A lack of advocacy volunteers in West and Central
Time and transportation constraints were Java who educate women about CC within their
reported as barriers to access in eight studies con­ community and thereby encourage them to access
ducted in Yogyakarta, Jakarta, Central and West Java. CC screening was identified as an important chal­
Excessive travel distance was identified as a barrier lenge to CC screening uptake [22,52]. Moreover,
for women to access CC screening, particularly for a lack of educational material posted on walls at
women who live far from a primary health centre or healthcare centres was seen as a factor for low uptake
have limited means of transportation and awareness of screening services [52]. Insufficient
[22,31,41,42,46,50–52,57]. The barriers of time con­ use of media and targeted counselling for women was
straints and excessive travel distance were also logi­ also identified as a barrier to screening uptake in
cally linked, due to the cost and time it takes to travel Central Java [44].
long distances. Inadequate implementation and coordination of
Low education and/or socioeconomic status were national CC screening efforts was identified as
identified as barriers to women accessing the ade­ a supply-side barrier in two studies in Central Java
quate information about CC screening and attending and Riau [39,44]. CC screening implementation was
CC screening in four studies in Yogyakarta, Jakarta, found to be challenged in particular by a combination
Banten and Central Java [45,58,59,63]. A study with of miscommunication among healthcare centre staff,
384 women in Yogyakarta and a study with 124 lack of human resources, equipment and limited
women in Jakarta, each identified that the cost of supervision of HCPs in an evaluation of a health
seeking health services is a barrier for women to centre in Central Java [44]. In another study in
access CC screening [31,41]. Riau, it was also evaluated that operating standards
for CC could not be implemented due to inadequate
facilities and infrastructure. Limited funding, infor­
mation and miscommunication about requirements
Supply-side barriers
for the CC program implementation also caused
Limited access/coverage and operating hours were operational issues [39].
identified as a barrier in two studies in West Java and Resource constraints such as lack of, or broken
Jakarta [22,31]. An evaluation study of seven public screening equipment, and lack of funding for screen­
health centres in West Java for example, showed that ing services was a barrier for delivery of CC screening
CC screening was only offered on limited days and services in two studies [22,39]. In a study in Riau for
specific hours. This was found to be a barrier for example, inadequate budgets did not allow the pur­
women intending to access regular screening as chase of adequate screening equipment and an unre­
most of them live far away from healthcare centres liable electricity supply forced HCPs to switch to
and need to make special arrangements to undertake battery-operated examination lamps. Hence, it was
a trip for this purpose [22]. Moreover, limited cover­ identified as a barrier to CC screening delivery [39].
age of screening services was observed to impact Additionally, a lack of communication between
women’s decision to travel long distance to access screening providers, clinical managers and directors
them in a study in Jakarta [31]. of primary health clinics on guidelines goals and
10 G. M. L. ROBBERS ET AL.

targets was observed as a barrier constraining the constraints (3 studies); and lack of communication
provision of screening services in three studies in and support for HCPs (3 studies).
Central Java and Riau [22,39,44]. Lack of communi­ The imbalance in investigation of supply and
cation was found to be a major source of confusion demand side factors, is problematic because it can
over roles, responsibilities and inefficient cooperation lead to interpretations of limited data that infer vic­
among HCPs leading to poor service execution in tim blaming – that is blaming women for their failure
health centres in West Java and Riau [22,39]. Lack to access screening [64]. Despite the apparent defi­
of communication among staff members was also ciencies and challenges highlighted in the research
attributed to a lack of regular meetings of all HCPs very few studies have focused on the supply-side
to ensure that appropriate screening guidelines, aspects shaping the delivery and uptake CC screen­
related responsibilities and screening program targets ing. This pattern is also apparent in the published
are continuously followed as shown in a study in research on this topic focused on LMICs more gen­
Central Java [44]. erally. The tendency to focus research on individual-
Finally, the same three studies identified a lack of based (demand side) factors that prevent was also
support for screening staff in the form of regular feed­ noted in a recent systematic review of 2021 on bar­
back and supervision as supply-side barrier [22,39,44]. riers and facilitators to CC screening in Southeast
Limited supervision and feedback for working screening Asia [12,65,66]. The imbalance in focus of individual
providers also negatively contributed to HCP’s motiva­ behavioural factors has also be observed within other
tion, understanding and commitment towards CC pro­ research areas as demonstrated in a recent systematic
gram targets in Central Java [44]. A need for greater review on NCDs by Schröders et al. (2017) [3], which
support for HCPs through regular communication and noted a focus on risk factors on the individual level
affirmation of screening goals through regular meetings for the management of NCDs rather than a more
was also identified in a study in Riau [39]. In West Java, efficient public health approach within Indonesia
HCPs also pointed out the need for more support from [3]. We recommend that further research into sup­
outside the healthcare centres such as community advo­ ply-side factors should be undertaken to identify
cacy teams to mobilize and reach more women on the strategies to address the interconnectedness of both
community level and to encourage them to access CC demand- and supply-side factors. Combined supply
screening [22]. and demand side research is needed to inform
improvements in the efficiency, accessibility and
quality of the CC screening program, making it
Discussion
more responsive to the needs and preferences of
This is the first scoping review to discuss demand- women, and subsequently improving rates of screen­
and supply-side facilitators and barriers to CC ing uptake.
screening in Indonesia. However, included research This review highlights multiple gaps in the existing
predominately focused on demand-side facilitators research on the facilitators and barriers to CC screen­
such as husband, family or social/peer support (14 ing in Indonesia. There is a clear bias in the geogra­
studies); information availability, knowledge and phical coverage of the research towards provinces on
awareness (12 studies); positive attitude, motivation Java island, with 34 included studies being conducted
and perception of benefit of screening and serious­ across only 10 out of 34 provinces, six of which are in
ness of CC (12 studies); higher education and socio­ Java. Additionally, the studies were mainly conducted
economic status (11 studies) and having health in urban or semi-urban locations with limited inclu­
insurance and short travel distance to CC screening sion of the CC screening experiences of women and
(4 studies). Limited evidence was identified for sup­ HCPs in rural or remote areas. This is of concern
ply-side facilitators resulting in the most commonly because women in rural areas face greater cumulative
identified facilitators including counselling and sup­ barriers to accessing to CC screening. Leaving out
port (6 studies) and ease of access (6 studies). their experiences obscures inequities between
Similarly, most included studies also focused primar­ women in different provinces and with different life
ily on demand-side barriers with most evidence circumstances. Most research is also focused on mar­
focusing on lack of knowledge, awareness and lack ried women’s CC screening experiences, excluding
of confidence in screening outcome or quality (14 those of unmarried women or women within same
studies); fear, fatalism and shame (10 studies); time sex unions. We recommend that additional research
and transportation constraints (8 studies) and lack of should be conducted with greater geographical cover­
husband’s permission and general support (6 studies). age, to include women living outside urban and peri-
However, evidence on supply-side barriers was parti­ urban centres, married and unmarried women, and
cularly scarce as most studies focused on lack of women from marginalised groups.
skilled CC screening providers (3 studies); lack of The most commonly identified facilitators and
advocacy and health promotion (3 studies); resource barriers on the demand- and supply-sides, were
 GLOBAL HEALTH ACTION 11

typically interconnected and sometimes interdepen­ facilitator across research on CC screening in

dent. Support to access CC screening provided by LMICs including in Southeast Asia, which affirms
husbands or women’s close social circles was found the findings of our review [12,66]. However, it also
to be both the most common facilitator, and where underlines the persistent global focus on women in
support was lacking the most common barrier research as a main source for low CC screening
[22,23,31,35–38,40,41,45,49,50,53,55–57,59,62]. uptake, without contextualising uptake within
Despite husbands’ significant influence, legally as well broader structural issues of the respective health sys­
as culturally in Indonesia, only three studies included tem. We recommend more research that investigates
men’s perceptions and roles (demand-side facilitator the impact of broader social determinants of health
and barrier) [22,31,40]. According to national screen­ on screening patterns in order to achieve a more
ing guidelines Indonesian husbands’ permission is comprehensive understanding of CC screening deliv­
required for women to participate in CC screening, ery and uptake in Indonesia [69,70]. This review
however one study reported that some men struggle establishes that supply-side factors can positively
to support their partners due to their lack of knowl­ influence women’s CC awareness and knowledge
edge of CC screening, despite having a supportive through counselling and support by HCPs
attitude towards CC screening [40]. There is increas­ [22,33,37–39,47]. However, we also identified a lack
ing evidence within global health research that of trained HCPs as a common supply-side barrier
greater male involvement in women’s reproductive [39]. The importance of the availability of skilled
health can be beneficial for women’s health out­ HCPs who can counsel women on CC appropriately
comes, yet there remains limited evidence on effective in order to facilitate screening uptake has been noted
strategies for facilitating male involvement for CC in other LMICs [66,71,72]. Effective and culturally
screening [67]. Two recent studies in Kenya and appropriate training on CC screening for HCPs is
Ghana, parallel our finding in Indonesia, that men essential and research on training interventions for
can be supportive of CC screening for their female HCPs within Indonesia is recommended.
partners but have limited understanding of the pro­ While knowledge of CC is important, a positive atti­
cedure [67,68]. Future research in Indonesia should tude, motivation and perception of benefit of screening
include men’s involvement in and influence over and seriousness of CC was another common demand-
women’s access to CC screening, and encourage the side facilitator, conversely lack of confidence in screen­
implementation and evaluation of strategies for male ing outcome or quality was a common demand-side
involvement in screening. Further research into effec­ barrier [22,23,31,33,34,36,40,48,51,55,57–59,62]. Lack
tive strategies for peer support interventions is war­ of confidence can be a consequence of negative prior
ranted as peers have been found to be an important experiences of screening, unavailability of quality ser­
demand-side facilitator on screening uptake vices and a lack of trust in HCPs [31,57,59,73]. Other
[22,23,36–38,56,57,62]. One study conducted in research in Southeast Asia has identified negative
Central Java found that women felt more comfortable experiences with HCPs as a common barrier to CC
and less embarrassed if screened together with peers screening uptake [66,74].
in community screening events, presenting an oppor­ The studies reviewed established that the cost of
tunity for expanding mobile outreach efforts in areas travel and services, and travel distance are crucial for
with limited healthcare coverage [40]. We recom­ women’s decision to access screening [22,41,42,50–
mend upscaling research on interventions that 52,57]. This is consistent with the finding that ease of
further explore and utilise the benefits of peer sup­ access is a common supply-side facilitator, deter­
port in different Indonesian communities and among mined by limitations in geographic coverage of the
different groups of women. ‘national’ CC screening program within Indonesia
Knowledge, awareness and access to information [22,42]. Other studies in low-resource settings have
were common demand-side facilitators and supply- shown that distance to services and related costs
side barriers across the included studies affect women’s decisions to access screening, espe­
[22,23,31,33,34,36,40,45,46,48,49,51–53,55–59,61,62]. cially in rural areas [69,75]. Our review also found
Women who are aware of CC screening and its that women are more inclined to access services if
benefits are more likely to access CC screening they are provided free of charge through the National
whereas women who lack awareness are less likely Health Insurance [22,33,41,51]. This could also
to. Low-risk perception and education status were explain why socioeconomic status for women is an
also relevant, as women with higher education are important demand-side facilitator and barrier to CC
more aware of how to independently access reliable screening, especially when free government-run CC
information on CC [23,38,40,47,50–52,55,57,58,61– screening coverage within Indonesia only covers 12%
63]. The significance of education, knowledge and of the eligible female population in Indonesia. The
awareness of CC and related screening services is cost of screening or having health insurance has also
a frequently observed demand-side barrier and been associated with decreased screening attendance
12 G. M. L. ROBBERS ET AL.

in other LMICs, which stresses its importance for the interplay of demand-side and supply-side factors that
uptake of CC screening [69]. drive the delivery and uptake of CC screening services.
Crucial demand-side barriers observed in ten stu­ While this review has demonstrated some significant
dies were fear, fatalism and shame experienced by barriers and facilitators that link demand- and supply
women [22,33,34,39–41,47,50,51,55]. Women experi­ side, there is still a great demand for further research in
enced shame due to genital exposure and the invasive order to explore these factors and to translate them into
nature of CC screening, especially if the HCP was male tangible solutions for CC screening uptake and deliv­
[40,41]. The invasive nature of CC screening and the ery, to increase access to CC screening via UHC and to
exposure of the genitals leads to diverse sociocultural meet nations screening targets set for 2030.
challenges for many women and presents a frequent
demand-side barrier for many women in LMICs
[66,73,74]. We recommend to further investigate Acknowledgments
women’s preferences with respect to CC screening to The authors wish to thank Hanum Atikasari for her sup­
increase their comfort during screening. port in the identification and translation of relevant CC
Finally, the review has highlighted that Indonesia prevention policies for the preparation of this review.
faces significant challenges in terms of the health
system capacity required to achieve wider coverage
Author contributions
of screening services, with a lack of necessary
resources and equipment for screening occurring in All authors contributed to the development and framework
primary health centre settings as a main supply-side of the review, the analysis and interpretation of the find­
ings, drafted the manuscript, revised it critically and
barrier to the delivery of quality CC screening
approved the final manuscript.
[22,36,39]. Health workforce limitations were also
noted in three studies [36,39,44]. Hence, we recom­
mend focused on the specific health workforce and Disclosure statement
resource needs required to improve CC screening
No potential conflict of interest was reported by the author(s).
delivery and coverage. However, even when skilled
HCPs were available, a lack of communication and
support for HCPs was noted as another common Ethics and consent
supply-side barrier [22,39,44]. Lack of communica­
No ethical clearance was sought for this paper as it is based
tion between HCPs at screening services and limited
on secondary data.
supervision has shown to decrease the efficiency and
quality of services, relating to a lack of confidence
and trust among women in HCPs and their services Funding information
(demand-side barrier) [22,39,44]. Inadequate quality
assurance of CC screening also been noted in litera­ The article was written as part of a PhD project, funded by
the University of Melbourne Human Rights Scholarship.
ture in other LMICs as a key supply-side barrier to The open access publication fee for this article was funded
delivery of CC screening [66,76,77]. Further research by the Australian Research Council as part of the Discovery
on how to efficiently increase constructive monitor­ Grant [DP180100651].
ing and supervision for HCPs, and to investigate
HCP’s needs for support, is needed in order to
improve quality of care with respect to CC screening. Paper context
CC screening uptake in LMICs incl. Indonesia is insufficient
but evidence of existing research on the range of barriers and
Limitations facilitators that influence the delivery and uptake of CC
This scoping review identified a lack of research on screening is limited. The underlying dynamics and challenges
from demand and supply-sides need to be understood to
barriers and facilitators to CC screening in Indonesia. undertake meaningful improvements. This review identifies
Consequently, recommendations made have to be facilitators and barriers to the delivery and uptake of CC
considered with respect to the limited evidence avail­ screening and offers recommendations for future research
able. Moreover, this review drew on records about the needed in Indonesia and comparable settings.
government-run CC screening program. Potential
insights about screening services provided in the pri­
ORCID
vate sector were not included.
Gianna Maxi Leila Robbers http://orcid.org/0000-0001-
5862-4244
Conclusion Linda Rae Bennett http://orcid.org/0000-0002-6472-
4185
The review has demonstrated how crucial it is for Belinda Rina Marie Spagnoletti http://orcid.org/0000-
implementers and policy makers to consider the 0001-5531-9279
 GLOBAL HEALTH ACTION 13

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