The Effect of Multimodal Interventions Regarding Early Cervical Cancer Diagnosis on the Women’s Knowledge, Attitude and Participation in Cervical Screening Program

Objective: The objective of the present study was to assess the effect of multimodal interventions on women’s knowledge, attitude, and behavior towards the participation in the cervical screening test. Methods: A quasi-experimental design is executed with a multi-stage sampling of 300 women residing in rural India. Various multimodal interventions, including a documentary film, face-to-face meetings, written booklets, reminder letters, SMS, and telephone calls, are used to motivate the women for cervical cancer screening. Results: Following the interventions, 99% of the participants became aware of cervical cancer and increased their participation in screening from 3.0 % (Pretest) to 79.9% (Posttest). Three reminders have been sent to the participants, throughout the intervention period which has led to a considerable rise in the participants’ willingness to participate in screening, hiking from 58% to 79.9%. The Pap smear test results have shown that: among 288 women, 21 have Typical Malignant cells on their cervix, and two women have been diagnosed with cervical cancer (Stage 1a and Stage 1b). Conclusion: The findings of the study indicate that utilizing diverse interventions in health education alters women’s behavior, enhances the compliance of cervical cancer screening, and ultimately helps to prevent life-threatening risks.


Introduction
The prevalence of Cervical Cancer (CC) draws the attention of clinicians, other healthcare professionals, and researchers.According to the World Health Organization report, Cervical Cancer is the fourth most frequently occurring cancer in women worldwide, with estimated new cases of 604,000 and 342,000 deaths per year.In India, CC is the third most typical cancer and the second leading cause of mortality at 9.1% (Sung et al., 2021).Papumpare district in Arunachal Pradesh, India, identified the highest incidence rate of CC in Asia (GACD, 2020).

The Effect of Multimodal Interventions Regarding Early
Cervical Cancer Diagnosis on the Women's Knowledge, Attitude and Participation in Cervical Screening Program 16 and 18 (Bruni et al., 2010;Gollu et al., 2021).
WHO South-East Asia Region has developed deliberative guidelines for implementing cervical screening programs to detect precancerous lesions and CC at an early stage.As per these guidelines, the women need to be screened for CC within the age span of 30 to 60 years.As per the recent WHO strategies, there are three steps of CC prevention, including timely vaccination, periodic screening, and systematic treatment (Mehrotra and Yadav, 2021).As per the new targets of WHO (2021), 90% of girls should be vaccinated with two doses of HPV by the age of 15 years, 70 % of the women should be screened, and 90% of CC cases should receive the treatment precancerous stage itself.
The following are the primary reasons for the failure of the cervical screening programs: insufficient public awareness of HPV vaccination and cervical screening tests, scarcity of qualified healthcare providers, logistical difficulties reaching people for screening, expensive vaccinations, screening tests, etc.The improved educational programs and effective screening programs are required to lower the burden of cervical cancer (Drokow et al., 2021;Staley et al., 2021).
Midwives and nurses are the first frontline healthcare

Seeta Devi*, Sonopant Joshi
providers to improve women's health.They can play a vital role in educating and increasing awareness of CC prevention.To increase cervical cancer screening rates among women, midwives should contemplate playing documentary films in outpatient departments and distributing written materials on cervical cancer to women during their clinic, hospital, and community visits.This exercise can reduce the burden of the CC.
The researchers of the current study developed a deep interest in developing multimodal interventions, including documentary films and distribution of written material on CC prevention, face-to-face meetings with women, and sending reminders via letters, SMS messages, and phone calls.The authors assumed that a multimodal interventional program would enhance the women's awareness of CC prevention.

The study's objective as follows
To assess the effectiveness of multimodal interventions on the women's knowledge, attitude and participation in cervical screening programs.
Hypothesis of the study: Ho-There was no significant difference between knowledge, attitude, regarding CC and participation of women in screening and multimodal interventions.

Related work
As per the Literature Section Criteria (LSC), the authors have reviewed the relevant data in various databases, including SCOPUS, PubMed, and Web of Science, published between 2015 and December 2022.The importance of CC prevention and measures to prevent HPV transmission has been demonstrated in developed and developing nations, where they are readily accessible, durable, effective, and well-executed (Kifle et al., 2020).To some extent, the incidence and mortality rates of cervical cancer have significantly decreased by well-coordinated initiatives on HPV vaccination and CC screening in several countries (Cubie and Campbell, 2020).The Cervical vaccination is proven efficient, immunogenic, and effective in eliminating approximately 70% of CC globally (Huh wt al., 2017).However, inadequate awareness and knowledge could negatively impact HPV vaccination programs (Perlman et al., 2014).Modifying and establishing health behavior can assist in preventing the diseases that cause considerable morbidity and death (Anand et al., 2008).
Healthcare awareness can be influenced by various instructional practices, including web-based apps, faceto-face interaction, documentary films, pamphlets, and other reading materials (Dattilo et al., 2020).Online-based learning with the eccentric visual and audio instructional materials enables people to acquire knowledge from any location with network connectivity (Karakuş and Yanikkerem, 2020;Nho, 2016).A significant reduction in the prevalence was observed in the United States of America after implementing a Video-Based Educational Intervention (VBEI) (Stanczyk et al., 2015).VBEI is more welcoming to those with minimal health knowledge as it can be executed in various formats, such as downloaded media files, streaming videos, and multifunctional floppy disk video (Salim et al., 2020 andSader., 2020).According to Ampofo et al., (2020) and Karakuş et al., (2019) the video-based instructional model is an excellent way to increase awareness about CC prevention and changed women's behavior.Altinel et al., (2022) stated that participation of women in screening from experimental group increased up to 93% after attending multiple interventions.The utilization of communication and information technologies presents an opportunity to enhance the knowledge of Indian women regarding CC prevention.

Study setting, population, sample size and sampling procedures
The study was executed at Primary Health Centers (PHC), Pune district, Maharashtra, India.The inclusion criteria of the study comprised women between 30-60 years of age, who visited the PHC.
Researchers calculated the sample size using the method "n = Z 2 P(1-P)/d 2 ," where 'n' represents the sample size, Z represents the z statistic for a certain level of confidence, typically 1.96 for a conventional level of 95% confidence.The calculated sample size in this study was 300.However, this study had a dropout rate of 12 out of 300.
PHCs and samples were selected using a simple and systematic Random Sampling Technique.In stage I, a Simple Random Sampling Technique was employed to select the four PHCs, namely PHC-Abdullah Shirol, PHC-Bijawadi, PHC-Mahalunge Padwal, and PHC-Rahu, Daund.In the second stage, Systematic Random Sampling was used to recruit the Kth sample, which was nominated, rendering the mean attendance of the women to the PHC (100) and the count per Month was 2,500; it was divided by a sample size of 300; Kth subject was 8.The first subject was randomly selected and 2 nd sample onwards; every 8th sample was included in the study.

Study Design, data collection procedures and interventions
This study was undertaken during January 2019 to December 2020 to investigate the effect of multimodal interventions on CC prevention.
The sequence of the study is as follows: the first step includes a collection of baseline data and a pretest, and 2 nd step consists of the administration of documentary film, face-to-face education, and distribution of the written content.The 3 rd step comprises of the performance of the cervical screening (Pap test) for the women who were interested in taking part on the day of intervention, and 4th step consists of distributing initial letters to women who did not participate in the screening on the day of intervention, which consisted of next schedule of the Pap test.The 5 th step includes the sending of three reminders: 1st reminder by written letter within 10 -15 days of intervention (to the women those who had not participated on the day of intervention and with initial letters), 2 nd reminder was sent by SMS within 10 -15 days after 1st reminder (to the women who did not participate with 1st reminder) and 3 rd reminder was sent by telephonic call age of below 15 years, and 9.67 % of participants had more than one sexual partner and 97% of participants had never experienced cervical screening.Table 2 displays that before the intervention, the percentage of participants' knowledge of cervical cancer risk factors ranged from 10.67% to 20.33%, whereas after the intervention, knowledge significantly increased from 69.79% to 87.85%.Regarding the preventive measures, the knowledge score increased from 13% (pretest) to 77% (Posttest).Table 3 displays that 33.13% to 73.82% of women believed the Pap smear test may cause pain and discomfort.Similarly, 39.64% and 40.60% of women thought that Pap smear tests would be embarrassing leading them to the exposure to other infections individually.
Table 4 displays that p-values are less than 0.05 and the rejection of null hypothesis.The intervention was very effective in improving women's awareness and attitude on CC prevention.Table 5 reports that approximately 58% (167) of women participated in cervical screening on the day of interventions.About 5.20% (15) of women through initial letters, 6.6% (19) of women by written letters, 1% (3) of women via SMS, and 9% (26) of women through telephonic calls participated in cervical screening.Table 6 describes 21 (9.13 %) women who had Typical Malignant cells on their cervix.Table 7 reports that majority of the within 10-15 days of 2nd reminder (to the women who did not participate with the 1st and 2 nd reminders) and 6th step includes the administration of posttest after one month of intervention and cervical screening to the women who had shown interest following the reminders.Women with abnormal Pap smear results were directed for biopsy and further referral.Blinding was maintained to ensure the participants' Pap smear results and other details remained confidential throughout the study.
The intervention in this study was employed based on the Health Belief Model (HBM) to overcome obstacles and highlight the benefits of screening, as this model is effective in recognizing barriers and encouraging favorable changes in behavior.
The documentary film used in this study was produced with the help of the Film and Television Institute of India (FTII) and experts from the Federation of Obstetric and Gynecological Societies in India (FOGSI).The film covered various topics related to cervical cancer, such as its causes, risk factors, symptoms, and prevention, including the HPV vaccine and Pap smear tests.FOGSI endorsed the content of all interventions used in the study.
The SMS invitation content included the woman's first and last name, the purpose of the invitation, appointment date, day and time, and information about the appointment and test.The woman was also asked to confirm the appointment by replying to the message with the word CONFIRM.The telephonic invitation involved greeting the woman by her first and last name and specifying the date, day, and time of the Pap test.

Outcome assessment
The experts in research methodology, gynecology and obstetrics, and oncology assessed and validated to ensure the legitimacy and soundness of the questionnaire.
Assessment of the knowledge: The structured Cervical Cancer questionnaire contains 37 items.The first two questions had four possible options; each with one has one right answer.Questions three to five have multiple-choice answers of "yes," "no," and "don't know."Questions six to eight give four options, each with one potentially valid solution.Question nine contains multiple options, allowing for more than one right answer.
Assessment of the Attitude: The attitude scale was made up of 13 statements, each having five response possibilities and related scores like: Strongly Agree (SA) received 5, Agree (A) received 4, Neither Agree Nor Disagree (NAND) received 3, Disagree (D) received 2, and Strongly Disagree (SD) received 1. Item analysis was performed in the current study.
Assessment of the barriers for non-participation in Pap test: The scale on reasons for non-participation in cervical screening following interventions consists of 13 items with three response options: Agree (A), Neither Agree Nor Disagree (NAND), and Disagree (D).

Discussion
The study focuses on assessing the effectiveness of the multimodal interventions in increasing the awareness and attitude regarding CC and, importantly, women's willingness for cervical screening.The study shows that multimodal interventions can enhance women's knowledge and cervical screening participation.The results of the previous study conducted by Al-Hosni et al., (2021) were consistent with the results of the current study.This study directed the current researchers to incorporate multimodal interventions, including oral, printed, and digital materials, to enhance knowledge and participation in cervical screening.Kocaöz et al., (2018) reported that educating participants regularly could significantly improve women's participation in cervical screening.According to the findings of the current study, there has been a substantial improvement in women's knowledge and attitude about CC and their participation in cervical screening.These findings were also lined up with earlier research studies (Huh et al., 2017;Ampofo et al., 2020).Rosser et al., (2015) and Kenya et al., (2015) reported that health education with multiple interventions could increase the knowledge regarding cervical cancer.However, stigmatization and faulty perceptions regarding the Pap test failed to improve after simply informing women about free screening.The current study observed that 23.33% (70) of women did not participate in screening due to certain barriers such as fear of tests, embarrassment, discomfort/pain, and lack of family/husband support.Lott et al., (2020) review also supported the results of the current study.The outcomes of the present study regarding barriers to participation in cervical screening were aligned with the results of Ahmed et al., (2022)    women had a high perception of barriers to intervention, even after its implementation.Ornelas et al., (2018) results suggested that culturally tailored narrative, educational videos could effectively increase cervical screening.In the current study, the authors provided face-to-face education to the participants after showing the documentary film in their local language that could increase their participation in cervical screening.It was implemented as per the Guide to Community Preventive Services (2027).Similarly, Abiodun et al., (2014) provided face-to-face education and a video presentation which effectively increased awareness and perception of women about CC and improved attendance in cervical screening.Tavasoli et al., (2016) reported that the invitation and reminder letters strategy could increase cervical screening participation, whereas contrary results were noticed in the current study.In our study, phone call reminders showed  Kiran et al., (2018).Automated voice calls are a low-cost alternative that is more efficient when used with letters for cancer screening than either strategy alone.Other strategies such as follow-up by telephonic conversation following nonresponse to a mailed letter and participant navigation (Staley et al., 2021).Despite implementing practical measures to address shortcomings and limitations, however, certain limitations remained as the challenges.For instance, the participant's responses to questions about their readiness for screening might have been impacted by the quality of their relationship with the research team.Tracking the participants, which involved sending reminders and making phone calls, was one of the challenges of the study.The proposed study design was carried out effectively owing to the project's financing, despite the challenges.In addition, the participants were allowed to receive free Pap tests.
In conclusion, the current study highlighted the significance of employing multimodal interventions as health education in transforming knowledge, attitudes and increasing cervical cancer screening uptake.The initiatives such as face-to-face interaction and personalized telephonic calls to the participants could help to reduce the likelihood of cervical screening barriers.

Table 2 .
Table 1 reports that the majority of the participants (84.33%) were in the age group between 30 to 50 years, 25.67% of participants started sexual exposure from the Participants' Knowledge on Risk Factors of Cervical Cancer, Warning Signs and Controlling Measures of in which Egyptian Figure 1.Management of Women with Abnormal Pap Test VariablePre-test (n,%) Post-test(n,%) Difference in%

Table 3 .
The Attitude of Women towards Cervical Screening before and after Interventions

Table 4 .
Descriptive Statistics Regarding Knowledge and Attitude of Women in Pre-Test and Post-Test

Table 6 .
Reports of Pap Test of Women Participated in Cervical Screening

Table 7 .
Barriers for Non-Participation in Cervical Screening more effective results than text messages and written letters, comparable to the study conducted by