Accelerating Cervical Cancer Screening in Indonesia: A Review of Implementation Barriers and Strategies

1. Introduction

Cervical cancer is one of the most preventable and curable forms of cancer if caught early, yet it remains one of the leading causes of death among women globally[1]. In Indonesia, cervical cancer ranks as the third most frequently diagnosed cancer when compared against total national cancer incidence in both sexes combined and constitutes the second most prevalent cancer among women[2]. Indonesia has an estimated 102.5 million women aged 15 years and older who are at risk for developing cervical cancer. Current data suggest that approximately 36,633 new cervical cancer cases are diagnosed annually, with about 21,003 deaths attributed to the disease each year[3]. In Asia, Indonesia have the second highest ASIR (age-standardised incidence rate) of 23.4 for cervical cancer and ASMR (age-standardised mortality rate) of 13.9 per 100,000 women[4].

Despite the substantial disease burden, national cervical cancer screening coverage in Indonesia remains very inadequate. In 2023, only 7.02% of eligible women were screened, far below the national target of 70% for that year. Low screening rates have led to a rise in cervical cancer incidence in Indonesia. Approximately 70% of patients present with advanced stages, resulting in significantly higher treatment costs and a significant burden on the national health insurance system[5].

Screening is secondary prevention, with the primary goal of identifying and treating asymptomatic precancerous lesions (cervical intraepithelial neoplasia) to halt the progression to invasive carcinoma[6]. Screening is projected to prevent nearly 500,000 deaths by 2070, more than vaccination and treatment combined over a 50-year period[7]. Therefore, low participation in screening results in missed opportunities for early intervention and contributes to a higher incidence of life-threatening, advanced cervical cancer.

Screening in Indonesia relies primarily on Visual Inspection with Acetic Acid (VIA) due to its low cost and the most feasible “see-and-treat” approach in resource-limited areas[8]. Pap smears are also used in urban or private settings with adequate laboratory infrastructure.

Indonesia is currently planning a transition to Human Papillomavirus (HPV) DNA testing. This policy change is outlined in the National Action Plan for Cervical Cancer Elimination 2023-2030, which sets a target of 75% of women aged 30 to 69 years to undergo cervical cancer screening using HPV-DNA testing, in line with the World Health Organization's (WHO) 90-70-90 global elimination targets[9]. Achieving this target by 2030 could lead to the elimination of cervical cancer as a public health problem in Indonesia by 2072 and save more than three million lives by 2120.

Furthermore, this screening program represents a moral imperative and a sound economic investment for Indonesia. Increasing workforce participation and broader social benefits as women in their productive age are less likely to develop cervical cancer resulting in high projected return on investment, reaching USD 43.14 over 30 years, and increasing to USD 120.43 over 50 years for every dollar spent on prevention and screening[7].

To be able to successfully implement the National Action Plan’s screening program, it is crucial to first understand the implementation barriers or challenges to screening and explore strategies or interventions that can address these barriers to implement this screening program effectively and equitably in Indonesia.Therefore, this narrative review focuses on addressing the following issues: (1) barriers or challenges contributing to low cervical cancer screening rates in Indonesia, (2) strategies and interventions that have been proposed or implemented in Indonesia or other countries with similar backgrounds to address these barriers, and (3) future public health policy directions to increase cervical cancer screening participation in Indonesia.

2. Methods

This study was conducted as a narrative review of the literature based on the framework proposed by Ferrari[10]. Databases searched for articles include PubMed, Scopus, ScienceDirect, Garuda, Neliti, and Google Scholar (the first 100 articles in Google Scholar and Neliti). Neliti and Garuda are Indonesian databases. Full database-specific search strategies are detailed in Supplementary Material 1. The review prioritized literature published in the last 10 years to ensure relevance. The search included peer-reviewed articles and policy documents in both English and Bahasa Indonesia to gather a comprehensive range of evidence.

Inclusion criteria were that studies must discuss topics related to barriers to cervical cancer screening in Indonesia and strategies to address the barriers, were published in the last ten years, and were published in English or Bahasa Indonesia. Studies that discussed only basic science/molecular studies or other pillars of cervical cancer elimination were excluded.

3. Results

A total of 1338 articles were identified using the search strategy. From these, 61 eligible studies were included in this review.

3.1 The Landscape of Cervical Cancer Screening in Indonesia

The primary method of cervical cancer screening in Indonesia is Visual Inspection with Acetic Acid (VIA), which involves applying 3-5% acetic acid to the uterine cervix, followed by visual inspection for an aceto-white change that marks a positive result. VIA is primarily utilized in Indonesia because of its low-cost and feasibility. VIA often integrated into the “See and Treat” framework, including the test and if positive findings are found, it then managed with treatment modalities like cryotherapy or Trichloroacetic acid (TCA)[8]. Despite these advantages, VIA faces limitations, including the fact that its clinical performance shows considerable variability in low-resource settings, with reported average sensitivity is 50% with a specificity of 85%[11].

Supplementing VIA, the Papanicolaou (Pap) smear (conventional cytology) is also available, though its use is largely concentrated in urban areas, hospitals, and private clinics with the requisite laboratory infrastructure. This method involves taking a cytological sample from the cervix, which is then subjected to a laboratory examination to identify cellular abnormalities. The diagnostic value is often high; studies report accuracy up to 98% and specificity up to 93%. However, the Pap smear method is susceptible to false negative results probability range from 5% to 15% and often low sensitivity and the collection of non-representative samples[12]. Furthermore, results can be compromised by factors across the pre-analytic, analytic, and post-analytic stages, such as delayed fixation or errors in cytopathology interpretation[13]. In Indonesia, despite being a known screening tool, the Pap smear is difficult to implement as a routine national program due to logistical and financial constraints.

In line with the WHO 2020 global strategy, the Indonesian Ministry of Health, through its National Action Plan for Cervical Cancer Elimination, outlined a programmatic shift toward HPV-DNA testing as the new primary screening method[9]. This preference is based on strong evidence indicating that HPV-DNA tests are more sensitive than conventional cytology, leading to earlier detection of high-grade cervical intraepithelial neoplasia (CIN) and ultimately preventing more cervical cancers[14–17]. A critical advantage of the HPV-DNA test is the enhanced prognostic value of a negative result, which is stronger than for a negative cytology. For example, after five years of follow-up, the estimated cumulative incidence of CIN3+ was significantly lower in hrHPV negative women (0.23%) compared to cytology negative women (0.38%)[15]. This superior prognostic strength suggests that screening intervals could be extended in HPV-DNA screenings. However, the implementation of HPV-DNA testing presents concerns of the test's lower specificity that could lead to unnecessary examinations[15].

3.2 Cervical Cancer Screening Barriers

Addressing the challenge of cervical cancer in Indonesia necessitates a deep understanding of the barriers that prevent women from engaging in screening. Literatures consistently identify a multi-layered and interconnected set of barriers that prevent women from accessing or accepting screening services. These barriers involve individual, socio-cultural, and health system factors. Demand-side barriers (individual and social) are the most frequently documented barriers[18].

3.2.1. Individual and Psychosocial Barriers

Individual and psychosocial barriers represent the intrinsic factors, cognitive, emotional, and self-belief systems, that women internalize, often leading to avoidance even when external services are physically available or free of charge[18].

One of the most significant individual barriers to cervical cancer screening in Indonesia is a lack of adequate knowledge and awareness about the disease, its prevention, and the importance of screening. This knowledge gap has consistently been identified as the biggest barrier to screening participation[19]. Furthermore, misinformation exacerbates this matter[20].

Low educational attainment is also strongly linked to limited knowledge[21]. This educational gap is directly related to poor health literacy, defined as the difficulty an individual faces in obtaining, understanding, and utilizing basic health information to make informed decisions. For women in Indonesia, low health literacy restricts their ability to understand the importance of early detection and screening of cervical cancer[22]. Low health literacy also poses barriers to long-term compliance, limiting a woman's ability to evaluate the necessity of screening and preventing her from undertaking necessary follow-up after receiving test results. Some individuals also maintain a negative attitude toward screening outcomes, quality, and trust in medical services[23].

Beside educational gap, emotional responses are frequently cited as the most difficult barriers to overcome, often overshadowing cognitive or practical concerns[24]. A prevalent psychological barrier is fear of the test results[25,26]. This leads some women to practice avoidance, preferring ignorance over the stress and worry associated with a potential positive diagnosis[25]. Accompanying this emotional distress is the fear of pain or discomfort associated with the gynecological examination inherent in Pap smear or VIA testing[27].

Furthermore, low self-efficacy, the lack of confidence in one’s personal ability to successfully perform the screening behavior, is another major barrier to uptake. Low self-efficacy limits a woman's motivation, even if she possesses good knowledge[21],[23].

3.2.2. Socio-Cultural Barrierseading

Socio-cultural dynamics present profound barriers to the uptake of cervical cancer screening in Indonesia originate from traditional norms, gender-based expectations, and community perceptions discouraging women to do screening.

Significant barriers stem from conflicts between standard screening procedures and cultural attitudes about modesty and privacy. Women consistently report intense shame, awkwardness, and discomfort associated with mandatory gynecological examinations for procedures such as Pap smears or VIA, particularly when rooted in cultural and religious values[21]. These psychological barriers are often considered among the most significant, as they make screening an embarrassing process and can cause anxiety, stress, and a sense of loss of privacy for women undergoing screening[18,28].

Furthermore, screening is heavily impacted by community and social stigma, often driven by the sexual transmission association of HPV, the cause of cervical cancer. Women often fear negative judgment or being labeled as immoral or promiscuous. This stigma can cause women to avoid screenings altogether, a phenomenon termed “label avoidance”, where silence is preferred over the risk of social exclusion[29].

In patriarchal cultural contexts, particularly in Indonesia, the influence of husbands on a woman's healthcare decisions is a major determinant of screening behavior[30],[31]. Effective support further depends on the husband's level of knowledge about the disease and the benefits of screening, as his encouragement, provided through emotional, instrumental, or informative means, directly enhances the wife's self-efficacy and motivation. Beside spousal influence, the support provided by peers and community members can also significantly influence a woman's decision to do screening[32].

3.2.3. Health System and Logistical Barriers

Health system barriers are structural, supply-side factors, whereas logistical barriers are practical constraints that impede physical access and utilization of screening services. A critical barrier within the health system is the widespread inadequacy of the capacity and resources needed to deliver high-quality screening and subsequent management. In Indonesia, structural issues have been identified as supply-side barriers, including the availability and accessibility of facilities[22]. Specialized infrastructure is markedly limited[19]. Moreover, screening is restricted by human resource deficit, with low percentages of eligible healthcare providers receiving necessary cervical cancer screening training[33–35]. The complexity of the laboratory techniques required for cervical cancer screening implies that only a small number of facilities have the necessary capacity, and these facilities are not evenly distributed. Resource limitations also manifest materially through a lack of or inadequate screening equipment and inadequate funding for services, thus undermining the stability and quality of the screening process[33]. Limited government health expenditure per capita in most ASEAN countries directly constrains the necessary funding for sustaining effective screening programs[19].

Systemic operational failures further contribute to barriers by compromising the continuity and quality of care[19]. In many ASEAN countries, incomplete health tracking and information systems prevent women with abnormal screening results from being effectively recalled for necessary follow-up and care. Furthermore, health system efficiency is undermined by poor organizational factors, including miscommunication among healthcare center staff, insufficient use of media for promotion, inadequate equipment, and limited supervision of healthcare providers[18,33,34]. A lack of advocacy and health promotion activities is a supply-side barrier in Indonesia, leading to low community awareness and insufficient commitment from service providers to encourage screening.

Logistically, the attainment of screening services is severely hampered by difficulties related to physical access and time constraints. For many women, barriers include excessive travel distance to reach primary health centers and insufficient means of transportation[18,25,30,36,37]. Furthermore, operational limitations at the facility level, such as limited working hours and the presence of long waiting lists, create logistical disincentives that deter attendance[38]. The busy schedules of women, compounded by time constraints due to professional or household responsibilities, also contribute to low screening rates across Asia[39].

3.3. Identified Strategies to Improve Screening Uptake

The implementation of strategies to bolster cervical cancer screening uptake in nations sharing similar socioeconomic and logistical constraints with Indonesia, such as other Upper-Middle and Lower-Middle Income Countries (UMICs/LMICs) across the Asia-Pacific region and Africa, has centered on technological shifts, service reorganizations, and community engagement. The table below present the summary of cervical cancer screening and prevention initiatives in different populations and countries.

One highly successful strategy involves the integration of HPV self-sampling. In Malaysia, an UMIC neighboring Indonesia, Program ROSE (Removing Obstacles to Cervical Screening) was implemented as a cervical cancer screening program, incorporating self-sampling and digital technology to ensure effective linkage to care. This program demonstrated high public acceptance and achieved a substantial 91% follow-up rate for women who tested HPV-positive, effectively addressing policy, infrastructure, and community barriers. The program leverages a secure digital e-health platform and digital registry to deliver results quickly via SMS, ensuring women who test positive are followed up by dedicated program staff and linked to necessary care, achieving a high treatment linkage rate. This linkage of care includes four steps: consultation, follow-up, referral letter to facilitate further follow-up, and appointments, making sure that women who tested positive get the necessary treatments[42].

More broadly, incorporating mobile phone messaging, such as text reminders and educational materials, is feasible and effective in significantly increasing screening uptake and adherence[46–48]. El Salvador also offers a strong example by effectively integrating technology into cervical cancer screening surveillance and follow-up through a web-based system that monitored women from their initial enrollment in primary care through referral and management at secondary or tertiary facilities. The use of technology not only reduced unnecessary repeat HPV testing but also minimized loss to follow-up by providing timely reminders and notifications[49].

Furthermore, telemedicine and smartphone-based systems are transforming service delivery, particularly in remote areas, evidenced by a program in Indonesia that used HPV self-sampling and teleconsultation to achieve a high participation rate of 76%, largely due to the convenience and accessibility offered[50]. Innovative localized technology, such as the SINARA application in Indonesia, allows women to detect their cervical cancer risk independently and provides essential features like location services for screening facilities and personalized reminder notifications for follow-up, thereby addressing the crucial barrier of low awareness[27]. However, it needs to be further developed for the socialization and integration of this application into primary care.

Similar with the previously mentioned HPV self-sampling programs, Australia, leveraging its universal health coverage system, introduced universal access to self-sampling for HPV testing in 2022 to reach historically underserved populations. Implementation models include programs utilizing a nurse-led community engagement model for self-sampling or allowing flexible, community-based settings for sample collection, which has proven feasible and acceptable in rural and remote Aboriginal communities[45]. Further evidence of its feasibility in overcoming access issues was shown in Bhutan, where a cross-sectional study successfully used the CareHPV test on self-collected samples in rural areas[41].

To enhance outreach and reduce socio-cultural barriers, community health workers (cadres) mobilization is very important. In Nigeria, task-sharing models were implemented, with cadres provided education to increase the uptake of cervical cancer screening services[40].

India employed cadres within a scale-up project for secondary prevention in regional urban hospitals, and Brazil utilized cadres to lead HPV self-sampling demonstrations[43,44]. Alongside these strategies, fostering effective patient-physician communication is also needed, as high communication index, includes addressing patient feelings and involving them in health decisions, is significantly associated with higher likelihood of adherence to screening[51].

4. Discussion

4.1 Implications and Future Research

Indonesia's National Action Plan for Cervical Cancer Elimination (2023–2030) represents a significant paradigm shift in national screening policy, prioritizing high-performance HPV-DNA testing as the primary screening. This plan is highly strategic and aligns with WHO recommendations, which emphasize the etiologic role of high-risk HPV infection in nearly all cervical cancer cases. This is a positive step by the Indonesian government, but its implementation raises questions about whether this ambitious policy shift is feasible, especially considering the high targets of 70% coverage by 2027 and 75% by 2030.

The first discussion concerns the cost. HPV-DNA testing has historically been very expensive, fortunately, locally produced test has been developed and offered at much lower price[5,52]. However, despite its relatively high cost, research shows that HPV-DNA testing is more cost-effective in Indonesia compared to VIA and Pap smears, due to it being able to detect more cases of precancerous lesions, which can be treated and prevented from developing into cancer, ultimately making it more cost-effective[53]. The government is progressing to cover the cost of HPV-DNA testing. This is a very important positive development, but many limitations, particularly supply-side barriers, remain in practice that heightens the need for trainings, standardized protocols, strengthening laboratory services, and quality assurance programs to ensure the implementation[9,54].

To address health system barriers, Indonesia should focus on integrating technology into existing infrastructure. One potential option is to utilize previously used infrastuctures, for example, the GeneXpert system, currently used for TB testing, which is compatible with HPV test cartridges. This approach minimizes new infrastructure investment and has proven successful in LMICs, such as Zimbabwe[55]. HPV tests can also be run on the same equipment used for multiple tests, including COVID-19, HIV, and Hepatitis B tests, so they can be incorporated into existing laboratory systems[56].

Another critical challenge is the persistent demand-side barrier despite the availability of screening services and increasing access to HPV-DNA testing. Efforts through group education approaches have shown limited impact because participants often do not fully engage or retain information[57]. Therefore, more personalized strategies are needed through the role of cadres. Studies show that non-medical service providers-led interventions are acceptable and effective for increasing health literacy and screening intentions[58]. To ensure the sustainability and scale-up of the program, it is necessary to provide them with adequate rewards and training.

The next issue stems from socio-cultural barriers. HPV-DNA self-sampling (HPV-SS) is a culturally and logistically appropriate innovation capable of overcoming this socio-cultural barriers. HPV-SS is highly beneficial because it significantly increases participation rates, with a study showing acceptance as high as 99.1% in Indonesian primary care settings[58]. Moreover, evidence confirms that self-collected vaginal swabs or urine samples possess diagnostic accuracy comparable to clinician-collected samples when processed using validated PCR-based assays[6,59,60].

However, while HPV-SS may improves screening uptake, it also introduces a new set of implementation challenges, particularly around follow-up and linkage to care. Benefits of expanded screening may be lost if women who test positive fail to continue in the management pathway. This risk is especially concerning in self-sampling models, where women may not interact directly with a healthcare provider at the time of testing. Addressing this gap requires strengthening digital platforms for timely result notification, enhancing cadres involvement to support active follow-up, and building integrated referral systems that ensure smooth transitions from screening to diagnostic triage and treatment.

In rural or remote areas, HPV-SS is very important as it reduces the reliance on facility visits[61]. Especially when integrated with point-of-care (POC) molecular testing platforms, which shorten result turnaround times to approximately one hour, enabling a “screen-and-treat” model where women who test positive can receive immediate counseling, triage, and treatment[62]. This is especially beneficial in low-resource settings where follow-up loss is common due to high distance and cost of returning to health facilities[63]. Beside POC, telemedicine has increasingly been recognized as a transformative approach for cervical cancer screening in rural and remote areas. Telemedicine platforms enable remote consultations, personalized counseling, and timely referrals to distant facilities for management without requiring patients to travel long distances, significantly reducing costs and time burdens[50].

Furthermore, programs are needed to support increased community participation in cervical cancer screening. Currently, HPV-DNA testing is mainly performed as opportunistic screening, which can then be gradually scaled to population-based screening that strategically integrates screening into routine health care visits, such as antenatal care, family planning, reproductive health, and HIV/STI counseling, particularly in primary care settings. This integrative approach, often called the diagonal approach, is crucial because it enables cervical cancer screening to be a part of a comprehensive component of patient care[64]. This service integration increases the accessibility and ease of screening, reduces time and cost constraints associated with healthcare travel[65,66]. Leveraging the infrastructure of existing HIV care centers is cost-effective, reduces logistical burdens on patients, and promotes compliance within a familiar environment[67].

With Indonesia's ultimate goal of eliminating cervical cancer by 2072, if the 90-70-90 target is achieved by 2030, Indonesia should undertake a gradual transition with maximum acceleration by using strategies that have been discussed before. Relying solely on VIA test could hinder the achievement of this long-term goal. The available evidences strongly support the superior performance and economic feasibility of HPV-based screening over time. Therefore, VIA should be used as an efficient and affordable triage method for HPV-positive women in areas with limited colposcopy resources[9].

Future research and evaluation are necessary to refine program implementation. Ongoing operational research on the diagnostic accuracy of locally produced tests, long-term outcomes of self-sampling, and cost-effectiveness across diverse regions will be essential for informing adaptive policy decisions. Monitoring equity outcomes, particularly across rural–urban divides and among vulnerable populations, should remain a critical component of program evaluation. Therefore, collaboration between various parties, including the government, healthcare workers, and the community, is needed to ensure the success of the cervical cancer screening program and ultimately eliminate it in Indonesia.

4.2 Limitations

This review has several limitations. First, its selection of literature, while structured, follows a narrative approach and is not designed to be fully reproducible, and it’s single-reviewed. Second, the review's scope was intentionally limited to literature published within the last 10 years to ensure its relevance. Third, due to recent introduction of the National Action Plan, there is currently lack of studies about the topic. Finally, the search was restricted to articles published in English and Bahasa Indonesia, and may not have captured all relevant documents, such as non-public government reports.

5. Conclusion

Indonesia's transition to HPV-DNA-based national screening program represents a critical and evidence-based step towards the goal of cervical cancer elimination. However, the findings of this review indicate that the success of this new policy depends on systematically addressing various barriers that limit the implementation of screening in Indonesia.

This review has identified a future pathway that centered on an integrated strategy. This pathway leverages HPV self-sampling to overcome socio-cultural and access barriers and incorporating existing diagnostic infrastructure to ensure cost-effective testing. These elements must be managed and connected by an empowered network of cadres, and also supported by digital health platforms. This technology is essential for ensuring systematic patient tracking, managing the cascade of care, and minimizing loss of follow-up. Ultimately, achieving Indonesia's ambitious elimination targets requires sustained political will and collaboration to ensure this comprehensive strategy, from technology-enabled screening to systematic and accessible treatment pathways, is implemented effectively, equitably, and successfully.

Author Contributions

The author contributed to the conceptualization and design of the review, literature search and selection, analysis and interpretation of the available evidence, and writing of the original manuscript. The author critically reviewed and edited the manuscript, approved the final version, and accepts responsibility for the integrity and accuracy of the work.

Funding

No external funding was received for this study.

Conflicts of Interest

The author declares no conflicts of interest related to this work.

Publisher’s Note

All claims expressed in this article are solely those of the author and do not necessarily represent those of the author’s affiliated organization, the publisher, the editors, or the reviewers. Any product evaluated in this article, or claim made by its manufacturer, is neither guaranteed nor endorsed by the publisher.

References

1. 1.Soares L. Cervical Cancer and Quality of Life : Systematic Review. Clin J Obstet Gynecol. 2024; https://doi.org/10.29328/journal.cjog.1001158
2. 2.International Agency for Research on Cancer. Global Cancer Statistics Indonesia. 2022.
3. 3.ICO/IARC HPV Information Centre. Human Papillomavirus and Related Cancers, Fact Sheet 2023 Indonesia. 2023;
4. 4.Ekawati FM, Listiani P, Idaiani S, Thobari JA, Hafidz F. Cervical cancer screening program in Indonesia : is it time for HPV-DNA tests ? Results of a qualitative study exploring the stakeholders ’ perspectives. BMC Womens Health. 2024;1–9. https://doi.org/10.1186/s12905-024-02946-y
5. 5.Indarti J. The Role of Social Obstetrics and Gynecology in the Coverage of Cervical Cancer Screening in the Era of Health Transformation in Indonesia. Indones J Obs Gynecol. 2023;198–200. https://doi.org/10.1093/annonc/mdr015.
6. 6.Eun TJ, Perkins RB. Screening for Cervical Cancer. Med Clin North Am. 2022;104:1063–78. https://doi.org/10.1016/j.mcna.2020.08.006.Screening
7. 7.International Agency for Research on Cancer. Elimination Planning Tool: Advancing Towards Cervical Cancer Elimination Indonesia. 2025;
8. 8.Nuranna L. See and Treat : Cervical cancer prevention strategy in Indonesia with VIA- DoVIA screening and prompt treatment. Indones J Cancer Control. 2022;32–8.
9. 9.Kementerian Kesehatan Republik Indonesia. Rencana Aksi Nasional Eliminasi Kanker Leher Rahim di Indonesia tahun 2023-2030. 2023;
10. 10.Ferrari R. Writing narrative style literature reviews. Med Res. 2015;24.
11. 11.Das SK, Khanam S, Rosy N. Original Article Visual Inspection of Cervix with Acetic Acid ( VIA ) as a Screening Tool for Early Detection of Cervical Pre-Cancer & Cancer . Faridpur Med Coll J. 2018;13:24–7.
12. 12.Maelissa MM, Rahawarin H, Kailola NE, Latuconsina VZ. Pap Smear as A Cervical Cancer Screening in Women of Childbearing Age in 2020. J Penelit Pendidik IPA. 2022;8:1863–7. https://doi.org/10.29303/jppipa.v8i4.2074
13. 13.Handayati A, Putri TD, Astuti SSE. Pap Smear Diagnostic Test Towards Gold Standard Histopathology In Cervic Cancer Uji Diagnostik Pap Smear Terhadap Baku Emas. Medicra (Journal Med Lab Sci Technol. 2024;7:63–8. https://doi.org/10.21070/medicra.v7i2.1655
14. 14.Ramírez AT, Valls J, Baena A, Rojas D, Ramírez K, Álvarez R, et al. Articles Performance of cervical cytology and HPV testing for primary cervical cancer screening in Latin America : an analysis within the ESTAMPA study. Lancet Reg Heal. 2023;26:1–11. https://doi.org/10.1016/j.lana.2023.100593
15. 15.Kjær SK, Frederiksen K, Ørnskov D, Munk C, Waldstrøm M. Gynecologic Oncology Comparative analysis of HPV testing versus cytology in Danish cervical cancer screening : Insights from a large-scale implementation study. Gynecol Oncol. 2024;191:45–55. https://doi.org/10.1016/j.ygyno.2024.09.013
16. 16.Ang JX, Tay SK. Comparison of Clinical Ef fi cacy of Liquid-Based Cytology and High-Risk Human Papillomavirus Testing With Partial Genotyping in Cervical Screening of Women Below 30 Years Old. Cancer Control. 2025; https://doi.org/10.1177/10732748251336414
17. 17.Koliopoulos G, Vn N, Santesso N, Bryant A, Ppl M, Ra M, et al. Cytology versus HPV testing for cervical cancer screening in the general population (Review). Cochrane. 2017; https://doi.org/10.1002/14651858.CD008587.pub2.www.cochranelibrary.com
18. 18.Maxi G, Robbers L, Bennett LR, Rina B, Spagnoletti M. Facilitators and barriers for the delivery and uptake of cervical cancer screening in Indonesia : a scoping review. Glob Health Action. Taylor & Francis; 2021;14:1–15. https://doi.org/10.1080/16549716.2021.1979280
19. 19.Zhao S, Huang L, Basu P, Javier E. Cervical cancer burden , status of implementation and challenges of cervical cancer screening in Association of Southeast Asian Nations ( ASEAN ) countries. Cancer Lett. Elsevier B.V.; 2022;525:22–32. https://doi.org/10.1016/j.canlet.2021.10.036
20. 20.Umami A, Wahyu T, Pratama Y. Knowledge , Barriers , and Motivation Related to Breast and Cervical Cancer Screening Among Women in Bojonegoro , East Java : A Qualitative Study. J Heal Promot Behav. 2020;5:1–10. https://doi.org/10.26911/thejhpb.2020.05.01.01
21. 21.Munizar M, Royan HA, Yolanda F. Barriers to Cervical Cancer Screening through Pap Smear Examination among Women Attending the Gynecology Polyclinic at Dr . Zainoel Abidin General Hospital in 2024 : A Cross-Sectional Study. Asian Pac J Cancer Prev. 2025;26:3309–17. https://doi.org/10.31557/APJCP.2025.26.9.3309
22. 22.Heny K, Paramita P, Astuti IW, Pramitaresthi IGA, Sanjiwani IA. Hubungan Literasi Kesehatan Dengan Perilaku Deteksi Dini Kanker Serviks Pada Wanita Usia Subur ( Wus ). Community Publ Nurs. 2025;13:214–21.
23. 23.Imansari B. Pengetahuan dan efikasi diri wanita usia subur terhadap skrining kanker serviks Knowledge and self-efficacy of women in childbearing age regarding cervical cancer screening. J Kebidanan dan Keperawatan Aisyiyah. 2022;18:192–7. https://doi.org/10.31101/jkk.2335
24. 24.Brennan KJ, Reay JL. Emotional barriers pose the greatest threat to cervical cancer screening for young adult women in the United Kingdom. Prev Med (Baltim). 2024;189.
25. 25.Widayanti DM, Qomaruddin MB, Irawandi D. Mother ’ s knowledge and attitudes towards Visual Acetate Acid Inspection. J Public health Res. 2020;9:113–6.
26. 26.Rina B, Spagnoletti M, Bennett LR, Wahdi AE, Wilopo SA, Keenan CA. A Qualitative Study of Parental Knowledge and Perceptions of Human Papillomavirus and Cervical Cancer Prevention in Rural Central Java , Indonesia : Understanding Community Readiness for Prevention Interventions. Asian Pac J Cancer Prev. 2019;20:2429–34. https://doi.org/10.31557/APJCP.2019.20.8.2429
27. 27.Madiuw D, Nivaan GV, Baumase R. SINARA Application to Detect Cervical Cancer Risk : Development and Validity. Wind Heal. 2025;8:491–501.
28. 28.Dzobo M, Dzinamarira T, Strauss M, Mashamba-thompson T. Rural women ’ s preferences for cervical cancer screening via HPV self-sampling : a discrete choice experiment study in chidamoyo , Hurungwe. AJOG Glob Reports. Elsevier Inc.; 2024;4:100414. https://doi.org/10.1016/j.xagr.2024.100414
29. 29.Liana N, Putriyuni A, Oktora MZ, Aliefia D, Rasyid L, Kedokteran F, et al. Persepsi Stigma Kesehatan Reproduksi Sebagai Faktor Penghambat Kepatuhan Skrining Kanker Serviks. J Public Heal Sci. 2025;2:172–82.
30. 30.Afsah YR. Perceived Barriers Of Cervical Cancer Screening Among Married Women In Minggir , Godean , Gamping Sub-Districts , Sleman District Yogyakarta. Indones J Nurs Pract. 2017;75–82. https://doi.org/10.18196/ijnp.1264
31. 31.Kholifah S, Budihastuti UR, Murti B. Factors Affecting the Use of Visual Inspection Acetic Acid Test : Multilevel Analysis on the Contextual Effect of Health Center. J Heal Promot Behav. 2019;1–11. https://doi.org/10.26911/thejhpb.2019.04.01.01
32. 32.Wakhidah MS, Retno U, Hastuti B, Lanti Y, Dewi R. The Influence of Personal Factor , Husband ’ s support , Health Workers and Peers toward the Use of IVA Screening among Women of Reproductive Age in the Regency of Karanganyar. J Heal Promot Behav. 2017;2:124–37. https://doi.org/10.26911/thejhpb.2017.02.02.03
33. 33.Rahayu S, Suhaimi D, Yunita J, Abidin Z, Bahri S. Pelaksanaan Program Deteksi Dini Kanker Cerviks ( Ca Cervix ) dengan Metode Inspeksi Visual Asam Asetat ( IVA ) di Kabupaten Kampar Implementation of the Cervical Cancer Early Detection Program ( Ca Cervix ) with Visual Inspection with Acetic Acid Method. J Kesehat Komunitas. 2018;4:68–75.
34. 34.Saraswati M, Sriatmi A, Jati SP. Analisis Implementasi Program Deteksi Dini Kanker Serviks Melalui Metode Inspeksi Visual Asam Asetat (IVA) Di Puskesmas Kota Semarang. J Kesehat Masy. 2017;5.
35. 35.Parapat FT, S HS, Sc M, Saraswati LD, Epid M. Faktor Faktor Yang Berhubungan Dengan Perilaku Deteksi Dini Kanker Leher Rahim Metode Inspeksi Visual Asam Asetat Di Puskesmas Candiroto Kabupaten Temanggung. J Kesehat Masy. 2016;4:363–70.
36. 36.Wulan R, Murti B. The Effect of Community Health Center on Visual Acetic Acid Uptake in Pati , Central Java. J Heal Promot Behav. 2018;189–97. https://doi.org/10.26911/thejhpb.2019.04.03.04
37. 37.Martaningrum HI, Budihastuti UR, Murti B. Contextual Effect of Community Health Center on Visual Inspection Acetic Acid Uptake in Magelang , Central Java : A Multilevel Analysis. J Matern Child Heal. 2020;5:129–40.
38. 38.Salehiniya H, Momenimovahed Z, Allahqoli L. Factors related to cervical cancer screening among Asian women. Eur Rev Med Pharmacol Sci. 2021;6109–22.
39. 39.Suartini NW. Studi Fenomenologi : Faktor-Faktor Yang Menyebabkan Wanita Usia Subur Tidak Menjalani Deteksi Kanker Serviks Dengan Tes Inspeksi Visual Asam Asetat (IVA) Di Provinsi Bali. Infokes. 2017;7.
40. 40.Awolude OA, Oyerinde SO, Akinyemi JO. Screen and Triage by Community Extension Workers to Facilitate Screen and Treat : Task-Sharing Strategy to Achieve Universal Coverage for Cervical Cancer Screening in Nigeria. J Glob Oncol. 2018;
41. 41.Baussano I, Tshering S, Choden T, Lazzarato F, Tenet V, Plummer M, et al. Cervical cancer screening in rural Bhutan with the care HPV test on self- collected samples : an ongoing cross- study ( REACH-Bhutan ). BMJ. 2017;1–9. https://doi.org/10.1136/bmjopen-2017-016309
42. 42.Woo YL, Khoo SP, Gravitt P, Hawkes D, Rajasuriar R, Saville M. The Implementation of a Primary HPV Self-Testing Cervical Screening Program in Malaysia through Program ROSE — Lessons Learnt and Moving Forward. Curr Oncol. 2022;7379–87.
43. 43.Fregnani H, Oliveira CM De, Sant R. Evaluation of human papillomavirus self-collection offered by community health workers at home visits among under-screened women in Brazil. 2021; https://doi.org/10.1177/0969141320941056
44. 44.Poli UR, Muwonge R, Bhoopal T, Lucas E, Basu P. Feasibility , Acceptability , and Ef fi cacy of a Community Health Worker – Driven Approach to Screen Hard-to-Reach Periurban Women Using Self-Sampled HPV Detection Test in India original reports abstract. 2020; https://doi.org/10.1200/GO.20.00061
45. 45.Dutton T, Marjoram J, Burgess S, Montgomery L, Vail A, Callan N, et al. Uptake and acceptability of human papillomavirus self-sampling in rural and remote aboriginal communities : evaluation of a nurse-led community engagement model. BMC Health Serv Res. BMC Health Services Research; 2020;5:1–9. https://doi.org/10.1186/s12913-020-05214-5
46. 46.Firmino-Machado J, Varela S, Mendes R, Moreira A, Lunet N. Stepwise strategy to improve cervical cancer screening adherence (SCAN-Cervical Cancer) – Automated text messages, phone calls and reminders: Population based randomized controlled trial. Prev Med (Baltim). 2018; https://doi.org/10.1016/j.ypmed.2018.06.004
47. 47.Addo-lartey AA, Bonful HA, Sefenu RS, Abagre TA, Asamoah A, Bandoh DA, et al. Effectiveness of a culturally tailored text messaging program for promoting cervical cancer screening in accra , Ghana : a quasi- experimental trial. BMC Womens Health. 2024;1–15.
48. 48.Wanyoro AK, Kabiru EW. Use of Mobile Phone Short Text Message Service to Enhance Cervical Cancer Screening at Thika Level 5 Hospital , Kiambu County , Kenya : A Randomised Controlled Trial. Res Obstet Gynecol. 2020;5:10–20. https://doi.org/10.5923/j.rog.20170501.03
49. 49.Alfaro K, Maza M, Felix JC, Gage JC, Castle PE. Outcomes for Step-Wise Implementation of a Human Papillomavirus Testing – Based Cervical Screen-and-Treat Program in El Salvador original reports abstract. JCO Glob Oncol. 2020;1519–30. https://doi.org/10.1200/GO.20.00206
50. 50.Kristianti S, Andrianto R, Syarifah S, Suharyana T. Assessing the Effectiveness of Telemedicine for Cervical Cancer Screening in. Sriwij J Obstet Gynecol. 2020; https://doi.org/10.59345/sjog.v1i2.86
51. 51.Juliet O, Tundealao S, Ruth O, Ope O, Desai M, Malgave D, et al. Impact of patient-physician communication on cervical cancer screening among women aged 25 –
52. 52.J Med Surgery, Public Heal. Elsevier Ltd; 2025;5:100182. https://doi.org/10.1016/j.glmedi.2025.100182
53. 53.Mongan S, Byrnes J, Lam A, Kim H. Health Technology Assessment Of Cervical Cancer Screening In Indonesia. Cambridge Univ Press. 2018;1017. https://doi.org/https://doi.org/10.1017/S0266462324003672
54. 54.Hafidz F, Icanervilia AV, Rizal MF, Setiyaningsih H, Sasanti ML, Murriya F, et al. Economic Evaluation of Cervical Cancer Screening by HPV DNA , VIA , and Pap smear Methods in Indonesia. Asian Pac J Cancer Prev. 2024;25:3015–22. https://doi.org/10.31557/APJCP.2024.25.9.3015
55. 55.Cherniak W, Tyler N, Arora K, Lapidos- I, Sczudlo E, Lin A, et al. From potential to practice : how accelerating access to HPV tests and screen and treat programmes can help eliminate cervical cancer. Fam Med Community Heal. 2019;1–7. https://doi.org/10.1136/fmch-2019-000182
56. 56.Id KE, Wormenor CM, Tekpor E, Amuah JE, Owusu N, Id ME, et al. Evaluating operational parameters of the care HPV , GeneXpert , AmpFire , and MA-6000 HPV systems for cervical precancer screening : Experience from Battor , Ghana. PLOS Glob PUBLIC Heal. 2023;1–14. https://doi.org/10.1371/journal.pgph.0001639
57. 57.Dwiza M, Witri R, Kartika R. Challenges and Opportunities in HPV DNA Testing for Cervical Cancer Screening: A Study at Public Health Center, Jambi, Indonesia. E-SEHAD. 2024;5.
58. 58.Nisha M, Bateson D, Saville M, Nightingale CE, Bavor C, Canfell K, et al. The role of non- ¬ medical providers in increasing access to cervical screening : a scoping review. BMJ Glob Heal. 2025; https://doi.org/10.1136/bmjgh-2025-019041
59. 59.Wenang S. Population-based self-sampling under primary care conditions – a possible approach for cervical cancer screening in Indonesia ( IndoCerCa study ). Res Sq. 2025;1–19.
60. 60.Martinelli M, Giubbi C, Letizia M, Meo D, Perdoni F, Musumeci R, et al. Accuracy of Human Papillomavirus ( HPV ) Testing on Urine and Vaginal Self-Samples Compared to Clinician-Collected Cervical Sample in Women Referred to Colposcopy. Viruses. 2023;
61. 61.Andrijono, Wulandari D, Widyahening IS, Mahardhika D, Nurainy N, Sari RM. Diagnostic Performance of Urine-based HPV-DNA Test ( CerviScan , Bio Farma ) as Cervical Cancer Screening Tool in Adult Women. Indones J Obs Gynecol. 2023;11.
62. 62.Pratt R, Bliss C, Lin J, Desai J, Fordyce K, Ghebre R, et al. Integrating HPV self-collection into primary care to address cervical cancer screening disparities. Prev Med Reports. 2024;38. https://doi.org/10.1016/j.pmedr.2024.102599
63. 63.Allanson E, Schmeler K. Cervical cancer prevention in low and middle income countries ER. Clin Obs Gynecol. 2022;64:501–18. https://doi.org/10.1097/GRF.0000000000000629.Cervical
64. 64.Gupta R, Gupta S. Point-of-care tests for human papillomavirus detection in uterine cervical samples : A review of advances in resource-constrained settings. Indian J Med Res. 2023;509–21. https://doi.org/10.4103/ijmr.ijmr
65. 65.Haas JS, Vogeli C, Yu L, Atlas SJ, Sugg C, Harris KA, et al. Patient , provider , and clinic factors associated with the use of cervical cancer screening. Prev Med Reports. Elsevier Inc.; 2021;23:101468. https://doi.org/10.1016/j.pmedr.2021.101468
66. 66.Narasimhamurthy M, Kafle SU. Cervical cancer in Nepal : Current screening strategies and challenges. Front Public Heal. 2022;2017.
67. 67.Clinton Health Access Initiative. Introducing and Scaling up HPV testing to strengthen Cervical Cancer screening in LMIC ’ s. 2020;16.
68. 68.Nega R, Id K, Shifti DM, Id KA, Id OO. Integration of cervical cancer screening into healthcare facilities in low- and middle- income countries : A scoping review. PLOS Glob Public Heal. 2024;1–22. https://doi.org/10.1371/journal.pgph.0003183