Policies and Programs for Cervical Cancer Prevention and Control in Public Health Services: An Integrative Review

Aim: analyzing and assessing the scientific evidences about Health Services Administration through the practice of cervical cancer prevention programs and policies. Methodology: integrative literature review carried out in September/October 2017. Electronic search for publications in databases such as PubMed, Portal Periódicos CAPES, BVS, EBSCO and SciELO. Results and Discussion: eighteen articles approaching the topic were selected and their analyses resulted in the following thematic axes: Organization of cervical cancer prevention and control policies/programs, Follow-up and monitoring of actions taken and Quality Management of Cytopathological exams for diagnostic and treatment. There were differences between programs in the country, either in their recommendations or in their effectiveness. Final considerations: investments must be done in order to qualify technical procedures and involved health professionals, as well as to support health education in the target population. Policies and Programs for Cervical Cancer Prevention and Control in Public Health Services: An Integrative Review


Introduction
Uterine Cervical Neoplasm is the fourth most common type of cancer in women (approximately 530 thousand cases and 265 thousand deaths/year worldwide) and the third in number of cases in Brazil (5,797

Characterizing the studies
Eighteen articles were selected and included in the research after the search in the defined databases was performed. Twelve articles out of this total were published in English and six in Portuguese. There were no publications in Spanish; therefore, only articles in English and Portuguese were included in the review. Articles gathered during the search described research conducted in many countries around the world. Six studies were carried out in Brazil [13,14,15,16,17,18] and four in the United States [19,20,21,22] . There was only one article from each of the following countries: Argentina [23] , Australia [24] , Canada [25] , England [26] , Italy [27] , Malawi [28] , Zambia [29] and United Kingdom [30] . Thus, the final sample comprised 18 articles. Forty percent (40.0%) (08 articles) of the articles were published in journals about Public Health and Epidemiology. With regard to the method and design, 50% (09 articles) of the articles were quantitative, 16.6% (03) were quali-quantitative, 16.6% (03) were documental research, 11.1% (02) were qualitative and 5.5% (01) were retrospective studies.

Organization of UCN prevention and control policies/programs
The organization of UCN prevention and control policies/programs is different from country to country.
The articles based on studies performed in the United States concern different guidelines base on topics such as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) -a program in the Centers for Disease Control and Prevention's (CDC) [31] -, and Healthy People [32] . However, there is no consensus about the use of a single guideline as the main reference and subsidy in public health. Each health service chooses the guideline it will follow, and the chosen ones can differ from state to state. Ronco et al (2007) and Canfell et al (2004) [27,30] conducted a study in United Kingdom countries based on using the European Guidelines Cervical Cancer Screening [3] in health systems, although each country in this group has its own UCN prevention and control program.
All research performed in Brazil described in the selected articles follow the protocol proposed by the cervical and breast cancer prevention and control program of the Ministry of Health. All public health services in Brazilian states are subsidized by this program. components focused on preventing cervical cancer such as health education, screening, treatment and palliative care when they analyzed data related to programs, guidelines and the legislation about the topic in their country [28] . On the other hand, Maar et al (2013) (CA) identified lack of indigenous women description as special population in the country's policy [25] .

Following-up and monitoring the actions taken
There were differences in the screening references between studies. According to the study conducted by Olesen et al. (2012), the guidelines in the country are oriented to screen the disease through Pap smear exam (every two years), one or two years after the beginning of the sexual activity until de age of 70. The guideline also recommends the HPV vaccine [24] .
The UCN prevention program in the United Kingdom cited by Canfell et al (2004) suggests screening from the age of 25 until the age of 49, with three years interval between exams, and in women in the age group 50-64 years, with five years interval between exams. In England, which also belongs to the United Kingdom group, the research conducted by Herbert, Holdsworth and Kubba (2008) evidences the need of starting the screening in women in the age group 20-24 years, since the program in the country recommends starting the screening after such age [30,26] .
The lack of access to health services and of active search, as well as socio-demographic, economic and race differences between target populations, physical and structural barriers, and lack of health education and promotion were factors evidenced in three (3) Brazilian studies [13,17,16] , in three (3) American ones [20,21,22] , in one Canadian research [25] and in one Australian article [24] . One of the main crossroads in one of the Brazilian studies concerns services' structural accessibilities such as lack of gynecology outpatient clinics in all health services [13] .

Quality management of Cytopathological Exams for diagnosis and treatment
There were fragilities in the quality screening and laboratory control of exams in three of the selected studies. The study conducted in Argentina showed no quality control in laboratories responsible for the analysis of material collected for cytopathological exams, as well as lack of data about the segment and treatment of women diagnosed with UCN precursor lesions [23] .
Barcelos and colleagues (2017) (BR) mention increased number of screening quality issues related to HDI decrease in some regions in the country, besides association with population growth, with Family Health Strategies coverage and with the public health strategies adopted in Brazil [16] . Ronco  is acceptable, but the desired rate is 5%. Approximately 9% of health services reached acceptable rates and 81% reached the desired rate [27] .
With regard to the treatment and diagnostic of precursor lesions identified in the target population, data from three Brazilian [16,18,17] , one Zambian [29] and one British studies [26] were identified.
Bottari, Vasconcelos and Mendonça (2008) report the difficulty in treating changes identified in the performed cytopathological exams, without mentioning the amount of the most prevailing changes and/or alteration rates. These data are found in the study by Uchimura et al (2009), who recorded low colpocytologic change and ASCUS (Atypical Squamous Cells of Undetermined Significance) index in the following year. However, they state that this result can be linked to low quality diagnostics, and it increases the rate of false-negative exams [16,18] .
Brito-Silva et al (2014) showed the prevalence of malignant changes between women at the age of 50. Adenocarcinoma / Carcinoma diagnostics were mainly detected among women in the age group 50-59. On the other hand, the diagnostic of benign and/or pre-malignant changes was mainly recorded in women in the age group 23-39 years [17] .
Pharam et al (2015) conducted a screening in Zambia through cytopathological exam to get the diagnostic and treatment necessary for high and low degree lesions. They found extremely satisfactory results due to the agility of the processes. They also identified a larger number of histological exams in HIV-positive women than in HIV-negative ones, who were part of the population in their research [29] .
Herbert, Holdsworth and Kubba (2008) found that NIC 3 (advanced pre-malignant lesion) was the alteration recording the highest index, mainly in women between 20 and 39 years old. Growing NIC 3 rates were recorded for women in the age group 20.24 years in the last decade (3000-4000 cases/year), despite the drop in screening coverage [26] .

Discussion
The results of the searches highlighted many research on the topic of interest in many countries around the world. Each country has a different way to organize their UCN prevention and control policies/programs, as well as their public health organization.
In the United States, where we found four articles about the herein addressed topic, the public health system is featured as a sub-system based on health insurances and plans. Thus, there are public and private health plans. The most common public health plans are Medicaid and Medicare; they give free access to services, assistance and procedures and are only available for individuals with proven low income [33] . The adhesion of guidelines related to the topic change from state to state in the whole country, i.e., each state chooses one of the guidelines available in the country; there is national consensus.
The United Kingdom and Canada have a public health system based on a common guideline, such as the European Guidelines (United Kingdom) and the Canadian Task Force on Preventive Health Care (CTFPHC) [3,34] . Public health in Brazil is organized by SUS (Unified Health System), which is ruled by the Federal Cervical Cancer Screening (2016) [2,6] .
Most studies carried out in Latin America (Brazil and Argentina) recorded low screening rates in the target population: between 20% and 16%. These rates are quite below the recommended by WHO, which suggests 80% minimal relative coverage for the target population [35] . Some studies in North America (USA) show satisfactory indices. Countries in Latin America and in the Caribbean, which are considered developing countries, present mortality rate due to cervical cancer three times higher than developed countries in North America; 85% of death recorded due to this cancer type are also recorded in poorer countries [36,37] .
Studies conducted in Malawi and Canada reported fragilities and gaps in the accomplishment of contents proposed by the programs. When some factors are analyzed, a new evaluation of such factors is also performed. Many studies focused on these evaluations can identify and report gaps and deficiencies in the system, or even show that the target population of the program is not well defined [38] . This reality is often found in the selected research, and it evidences fragmentation in the health programs and services. It is an important obstacle for the assistance model [39] .
Aspects related to the barriers and fragilities in the accessibility (health education, active search, socioeconomic and race inequalities) to health services are recorded both in developed and developing countries.
However, a recent research pointed out that countries in Latin America and the Caribbean (developed and developing ones) record the highest economic inequality rates among women [40] , fact that goes against the high mortality rates due to UCN in these countries.
With regard to guidelines addressed in the studies, it is possible noticing that there is no consensus about the age to start screening the disease and for performing exams for its prevention and diagnostic in women.
In the United States, after redefinitions applied by experts to many guidelines in 2012, new screening recommendations were concluded. Women should start having their Pap smear exams at the age of 21, and it must be repeated every three years up to the age of 29. Pap smear associated with DNA-HPV screening should be performed every five years after this age (in case they both present negative results) or Pap smear must be performed every three years in women older than 30 years. Screening can stop in women in the age group 65-years or older, when there is no history of high-grade intraepithelial lesions (LSIL) in the last twenty years [41] .
In Brazil, Ministry of Health recommendation in the latest elaborated and recommended guidelines lie on screening through Pap smear in women in the age group 25-64 every three years after two consecutive negative cytological results. Screening must stop after the age of 64 after the last negative results [2] . European countries follow the European Guidelines, which recommend start screening in the age group 20-30 years through Pap smear every three years, and through Pap smear associated with DNA-HPV test after the age of 30 until 60-65 years old, every five years [3] .
There is no international consensus about the topic; however, according to Jin and colleagues (2013), DNA-HPV tests have better precursor lesion diagnostic than some cytological exams. Besides, emphasis could be given to screening in women presenting higher risk to develop precursor lesions, such as the ones presenting high HPV risk. It is recommended to carry out the test in women older than 30 years, when there is chance of HPV persistence and, consequently, higher risk to develop lesions and cancer [41] . Some of the main measures to overcome health barriers and to fill the gaps between the target population in the planet would be to provide this test due to cost reduction and associate it with HPV vaccination programs subsidized by the government to the whole population [41] .
Regarding the analysis of factors related to UCN screening quality, human development inequality between different regions in the country and the lack of laboratory control over the analysis of cytopathological exams were identified in Brazilian and Argentinian studies, respectively [16,18,23] .
HDI variations in Brazil and in other countries in Latin America remain a reality [42] . The unbalanced investments made by authorities in health, as well as the deficiencies in UCN prevention and control policies, became the main factors triggering the unsatisfactory results [43] .
The studies highlighted the difficulty to provide treatment to women with alterations in the screening exams and low-quality diagnostics. On the other hand, recent studies assessed the development of UCN care procedures and recorded deficit in the production of screening exams and biopsy, as well as a large number of colposcopy exams in most Brazilian regions, mainly in Northern and Northeastern Brazil [44] . These findings evidence the need of reinforcing the continuous education of cytotechnologists, as well as of health professionals responsible for screening the target population. Good laboratory infrastructure and quality control standardization are also necessary [43] .
Different from Latin American countries, Europe records better screening results [27] : acceptable and desired coverage rates by 81% and 90% in health services. Assumingly, such outcomes result from the better organization of their programs, although they also have gaps to be filled and improvements to be put in place [45] .

Conclusion
It is worth to have health services managers and government authorities following-up the policies and program adopted by the public health system by systematically assessing the actions, the production, accessibility and barriers to be identified. Moreover, investments must be optimized in order to qualify the technical procedures and health professionals, as well as to boost health education in the target population. Accordingly, the possibility to reach better results in UCN prevention and control will be much higher.