Health Education practices on breast and cervical cancer: integrative review Prácticas de Educación en Salud en cáncer de mama y cervicouterino: revisión integrativa

RESUMO

Objetivo: identificar na literatura brasileira as práticas de Educação em Saúde voltadas para a população feminina relacionadas ao câncer de mama e colo de útero. Método: Revisão Integrativa da Literatura realizada em abril de 2021, com busca nas bases de dados LILACS, BDENF, MEDLINE e biblioteca SciELO, respondendo a questão: Quais as práticas de Educação em Saúde desenvolvidas para a população feminina brasileira na abordagem da prevenção, diagnóstico, tratamento e reabilitação do câncer de mama e colo de útero? Resultado: amostra final constituída por 19 pesquisas, publicadas de 2015 a 2021. As práticas de Educação em Saúde tiveram foco na prevenção, tendo como cenário educativo a atenção primária. Como estratégias educativas,verificou-se o diálogo, materiais educativos, palestras, atividades em grupos, mídias, ligações telefônicas e visitas domiciliares. Conclusão:as práticas de Educação em Saúde se mostraram de grande valia à comunidade, promovendo o conhecimento, aumento da adesão aos exames e autocuidado.

DESCRITORES:Educação em Saúde; Promoção da Saúde; Neoplasias de Mama; Neoplasias do Colo do Útero; Neoplasias Uterinas.

SUMMARY

Objective: to identify, in the Brazilian literature, Health Education practices aimed at the female population related to breast and cervical cancer. Method: Integrative Literature Review carried out in April 2021, with a search in the LILACS, BDENF, MEDLINE and SciELO library databases, answering the question: What are the Health Education practices developed for the Brazilian female population in the approach to prevention, diagnosis, treatment and rehabilitation of breast and cervical cancer? Result: final sample consisting of 19 studies, published from 2015 to 2021. Health Education practices focused on prevention, with primary care as an educational scenario. As educational strategies, dialogue, educational materials, lectures, group activities, media, telephone calls and home visits were verified. Conclusion: Health Education practices proved to be of great value to the community, promoting knowledge, increased adherence to exams and self-care.
DESCRIPTORS:Health Education; Health promotion; Breast Neoplasms; Cervical Neoplasms; Uterine Neoplasms.

 

INTRODUCTION

Cancer is a disease in which cells grow irregularly, invading organs and tissues, whose prevention, early diagnosis and monitoring are extremely important for the individual. In the female public, breast and cervical cancers have the highest incidence and mortality. Breast cancer is the main cause, among the types of cancer, of death among women, whose risk factors are diverse, such as age, reproductive history, endocrine, behavioral, environmental, genetic and hereditary factors. ⁽¹⁾

Cervical cancer, in turn, is related to infection by oncogenic subtypes of the Human Papillomavirus (HPV) virus, the etiologic agent of about 70% of cervical cancers and the fourth leading cause of cancer death among women in Brazil. ⁽²⁾

The main means for the early detection of both cancers are early diagnosis and screening, which allow the disease to be treated in its initial phase, with greater chances of cure, including breast self-examination, mammography and preventive examination of the cervix. ^(3-4)

However, many reasons end up preventing women from going to the Basic Health Units (UBS), where these exams and health follow-ups are carried out. Among them is the troubled routine that many have, with jobs whose hours coincide with those of medical and nursing consultations, in addition to the fear of the examination procedure; fear of positive outcomes; lack of knowledge of the procedure and the need for the exam; shame and difficulty accessing the service, leading them to put aside even their own health. ⁽⁵⁾

Thus, Primary Health Care (PHC) is the population's gateway to the Unified Health System (SUS), where control actions aimed at preventing these diseases are developed.⁽⁶⁾ It is up to the health professional, then, to carry out Health Education actions that include information necessary for prevention and also to encourage women to perform self-care and get to know their bodies, going beyond a merely care and technical role.

In addition to educational activities aimed at preventing breast and cervical cancer, it is essential that Health Education practices are developed, also focusing on diagnosis, treatment, and also rehabilitation. Appropriate guidelines regarding preventive exams and self-care are relevant educational strategies for coping with gynecological cancer,   requiring competent actions from health professionals, being extremely relevant studies that lead them to seek strategies that provide the female population with quality assistance in this process. ⁽⁷⁾

In this direction, it was interesting to know what are the approaches commonly used in Health Education practices for the female public in this theme, presenting extremely relevant data to improve and expand the existing knowledge about the educational practices developed in the context of breast and cervical cancer, filling the existing scientific gaps. Furthermore, in addition to adding to existing publications, this research is of great social value, as it adds information to those interested in the subject, who may benefit from knowing the educational strategies developed in Brazil for these types of cancers, and then, combining knowledge with practice.

Thus, this research had as a study question: what are the Health Education practices aimed at the Brazilian female population in the approach to prevention, diagnosis, treatment and rehabilitation of breast and cervical cancer? Considering the above, the study aimed to identify, in the Brazilian literature, Health Education practices aimed at the female population related to breast and cervical cancer.

 

METHOD

It was an Integrative Literature Review, whose review process was developed in the following stages: identification of the theme and selection of the research's guiding question; establishment of criteria for inclusion and exclusion of studies; definition of the information to be extracted from them; assessment of those included in the review; analysis and interpretation of results and presentation. ⁽⁸⁾

As a question that guided the present study, it was adopted: What are the Health Education practices developed for the Brazilian female population in the approach to prevention, diagnosis, treatment and rehabilitation of breast and cervical cancer?

The search and selection of scientific production was carried out using the flowchart Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ⁽⁹⁾, during the month of April 2021. For data collection, an electronic consultation was carried out in the following online databases: Latin American and Caribbean Literature in Health Sciences (LILACS), Nursing Database (BDENF), Medical Literature Analysis and Retrieval System (MEDLINE) via PubMed, and the ScientificElectronic Library Online (SciELO).

To systematize the collection of publications, we used the controlled descriptors and coincidentally inserted in the database of Descriptors in Health Sciences (DeCS) and Medical SubjectHeadings (MeSH) combined with the Boolean operators “AND” and “OR”, which enabled the construction of search strategies (Chart 1).

 

Table 1. Search strategies used to systematize the collection of publications in databases – Maringá, PR, Brazil, 2021.

Database	Search strategies
LILACS BDENF	"Educação em Saúde" OR "Promoção da Saúde" [Descritor de assunto] AND "Neoplasias da Mama" OR "Neoplasias do Colo do Útero" OR “Neoplasias Uterinas” OR “Infecções por Papillomavirus” OR “Autoexame de Mama” OR “Teste de Papanicolaou” [Descritor de assunto] and "2015" or "2016" or "2017" or "2018" or "2019" or "2020"or “2021” [País, ano de publicação]
MEDLINE	((Health Education[MeSH Terms]) OR (Health Promotion[MeSH Terms])) AND ((((((Breast Neoplasms[MeSH Terms]) OR (Uterine Cervical Neoplasms[MeSH Terms])) OR (Uterine Neoplasms[MeSH Terms])) OR (Papillomavirus Infections[MeSHTerms])) OR (Breast Self-Examination[MeSH Terms])) OR (Papanicolaou Test[MeSH Terms])) AND (y_5[Filter])
SciELO	((Educação em Saúde) OR (Promoção da Saúde)) AND ((Neoplasia de Mama) OR (Neoplasias de Colo do Útero) OR (Neoplasias Uterinas) OR (Infecções por Papillomavirus) OR (Autoexame de Mama) OR (Teste de Papanicolaou)) AND year_cluster:("2015" OR "2016" OR "2017" OR "2018" OR "2019" or “2020”or “2021”)

Source: Research Data, Maringá, PR, Brazil, 2021.

 

Studies were included that addressed as a central theme the practices of Health Education developed in Brazil for the prevention, diagnosis, treatment and rehabilitation of breast and cervical cancer; available in Portuguese, Spanish or English, and published in the last six years (2015-2021), aiming to cover the most recent scientific production on the subject. Publications not related to the theme, duplicates, not freely available in full, editorials, letters to the editor, abstracts in annals of scientific events, manuals, booklets, reviews, or still without results were excluded.

After selection of publications based on the application of inclusion/exclusion criteria and use of the PRISMA protocol, a final sample of 19 publications was obtained (Figure 1).

 

 

Figure 1. Study selection flowchart for review. Maringá, PR, Brazil, 2021.

Source: Research Data, Maringá, PR, Brazil, 2021.

 

After reading the selected material in full, critical analysis and interpretation of the results, the concepts addressed and of interest to the study were extracted from the publications. It is noteworthy that the data were presented in tables and also in descriptive language. Thus, for document extraction, three tables of Microsoft Word® 2013 software were prepared, presenting a synthesis of the knowledge produced.

After crossing the scientific evidence, the discussion was carried out according to the results shown, and it was analyzed in the light of current and relevant literature related to Health Education practices. As for the ethical aspects, as it is a literature review study that did not involve human beings, the study was not submitted to the Research Ethics Committee.

 

RESULTS

The final sample of publications consisted of 19 studies, as shown below (Chart 2).

 

Chart 2. Characteristics of scientific productions on “Health Education Practices aimed at the female population on breast and cervical cancer”, Maringá, PR, Brazil, 2021.

ID	Origin/Journal	Year of publication / Language	Title/ Authors	Place where the studies were carried out	Type of publication/ Methodological nature
A1	LILACS   Ciência, Cuidado e Saúde	2015   Portuguese	Health education: an intervention strategy against breast cancer (Educação em saúde: uma estratégia de intervenção frente ao câncer de mama)(10) Bushatsky M, Cabral LR, Cabral JR, Barros MBSC, Gomes BMR, Filho ASSF.	Sirinhaém, Pernambuco, Brazil	Original article   Quasi-experimental study
A2	LILACS   Revista de Pesquisa: Cuidado é Fundamental	2015   Portuguese	Cervical cancer control: actions developed by nurses in the light of the collective subject discourse (Controle do câncer do colo do útero: ações desenvolvidas pelo enfermeiro à luz do discurso do sujeito coletivo)(11) Correio KDL, Ramos AIG, Santos RLG, Bushatsky M, Correio MBSCB.	Carpina, Pernambuco, Brazil	Original article   Interpretive study with a qualitative approach
A3	LILACS   Revista Cuidarte	2015   Portuguese	Popular education as a participatory instrument for the prevention of gynecological cancer: women's perception (Educação popular como instrumento participativo para a prevenção do câncer ginecológico: percepção de mulheres)(12) Souza KR, Paixão GPN, Almeida ES, Sousa AR, Lirio JGS, Campos LM.	Senhor do Bonfim, Bahia, Brazil	Original article   Action research with a qualitative approach
A4	BDENF   Revista Gaúcha de Enfermagem	2015   Portuguese	Attention to women's health after 50 years of age: programmatic vulnerability in the Family Health Strategy (Atenção à saúde da mulher após os 50 anos: vulnerabilidade programática na Estratégia Saúde da Família)(13) Pasqual KK, Carvalhaes MABL, Parada CMGL.	Botucatu, São Paulo, Brazil	Original article   Descriptive epidemiological study
A5	MEDLINE   Revista Brasileira de Enfermagem	2016   Portuguese	Interventions that favor adherence to Pap smear examination: integrative review (Intervenções que favorecem a adesão ao exame de colpocitologia oncótica: revisão integrativa)(14) Soares MBO, Silva SR.	Uberaba, Minas Gerais, Brazil	Literature review   Integrative literature review
A6	LILACS   Ciência, Cuidado e Saúde	2016   Portuguese	Popular health education as a strategy for adherence to the Pap test (Educação popular em saúde como estratégia à adesão na realização do exame colpocitológico)(15) Alves SR, Alves AO, Assis MCS.	Porto Alegre, Rio Grande do Sul, Brazil.	Original article   Experience report
T1	LILACS   Repositório Institucional da Universidade Federal do Ceará	2016   Portuguese	Knowledge, attitude and practice regarding the early detection of breast cancer within the scope of the family health strategy (Conhecimento, atitude e prática acerca da detecção precoce do câncer de mama no âmbito da estratégia de saúde da família)(16) Almeida AIM.	Crato, Ceará, Brazil	Completion of course work   Cross-sectional descriptive study
A7	SCIELO   Revista Latino-Americana de Enfermagem	2017   Portuguese	Interventions by telephone for adherence to the Pap test (Intervenções por telefone para adesão ao exame colpocitológico)(17) Lima TM, Nicolau AIO, Carvalho FHC, Vasconcelos CTM, Aquino PS, Pinheiro AKB.	Fortaleza, Ceará, Brazil	Original article   Quasi-experimental study
A8	SCIELO   Revista Latino-Americana de Enfermagem	2017   English	Comparison among the efficacy of interventions for the return rate to receive the pap test report: randomized controlled clinical trial (18) Vasconcelos CTM, Pinheiro AKB, Nicolau AIO, Lima TM, Barbosa DFF.	Fortaleza, Ceará, Brazil	Original article   Controlled randomized experimental study
A9	SCIELO   Revista Brasileira de Educação Médica	2017   Portuguese	“Beyond the Mama”: the Pink October Scenario in Medical Training Learning (“Além da Mama”: o Cenário do Outubro Rosa no Aprendizado da Formação Médica)(19) Couto VBM, Sampaio BP, Santos CMB, Almeida IS, Santos NGS, Santos DC, et al.	Ilhéus, Bahia, Brazil	Original article   Experience report
A10	LILACS   Revista Eletrônica de Comunicação Informação e Inovação em Saúde	2017   Portuguese	m-Health in the control of cervical cancer: prerequisites for the development of an application for smartphones (m-Health no controle do câncer de colo do útero: pré-requisitos para o desenvolvimento de um aplicativo para smartphones)(20) Bilotti CC, Nepomuceno LD, Altizani GM, Macuch RS, Lucena TFR, Bortolozzi F, et al.	Maringá, Paraná, Brazil	Original article   Descriptive cross-sectional study
A11	LILACS   Revista de Enfermagem UERJ	2017   Portuguese	Knowledge and practice of self-palpation of the breasts among public school students in the evening period (Conhecimento e prática da autopalpação das mamas entre estudantes de escolas públicas do período noturno)(21) Mendes LC, Elias TC, Silva SR.	Uberaba, Minas Gerais, Brazil	Original article   Quasi-experimental before-and-after study
A12	LILACS   Estudos Interdisciplinares em Psicologia	2017   Portuguese	Construction of an educational material for the prevention of cervical cancer(Construção de um material educativo para a prevenção do câncer de colo do útero)(22) Peuker AC, Lima NB, Freire KM, Oliveira CMM, Castro EK.	Porto Alegre, Rio Grande do Sul, Brazil	Original article   Experience report
A13	LILACS   Revista Ciência Plural	2017   Portuguese	Cervical uterine cancer prevention: an action performed by family health strategy nurses? (Prevenção do câncer cervicouterino: uma ação realizada pelos enfermeiros da estratégia saúde da família?) (23) Silva AB, Rodrigues MP, Oliveira AP, Melo RHV.	Assú, Rio Grande do Norte, Brazil	Original article   Exploratory study of a qualitative nature
A14	LILACS   Nutrition&Cancer	2018   English	Adherence to the WCRF/AICR for Women in Breast Cancer Adjuvant Treatment submitted to Educational Nutritional Intervention(24) Liz S, Vieira FGK, Assis MAA, Cardoso AL, Pazini CPL, Pietro PFD.	Florianópolis, Santa Catarina, Brazil	Original article   Non-randomized clinical trial
A15	SCIELO   Revista de Saúde Coletiva	2020   Portuguese	Early detection of breast cancer in the Brazilian media during Pink October (Detecção precoce do câncer de mama na mídia brasileira no Outubro Rosa)(25) Assis M, Santos ROM, Migowski A.	Brazil (Brazilian media)	Original article   Document analysis
A16	LILACS   Revista Brasileira em Promoção da Saúde	2020   Portuguese	Coping strategies after breast cancer diagnosis (Estratégias de enfrentamento após o diagnóstico de câncer de mama)(26) Silva KK, Barreto FA, Carvalho FPB, Carvalho PRS.	Pau dos Ferros, Rio Grande do Norte, Brazil	Original article   Descriptive and qualitative research
A17	LILACS   Revista Brasileira em Promoção da Saúde	2020   Portuguese	Health education for indigenous women about breast and cervical cancers (Educação em saúde para mulheres indígenas sobre cânceres de mama e de colo uterino)(27) Souza ATS, Vilarinho MLCM, Brandão SASM, Rodrigues AK, Amaral LRS, Milanez LS, et al.	Lagoa de São Francisco, Piauí, Brazil	Original article   Experience report
A18	SCIELO   Revista Brasileira de Estudos de População	2021   Portuguese	Challenges for the prevention and treatment of cervical cancer in the interior of the Northeast (Desafios para prevenção e tratamento do câncer cervicouterino no interior do Nordeste)(28) Fernandes NFS, Almeida PF, Prado NMBL, Carneiro AO, Anjos EF, Amorim J, et al.	Bahia, Brazil	Original article   Qualitative study

Source: the authors, 2021.

It was identified that most of the studies are original (n=17), are available in the LILACS database (n=12), were published in several journals in the field of nursing, especially in the year 2017 (n=7), and in Portuguese (n=17). They were developed in teaching institutions in the Northeast Region (n=11) of Brazil, using a qualitative approach (n=5), mostly (Chart 2).

 

Chart 3. Characteristics of Health Education practices in the context of breast and cervical cancer. Maringá, PR, Brazil, 2021.

ID/ Type of Cancer	Scenario of educational practices	Target Audience	Those responsible for carrying out the practices / Focus of educational practices
A1   Breast Cancer	Family Health Unities	Women users of Primary Care in the municipality of Sirinhaém, Pernambuco (Recife).	Community health agents   Prevention
A2 Cervical Cancer	Family Health Unities	Women attending Basic Health Units in the city of Carpina, Pernambuco.	FHS Nurses   Prevention
A3   Cervical Cancer	Basic Health Units	Women who attend the Basic Health Unit in the Municipality of Senhor do Bonfim-Ba.	Student of the graduation course in Nursing and health professionals   Prevention
A4   Breast Cancer and Cervical Cancer	Family Health Unities	Women from 50 years of age who attend the Family Health Unit, in the city of Botucatu, São Paulo, Brazil.	Nurses and other professionals working in the area of women's health   Prevention
A5   Cervical Cancer	Domicile of women in 19 municipalities in the interior of São Paulo	Women residing in 19 cities in the interior of São Paulo, Brazil.	Community health agents   Prevention
A6   Cervical Cancer	Various social and community environments (religious temples, Basic Health Unit, homes, schools, events, among others)	Women taking Pap smear	Members of the Family Health Strategy Team   Prevention
T1   Breast Cancer	Family Health Strategy teams in urban and rural areas	Women who are part of the Family Health Strategy (ESF) in the city of Crato-CE, located in the south of the State of Ceará.	Family Health Strategy Nurses   Prevention and diagnosis
A7   Cervical Cancer	Basic Health Unit and via telephone	Women in the age group between 25 and 64 years old, having started sexual activity, with their mobile or landline telephone number in the medical record and with inadequate periodicity for the Pap smear.	Nurse   Prevention
A8   Cervical Cancer	Primary Health Care Unit	Women who were waiting for the Pap test to be performed in a Primary Health Care Unit located on the outskirts of the city of Fortaleza, state of Ceará.	Nurse   Prevention
A9   Breast Cancer	Family Health Unities	17 women aged between 26 and 71 years old, with an approximate average of 50 years old, at the USF in Iguape.	Medical students and members of the Family Health Strategy team   Prevention
A10   Cervical Cancer	Home of women registered in 32 Basic Health Units	Women between 20 and 60 years old.	Community Health Agent, nurses, doctors and other health professionals   Prevention
A11   Breast Cancer	Public schools with night shift	Night high school students, youth and adult education (EJA) and teachers from all night high schools in the city of Uberaba/Minas Gerais.	Nurse   Prevention
A12   Cervical Cancer	Basic Health Units	Women who use Primary Health Care.	Psychology, nursing and design professionals   Prevention
A13   Cervical Cancer	Family Health Strategy Teams	Women in the municipality of Assú who use primary care.	Family Health Strategy team nurses   Prevention
A14   Breast Cancer	Hospital	Women undergoing surgical treatment for breast cancer at the Carmela Dutra Hospital, Florianópolis, Santa Catarina..	Health professionals   Treatment
A15   Breast Cancer	Brazilian media	Women who somehow use some form of social media.	Brazilian media   Prevention
A16   Breast Cancer	Domicile of women enrolled in the Support Center for Cancer Patients	Women with breast cancer.	Multiprofessional team (Nurses, Psychologists, Social Workers, among others)   Treatment
A17   Breast Cancer and Cervical Cancer	Indigenous community	Adult and elderly indigenous women in the Nazaré indigenous community, located in the municipality of Lagoa de São Francisco, Piauí, Brazil.	Residents of the Multiprofessional Residency Course, under the supervision of preceptors   Prevention
A18   Cervical Cancer	Basic Units and Family Health Teams	Women in a region of Bahia who use the Basic Health Unit.	Nurses and Community Health Agents   Prevention and treatment

Source: the authors, 2021.

 

The type of cancer most discussed in educational practices was that of the cervix (n=10), with actions carried out mostly in Basic Health Units (n=12) (Chart 3). It was also observed the domicile of the women registered in the units in question (n=4); schools (n=2), Hospital (n=1), media (n=1), and indigenous community (n=1). The public-were women who attend the service and are within the recommended age range for prevention actions. Only four of the articles are aimed at high school students, carriers of one of the cancers or women who use some type of social media.

 

Quadro 4. Estratégias pedagógicas adotadas e repercussões dos estudos. Maringá, PR, Brasil, 2021.

ID	Adopted pedagogical strategies	Repercussions
A1	Pre-test, intervention, and post-test on breast cancer. Conducting dialogue exhibitions, with audiovisual resources, discussion, expository charts on risk and protective factors for breast cancer, self-examination theater and communication dynamics for the exchange of experiences and knowledge	The action was effective, with changes being observed in the patterns of responses in the pre- and post-test, with learning about the main risk factors, therapeutic modalities, prevention and among other factors analyzed.
A2	Lectures in the physical space of the USF, and in nursing consultations there is clarification of doubts and guidance	Health education contributed to the satisfactory adherence of users to the services, facilitating understanding and sensitizing them to the preventive examination and to changes in behavior that enable a healthy and good quality life.
A3	Circles of dialogical and dynamic conversations, valuing pre-existing knowledge and building new knowledge, encouraging dialogue	The adopted strategy was effective, and it was possible to observe a pre-existing knowledge among the participants about the prevention of gynecological cancer. It is necessary for health professionals to work on popular education as an instrument for women's dialogic participation, there is a lack of information by health professionals who carry out the Papanicolaou test. Playful activities should be prioritized, always correlating with the daily culture of each community, for early diagnosis and tracking asymptomatic and symptomatic women.
A4	Collective actions in the community and group activities	The participation of women in these actions/activities was quite limited. Only 11.2% of the women said they participated in educational groups, which could have contributed to the expansion of the bond, complementing the individual consultation, allowing the exchange of information and the provision of guidance and health education. Greater reflection by USF managers and staff is needed on this strategy, so that it can be used in a more reflective and effective way.
A5	Awareness strategies, such as distribution of leaflets and pamphlets; media broadcasts (via radio and car speakers); and home visits by Community Health Agents (CHA) to discuss the performance of the exams	The strategies had a positive result in increasing the participation of women in the examination and a low financial cost. It was noted the need to combine these practices with the proper structuring of health services and carrying out population-based screening. It is necessary to consider the specific characteristics of each location in order to apply the interventions that best match the local reality.
A6	Meetings with community and religious leaders; Multidisciplinary approach on the subject with women and the community in the waiting room, in home visits and in consultations; and popular health education activities in schools and community events, based on dialogue and exchange of experiences	The team's participation in religious events had a significant impact on the women's adherence to the test, who began to take the test after being guided in their religious ceremonies. The photographic studios set up inside the health unit had a positive impact because many women who refused to take the exam became interested in it, for having experienced a moment of understanding of its importance, stimulating and raising awareness about the importance of carrying it out.
T1	Education about breast cancer, its symptoms, risk factors, detection in early stages and about the composition and variability of the normal breast, during clinical breast examination and mammography. Active search for breast cancer screening and educational activities in Pink October. Nursing consultation as an orientation strategy regarding risk factors and manifestations of breast cancer during gynecological prevention.	Nurses do not use many strategies to prevent breast cancer and women do not have enough knowledge. There is a need for updating and training of nurses. With the implementation of preventive measures by nurses, through learning, women can be capable of self-knowledge and professionals can make them feel welcome and that they have an active participation in their health care.
A7	Educational intervention by telephone, addressing the CC and its risks, the purpose of the Pap smear test, the importance of periodicity of the test, pre-examination care and the return to collect the result	The intervention carried out by telephone was effective in the women's adherence to the pap smear test.
A8	Educational groups using graphic representations or illustrations (pictures) that generate discussion; and demonstration of the Pap test, using an anatomical model of the female pelvis and the material used in the test	Women in the educational group returned in greater proportion and earlier for the consultation, confirming the superiority of the educational intervention.
A9	Exchange of experiences, practice of health education, space for dialogue between appointments, waiting room groups, explanations about risk factors, protection factors, signs and symptoms, and early detection of breast cancer	The intervention proved to be effective, as the users were receptive and collaborative, responding to questions and reflecting on the importance of following the guidelines. It was easier for the professional to interact with the user, reinforcing the co-responsibility pact for her health. The experience allowed academics to recognize and better understand the difficulties of users in relation to the prevention and promotion of breast health.
A10	Lectures, distribution of pamphlets on the subject, Pink October campaigns and guidance on the cervical cancer prevention exam, by UBS and social media	Women are aware of the existence of CC, undergo preventive exams, receive pamphlets and information on the prevention of CC in the UBS, but the prevalence and mortality by CC have not decreased, showing the ineffectiveness of actions. Thus, the development of m-Health tools can be applied to strengthen CC control actions based on individual and collective empowerment in relation to self-care.
A11	Educational activities based on dialogue and exchange of knowledge, using didactic resources of verbal explanation of the APM theme and audiovisual resources such as banner	It is believed that the activity was effective in transmitting information to the population and that the gain in knowledge will remain in the long term, since there was a considerable increase in the proportion of correct answers after carrying out the educational activity.
A12	Creation of prototypes of an origami flower with information about cervical cancer. As the women unfolded the petals there were questions and answers through testimonials from women	The educational material created is innovative because it was built from the results of empirical research with the target population and used design knowledge in its elaboration, uniting knowledge and bringing areas closer together. The active participation of women and health professionals in the construction of the material is another point to be highlighted, which shows the importance and applicability of the material. As a limitation of the study, the material is not accessible to the entire population, such as illiterate and functionally illiterate women. It was well evaluated by women and health professionals, and can help in the search for cervical cancer prevention.
A13	Ministry of Health campaign; existing groups at USF; search for women by the CHA, educational actions on specific occasions (Pink October campaigns); use of the waiting room and hyperdia for holding a lecture, providing guidance on how to prevent themselves; lectures, guided by the pedagogy of transmission and conditioning	FHS nurses are still unable to effectively prevent cervical cancer and their actions are not in line with the guidelines of the Ministry of Health. Health education has flaws, since the methodology used does not encourage women's empowerment and autonomy.
A14	Biweekly phone calls, face-to-face meetings, and monthly handouts	The nutritional educational intervention improved several factors such as BMI, diet energy density, WC, among others. The intervention positively improved adherence to recommendations, with increased intake of plant foods. Intervention in the educational nutritional framework during breast cancer treatment was important for improving food intake, leading a healthier lifestyle and perhaps improving prognosis and decreasing cancer risk.
A15	Publications in the Brazilian media, print, internet, radio, television and social media about Pink October. Dissemination of social mobilization and support actions (lectures, debates, service offerings, walks/sports practices, exhibitions, solidarity actions, among others), early detection, primary prevention and risk factors.	Different recommendations on age range and periodicity of mammograms are released during this campaign, with a certain predominance of recommendations from medical societies, in addition to many incomplete recommendations. Few articles reported on the coexistence of different recommendations for breast cancer screening, failing to bring up the contradiction, and very few brought up the issue of the risks and benefits involved. Many incorrect statements are propagated by the media in a clarification campaign, with the need for qualification on the part of the press vehicles.
A16	Support network, space where they can dialogue and share their stories with other female patients and professionals, providing an exchange of lived experiences, and guidance through home visits	The multidisciplinary practice makes it possible to update health promotion strategies that have a more comprehensive and effective reach. Thus, the Cancer Support Center can be highlighted as a network that makes it possible to interact with people who have similar feelings, such as fears and insecurities, among many others, experienced during the stages of diagnosis and treatment of cancer, positively influencing the process of treatment and cure of breast cancer.
A17	Health education, using the “myth or truth” dynamics. Presentation of the breast self-examination technique, guidance on clinical examination and mammography, exchange of experiences and health care	The action made it possible to promote health with indigenous women through an education capable of problematizing and building, intertwining scientific knowledge with popular knowledge. Provided an emancipating space for teaching and learning, so that debating the topic of breast and cervical cancer within this environment required facilitators to manage the use of a methodology that would enable communication with the target audience, considering its specificity as an indigenous population, this being the greatest lesson for the future practices of program residents.
A18	Educational interventions during the Papanicolaou exam, where, when detecting any gynecological alteration, the nurses guided the women, maintaining the continuity of care and establishing relationships of proximity and bond with the community.	Municipalities have difficulties in providing health education practices. The health professionals' actions also require a close look at the needs of women who live in vulnerable territories and who, therefore, need proactive practices and immersion in community life to reverse possible inequities.

Source: the authors, 2021.

 

Those responsible for the practices, in the vast majority of studies, are the health professionals of the Family Health Strategy teams, with emphasis on nurses (n=11), Community Health Agents (CHA) (n=3), in addition to Nursing (n=1) and Medicine (n=1) academics.

With regard to the pedagogical strategies adopted, different actions were observed in the analyzed studies, with seven using dialogue (A1, A3, A6, A8, A9, A11 and A16), five lectures (A2, A10, A13 and A15 ); followed by support groups and networks (A4, A8, A13 and A16); and carrying out home visits and active searches (A5, A6, T1, A13 and A16). There were also educational activities during consultations and in the waiting room (A2, A6, T1, A9, A13 and A18); in addition to these, educational materials were also used (A1, A5, A8, A10, A11, A12, A14 and A15), which were given through leaflets, pamphlets, exhibition boards; use of media (A5, A10 and A15) ; telephone calls (A7 and A14); and use of dynamics (A17). In addition to actions with the community, in schools, events, meetings with religious and community leaders (A6).

With regard to the theme of pedagogical practices, 16 studies focused on the prevention of the cancers addressed, two on treatment (A14 and A16), and only one study on the diagnosis (T1). There was no focus on rehabilitation.

Regarding the repercussions obtained in the selected publications, which concern the potential and perceptions of points related to educational activities, 13 of the strategies used were considered effective and/or satisfactory (A1, A2, A3, A5, A6, A7, A8 , A9, A11, A12, A14, A16 and A17).

 

DISCUSSION

The reviewed studies presented several strategies, showing that Health Education is essential in PHC services, being exercised by all professionals with the objective of awakening in the population the desire for care, to be able to recognize the risk factors and thus be able to prevent cancer. ⁽²⁹⁾ Thus, the Basic Health Units (UBS) are presented as a privileged place for educational practices in health, due to the multidisciplinary work and access to the community. ⁽³⁰⁾

            In addition to the UBSs, another scenario present in the pedagogical practices was the women's homes, since through home visits, health professionals obtain a greater proximity to the population, being able to introduce new teachings and practices for the users. ⁽¹⁴⁾

The important role of PHC in the line of care for cancer in the country is also highlighted, according to the ordinance established by the National Policy for Cancer Prevention and Control (PNPCC - Política Nacional para Prevenção e Controle do Câncer), involving actions aimed at health promotion and cancer prevention, as well as early diagnosis, treatment, clinical actions and palliative care of treated patients. ⁽³¹⁾

Regarding the professionals responsible for implementing these pedagogical strategies, there is a recurrence of professional nurses, who were present in most of the analyzed studies, since the strategies carried out were present, for the most part, in PHC, given that these professionals play an important role, encompassing actions aimed at individuals, families and the community, with the purpose of guaranteeing integral assistance in the promotion and protection of health, prevention of injuries, diagnosis, treatment, rehabilitation and maintenance of health, in different social spaces and in all phases of the life cycle. ⁽³²⁾

            In addition, other professionals and members of the ESF teams were also mentioned, as they also have a significant role in developing important actions, mediating the relationship between the health unit and the community, with communication, active listening and respect for particularities. ⁽³²⁾

The use of media was also pointed out as a way of carrying out educational actions, which requires attention, as it can enhance massive awareness actions as long as the content is checked by health professionals, following ministerial guidelines. ⁽²⁵⁾

Regarding the different strategies identified in the studies, emphasis was given to those that focused on preventive pedagogical practices, increasing the level of knowledge, encouraging self-care and allowing early detection. Being a strategy to reduce the chances of possible consequences and intensive therapies, through prior identification of the disease, correct treatment and increase the frequency of women to resources and tests, encouraging self-monitoring of care, as well as empowering women in relation to their health. ⁽³³⁾

Among the actions in the axis of prevention of breast and cervical cancer evidenced, it was noted the greater use of educational materials, such as leaflets, pamphlets, exhibition boards, media broadcasts (radio, television, loudspeakers, automobiles, print, social networks), graphic representations and/or illustrations, anatomical model, origami flower and banner. The use of these materials is capable of improving health care, as they should encourage dialogue and criticality, going far beyond the transmission of information. ⁽³⁴⁾

One of the educational materials identified in the studies was innovative, as it was created by health professionals and women, based on the results of empirical research with the target population and used design knowledge in its preparation, uniting knowledge and ensuring the applicability of the material. ⁽²²⁾

Still in prevention, dialogue is presented as a facilitating strategy for the reflection process, promoting the exchange of knowledge and supporting the learning provided by health promotion actions, clarifying the participants' doubts, guaranteeing participation and the construction of knowledge ⁽¹²⁾, as well as the recognition of the difficulties of the users.⁽¹⁹⁾

            Also, providing guidance during consultations, exams, in the operating room is relevant for sharing knowledge, clarifying doubts and guiding patients about breast and cervical cancer. This space with women is not only characterized as clinical, but an opportunity to approach topics relevant to care, promoting reflection and empowerment of these users. ⁽¹¹⁾

            Lectures were also identified as one of the actions used in the articles, in order to pass on the necessary instruction to the female audience, which must be developed with a focus on the needs of those involved and in a dialogic participatory way, promoting more open and comfortable pedagogical interaction with participants. ^(11,23)

Furthermore, still with a focus on prevention, group activities were also carried out, which were very well evaluated and received by the women in question, proving to be of great value for women's learning and contribution to self-care, as it expands the bond and allows the exchange of information, integrating the individual consultation. ⁽¹³⁾

Home visits and active searches were also present as educational methods for prevention, since in these, health agents achieve a greater bond with the population in question, managing to approach them in their homes and transmitting the necessary knowledge for these women to practice the necessary care. ⁽²³⁾

The Brazilian media covers print, internet, radio, television and social networks, and can also be used as a prevention strategy, and presenting a large volume of articles on breast cancer, showing the strength of the Pink October campaign and the media's interest in the subject, highlighting various information actions, social support and other services offered to women in general and those facing the disease ⁽²⁵⁾, as well as social networks ⁽²⁰⁾ and telephone calls, which facilitate access to information and communication. ⁽¹⁷⁾

So that they can offer this quality information to the public in question, it is necessary that health workers are always up to date and prepared to share the necessary information and take fundamental actions that really work so that women are more informed and confident about how to take care of their bodies against breast and cervical cancer. ⁽³⁵⁾

            Among the inefficient and/or negative repercussions, we scored six articles in which it was noted that the practices carried out did not reach the desired objective in terms of prevention, treatment and/or diagnosis of cancers. It was evident that the participation of the female population in the activities and/or in the groups offered did not take place effectively, proving to be quite limited, manifesting a need for reflection by managers and components of the Family Health Strategy on the action taken, so that it is carried out more effectively and that it attracts the participation of users. ⁽¹³⁾

In addition, exploring the challenges in the prevention and treatment of uterine cancer in the northeast region of Brazil, it was detected that a chain of socioeconomic problems increases the difficulty of adherence to screening. In turn, the fragility of Primary Health Care with exclusionary characteristics and the network of services with low inclusion expose women who adhered to screening and those who managed to access the uncertainties of continuity and resolvability of care. In addition, professionals have difficulties in resolving the unfavorable structure, however, they also feed back or reproduce inequalities when they work with practices centered on the procedure, to the detriment of care for women. ⁽²⁸⁾

It is noteworthy that there are still few resources, in terms of funding and research, given its relatively high incidence compared to other types of cancer. High-quality studies are needed to assess whether educational interventions can improve early presentation and referral for women with cancer symptoms. It is also emphasized that studies should include an assessment of referral times for adequate provision of information for clinical decision-making. ⁽¹⁴⁾

 

CONCLUSION

It was possible to identify in the literature the practices of Health Education developed for the Brazilian female population in the approach of prevention, diagnosis, treatment and rehabilitation of breast and cervical cancer, and there was a predominance of actions aimed at prevention, highlighting nurses as the main responsible for the execution of these actions, developed mainly in the PHC scenario, showing a shortage of educational practices focused on the area of diagnosis, treatment and rehabilitation.

 Both the strategies for breast cancer and those for cervical cancer had educational interventions that emphasized women's autonomy in the teaching and learning process, bringing women to the fore as protagonists of their knowledge. As Health Education strategies, it was observed the use of dialogue, lectures, conversation wheel, technological resources (such as social networks, media, cell phone applications), educational materials (such as leaflets, pamphlets, display boards, graphic representations and/or illustrations, anatomical model, origami flower, banner and handouts), activities in groups and actions with the community, which must be carried out with a sensitive and empathetic look at the reality in which they find themselves.

            Health Education actions proved to be of great value to the community, but it is worth mentioning that those that reached the issues in order to achieve participation and discussion with the women in question stood out, thus reaching the objective of promoting their knowledge and increasing the adherence to the exams, making them understand the importance of self-care and concluding the objective of the pedagogical practices.

 

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