1.1 The need for the study

Cervical cancer is a malignancy that affects the female genital tract, with approximately 3800 new cases and 800 deaths reported in South Korea in 2022. It ranks seventh in overall cancer incidence and is the third most common cancer among women aged 15 to 34 years. This highlights the urgent need for preventive measures targeting young women [1]. The primary cause of cervical cancer is infection with the human papillomavirus (HPV), particularly HPV types 16 and 18, which account for over 70% of cases [2]. HPV is transmitted through sexual contact; while most infections are naturally cleared, some persist and may progress to cervical cancer [2]. Additional risk factors include smoking, multiple sexual partners, low socioeconomic status, limited educational attainment, early sexual initiation, early marriage, and a history of sexually transmitted infections [3]. Although cervical cancer typically develops over several years, it can be effectively prevented and treated through early screening [3].

The two most effective preventive measures for cervical cancer are the Pap test and HPV vaccination. The Pap test detects abnormal cervical cells at an early stage, enabling timely intervention before they develop into cancer. The HPV vaccine, recommended for adolescents and young adults, is a crucial tool for preventing HPV infection, the primary cause of cervical cancer. However, since the vaccine does not protect against all HPV types, regular screening remains essential [4].

College students (aged 18–22), often living independently from their parents and exposed to a more permissive sexual culture, face an increased risk of HPV infection [5]. A Korean survey reported a sexual experience rate of 65.5% among college students, with HPV infection rates of 38.8% among female students and 10.6% among male students [5]. However, cervical cancer screening rates in this population remain critically low at only 4.8%. Factors contributing to low screening participation include lack of awareness, financial constraints and fear of the procedure. Thus, active outreach and education are urgently needed [4].

Cervical cancer prevention depends largely on individual intentions, which are key predictors of actual preventive behavior. However, intentions alone often do not translate into participation in screening programs, emphasizing the need to explore the link between intention and actual behavior. It is essential to enhance both preventive intentions and participation through effective educational programs [3]. As of 2023, 71 World Health Organization member countries have included HPV vaccination in their national immunization programs. In Korea, the vaccine has been provided to girls aged 11–12 since June 2016 [6], while in the United States, it is administered to both boys and girls aged 9–26, as recommended by the Centers for Disease Control and Prevention (CDC) [7].

Despite being part of the national vaccination program, Korea still reports low vaccination rates. One key reason is the lack of cervical cancer education programs targeting parents [8, 9, 10, 11] and college-aged women [12, 13, 14, 15, 16, 17]. A 2016 survey of unvaccinated parents of 12-year-old girls revealed that 73.5% were concerned about side effects, and 68.5% had encountered negative information about the vaccine through mass media [18].

Since HPV vaccination is most effective when administered before sexual debut, ideally between ages 9 and 26 [2], there is a pressing need to provide parents—who are primary decision-makers for adolescent health—with accurate, unbiased information. Studies show that parents with greater HPV knowledge [8] and active cancer prevention behaviors [9] are more likely to vaccinate their daughters. Educational programs that emphasize the HPV-cervical cancer link have been found to enhance knowledge, attitudes, perceived behavioral control and vaccination intentions [10], highlighting the pivotal role of parental education in increasing HPV vaccination rates.

Public ignorance about cervical cancer remains a major barrier to effective prevention. Insufficient knowledge about when, where, and how to get vaccinated, and doubts about vaccine efficacy, all contribute to low vaccination rates [9, 10, 11]. Therefore, delivering clear and relevant education is crucial to improving these outcomes.

Systematic review offers a structured method for synthesizing existing research to inform evidence-based practices [19]. This study employs a systematic review approach, rather than a meta-analysis, to identify effective strategies for increasing cervical cancer prevention behaviors and screening uptake among college students. Given the heterogeneity of the included studies, a quantitative synthesis was not feasible. Instead, we qualitatively summarized and interpreted the findings. By evaluating current interventions, we aim to provide policy recommendations and practical guidelines for enhancing prevention efforts in this high-risk population.

1.2 Purpose of study

The purpose of this study is to provide evidence for evidence-based practice by conducting a systematic review of randomized controlled trials and controlled clinical trials on cervical cancer prevention educational interventions, and by qualitatively evaluating the effectiveness of each intervention.

2.1 Research design

This study is a systematic review, not a meta-analysis, due to the heterogeneity in study designs, outcome variables and intervention types. The review followed the PRISMA 2020 guidelines, and the protocol was registered in the PROSPERO database (CRD420251032287) to ensure transparency and replicability. A completed PRISMA 2020 checklist is available in the Supplementary material 1.

The research team developed the central research question based on the PICO-SD framework through internal group discussions to clarify each component:

- Population: Women aged 15 years and older in need of cervical cancer prevention education.

- Intervention: Health education interventions including HPV vaccination education, cervical cancer screening (Pap smear, HPV test), or any related program provided by nurses or public health personnel.

- Comparator: General health education, standard care or no intervention; some studies included comparisons among different types of interventions.

- Outcomes: Changes in knowledge, attitudes, preventive behavior (e.g., Pap test uptake) and HPV vaccination rates.

- Study Design: Randomized Controlled Trials (RCTs) and Controlled Clinical Trials (CCTs) were included. Preclinical, qualitative or single-arm studies were excluded.

The PICO question was refined through internal discussions among the research team members to ensure clarity and consensus regarding the population and the comparison groups. During this process, we clearly defined the population as women aged 15 years or older who are eligible for cervical cancer prevention education, and the comparison group as those receiving standard care, general health education or no intervention. These definitions guided both the inclusion criteria and the interpretation of findings across studies.

2.2 Literature search strategy

The literature search was conducted in February 2025. International databases including PubMed, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and ProQuest Nursing & Allied Health Source were used. Korean databases such as DBpia, the Korean Studies Information Service System (KISS), and the Research Information Service System (RISS) were also searched. In addition, gray literature sources—including theses, conference presentations and news reports—were manually searched to ensure comprehensive coverage. Keywords used in the search combined Medical Subject Headings (MeSH) terms and free-text terms such as “Cervical cancer”, “Nursing”, “Medical intervention”, “Disease prevention education” and “Preventive effect”.

Inclusion criteria were as follows:

- Studies involving female participants aged 15 years and older.

- Interventions focused on cervical cancer prevention and/or education.

- Studies published in Korean or English.

- Peer-reviewed journal articles or academic theses.

- Studies reporting quantifiable outcomes related to cervical cancer prevention.

- Studies with a comparison group (RCTs or CCTs).

Exclusion criteria included:

- Preclinical or animal studies.

- Single-arm studies or studies without a control/comparator group.

- Studies not published in Korean or English.

- Abstract-only publications, commentaries or editorials.

- Duplicate publications, with preference given to peer-reviewed journal articles when overlap with theses was found.

2.3 Quality assessment

We conducted a comprehensive review of the literature and assessed methodological quality using both the Newcastle-Ottawa Scale (NOS) and the Cochrane Risk of Bias 2 (RoB 2) tool, depending on the study design. For non-randomized controlled studies, the NOS was used to evaluate selection, comparability and outcome assessment across eight items. For randomized controlled trials (RCTs), we applied the Cochrane RoB 2 tool to ensure a rigorous and comprehensive evaluation of study quality. The RoB 2 tool assesses bias across five domains: (1) the randomization process, (2) deviations from intended interventions, (3) missing outcome data, (4) measurement of the outcome, and (5) selection of the reported result. Each domain was rated as low risk, some concerns or high risk of bias, in accordance with Cochrane guidelines [19].

2.4 Data analysis

The selected studies were systematically identified, reviewed, and qualitatively synthesized according to Cochrane and PRISMA 2020 guidelines [19]. For each study, we extracted the following information: author, year of publication, study design, sample size, intervention methods in both experimental and control groups, outcome variables, differences between groups and authors’ conclusions.

Data extraction was conducted by a single reviewer using a standardized form. Although care was taken to ensure accuracy, the lack of duplicate independent extraction is recognized as a methodological limitation that may affect the internal validity of the review.

Due to heterogeneity in study designs, interventions and outcome measures, a quantitative meta-analysis was not performed. Instead, a narrative synthesis was conducted. The findings were grouped thematically by outcome type (e.g., knowledge improvement, HPV vaccination rates, screening behavior) and common patterns, contrasts, and implications across studies were analyzed.

3.1 Search and selection of literature for a systematic review

The literature selection process for this study followed a step-by-step approach, as illustrated in Fig. 1. A total of 325 articles were initially identified through a search of eight electronic databases. After the removal of 218 duplicate articles, we reviewed the titles and abstracts of 107 articles and excluded 91 articles that did not meet the eligibility requirements. Finally, 16 papers were selected for inclusion in this systematic review.

Fig. 1.Flowchart of included studies through database search. RISS: Research Information Service System; KISS: Korean Studies Information Service System; CINAHL: Cumulative Index of Nursing and Allied Health Literature.

Given the diversity in study designs and outcomes, the findings were synthesized narratively rather than statistically.

3.2 General characteristics of the literature eligible for systematic review

This study conducted a systematic review of previous research examining the effectiveness of cervical cancer prevention education interventions and analyzed the general characteristics of the selected studies. The primary characteristics of the studies were categorized by year of publication, journal, country of study, study design, methodological characteristics and study population characteristics (see Table 1).

A total of 16 studies were ultimately selected, published between 2015 and 2023. When analyzing the distribution of publications by year, 6 studies (37.6%) were published between 2015 and 2020, and 10 studies (62.4%) were published between 2021 and 2023. The studies were published in a total of 15 journals, with 2 articles (11.8%) appearing in Cancer Causes Control, accounting for the highest proportion. Additionally, the following journals each published one article (6.30%): J Community Health, J Cancer Educ, BMC Cancer, Health Educ Res, Am J Prev Med, Cancer Control, Prev Med, Patient Educ Couns, Cancer Nurs, J Med Internet Res, Asian Pac J Cancer Prev, JCO Glob Oncol, Soc Sci Med and Jour. of KoCon.a.

The studies were conducted in a total of 10 countries. Six studies (37.5%) were conducted in the United States, followed by two studies (12.5%) in Turkey. South Korea, the United Kingdom, Uganda, Tanzania, the Netherlands, Malaysia, Kenya and Nigeria each contributed one study (6.25%). Geographically, the studies were primarily conducted in North America (US), Europe (UK, Netherlands, Turkey), Asia (South Korea, Malaysia, Turkey) and Africa (Uganda, Tanzania, Kenya, Nigeria).

Regarding study design, all studies employed quantitative research methods. Randomized controlled trials were the most commonly used design, accounting for 15 studies (93.75%). One study (6.25%) conducted in South Korea was a quasi-experimental study utilizing a non-equivalent control group in a pretest-posttest design.

The total number of subjects included in the studies was 6144, with a minimum of 40 and a maximum of 5793 participants per study. An analysis of recruitment characteristics revealed that 7 studies (43.8%) targeted the general adult population in the community, 5 studies (31.2%) focused on candidates for cervical cancer screening (including HPV vaccine recipients) and participants in screening programs, and 4 studies (25.0%) examined interventions tailored to specific populations.

All 16 studies (100%) were conducted with female participants. In terms of racial composition, 13 studies (81.3%) included multiracial populations, while 3 studies (18.6%) involved monoracial groups.

The interventions analyzed in this review were predominantly randomized controlled trials conducted across various countries and among diverse ethnic groups. These general patterns informed the narrative synthesis of findings presented in subsequent sections, rather than statistical aggregation.

3.3 How the effectiveness of cervical cancer prevention education interventions was evaluated

This study analyzed a total of 16 research articles that assessed the effectiveness of cervical cancer prevention education interventions. Among these, the majority employed self-report surveys, while approximately half utilized objective indicators such as actual screening rates. Several studies used both types of evaluations, combining subjective perceptions with behavioral outcomes. Self-report surveys were the most common method of evaluation, with some studies also assessing changes in actual screening behavior. Studies incorporating supplementary interventions generally reported greater impact on screening behavior (see Table 2, Supplementary material 2).

(1) Subjective evaluation methods

Most studies used self-report surveys to evaluate outcomes such as changes in knowledge, attitudes, health beliefs and behavioral intentions. Several studies utilized frameworks like the Health Belief Model to guide survey design. Improvements were frequently observed in knowledge about cervical cancer and HPV, perceived susceptibility and severity, and intentions to participate in screening programs.

(2) Objective evaluation methods

About half of the studies employed objective measures such as medical record-based screening rates (e.g., Pap test or mammography uptake). These studies generally reported increases in screening behavior following the interventions. The most notable improvements were observed in studies that incorporated additional support components such as counseling, patient navigation or reminder systems.

(3) Mixed methods studies

A subset of studies used both subjective and objective measures to assess the effectiveness of interventions. These mixed-methods studies revealed that positive changes in attitudes and knowledge often coincided with actual increases in screening uptake, suggesting a link between psychological readiness and behavior change.

Although the modes of education delivery varied—including group sessions, video-based learning, counseling and mobile health (mHealth) technologies—this review did not conduct a comparative analysis of these modalities. Nonetheless, some patterns emerged. Digital and multimodal approaches, particularly those integrating reminders or peer support, tended to show higher levels of engagement and behavioral change. These findings suggest that interactive, technology-enhanced interventions may enhance both knowledge retention and preventive action more effectively than single-modality approaches.

3.4 Assessing the quality of the literature

In this study, the quality of the included research was systematically assessed using the Newcastle-Ottawa Scale (NOS), which evaluates studies based on selection, comparability and outcome criteria. A total of 10 studies (62.5%) were categorized as “High Quality”. Among these, three studies (S4, S6, S10) received 9 points, four studies (S1, S5, S7, S12) scored 8 points and three studies (S3, S9, S14) received 7 points (see Table 3). The remaining six studies (37.5%) were classified as “Moderate Quality”, with five studies (S2, S8, S11, S15, S16) scoring 6 points and one study (S13) scoring 5 points.

The quality assessments were interpreted narratively, without statistical aggregation. Higher NOS scores were generally associated with greater methodological rigor, including more robust designs, appropriate comparison groups and clearly reported outcomes.

Publication bias and statistical effect size calculations were not conducted, as this review did not employ meta-analytic methods. Instead, methodological strengths and limitations were qualitatively described based on the NOS domains.