Hrev_master Healthcare in Low-resource Settings 2023; volume 11:11789 Effect of E-Duva application on knowledge and attitude of visual inspection using acetic acid (VIA) among women of childbearing age Jasmawati Jasmawati, Siti Raihanah, Ratna Wati Health Polytechnic of the Ministry of Health of East Kalimantan, Samarinda, Indonesia Abstract E-Duva is an application model designed to introduce innova- tions for delivering information and education about visual inspec- tion with acetic acid (VIA) tests. The use of the E-Duva application can facilitate access to information and education for mothers with- out the need to visit a healthcare facility to learn about the VIA test. This study aimed to assess the effectiveness of the E-Duva appli- cation on the knowledge and attitudes of women of childbearing age (WUS). The study population comprised women of childbear- ing age (WUS). We employed a quasi-experimental research design with a pretest-posttest design using non-probability purpo- sive sampling. The total sample size in this study was 30 respon- dents, with 15 women in the control group and 15 women in the intervention group. A questionnaire was used to assess the knowl- edge of WUS regarding cervical cancer and the VIA test. Statistical analysis was conducted using the Paired T-test. The study results indicate a significant increase in knowledge in both the experimen- tal group (p=0.000; mean SD 90.88±6.9) and the control group (p=0.000; mean SD 78.40±10.1). Attitudes toward early detection of cervical cancer were significantly related (p=0.015). This sug- gests that a more positive attitude towards early detection of cervi- cal cancer among WUS is associated with a greater willingness to undergo cervical cancer screening. The findings of this study sup- port the role of the E-Duva application in enhancing the knowledge and attitudes of women of childbearing age regarding VIA tests and cervical cancer, emphasizing the potential of technology-driven health education in improving women’s health outcome. Introduction Cervical cancer, also known as cervical carcinoma, is a malig- nant tumor that primarily affects the surface layer (epithelium) of the cervix or uterine cervix.1 Infection from the Human Papillomavirus (HPV) is the leading cause of cervical cancer.2,3 HPV is transmitted through sexual intercourse and is responsible for approximately 95% of cervical cancer cases.4 According to the World Health Organization (WHO), approximately 490,000 women worldwide are diagnosed with cervical cancer annually.5 In Indonesia, it is estimated that there are 40-45 new cases daily, resulting in 20-25 fatalities, equating to approximately one woman losing her life to cervical cancer every hour.6 This staggering statistic implies that Indonesia faces the loss of 600-750 produc- tive women every month.7 The lack of knowledge among women about cervical cancer often leads to delays in diagnosis, resulting in patients presenting with advanced cancer stages, weakened overall health, low socioeconomic status, and limited access to healthcare resources, facilities, and infrastructure.8 The increasing incidence of cervical cancer can also be attributed to the absence of effective screening programs for early detection and treatment of pre-cancerous con- ditions.9 The coverage of early detection for cervical cancer through VIA tests remains very low at approximately 5%,10 despite the potential for early detection to significantly reduce morbidity and mortality rates.11 Understanding the importance of the VIA test is vital for fostering the willingness and awareness needed for its Correspondence: Jasmawati Jasmawati, Health Polytechnic of the Ministry of Health of East Kalimantan, Samarinda, Indonesia E-mail: jaswatijaswati@gmail.com Key word: VIA; WUS; E-Duva; application. Contributions: JW, Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Visualization, Writing – Original Draft, Review & Editing,Conceptualization, Investigation, Methodology, Validation, and Writing – Original Draft, Review & Editing; SR, Conceptualization, Methodology, Formal Analysis, Validation, and Writing – Original Draft, Review & Editing; RW, Methodology, Visualization, Writing – Review & Editing, Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the research has received ethical approval from the Health Research Ethics Commission, Poltekkes Kemenkes Kalimantan Timur, based on ethical certificate DL.02.03/4.3/10434/2022. During the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 13 September 2023. Accepted: 25 October 2023. Early access: 14 November 2023. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2023 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2023; 11:11789 doi:10.4081/hls.2023.11789 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affili- ated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed [page 136] [Healthcare in Low-resource Settings 2023; 11:11789] Non -co mmerc ial us e o nly adoption.12 As of 2019, the screening coverage for early detection of cervical and breast cancer in Indonesia was still minimal, with only 909,099 screenings (3.5%), 49,659 positive VIA results (5.93%), and 1,086 suspected cervical cancer cases (1.2 per 1,000 people).13,14 An ideal screening implementation should reach 80% of the female population in a given area.15,16 Attitudes remain a sig- nificant barrier for women of childbearing age (WUS) when it comes to early detection of cervical cancer.17 Shifting people’s atti- tudes toward early detection can be achieved through health behav- ior interventions.18 Factors associated with attitudes regarding cer- vical cancer early detection screening include knowledge and maternal age.19 Among these factors, attitude is the most influential in motVIAting mothers to undergo VIA tests.20 Negative attitudes toward the VIA test often result from a lack of awareness regarding its significance, leading women to underestimate its importance.21 Modern health services are increasingly embracing smart- phone applications, providing individuals with convenient access to information irrespective of time and location.22 These applica- tions, which operate on smartphones, offer a wide range of func- tions.23 The rapid advancement of technology has permeated all aspects of life, offering tools that enhance daily activities.24 As per health regulations, technology plays a pivotal role in disease pre- vention, allowing health workers to leverage the widespread avail- ability of smartphones for disease prevention and control.25,26 “E-Duva” is an application model developed to deliver infor- mation and education about VIA tests. E-Duva, short for Education for VIA Test, simplifies access to information and education for mothers, eliminating the need for them to visit healthcare facilities to learn about the VIA test. The E-Duva application only requires a one-time download and can be used continuously without an internet connection. Given this description, our research aims to investigate the effectiveness of the E-Duva Application among women of childbearing age. Materials and Methods The study population consisted of women of childbearing age in the Samarinda region who visited the Clinic and Puskesmas. This research employed a Quasi-Experimental research design with a pretest-posttest design and a control group. This design was utilized to assess the effectiveness of the Educational Application of VIA test (E-Duva) on Women of Childbearing Age (WUS) through purposive sampling. In this study, the independent vari- able was the application of the Educational Application of VIA test (E-Duva), and the dependent variable was the change in knowl- edge and attitude of WUS. The sampling technique used in this study was non-probability sampling. The total sample size was 30 respondents, with 15 women in the control group and 15 women in the intervention group. A questionnaire was employed to gauge the level of knowledge among WUS regarding cervical cancer and the VIA test. The research utilized the Paired T-Test. Respondents in this study used the E-Duva application five times over a two-week period. Inclusion criteria encompassed women of childbearing age who were married, willing to participate in the study, possessed a smartphone, were aged between 20 and 35 years, and could oper- ate it. Exclusion criteria included individuals who did not have a smartphone or had a smartphone but were unable to operate it. The intervention group received education through the application, while the control group received education through a leaflet. Ethical clearance was obtained with the number DL.02.03/4.3/ 10434/2022 from Poltekkes Kemenkes Kalimantan Timur. Respondents were provided with explanations on how to complete informed consent. They were also informed about the potential risks associated with the study and were granted the right to with- draw voluntarily. No coercion was exerted during this study. Results Based on the information presented in Table 1, it is evident that the most common age group in this study was 25-28 years, com- prising 33.3% of the total sample, and 40% in the control group. Additionally, the most common parity in this study was primipara, with 60% of the total sample and 26.7% in the control group. Based on the data presented in Table 2, it is evident that in the intervention group using the E-Duva Application, the mean value increased from 70.40 in the pretest to 90.88 in the post-test. In the Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 1. Frequency distribution of respondents' characteristics based on age, and parity. Characteristic Groups Intervention n (%) Control n (%) Age/Mean ±SD 28.33±4.1 29.27±3.9 20-24 3 (20) 0 (0) 25-28 5 (33.3) 6 (40) 29-32 5 (33.3) 7 (46.7) 33-35 2 (13.3) 2 (13.3) Parity Primipara 9 (60) 11 (73.3) Multipara 6 (40) 4(26.7) Total 30 (100%) 30 (100%) [Healthcare in Low-resource Settings 2023; 11:11789] [page 137] Table 2. Mean difference between pretest and posttest score on the application of educational application for VIA Test (E-Duva) in exper- imental group and control group. Group Mean p Pretest SD Post-test SD Experiment 70.40 11.4 90.88 6.9 0.000* Control 71.20 11.1 78.40 10.1 0.000* *p<0.05. Non -co mmerc ial us e o nly control group that received the leaflet, there was an increase in the mean value from 71.20 in the pretest to 78.40 in the post-test. The results of the paired sample t-tests conducted on both groups indi- cated a p-value of <0.05. This suggests that there is a significant difference between the pretest and post-test values in both the experimental and control groups. This significant difference signi- fies an increase in knowledge in both the experimental and control groups. Based on the data presented in Table 3, it is evident that there is a significant relationship between attitude towards early detec- tion of cervical cancer and the p-value is 0.015. This finding indi- cates that as Women of Childbearing Age (WUS) develop a more favorable attitude towards early detection of cervical cancer, they are more likely to be willing to undergo early detection measures for cervical cancer. Discussion The E-Duva application can be categorized as mobile learning- based educational media. This classification aligns with the defini- tion of mobile learning, which involves learning where learners are not confined to a specific location and utilize mobile technology devices for educational purposes. The E-Duva application offers several advantages, including compatibility with Android-based devices, attractive and easily understandable presentation of mate- rials, and the inclusion of engaging images. The smaller increase in knowledge scores observed in the con- trol group can be attributed to the fact that it relied solely on visual information. Additionally, the content provided in the leaflet was more limited and concise in comparison to the material accessible to the intervention group through the E-Duva Application. This observation aligns with Edgar Dale’s cone theory, which posits that the effectiveness of teaching aids is influenced by the extent to which knowledge is delivered through the five senses.27 The more senses involved in learning, the richer and clearer the knowledge acquired.28 In the intervention group using the E-Duva Application, there was a noticeable increase in the mean score, rising from 70.40 in the pretest to 90.88 in the post-test. Conversely, in the control group, which received information through leaflets, the mean score increased from 71.20 in the pretest to 78.40 in the post-test. This finding corroborates previous research indicating that health pro- motion via mobile phones is easily accepted due to the conve- nience and confidentiality of interactions on mobile platforms, which offer simpler and more informative content.29 Providing health-related information, particularly regarding sexually trans- mitted infections (STIs), through mobile media has been shown to enhance respondents’ knowledge about reproductive health and STIs.30 Text messaging programs have also proven effective in improving knowledge of reproductive health.31 The significant relationship between a positive attitude toward early detection of cervical cancer (with a p-value of 0.015) high- lights the correlation between attitude and the willingness to under- go cervical cancer early detection checks.32 This aligns with previ- ous research that suggests smartphone applications effectively influence women’s positive attitudes toward early detection of cer- vical cancer.33 Presenting information in a visually engaging man- ner is considered more effective and efficient than traditional methods. Smartphone applications aid in comprehension by dis- playing interesting visual elements, making respondents more engaged, receptive, and less likely to find the material boring.34 Efficient information dissemination about the VIA test is achieved through health education, which aims to improve the knowledge and attitudes of women of childbearing age.35 The rela- tionship between good knowledge of the VIA test and a positive attitude is evident in the motVIAtion to undergo the VIA Test. Attitude reflects a mother’s preference and is a significant influ- ence on the decision to undergo the VIA test.36 Attitude represents a person’s response to a stimulus or object, which is not directly observable but can be inferred from their behavior. Women of childbearing age should not only possess knowledge about early detection of cervical cancer through the VIA method but also exhibit it in their attitudes 37. Women with a positive attitude are more likely to seek early detection of cervical cancer through the VIA test38 Attitude represents a person’s response to a stimulus or object,39 which is not directly observable but can be inferred from their behavior. Women of childbearing age should not only possess knowledge about early detection of cervical cancer through the VIA method but also exhibit it in their attitudes.40 Women of child- bearing age should not only possess knowledge about early detec- tion of cervical cancer through the VIA method but also exhibit it in their attitudes.41 Women with a positive attitude are more likely to seek early detection of cervical cancer through the VIA test.42 Convenient access to information plays a pivotal role in chang- ing health behaviors, especially in promoting early detection of cervical cancer. The accessibility of health information is a deter- mining factor in the level of knowledge and attitudes, ultimately influencing the behavior of women of childbearing age.43,44 The E- Duva application streamlines access to information and education, eliminating the need for physical visits to healthcare facilities. It requires a one-time download and can be used offline. However, the study identified limitations, including the application’s size (about 21 MB), which may challenge users with limited smart- phone memory. Additionally, the application is not compatible with iOS devices, and some smartphones may have stringent secu- rity settings that hinder installation, which can be addressed by adjusting these settings to allow for installation. Transforming Healthcare in Low-Resource Settings: a Multidisciplinary Approach Towards Sustainable Solutions Table 3. Attitude about the application of educational application for VIA test (E-Duva). Variables Yes No p n % n % Attitude 0.015* Support 47 85.5 8 14.5 Not supportive 27 64.3 15 35.7 *p<0.05. [page 138] [Healthcare in Low-resource Settings 2023; 11:11789] Non -co mmerc ial us e o nly Conclusions The E-Duva application has been effectively developed to pro- vide information about VIA examinations, cervical cancer, and guidelines for assessing the nutritional status of women of fertile age (WUS). It underscores the importance of technology-based health education as a means to enhance public awareness, particu- larly among women of childbearing age. Given the widespread use of smartphones in today’s society, educational resources in the form of Android applications are essential and deserve further development. Furthermore, the E-Duva application has been demonstrated to successfully enhance the knowledge and attitudes of women of childbearing age concerning VIA tests and cervical cancer. 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