Effect of a community action intervention on cervical cancer screening rates in rural Australian towns: the CART project

Translating qualitative data into intervention content using the Theoretical Domains Framework and stakeholder co-design: a worked example from a study of cervical screening attendance in older women

Background

Previous screening interventions have demonstrated a series of features related to social determinants which have increased uptake in targeted populations, including the assessment of health beliefs and barriers to screening attendance as part of intervention development. Many studies cite the use of theory to identify methods of behaviour change, but fail to describe in detail how theoretical constructs are transformed into intervention content. The aim of this study was to use data from a qualitative exploration of cervical screening in women over 50 in the UK as the basis of intervention co-design with stakeholders using behavioural change frameworks. We describe the identification of behavioural mechanisms from qualitative data, and how these were used to develop content for a service-user leaflet and a video animation for practitioner training. The interventions aimed to encourage sustained commitment to cervical screening among women over 50, and to increase sensitivity to age-related problems in screening among primary care practitioners.

Methods

Secondary coding of a qualitative data set to extract barriers and facilitators of cervical screening attendance. Barrier and facilitator statements were categorised using the Theoretical Domains Framework (TDF) to identify relevant behaviour change techniques (BCTs). Key TDF domains and associated BCTs were presented in stakeholder focus groups to guide the design of intervention content and mode of delivery.

Results

Behavioural determinants relating to attendance clustered under three domains: beliefs about consequences, emotion and social influences, which mapped to three BCTs respectively: (1) persuasive communication/information provision; (2) stress management; (3) role modelling and encouragement. Service-user stakeholders translated these into three pragmatic intervention components: (i) addressing unanswered questions, (ii) problem-solving practitioner challenges and (iii) peer group communication. Based on (ii), practitioner stakeholders developed a call to action in three areas – clinical networking, history-taking, and flexibility in screening processes. APEASE informed modes of delivery (a service-user leaflet and a cartoon animation for practitioners).

Conclusion

The application of the TDF to qualitative data can provide an auditable protocol for the translation of qualitative data into intervention content.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07926-2.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Evaluation of systems-oriented public health interventions: alternative research designs

The need to provide sound evidence of the costs and benefits of real-world public health interventions has driven advances in the development and analysis of designs other than the controlled trial in which individuals are randomized to an experimental condition. Attention to methodological quality is of critical importance to ensure that any evaluation can accurately answer three fundamental questions: (a) Has a change occurred, (b) did the change occur as a result of the intervention, and (c) is the degree of change significant? A range of alternatives to the individual randomized controlled trial (RCT) can be used for evaluating such interventions, including the cluster RCT, stepped wedge design, interrupted time series, multiple baseline, and controlled prepost designs. The key features and complexities associated with each of these designs are explored.

State-of-the-art and future directions in multilevel interventions across the cancer control continuum

We conducted literature searches and analyses to describe the current state of multilevel intervention (MLI) research and to identify opportunities to advance cancer control and prevention. We found single-level studies that considered other contextually important levels, and multilevel health-care systems research and community-wide studies. This literature is characterized by limited reporting of theoretical, contextual, temporal, and implementation factors. Most MLIs focus on prevention and screening, rather than diagnosis, treatment, or survivorship. Opportunities relate to 1) dynamic, adaptive emergent interventions and research designs that evolve over time by attending to contextual factors and interactions across levels; 2) analyses that include simulation modeling, or multimethod approaches that integrate quantitative and qualitative methods; and 3) translation and intervention approaches that locally reinvent MLIs in different contexts. MLIs have great potential to reduce cancer burden by using theory and integrating quantitative, qualitative, participatory, and transdisciplinary methods that continually seek alignment across intervention levels, pay attention to context, and adapt over time.

Avoiding piecemeal research on participation in cervical cancer screening: the advantages of a social identity framework

BACKGROUND

Cervical cancer screening research has predominantly focused on one type of participation, namely compliance with medical recommendations, and has largely ignored other types of participation. While there is some research that has taken a different approach, findings in this research area are not well integrated under a theoretical framework.

OBJECTIVE

The aim of this study is to show how consideration of a broader definition of participation and better integration of the theoretical conceptualization of participation in cervical cancer screening are both possible and desirable to enable a better understanding of women's experiences of cervical cancer screening specifically and to improve women's health generally.

MAIN CONCLUSION

It is suggested that alternative types of participation in cervical cancer screening warrant further investigation and that a social identity theoretical approach offers one way of integrating such conceptualizations of participation. The paper also argues for more explicit consideration of the role of social processes and of the variables, such as power, social identity and relational justice, which are involved in participation in cervical cancer screening.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

Cluster randomized trials of cancer screening interventions: are appropriate statistical methods being used?

The design and analysis of cluster randomized trials can require more sophistication than individually randomized trials. However, the need for statistical methods that account for the clustered design has not always been appreciated, and past reviews have found widespread deficiencies in methodology and reporting. We reviewed cluster randomized trials of cancer screening interventions published in 1995-2010 to determine whether the use of appropriate statistical methods had increased over time. Literature searches yielded 50 articles reporting outcome analyses of cluster randomized trials of breast, cervix and colorectal cancer screening interventions. Of studies published in 1995-1999, 2000-2002, 2003-2006 and 2007-2010, 55% (6/11), 82% (9/11), 92% (12/13) and 60% (9/15) used appropriate analytic methods, respectively. Results were suggestive of a peak in 2003-2006 (p =.06) followed by a decline in 2007-2010 (p =.08). While the sample of studies was small, these results indicate that many cluster randomized trials of cancer screening interventions have had deficiencies in the application of correct statistical procedures for the outcome analysis, and that increased adoption of appropriate methods in the early and mid-2000's may not have been sustained.

Randomised trial of intensive academic detailing to promote opportunistic recruitment of women to cervical screening by general practitioners

OBJECTIVE

To evaluate a multifaceted intervention involving intensive academic detailing for general practitioners (GPs) to improve recruitment of women for cervical screening.

METHODS

We conducted a cluster randomisation trial involving 39 general practices in inner-metropolitan Sydney. GPs' knowledge, propensity to an opportunistic approach, competence and confidence were assessed by self-report before and after the intervention. To measure GP behaviour, recall of an opportunistic discussion about cervical screening was determined in cross-sectional samples of female patients at baseline (n = 1,090) and post-test (n = 1,062).

RESULTS

Knowledge improved marginally in both groups but there were no changes in other GP self-reported measures. At post-test, women attending GPs in the intervention group were no more likely than those in the control group to recall an opportunistic inquiry about their cervical screening status (OR 0.65, 95% CI 0.40-1.08). Women in the intervention group who were overdue for cervical screening were no more likely than their control group counterparts at post-test to recall advice about cervical screening (OR 2.16, 95% CI 0.75-6.14) or written information (OR 0.34, 95% CI 0.04-26.5).

CONCLUSIONS

Intensive academic detailing does not improve an opportunistic approach to cervical screening in general practice.

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

In an evidence-based climate, implementation of academic detailing as a strategy to improve cervical screening rates in general practice would be premature.

Celebremos la salud! a community randomized trial of cancer prevention (United States)

BACKGROUND

Compared to non-Hispanic whites, Hispanics in the United States are at higher risk for certain types of cancer.

METHODS

In a randomized controlled trial of 20 communities, we examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices.

RESULTS

We found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. We found no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities.

CONCLUSIONS

Our null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed.

Pressing the key pad: trial of a novel approach to health promotion advice

BACKGROUND

A relatively simple procedure, the Pap test, is effective in detecting early changes in the cervix; however, many at-risk women, even in developed countries, do not have regular Pap tests.

METHODS

A randomized controlled trial of an interactive voice response (IVR) cervical screening brief advice involving 17,008 households is described. The IVR system automatically made calls to households and explained the nature of the call; selected one eligible woman aged 18-69 years; determined her screening status; delivered a message appropriate to her screening status; offered additional messages to counter common barriers; offered additional information on cervical screening and cancer; offered additional contact numbers; and offered to arrange for someone to call back. Cervical screening rate data were obtained from the Australian Health Insurance Commission (HIC) for 6 months before and following the intervention.

RESULTS

The cervical screening rate was found to have increased by 0.43% in intervention compared to the control postcodes, and the increase was greater for older women at 1.34%.

CONCLUSIONS

The overall conclusion was that IVR technology was a feasible means to contact women to deliver brief interventions aimed at increasing cervical screening rates and could economically target at-risk groups. The potential for linking IVR to centralized Pap test Registers to issue Pap test reminders should be explored.

Mounting a community-randomized trial: sample size, matching, selection, and randomization issues in PRISM

This paper discusses some of the processes for establishing a large cluster-randomized trial of a community and primary care intervention in 16 local government areas in Victoria, Australia. The development of the trial in terms of design factors such as sample size estimates and the selection and randomization of communities to intervention or comparison is described. The intervention program to be implemented in Program of Resources, Information and Support for Mothers (PRISM) was conceived as a whole community approach to improving support for all mothers in the first 12 months after birth. A cluster-randomized trial was thus the design of choice from the outset. With a limited number of communities available, a matched-pair design with eight pairs was chosen. Sample size estimates, adjusting for the cluster randomization and the pair-matched design, showed that with eight pairs, on average, 800 women from each community would need to respond to provide sufficient power to determine a 3% reduction in the prevalence of maternal depression 6 months after birth-a reduction deemed to be a worthwhile impact of the intervention to be reliably detected at 80% power. The process of selecting suitable communities and matching them into pairs required careful collection of data on numbers of births, size of the local government areas (LGAs), and an assessment of the capacity of communities to implement the intervention. Ways of dealing with boundary issues associated with potential contamination are discussed. Methods for the selection of feasible configurations of sets of pairs and the ultimate allocation to intervention or comparison are provided in detail. Ultimately, all such studies are a balancing act between selecting the minimum number of communities to detect a meaningful outcome effect of an intervention and the maximum size budget and other resources allow.