A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America

Patient navigation job roles by levels of experience: Workforce Development Task Group, National Navigation Roundtable

PLAIN LANGUAGE SUMMARY

Cancer patient navigators work in diverse settings ranging from community-based programs to comprehensive cancer centers to improve outcomes in underserved populations by eliminating barriers to timely cancer prevention, early detection, diagnosis, treatment, and survivorship in a culturally appropriate and competent manner. This article clarifies the roles and responsibilities of Entry, Intermediate, and Advanced level cancer patient navigators. The competencies described in this article apply to patient navigators, nurse navigators, and social work navigators. This article provides a resource for administrators to create job descriptions for navigators with specific levels of expertise and for patient navigators to advance their oncology careers and attain a higher level of expertise.

Evaluating an immunization carpool service for women in rural areas for facilitating routine childhood immunizations in Pakistan -a feasibility study on acceptability, demand, and implementation

Introduction

Poor accessibility of immunization services coupled with limited options for transportation and socio-cultural norms that hinder women's mobility are among the key factors contributing to poor immunization coverage in rural areas. We assessed the feasibility and acceptability of establishing a free-of-cost, women-only carpool service for immunization in a rural setting in Pakistan and evaluated its preliminary impact on immunization coverage and timeliness among children.

Methods

We conducted a feasibility study in four selected immunization facilities in Shikarpur District, Sindh. A local transport vehicle was hired and branded as an immunization carpool service. Women having un- or under-immunized children aged ≤2 years were invited to visit immunization facilities using carpool vehicles. Information on demographic indicators and service experience was collected. Child immunization details were extracted using the government's provincial electronic immunization registry to estimate immunization coverage and timeliness.

Results

Between January and October 2020, six immunization carpool vehicles provided uninterrupted service and transported 2422 women-child pairs, completing 4691 immunization visits. Majority of women reported that the carpool service improved accessibility (99.6%) by offering group travel (82.9%) and reducing their dependency on family members (93.4%). Preliminary estimates reported an increase in immunization coverage and timeliness across antigens among participating children compared to non-participating children, with significant increase in proportion for BCG coverage (38.1%; p < 0.001, CI: 32.8%, 43.4%) and measles-2 timeliness (18%; p < 0.001, CI: 13.3%, 22.4%).

Conclusion

A women-only immunization carpool service implemented within a rural setting is feasible and highly acceptable. Key factors contributing to the model's success include increased mobility and independence of women, cost-savings, and a culturally and contextually appropriate mechanism of transport embedded within the local setting. Increased accessibility to health services also contributed to improved immunization coverage and timeliness among children.

Knowledge and Practices Regarding Human Papillomavirus and Cervical Cancer Screening Among Women in Low-Income Areas of China: A Cross-Sectional Study

BACKGROUND

Persistent human papillomavirus (HPV) infection is the primary cause of cervical cancer. However, this can be prevented through vaccination and screening. This study aimed to clarify the relationship between behavior, knowledge, and attitude toward cervical cancer and regular screening and HPV infection among women in Lueyang County.

METHODS

Women who underwent cervical cancer screening at the outpatient department of a maternal and child health center between September and December 2021 were invited to participate. In total, 2,303 women completed the questionnaire. Women who underwent regular or irregular screening were 1:1 matched for age. Differences in knowledge of HPV and attitudes toward HPV vaccination among different populations were assessed. Logistic regression analysis was performed to identify the factors influencing HPV infection.

RESULTS

 In total, 417 pairs of women who underwent regular and irregular screening were successfully matched. Multivariate logistic regression results indicated that age is a risk factor for HPV infection (OR=1.056 95%CI: [1.031 1.082]), while regular screening acts as a protective factor against HPV infection (OR=0.174 95%CI: [0.117 0.259]). Additionally, regular screening was associated with a higher level of knowledge about HPV among women compared to those who did not undergo regular screening (p<0.001).

CONCLUSIONS

 Women in Lueyang County have low levels of knowledge regarding HPV and cervical cancer. Regular screening is a protective factor against HPV infection. The regular screening group demonstrates a higher level of HPV knowledge compared with the irregular screening group. These findings highlight the importance of regular screening and the need to strengthen public health education.

A Cervical Cancer Screening Toolkit for Somali Women: A Pilot Randomized Controlled Trial

This study aims to determine whether a novel cervical cancer screening toolkit will increase rates of pap test completion and HPV vaccination among Somali women living in the United States. We conducted a randomized controlled, pilot trial from June 2021 to February 2022. Somali women aged 21 to 70 were randomized to either receive a toolkit (infographic, video and an in-person health seminar) or not. Health passports confirming a completed pap test and/or HPV vaccination by clinician signature were used to measure outcomes. The primary outcome was pap test completion and the secondary outcome was HPV vaccination. We enrolled 57 participants. Patients randomized to the treatment arm were significantly more likely to have had a pap test (53.7% vs. 3.7%, p < 0.0001) and were also more likely to have received the HPV vaccine (10.7% vs. 3.7%, p = 0.6110). This toolkit increased rates of pap test completion and more participants in the intervention arm received HPV vaccination, though numbers were low. The study design may serve as a reproducible model to determine the effectiveness of patient education materials.

Interventions for improving health literacy in migrants

BACKGROUND

Health literacy (HL) is a determinant of health and important for autonomous decision-making. Migrants are at high risk for limited HL. Improving HL is important for equitable promotion of migrants' health.

OBJECTIVES

To assess the effectiveness of interventions for improving HL in migrants. To assess whether female or male migrants respond differently to the identified interventions.

SEARCH METHODS

We ran electronic searches to 2 February 2022 in CENTRAL, MEDLINE, Embase, PsycInfo and CINAHL. We also searched trial registries. We used a study filter for randomised controlled trials (RCTs) (RCT classifier).

SELECTION CRITERIA

We included RCTs and cluster-RCTs addressing HL either as a concept or its components (access, understand, appraise, apply health information).

DATA COLLECTION AND ANALYSIS

We used the methodological procedures recommended by Cochrane and followed the PRISMA-E guidelines. Outcome categories were: a) HL, b) quality of life (QoL), c) knowledge, d) health outcomes, e) health behaviour, f) self-efficacy, g) health service use and h) adverse events. We conducted meta-analysis where possible, and reported the remaining results as a narrative synthesis.

MAIN RESULTS

We included 28 RCTs and six cluster-RCTs (8249 participants), all conducted in high-income countries. Participants were migrants with a wide range of conditions. All interventions were adapted to culture, language and literacy. We did not find evidence that HL interventions cause harm, but only two studies assessed adverse events (e.g. anxiety). Many studies reported results for short-term assessments (less than six weeks after total programme completion), reported here. For several comparisons, there were also findings at later time points, which are presented in the review text. Compared with no HL intervention (standard care/no intervention) or an unrelated HL intervention (similar intervention but different information topic) Self-management programmes (SMP) probably improve self-efficacy slightly (standardised mean difference (SMD) 0.28, 95% confidence interval (CI) 0.06 to 0.50; 2 studies, 333 participants; moderate certainty). SMP may improve HIV-related HL (understanding (mean difference (MD) 4.25, 95% CI 1.32 to 7.18); recognition of HIV terms (MD 3.32, 95% CI 1.28 to 5.36)) (1 study, 69 participants). SMP may slightly improve health behaviours (3 studies, 514 participants), but may have little or no effect on knowledge (2 studies, 321 participants) or subjective health status (MD 0.38, 95% CI -0.13 to 0.89; 1 study, 69 participants) (low certainty). We are uncertain of the effects of SMP on QoL, health service use or adverse events due to a lack of evidence. HL skills building courses (HLSBC) may improve knowledge (MD 10.87, 95% CI 5.69 to 16.06; 2 studies, 111 participants) and any generic HL (SMD 0.48, 95% CI 0.20 to 0.75; 2 studies, 229 participants), but may have little or no effect on depression literacy (MD 0.17, 95% CI -1.28 to 1.62) or any health behaviour (2 studies, 229 participants) (low certainty). We are uncertain if HLSBC improve QoL, health outcomes, health service use, self-efficacy or adverse events, due to very low-certainty or a lack of evidence. Audio-/visual education without personal feedback (AVE) probably improves depression literacy (MD 8.62, 95% CI 7.51 to 9.73; 1 study, 202 participants) and health service use (MD -0.59, 95% CI -1.11 to -0.07; 1 study, 157 participants), but probably has little or no effect on health behaviour (risk ratio (RR) 1.07, 95% CI 0.91 to 1.25; 1 study, 135 participants) (moderate certainty). AVE may improve self-efficacy (MD 3.51, 95% CI 2.53 to 4.49; 1 study, 133 participants) and may slightly improve knowledge (MD 8.44, 95% CI -2.56 to 19.44; 2 studies, 293 participants) and intention to seek depression treatment (MD 1.8, 95% CI 0.43 to 3.17), with little or no effect on depression (SMD -0.15, 95% CI -0.40 to 0.10) (low certainty). No evidence was found for QoL and adverse events. Adapted medical instruction may improve understanding of health information (3 studies, 478 participants), with little or no effect on medication adherence (MD 0.5, 95% CI -0.1 to 1.1; 1 study, 200 participants) (low certainty). No evidence was found for QoL, health outcomes, knowledge, health service use, self-efficacy or adverse events. Compared with written information on the same topic SMP probably improves health numeracy slightly (MD 0.7, 95% CI 0.15 to 1.25) and probably improves print literacy (MD 9, 95% CI 2.9 to 15.1; 1 study, 209 participants) and self-efficacy (SMD 0.47, 95% CI 0.3 to 0.64; 4 studies, 552 participants) (moderate certainty). SMP may improve any disease-specific HL (SMD 0.67, 95% CI 0.27 to 1.07; 4 studies, 955 participants), knowledge (MD 11.45, 95% CI 4.75 to 18.15; 6 studies, 1101 participants) and some health behaviours (4 studies, 797 participants), with little or no effect on health information appraisal (MD 1.15, 95% CI -0.23 to 2.53; 1 study, 329 participants) (low certainty). We are uncertain whether SMP improves QoL, health outcomes, health service use or adverse events, due to a lack of evidence or low/very low-certainty evidence. AVE probably has little or no effect on diabetes HL (MD 2, 95% CI -0.15 to 4.15; 1 study, 240 participants), but probably improves information appraisal (MD -9.88, 95% CI -12.87 to -6.89) and application (RR 1.51, 95% CI 1.29 to 1.77) (1 study, 608 participants; moderate certainty). AVE may slightly improve knowledge (MD 8.35, 95% CI -0.32 to 17.02; low certainty). No short-term evidence was found for QoL, depression, health behaviour, self-efficacy, health service use or adverse events. AVE compared with another AVE We are uncertain whether narrative videos are superior to factual knowledge videos as the evidence is of very low certainty. Gender differences Female migrants' diabetes HL may improve slightly more than that of males, when receiving AVE (MD 5.00, 95% CI 0.62 to 9.38; 1 study, 118 participants), but we do not know whether female or male migrants benefit differently from other interventions due to very low-certainty or a lack of evidence.

AUTHORS' CONCLUSIONS

Adequately powered studies measuring long-term effects (more than six months) of HL interventions in female and male migrants are needed, using well-validated tools and representing various healthcare systems.

Video Interventions for Reducing Health Inequity in Cancer Screening Programmes: a Systematic Review

BACKGROUND

Health equity can lead to disparities in cancer screening, treatment, and mortality. This systematic review aims to identify and describe interventions that used video or DVD formats to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates compared to usual care conditions.

METHODS

We searched PubMed, Web of Science, Embase, and Cochrane databases for randomized control trials (RCTs) published until 18/01/2023 that compared intervention versus usual care control groups, with the percentage of cancer screening uptake during follow-up as an outcome. The risk of Bias was assessed with the Cochrane Collaboration tool.

RESULTS

After screening 4201 abstracts, 192 full texts were assessed for eligibility and 18 were included that focused on colorectal (n = 9), cervical (n = 5), breast (n = 5), and prostate (n = 1) cancer screening. All were based in the USA except one and most focused on ethnicity/race, while some included low-income populations. Most of the video interventions used to increase cervical cancer screening reported positive results. Studies aimed at increasing mammography uptake were mostly effective only in specific groups of participants, such as low-income or less-educated African American women. Results for colorectal cancer screening were conflicting. Videos that were culturally tailored or used emotive format were generally more effective than information-only videos.

CONCLUSIONS

Video interventions to increase cancer screening among populations with low screening uptake show some positive effects, though results are mixed. Interventions that use individual and cultural tailoring of the educational material should be further developed and investigated outside of the USA.

Cost-effectiveness of Human Papillomavirus Self-collection Intervention on Cervical Cancer Screening Uptake among Underscreened U.S. Persons with a Cervix

BACKGROUND

We evaluate the cost-effectiveness of human papillomavirus (HPV) self-collection (followed by scheduling assistance for those who were HPV+ or inconclusive) compared with scheduling assistance only and usual care among underscreened persons with a cervix (PWAC).

METHODS

A decision tree analysis was used to estimate the incremental cost-effectiveness ratios (ICER), or the cost per additional PWAC screened, from the Medicaid/state and clinic perspectives. A hypothetical cohort represented 90,807 low-income, underscreened individuals. Costs and health outcomes were derived from the MyBodyMyTest-3 randomized trial except the usual care health outcomes were derived from literature. We performed probabilistic sensitivity analyses (PSA) to evaluate model uncertainty.

RESULTS

Screening uptake was highest in the self-collection alternative (n = 65,721), followed by the scheduling assistance alternative (n = 34,003) and usual care (n = 18,161). The self-collection alternative costs less and was more effective than the scheduling assistance alternative from the Medicaid/state perspective. Comparing the self-collection alternative with usual care, the ICERs were $284 per additional PWAC screened from the Medicaid/state perspective and $298 per additional PWAC screened from the clinic perspective. PSAs demonstrated that the self-collection alternative was cost-effective compared with usual care at a willingness-to-pay threshold of $300 per additional PWAC screened in 66% of simulations from the Medicaid/state perspective and 58% of simulations from the clinic perspective.

CONCLUSIONS

Compared with usual care and scheduling assistance, mailing HPV self-collection kits to underscreened individuals appears to be cost-effective in increasing screening uptake.

IMPACT

This is the first analysis to demonstrate the cost-effectiveness of mailed self-collection in the United States.

Components and effectiveness of patient navigation programmes to increase participation to breast, cervical and colorectal cancer screening: A systematic review

BACKGROUND

Inequalities in cancer incidence and mortality can be partly explained by unequal access to high-quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier-focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening.

METHODS

We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated.

RESULTS

The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher).

CONCLUSION

Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.

Interventions to increase cervical screening uptake among immigrant women: A systematic review and meta-analysis

Numerous intervention studies have attempted to increase cervical screening uptake among immigrant women, nonetheless their screening participation remains low. This systematic review and meta-analysis aimed to summarise the evidence on interventions to improve cervical screening among immigrant women globally and identify their effectiveness. Databases PubMed, EMBASE, Scopus, PsycINFO, ERIC, CINAHL and CENTRAL were systematically searched from inception to October 12, 2021, for intervention studies, including randomised and clinical controlled trials (RCT, CCT) and one and two group pre-post studies. Peer-reviewed studies involving immigrant and refugee women, in community and clinical settings, were eligible. Comparator interventions were usual or minimal care or attention control. Data extraction, quality appraisal and risk of bias were assessed by two authors independently using COVIDENCE software. Narrative synthesis of findings was carried out, with the main outcome measure defined as the cervical screening uptake rate difference pre- and post-intervention followed by random effects meta-analysis of trials and two group pre-post studies, using Comprehensive Meta-Analysis software, to calculate pooled rate ratios and adjustment for publication bias, where found. The protocol followed PRISMA guidelines and was registered prospectively with PROSPERO (CRD42020192341). 1,900 studies were identified, of which 42 (21 RCTS, 4 CCTs, and 16 pre-post studies) with 44,224 participants, were included in the systematic review, and 28 with 35,495 participants in the meta-analysis. Overall, the uptake difference rate for interventions ranged from -6.7 to 96%. Meta-analysis demonstrated a pooled rate ratio of 1.15 (95% CI 1.03-1.29), with high heterogeneity. Culturally sensitive, multicomponent interventions, using different modes of information delivery and self-sampling modality were most promising. Interventions led to at least 15% increase in cervical screening participation among immigrant women. Interventions designed to overcome logistical barriers and use multiple channels to communicate culturally appropriate health promotion messages are most effective at achieving cervical screening uptake among immigrant women.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews

INTRODUCTION

Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening.

METHODS

Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community.

RESULTS

The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status.

DISCUSSION

Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Community-based health literacy focused intervention for cervical cancer control among Black women living with human immunodeficiency virus: A randomized pilot trial

BACKGROUND

Health literacy plays an essential role in how individuals process health information to make decisions about health behaviours including cancer screening. Research is scarce to address health literacy as a strategy to improve cancer screening participation among women living with human immunodeficiency virus (HIV), particularly Black women who, despite the heavy burden of cervical cancer, report consistently low screening rates.

AIM

To assess the feasibility, acceptability and preliminary efficacy of a health literacy-focused intervention called CHECC-uP-Community-based, HEalth literacy focused intervention for Cervical Cancer control-among women living with HIV.

METHODS

We conducted a community-based, single-blinded randomized pilot trial. A total of 123 eligible women were enrolled and randomized to one of two conditions, control (i.e., cervical cancer brochure) or intervention (cervical cancer brochure plus 30-60 min health literacy-focused education followed by monthly phone counselling and navigation assistance for 6 months). Study assessments were done at baseline, 3 and 6 months. The final analysis sample included 58 women who completed all data points and whose Papanicolaou (Pap) test status was confirmed by medical records.

RESULTS

All intervention participants who completed the programme would recommend the CHECC-uP to other women living with HIV. However, adherence in the experimental conditions was low (49.6% attrition rate including 20 women who dropped out before the intervention began) due, in large part, to phone disconnection. Those who had received the intervention had a significantly higher Pap test rate compared to women in the control group at 6 months (50% vs. 21.9%, p = .025). Participation in the intervention programme was associated with improved health literacy and other psychosocial outcomes at 3 months but the trend was attenuated at 6 months.

CONCLUSIONS

The CHECC-uP was highly acceptable and led to improved Pap testing rates among Black women living with HIV. Future research should consider addressing social determinants of health such as phone connectivity as part of designing a retention plan targeting low-income Black women living with HIV.

IMPLICATIONS

The findings should be incorporated into a future intervention framework to fulfil the unmet needs of Black women living with HIV to facilitate their decision-making about Pap test screening.

PATIENT OR PUBLIC CONTRIBUTION

Nineteen community members including women living with HIV along with HIV advocates and care providers participated in four focus groups to develop cervical cancer screening decision-relevant information and the health literacy intervention. Additionally, a community advisory board was involved to provide guidance in the general design and conduct of the study.

Combined incentive actions, focusing on primary care professionals, to improve cervical cancer screening in women living in socioeconomically disadvantaged geographical areas: a study protocol of a hybrid cluster randomised effectiveness and implementation trial- RESISTE

INTRODUCTION

Cervical cancer (CC) causes thousands of deaths each year. Nearly 100% of cases are caused by oncogenic strains of human papillomavirus (HPV). In most industrialised countries, CC screening (CCS) is based on the detection of HPV infections. For many reasons including lower adherence to CCS, underserved women are more likely to develop CC, and die from it. We aim to demonstrate that the use of incentives could improve screening rates among this population.

METHODS AND ANALYSIS

Our cluster randomised, controlled trial will include 10 000 women aged 30-65 years eligible for CCS, living in deprived areas in four French departments, two mainlands and two overseas, and who did not perform physician-based HPV testing within the framework of the nationally organised screening programme. HPV self-sampling kit (HPVss) will be mailed to them. Two interventions are combined in a factorial analysis design ending in four arms: the possibility to receive or not a financial incentive of €20 and to send back the self-sampling by mail or to give it to a health professional, family doctor, gynaecologist, midwife or pharmacist. The main outcome is the proportion of women returning the HPVss, or doing a physician-based HPV or pap-smear test the year after receiving the HPVss. 12-month follow-up data will be collected through the French National Health Insurance database. We expect to increase the return rate of HPV self-samples by at least 10% (from 20% to 30%) compared with the postal return without economic incentive.

ETHICS AND DISSEMINATION

Ethics approval was first obtained on 2 April 2020, then on July 29 2022. The ethics committee classified the study as interventional with low risk, thus no formal consent is required for inclusion. The use of health insurance data was approved by the Commission Nationale Informatique et Libertés on 14 September 2021 (ref No 920276). An independent data security and monitoring committee was established. The main trial results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04312178.

Improving cervical cancer screening rates: a scoping review of resources and interventions

INTRODUCTION

Cervical cancer mortality can be prevented through early detection with screening methods such as Pap and high-risk human papillomavirus (hrHPV) tests; however, only 81% of women aged 21-65 are up-to-date on screening. Many interventions to increase cervical cancer screening have been implemented, but there is limited understanding about which intervention components are most successful.

METHODS

We conducted a scoping review of existing literature and available resources for cervical cancer screening interventions to identify gaps in the research. We used t tests and correlations to identify associations among intervention components and effect sizes.

RESULTS

Out of nine studies, the mean overall effect size for interventions was 11.3% increase in Pap testing for cervical cancer screening (range =  - 4-24%). Interventions that included community health workers or one-on-one interaction had the biggest effect size (p < 0.05). No associations with effect size were noted for literacy level, number of intervention components, or targeting by race/ethnicity.

CONCLUSIONS

Future interventions may include educational sessions with community health workers or one-on-one patient interaction to improve cervical cancer screening. Further research is needed to establish effect sizes for large-scale interventions and hrHPV screening interventions.

Impact of health education intervention on demand of women for cervical cancer screening: a cluster-randomized controlled trial

Background

Cervical cancer is considered preventable disease, though it is the second largest killer of women’s cancer in low and middle-income countries. Despite the government’s attempts to broaden screening facilities, the screening service utilization was poor. Our study evaluated the impact of health education intervention on women’s demand for cervical cancer screening.

Methods

Community-based cluster-randomized controlled trial was conducted in thirty district towns as clusters in Tigray region, Ethiopia. A total of 700 women aged 20 to 60 years were recruited for both groups using simple random sampling from April to July, 2018. After baseline data collection, health education intervention was given to the intervention group by trained health professionals using power point presentation and peer group discussion at the nearest health institution. The health education was given for three days followed by subsequent consultations for 6 months. The outcome variable was demand of women for cervical cancer screening. The intent-to-treat and per-protocol analysis were considered to evaluate the inflation of the loss to follow-up on effect size. Chi-square test was used to assess the difference of variables between control and intervention groups at baseline data. Finally, difference in difference analysis was used to see the true effect of the intervention on outcome variable.

Results

A total of 674 participants (340 in intervention and 334 in control groups) were able to complete the follow-up, making a response rate of 96.3%. At baseline, the differences in proportion of all outcome variables in control and intervention groups were not statistically significant. After follow-up, a statistically significant difference between control and intervention groups was observed in the proportion of willingness to screen (p value = 0.000), having plan to screen (p value = 0.000), ever screened (p value = 0.000), and the overall demand for cervical cancer screening (p value = 0.000). Finally, the impact of intervention was explained by the difference in differences in the proportion of willingness to screen (36.6%) (p value < 0.000), having plan to screen (14.6%) (p value < 0.000), ever screened (16.9%) (p value < 0.000), and overall demand for cervical cancer screening (36.9%) (p value < 0.000).

Conclusion

This study revealed that health education intervention could increase in overall demand of women for cervical cancer screening. Thus, it would be helpful to consider health education in health planning and service provision.

Trial registration

The registration number is PACTR201808126223676; date registered: 23 April 2018, and the type is “retrospectively registered.”

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06765-0.

The Road Less Traveled: Transportation Barriers to Cancer Care Delivery in the Rural Patient Population

Patients with cancer residing in geographically rural areas experience lower rates of preventative screening, more advanced disease at presentation, and higher mortality rates compared with urban populations. Although multiple factors contribute, access to transportation has been proposed as a critical barrier affecting timeliness and quality of health care delivery in rural populations. Patients from geographically rural regions may face a variety of transportation barriers, including lack of public transportation, limited access to private vehicles, and increased travel distance to specialized oncologic care. A search using PubMed was conducted to identify articles pertaining to transportation barriers to cancer care and tested interventions in rural patient populations. Studies demonstrate that transportation barriers are associated with delayed follow-up after abnormal screening test results, decreased access to specialized oncology care, and lower rates of receipt of guideline-concordant treatment. Low clinical trial enrollment and variability in survivorship care are also linked to transportation barriers in rural patient populations. Given the demonstrated impact of transportation access on equitable cancer care delivery, several interventions have been tested. Telehealth visits and outreach clinics appear to reduce patient travel burden and increase access to specialized care, and patient navigation programs are effective in connecting patients with local resources, such as free or subsidized nonemergency medical transportation. To ensure equal access to high-quality cancer care and reduce geographic disparities, the design and implementation of tailored, multilevel interventions to address transportation barriers affecting rural communities is critical.

Explaining Correlates of Cervical Cancer Screening among Minority Women in the United States

Globally, cervical cancer is the fourth leading cause of death among women. While overall cervical cancer rates have decreased over the last few decades, minority women continue to be disproportionately affected compared to White women. Given the paucity of theory-based interventions to promote Pap smear tests among minority women, this cross-sectional study attempts to examine the correlates of cervical cancer screening by Pap test using the Multi-theory Model (MTM) as a theoretical paradigm among minority women in the United States (U.S.). Structural Equation Modelling (SEM) was done for testing the construct validity of the survey instrument. Data were analyzed through bivariate and multivariate tests. In a sample of 364 minority women, nearly 31% (n = 112) of women reported not having received a Pap test within the past three years compared to the national rate (20.8%) for all women. The MTM constructs of participatory dialogue, behavioral confidence, and changes in the physical environment explained a substantial proportion of variance (49.5%) in starting the behavior of getting Pap tests, while the constructs of emotional transformation, practice for change, and changes in the social environment, along with lack of health insurance and annual household income of less than $25,000, significantly explained the variance (73.6%) of the likelihood to sustain the Pap test behavior of getting it every three years. Among those who have had a Pap smear (n = 252), healthcare insurance, emotional transformation, practice for change, and changes in the social environment predicted nearly 83.3% of the variance in sustaining Pap smear test uptake behavior (adjusted R² = 0.833, F = 45.254, p < 0.001). This study validates the need for health promotion interventions based on MTM to be implemented to address the disparities of lower cervical cancer screenings among minority women.

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.

Association of Immigration Status and Chinese and South Asian Ethnicity With Incidence of Head and Neck Cancer

Importance

Head and neck cancer (HNC) incidence varies worldwide, although it remains one of the most common cancers among those of East Asian and South Asian ethnicity.

Objective

To determine the association of Chinese and South Asian ethnicity, independent of immigration status, with HNC incidence.

Design, Setting, and Participants

This was a retrospective population-based matched cohort study that examined data collected between 1994 and 2017 in Ontario, Canada. Data were analyzed between July 2019 and March 2020. Individuals who immigrated to Canada between 1985 and 2017 were classified as immigrants, whereas Canadian-born individuals and those who immigrated prior to 1985 were classified as long-standing residents. Two separate, matched cohorts were created: an immigration cohort, consisting of immigrants and long-standing residents hard matched on age and sex, and an ethnicity cohort, where participants were further matched on ethnicity (Chinese, South Asian, or non-Chinese/non-South Asian).

Exposures

Chinese ethnicity, South Asian ethnicity, and immigration status.

Main Outcomes and Measures

Patients newly diagnosed with primary HNC were captured in both the immigration and the ethnicity cohorts. Cause-specific hazard models were used to estimate the association of immigration status and ethnicity with HNC incidence.

Results

In the immigration cohort, 3 328 434 matched individuals (mean [SD] age, 36.73 [13.46] years; 52.8% female) were followed, across which 3173 unique HNC diagnoses were made. The hazard ratio (HR) for a new diagnosis of oropharynx cancer was lower in immigrants compared with long-standing residents (HR, 0.26 [95% CI, 0.22-0.31]). In the ethnicity cohort, after adjusting for age, sex, rurality, and deprivation, the rate of HNC diagnosis was higher for Chinese individuals (HR, 1.49 [95% CI, 1.36-1.64]) and South Asian individuals (HR, 1.29 [95% CI, 1.14-1.45]), although it was lower for immigrants (HR, 0.48 [95% CI, 0.44-0.52]) when compared with non-Chinese and non-South Asian individuals. There was no difference in the incidence of nasopharynx cancer when comparing immigrants and long-standing residents of Chinese ethnicity.

Conclusions and Relevance

Immigration status appears to offer a protective effect against a diagnosis of HNC. Chinese and South Asian ethnic groups may experience higher HNC incidence when compared with the general Ontario population.

Demographic factors associated with missed follow-up among solid tumor patients treated at a large multi-site academic institution

Aim: To identify demographic predictors of patients who miss oncology follow-up, considering that missed follow-up has not been well studies in cancer patients. Methods: Patients with solid tumors diagnosed from 2007 to 2016 were analyzed (n = 16,080). Univariate and multivariable logistic regression models were constructed to examine predictors of missed follow-up. Results: Our study revealed that 21.2% of patients missed ≥1 follow-up appointment. African-American race (odds ratio [OR] 1.33; 95% CI: 1.17-1.51), Medicaid insurance (OR 1.59; 1.36-1.87), no insurance (OR 1.66; 1.32-2.10) and rural residence (OR 1.78; 1.49-2.13) were associated with missed follow-up. Conclusion: Many cancer patients miss follow-up, and inadequate follow-up may influence cancer outcomes. Further research is needed on how to address disparities in follow-up care in high-risk patients.

A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases

Transportation is an important social determinant of health. Transportation barriers disproportionately affect the most vulnerable groups of society who carry the highest burden of chronic diseases; therefore, it is critical to identify interventions that improve access to transportation. We synthesized evidence concerning the types and impact of interventions that address transportation to chronic care management. A systematic literature search of peer-reviewed studies that include an intervention with a transportation component was performed using three electronic databases-PubMed, EMBASE, and CINAHL-along with a hand-search. We screened 478 unique titles and abstracts. Two reviewers independently evaluated 41 full-text articles and 10 studies met eligibility criteria for inclusion. The transportation interventions included one or more of the following: providing bus passes (n = 5), taxi/transport vouchers or reimbursement (n = 3), arranging or connecting participants to transportation (n = 2), and a free shuttle service (n = 1). Transportation support was offered within multi-component interventions including counseling, care coordination, education, financial incentives, motivational interviewing, and navigation assistance. Community health/outreach workers (n = 3), nurses (n = 3), and research or clinic staff (n = 3) were the most common interventionists. Studies reported improvements in cancer screening rates, chronic disease management, hospital utilization, linkage and follow up to care, and maternal empathy. Overall, transportation is a well-documented barrier to engaging in chronic care among vulnerable populations. We found evidence suggesting transportation services offered in combination with other tailored services improves patient health outcomes; however, future research is warranted to examine the separate impact of transportation interventions that are tested within multi-component studies.

Evaluating the Effectiveness of Interventions on Increasing Participation in Cervical Cancer Screening

Background:

Although cervical cancer is highly preventable through regular screenings using Pap smear or human papillomavirus–deoxyribonucleic acid tests, cervical cancer remains a prevalent women's health issue across the world. Therefore, encouraging women to screen for cervical cancer is very important for the early detection of cervical cancer.

Purpose:

The purposes of this study were to (1) assess the effectiveness of three interventions that are typically used to increase the uptake of cervical cancer screening during home visits and (2) determine the participation rate in cervical cancer screenings after invitation, the health promotion perceptions, and the cervical cancer and screening-related knowledge of women. The three interventions noted in Purpose 1 were one-on-one training accompanied by an educational brochure, providing the educational brochure only, and giving an invitation without any relevant information.

Methods:

This interventional study was conducted on women who were between the ages of 30 and 65 years in three Turkish provinces (Ankara, Malatya, and Trabzon). Five hundred twenty home visits were made, and 356 women who did not have a Pap smear test within the previous year were invited for cervical cancer screening. Women were randomized into one of three intervention groups, and the participants in each group were invited to attend a national cervical cancer screening program and to undergo a cervical cancer screening using the related intervention type.

Results:

The results showed that the interventions used during home visits and knowledge were effective in encouraging women to participate in cervical cancer screening. It was determined that the participants who had received one-on-one training accompanied by an educational brochure had a higher cervical cancer screening rate than their peers who were offered a brochure only or a verbal invitation only.

Conclusions:

Invitations to screenings that are made by providing training accompanied with a brochure were found to be effective in increasing the participation of women in cervical cancer screening.

Benefits, Cost, and Activities of Patient Navigation (PN) Program for Colorectal Cancer Screening at the Charles B. Wang Community Health Center (CBWCHC)

To evaluate the benefits of a PN program for colorectal cancer (CRC) screening at Charles B. Wang Community Health Center (CBWCHC) in New York City from June 2012 to May 2015, estimate the cost of implementation, and describe time allocation patterns of PN activities. Semi-structured interviews were conducted with key informants of the CBWCHC in 2015. The electronic PN database was used to evaluate the program's effectiveness. New York State Department of Health budgeting and cost data were used to estimate the implementation cost. Self-reported activities of PNs were used to analyze time allocation patterns. A total of 3723 screen-eligible patients were contacted by PNs and 2552 (68.5%) completed at least one CRC screening test. Of these, 266 (10.4%) patients were diagnosed with precancerous polyps and two patients were diagnosed with CRC. The CRC screening rate at CBWCHC increased from 56% to 60% during the program period. The total cost was estimated to be $295,296.51 (in 2014 dollar terms). Overall, this relatively inexpensive CRC screening PN program was effective in increasing CRC screening in a low-income Asian-American community.

Interventions to improve the uptake of screening across a range of conditions in Ethnic Minority Groups: a systematic review

BACKGROUND

Screening programmes are well established in cancer, and are now being implemented in other conditions. An effective screening programme leads to early disease detection and improved outcomes but its impact is dependent on the quality of the test and the proportion of the target population participating. A further consideration is that uptake of screening by minority groups is low.

PURPOSE

To determine which interventions have successfully increased screening uptake amongst minorities.

DATA SOURCES

Medline, Cochrane database and the grey literature were searched from 1990 to 1st March 2016.

STUDY SELECTION

Fifty-five English language studies that assessed uptake of screening in any minority population in the country of study aged over 18 years and that included a comparison arm.

DATA EXTRACTION

Independent data extraction was undertaken by two researchers (CK and MP), using a predesigned data extraction form (DEF) which assisted retrieval of the core contents of each study and the organisation of material.

DATA SYNTHESIS

Evidence was organised by screening test and type of intervention. Two authors (CK and MP) extracted data into evidence tables to enable comparison of study characteristics and findings. The heterogeneity of methods precluded a meta-analysis thus results are descriptive. Evidence was also assessed, using the Cochrane Collaboration risk of bias tables.

RESULTS

This systematic review appraises data from international studies on a variety of minority groups, interventions and screening programmes providing a narrative review of their success and limitations.

Providing Health Education to Mixtec Farmworkers in California via Workshops and Radio: A Feasibility Study

Originating from one of the poorest areas in Mexico, Mixtecs are one of the largest indigenous groups of workers in California. Providing health education to this group is challenging because many do not speak English or Spanish, and indigenous languages are mainly oral, not written. We explored the feasibility of conveying health information through the radio and in promotora-led workshops. The study included an evaluation of the workshops through surveys before the workshop and 4 to 6 months later in a subsample of 96 indigenous women. The number of radio listeners averaged more than 2,000 per month, and 500 community members attended a workshop. Among women who completed pre- and postworkshop assessments (N = 75), there was a statistically significant increase in knowledge of how to get a wellness visit, where to get a free mammogram, and mammography screening guidelines. Women who ever had a mammogram or wellness visit at baseline were significantly more likely to report receipt of this service during the follow-up period than women who never had this service. Educational workshops and radio are promising and culturally appropriate strategies to provide health information in this community. However, many women need additional assistance to navigate access to health care.

Educational Interventions for Cervical Cancer Screening Behavior of Women: A Systematic Review

Background:

Cervical cancer is the second most common cancer in women worldwide; early detection can play a key role in reducing the associated morbidity. The objective of this study was to systematically assess the effects of educational interventions on cervical cancer screening (CCS) behavior of women.

Methods:

In this review the Cochrane library, Web of Science, Science Direct, PubMed, Scopus and search engine of Google scholar were searched for all interventional studies (trails, pre- and post-test or quasi-experimental) published in 2000-2017 for a systematic review, The search was based on the following keywords: cervix cancer, uterine cervical neoplasms, screening, prevention and control, Papanicolaou Test, pap test, pap smear, education, intervention, systematic review. Due to the heterogeneity of the data, a qualitative analysis was performed.

Results:

Thirty seven articles with 15,658 female participants in different parts of world were included in the review. About three quarters of the articles covered behavior change interventions. About one fourth of the articles were based on health education methods. The heath belief model is the most popular used framework for cervical cancer screening interventions. The results of our study showed that different health education methods (such as calls, mailed postcards, mother/daughter education. consultation sessions, picture books, videos, PowerPoint slides, small group discussions, educational brochures, radio broadcast education, lecture presentations, tailored counseling and a fact sheet, Self-learning package, face-to- face interviews and etc) are effective in modifying cervical cancer screening behavior of women.

Conclusions:

Our results showed that the different interventions and health behavior change frameworks provide an effective base for cervical cancer prevention. Heath providers can chose educational methods based on the particular client situations.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Patient navigators for people with chronic disease: A systematic review

BACKGROUND

People with chronic diseases experience barriers to managing their diseases and accessing available health services. Patient navigator programs are increasingly being used to help people with chronic diseases navigate and access health services.

OBJECTIVE

The objective of this review was to summarize the evidence for patient navigator programs in people with a broad range of chronic diseases, compared to usual care.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, PsycINFO, and Social Work Abstracts from inception to August 23, 2017. We also searched the reference lists of included articles. We included original reports of randomized controlled trials of patient navigator programs compared to usual care for adult and pediatric patients with any one of a defined set of chronic diseases.

RESULTS

From a total of 14,672 abstracts, 67 unique studies fit our inclusion criteria. Of these, 44 were in cancer, 8 in diabetes, 7 in HIV/AIDS, 4 in cardiovascular disease, 2 in chronic kidney disease, 1 in dementia and 1 in patients with more than one condition. Program characteristics varied considerably. Primary outcomes were most commonly process measures, and 45 of 67 studies reported a statistically significant improvement in the primary outcome.

CONCLUSION

Our findings indicate that patient navigator programs improve processes of care, although few studies assessed patient experience, clinical outcomes or costs. The inability to definitively outline successful components remains a key uncertainty in the use of patient navigator programs across chronic diseases. Given the increasing popularity of patient navigators, future studies should use a consistent definition for patient navigation and determine which elements of this intervention are most likely to lead to improved outcomes.

TRIAL REGISTRATION

PROSPERO #CRD42013005857.

Provider Perspectives on Promoting Cervical Cancer Screening Among Refugee Women

Many refugees in the United States emigrated from countries where the incidence of cervical cancer is high. Refugee women are unlikely to have been screened for cervical cancer prior to resettlement in the U.S. National organizations recommend cervical cancer screening for refugee women soon after resettlement. We sought to identify health and social service providers' perspectives on promoting cervical cancer screening in order to inform the development of effective programs to increase screening among recently resettled refugees. This study consisted of 21 in-depth key informant interviews with staff from voluntary refugee resettlement agencies, community based organizations, and healthcare clinics serving refugees in King County, Washington. Interview transcripts were analyzed to identify themes. We identified the following themes: (1) refugee women are unfamiliar with preventive care and cancer screening; (2) providers have concerns about the timing of cervical cancer education and screening; (3) linguistic and cultural barriers impact screening uptake; (4) provider factors and clinic systems facilitate promotion of screening; and (5) strategies for educating refugee women about screening. Our findings suggest that refugee women are in need of health education on cervical cancer screening during early resettlement. Frequent messaging about screening could help ensure that women receive screening within the early resettlement period. Health education videos may be effective for providing simple, low literacy messages in women's native languages. Appointments with female clinicians and interpreters, as well as clinic systems that remind clinicians to offer screening at each appointment could increase screening among refugee women.

Cervical Cancer Screening Experiences Among Chinese American Immigrant Women in the United States

OBJECTIVE

To understand the experiences and perceptions of having cervical cancer screening tests and to explore the extant barriers to having the tests among first-generation Chinese American women in the United States.

DESIGN

Qualitative, descriptive, phenomenological research.

SETTING

Los Angeles, California.

PARTICIPANTS

Snowball and purposive sampling of 12 Chinese American immigrant women ages 20 to 65 years.

METHODS

Individual face-to-face, in-depth, semistructured interviews in which participants were asked about their experiences and perceptions about cervical cancer screening. Interviews were audiotaped, transcribed, and translated into English. Data analysis included comparing and distinguishing, collecting and counting, and presupposing and inferring.

RESULTS

Through the analysis process, we identified four major themes that reflected the experiences, perceptions, and barriers to having cervical cancer screening among Chinese American women: Belief in a Healthy Lifestyle, Maintaining Privacy for Female Health Problems, Fear of Losing Control, and Feeling Vulnerable in an Unfamiliar Health Care System. These themes indicated that Chinese immigrant women in the United States face challenges to their cultural health beliefs and practices with regard to decision-making and health-seeking behaviors related to cervical cancer screening. They felt more vulnerable as immigrants because of systematic barriers to navigation of the unfamiliar health care system and limited resources.

CONCLUSION

Women's health care providers should be aware of and give consideration to cultural differences through the provision of more educational information and comfort to Chinese immigrant women who seek cervical cancer screening. Ultimately, the development of culturally appropriate and affordable cancer prevention programs with effective strategies is important to ease Chinese American women's senses of vulnerability.

Strategic Distributional Cost-Effectiveness Analysis for Improving National Cancer Screening Uptake in Cervical Cancer: A Focus on Regional Inequality in South Korea

PURPOSE

The purpose of this study was to conduct a cost effectiveness analysis of strategies designed to improve national cervical cancer screening rates, along with a distributional cost effectiveness analysis that considers regional disparities.

MATERIALS AND METHODS

Cost effectiveness analysis was conducted using a Markov cohort simulation model, with quality adjusted life years as the unit of effectiveness. The strategies considered were current (biennial Papanicolaou smear cytology of females aged 20 or above), strong screening recommendation by mail to target regions (effect, 12% increase in screening uptake; cost, 1,000 Korean won per person), regular universal screening recommendation by mail (effect, 6% increase in screening uptake; cost, 500 Korean won per person), and strong universal screening recommendation by mail (effect, 12% increase in screening uptake; cost, 1,000 Korean won per person). Distributional cost effectiveness analysis was conducted by calculating the cost effectiveness of strategies using the Atkinson incremental cost effectiveness ratio.

RESULTS

All strategies were under the threshold value, which was set as the Korean gross domestic product of $25,990. In particular, the 'strong screening recommendation to target regions' strategy was found to be the most cost effective (incremental cost effectiveness ratio, 7,361,145 Korean won). This was also true when societal inequality aversion increased in the distributional cost effectiveness analysis.

CONCLUSION

The 'strong screening recommendation to target regions' strategy was the most cost effective approach, even when adjusting for inequality. As efficiency and equity are objectives concurrently sought in healthcare, these findings imply a need to develop appropriate economic evaluation methodologies to assess healthcare policies.

Results From a Pilot Video Intervention to Increase Cervical Cancer Screening in Refugee Women

Many refugee women emigrate from countries with high cervical cancer incidence rates and have low rates of cervical cancer screening both before and after resettlement. Refugee women face many barriers to cervical cancer screening, including limited knowledge of cervical cancer and screening recommendations and cultural and linguistic barriers to being screened. Our pilot study aimed to develop and evaluate educational videos to promote cervical cancer screening among Karen-Burmese and Nepali-Bhutanese refugees, two of the largest groups of refugees arriving to the United States in recent years. We developed culturally tailored narrative videos for each ethnic group. Karen-Burmese and Nepali-Bhutanese women ( N = 40) were recruited through community health educators to participate in a pre- and posttest study. We assessed changes in cervical cancer knowledge and intentions to be screened, and satisfaction with the videos. We found that women were significantly more likely to report having heard of a test for cervical cancer and indicated significantly greater intentions to be screened after watching the video. Their knowledge about cervical cancer and screening also improved significantly, and they reported high levels of acceptability with the video. Our results suggest that culturally tailored narrative educational videos were acceptable to the target audiences and may be effective in increasing cervical cancer screening among refugee women. Further research should assess how health care and social service providers could implement video-based interventions to encourage women to be screened for cervical cancer during early resettlement.

Stepwise strategy to improve Cervical Cancer Screening Adherence (SCAN-CC): automated text messages, phone calls and face-to-face interviews: protocol of a population-based randomised controlled trial

INTRODUCTION

Screening is highly effective for cervical cancer prevention and control. Population-based screening programmes are widely implemented in high-income countries, although adherence is often low. In Portugal, just over half of the women adhere to cervical cancer screening, contributing for greater mortality rates than in other European countries. The most effective adherence raising strategies are based on patient reminders, small/mass media and face-to-face educational programmes, but sequential interventions targeting the general population have seldom been evaluated. The aim of this study is to assess the effectiveness of a stepwise approach, with increasing complexity and cost, to improve adherence to organised cervical cancer screening: step 1a-customised text message invitation; step 1b-customised automated phone call invitation; step 2-secretary phone call; step 3-family health professional phone call and face-to-face appointment.

METHODS

A population-based randomised controlled trial will be implemented in Portuguese urban and rural areas. Women eligible for cervical cancer screening will be randomised (1:1) to intervention and control. In the intervention group, women will be invited for screening through text messages, automated phone calls, manual phone calls and health professional appointments, to be applied sequentially to participants remaining non-adherent after each step. Control will be the standard of care (written letter). The primary outcome is the proportion of women adherent to screening after step 1 or sequences of steps from 1 to 3. The secondary outcomes are: proportion of women screened after each step (1a, 2 and 3); proportion of text messages/phone calls delivered; proportion of women previously screened in a private health institution who change to organised screening. The intervention and control groups will be compared based on intention-to-treat and per-protocol analyses.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Northern Health Region Administration and National Data Protection Committee. Results will be disseminated through communications in scientific meetings and peer-reviewed journals.

TRIAL NUMBER

NCT03122275.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis

Background

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

Objectives

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

Methods

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I² was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

Results

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

Conclusion

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women’s participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Cervical and Breast Cancer Screening After CARES: A Community Program for Immigrant and Marginalized Women

INTRODUCTION

Marginalized populations such as immigrants and refugees are less likely to receive cancer screening. Cancer Awareness: Ready for Education and Screening (CARES), a multifaceted community-based program in Toronto, Canada, aimed to improve breast and cervical screening among marginalized women. This matched cohort study assessed the impact of CARES on cervical and mammography screening among under-screened/never screened (UNS) attendees.

METHODS

Provincial administrative data collected from 1998 to 2014 and provided in 2015 were used to match CARES participants who were age eligible for screening to three controls matched for age, geography, and pre-education screening status. Dates of post-education Pap and mammography screening up to June 30, 2014 were determined. Analysis in 2016 compared screening uptake and time to screening for UNS participants and controls.

RESULTS

From May 15, 2012 to October 31, 2013, a total of 1,993 women attended 145 educational sessions provided in 20 languages. Thirty-five percent (118/331) and 48% (99/206) of CARES participants who were age eligible for Pap and mammography, respectively, were UNS on the education date. Subsequently, 26% and 36% had Pap and mammography, respectively, versus 9% and 14% of UNS controls. ORs for screening within 8 months of follow-up among UNS CARES participants versus their matched controls were 5.1 (95% CI=2.4, 10.9) for Pap and 4.2 (95%=CI 2.3, 7.8) for mammography. Hazard ratios for Pap and mammography were 3.6 (95% CI=2.1, 6.1) and 3.2 (95% CI=2.0, 5.3), respectively.

CONCLUSIONS

CARES' multifaceted intervention was successful in increasing Pap and mammography screening in this multiethnic under-screened population.

Impact of a student-led community education program to promote Pap test screening among Asian-American women

INTRODUCTION

Among ethnic groups, Asian-American women have the highest incidence of cervical cancer, low cervical cancer screening rates, and are more likely to state they have "never thought about" and/or "do not need" Pap testing. Through a Patient Advocacy grant awarded by the American Society of Cytopathology Foundation, we developed a culturally sensitive educational outreach program to encourage Pap screening among Asian-Americans in our community.

MATERIALS AND METHODS

Educational materials, translated into three languages, were shared at nine community events by undergraduate and medical student volunteers. Pre- and post-education surveys on awareness, knowledge, and attitudes towards screening were administered. Results were tallied and reported as raw percentages.

RESULTS

A total of 328 surveys were completed; 80% were Asian respondents. Twenty percent of respondents were not up to date (NUTD) with Pap screening. Knowledge of Pap tests reported as "excellent"/"good" rose from 46% before to 85% after education. Those reporting "very likely"/"likely" to schedule a Pap test increased from 72% to 92% in the NUTD group and from 84% to 97% in the 21-29 age group. Those reporting "very likely"/"likely" to recommend a Pap test to others increased from 68% to 98% in the NUTD group and 77% to 97% in those aged 21-29.

CONCLUSIONS

A student-led community-based culturally sensitive outreach approach improved Pap test knowledge and awareness among Asian-Americans. The largest increase in likelihood to obtain a Pap test and recommend the test to others was the NUTD and 21-29 age groups, suggesting influence on those in need of screening.

Breast and Cervical Cancer Screening Literacy Among Korean American Women: A Community Health Worker-Led Intervention

OBJECTIVES

To test a community health worker (CHW)-led health literacy intervention on mammogram and Papanicolaou test screening among Korean American women.

METHODS

We conducted a cluster-randomized trial at 23 ethnic churches in the Baltimore, Maryland-Washington, DC, metropolitan area between 2010 and 2014. Trained CHWs enrolled 560 women. The intervention group received an individually tailored cancer-screening brochure followed by CHW-led health literacy training and monthly telephone counseling with navigation assistance. Study outcomes included receipt of an age-appropriate cancer screening test, health literacy, cancer knowledge, and perceptions about cancer screening at 6 months.

RESULTS

The odds of having received a mammogram were 18.5 (95% confidence interval [CI] = 9.2, 37.4) times higher in the intervention than in the control group, adjusting for covariates. The odds of receiving a Papanicolaou test were 13.3 (95% CI = 7.9, 22.3) times higher; the odds of receiving both tests were 17.4 (95% CI = 7.5, 40.3) times higher. Intervention effects also included increases in health literacy and positive perceptions about cancer screening.

CONCLUSIONS

A health literacy-focused CHW intervention successfully promoted cancer-screening behaviors and related cognitive and attitudinal outcomes in Korean American women.

Using community-based participatory research to address Chinese older women's health needs: Toward sustainability

Although community-based participatory research (CBPR) has been recognized as a useful approach for eliminating health disparities, less attention is given to how CBPR projects may address gender inequalities in health for immigrant older women. The goal of this article is to share culturally sensitive strategies and lessons learned from the PINE study—a population-based study of U.S. Chinese older adults that was strictly guided by the CBPR approach. Working with Chinese older women requires trust, respect, and understanding of their unique historical, social, and cultural positions. We also discuss implications for developing impact-driven research partnerships that meet the needs of this vulnerable population.

Effects of Community-Based Health Worker Interventions to Improve Chronic Disease Management and Care Among Vulnerable Populations: A Systematic Review

BACKGROUND

Community-based health workers (CBHWs) are frontline public health workers who are trusted members of the community they serve. Recently, considerable attention has been drawn to CBHWs in promoting healthy behaviors and health outcomes among vulnerable populations who often face health inequities.

OBJECTIVES

We performed a systematic review to synthesize evidence concerning the types of CBHW interventions, the qualification and characteristics of CBHWs, and patient outcomes and cost-effectiveness of such interventions in vulnerable populations with chronic, noncommunicable conditions.

SEARCH METHODS

We undertook 4 electronic database searches-PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane-and hand searched reference collections to identify randomized controlled trials published in English before August 2014.

SELECTION

We screened a total of 934 unique citations initially for titles and abstracts. Two reviewers then independently evaluated 166 full-text articles that were passed onto review processes. Sixty-one studies and 6 companion articles (e.g., cost-effectiveness analysis) met eligibility criteria for inclusion.

DATA COLLECTION AND ANALYSIS

Four trained research assistants extracted data by using a standardized data extraction form developed by the authors. Subsequently, an independent research assistant reviewed extracted data to check accuracy. Discrepancies were resolved through discussions among the study team members. Each study was evaluated for its quality by 2 research assistants who extracted relevant study information. Interrater agreement rates ranged from 61% to 91% (average 86%). Any discrepancies in terms of quality rating were resolved through team discussions.

MAIN RESULTS

All but 4 studies were conducted in the United States. The 2 most common areas for CBHW interventions were cancer prevention (n = 30) and cardiovascular disease risk reduction (n = 26). The roles assumed by CBHWs included health education (n = 48), counseling (n = 36), navigation assistance (n = 21), case management (n = 4), social services (n = 7), and social support (n = 18). Fifty-three studies provided information regarding CBHW training, yet CBHW competency evaluation (n = 9) and supervision procedures (n = 24) were largely underreported. The length and duration of CBHW training ranged from 4 hours to 240 hours with an average of 41.3 hours (median: 16.5 hours) in 24 studies that reported length of training. Eight studies reported the frequency of supervision, which ranged from weekly to monthly. There was a trend toward improvements in cancer prevention (n = 21) and cardiovascular risk reduction (n = 16). Eight articles documented cost analyses and found that integrating CBHWs into the health care delivery system was associated with cost-effective and sustainable care.

CONCLUSIONS

Interventions by CBHWs appear to be effective when compared with alternatives and also cost-effective for certain health conditions, particularly when partnering with low-income, underserved, and racial and ethnic minority communities. Future research is warranted to fully incorporate CBHWs into the health care system to promote noncommunicable health outcomes among vulnerable populations.

Teaching tools to engage Anishinaabek First Nations women in cervical cancer screening: Report of an educational workshop

OBJECTIVE

To explore educational strategies for engaging First Nations women in Canada to attend cervical cancer screening.

DESIGN

Within a participatory action research framework, semi-structured interviews with health-care providers in First Nations communities revealed that education about the value of screening is perceived as being a key factor to promote cervical cancer screening.

SETTING

To obtain feedback from workshop informants, a 1-day educational workshop was held to identify appropriate educational intervention strategies, which would be applied in a forthcoming randomised controlled cervical screening trial.

METHODS

Common discussion and discussion groups, which were facilitated by a First Nations workshop moderator and a note taker.

RESULTS

This workshop helped to strengthen the ethical space dialogue with the First Nations communities with whom the study team had established research partnerships. The workshop atmosphere was relaxed and the invited informants decided that an educational health promotion event for community women needed to be held prior to inviting them to the cervical screening trial. Such an event would provide an opportunity to communicate the importance of attending regular cervical screening allowing women to make informed decisions about screening participation. Complementary promotional items, including an eye-catching pamphlet and storytelling, were also suggested.

CONCLUSION

The key messages from the events and promotional items can help to destigmatise women who develop a type of cancer that is caused by a sexually transmitted virus that affects both men and women. Developing and implementing positive health education that respectfully depicts female bodies, sexuality and health behaviours through a First Nations lens is strongly warranted.

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario

BACKGROUND

Breast cancer stage at diagnosis is an important predictor of survival. Our goal was to compare breast cancer stage at diagnosis (by American Joint Committee on Cancer criteria) in Chinese and South Asian women with stage at diagnosis in the remaining general population in Ontario.

METHODS

We used the Ontario population-based cancer registry to identify all women diagnosed with breast cancer during 2005-2010, and we applied a validated surname algorithm to identify South Asian and Chinese women. We used logistic regression to compare, for Chinese or South Asian women and for the remaining general population, the frequency of diagnoses at stage ii compared with stage i and stages ii-iv compared with stage i.

RESULTS

The registry search identified 1304 Chinese women, 705 South Asian women, and 39,287 women in the remaining general population. The Chinese and South Asian populations were younger than the remaining population (mean: 54, 57, and 61 years respectively). Adjusted for age, South Asian women were more often diagnosed with breast cancer at stage ii than at stage i [odds ratio (or): 1.28; 95% confidence interval (ci): 1.08 to 1.51] or at stages ii-iv than at stage i (or: 1.27; 95% ci: 1.08 to 1.48); Chinese women were less likely to be diagnosed at stage ii than at stage i (or: 0.82; 95% ci: 0.72 to 0.92) or at stages ii-iv than at stage i (or: 0.73; 95% ci: 0.65 to 0.82).

CONCLUSIONS

Breast cancers were diagnosed at a later stage in South Asian women and at an earlier stage in Chinese women than in the remaining population. A more detailed analysis of ethnocultural factors influencing breast screening uptake, retention, and care-seeking behavior might be needed to help inform and evaluate tailored health promotion activities.

A systematic review of randomised controlled trials examining the effectiveness of breast and cervical cancer screening interventions for ethnic minority women

PURPOSE

To examine the effect that breast and/or cervical cancer screening programmes for ethnic minority women have on their knowledge of and beliefs about breast or cervical cancer and screening, and on their screening intentions and uptake rates. Recommendations are also made for the format and content of such programmes, based on existing evidence.

METHODS

A comprehensive literature search was carried out both manually and by means of five electronic databases. The findings are summarised and synthesised in narrative fashion.

RESULTS

The ten RCTs included here were conducted among ethnic minority women in the United States or Canada, where breast or cervical cancer screening programmes have led to improvements in screening intentions, knowledge of cervical cancer and pap test uptake. The Breast Cancer Screening Belief Scale and self-reporting were the methods commonly used to measure outcomes. The shared characteristics of both countries' programmes were that they were theory- and language-based, the instruction took place in a community setting, the materials were culturally relevant, the content highlighted key messages about breast or cervical cancer and screening measures, and there were multiple intervention strategies.

CONCLUSION

Breast or cervical cancer screening programmes in Western countries have demonstrated improvements in knowledge of the disease, screening intentions and pap test uptake, although evidence on the effectiveness of the interventions has been limited. The common characteristics of programmes are identified, but a comprehensive model is still needed to link these characteristics with other factors and mediators influencing outcomes.

Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial

BACKGROUND

Control of cervical cancer in developing countries has been hampered by a failure to achieve high screening uptake. HPV DNA self-collection could increase screening coverage, but implementation of this technology is difficult in countries of middle and low income. We investigated whether offering HPV DNA self-collection during routine home visits by community health workers could increase cervical screening.

METHODS

We did a population-based cluster-randomised trial in the province of Jujuy, Argentina, between July 1, 2012, and Dec 31, 2012. Community health workers were eligible for the study if they scored highly on a performance score, and women aged 30 years or older were eligible for enrolment by the community health worker. 200 community health workers were randomly allocated in a 1:1 ratio to either the intervention group (offered women the chance to self-collect a sample for cervical screening during a home visit) or the control group (advised women to attend a health clinic for cervical screening). The primary outcome was screening uptake, measured as the proportion of women having any HPV screening test within 6 months of the community health worker visit. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02095561.

FINDINGS

100 community health workers were randomly allocated to the intervention group and 100 were assigned to the control group; nine did not take part. 191 participating community health workers (94 in the intervention group and 97 in the control group) initially contacted 7650 women; of 3632 women contacted by community health workers in the intervention group, 3049 agreed to participate; of 4018 women contacted by community health workers in the control group, 2964 agreed to participate. 2618 (86%) of 3049 women in the intervention group had any HPV test within 6 months of the community health worker visit, compared with 599 (20%) of 2964 in the control group (risk ratio 4·02, 95% CI 3·44-4·71).

INTERPRETATION

Offering self-collection of samples for HPV testing by community health workers during home visits resulted in a four-fold increase in screening uptake, showing that this strategy is effective to improve cervical screening coverage. This intervention reduces women's barriers to screening and results in a substantial and rapid increase in coverage. Our findings suggest that HPV testing could be extended throughout Argentina and in other countries to increase cervical screening coverage.

FUNDING

Instituto Nacional del Cáncer (Argentina).

CBPR-Informed Recruitment and Retention Adaptations in a Randomized Study of Pap Testing Among Pacific Islanders in Southern California

BACKGROUND

Pacific Islanders (PIs) experience high cervical cancer rates in the United States. Stage of diagnosis is also later for PIs than non-Hispanic Whites. The Pap test is severely underutilized among PIs: only 71% of Asian American and Pacific Islander women age 25 years or older received a Pap test within the last 3 years (U.S. average, 82%). Community-based participatory research (CBPR) is increasingly seen as an essential approach in designing and conducting culturally relevant and appropriate studies that reduce cancer incidence and other health disparities among minority and other medically underserved populations.

PURPOSE

The purpose of this article is to describe the lessons learned thus far regarding the identification, recruitment, and retention of PI community organizations and members into a CBPR-informed, randomized, community trial promoting Pap testing.

METHODS

This 5-year study used CBPR to develop and test the efficacy of a social support intervention for Chamorro, Samoan, and Tongan women to increase Pap testing in southern California. Eligible women were between the ages of 21 and 65, and married or in a long-term relationship with a man for at least 5 years. Women and their husbands or significant others received a 2-hour, culturally tailored workshop that include a group activity, information on Pap testing, a video, and corresponding materials. Comparison participants received a brochure about Pap testing. Three waves of data are collected from all participants: pretest (before workshop or brochure), posttest 1 (immediately after workshop or brochure), and posttest 2 (6 months follow-up).

RESULTS

Of the 76 organizations approached to participate in the study, 67 (88.2%) eventually agreed to participate. Thus far, 473 women and 419 men completed the study pretest, post-test, education, and 6-month follow-up. Only 242 women and 204 men of the eligible participants have completed the follow-up survey (63.5% of women and 60.5% of men retained after 6 months).

LESSONS LEARNED

The main strategy to overcome initial recruitment challenges was study staff persistence, because they averaged five contacts with each church or clan leader before receiving confirmation that an educational session can be scheduled. Personal connections provided an introduction to the most appropriate church or clan leader. Other efforts for retention include creation of an online version of the survey, re-attending church services, and creating special events organized around clan activities.

CONCLUSIONS

Although CBPR improves the cultural competence and relevance of study activities for ethnically diverse populations, selected past research shows that it does not ensure that such designs overcome all of the unique challenges in ethnically diverse communities. PI-specific organizational recruitment and individual retention is influenced by study issues and cultural factors in each community.

Barriers and facilitating factors perceived in Turkish women's behaviors towards early cervical cancer detection: a qualitative approach

BACKGROUND

The aim of the present study was to investigate perceived inhibiting and facilitating factors concerning cervical cancer early diagnosis behavior in Turkish women over the age of 40.

MATERIALS AND METHODS

The study was carried out by qualitative focus group interview with 35 participating women, in the period between April-June 2010. A semi-structured interview questionnaire based on the Health Belief Model and the Health Promotion Model was used. Content analysis was applied to the study data.

RESULTS

Barriers such as lack of knowledge of women as regards to the cervical cancer and early detection, lack of sensitivity- negligence, forgetting, fear, inadequacy of health insurance and transportation, financial problems, inability to get an appointment, lack of female doctors, embarrassment, fatalist approach were frequently addressed. As for facilitating factors, these included provision of information, health professionals showing interest and tolerance, free services, provision of transportation means and reminding telephone calls.

CONCLUSIONS

Focus group interviews were found to be effective in determining inhibiting and facilitating factors concerning cervical cancer early diagnosis behavior. In line with the results of the study, preparation of structured national and regional education programs and their addition to curriculum programs may be effective in realizing and maintaining positive early detection behavior.

Evaluation of a free-coupon program for cervical cancer screening among the young: a nationally funded program conducted by a local government in Japan

Background

Finding ways to improve the cervical cancer screening rates among young women has been seen as a critical national health problem in many countries, including Japan. The aim of the present study was to evaluate the effects of a free-coupon program for cervical cancer screening conducted by a local government under financial support from the Japanese national government.

Methods

The personal cervical cancer screening information was analyzed for all female residents of Toyonaka City, including any past screening history and clinical results since the year 2009, when a free-coupon program for screening was started. These results were compared to results from 2008, prior to implementation of the free-coupon screening program.

Results

The screening rates of women eligible for the free-coupon peaked dramatically compared to women of similar age who paid for their screening; however, the rates for the ineligible-age population also increased significantly in parallel to those in the free-coupon program, possibly by indirect peer and publicity effects. In women aged 20 to 25 years, the consecutive screening rate after a free-coupon screening was significantly lower than for those women who received a regular residential screening. After a free-coupon screening, the rate for participating in consecutive screenings depended significantly on the institution where the participant received her first screening test.

Conclusions

These results suggest that, for a generation of young women 20–25 years of age, a free-coupon program for cervical cancer screening was effective in increasing the first-time participation rate for screening; however, the increase in first-time participation did not lead to the expected increase in consecutive screenings.

Home visits to improve breast health knowledge and screening practices in a less privileged area in Jordan

Background

Breast cancer is the most common cancer afflicting women in Jordan. This study aimed to assess the effects of an educational intervention through home visits, including offering free mammography screening vouchers, on changing women’s breast health knowledge and screening practices for early detection of breast cancer in a less privileged area in Jordan.

Methods

Two thousand four hundred breast health awareness home visits were conducted and 2363 women aged 20-79 years (median: 41) answered a pre-test interview-administrated questionnaire to assess their breast health knowledge and practices at the baseline. After a home-based educational session, 625 women aged 40 years or older were referred to free mammography screening. Five hundred and ninety six homes were revisited six months later and out of these 593 women participated in a post-test. The women’s retained breast health knowledge, the changes in their reported breast health practices and their usage of the free mammography voucher, were assessed.

Results

The mean knowledge score increased significantly (p < 0.001) from 11.4 in the pre-test to 15.7 in the post-test (maximum score: 16). At the six month follow-up the post-test showed significant (p < 0.001) improvement in women’s perceived breast self-examination (BSE) knowledge, reported BSE practice and mammography screening. Out of 625 women that received a voucher for free mammography screening 73% attended the mammography unit, while only two women without a voucher went for mammography screening at the assigned unit. Women who received a follow-up visit were more likely to use the free mammography voucher compared to those who were not followed-up (83% vs. 67%; p < 0.001).

Conclusions

Home visits by local community outreach workers that incorporated education about breast cancer and breast health in addition to offering free mammography screening vouchers were effective in improving women’s breast health knowledge and practices in a less privileged area in Jordan.

The effect of a couples intervention to increase breast cancer screening among korean americans

PURPOSE/OBJECTIVES

To assess the efficacy of Korean Immigrants and Mammography-Culture-Specific Health Intervention (KIM-CHI), an educational program for Korean American (KA) couples designed to improve mammography uptake among KA women.

DESIGN

A two-group cluster randomized, longitudinal, controlled design.

SETTING

50 KA religious organizations in the Chicago area.

SAMPLE

428 married KA women 40 years of age or older who had not had a mammogram in the past year. The women and their husbands were recruited from 50 KA religious organizations.

METHODS

Couples were randomly assigned to intervention or attention control groups. Those in the KIM-CHI program (n = 211 couples) were compared to an attention control group (n = 217 couples) at baseline, as well as at 6 and 15 months postintervention on mammogram uptake.

MAIN RESEARCH VARIABLES

Sociodemographic variables and mammography uptake were measured. Level of acculturation was measured using the Suinn-Lew Asian Self-Identity Acculturation Scale. Researchers asked questions about healthcare resources and use, health insurance status, usual source of care, physical examinations in the past two years, family history of breast cancer, and history of mammography.

FINDINGS

The KIM-CHI group showed statistically significant increases in mammography uptake compared to the attention control group at 6 months and 15 months postintervention.

CONCLUSIONS

The culturally targeted KIM-CHI program was effective in increasing mammogram uptake among nonadherent KA women.

IMPLICATIONS FOR NURSING

Nurses and healthcare providers should consider specific health beliefs as well as inclusion of husbands or significant others. They also should target education to be culturally relevant for KA women to effectively improve frequency of breast cancer screening.