A randomised controlled trial of strategies to prompt attendance for a Pap smear

The impact of age-relevant and generic infographics on knowledge, attitudes and intention to attend cervical screening: A randomized controlled trial

OBJECTIVES

Cervical screening uptake in England is falling. Infographics could strengthen intention to attend, increase positive attitudes and improve knowledge. Age targeting could improve these outcomes further. We tested the impact of generic and age-targeted infographics.

DESIGN

A randomized controlled trial using an age-stratified, parallel-group design.

METHODS

Women aged 25-64 (n = 2095) were recruited through an online panel and randomized to see one of the three infographics. We tested: (i) impact of a generic cervical screening infographic compared to a control infographic on an unrelated topic with all screening age women and (ii) impact of an age-targeted infographic compared to a generic cervical screening infographic with older women (50-64 years). Intentions, knowledge and attitudes were measured.

RESULTS

Women aged 25-64 years who viewed the generic infographic had significantly higher intentions [F(1, 1513) = 6.14, p = .013,η p 2  = .004], more accurate beliefs about the timeline of cervical cancer development (OR: 5.18, 95% CI: 3.86-6.95), more accurate social norms (OR: 3.03, 95% CI: 2.38-3.87) and more positive beliefs about screening benefits (OR: 2.23, 95% CI: 1.52-3.28) than those viewing the control infographic. In the older age group, there was no significant difference in intention between those viewing the generic versus age-targeted versions [F(1, 607) = .03, p = .853,η p 2  < .001], but the age-targeted version was more engaging [F(1, 608) = 9.41, p = .002,η p 2  = .015].

CONCLUSIONS

A cervical screening infographic can result in more positive attitudes and better knowledge and may have a small impact on intentions. Although age targeting did not affect intention, it had a positive impact on engagement and may therefore be useful in encouraging women to read and process materials.

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.

Cervical cancer screening uptake: A randomized controlled trial assessing the effect of sending invitation letters to non-adherent women combined with sending their general practitioners a list of their non-adherent patients (study protocol)

Introduction

Cervical cancer (CC) is the fourth most common cancer among women. It can be cured if diagnosed at an early stage and treated promptly. The World Health Organization suggests that 70% of women should be screened with a high-performance test by the age of 35. This paper reports a protocol to assess the effect of two modalities of organized CC screening programmes on CC screening uptake.

Methods and analysis

Design and setting: The design involves a 3-arm randomized controlled study performed in a French geographic area on the west coast. A total of 1,395 general practitioners will be randomized, depending on their general practice surgeries. Participants: The design is based on a total of 94,393 women aged 40 to 65 years who are eligible for CC screening. Intervention: In the "optimized cancer screening" group, the intervention will combine sending invitation letters to non-adherent women with sending general practitioners (GPs) a list of their non-adherent patients. In the "standard cancer screening" group, the intervention will be limited to sending invitation letters to non-adherent women. In the "usual care" group, no letter will be sent either to women or to their GPs. Primary endpoint: CC screening test uptake will be assessed after a 6-month follow-up period. Statistical analysis: The percentage of women who are up-to-date with their screening at 6 months after the intervention will be compared across arms using a generalized mixed linear model.

Discussion

A large-scale randomized trial of this nature is unprecedented. The study will enable us to assess a strategy relying on GPs, identified as the coordinators in this screening strategy. The study results should help policy makers to implement organized CC screening programs in the future.

Ethics and dissemination

The study was approved was approved by the Ethics Committee of the National College of Teaching General practitioners (IRB00010804). It was recorded in ClinicalTrials.gov on the number NCT04689178 (28 December 2020). The study findings will be used for publication in peer-reviewed scientific journals and presentations in scientific meetings.

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.

Impact of postal correspondence letters on participation in cancer screening: a rapid review

The purpose of this rapid review was to identify and synthesize evidence on the impact of postal correspondence letters on participation in cancer screening and to determine whether impact varied by cancer site or inclusion of the participant's physician's name within the letter (i.e., physician-linked). PubMed and the Cochrane Database of Systematic Reviews were searched for English-language systematic reviews and randomized controlled trials (RCTs) published up until October 2019. One reviewer completed citation screening and data extraction with 30% verification by a second reviewer. Systematic reviews and RCTs were appraised using A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 and Cochrane Risk of Bias 2.0 tools, respectively, by one reviewer with complete verification by a second reviewer. Findings from systematic reviews and RCTs were examined separately and presented narratively. Six systematic reviews and 18 RCTs of generally low quality were included. Evidence generally demonstrated a positive impact of a letter as compared to no letter or usual practice on screening participation. This finding was consistent for breast cancer and cervical screening participation but inconsistent for colorectal cancer screening participation. Studies comparing physician-linked letters to no letters or usual practice reported similar effect estimates as those examining letters in general. Limited and inconsistent evidence was identified on the impact of physician-linked letters as compared to non-physician-linked letters on screening participation. Evidence identified in this rapid review, and other contextual and implementation considerations, may be useful for jurisdictions considering how to promote cancer screening participation.

Participants, Physicians or Programmes: Participants' educational level and initiative in cancer screening

This study is an in-depth examination of at whose initiative (participant, physician or screening programme) individuals participate in cervical, breast and colorectal cancer screening across the EU-28. Special attention is paid to (1) the association with educational attainment and (2) the country's cancer screening strategy (organised, pilot/regional or opportunistic) for each type of cancer screened. Data were obtained from Eurobarometer 66.2 'Health in the European Union' (2006). Final samples consisted of 10,186; 5443 and 9851 individuals for cervical, breast, and colorectal cancer, respectively. Multinomial logistic regressions were performed. Surprisingly, even in countries with organised screening programmes, participation in screenings for cervical, breast and colorectal cancer was most likely to be initiated by the general practitioner (GP) or the participant. In general, GPs were found to play a crucial role in making referrals to screenings, regardless of the country's screening strategy. The results also revealed differences between educational groups with regard to their incentive to participate in cervical and breast cancer screening and, to a lesser extent, in colorectal cancer screening. People with high education are more likely to participate in cancer screening at their own initiative, while people with less education are more likely to participate at the initiative of a physician or a screening programme. Albeit, the results varied according to type of cancer screening and national screening strategy.

Invitation to cervical cancer screening does increase participation in Germany: Results from the MARZY study

The effect of different invitation models on participation in cervical cancer screening (CCS) was investigated in a randomized population-based cohort study in Germany. Participants were randomly selected via population registries and randomized into intervention Arm A (invitation letter) and Arm B (invitation letter and information brochure) or control Arm C (no invitation). The intervention and control arms were compared with regard to 3-year participation and the two invitation models were compared between intervention arms. Of the 7,758 eligible women aged 30-65 years, living in the city of Mainz and in the rural region of Mainz-Bingen, 5,265 were included in the analysis. Differences in proportions of women attending CCS were investigated and logistic regression was performed to analyze various factors influencing participation. In the intervention group, 91.8% participated in CCS compared to 85.3% in the control group (p < 0.0001), with a 6.6 percentage point increase in participation [95% confidence interval (CI) 4.6-8.6] and an adjusted odds ratio (OR) of 2.69 (95% CI 2.15-3.37). Effect estimators increased to 21.9 percentage points (95% CI 16.7-27.1) and an OR of 3.64 (95% CI 2.74-4.82), respectively, when women who participated in screening annually were excluded from the analysis. The invitation letter was particularly effective among women with lower school education, migrant women and older women. No difference in participation was found between the intervention Arm A and Arm B. An accompanying information brochure did not motivate more women to undergo CCS. However, a written invitation statistically significantly increased participation in CCS in Germany.

The costs of offering HPV-testing on self-taken samples to non-attendees of cervical screening in Finland

Background

Offering self-sampling to non-attendees of cervical screening increases screening attendance.

Methods

We used observations from two Finnish studies on the use of self-sampling among the non-attendees to estimate in a hypothetical screening population of 100,000 women the possible costs per extra screened woman and costs per extra detected and treated CIN2+ with three intervention strategies; 1) a primary invitation and a reminder letter, 2) a primary invitation and a mailed self-sampling kit and 3) two invitation letters and a self-sampling kit. The program costs were derived from actual performance and costs in the original studies and a national estimate on management costs of HPV related diseases.

Results

The price per extra participant and price per detected and treated CIN2+ lesion was lower with a reminder letter than by self-sampling as a first reminder. When self-sampling was used as a second reminder with a low sampler price and a triage Pap-smear as a follow-up test for HPV-positive women instead of direct colposcopy referral, the eradication of a CIN2+ lesion by self-sampling was not more expensive than in routine screening, and the addition of two reminders to the invitation protocol did not increase the price of an treated CIN2+ lesion in the entire screened population.

Conclusions

As a first reminder, a reminder letter is most likely a better choice. As second reminder, the higher costs of self-sampling might be compensated by the higher prevalence of CIN2+ in the originally non-attending population.

The Effectiveness of Health Screening

Using a matched insurant-general practitioner panel data set, we estimate the effect of a general health-screening program on individuals' health status and health-care cost. To account for selection into treatment, we use regional variation in the intensity of exposure to supply-determined screening recommendations as an instrumental variable. We find that screening participation increases inpatient and outpatient health-care costs up to 2 years after treatment substantially. In the medium run, we find cost savings in the outpatient sector, whereas in the long run, no statistically significant effects of screening on either health-care cost component can be discerned. In sum, screening participation increases health-care cost. Given that we do not find any statistically significant effect of screening participation on insurants' health status (at any point in time), we do not recommend a general health-screening program. However, given that we find some evidence for cost-saving potential for the sub-sample of younger insurants, we suggest more targeted screening programs.

Utilisation of preventative health check-ups in the UK: findings from individual-level repeated cross-sectional data from 1992 to 2008

OBJECTIVES

To analyse and compare the determinants of screening uptake for different National Health Service (NHS) health check-ups in the UK.

DESIGN

Individual-level analysis of repeated cross-sectional surveys with balanced panel data.

SETTING

The UK.

PARTICIPANTS

Individuals taking part in the British Household Panel Survey (BHPS), 1992-2008.

OUTCOME MEASURE

Uptake of NHS health check-ups for cervical cancer screening, breast cancer screening, blood pressure checks, cholesterol tests, dental screening and eyesight tests.

METHODS

Dynamic panel data models (random effects panel probit with initial conditions).

RESULTS

Having had a health check-up 1 year before, and previously in accordance with the recommended schedule, was associated with higher uptake of health check-ups. Individuals who visited a general practitioner (GP) had a significantly higher uptake in 5 of the 6 health check-ups. Uptake was highest in the recommended age group for breast and cervical cancer screening. For all health check-ups, age had a non-linear relationship. Lower self-rated health status was associated with increased uptake of blood pressure checks and cholesterol tests; smoking was associated with decreased uptake of 4 health check-ups. The effects of socioeconomic variables differed for the different health check-ups. Ethnicity did not have a significant influence on any health check-up. Permanent household income had an influence only on eyesight tests and dental screening.

CONCLUSIONS

Common determinants for having health check-ups are age, screening history and a GP visit. Policy interventions to increase uptake should consider the central role of the GP in promoting screening examinations and in preserving a high level of uptake. Possible economic barriers to access for prevention exist for dental screening and eyesight tests, and could be a target for policy intervention.

TRIAL REGISTRATION

This observational study was not registered.

The role of primary care in early detection and follow-up of cancer

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

Methods to increase participation in organised screening programs: a systematic review

BACKGROUND

The European Community recommends the implementation of population-based screening programmes for cervical, breast, and colorectal cancers. This recommendation is supported by many observational studies showing that organised programmes effectively reduce mortality and control the inappropriate use of screening tests. We conducted a systematic review of studies assessing the efficacy of interventions to increase participation in organised population-based screening programs.

METHODS

We included all studies on interventions aimed at increasing screening participation published between 1/1999 and 7/2012. For those published before 1999, we considered the Jepson et al. (2000) review (Health Technol Assess 4:1-133, 2000).

RESULTS

Including studies from the Jepson review, we found 69 with quantitative information on interventions in organised screening: 19 for cervical, 26 for breast, 20 colorectal cancers, and 4 for cervical and breast cancer together.Effective interventions were: postal (breast RR = 1,37 95% Confidence Interval (95% CI): 1.25-1.51; cervical RR = 1.71 95% CI: 1.60-1.83; colorectal RR = 1.33 95% CI: 1.17-1.51) and telephone reminders (with heterogeneous methods for implementation); GP's signature on invitation letter (breast RR = 1.13 95% CI: 1.11-1.16; cervical RR = 1.20 95% CI: 1.10-1.30; colorectal RR = 1.15 95% CI: 1.07-1.24); scheduled appointment instead of open appointment (breast RR = 1.26 95% CI: 1.02-1.55; cervical RR = 1.49 95% CI: 1.27-1.75; colorectal RR = 1.79 95% CI: 1.65-1.93). Mailing a kit for self-sampling cervical specimens increased participation in non-responders (RR = 2.37 95% CI: 1.44-3.90).

CONCLUSION

Although some interventions did prove to be effective, some specific variables may influence their effectiveness in and applicability to organised population-based screening programs.

How to increase uptake in oncologic screening: a systematic review of studies comparing population-based screening programs and spontaneous access

BACKGROUND

Cervical, breast and colorectal cancer (CRC) screenings are universally recommended interventions. High coverage of the target population represents the most important factor in determining their success. This systematic review aimed at assessing the effectiveness of population-based screening programs in increasing coverage compared to spontaneous access.

METHODS

Electronic databases and national and regional websites were searched. We included all studies on interventions aimed at increasing screening participation published between 1999 and 2009; for those published before, we consulted the Jepson et al. review (2000). We compared spontaneous access (including no intervention) vs population-based screening programs actively inviting the target population. Among the latter, we compared GP-based vs invitation letter-based interventions.

RESULTS

The invitation letter vs no intervention showed significantly more participation (RR=1.60 95%CI 1.33-1.92; RR=1.52 95%CI 1.28-1.82; RR=1.15 95%CI 1.12-1.19, for breast, cervical and CRC screenings, respectively). GP-based interventions, although more heterogeneous, showed a significant effect when compared with no intervention for breast (RR=1.74 95%CI 1.25-2.43), but not for cervical and CRC. No significant differences were found between invitation letter-based and GP-based organization (RR=0.99 95%CI 0.94-1.05; RR=1.08 95%CI 0.99-1.17, for breast and cervical cancer, respectively).

CONCLUSION

Population-based programs are more effective than spontaneous screening in obtaining higher testing uptake. Both invitation letter-based and GP-based programs are effective.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Acceptability of reminder letters for Papanicolaou tests: a survey of women from 23 Family Health Networks in Ontario

OBJECTIVE

To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations.

METHODS

A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents.

RESULTS

The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures.

CONCLUSIONS

Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Determinants of womens participation in cervical cancer screening trial, Maharashtra, India

OBJECTIVE

To determine the factors associated with participation in cervical cancer screening and follow-up treatment in the context of a randomized controlled trial. The trial was initiated to evaluate the efficacy and cost effectiveness of visual inspection with acetic acid, cytological screening and testing for human papillomavirus in reducing the incidence of and mortality from cervical cancer in Maharashtra, India.

METHODS

Between October 1999 and November 2003 women aged 30-59 years were randomized to receive one of the three tests or to a control group. Participation was analysed for all three intervention arms. The differences between those who were screened versus those who were not was analysed according to the sociodemographic characteristics of the 100,800 eligible women invited for screening. Those who were treated versus those who were not were analysed according to the sociodemographic characteristics of the 932 women diagnosed with high-grade lesions. Participation in screening and compliance with treatment were also analysed according to the type of test used.

FINDINGS

Compared with women who were not tested, screened women were younger (aged 30-39), better educated and had ever used contraception. A higher proportion of screened women were married and a lower proportion had never been pregnant. Of the 932 women diagnosed with high-grade lesions or invasive cancer, 85.3% (795) received treatment. Women with higher levels of education, who had had fewer pregnancies and those who were married were more likely to comply with treatment. There were no differences in rates of screening or compliance with treatment when results were analysed by the test received.

CONCLUSIONS

Irrespective of the test being used, good participation levels for cervical cancer screening can be achieved in rural areas of developing countries by using appropriate strategies to deliver services. Communication methods and delivery strategies aimed at encouraging older, less-educated women, who have less contact with reproductive services, are needed to further increase screening uptake.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Large Population-Based Randomized Controlled Trial to Increase Attendance at Screening for Cervical Cancer

Objective: Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved. Methods: We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities. Results: The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) −0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9–10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9–35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled. Conclusion: Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives.

Understanding the barriers to cervical cancer screening among older women

Despite the fact that 90% of cervical cancers can be prevented by regular Pap screening, many women are not screened regularly, particularly older women. To understand better the barriers to screening, the authors held five focus groups during April 2000 in Prince Edward Island (PEI), Canada. Of the 32% of women aged 45 to 70 who had not been screened over a 5-year period (1995-2000), 60 randomly selected women participated in this research. The authors analyzed discussions for themes using an inductive approach, with interpretation guided by the population health model. Women who have avoided a Pap test are falling between the cracks created by a complex interaction between personal experiences and the health system's approach to Pap screening.

Nurse practitioners and preventive screening in the hospital

The purpose of this study was to investigate a reminder to discuss cervical cancer screening with hospitalized females. A quasi-experimental design was used to compare the association of a reminder intervention for nurse practitioners with two outcomes: prevalence of cervical cancer screening as documented in patients' charts and patients' self-report of cervical cancer screening 4 months after discharge. Data were collected by chart review and phone survey. The sample consisted of nurse practitioners caring for eligible female patients at a university teaching hospital. Chi-square was used to test all research questions. The rate of documentation of cervical cancer screening increased from 2% to 69% after implementation of the reminder intervention. The reminder intervention did not impact patients actually receiving Pap smears after discharge. The significant increase in documentation of screening associated with the use of the single reminder in the patients' charts support the use of this low-cost intervention.

A systematic literature review of the effectiveness of community-based strategies to increase cervical cancer screening

OBJECTIVE

To evaluate and summarize evidence of the effectiveness of interventions available to public health staff that could be used to increase cervical cancer screening to women.

METHOD

A thorough literature review was conducted, articles screened for relevance and assessed for quality.

RESULTS

Of 42 relevant studies, 1 was rated 'strong', 18 'moderate' and 23 'weak'. Among the strong/moderate studies, 10 were aimed at disadvantaged women. The most frequently used intervention was mass media campaigns, alone or combined with individual strategies; followed by individual education using lay health educators; and last, letters of invitation. Thirteen of the moderate/strong studies evaluated strategies that reported statistically significant increases in Pap smear rates and other outcomes.

CONCLUSIONS

Strategies that combined mass media campaigns with direct tailored education to women and/or health care providers seemed most successful. The importance of accurate centralized cytology databases for recall is underscored.

Effectiveness of an intervention to increase Pap test screening among Chinese women in Taiwan

This study assessed the effectiveness of a theory-based direct mail campaign in encouraging non-compliant women, aged 30 and older or younger if married, to obtain a Pap test. Participants were female family members of inpatients admitted to one of the major teaching hospitals in Taiwan during August-September 1999. A total of 424 women were recruited in the randomized intervention trial. Three months following implementation of the intervention, women in the intervention group reported a higher rate of Pap test screening than women in the comparison group (50% versus 32%) (p = 0.002). Women in the intervention group also showed higher perceived pros of a Pap test at follow-up (p = 0.031). Although women in both groups showed an increased knowledge and intention to obtain a Pap, only the intervention group had significantly higher follow-up scores on perceived pros and susceptibility. The results shows that the intervention was effective in increasing Pap test screening among Chinese women within three months. The results also support the use of Intervention Mapping, a systematic program development framework for planning effective interventions.

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

BACKGROUND

North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.

METHODS

Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants' Pap testing behavior. All statistical tests were two-sided.

RESULTS

A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P =.03 for direct mail versus control, and P =.02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.

CONCLUSION

Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

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

OBJECTIVES

To assess the effectiveness of interventions aimed at increasing uptake, and informed uptake of cervical cancer screening.

SEARCH STRATEGY

Twenty-three electronic databases (to March 2000) were searched with no language restrictions.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Data on study characteristics and quality were extracted independently by two reviewers. Where data were available, relative risks and 95% CI were calculated and a chi-squared test for heterogeneity was performed.

MAIN RESULTS

Thirty-five studies were included (27 RCTs and eight quasi-RCTs). Heterogeneity between studies limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. The number and quality of included studies limited evidence regarding effectiveness of other interventions. Informed uptake of cervical screening was not considered by any studies.

REVIEWER'S CONCLUSIONS

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

Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis

OBJECTIVE

To perform a meta-analysis on existing randomized controlled trials to investigate the efficacy of patient letter reminders on increasing cervical cancer screening using Pap smears.

METHODS

A search was conducted for all relevant published and unpublished studies between the years 1966 and 2000. Eligibility criteria included randomized controlled studies that examined populations due for Pap smear screening. The intervention studied was in the form of a reminder letter. The Mantel-Haenszel method was used to measure the summary effect of the intervention. A test for homogeneity using the Mantel-Haenszel method was performed.

RESULTS

Ten articles fulfilled the inclusion criteria, including one unpublished study. The test for homogeneity showed evidence of heterogeneity (chi2 = 31, 9 df, P <.001). An analysis for causes of heterogeneity was pursued. Division into subpopulations based on socioeconomic status resolved the heterogeneity (chi2 = 5.2, 8 df, P =.75). The studies evaluating those in lower socioeconomic groups had a smaller response (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.99 to 1.35) than those studies using mixed populations (OR, 2.02; 95% CI, 1.79 to 2.28). The pooled odds ratio showed that patients who received the intervention were significantly more likely to return for screening than those who did not (OR, 1.64; 95% CI, 1.49 to 1.80).

CONCLUSIONS

Patient reminders in the form of mailed letters increase the rate of cervical cancer screening. Patient letter reminders have less efficacy in lower socioeconomic groups.

Intention to return for papanicolaou smears in adolescent girls and young women

OBJECTIVE

Sexually active adolescent girls have high rates of abnormal cervical cytology. However, little is known about factors that influence intention to return for Papanicolaou screening or follow-up. The aim of this study was to determine whether a theory-based model that assessed knowledge, attitudes, and behaviors predicted intention to return.

METHODS

The study design consisted of a self-administered, cross-sectional survey that assessed knowledge, beliefs, perceived control over follow-up, perceived risk, cues for Papanicolaou smears, impulsivity, risk behaviors, and past compliance with Papanicolaou smear follow-up. Participants were recruited from a hospital-based adolescent clinic that provides primary and subspecialty care, and the study sample consisted of all sexually active girls and young women who were aged 12 to 24 years and had had previous Papanicolaou smears. The main outcome measure was intention to return for Papanicolaou smear screening or follow-up.

RESULTS

The enrollment rate was 92% (N = 490), mean age was 18.2 years, 50% were black, and 22% were Hispanic. Eighty-two percent of participants intended to return. Variables that were independently associated with intention to return included positive beliefs about follow-up (odds ratio [OR]: 1.07; 95% confidence interval [CI]: 1.02-1.11), perception that important others believe that the participant should obtain a Papanicolaou smear (OR: 1.93; 95% CI: 1.38-2.74), perceived control over returning (OR: 1.24; 95% CI: 1.06-1.46), and having received cues to obtain a Papanicolaou smear (OR: 1.31; 95% CI: 1.08-1.60).

CONCLUSIONS

Analysis of this novel theoretical framework demonstrated that knowledge and previous behaviors were not associated with intention to return for Papanicolaou smear screening and follow-up in this population of young women. However, modifiable attitudinal components, including personal beliefs, perception of others' beliefs, and cues to obtaining Papanicolaou smears, were associated with intention to return.

Attendance to cervical cancer screening in family practices in The Netherlands

BACKGROUND

The effectiveness of three different organizational approaches to cervical cancer screening (community based, family practice based, and a combination) was evaluated in nationally representative family practices.

METHOD

We selected 122 family practices with a computerized sex-age register from a database of 1, 251 family practices, representative of all 4,758 family practices in The Netherlands. Approximately 40 practices were linked with each approach. We measured the attendance, the reasons for nonattendance, and the influence of a reminder on the attendance of women invited for cervical screening in September, October, and November 1996. The patients were grouped according to age. A cross-sectional design was used for the study.

RESULTS

For younger women, the total attendance rate, coverage (percentage of women "protected" against cervical cancer), and control rate (percentage of women with medical reasons for nonattendance or postponement of the smear) were highest in practices using the family practice-based approach (68, 77, and 90%, respectively) and lowest in practices with the community-based approach (53, 62, and 68%, respectively). For older women, the family practice-based approach and the combination approach were associated with attendance rates significantly higher than those for the community-based approach (approximately 60, 80, and 80% vs 47, 67, and 70%, respectively). A reminder sent by the family physician to women not responding to an initial invitation increased the attendance rate by 7 to 11% in both age categories, depending on who had sent the first invitation.

CONCLUSION

A family practice-based cervical screening approach appeared to be the most effective at a national level, achieving the highest attendance rate, coverage, and control rate.

Cervical cancer screening in rural NSW: Health Insurance Commission data compared to self-report

There are several sources of data for estimates of community Pap test rates, including self-report, pathology laboratory records and Health Insurance Commission (HIC) data. Estimates of screening rates can vary considerably according to the sampling frame and data source. This study aimed to compare the self-reported estimates of cervical cancer screening with HIC estimates for women in rural NSW towns. Self-report of a Pap test in the past two years from 2,498 women in 19 rural towns of NSW was compared to HIC-provided Pap test rates. Self-report levels were adjusted for non-HIC providers and HIC levels included data from the Victorian Cytology Register. Self-report estimates were significantly higher than HIC estimates in 18 of the 19 towns, with discrepancies ranging from 13% to 29%. HIC-recorded providers accounted for between 65% and 100% of Pap tests per town, according to self-report. The highest Pap test rate by self-report was 70.1%, the highest by HIC was 49.2%. The lowest Pap test rate by self-report was 45.2%, the lowest by HIC was 26.1%. There was significant variation in Pap test rates between towns for adjusted self-report estimates, but not for the crude self-report estimates. Researchers should always be aware of both the possible variations according to data source and the inherent biases for whichever data source is used. An extra caution is given to consider the public/private provider profile when exploring possible geographical differences in Pap test rates.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Encouraging underscreened women to have cervical cancer screening: the effectiveness of a computer strategy

BACKGROUND

Computers that collect data from patients and provide both patients and practitioners with printed feedback on a range of health risks are a tool for assisting general practitioners with preventive care. This study assessed the impact of computer-generated printed feedback on cervical screening among women who were underscreened for cervical cancer.

METHOD

Female attenders at two Australian general practices were randomly allocated to Experimental or Control groups. Women in both groups completed a health risk survey on a touch screen computer prior to their consultation. Those in the Experimental group received printed pages summarizing their results, including their eligibility for cervical screening and last Pap test, for themselves and their doctor. The number and proportion of underscreened women who had a Pap test in the 6 months after completing the computer survey, as determined by pathology records, were examined.

RESULTS

Of the 679 participants, 139 were classified as underscreened on the basis of self-report (74 Experimental, 65 Control) and 272 on the basis of their pathology records (148 Experimental, 124 Control). Overall about one-third of women had a test in the 6-month period, and the differences between the groups were not significant for women overall (18-70 years) or for women 18-49 years. Among women 50-70 who were underscreened based on self-report, those receiving the printout were more likely to have a Pap test in the next 6 months (P < 0.05). This pattern was also evident, but did not reach statistical significance, for older women who were underscreened based on pathology records.

CONCLUSIONS

We are unable to draw conclusions regarding the effectiveness of the computer system due to the modest proportions of women screened, the small numbers, and the fact that the computer survey may have created an intervention effect in the Control group. As the study suggests the computer system is acceptable to women and may be effective for encouraging screening among older women, further exploration of the system is desirable.