November, 2016 - SUPPORT Summary of a systematic review | print this article |

What is the effectiveness of interventions targeted at women to improve the uptake of cervical cancer screening?

World-wide, cervical cancer is the second most common cancer in women and more than 85% of women dying from cervical cancer live in the developing world. Increasing the uptake of screening, alongside increasing informed choice, is key to controlling this disease through prevention and early detection. Methods of encouraging women to undergo cervical screening include invitations to screening; reminders to attend screening; education to increase knowledge of screening programmes or of cervical cancer; message framing (positive or negative messages about screening); counselling regarding barriers to screening; risk factor assessment of individuals; procedures, such as making the screening process easier; and economic interventions, such as incentives to attend screening.

Key messages

 

  • Education, counselling, access to health promotion nurse, invitations to attend cervical screening programmes, and intensive recruitment probably increase the uptake of cervical screening.
  • Enhanced risk factor assessment may lead to little or no difference in the uptake of screening.
  • Photo-comic book and message framing probably lead to little or no difference on the uptake of screening.
  • Most of the included studies were conducted in high-income countries.

 

Background

A woman's risk of developing cervical cancer by the age of 65 ranges from 0.8% in developed countries to 1.5% in developing countries. The Papanicolau, or Pap smear, screening test is the most widely used and is primarily aimed at detecting pre-cancerous changes within the cervix (i.e. abnormalities in the cells of the cervix known as dysplasia) before they have an opportunity to progress to more advanced disease. Pap smear uptake and coverage not only varies between countries, but differences also exist within countries between different socio-demographic groups, according to ethnic origin, age, education and socio-economic status. Women from ethnic minorities and deprived sub-groups in the population have shown consistently lower uptake over decades of screening in countries worldwide.

 



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of interventions aimed at women, to increase the uptake of cervical cancer screening
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials assessing universal, selective or opportunistic cervical cancer screening.
38 randomised trials, including 6 cluster randomised trials assessed invitations (17 studies), education (6), message framing (1), counselling (2), risk factor assessment (2), procedures (1), use of a photo comic book (1) and intensive recruitment (1).
Participants Women eligible to participate in cervical cancer screening.
Women receiving care in community clinics, primary care practices and Health Maintenance Organisations, mostly located in urban areas.
Settings Community, workplace, health centre and hospital settings.
USA (16 studies), Australia (9), UK (7), Canada (2), Sweden (2), South Africa (1) and Italy (1).
Outcomes

Primary outcomes: Uptake of cervical screening as recorded by health service records and via self-report.

Secondary outcomes: booking of appointments; reported intentions to attend screening; satisfaction with screening service, attitudes and knowledge about screening; costs of the interventions.


All primary outcomes, booking of appointments (1 study), acceptability of the intervention (1) and costs of the interventions (5).
Date of most recent search: March 2009
Limitations: This is well-conducted systematic review with only minor limitations.

Everett T, Bryant A, Griffin MF, Martin-Hirsch PP, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. The Cochrane database of systematic reviews. 2011(5):CD002834.

Summary of findings

The 38 included studies assessed varied interventions (invitations, education, counselling, risk factor assessment, message framing, procedures, photo comic book and intensive recruitment). Secondary outcomes, including cost data, were incompletely documented.

1) Invitations to attend cervical screening

Seventeen studies compared the effects of invitations to women to attend cervical screening programmes to usual care or no invitation. Diverse types (face-to-face, letter, telephone, celebrity letter, letter with fixed appointment, letter with open invitation to make an appointment) and sources of invitations (general practitioners, health clinics, programme coordinators) were examined. Effects were found to vary by types and sources of the invitations.

  • Invitations to attend cervical screening programmes probably increase the uptake of cervical screening. The certainty of this evidence is moderate.

Effect of invitations compared to usual care on uptake of cervical screening

People                Women eligible to participate in cervical cancer screening

Settings              Community clinics, primary care practices

Intervention       Invitations

Comparison        Usual care or no invitation

Outcomes

Usual care or no invitation

Invitations

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Absolute effect (95% CI)

Uptake of screening

55 per 1000

91 per 1000

(79 to 105)

RR 1.65

(1.44 to 1.90)

Moderate

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)


2) Education

Six studies compared the effects of education interventions to usual care or no education. Educational interventions were also compared with other interventions, such as invitation letters and risk assessment, to increase the uptake of cervical screening (these studies showed that educational interventions probably lead to little or no difference in cervical screening uptake, compared to other interventions).

 

  • Educational interventions for women probably increase the uptake of cervical screening. The certainty of this evidence is moderate.

Effect of education compared to usual care on uptake of cervical screening

People                  Women eligible to participate in cervical cancer screening

Settings                 Community clinics, primary care practices

Intervention          Educational interventions for women

Comparison           Usual care or no invitation

Outcomes (for specific educational interventions)

Control

Education

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Absolute effect (95% CI)

Uptake of screening with printed material

301 per 1000

334 per 1000
(265 to 424)

RR 1.11
(0.88 to 1.41)

Moderate

Uptake of screening with educational exercises or materials

187 per 1000

359 per 1000
(232 to 555)

RR 1.92

(1.24 to 2.97)

Moderate

Uptake of screening with face-to-face home visits

215 per 1000

502 per 1000
(224 to 1000)

RR 2.33

(1.04 to 5.23)

Moderate

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

3) Counselling

Two studies compared the effects of telephone or face-to-face counselling to usual care or no counselling. Telephone counselling to increase awareness of cervical screening programme probably leads to little or no difference compared to provider prompts.

  • Counselling probably increases the uptake of cervical screening. The certainty of this evidence is moderate.

Effect of counselling compared to usual care on uptake of cervical screening

People                 Women eligible to participate in cervical cancer screening

Settings               Community clinics, primary care practices

Intervention        Counselling

Comparison         Usual care or no counselling

Outcomes

Usual care or no invitation

Counselling

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Absolute effect (95% CI)

Uptake of screening

533 per 1000

656 per 1000
(554 to 773)

RR 1.23

(1.04 to 1.45)

Moderate

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

4) Risk Factor Assessment

Two studies compared the effects of providing enhanced risk factor assessment (a personally tailored assessment followed by a discussion with the healthcare provider about the woman’s personal risk factors for developing cervical cancer) to usual care or no risk factor assessment.

 

  • It is uncertain whether enhanced risk factor assessment affects the uptake of cervical screening, because the certainty of this evidence is very low.

Effect of enhanced risk factor assessment compared to usual care on uptake of cervical screening

People                 Women eligible to participate in cervical cancer screening

Settings               Community clinics, primary care practices

Intervention        Risk factor assessment

Comparison         Usual care or no risk factor assessment

Outcomes

Usual care or no invitation

Risk factor assessment

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Absolute effect (95% CI)

Uptake of screening

431 per 1000

654 per 1000
(250 to 1000)

RR 1.52

(0.58 to 3.95)

 

Very low

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

5) Other interventions aimed to increase the uptake of cervical screening

The review identified a number of other interventions to increase the uptake of cervical screening. Each of these was assessed by one study only. The findings were as follows:

 

  • Access to a health promotion nurse probably increases the uptake of cervical screening. The certainty of this evidence is moderate.
  • Photo-comic book may lead to little or no difference on the uptake of screening. The certainty of this evidence is low.
  • Intensive recruitment probably increases the uptake of cervical screening. The certainty of this evidence is moderate.
  • It is uncertain whether message framing (verbal or written messages about screening that are framed either positively or negatively) affects uptake of screening, because the certainty of this evidence is very low.

Effect of ‘other’ interventions compared to usual care on uptake of cervical screening

People              Women eligible to participate in cervical cancer screening

Settings            Community clinics, primary care practices

Intervention     Risk factor assessment

Comparison      Usual care or no risk factor assessment

Outcomes (for specific interventions)

Usual care or no intervention

interventions to increase the uptake of cervical screening

Relative effect

(95% CI)

Certainty

of the evidence

(GRADE)

Absolute effect (95% CI)

Uptake of screening through access to a health promotion nurse

431 per 1000

509 per 1000
(474 to 543)

RR 1.18

(1.10 to 1.26)

Moderate

Uptake of screening with photo-comic book

69 per 1000

66 per 1000
(37 to 119)

RR 0.96

(0.53 to 1.73)

Low

Uptake of screening with intensive recruitment

185 per 1000

294 per 1000
(229 to 381)

RR 1.59

(1.24 to 2.06)

Moderate

Uptake of screening with message framing

514 per 1000

406 per 1000
(247 to 668)

RR 0.79

(0.48 to 1.30)

 

Very low

Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
All except one of the included studies were conducted in high-income countries. One study was conducted in a middle-income country.

When assessing the transferability of these findings to low-income countries, the following factors should be considered:

− Literacy levels (e.g. for printed materials)

− Population migration, and access to remote areas

− Availability of resources for the intervention or devices, such as mobile phones, to disseminate messages

Acceptability and costs of the interventions


EQUITY

There was little information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations.

Amongst ethnic minority groups, lay members of the community could be useful in presenting culturally-tailored information, particularly when performed "face-to-face".


In many settings, women from ethnic minorities and deprived sub-groups in the population have lower uptake of cervical screening.

Resources needed for interventions may be less available in disadvantaged populations.

The interventions may increase inequity if they are not applied or adapted to these populations.


ECONOMIC CONSIDERATIONS
No trials assessing cost-effectiveness were identified. Five trials presented cost data, but all were conducted in high-income countries.

Scaling up of these interventions will require resources, and this should be considered when making decisions regarding implementation.

Local costings studies are desirable before scaling up these interventions.


MONITORING & EVALUATION

Sending invitations to women to attend cervical screening programmes is the intervention that has received most evaluation.

It is uncertain which type of interventions, for each categories of interventions are most effective.


Larger and more rigorous studies are required to determine the effects and the cost-effectiveness of interventions, particularly in resource-poor settings.

For each category of intervention, studies should identify which types are the most effective.

Future trials should also consider combination of interventions and ongoing changes in screening technology.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see:
www.supportsummaries.org/methods


 

Additional information

Related literature

Glick SB, Clarke AR, Blanchard A, Whitaker AK. Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review. Journal of general internal medicine. 2012;27(8):1016-1032.

 

Camilloni L, Ferroni E, Cendales BJ, et al. Methods to increase participation in organised screening programs: a systematic review. BMC public health. 2013; 13:464.

 

Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services. American journal of preventive medicine. 2012;43(1):97-118.

 

Brouwers MC, De Vito C, Bahirathan L, et al. What implementation interventions increase cancer screening rates? A systematic review. Implementation science: IS. 2011;6:111.

 

Baron RC, Rimer BK, Breslow RA, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review. American journal of preventive medicine. 2008;35(1 Suppl):S34-55.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Thomas Everett and Lize Maree.

 

This review should be cited as

Everett T, Bryant A, Griffin MF, Martin-Hirsch PP, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. The Cochrane database of systematic reviews. 2011(5):CD002834.

 

The summary should be cited as

Ciapponi A. What is the effectiveness of interventions targeted at women to improve the uptake of cervical cancer screening? November 2016. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care.

Antibiotic prescribing, hospital inpatients, antimicrobial stewardship, antibiotic policies, intervention strategies.

 



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