Increasing participation in cervical cancer screening: Telephone contact with long-term non-attendees in Sweden. Results from RACOMIP, a randomized controlled trial

Women's experiences with opting out of cervical cancer screening and the role of the nurse in the women's decision-making process

AIM

To explore Danish women's experiences with opting out of cervical cancer screening and the role of the nurse in the women's decision-making process.

DESIGN

A qualitative study using semi-structured, individual interviews with a phenomenological-hermeneutic approach.

METHODS

Interviews were conducted with 13 women with experience in opting out of cervical cancer screening. Women were recruited through a public flyer and interviewed virtually or by phone. The interviews were analysed using the theory of interpretation from Paul Ricoeur and consisted of three levels: naïve reading, structural analysis, and critical discussion and analysis. The present study adheres to the COREQ guidelines.

RESULTS

The women experience various personal causes for opting out of cervical cancer screening, such as low accessibility of screening appointments, discomfort during the smear test, fear of being sick, and insufficient information about the relevance of screening to the individual woman. The perceived disadvantages of screening outweighed their perceived advantages. The women's experiences did not include the role of the nurse in the procedures and knowledge sharing related to cervical cancer screening. However, nurses were described as having good communicative and relational qualifications relevant to being involved in cervical cancer screening.

CONCLUSION

It was challenging for the women to weigh the advantages and disadvantages of cervical cancer screening and thus to make an informed decision about participation. They expressed a need for more information on which to base their decision. This places nurses in a much needed, yet unexplored, role of identifying and lowering potential personal barriers that may outweigh the women's perceived benefits of participating in screening.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Nurses should play a more active role in cervical cancer screening such as improving general knowledge and facilitating two-way communication about its relevance.

REPORTING METHOD

The present study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Evaluation of self-sampling-based cervical cancer screening strategy using HPV Selfy CE-IVD test coupled with home-collection kit: a clinical study in Italy

BACKGROUND

Primary human papillomaviruses (HPV) cervical cancer screening can be strengthened by offering home-collection of biological specimen as a valuable option to increase screening coverage. As recommended by World Health Organization (WHO), screening programs should consider whether the inclusion of HPV self-sampling as a complementary option within their existing screening algorithms could address the gaps in current coverage. However, few HPV screening tests are validated for self-sampling according to international guidelines. This study aimed to test a self-sampling-based screening strategy, complementary to the main screening program based on clinician-collected cervical samples. The study took place in Trieste, Italy, and it aimed to evaluate the feasibility of self-testing at home under an opt-in system during COVID-19 pandemic in order to exploit self-sampling to reduce the screening delay generated by the lockdown.

METHODS

500 women, who should have received the screening call in 2020, were asked, via phone call, to participate in the study. To whom agreed, a home-collection kit, including a vaginal dry swab for specimen collection, was sent. The recipients performed the sample self-collection and sent back the swab through traditional mail using a prepaid envelope. Once received by the hospital, the samples were analyzed with HPV Selfy (Ulisse BioMed, Italy), a CE-IVD HPV screening test specifically validated for self-collection. Results were further compared using cobas® 4800 HPV (Roche, Switzerland).

RESULTS

80% women sent back their swab, showing one of the highest return rate obtained in comparable studies. 34 HPV-positive women were followed up and underwent the Pap test, that revealed 8 low squamous intraepithelial lesions (LSIL) cases, later triaged to colposcopy. HPV Selfy was confirmed to be an adequate test for self-sampling-based screening.

CONCLUSIONS

This study further confirmed the feasibility of self-test at home screening strategy based on self-sampling with an opt-in system as a support method to enhance cervical cancer screening coverage in Italy. Enrolled women showed a high appreciation for this approach. HPV Selfy test demonstrated to be a valuable assay for cervical cancer screening based on home self-collection.

TRIAL REGISTRATION

ASUGI Trieste n. 16008/2018 and amendment 02-11/09/2020.

Socioeconomic, lifestyle and biological determinants of cervical screening coverage: Lolland-Falster Health Study, Denmark

BACKGROUND

Cervical cancer is preventable. Screening is important for early detection. However, even in high-income countries, coverage is sub-optimal. We identified socioeconomic, lifestyle and biological determinants of cervical screening coverage.

METHODS

In Denmark, women aged 23-64 are free of charge personally invited to screening. All cervical cell samples are registered centrally in the Patobank. We linked data from the Lolland-Falster Health Study (LOFUS) with Patobank data. LOFUS was a population-based health survey undertaken in 2016-2020. With logistic regression, coverage defined as ≥1 cervical sample registered within a 6-year period from 2015 to 2020 was compared across levels of risk factors expressed as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Among 13 406 women of screening aged 23-64 and invited to LOFUS, 72% had ≥1 cervical sample registered. Non-participation in LOFUS was a strong predictor of low coverage; aOR 0.32; 95% CI 0.31-0.36. Among LOFUS participants, education was a strong predictor of coverage in univariate analysis, OR 0.58; 95% CI 0.48-0.71, but this association disappeared in multi-variate analysis, aOR 0.86; 95% CI 0.66-1.10. In multi-variate analysis, predictors of low coverage were high age, living without a partner, retired, current smoker, poor self-rated health, elevated blood pressure and elevated glycated haemoglobin.

CONCLUSIONS

Women with low cervical screening coverage had limited contact to healthcare, exemplified by non-participation in LOFUS, and pertinent health and social problems, exemplified by elevated blood pressure and glycated haemoglobin, poor self-rated health, and retirement already in screening age. Structural changes in screening are needed to reach non-screened women.

The Effects of Theory-Based Educational Intervention and WhatsApp Follow-up on Papanicolaou Smear Uptake Among Postnatal Women in Malaysia: Randomized Controlled Trial

Background

Despite the availability and accessibility of free Papanicolaou (Pap) smear as a screening tool for cervical cancer, the uptake of Pap smear in Malaysia has not changed in the last 15 years. Previous studies have shown that the high uptake of Pap smear reduces the mortality rate of patients with cervical cancer. The low uptake of Pap smear is multifactorial, and the problem could be minimized through the use of mobile technologies. Nevertheless, most intervention studies focused on individual factors, while other important aspects such as mobile technologies, especially WhatsApp, have not been investigated yet.

Objective

This study aims to determine the effects of a theory-based educational intervention and WhatsApp follow-up (Pap smear uptake [PSU] intervention) in improving PSU among postnatal women in Seremban, Negeri Sembilan, Malaysia.

Methods

A 2-arm, parallel single-blind cluster randomized controlled trial was conducted among postpartum women from the Seremban district. Twelve health clinics were randomly assigned to the intervention and control groups. At baseline, both groups received a self-administered questionnaire. The intervention group received standard care and PSU intervention delivered by a researcher. This 2-stage intervention module was developed based on Social Cognitive Theory, where the first stage was conducted face-to-face and the second stage included a WhatsApp follow-up. The control group received standard care. Participants were observed immediately and at 4, 8, and 12 weeks after the intervention. The primary endpoint was PSU, whereas the secondary endpoints were knowledge, attitude, and self-efficacy scores for Pap smear screening self-assessed using a Google Forms questionnaire. A generalized mixed model was used to determine the effectiveness of the intervention. All data were analyzed using IBM SPSS (version 25), and P value of .05 was considered statistically significant.

Results

We analyzed 401 women, of whom 76 (response rate: 325/401, 81%) had withdrawn because of the COVID-19 pandemic, with a total of 162 respondents in the intervention group and 163 respondents in the control group. The proportion of Pap smears at the 12-week follow-up was 67.9% (110/162) in the intervention group versus 39.8% (65/163) in the control group (P<.001). Significant differences between the intervention and control groups were found for Pap smear use (F_4,1178; P<.001), knowledge scores (F_4,1172=14.946; P<.001), attitude scores (F_4,1172=24.417; P<.001), and self-efficacy scores (F_1,1172=10.432; P<.001).

Conclusions

This study demonstrated that the PSU intervention is effective in increasing the uptake of Pap smear among postnatal women in Seremban district, Malaysia. This intervention module can be tested in other populations of women.

Trial Registration

Thai Clinical Trials Registry TCTR20200205001; https://www.thaiclinicaltrials.org/show/TCTR20200205001

The Significant Predictors for Breast, Cervical, Colorectal, or Oral Cancer Screening Intention and Behavior in Taiwan

BACKGROUND

Cancer screening can improve outcomes in patients with cancer. Accordingly, under the direction of the National Health Insurance program, the Taiwan government conducts screenings for breast cancer, cervical cancer, oral cancer, and colorectal cancer.

OBJECTIVE

The aim of this study was to identify the primary predictors of cancer screening intention and behavior at 1 and 6 months after patients are provided information and an invitation by telephone to attend cancer screenings.

METHODS

In this prospective longitudinal study, 339 participants meeting the screening criteria were recruited. At baseline, telephone interviews were used to collect information on demographic characteristics, exercise and smoking habits, family cancer history, screening beliefs, and screening intention. Screening behavior was followed up at 1 and 6 months after the telephone interviews.

RESULTS

At baseline, 87.02% of the participants intended to undergo screening, and 31.86% and 63.42% had undergone screening after 1 and 6 months, respectively. The predictors of screening intention were awareness of the screening policy, willingness to learn about screening, and believing in the health benefits of screening. The predictor of screening behavior after 1 month was screening intention at baseline, and the predictors of behavior after 6 months were screening intention, marital status, and belief that cancer is a hereditary disease.

CONCLUSION

Adults with screening intention tended to undergo cancer screenings.

IMPLICATIONS FOR PRACTICE

The use of strategies based on screening intention, beliefs, and information can be used to improve participation in cancer screening in Taiwan.

Family-Centered Sexual Health Intervention to Promote Cervical Cancer Screening Uptake Among Low-income Rural Women in India: A Community-Based Mixed-Method Pilot study (Preprint)

Background

Objective

Methods

Results

Conclusions

International Registered Report Identifier (IRRID)

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.

Out of reach? Correlates of cervical cancer underscreening in women with varying levels of healthcare interactions in a United States integrated delivery system

One in five U.S. women with health insurance are underscreened for cervical cancer. We sought to identify whether underscreening correlates differed among women with different levels of health care interaction. Among women age 30-64 years who were members of an integrated U.S. health system, we used 2014-2015 electronic health record data to identify underscreened cases (≥3.4 years since last Papanicolaou (Pap) test, n=3352) and screening-adherent controls (<3.4 years since last Pap test, n=45,359) and extracted data on potential underscreening correlates (demographics, health history, and healthcare utilization). We calculated the odds of underscreening in the total population and by subgroups defined by healthcare visits and online health portal usage in the prior 12 months. Underscreening was associated with older age (50-64 vs. 30-39; odds ratio (OR)=1.6; 95%CI=1.4-1.8), current tobacco use (vs. never use; OR=2.1; 95%CI=1.8-2.2), higher BMI (≥35 kg/m² vs <25 kg/m², OR=2.0; 95%CI=1.8-2.3), screening non-adherence for colorectal cancer (OR=5.1; 95%CI=4.6-5.7) and breast cancer (OR=8.1, 95%CI=7.2-9.0), and having no recent visit with their primary care provider (PCP) nor recent health portal use (vs. recent PCP visit and portal use; OR=8.4, 95%CI=7.6-9.4). Underscreening correlates were similar between the total study population and within all healthcare interaction groups. Interaction with the healthcare system is associated with lower odds of underscreening, but sociodemographic and health status correlates are similar regardless of primary care visits or online portal use. These data support the need for additional interventions to reach insured women who remain underscreened for cervical cancer.

Interventions using mHealth strategies to improve screening rates of cervical cancer: A scoping review

MHealth interventions are extensively used to inform and remind women about cervical cancer and their upcoming screening appointments. Our scoping review aims to examine the effectiveness these interventions targeted to increase the uptake of cervical cancer screening along with its barriers and facilitators. We searched 4 databases (PsycINFO. PUBMED, CINAHL, and MEDLINE) for studies that were published between January 1, 2009 and October 2019. References were further screened manually for additional papers. Studies were included in the review if they used interventions including phone calls, text messages and mobile applications as their primary strategy to contact women. We identified 12 unique studies that met the inclusion criteria; seven were international studies. Most studies sent multiple messages (informative and reminder) and/or made numerous phone calls (manual/automated) to inform participants about cervical cancer screening, their nearest screening clinic, and their upcoming appointments. Five studies documented a significant increase in the uptake of cervical cancer screenings during the follow-ups conducted within 12 months. Qualitative studies suggested participants prefer particular communication mediums, and they were concerned about privacy and confidentiality issues when text messages were sent with their health information. Findings suggest mHealth interventions may be an effective strategy to reach women for improving their cervical cancer uptake. Barriers including transportation cost, inaccessibility, and inability to come for walk-in appointments in the health clinics need to be addressed, beyond reminders, in mobile phone-based interventions to facilitate their presence in their next appointment.

Non-participation in cervical cancer screening according to health, lifestyle and sexual behavior: A population-based study of nearly 15,000 Danish women aged 23-45 years

High participation in cervical cancer screening is essential for an effective screening program. In this population-based study, we investigated associations between general health, lifestyle and sexual behavior, and non-participation in cervical cancer screening in Denmark. During 2011-2012, a random sample of women aged 18-45 years from the general female population were invited to participate in a survey regarding health, lifestyle and sexual habits. Altogether 18,631 women responded (response rate: 75.1%), of whom 14,271 women aged 23-45 years were included in this analysis. Information on screening participation within four years after response, and data on sociodemographic characteristics, was obtained from nationwide registers. Logistic regression was used to calculate odds ratios (ORs) for non-participation, crude and adjusted for sociodemographic characteristics. Overall, 13.9% of the women were not screened during follow-up. The odds of non-participation was increased in women who were overweight (OR_adj. = 1.20; 95% CI, 1.06-1.35), obese (OR_adj. = 1.46; 95% CI, 1.27-1.67), perceived themselves as much too fat (OR_adj. = 1.50; 95% CI, 1.29-1.74), had poor self-perceived health (OR_adj. = 1.22; 95% CI, 1.03-1.45) or smoked daily (OR_adj. = 1.81; 95% CI, 1.61-2.03). Conversely, women with previous genital warts or other sexually transmitted infections, and young women with ≥10 lifetime sexual partners or ≥2 new recent partners, had decreased odds of non-participation. In conclusion, obesity, poor self-perceived health and daily smoking were associated with lower participation in cervical cancer screening. Interventions targeting these groups are needed.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health

BACKGROUND

The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH.

OBJECTIVES

To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second.

MAIN RESULTS

We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences.

AUTHORS' CONCLUSIONS

The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Targeted client communication via mobile devices for improving sexual and reproductive health

BACKGROUND

The burden of poor sexual and reproductive health (SRH) worldwide is substantial, disproportionately affecting those living in low- and middle-income countries. Targeted client communication (TCC) delivered via mobile devices (MD) (TCCMD) may improve the health behaviours and service use important for sexual and reproductive health.

OBJECTIVES

To assess the effects of TCC via MD on adolescents' knowledge, and on adolescents' and adults' sexual and reproductive health behaviour, health service use, and health and well-being.

SEARCH METHODS

In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification.

SELECTION CRITERIA

We included randomised controlled trials of TCC via MD to improve sexual and reproductive health behaviour, health service use, and health and well-being. Eligible comparators were standard care or no intervention, non-digital TCC, and digital non-targeted communication.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. We have presented results separately for adult and adolescent populations, and for each comparison.

MAIN RESULTS

We included 40 trials (27 among adult populations and 13 among adolescent populations) with a total of 26,854 participants. All but one of the trials among adolescent populations were conducted in high-income countries. Trials among adult populations were conducted in a range of high- to low-income countries. Among adolescents, nine interventions were delivered solely through text messages; four interventions tested text messages in combination with another communication channel, such as emails, multimedia messaging, or voice calls; and one intervention used voice calls alone. Among adults, 20 interventions were delivered through text messages; two through a combination of text messages and voice calls; and the rest were delivered through other channels such as voice calls, multimedia messaging, interactive voice response, and instant messaging services. Adolescent populations TCCMD versus standard care TCCMD may increase sexual health knowledge (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.23 to 1.71; low-certainty evidence). TCCMD may modestly increase contraception use (RR 1.19, 95% CI 1.05 to 1.35; low-certainty evidence). The effects on condom use, antiretroviral therapy (ART) adherence, and health service use are uncertain due to very low-certainty evidence. The effects on abortion and STI rates are unknown due to lack of studies. TCCMD versus non-digital TCC (e.g. pamphlets) The effects of TCCMD on behaviour (contraception use, condom use, ART adherence), service use, health and wellbeing (abortion and STI rates) are unknown due to lack of studies for this comparison. TCCMD versus digital non-targeted communication The effects on sexual health knowledge, condom and contraceptive use are uncertain due to very low-certainty evidence. Interventions may increase health service use (attendance for STI/HIV testing, RR 1.61, 95% CI 1.08 to 2.40; low-certainty evidence). The intervention may be beneficial for reducing STI rates (RR 0.61, 95% CI 0.28 to 1.33; low-certainty evidence), but the confidence interval encompasses both benefit and harm. The effects on abortion rates and on ART adherence are unknown due to lack of studies. We are uncertain whether TCCMD results in unintended consequences due to lack of evidence. Adult populations TCCMD versus standard care For health behaviours, TCCMD may modestly increase contraception use at 12 months (RR 1.17, 95% CI 0.92 to 1.48) and may reduce repeat abortion (RR 0.68 95% CI 0.28 to 1.66), though the confidence interval encompasses benefit and harm (low-certainty evidence). The effect on condom use is uncertain. No study measured the impact of this intervention on STI rates. TCCMD may modestly increase ART adherence (RR 1.13, 95% CI 0.97 to 1.32, low-certainty evidence, and standardised mean difference 0.44, 95% CI -0.14 to 1.02, low-certainty evidence). TCCMD may modestly increase health service utilisation (RR 1.17, 95% CI 1.04 to 1.31; low-certainty evidence), but there was substantial heterogeneity (I2 = 85%), with mixed results according to type of service utilisation (i.e. attendance for STI testing; HIV treatment; voluntary male medical circumcision (VMMC); VMMC post-operative visit; post-abortion care). For health and well-being outcomes, there may be little or no effect on CD4 count (mean difference 13.99, 95% CI -8.65 to 36.63; low-certainty evidence) and a slight reduction in virological failure (RR 0.86, 95% CI 0.73 to 1.01; low-certainty evidence). TCCMD versus non-digital TCC No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may modestly increase in service attendance overall (RR: 1.12, 95% CI 0.92-1.35, low certainty evidence), however the confidence interval encompasses benefit and harm. TCCMD versus digital non-targeted communication No studies reported STI rates, condom use, ART adherence, abortion rates, or contraceptive use as outcomes for this comparison. TCCMD may increase service utilisation overall (RR: 1.71, 95% CI 0.67-4.38, low certainty evidence), however the confidence interval encompasses benefit and harm and there was considerable heterogeneity (I2 = 72%), with mixed results according to type of service utilisation (STI/HIV testing, and VMMC). Few studies reported on unintended consequences. One study reported that a participant withdrew from the intervention as they felt it compromised their undisclosed HIV status.

AUTHORS' CONCLUSIONS

TCCMD may improve some outcomes but the evidence is of low certainty. The effect on most outcomes is uncertain/unknown due to very low certainty evidence or lack of evidence. High quality, adequately powered trials and cost effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCC delivered by mobile devices. Given the sensitivity and stigma associated with sexual and reproductive health future studies should measure unintended consequences, such as partner violence or breaches of confidentiality.

Participation in interventions and recommended follow-up for non-attendees in cervical cancer screening -taking the women's own preferred test method into account-A Swedish randomised controlled trial

Background

Cervical cancer is a highly preventable disease. To not attend an organized cervical cancer screening program increases the risk for cervical dysplasia and cervical cancer. The aim was to investigate the participation rate in three different intervention groups for non- attendees in the Swedish national program for cervical screening. The participation in the recommended follow up, and the histology found were also examined.

Method

Population-based randomized control trial. It included10,614 women that had not participated in the cervical cancer screening programme during the last six years (ages 30–49) and the last eight years (ages 50–64) were randomised 1:1:1(telephone call from a midwife (offering the choice between a visit for a pap smear or an HPV self-sampling test); an HPV self-sampling test only; or the routine procedure with a yearly invitation).

Results

In the intention to treat analysis the participation rates were 25.5% (N = 803/3146) vs 34.1% (N = 1047/3068) and 7.0% (N = 250/3538) (p<0.001) for telephone, HPV self-test and control groups respectively. In the by protocol analysis including women that answered the phone call the participation rates were 31.7% (N = 565/1784) vs 26.1% (N = 788/3002) and 7.0% (N = 250/3538) (p<0.001) for telephone, HPV self-test and control groups. The corresponding results in the by protocol analysis including women that did not answer the phone call was 19.7% (N = 565/2870) vs 26.1% (N = 788/3002) and 7.0% (N = 250/3538) (p< 0.001). The majority of the women 63,4% (1131/1784) who answered the telephone wanted to participate either by booking a visit for pap smear (38,5%) or to be sent a HPV self- sampling test (24,9%) (p<0.001). Women who chose an HPV self-test were older and gave anxiety/ fear as a reason to decline participation, and they were also less likely to participate in the follow-up if found to be HPV-positive compared to the women who chose a Pap smear. The attendance to the recommended follow-up after abnormality was in total 87%. The non-attendees had a three or eight times higher risk of having a cytology result of HSIL or suspected SCC respectively, in the index sample compared to women screened as recommended (OR 3.3 CI 95% 1.9–5.2, OR 8.6 CI 1.6–30). A total of ten SCC and one adenocarcinoma were found in the histopathology results from the non-attendee group with a study intervention, while there was only one SCC in the non-attendee group without any study intervention (p = 0.02, OR 8.1 CI 95% 1.2–350).

Conclusions

Our study suggests, according to intention to treat analysis, that the best intervention to get as many non-attendees as possible to participate is to send an HPV self-sampling test together with an invitation letter. Almost 90% of women in the study with an abnormal index sample attended follow-up. This is high enough to indicate that interventions to increase the participation among non-attendees are meaningful.

Registry

International Standard Randomised Controlled Trial Number (ISRCTN)

Registration number ISRCTN78719765.

Cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening

BACKGROUND

Cervical cancer screening is effective in reducing mortality, but adherence is generally low. We aimed to investigate the cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening in Portugal.

METHODS

We developed a decision tree model to compare the cost-effectiveness of four competing interventions to increase adherence to cervical cancer screening: (i) a written letter (standard-of-care); (ii) automated short message service text messages (SMS)/phone calls/reminders; (iii) automated SMS/phone calls/reminders + manual phone calls; (iv) automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. The main outcome measure was cost per quality-adjusted life year (QALY) measured over a 5-year time horizon. Costs were calculated from the societal and provider perspectives.

RESULTS

From the societal perspective, the optimal strategy was automated SMS/phone calls/reminders, below a threshold of €8171 per QALY; above this and below €180 878 per QALY, the most cost-effective strategy was automated SMS/phone calls/reminders + manual phone calls and above this value automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. From the provider perspective, the ranking of the three strategies in terms of cost-effectiveness was the same, for thresholds of €2756 and €175 463 per QALY, respectively.

CONCLUSIONS

Assuming a willingness-to-pay threshold of one time the national gross domestic product (€22 398/QALY), automated SMS/phone calls/reminders + manual phone calls is a cost-effective strategy to promote adherence to cervical cancer screening, both from the societal and provider perspectives.

Cervical cancer prevention among long-term screening non-attendees by vaginal self-collected samples for hr-HPV mRNA detection

Background

The efficacy of cervical cancer screening programs is dependent on the participation rate. To increase participation among women not attending cervical cancer screening, self-collected samples for detection of high-risk human papillomavirus (hr-HPV) may be an option.

The aims of this study were: to investigate the response rate to sending a self-collected vaginal sample for hr-HPV mRNA detection to long-term non-attendees; the compliance with follow-up among women positive for HPV in the self-sample; the prevalence of cervical dysplasia (high grade squamous intraepithelial lesion (HSIL), atypical squamous cells that cannot exclude HSIL (ASC-H) or adenocarcinoma in situ (AIS)) or cancer among the responders; as well as to explore reasons for not returning a self-sample.

Methods

A vaginal self-sampling kit was sent to 6023 women aged 30–70 years who had not provided a cervical screening sample for ≥7 years in the Region of Skåne, Sweden in November and December 2017. The self-sample was analyzed by Aptima HPV mRNA assay (Hologic). All vaginal self-samples returned no later than May 31, 2018 were included in the study. Follow-up of the results was registered until January 31, 2019 with a follow-up time varying between eight to 14 months. Women positive for hr-HPV mRNA were invited for a follow-up examination. This examination consisted of a cervical sample for cytological analysis and renewed Aptima HPV mRNA testing. Two hundred thirty-five women who had not returned the self-sample were randomly selected for telephone interviews, in order to explore their reasons.

Results

The response rate for the self-collected vaginal hr-HPV sample was 13.2% [(797/6023), 95% CI 12.4–14.1%] and 9.9% [(79/796), 95% CI 7.9–12.2%] were positive for hr-HPV mRNA. The prevalence of severe dysplasia or cancer in the whole group of responders was 1.3% [(10/796), 95% CI 0.6–2.3%], with a cervical cancer prevalence of 0.4% [(3/796), 95% CI 0.1–1.1%]. Only 27 women participated in the telephone interviews, no particular reason for not returning self-samples was observed.

Conclusions

Self-collected vaginal hr-HPV samples increased participation in the cervical cancer screening among long-term non-attendees. The prevalence of cervical cancer was almost seven times higher for long-term non-attendees than in the organized screening population.

The Cost-Effectiveness Analysis of Cervical Cancer Screening Using a Systematic Invitation System in Lithuania

In Lithuania, cytological screening of cervical cancer (CC) is largely opportunistic. Absence of standardized systematic invitation practice might be the reason for low participation rates. The study aimed to assess the cost-effectiveness of systematic invitation approach in CC screening programme from the perspective of a healthcare provider. A decision tree was used to compare an opportunistic invitation by a family doctor, a personal postal invitation letter with appointment time and place, and a personal postal invitation letter with appointment time and place with one reminder letter. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) per one additionally screened woman and per one additional abnormal Pap smear test detected. The ICER of one personal postal invitation letter was €9.67 per one additionally screened woman and €55.21 per one additional abnormal Pap smear test detected in comparison with the current screening practice. The ICER of a personal invitation letter with an additional reminder letter compared to one invitation letter was €13.47 and €86.88 respectively. Conclusions: A personal invitation letter approach is more effective in increasing the participation rate in CC screening and the number of detected abnormal Pap smears; however, it incurs additional expenses compared with current invitation practice.

Organised Versus Opportunistic Cervical Cancer Screening in Urban and Rural Regions of Lithuania

Background and Objectives: In 2004, Lithuania started the Nationwide Cervical Cancer Screening Programme. However, screening is more opportunistic than population-wide and the programme’s coverage is insufficient. The aim of this study was to assess the effect of systematic personal invitation on coverage of cervical cancer (CC) screening in urban and rural regions of Lithuania. Materials and Methods: The study was conducted in an urban primary healthcare centre (PHCC) and in a rural PHCC, where prevailing CC screening practice was highly opportunistic. Over the first year, all women aged 25–60 who had not received a Pap smear test within the last three years in urban (n = 1591) and rural (n = 1843) PHCCs received a personal invitation letter to participate in the screening. Over the second year, the reminder letter was sent to the non-attendees (n = 1042 in urban and n = 929 in rural PHCCs). A random sample of women (n = 93), who did not attend for screening after two letters, was contacted by phone in order to identify the barriers of non-attendance. Results: Before the study, only 9.6% of the target population in urban and 14.7% in rural PHCCs participated in CC screening. After the first invitation letter, the participation in CC screening increased up to 24.6% in urban and 30.8% in rural areas (p < 0.001). After the reminder letter, the attendance was 16.4% in urban and 22.2% in rural PHCCs (p < 0.001). The most common barriers for the non-attendance were lack of time, long waiting time for family doctor’s appointment, worries that a Pap test might be unpleasant and preventive gynaecological examination outside of the screening program. Conclusions: A systematic personal invitation with one reminder letter significantly increased the coverage of CC screening and was more effective in rural regions than in urban regions. The assessed barriers for non-attendance can be used to improve the coverage of screening.

Challenges in delivery and performance of a cervical cancer prevention program in the Kurdistan Region of the Iraq health system

OBJECTIVE

To investigate health-system challenges responsible for the poor performance of a cervical cancer prevention program in the Kurdistan Region of Iraq.

METHOD

A qualitative study was conducted among a purposive sample of healthcare providers and female volunteers in Erbil, Kurdistan Region of Iraq, between December 10, 2014, and July 23, 2016. Data were collected from participants using in-depth semi-structured interviews. The interviews were then transcribed and analyzed with an inductive content analysis approach.

RESULTS

In total, 23 individuals completed the interviews. The participants included 8 (35%) female volunteers; 5 (22%) nurses; 4 (17%) managers; 3 (13%) doctors; and 3 (13%) gynecologists. The health-system challenges were classified into three main categories: existence of an official reminder system, public information delivery programs, and infrastructures of facilities, which included three subcategories-cervical cancer screening center, material resources, and human resources.

CONCLUSIONS

The Kurdistan Region of Iraq health system faced several challenges in delivering a cervical cancer prevention program. These challenges must be addressed to improve the coverage of cervical cancer screening, diagnosis, and treatment.

Stepwise strategy to improve cervical cancer screening adherence (SCAN-Cervical Cancer) - Automated text messages, phone calls and reminders: Population based randomized controlled trial

The aim of this study was to test the effectiveness of invitation to cervical cancer screening through a very low-cost strategy based on automated and customized text messages, phone calls and reminders. A randomized (1:1) controlled trial was conducted among 13 Portuguese primary care units, recruiting women aged 25 to 49 years, eligible for cervical cancer screening, with an available mobile phone number. In the intervention group, participants were invited for cervical cancer screening through automated/customized text messages and phone calls, followed by text message reminders. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women adherent to screening up to 45 days after invitation and the secondary outcome was defined as the adherence proportion after invitation based only on text messages and reminders. A total of 1220 women were randomized, 605 to intervention and 615 to control group. The adherence to cervical cancer was significantly higher among women assigned to intervention (39.0% vs. 25.7%, p < 0.001); this corresponds to a difference of 13.3% (95% CI 8.1 to 18.5). The difference in adherence between an invitation strategy based only on text messages and reminders and the standard of care was -0.4%, 95% CI -5.3 to 4.5. In conclusion, an invitation to cervical cancer screening using automated text messages/phone calls and reminders increases the adherence to cervical cancer screening. Such a low-cost and operator-independent strategy of invitation may contribute to the sustainability of organized screening programs.

TRIAL REGISTRATION NUMBER

NCT03122275.

Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study

Background

Cervical screening programs are highly protective for cervical cancer, but only for women attending screening procedure.

Objective

Identify socio-economic and demographic determinants for non-attendance in cervical screening.

Methods

Design: Population-based case-control study.

Setting: Sweden.

Population: Source population was all women eligible for screening. Based on complete screening records, two groups of women aged 30–60 were compared. The case group, non-attending women, (N = 314,302) had no smear registered for 6–8 years. The control group (N = 266,706) attended within 90 days of invitation.

Main outcome measures: Risk of non-attendance by 9 groups of socioeconomic and demographic variables.

Analysis: Unadjusted odds ratios (OR) and OR after adjustment for all variables in logistic regression models were calculated.

Results

Women with low disposable family income (adjOR 2.06; 95% confidence interval (CI) 2.01–2.11), with low education (adjOR 1.77; CI 1.73–1.81) and not cohabiting (adjOR 1.47; CI 1.45–1.50) were more likely to not attend cervical screening. Other important factors for non-attendance were being outside the labour force and receiving welfare benefits. Swedish counties are responsible for running screening programs; adjusted OR for non-participation in counties ranged from OR 4.21 (CI 4.06–4.35) to OR 0.54 (CI 0.52–0.57), compared to the reference county. Being born outside Sweden was a risk factor for non-attendance in the unadjusted analysis but this disappeared in certain large groups after adjustment for socioeconomic factors.

Conclusion

County of residence and socio-economic factors were strongly associated with lower attendance in cervical screening, while being born in another country was of less importance. This indicates considerable potential for improvement of cervical screening attendance in several areas if best practice of routines is adopted.

Interventions that facilitate adherence to Pap smear exam: integrative review

RESUMO Objetivo: identificar produções científicas que apresentem intervenções relevantes para implementar o Programa de Prevenção do Câncer Cérvico-Uterino, aumentando a adesão à realização do exame. Método: revisão integrativa da literatura, realizada por busca on-line, nas bases de dados: LILACS, SciELO e Pubmed®, abrangendo artigos publicados de 2009 a 2014. Resultados: trinta e oito artigos compuseram a amostra final do estudo. Estes indicaram as seguintes intervenções: utilização de gerente de caso, contato telefônico, carta-convite, atividades educativas, divulgação na mídia, agentes de saúde da comunidade, parcerias, rastreamento de base populacional e múltiplas intervenções. Conclusão: as pesquisas concentram-se entre mulheres provenientes de países em desenvolvimento, e estas intervenções são eficazes no aumento da adesão e do conhecimento destas mulheres em relação à prevenção do câncer cérvico-uterino.

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.

The Effects of an Educational Intervention on Preventing Cervical Cancer Among Vietnamese Women in Southern Taiwan

This paper aims to conduct and evaluate an educational intervention on preventing cervical cancer among married immigrant women of Vietnamese origin. The study design was a quasi-experimental method with two groups. In total, 260 married immigrant women of Vietnamese origin with national health insurance at least 30 years of age were recruited from November 2013 to January 2015 in southern Taiwan. The effects of the educational intervention, including cervical cancer and Papanicolaou test knowledge, attitudes towards cervical cancer, fatalism, barriers to receiving Papanicolaou tests, intention for receiving Papanicolaou tests within the next year, and intention for receiving Papanicolaou tests within the next 3 years, were evaluated. Repeated measures analyses of variance showed significant interactions between the intervention group and time for cervical cancer knowledge, knowledge of Papanicolaou test, attitudes towards cervical cancer, and intention for receiving a Papanicolaou test within the next 3 years; in addition, 71.4 % reported being satisfied or very satisfied with the intervention. The results of this study can provide information for governments to make appropriate health policies for screening behavior of cervical cancer, increase healthcare professionals' competencies towards Vietnamese women, and increase Papanicolaou test screening rates to decrease cervical cancer mortality. Effective interventions may require particular consideration of married immigrant women.

Cost-effectiveness of strategies to increase screening coverage for cervical cancer in Spain: the CRIVERVA study

BACKGROUND

The aim of the study is to carry out a cost-effectiveness analysis of three different interventions to promote the uptake of screening for cervical cancer in general practice in the county of Valles Occidental, Barcelona, Spain.

METHODS

Women aged from 30 to 70 years (n = 15,965) were asked to attend a general practice to be screened. They were randomly allocated to one of four groups: no intervention group (NIG); one group where women received an invitation letter to participate in the screening (IG1); one group where women received an invitation letter and informative leaflet (IG2); and one group where women received an invitation letter, an informative leaflet and a phone call reminder (IG3). Clinical effectiveness was measured as the percentage increase in screening coverage. A cost-effectiveness analysis was performed from the perspective of the public health system with a time horizon of three to five years - the duration of the randomised controlled clinical trial. In addition, a deterministic sensitivity analysis was performed. Results are presented according to different age groups.

RESULTS

The incremental cost-effectiveness ratio (ICER) for the most cost-effective intervention, IG1, compared with opportunistic screening was € 2.78 per 1% increase in the screening coverage. The age interval with the worst results in terms of efficiency was women aged < 40 years.

CONCLUSIONS

In a population like Catalonia, with around 2 million women aged 30 to 70 years and assuming that 40% of these women were not attending general practice to be screened for cervical cancer, the implementation of an intervention to increase screening coverage which consists of sending a letter would cost on average less than € 490 for every 1000 women.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01373723 .

Effect of Fee on Cervical Cancer Screening Attendance--ScreenFee, a Swedish Population-Based Randomised Trial

BACKGROUND

Attendance in the cervical cancer screening programme is one of the most important factors to lower the risk of contracting the disease. Attendance rates are often low in areas with low socioeconomic status. Charging a fee for screening might possibly decrease attendance in this population. Screening programme coverage is low in low socio-economic status areas in Gothenburg, Sweden, but has increased slightly after multiple interventions in recent years. For many years, women in the region have paid a fee for screening. We studied the effect of abolishing this fee in a trial emanating from the regular cervical cancer screening programme.

METHOD

Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.

RESULTS

Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.

CONCLUSION

Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02378324.

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.

Cervical cancer screening at crossroads

Cervical screening has been one of the most successful public health prevention programmes. For 50 years, cytology formed the basis for screening, and detected cervical intraepithelial lesions (CIN) were treated surgically to prevent progression to cancer. In a high-risk country as Denmark, screening decreased the incidence of cervical cancer from 34 to 11 per 100,000, age-standardized rate (World Standard Population). Screening is, however, also expensive; Denmark (population: 5.6 million) undertakes close to half a million tests per year, and has 6-8 CIN-treated women for each prevented cancer case. The discovery of human papillomavirus (HPV) as the cause of cervical cancer dramatically changed perspectives for disease control. Screening with HPV testing was launched around 1990, and preventive HPV vaccination was licensed in 2006. Long-term randomized controlled trials (RCT) demonstrated that HPV testing provides better protection against cervical cancer than cytology, but it requires extra repeated testing. HPV vaccination RCTs, furthermore, have proved that HPV vaccination protects against vaccine-type high-grade CIN in women vaccinated prior to sexual activity, but less so in women vaccinated later. The challenge now is therefore to find an algorithm for screening of a heterogeneous population including non-vaccinated women; women vaccinated prior to start of sexual activity; and women vaccinated later.

Attending cervical cancer screening, opportunities and obstacles: a qualitative study on midwives' experiences telephoning non-attendees in Sweden

AIM

As part of a research project aimed at increasing participation in the cervical cancer screening program (CCS), we explored midwives' unique experiences of telephoning non-attendees and offering Pap smear appointments.

METHODS

Twenty midwives, in four focus groups, discussed their experiences of a study investigating ways to increase participation in the CCS. The group discussions were tape-recorded and transcribed verbatim and underwent qualitative content analysis.

RESULTS

Speaking with more than 1000 non-attendees provided the midwives with new perspective on the CCS and they realised that improving it might address a number of reasons for not participating. These reasons were often related to logistics, such as scheduling flexibility and appointment booking. The telephone conversations revealed that some women required more individual attention, while it was discovered that others did not require screening. The midwives considered the CCS to be life-saving; participating in this screening activity gave them a sense of satisfaction and pride.

CONCLUSIONS

This study shows that midwives can improve access and prevent non-attendance at the cervical cancer screening program when they are aware of women's varying requirements for attending screening.

Reasons for non-attendance to cervical screening and preferences for HPV self-sampling in Dutch women

OBJECTIVES

High attendance rates in cervical screening are essential for effective cancer prevention. Offering HPV self-sampling to non-responders increases participation rates. The objectives of this study were to determine why non-responders do not attend regular screening, and why they do or do not participate when offered a self-sampling device.

METHODS

A questionnaire study was conducted in the Netherlands from October 2011 to December 2012. A total of 35,477 non-responders were invited to participate in an HPV self-sampling study; 5347 women did opt out. Finally, 30,130 women received a questionnaire and self-sampling device.

RESULTS

The analysis was based on 9484 returned questionnaires (31.5%) with a self-sample specimen, and 682 (2.3%) without. Among women who returned both, the main reason for non-attendance to cervical screening was that they forgot to schedule an appointment (3068; 32.3%). The most important reason to use the self-sampling device was the opportunity to take a sample in their own time-setting (4763; 50.2%). A total of 30.9% of the women who did not use the self-sampling device preferred after all to have a cervical smear taken instead.

CONCLUSIONS

Organisational barriers are the main reason for non-attendance in regular cervical screening. Important reasons for non-responders to the regular screening to use a self-sampling device are convenience and self-control.

The value of improving failures within a cervical cancer screening program: an example from Norway

Failures in cervical cancer (CC) screening include nonparticipation, underscreening and loss to follow-up of abnormal results. We estimated the long-term health benefits from and maximum investments in interventions targeted to improving compliance to guidelines while remaining cost-effective. We used a mathematical model empirically calibrated to simulate the natural history of CC in Norway. A baseline scenario reflecting current practice using cytology-based screening was compared to scenarios that target different sources of noncompliance: (i) failure to follow-up women with abnormal results, (ii) screening less frequently than recommended (i.e., underscreening) and (iii) absence of screening. A secondary analysis included human papillomavirus (HPV)-based screening as the primary test. Model outcomes included reductions in lifetime cancer risk and incremental net monetary benefit (INMB) resulting from improvements with compliance. Compared to the status quo, improving all sources of noncompliance leads to important health gains and produced positive INMBs across a range of developed-country willingness-to-pay (WTP) thresholds. For example, a 2% increase in compliance could reduce lifetime cancer risk by 1-3%, depending on the targeted source of noncompliance and primary screening method. Assuming a WTP threshold of $83,000 per year of life saved and cytology-based screening, interventions that increase follow-up of abnormal results yielded the highest INMB per 2% increase in coverage [$19 ($10-21)]. With HPV-based screening, recruiting nonscreeners resulted in the largest INMB [$23 ($18-32)]. Considerable funds could be allocated toward policies that improve compliance with screening under the current cytology-based program or toward adoption of primary HPV-based screening while remaining cost-effective.