Breast and cervical cancer screening for women with mental illness: patient and provider perspectives on improving linkages between primary care and mental health

The impact of providing care for physical health in severe mental illness on informal carers: a qualitative study

BACKGROUND

People with severe mental illness (SMI) such as schizophrenia and bipolar disorder are at a substantially higher risk of premature death in that they die between 10 and 20 years earlier than the general population. Cardiovascular disease (CVD) and diabetes are the main potentially avoidable contributors to early death. Research that explores the experiences of people with SMI highlights their struggles in engaging with health professionals and accessing effective and timely interventions for physical health conditions. A consequence of such struggles to navigate and access physical healthcare results in many people with SMI relying heavily on support provided by informal carers (e.g., family members, close friends). Despite this, the experiences of informal carers, and the roles they undertake in relation to supporting the physical health and psychotropic medication use of people with SMI, remains under-researched.

AIMS

To explore the impacts of providing care for physical health in severe mental illness on informal carers.

METHOD

Thematic analysis of semi-structured interviews with eight informal carers of people with SMI in United Kingdom (UK) national health services.

RESULTS

Informal carers played an active part in the management of the patient's conditions and shared their illness experience. Involvement of informal carers was both emotional and practical and informal carers' own lives were affected in ways that were sometimes deeply profound. Informal carers were involved in both 'looking after' the patient from the perspective of doing practical tasks such as collecting dispensed medication from a community pharmacy (caring for) and managing feelings and emotions (caring about).

CONCLUSIONS

Providing care for the physical health of someone with SMI can be understood as having two dimensions - 'caring for' and 'caring about'. The findings suggest a bidirectional relationship between these two dimensions, and both have a cost for the informal carer. With appropriate support informal carers could be more actively involved at all stages of care without increasing their burden. This should be with an awareness that carers may minimise the information they share about their own needs and impacts of their role to spare the person they care and themselves any distress.

Barriers and Facilitators to Breast Cancer Screening for Women With Severe Mental Illness

BACKGROUND

Women with severe mental illness (SMI) are diagnosed with breast cancer at later stages, with greater mortality rates than the general population. Although breast cancer screening is an acknowledged strategy for early breast cancer detection, women with SMI are 32% to 50% less likely to have regular mammography screenings, yet the specific factors related to the disparity in this population have not been determined.

AIM

The purpose of this study was to identify the barriers and facilitators toward breast cancer screening in women diagnosed with SMI.

METHOD

In collaboration with a community-based mental health services agency, women aged 40 and older, diagnosed with SMI, and treated at that agency, were identified and asked if they were willing to participate. Fifteen women agreed to be interviewed. An interpretive descriptive approach was utilized to analyze the qualitative data.

RESULTS

The themes elicited included barriers and facilitators to screening. Barriers found were: Psychiatric Symptoms, Fear, Distrust in the Health care System, and Not my Priority. Among the facilitators were Support, Good Health care Experiences, Make it Easy, Integrated Care, and Self-Care.

CONCLUSION

Unique to this study was the understanding by participants that physical health needed to be integrated into their mental health care services through direct support and education, primarily because the process of recovery from mental illness itself entailed the increasing ability for self-care, encompassing a focus on both mental and physical health needs and preventive care.

Intervention recommendations to improve uptake of breast, cervical, and colorectal cancer screening among individuals living with serious mental illness

PURPOSE

Few efforts have been made to inform intervention design for increasing the uptake of cancer screening in individuals living with serious mental illness (ILSMI), who have lower cancer screening rates than the general population. This qualitative study explored ILSMI's and their care team member's (CTM) recommendations on the design of a breast, colorectal, and cervical cancer screening intervention for ILSMI.

METHODS

Twenty-five ILSMI (mean age: 71.4 years; 60% female) and 15 CTM (mean age: 45.3 years; 80% female) were recruited through purposive sampling. Semi-structured in-depth interviews were used to collect participants' intervention suggestions. Interviews were recorded, transcribed verbatim, and imported into NVivo. Content analysis and the constant comparison method were used to analyze interview data.

RESULTS

ILSMI and CTMs provided several salient recommendations. ILSMI should receive disease-specific, logistical, and screening education, and primary care staff should receive education on psychopathology. Mental health providers and patient navigators should be considered as the primary interventionist. The intervention should be delivered where ILSMI receive medical or mental health services, receive community and government services, and/or via various digital media. The intervention should improve the collaboration, communication, and coordination between primary and mental health care. Findings also pointed to the implementation of trauma-informed cancer care and integrated care models comprising mental health care and primary cancer care.

CONCLUSION

These findings bring the skills, knowledge, and expertise of ILSM and their care team to intervention design for increasing colorectal, breast, and cervical cancer screening in ILSMI attending an intensive outpatient program.

Cancer care for people with significant mental health difficulties (SMHD) - patient perspectives

OBJECTIVES

People with significant mental health difficulties (SMHD) experience inequities in cancer care. This study aims to deepen understanding of cancer care for individuals with SMHD.

METHOD

We conducted semi-structured interviews with seven individuals with SMHD regarding their experiences accessing and engaging with cancer care from August 2021 to February 2022. Data were analyzed using thematic analysis where both inductive and deductive coding was adopted through the lens of the socio-ecological model (SEM) as a theoretical framework.

RESULTS

The main themes included intrapersonal, interpersonal and organizational barriers and facilitators to care with a specific focus on modifiable factors related to cancer care delivery.

CONCLUSION

This study provides further evidence for promoting collaborative mental health and cancer care delivery to prevent inequalities in cancer care for patients with SMHD.

PRACTICE IMPLICATIONS

Adopting an interdisciplinary, team-based approach to cancer care and help with patient navigation across services are potential factors in improving cancer care for individuals with SMHD.

Inequalities in cancer screening participation between adults with and without severe mental illness: results from a cross-sectional analysis of primary care data on English Screening Programmes

BACKGROUND

People with severe mental illness (SMI) are 2.5 times more likely to die prematurely from cancer in England. Lower participation in screening may be a contributing factor.

METHODS

Clinical Practice Research Datalink data for 1.71 million, 1.34 million and 2.50 million adults were assessed (using multivariate logistic regression) for possible associations between SMI and participation in bowel, breast and cervical screening, respectively.

RESULTS

Screening participation was lower among adults with SMI, than without, for bowel (42.11% vs. 58.89%), breast (48.33% vs. 60.44%) and cervical screening (64.15% vs. 69.72%; all p < 0.001). Participation was lowest in those with schizophrenia (bowel, breast, cervical: 33.50%, 42.02%, 54.88%), then other psychoses (41.97%, 45.57%, 61.98%), then bipolar disorder (49.94%, 54.35%, 69.69%; all p-values < 0.001, except cervical screening in bipolar disorder; p-value > 0.05). Participation was lowest among people with SMI who live in the most deprived quintile of areas (bowel, breast, cervical: 36.17%, 40.23%, 61.47%), or are of a Black ethnicity (34.68%, 38.68%, 64.80%). Higher levels of deprivation and diversity, associated with SMI, did not explain the lower participation in screening.

CONCLUSIONS

In England, participation in cancer screening is low among people with SMI. Support should be targeted to ethnically diverse and socioeconomically deprived areas, where SMI prevalence is greatest.

Breast Cancer Screening Rates Among Medicaid Beneficiaries With Schizophrenia

OBJECTIVE

Women with serious mental illness are more likely to be diagnosed as having late-stage breast cancer than women without serious mental illness, suggesting a disparity in screening mammography. This study aimed to compare screening mammography rates in a nationally representative sample of Medicaid beneficiaries with and without schizophrenia.

METHODS

Medicaid Analytic eXtract files, 2007-2012, were used to identify a cohort of women ages 40-64 with schizophrenia who were eligible for Medicaid but not Medicare (N=87,572 in 2007 and N=114,341 in 2012) and a cohort without schizophrenia, frequency-matched by age, race-ethnicity, and state (N=97,003 in 2007 and N=126,461 in 2012). Annual screening mammography rates were calculated and adjusted for demographic characteristics and comorbid conditions. Multivariable logistic regression was used to estimate the association between beneficiary characteristics and screening mammography rates.

RESULTS

In 2012, 27.2% of women with schizophrenia completed screening mammography, compared with 26.8% of the control cohort. In the schizophrenia cohort, American Indian/Alaskan Native women had significantly lower odds of receiving mammography (OR=0.82, p=0.02) than White women, whereas Hispanic/Latina women had higher odds (OR=1.16, p<0.001). Women with schizophrenia and a nonalcohol-related substance use disorder had lower odds of receiving mammography (OR=0.74, p<0.001) than women without a substance use disorder. Having at least one medical visit in the past year (vs. no visits) increased the odds of receiving screening mammography (OR=5.08, p<0.001).

CONCLUSIONS

Screening mammography rates were similar between Medicaid-insured women with and those without schizophrenia. Interventions to increase uptake may need to focus on improving socioeconomic conditions and primary care engagement for vulnerable populations, regardless of psychiatric condition.

Experiences and views of carers regarding the physical health care of people with severe mental illness: An integrative thematic review of qualitative research

WHAT IS KNOWN ON THE SUBJECT?: People with severe mental illness (SMI) have high rates of physical illnesses, and carers are core partners in managing their physical health. Qualitative research on carers' views/experiences of physical health care is limited, and there is no published systematic review that synthesizes the current evidence. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Carers' views from seven articles were synthesised into nine themes and six subthemes describing their perceived facilitators, barriers and roles regarding the physical health care of people with SMI. Carers' voiced similar concerns to those previously identified by professionals and service users, particularly in relation to poor service access/responsiveness and communication difficulties with healthcare professionals. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should be aware of the risk of diagnostic overshadowing and ensure they are both responsive and sensitive to carers concerns about the physical health of people with SMI. It is essential for mental health nurses to actively involve carers in managing physical health, especially in formulating physical healthcare plans and providing clear practical advice/information. ABSTRACT: Introduction People with severe mental illness (SMI) have high rates of physical illnesses. Informal carers are core partners in addressing these issues, however research on their views/experiences is limited and there is no systematic review published on the topic. Aim This integrative thematic review explored the experiences and views of carers on physical health care in SMI by synthesizing the existing qualitative research findings. Methods Six databases were searched from 2000 to 2021. Data were extracted and synthesised using thematic integrative analysis. The quality of included studies was assessed with the JBI Critical Appraisal Checklist. Results Five studies were included. Nine themes were identified conceptualising carers' perceived facilitators, barriers and roles regarding physical health care for people with SMI. Discussion Carers felt that receiving practical help and a specialised role for mental health nurses would facilitate better physical health care. Lack of coordination/communication and poor service access/responsiveness were common barriers, often compounded by diagnostic overshadowing. Carers are involved in promoting healthy lifestyles, monitoring physical health and supporting access to services. Implications for Practice Mental health nurses should ensure they are responsive to carers' concerns and proactively support them to promote the physical health of people with SMI.

A qualitative exploration of Ugandan mental health care workers’ perspectives and experiences on sexual and reproductive health of people living with mental illness in Uganda

Background

People with Mental Illness experience vast sexual and reproductive health challenges due to the affected mental health. Globally, prevalence of mental illness is on the rise with subsequent increase in the number of people with sexual and reproductive challenges warranting urgent public health intervention. However, information on the perceptions and experiences of mental health workers, the key health care providers for this population is generally lacking yet it’s essential for formulation of appropriate policies and public health interventions.

Aim

To explore Ugandan mental health care worker’s perspectives and experiences on the sexual and reproductive health of people living with mental illness in Uganda in order to generate recommendations to the ministry of health on how it can be improved.

Materials and methods

Qualitative study design was employed with utilization of phone call semi-structured in-depth interviews to collect data from 14 mental health workers from Uganda’s National mental referral hospital, Butabika. Purposive sampling and convenience recruitment was done and the collected data was analyzed using Thematic content analysis.

Results

Four themes were generated which included people with Mental illness having normal sexual needs, mental illness effect on sexuality and relationships, practices for safeguarding sexuality of people with mental illness and the barriers encountered in the provision of sexual and reproductive health services at a mental hospital.

Conclusion

People with mental illness experience a multitude of sexual and reproductive health challenges that need public health interventions. However, the integration of sexual and reproductive health services in a mental hospital are not yet successful making people with mental illness to remain with unaddressed health challenges. Policies should therefore be developed and implemented to ensure successful integration of sexual and reproductive health at all mental health service care provision points.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14128-2.

Clinicians' perceptions of barriers to cervical cancer screening for women living with behavioral health conditions: a focus group study

Background

Women with behavioral health (BH) conditions (e.g., mental illness and substance abuse) receive fewer cervical cancer (CC) screenings, are diagnosed at more advanced cancer stages, and are less likely to receive specialized treatments. The aim of this study was to identify barriers that healthcare providers face in providing CC screening to women with BH conditions.

Methods

Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups in North Florida with 26 primary care and BH clinicians and staff to examine perceived barriers to CC screening among their patients with BH conditions to guide the future development of a tailored cervical cancer screening and follow-up intervention. Thematic analysis was used to analyze verbatim transcripts from audiotaped focus groups.

Results

Three main themes of barriers emerged from the data: 1) BH conditions related barriers included a history of trauma, stigma and discrimination, and uncontrolled comorbid conditions, 2) System level barriers related to lack of integration between BH and primary care, and 3) Similar barriers to the general population including lack of health insurance, insufficient processes to send out reminders, and challenges with communicating with patients.

Conclusions

Tailored CC screening interventions that address the unique needs of women with BH conditions are needed. Strategies that address improving trust between patients and healthcare providers, identifying avenues to improve receipt of screening during time-limited clinical visits, connecting BH and primary care providers, and addressing the social determinants of health have potential to improve CC screening rates for women with BH conditions.

Barriers and facilitators to accessing cancer care for people with significant mental health difficulties: A qualitative review and narrative synthesis

OBJECTIVES

Inequities in cancer care contribute to higher rates of cancer mortality for individuals with significant mental health difficulties (SMHD) compared to the general population. The aim of the current systematic review was to identify, appraise and synthesise qualitative evidence of patient and clinician/system barriers and facilitators to cancer screening and treatment for individuals with SMHD.

METHODS

We conducted a systematic search across three electronic databases in May 2020 and we carried out a second search across five electronic databases in January 2021. A narrative synthesis was conducted across eligible studies.

RESULTS

We identified the same six studies from both searches, with 133 individuals with SMHD and experiences of cancer care and 102 healthcare professionals. Key barriers to cancer care were related to patients' uncontrolled psychiatric symptoms and the adverse impact of their symptoms on engaging with cancer care; clinician barrier-attitudes included stigmatising attitudes from clinicians and other staff towards individuals with SMHD and systems barrier-fragmentation included the fragmentation of mental health and cancer care delivery. Key patient facilitators to accessing cancer care and completing cancer treatment included being connected with mental health services and controlled psychiatric symptoms. Stronger collaboration among healthcare professionals working across different sectors in addition to the development of a patient navigator role were identified as key facilitators to enhance patient care.

CONCLUSIONS

Innovative approaches are needed to decrease mental health stigma, foster collaboration across disciplines, and facilitate the integration of timely mental health and cancer care for individuals with SMHD to address the mortality gap.

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.

Disparities in Breast Cancer Screening Uptake for Women With Mental Illness in the United Kingdom

INTRODUCTION

Although there is evidence of disparities in breast cancer screening for women with mental illness in the U.S., there is a dearth of studies examining this association in the United Kingdom, where health care is provided free at the point of access. This population-based study examines the influence of mental illness, as assessed by the uptake of psychotropic medications, on breast screening uptake in the United Kingdom.

METHODS

A cohort of 57,328 women identified from 2011 Census records within the Northern Ireland Longitudinal Study was followed through a single 3-year screening cycle (2011-2014) of the National Health Service Breast Screening Programme. Mental illness was identified by a receipt of psychotropic medication in the 3 months preceding screening invite. Individual- and household-level attributes were derived from Census records. Data were analyzed in 2019.

RESULTS

More than a third of women received ≥1 prescription for psychotropic medication in the 3 months preceding screening invite. The odds of attendance in these individuals were reduced by 15% (OR=0.85, 95% CI=0.81, 0.88). Attendance was particularly low for women prescribed antipsychotics (OR=0.63, 95% CI=0.56, 0.70), anxiolytics (OR=0.61, 95% CI=0.57, 0.66), and hypnotics (OR=0.68, 95% CI=0.63, 0.72).

CONCLUSIONS

These findings confirm the existence of significant disparities in breast screening uptake for women with mental illness. Targeted interventions are warranted to prevent avoidable breast cancer deaths in these individuals, especially given the increasing prevalence of mental illness.

Does poor mental health explain socio-demographic gradients in breast cancer screening uptake? A population-based study

BACKGROUND

Research from the USA indicates disparities in breast cancer screening uptake for women with poor mental health. However, no attempt has been made to examine the contribution of poor mental health to socio-demographic variations in breast screening uptake. The current study aims to examine the impact of self-reported chronic poor mental health on attendance at breast screening in the UK, and to what extent this explains socio-demographic inequalities in screening uptake.

METHODS

Breast screening records were linked to 2011 Census records within the Northern Ireland Longitudinal Study. This identified a cohort of 57 328 women who were followed through one 3-year screening cycle of the National Health Service Breast Screening Programme. Information on mental health status, in addition to other individual and household-level attributes, was derived from the 2011 Census. Logistic regression was employed to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of attendance at screening.

RESULTS

10.7% of women in the cohort reported poor mental health, and in fully adjusted analyses, these individuals were 23% less likely to attend breast screening (OR 0.77; 95% CI 0.73-0.82). Although poor mental health was a strong predictor of screening uptake, it did not explain the observed inequalities in uptake by socio-economic status, marital status, or area of residence.

CONCLUSIONS

This study provides novel evidence of inequalities in breast screening uptake for women with chronic poor mental health in the UK. Targeted interventions are necessary to ensure equitable screening access and to enhance overall mortality benefit.

Breast Cancer Screening in Women With Schizophrenia: A Systematic Review and Meta-Analysis

OBJECTIVE

Women with schizophrenia appear to receive breast cancer diagnoses at later stages of the disease compared with the general population. To study this disparity, this report reviewed and quantified the differences in rates of mammography screening for women with schizophrenia and other psychotic disorders compared with the general population.

METHODS

A systematic literature search was conducted in PubMed, Embase, Web of Science, and PsycINFO databases. Each database was searched from inception to September 14, 2018. The search strategy included search terms for breast cancer, mammography, schizophrenia, and psychosis. Two reviewers independently screened and evaluated eligible studies. The main outcome measure was the rate of mammography screening among women with schizophrenia and psychotic disorders versus a comparable population of women without these diagnoses. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for abstracting data, and the Newcastle-Ottawa Scale was used for assessing data quality. A meta-analysis with a random-effects model was performed.

RESULTS

From a total of 304 abstracts reviewed, 11 studies met the inclusion criteria, representing 25,447 women with diagnoses of schizophrenia or psychosis across four countries. The meta-analysis showed that women with schizophrenia were less likely than women without schizophrenia to receive mammography screening (pooled OR=0.50, 95% confidence interval=0.38-0.64, p<0.001). In subgroup analysis, this association was not significantly affected by quality of the study.

CONCLUSIONS

Women with schizophrenia and other psychotic disorders were about half as likely as the general population to receive mammography screening. Further research is needed to determine causes of this disparity.

Cancer Screening in Behavioral Health Care Programs

OBJECTIVE: Adults with serious mental illnesses have a lower life expectancy attributable to many factors including metabolic disorders and cancer. Access to cancer screening has been shown to decrease morbidity and increase chances of survival. This study examined access to cancer screening services among individuals with serious mental illnesses served by a community behavioral health care agency partial hospitalization program at four locations. METHOD: A self-administered paper-and-pencil survey was provided to adults attending partial hospitalization programs. The survey consisted of open- and closed-ended questions about utilization, access to, and barriers to cervical, breast, and colorectal cancer screenings. RESULTS: Surveys were completed by 136 individuals. Participant screening rates were above national rates for cervical and breast cancer but lower for colorectal cancer. The main cited barrier to receiving the screening tests was lack of physician recommendations. CONCLUSIONS: Psychiatric nurses are ideally suited to communicate with this population and other behavioral health care professions about the importance of these screenings. Communication should also advocate for improved education and increased support for cancer screenings to address this health care disparity.

Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4 717 839 people

BACKGROUND

Since people with mental illness are more likely to die from cancer, we assessed whether people with mental illness undergo less cancer screening compared with the general population.

METHODS

In this systematic review and meta-analysis, we searched PubMed and PsycINFO, without a language restriction, and hand-searched the reference lists of included studies and previous reviews for observational studies from database inception until May 5, 2019. We included all published studies focusing on any type of cancer screening in patients with mental illness; and studies that reported prevalence of cancer screening in patients, or comparative measures between patients and the general population. The primary outcome was odds ratio (OR) of cancer screening in people with mental illness versus the general population. The Newcastle-Ottawa Scale was used to assess study quality and I² to assess study heterogeneity. This study is registered with PROSPERO, CRD42018114781.

FINDINGS

47 publications provided data from 46 samples including 4 717 839 individuals (501 559 patients with mental illness, and 4 216 280 controls), of whom 69·85% were women, for screening for breast cancer (k=35; 296 699 individuals with mental illness, 1 023 288 in the general population), cervical cancer (k=29; 295 688 with mental illness, 3 540 408 in general population), colorectal cancer (k=12; 153 283 with mental illness, 2 228 966 in general population), lung and gastric cancer (both k=1; 420 with mental illness, none in general population), ovarian cancer (k=1; 37 with mental illness, none in general population), and prostate cancer (k=6; 52 803 with mental illness, 2 038 916 in general population). Median quality of the included studies was high at 7 (IQR 6-8). Screening was significantly less frequent in people with any mental disease compared with the general population for any cancer (k=37; OR 0·76 [95% CI 0·72-0·79]; I²=98·53% with publication bias of Egger's p value=0·025), breast cancer (k=27; 0·65 [0·60-0·71]; I²=97·58% and no publication bias), cervical cancer (k=23; 0·89 [0·84-0·95]; I²=98·47% and no publication bias), and prostate cancer (k=4; 0·78 [0·70-0·86]; I²=79·68% and no publication bias), but not for colorectal cancer (k=8; 1·02 [0·90-1·15]; I²=97·84% and no publication bias).

INTERPRETATION

Despite the increased mortality from cancer in people with mental illness, this population receives less cancer screening compared with that of the general population. Specific approaches should be developed to assist people with mental illness to undergo appropriate cancer screening, especially women with schizophrenia.

FUNDING

None.

Mental Health and Substance Use-Related Hospitalizations Among Women of Reproductive Age in Illinois and Wisconsin

INTRODUCTION

Mental health and substance use are growing public health concerns, but established surveillance methods do not measure the burden of these conditions among women of reproductive age. We developed a standardized indicator from administrative data to identify inpatient hospitalizations related to mental health or substance use (MHSU) among women of reproductive age, as well as co-occurrence of mental health and substance use conditions among those hospitalizations.

MATERIALS AND METHODS

We used inpatient hospital discharge data from 2012-2014 for women aged 15-44 residing in Illinois and Wisconsin. We identified MHSU-related hospitalizations through the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and first-listed ICD-9-CM external cause of injury code (E code). We classified hospitalizations as related to 1 of 3 mutually exclusive categories: a mental disorder, a substance use disorder, or an acute MHSU-related event. We defined co-occurrence as the presence of both mental health and substance use codes in any available diagnosis or E-code field.

RESULTS

Of 1 173 758 hospitalizations of women of reproductive age, 150 318 (12.8%) were related to a mental disorder, a substance use disorder, or an acute MHSU-related event, for a rate of 135.6 hospitalizations per 10 000 women. Of MHSU-related hospitalizations, 115 163 (76.6%) were for a principal mental disorder, 22 466 (14.9%) were for a principal substance use disorder, and 12 709 (8.5%) were for an acute MHSU-related event; 42.4% had co-occurring mental health codes and substance use codes on the discharge record.

PRACTICE IMPLICATIONS

MHSU-related disorders and events are common causes of hospitalization for women of reproductive age, and nearly half of these hospitalizations involved co-occurring mental health and substance use diagnoses or events. This new indicator may improve public health surveillance by establishing a systematic and comprehensive method to measure the burden of MHSU-related hospitalizations among women of reproductive age.

Addressing the sexual and reproductive health needs of women who use mental health services

Pregnancies in women with serious mental illness are high risk and such women are also less likely to engage in the recommended health screening for women of reproductive age. Hence, reproductive health issues are important aspects of physical healthcare that should be assessed in women accessing mental health services. Pregnancy planning and management are crucial in reducing risk of relapse in women with affective disorders, and psychiatrists should acquaint themselves with the screening programmes and reproductive and sexual health services in their area and encourage their patients' uptake of these. Clinicians should be aware of the reproductive impact of medications and the needs of specific groups of women.

Interventions to encourage uptake of cancer screening for people with severe mental illness

BACKGROUND

Adults with severe mental illness (i.e. schizophrenia or other related psychotic disorders and bipolar disorder) can be at greater risk of cancer than those without severe mental illness (SMI). Early detection of cancer through screening is effective in improving patient outcomes including death. However, people with SMI are less likely than others to take up available cancer screening.

OBJECTIVES

To determine the effectiveness of interventions targeted at adults with SMI, or their carers or health professionals, and aimed at increasing the uptake of cancer screening tests for which the adults with SMI are eligible.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (October 25, 2012; December 19, 2014; April 07, 2015; July 04, 2016).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of interventions, targeted towards adults with SMI or their carers or health professionals, to encourage uptake of cancer screening tests for which the adults with SMI were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and assessed these against the inclusion criteria.

MAIN RESULTS

We did not find any trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

A comprehensive search showed that currently there is no RCT evidence for any method of encouraging cancer screening uptake in people with SMI. No specific approach can therefore be recommended. High-quality, large-scale RCTs are needed urgently to help address the disparity between people with SMI and others in cancer screening uptake.

Influences on uptake of cancer screening in mental health service users: a qualitative study

BACKGROUND

Cancers are a leading cause of death worldwide. People with mental illness are 30 % more likely to die from cancer than the general population. One reason for this may be low uptake of nationally offered cancer screening tests by people with mental illness. We aimed to identify barriers and facilitators for breast, cervical and bowel cancer screening uptake by people with mental illness in order to inform interventions to promote equal access.

METHODS

The interview study was conducted in both urban and rural settings. The study was informed by the Theoretical Domains Framework, using framework analysis and triangulation across participant groups. Participants included 45 mental health service users (service users) eligible for cancer screening, 29 mental health professionals and 11 professionals involved in cancer screening.

RESULTS

Themes emerging from the data that affected uptake included knowledge of screening programmes by both service users and healthcare providers; knowledge of, and attitudes towards, mental illness; health service-delivery factors; service users' beliefs and concerns about cancer screening, and practical issues. These are relevant to different stages of the screening process. Service users do not receive invitations to screening or cancer testing kits if they are admitted to hospital. They are not routinely invited for screening if they are not registered with a general practitioner (GP). Lack of integrated care means that mental health staff do not know if someone is overdue for a test and cancer screening is often not considered during health promotion. Barriers including information processing problems, the extent to which the screening process aggravates symptoms, poor staff client relationships and travel difficulties vary between individuals. Screening professionals are motivated to help, but may lack time or training to manage mental health needs. Reactive measures are available, but service users must request help which they may find difficult.

CONCLUSIONS

There are specific barriers to cancer screening uptake for mental health service users that prevent equality of care. Interventions that can be personalised are needed at individual, policy and service-delivery levels. Primary and secondary care staff and policy-makers should work together to develop an integrated approach to cancer screening in this population.

Two sides of the coin: A qualitative study of patient and provider perspectives on colorectal, breast and cervical cancer screening in a low-income Asian community

Objectives:

Patient and provider barriers to cancer screening in disadvantaged Asian populations are understudied. We conducted a qualitative study of attitudes to screening for colorectal, cervical and breast cancer within low-income communities in Singapore.

Methods:

Interviewers elicited perceptions of barriers/enablers to cancer screening amongst patients eligible for fecal occult blood test (FOBT)/Pap smear/mammograms, and providers serving these low-income communities. Interview transcripts were analyzed thematically using established qualitative methodology.

Results:

Twenty patients and nine providers were interviewed. Patient and provider comments were grouped into seven content areas: primary care characteristics (PCC), procedural issues, knowledge, costs, priorities, attitudes, and information sources. For FOBT, the most frequently mentioned content areas were knowledge (61.2%) and attitudes (16.9%) for patients, and knowledge (19.5%) and PCC (18.6%) for providers. For Pap smears, it was knowledge (23.6%) and costs (20.5%) for patients, and PCC (33.8%) and knowledge (19.1%) for providers. For mammograms, it was knowledge (41.4%) and sources of information (15.9%) for patients, and knowledge (28.8%) and procedural issues (19.2%) for providers.

Conclusion:

While PCC, knowledge and costs were the main contributors as perceived by physicians, knowledge and attitudes were the biggest barriers from patients’ perspectives. Differences in perceptions of cancer screening exist between low-income patients and providers serving them.

Cancer Screening Among Peer-Led Community Wellness Center Enrollees

Growing evidence suggests health disparities exist in services for individuals with mental disorders served by the public mental health system. The current study assessed the use of cancer screening services among New Jersey residents in publicly funded mental health programs. Self-administered written surveys were completed by 148 adults using peer-led community wellness centers throughout New Jersey. Information was collected on (a) the use of breast, cervical, and colorectal cancer screening services; (b) barriers to receiving preventive services; and (c) perceptions of overall health. More males than females participated in the study, with equal participation among White and African American individuals. Schizophrenia spectrum disorders were the most common self-reported psychiatric condition. Colorectal cancers had lower screening levels compared to those of the general population. Physicians not advising patients to complete tests emerged as a main cause of low screening rates. Wellness initiatives designed by peers collaborating with health care providers may improve adherence to preventive cancer screening measures.

Mental Health Consumer Experiences and Strategies When Seeking Physical Health Care: A Focus Group Study

People with mental illness have higher rates of physical health problems and consequently live significantly shorter lives. This issue is not yet viewed as a national health priority and research about mental health consumer views on accessing physical health care is lacking. The aim of this study is to explore the experience of mental health consumers in utilizing health services for physical health needs. Qualitative exploratory design was utilized. Semistructured focus groups were held with 31 consumer participants. Thematic analysis revealed that three main themes emerged: scarcity of physical health care, with problems accessing diagnosis, advice or treatment for physical health problems; disempowerment due to scarcity of physical health care; and tenuous empowerment describing survival resistance strategies utilized. Mental health consumers were concerned about physical health and the nonresponsive health system. A specialist physical health nurse consultant within mental health services should potentially redress this gap in health care provision.

Breast Cancer Screening Barriers from the Womans Perspective: a Meta-synthesis

BACKGROUND

The principal aim of health service providers in the field of breast cancer is to detect and treat lesions at an appropriate time. Therefore, identification of barriers to screening can be very helpful. The present study aimed to systematically review the qualitative studies for extracting and reporting the barriers of screening for breast cancer from the womans perspective.

MATERIALS AND METHODS

In this systematic review; Pubmed, Google Scholar, Ovid Scopus, Cochrane Library, Iranmedex, and SID were searched using the keywords: screening barriers, cancer, qualitative studies, breast and their Persian equivalents, and the needed data were extracted and analyzed using an extraction table. To assess the quality of the studies, the Critical Appraisal Skills Programme (CASP) tool was used.

RESULTS

From 2,134 related articles that were found, 21 articles were eventually included in the study. The most important barriers from the point of view of 1,084 women were lack of knowledge, access barriers (financial, geographical, cultural), fear (of results and pain), performance of service providers, women's beliefs, procrastination of screening, embarrassment, long wait for getting an appointment, language problems, and previous negative experiences. Articles' assessment score was 68.9.

CONCLUSIONS

Increasing women's knowledge, reducing the costs of screening services, cultural promotion for screening, presenting less painful methods, changing beliefs of health service providers, provision of privacy for giving service, decreasing the waiting time, and providing high quality services in a respectful manner can be effective ways to increase breast cancer screening.

Preparing family physicians for the care of patients with severe and persistent mental illness: Examples from two U.S. residency programs

Individuals with severe and persistent mental illness have increased morbidity and mortality and significant barriers to accessing health care. Although primary care providers deliver most health care for this population, residency training programs generally lack specialized training in this area. This article describes the approaches of two family medicine residency programs in addressing this educational gap. Each program collaborated with external organizations to create service models that would enhance patient access, while immersing residents in the care of patients with severe and persistent mental illness. Residents educated in these programs gain experience with an underserved population, practice advanced skills in managing complex medical and psychiatric illness, and increase knowledge from collaborative work in unique care settings. Further implementation of programs like these, and rigorous study of such programs, could have significant benefits for family medicine education and the care of patients with severe and persistent mental illness.

Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake

BACKGROUND

There is a higher mortality rate due to cancer in people with mental illness and previous work suggests suboptimal medical care in this population. It remains unclear if this extends to breast cancer population screening.

AIMS

To conduct a systematic review and meta-analysis to establish if women with a mental health condition are less likely to receive mammography screening compared with those without mental ill health.

METHOD

Major electronic databases were searched from inception until February 2014. We calculated odds ratios (OR) with a random effects meta-analysis comparing mammography screening rates among women with and without a mental illness. Results were stratified according to primary diagnosis including any mental illness, mood disorders, depression, severe mental illness (SMI), distress and anxiety.

RESULTS

We identified 24 publications reporting breast cancer screening practices in women with mental illness (n = 715,705). An additional 5 studies investigating screening for those with distress (n = 21,491) but no diagnosis of mental disorder were identified. The pooled meta-analysis showed significantly reduced rates of mammography screening in women with mental illness (OR = 0.71, 95% CI 0.66-0.77), mood disorders (OR = 0.83, 95% CI 0.76-0.90) and particularly SMI (OR = 0.54, 95% CI 0.45-0.65). No disparity was evident among women with distress alone.

CONCLUSIONS

Rates of mammography screening are lower in women with mental illness, particularly women with SMI, and this is not explained by the presence of emotional distress. Disparities in medical care due to mental illness clearly extend into preventive population screening.

The prevalence and factors for cancer screening behavior among people with severe mental illness in Hong Kong

OBJECTIVES

Screening is useful in reducing cancer incidence and mortality. People with severe mental illness (PSMI) are vulnerable to cancer as they are exposed to higher levels of cancer risks. Little is known about PSMI's cancer screening behavior and associated factors. The present study examined the utilization of breast, cervical, prostate, and colorectal cancer screening among PSMI in Hong Kong and to identify factors associated with their screening behaviors.

METHOD

591 PSMI from community mental health services completed a cross-sectional survey.

RESULTS

The percentage of cancer screening behavior among those who met the criteria for particular screening recommendation was as follows: 20.8% for mammography; 36.5% for clinical breast examination (CBE); 40.5% for pap-smear test; 12.8% for prostate examination; and 21.6% for colorectal cancer screening. Results from logistic regression analyses showed that marital status was a significant factor for mammography, CBE, and pap-smear test; belief that cancer can be healed if found early was a significant factor for pap-smear test and colorectal screening; belief that one can have cancer without having symptoms was a significant factor for CBE and pap-smear test; belief that one will have a higher risk if a family member has had cancer was a significant factor for CBE; and self-efficacy was a significant factor for CBE and pap-smear test behavior.

CONCLUSIONS

Cancer screening utilization among PSMI in Hong Kong is low. Beliefs about cancer and self-efficacy are associated with cancer screening behavior. Health care professionals should improve the knowledge and remove the misconceptions about cancer among PSMI; self-efficacy should also be promoted.

Nurse views on the cardiometabolic health nurse as an approach to improving the physical health of people with serious mental illness in Australia

People with serious mental illness (SMI) die prematurely from common physical illnesses such as cardiovascular disease and diabetes. These cardiometabolic risks are preventable and manageable yet these aspects of health care have been neglected in mental health services. A potential nurse-based strategy to decisively improve cardiometabolic health of people with SMI is to introduce a cardiometabolic health nurse (CHN) into mental health services. The current study aimed to establish the views of nurses working in mental health care on the potential benefits and limits of CHN to improve physical health-care standards in Australia. All members of the Australian College of Mental Health Nurses were invited to participate in an online survey and 643 participated. Nurses generally agreed that a CHN role would provide a range of improvements to physical health care, such as increased detection, assessment on, and follow up of cardiometabolic risks, and decreased workload for other nurses. While participants were generally supportive of such a role, they felt it would not be suitable in all health-care settings in Australia.

Exploring cancer screening in the context of unmet mental health needs: a participatory pilot study

BACKGROUND

Cancer is the leading cause of preventable death in the Bronx, New York. Service providers in this mental health provider shortage area identified untreated mental illness as an important barrier to participation in cancer screening, a finding that supports existing literature. The Mental Health and Cancer (MHC) Connection partnership formed to investigate and address this issue.

OBJECTIVES

We sought to use an ecological framework to examine barriers and facilitators to obtaining mental health services in the Bronx, and to explore how lack of access to mental healthcare affects cancer screening.

METHODS

In this community-based participatory research (CBPR)-driven pilot study, semistructured, qualitative interviews based on an ecological framework were conducted with 37 Bronx-based service providers representing a range of professional perspectives. Data were analyzed using thematic content analysis and techniques from grounded theory.

RESULTS

Similar barriers and facilitators were reported for mental healthcare and cancer screening utilization across ecological levels. Providers emphasized the impact of urban poverty-related stressors on the mental health of their clients, and affirmed that mental health issues were a deterrent for cancer screening. They also recognized their own inability to connect clients effectively to cancer screening services, and rarely saw this as part of their present role.

CONCLUSIONS

Findings highlight how unmet mental health needs can affect cancer screening in impoverished urban contexts. Participants recommended improving linkages across healthcare and social service providers to address mental health and cancer screening needs simultaneously. Study results are being used to plan a collaborative intervention in the Bronx through the MHC Connection partnership.

Interventions to encourage uptake of cancer screening for people with severe mental illness

BACKGROUND

Adults with severe mental illness (i.e. schizophrenia or other related psychotic disorders and bipolar disorder) can be at greater risk of cancer than those without severe mental illness (SMI). Early detection of cancer through screening is effective in improving patient outcomes including death. However, people with SMI are less likely than others to take up available cancer screening.

OBJECTIVES

To determine the effectiveness of interventions targeted at adults with SMI, or their carers or health professionals, and aimed at increasing the uptake of cancer screening tests for which the adults with SMI are eligible.

SEARCH METHODS

We searched electronically the Cochrane Schizophrenia Group's Register (25th October 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of interventions, targeted towards adults with SMI or their carers or health professionals, to encourage uptake of cancer screening tests for which the adults with SMI were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts and assessed these against the inclusion criteria.

MAIN RESULTS

We did not find any trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

A comprehensive search showed that currently there is no RCT evidence for any method of encouraging cancer screening uptake in people with SMI. No specific approach can therefore be recommended. High-quality, large-scale RCTs are needed urgently to help address the disparity between people with SMI and others in cancer screening uptake.

Disparities in breast and cervical cancer screening in women with mental illness: a systematic literature review

CONTEXT

Breast and cervical cancer screening rates have improved substantially in the U.S. during the past decade. Cancer screening and other health outcomes in patients with mental illnesses, such as major depression and schizophrenia, remain suboptimal. Understanding the prevalence and root causes of these disparities is an essential first step toward developing effective interventions. This paper presents a systematic literature review of current evidence on breast and cervical cancer screening disparities in women with mental illness.

EVIDENCE ACQUISITION

A systematic PubMed/MEDLINE and PsycINFO search completed in May 2012 retrieved articles pertaining to cancer screening and mentally ill patients using pertinent search terms. Articles that met the inclusion criteria were appraised critically for evidence quality related to screening disparities using defined criteria. Articles that reported cancer screening rates in patients with mental illness were reviewed to determine whether any barriers to screening or factors that promote screening were identified.

EVIDENCE SYNTHESIS

Nineteen studies met the inclusion criteria. Many articles contributed to more than one of the identified areas of interest (i.e., screening utilization, barriers to screening, and factors that encourage screening).

CONCLUSIONS

Substantial evidence in the current literature confirms disparities in breast and cervical cancer screening rates among women with mental illness. However, the mentally ill population is more complex and diverse than many studies imply. Using a global functional indicator that measures the overall impact of mental illness may yield a more useful categorization of influences on cancer screening.

Perceptions of barriers to physical health care for people with serious mental illness: a review of the international literature

Premature death and poorer access to quality care for physical health concerns is common for people diagnosed with serious mental illness (SMI). However, there is lack of clarity regarding the nature of barriers encountered at different points in the physical health care process, and the level of consistency of these barriers both among countries, and between consumers with SMI and health care staff. The current narrative review integrates views of consumers and health care staff on barriers to physical health care. It involved a search of CINAHL, Proquest, and Web of Science, for peer-reviewed papers published between 2005 and June 2012, for studies of perceptions of barriers to physical health care, published in English. Despite variations in health care systems among countries, there is agreement between consumers and health care staff that division between physical and mental health care and stigma of mental illness act as barriers to all phases of the physical health care process. This uniformity is grounds for international policy development (in general public health and within mental health nursing) for reforms that improve the physical health care, quality of life, and longevity of people with serious mental illness.

Minding our own bodies: reviewing the literature regarding the perceptions of service users diagnosed with serious mental illness on barriers to accessing physical health care

International studies consistently demonstrate that individuals diagnosed with severe mental illness (SMI) have an increased risk of co-morbid physical health problems and premature death. During the past decade, government policy in the UK has focused on improving the physical health of those with SMI. Despite this, international research has continued to report barriers to accessing appropriate services. These have been identified as emanating from service users and professionals alike, and also from institutional bureaucracy. Most of this research has reported difficulties from the perspective of various professional groups, with little attention being paid to the service user voice. Studies from the service user perspective undertaken in the past 10 years equate to six qualitative and three quantitative studies, and it appears that poor physical health care remains a problem in the developed world. The quality of this care is compromised by practical problems and interpersonal difficulties between service users and health-care providers and between providers of mental health services and those providing physical health care. This paper presents a review of the nine international studies and discusses the implications for developing policy and practices that could lead to improved physical health-care services for people experiencing SMI.

Service innovation: a comparison of two approaches for physical screening of psychiatric inpatients

OBJECTIVE

Psychiatric medications have clear links to obesity, diabetes, dyslipidaemia, hypertension, hyperprolactinaemia and movement disorders. These disorders are a common cause of morbidity and mortality in psychiatric patients but physical screening by health services is often haphazard.

METHODS

We report the findings of an audit of physical screening across two hospital wards. Each ward undertook a process of service improvement. One ward modified the admissions proforma and the other developed a discharge screening clinic. The effectiveness of each of these interventions was then compared through a reaudit of practice across both wards.

RESULTS

At baseline, screening was performed inconsistently and infrequently. On average, the modified admissions proforma increased screening rates by 4.7% compared to 30.7% for discharge screening clinics. The discharge screening clinic demonstrated statistically significant improvements in screening rates and effectively delivered health promotion advice.

CONCLUSIONS

Discharge screening clinics are significantly more likely than improved admissions procedures to detect clinically significant abnormalities. If these abnormalities are detected and treated then the long-term physical health of psychiatric patients may be improved.

Predictors of cervical cancer being at an advanced stage at diagnosis in Sudan

Background

Cervical cancer is the second most common cancer among women in Sudan, with more than two-thirds of all women with invasive cervical cancer being diagnosed at an advanced stage (stages III and IV). The lack of a screening program for cervical cancer in Sudan may contribute to the late presentation of this cancer, but other factors potentially associated with advanced stages of cervical cancer at diagnosis are unknown. The purpose of this research was to investigate the relationship between age, marital status, ethnicity, health insurance coverage, residence in an urban vs a rural setting, and stage (at diagnosis) of cervical cancer in Sudan.

Methods

This was a cross sectional study of 197 women diagnosed with different stages of cervical cancer. Data was obtained from the cancer registry unit at the Radiation and Isotopes Centre in Khartoum for all women diagnosed with cervical cancer in 2007.

Results

There was an association between older age and advanced stage (at diagnosis) of cervical cancer (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01–1.05). Being of African ethnicity was associated with 76% increased odds (OR: 1.76, 95% CI: 1.01–3.05), living in a rural area was associated with 13% increased odds (OR: 1.13, 95% CI: 1.78–5.50), and being uninsured was associated with an almost eight-fold increase in odds (OR: 7.7, 95% CI: 3.76–15.38). Marital status and education level were not associated with an advanced stage of cervical cancer at diagnosis.

Conclusion

Women with cervical cancer who are elderly, not covered by health insurance, of African ethnicity, and living in a rural area are more likely to be diagnosed at an advanced stage of cervical cancer in Sudan. These women should be targeted for cervical cancer screening and a health education program, and encouraged to have health insurance.

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.

Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis

We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.

Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis

BACKGROUND

There has been long-standing concern about the delivery of preventive and screening services to patients with mental illness.

OBJECTIVE

We aimed to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our hypothesis was that patients with mental illness would be in receipt of lower quality or lower frequency of preventive care.

METHOD

Studies that examined the quality of care in those with and without comorbid mental illness were reviewed and comparative data extracted. By using only comparative studies we hope to ascertain whether inequalities in care existed by virtue of psychiatric diagnoses (or closely affiliated factors).

RESULTS

We identified 26 studies that examined preventive care in individuals with vs. without psychiatric illness. From these eligible studies, 61 comparisons were documented across 13 health care domains. These included mammography, cervical smears, vaccinations, cholesterol screening, lifestyle counseling, colonoscopy. Twenty-seven comparisons revealed inferior preventive health care in those with mental illness, but 10 suggested superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in those with schizophrenia and in relation to osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring.

CONCLUSIONS

We conclude there is strong evidence to suggest that the quality of preventive and screening services received by patients with mental illness is often lower, but occasionally superior to that received by individuals who have no comparable mental disorder. More work must be done to improve the quality of medical and preventive care for individuals with mental illness.

Assessment of a point-of-care metabolic risk screening program in outpatients receiving antipsychotic agents

STUDY OBJECTIVE

To assess the usefulness of a metabolic risk screening program, including point-of-care glucose testing, to quantify baseline metabolic risk in outpatients receiving antipsychotics.

DESIGN

Retrospective, cross-sectional, cohort study.

SETTING

University-affiliated department of psychiatry clinic.

PATIENTS

A total of 92 adult outpatients (49 women, 43 men; mean +/- SD age 38.96 +/- 12 yrs) who were receiving antipsychotics and had undergone screening for metabolic syndrome at the clinic during 2004-2007.

MEASUREMENTS AND MAIN RESULTS

Patient data were recorded on a metabolic screening checklist by a pharmacist or nurse. The checklist captured demographics, vital signs (height, weight, body mass index [BMI], blood pressure, waist and hip circumference, point-of-care random glucose level), personal and family knowledge of current illnesses (diabetes mellitus, hypertension, hyperlipidemia), modifiable risk factors (smoking, alcohol, level of activity), current drug therapy, and recommendations to the psychiatrist. The patient population who underwent screening included 49 African-Americans (53%), 21 Caucasians (23%), 16 Hispanics (17%), and 6 Asians (7%). Diagnoses were documented for 88 patients: schizophrenia or schizoaffective disorder in 53 patients (60%), and bipolar disorder and major depressive disorder was equally divided in the remaining 35 patients (40%). Of 89 patients (three patients had missing data on waist circumference), 63 (71%) met criteria for level 1 metabolic risk (abdominal obesity); of these 63 patients, 38 (60%) met criteria for level 2 risk (abdominal obesity plus hypertension). Patients with a random glucose level greater than 140 mg/dl had a higher likelihood for being at level 2 risk than level 1 risk (chi(2)=5.99, df=1, p=0.014). Women had a significantly higher likelihood for level 1 metabolic risk compared with men (chi(2)=5.99, df=1, p=0.019). African-Americans had a significantly higher likelihood of level 1 risk (p=0.026) and BMI greater than 30 kg/m(2) (p=0.003) compared with Caucasians. Patients with a BMI greater than 30 kg/m(2) had a significantly higher likelihood of diabetes (p=0.006), hypertension (p=0.03), and hyperlipidemia (p=0.05). Overall, 5 (5%) of the 92 patients met criteria for prediabetes risk.

CONCLUSION

Point-of-care metabolic risk screening, done with a systematic interprofessional team approach, can provide clinicians with a practical method for identifying metabolic risk in patients prescribed antipsychotics.