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

Comparing health literacy and behavioral changes in adulthood: A pilot study on alumni of a single school cancer education program

Cancer education programs are regularly conducted in schools in Japan. Previous reports on their effectiveness were based on surveys conducted several months after the education. We aimed to evaluate whether cancer education for children influenced their behavioral changes in adulthood. We targeted schools where the Japan Cancer Society has conducted the programs since 2011 and the program participants are older than 21 years currently. Invitations were sent to the participants and controls who graduated one year before or after the participants, and answers were obtained using an online questionnaire. Data were collected on the willingness to undergo cancer screening, sociodemographic characteristics, healthy behaviors, and health literacy. We compared the data from the program participants with those from controls. We requested cooperation from 13 schools; however, only one agreed. The common reason for refusal was privacy concerns. In the all-boys participating school in Tokyo, there was no significant difference in background information between the cancer education (38 participants) and control (55 participants) groups. Multiple linear regression showed that healthcare or welfare education background (β = 0.25, p = 0.01) and health literacy (β = 0.24, p = 0.02) were significant predictors of cancer screening intention, while the presence of cancer education (p = 0.25) was not. Despite severe selection bias, this is the first study to examine the long-term impacts of cancer education. We found no significant impacts on the measured outcome. However, the educational content at that time differed from that of today, and the program's efficacy should not be negated.

The Breast-Imaging Operations, Practices and Systems Inventory: A framework to examine mammography facility effects on screening in rural communities

PURPOSE

Develop and test a measurement framework of mammogram facility resources, policies, and practices in Appalachia.

METHODS

Survey items describing 7 domains of imaging facility qualities were developed and tested in the Appalachian regions of Kentucky, Ohio, Pennsylvania, Virginia, and West Virginia. Medicare claims data (2016-2018) were obtained on catchment area mammogram services. Construct validity was examined from associations with facility affiliation, community characteristics, mammogram screening uptake, and market reach. Analyses were performed with t-tests and ANOVA.

RESULTS

A total of 192 (of 377) sites completed the survey. Five factors were initially selected in exploratory factor analysis (FA) and refined in confirmatory FA: capacity, outreach & marketing, operational support, radiology review (NNFI = .94, GFI = 0.93), and diagnostic services (NNFI = 1.00, GFI = 0.99). Imaging capacity and diagnostic services were associated with screening uptake, with capacity strongly associated with catchment area demographic and economic characteristics. Imaging facilities in economically affluent versus poorer areas belong to larger health systems and have significantly more resources (P < .001). Facilities in economically distressed locations in Appalachia rely more heavily on outreach activities (P < .001). Higher facility capacity was significantly associated (P < .05) with larger catchment area size (median split: 48.5 vs 51.6), mammogram market share (47.4 vs 52.7), and screening uptake (47.6 vs 52.4).

CONCLUSIONS

A set of 18 items assessing breast imaging services and facility characteristics was obtained, representing policies and practices related to a facility's catchment area size, market share, and mammogram screening uptake.

Educational interventions to improve bowel cancer awareness and screening in Organisation for Economic Co-operation and Development countries: A scoping review

Objectives

Summarise theory informed educational interventions for improving bowel cancer awareness and screening.

Methods

A search was conducted in PubMed, EMBASE, Web of Science and CINAHL. English studies from 2016 to 2022 which implemented community-based bowel cancer awareness and/or screening education interventions for adults in Organisation for Economic Co-operation and Development countries were included.

Results

Sixty-two studies were included, 32 measured both screening and awareness (24 measured screening only, 6 measured awareness only). Education interventions were grouped and summarised in five education types: lay community health education/counselling (n = 28), education material (n = 5), health professional education/counselling (n = 10), mass media (n = 5) and other (n = 19). Other included education interventions which did not fit into the four types previously mentioned. Six studies tested more than one education type. Each type within these studies were reported/summarised separately within the appropriate education type. Lay educators resulted in improved awareness and screening. Brochures were effective education materials for screening and combined with lay educators resulted in increased awareness. State-wide mass media campaigns significantly improved screening uptake for up to 2-months post-campaign. Fear and loss-framed messaging improved screening intentions compared to humour or gain-based messaging. Decision aids had limited improvements in awareness. Facebook campaign and telephone counselling had limited improvements in screening.

Conclusions

Lay community health educators, brochures, and mass media campaigns occurring multiple times a year may be effective interventions in improving screening and/or awareness. Such approaches should be considered when developing community education. Education interventions should include multiple components suggested above to maximise improvements of awareness and screening.

Examining the roles of travel distance, medical mistrust, and cancer fatalism in the uptake of clinical cancer prevention among women in rural and urban US communities: A secondary data analysis

Introduction

Rural adults are less likely to receive cancer screening than urban adults, likely due to systematic differences in community- and individual-level factors. The purpose of this study was to analyze the relative contributions of rurality, travel time, medical mistrust, and cancer fatalism in explaining uptake of clinical cancer prevention services.

Methods

We conducted a secondary data analysis of 2019-2020 survey data from women, ages 45-65, in rural and urban counties in central Pennsylvania, examining rurality, travel time to a primary care provider, medical mistrust, and cancer fatalism, as well as uptake of guideline-recommended colorectal cancer screening, cervical cancer screening, and preventive check-up. Final models used multivariable logistic regression to assess the relationships among study variables, controlling for participant demographics.

Results

Among 474 participants, 48.9 % resided in rural counties. Most participants had received clinical cancer prevention services (colorectal cancer screening: 55.4 %; cervical cancer screening: 82.8 %; preventive check-up in the last year: 75.4 %). Uptake of services was less common among participants with higher medical mistrust (colorectal cancer screening: adjusted odds ratio [aOR] = 0.87, 95 % confidence interval [CI] = 0.76-1.00; cervical cancer screening: aOR = 0.79, 95 % CI = 0.63-1.00; last-year check-up: aOR = 0.74, 95 % CI = 0.63-0.88).

Conclusions

Patient attitudes, particularly medical mistrust, may contribute to rural/urban disparities in clinical cancer prevention among women. Community- and individual-level interventions are needed to improve cancer outcomes in rural areas.

Barriers and facilitators of colorectal cancer screening among East African men in Minnesota: a qualitative investigation

Objective: This study aimed to explore barriers and facilitators to colorectal cancer (CRC) screening among East African men in Minnesota.Design: Six focus groups were conducted in Minneapolis and St. Paul, MN, USA. Participants were asked to describe individual and structural barriers to CRC screening, and discuss strategies that would address individual and structural barriers to screening. Audio-recorded conversations were transcribed verbatim and translated to English. The transcriptions were analyzed using a thematic analysis. Major themes that emerged on individual barriers were lack of knowledge, fear, and privacy.Results: Themes that emerged on structural barriers were distrust in the medical system, lack of health care coverage, and access to the health care system. Education, client reminders, mass media, increased clarity in communication with the provider and translator, and increased access to health care were frequently mentioned strategies to increase CRC screening in the East African community. Participants expressed favorable views toward the concept of patient navigation.Conclusion: Our findings indicate the need to develop culturally appropriate, multi-faced, intervention programs that are aimed at eliminating personal, cultural, and structural barriers.

A scoping review of media campaign strategies used to reach populations living with or at high risk for Hepatitis C in high income countries to inform future national campaigns in the United Kingdom

BACKGROUND

With the advent of direct acting antivirals, the World Health Organisation proposed eliminating Hepatitis C as a public health threat by 2030. To achieve this, countries need to diagnose, engage in care and treat their undiagnosed populations. This will require sensitisation campaigns. However previous media campaigns have had mixed impact. We conducted a scoping review to identify and understand the impact of previous Hepatitis C media campaigns. These findings could inform the delivery of future campaigns.

METHODS

We searched five electronic databases for published literature on media campaigns conducted for Hepatitis C awareness, testing, and treatment in Organisation for Economic Co-operation and Development (OECD) countries since 2010. Two independent reviewers screened citations for inclusion. Additionally, we spoke to stakeholders in the Hepatitis C field in the UK and conducted a Google search to identify any unpublished literature. A quantitative synthesis was conducted to identify targeted populations, strategies and media used, aims and impact of the campaigns.

RESULTS

A title and year of publication screening of 3815 citations resulted in 113 papers that had a full abstract screen. This left 50 full-text papers, 18 were included of which 9 (50%) were from Europe. 5 (27.8%) of campaigns targeted minority ethnicities, and 9 (50%) aimed to increase testing. A Google search identified 6 grey literature sources. Most campaigns were not evaluated for impact. Discussions with stakeholders identified several barriers to successful campaigns including lack of targeted messaging, stigmatising or accusatory messaging, and short-lived or intermittent campaign strategies.

CONCLUSION

Future campaigns will likely need to be multifaceted and have multiple tailored interventions. Campaigns will need to be sizeable and robust, integrated into health systems and viewed as an ongoing service rather than one-offs.

Implications of Public Interest in Colonoscopy: Analysis of Google Trends Data From 12 European Countries

INTRODUCTION

Colorectal cancer (CRC) is one of the deadliest diseases in the European Union. Colonoscopy remains the gold standard of CRC screening. Analysis of colonoscopy-related Google Trends (GT; Google LLC, Mountain View, California, United States) data could provide useful information regarding interest in colonoscopy and potential barriers making patients unwilling to attend screening programs.

METHODS

Data were collected using GT for the main search term "colonoscopy" and the two most related queries. Colonoscopy volumes were extracted from the Eurostat database. Due to limited Eurostat data availability, analysis was performed from January 2004 to December 2015 for each of the 12 included countries.

RESULTS

Univariate linear regression analysis demonstrated statistically significant correlations between annual search volumes of "colonoscopy" and the annual number of colonoscopies performed in included countries (R2 = 0.923, P<.001). Trend analysis showed that the cumulative search volumes for "colonoscopy" gradually increased through the analyzed period. The spectrum of the most related queries encompassed "preparation for colonoscopy", "endoscopy", "after endoscopy", "colon", "colonoscopy diet", "virtual colonoscopy", "colonoscopy under anesthesia", "waiting times for colonoscopy" and "colonoscopy price". For eight out of nine queries, statistically significant correlations with procedure volumes were revealed.

CONCLUSIONS

GT could be a useful tool in assessing public interest in colonoscopy. Potential barriers that prevent people from attending CRC screening programs were identified. The study demonstrated that the internet has become an important field for CRC screening promotion. GT utility for colonoscopy and CRC screening providers was highlighted. This was the first analysis of GT data in colonoscopy focused on European countries.

Using User-Centered Design to Facilitate Adherence to Annual Lung Cancer Screening: Protocol for a Mixed Methods Study for Intervention Development

BACKGROUND

Lung cancer is the leading cause of cancer-related death in the United States, with the majority of lung cancer occurrence diagnosed after the disease has already metastasized. Lung cancer screening (LCS) with low-dose computed tomography can diagnose early-stage disease, especially when eligible individuals participate in screening on a yearly basis. Unfortunately, annual adherence has emerged as a challenge for academic and community screening programs, endangering the individual and population health benefits of LCS. Reminder messages have effectively increased adherence rates in breast, colorectal, and cervical cancer screenings but have not been tested with LCS participants who experience unique barriers to screening associated with the stigma of smoking and social determinants of health.

OBJECTIVE

This research aims to use a theory-informed, multiphase, and mixed methods approach with LCS experts and participants to develop a set of clear and engaging reminder messages to support LCS annual adherence.

METHODS

In aim 1, survey data informed by the Cognitive-Social Health Information Processing model will be collected to assess how LCS participants process health information aimed at health protective behavior to develop content for reminder messages and pinpoint options for message targeting and tailoring. Aim 2 focuses on identifying themes for message imagery through a modified photovoice activity that asks participants to identify 3 images that represent LCS and then participate in an interview about the selection, likes, and dislikes of each photo. A pool of candidate messages for multiple delivery platforms will be developed in aim 3, using results from aim 1 for message content and aim 2 for imagery selection. The refinement of message content and imagery combinations will be completed through iterative feedback from LCS experts and participants.

RESULTS

Data collection began in July 2022 and will be completed by May 2023. The final reminder message candidates are expected to be completed by June 2023.

CONCLUSIONS

This project proposes a novel approach to facilitate adherence to annual LCS through the development of reminder messages that embrace content and imagery representative of the target population directly in the design process. Developing effective strategies to increase LCS adherence is instrumental in achieving optimal LCS outcomes at individual and population health levels.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46657.

Educational material for social marketing and behaviours linked to early detection of breast cancer

BACKGROUND

Social marketing is an effective tool to ensure a populationbased behaviour change for a healthy lifestyle.

AIM

The aim was to investigate the effects of breast cancer-related printed educational materials on women's behaviours related to early detection and diagnosis of breast cancer within the framework of social marketing.

METHOD

This pre-post test one-group study was conducted with 80 women in a family health centre. An interview form, printed educational materials and follow-up form were used to collect the study data. The data were collected at the baseline and through phone calls at the third month.

RESULTS

Of the women, 36% had never performed breast self-examination (BSE), 55% had never had clinical breast examination (CBE), and 41% had never had mammography. There were no differences between the measurements made at the baseline and at the third month in terms of performing BSE, and having CBE and mammography.

CONCLUSION

The importance of expanding social marketing approaches in terms of global health investments is emphasised. Adoption of positive health behaviours will lead to improvements in health status, as assessed through measures of morbidity and mortality status in cancer.

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a systematic review

OBJECTIVE

To systematically identify interventions that increase the use of mammography screening in women living in low-income and middle-income countries (LMICs).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, Embase, Global Health, CINAHL, PsycINFO, Web of Science, Cochrane Central Register of Controlled Trials, Google Scholar and African regional databases.

ELIGIBILITY CRITERIA

Studies conducted in LMICs, published between 1 January 1990 and 30 June 2021, in the English language. Studies whose population included asymptomatic women eligible for mammography screening. Studies with a reported outcome of using mammography by either self-report or medical records. No restrictions were set on the study design.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and risk-of-bias assessment were conducted by two independent reviewers. A narrative synthesis of the included studies was conducted.

RESULTS

Five studies met the inclusion criteria consisting of two randomised controlled trials, one quasi-experiment and two cross-sectional studies. All included studies employed client-oriented intervention strategies including one-on-one education, group education, mass and small media, reducing client out-of-pocket costs, reducing structural barriers, client reminders and engagement of community health workers (CHWs). Most studies used multicomponent interventions, resulting in increases in the rate of use of mammography than those that employed a single strategy.

CONCLUSION

Mass and small media, group education, reduction of economic and structural barriers, client reminders and engagement of CHWs can increase use of mammography among women in LMICs. Promoting the adoption of these interventions should be considered, especially the multicomponent interventions, which were significantly effective relative to a single strategy in increasing use of mammography.

PROSPERO REGISTRATION NUMBER

CRD42021269556.

Association between employer-based health promotion programs and adherence to breast cancer screening in Texas

Breast cancer is the most common cancer diagnosed among women in Texas. Although adherence to recommended screening mammogram guidelines enables early detection and reduces breast cancer risks, screening mammogram adherence is low in Texas. With the rising percentage of women in the workforce, employer-based health promotion programs could be an effective measure in increasing mammogram adherence, thereby reducing breast cancer risk in Texas. Although employer-based health programs are common in the state, little is known about their effectiveness in increasing screening mammogram adherence among age-eligible employed females. The study survey was administered using Qualtrics and the study participants were representative of the Texas population. The study population included 318 females from Texas who were 50-74 years old. Among those who had access to employer-based health promotion programs, 65.4 % were adherent and 34.6 % were non-adherent to the guidelines. Population-weighted survey logistic regression analysis showed no significant association between access to employer-based health promotion programs and mammogram adherence for employed women (AOR: 0.85 [0.15-4.79], p-value = 0.86). However, access to healthcare coverage (AOR: 7.58 [2.89-19.88], p-value < 0.001), those who disagree with the fatalistic belief that everything causes cancer (AOR: 2.99 [1.45-6.19], p-value < 0.001), and those who perceive cancer screening important (AOR: 12.36 [2.26-67.47], p < 0.05) were found as significant determinants of mammogram adherence among females in Texas. The study concluded that access to employer-based health promotion programs alone was insufficient to improve breast cancer screening. The employers and the insurance companies, with support from the government, should develop a comprehensive program that addresses all structural and psychosocial barriers to employee breast cancer screening adherence.

Opportunities and Challenges When Using the Electronic Health Record for Practice-Integrated Patient-Facing Interventions: The e-Assist Colon Health Randomized Trial

Background

Even after a physician recommendation, many people remain unscreened for colorectal cancer (CRC). The proliferation of electronic health records (EHRs) and tethered online portals may afford new opportunities to embed patient-facing interventions within clinic workflows and engage patients following a physician recommendation for care. We evaluated the effectiveness of a patient-facing intervention designed to complement physician office-based recommendations for CRC screening.

Design

Using a 2-arm pragmatic, randomized clinical trial, we evaluated the intervention’s effect on CRC screening use as documented in the EHR (primary outcome) and the extent to which the intervention reached the target population. Trial participants were insured, aged 50 to 75 y, with a physician recommendation for CRC screening. Typical EHR functionalities, including patient registries, health maintenance flags, best practice alerts, and secure messaging, were used to support research-related activities and deliver the intervention to enrolled patients.

Results

A total of 1,825 adults consented to trial participation, of whom 78% completed a baseline survey and were exposed to the intervention. Most trial participants (>80%) indicated an intent to be screened on the baseline survey, and 65% were screened at follow-up, with no significant differences by study arm. One-third of eligible patients were sent a secure message. Among those, more than three-quarters accessed study material.

Conclusions

By leveraging common EHR functionalities, we integrated a patient-facing intervention within clinic workflows. Despite practice integration, the intervention did not improve screening use, likely in part due to portal-based interventions not reaching those for whom the intervention may be most effective.

Implications

Embedding patient-facing interventions within the EHR enabled practice integration but may minimize program effectiveness by missing important segments of the patient population.

Highlights

Interventions to increase mammography screening uptake among women living in low-income and middle-income countries: a protocol for a systematic review

INTRODUCTION

Breast cancer is the most prevalent cancer and the second leading cause of cancer-related deaths among women in low and middle-income countries (LMICs), including sub-Saharan Africa. Mammography screening is the most effective screening method for the early detection of breast cancers in asymptomatic individuals and the only screening test that decreases the risk of breast cancer mortality. Despite the perceived benefits, it has a low utilisation rate in comparison with breast self-examination and clinical breast examination. Several interventions to increase the uptake of mammography have been assessed as well as systematic reviews on mammography uptake. Nonetheless, none of the published systematic reviews focused on women living in LMICs. The review aims to identify interventions that increase mammography screening uptake among women living in LMICs.

METHODS AND ANALYSIS

Relevant electronic databases will be systematically searched from 1 January 1990 to 30 June 2021 for published and grey literature, including citation and reference list tracking, on studies focusing on interventions to increase mammography screening uptake carried out in LMICs and written in the English language. The search will incorporate the key terms: mammography, interventions, low- and middle-income countries and their associated synonyms. Randomised controlled trials, observational studies and qualitative and mixed methods studies of interventions (carried out with and without comparison groups) reporting interventions to increase mammography screening uptake in LMICs will be identified, data extracted and assessed for methodological quality by two independent reviewers with disagreements to be resolved by consensus or by a third author. We will use narrative synthesis and/or meta-analysis depending on the characteristics of the data.

ETHICS AND DISSEMINATION

Ethical approval is not required as it is a protocol for a systematic review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021269556.

Effect of Patient-Directed Messaging on Colorectal Cancer Screening: A Randomized Clinical Trial

IMPORTANCE

Colorectal cancer (CRC) screening is underused in the US. Tailored message interventions have shown benefit for increasing screening uptake of mammography and Papanicolaou testing, but their role in CRC screening is less clear.

OBJECTIVE

To evaluate the effectiveness of a tailored message telephone intervention prior to scheduling of a screening or surveillance colonoscopy and its effect on CRC screening completion rates.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted from July 2017 through August 2018 at the University of Pennsylvania Health System (UPHS), an urban academic medical center. Participants were asymptomatic patients aged 50 to 75 years who were eligible for CRC screening or surveillance, had been referred for colonoscopy, and did not have a scheduled colonoscopy appointment. Data analysis was conducted from January to September 2019.

INTERVENTIONS

Patients underwent block randomization in a 1:1:1 ratio to 1 of 3 study arms. Participants in the usual care group were contacted via a mailed letter and instructed to call to schedule a colonoscopy. In the generic message group, participants were contacted by telephone, completed an assessment, and received a uniform, nontailored message encouraging colonoscopy scheduling. Participants in the tailored message group were contacted by telephone, completed an assessment, and received a tailored message encouraging colonoscopy scheduling based on their identified assessment cohort.

MAIN OUTCOMES AND MEASURES

The primary outcome was colonoscopy completion rate within 120 days of enrollment. The secondary outcome was colonoscopy scheduling rate appointment within 120 days of enrollment.

RESULTS

A total of 600 participants (median [IQR] age, 56 [51-63] years; 373 women [62.2%]) were enrolled, including 200 participants randomized to usual care, 200 participants randomized to the generic message, and 200 participants randomized to the tailored message. The total sample included 12 Asian participants (2.0%), 324 Black participants (54.0%), and 227 White participants (37.8%), and 9 participants (1.5%) were of Latino or Hispanic ethnicity. Colonoscopy completion was significantly higher for both the tailored message group (69 participants [34.5%]) and the generic message group (64 participants [32.0%]) compared with the usual care group (37 participants [18.5%]) (P < .001 and P = .002, respectively). Scheduling rates were also significantly higher in both groups, with 106 participants (53.0%) in the tailored message group and 105 participants (52.5%) in the generic message group scheduling appointments, compared with 54 participants (27.0%) in the usual care arm (P < .001 for both).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial among individuals whose CRC screening was not up to date, both a tailored message intervention and a generic message intervention were significantly more effective at increasing colonoscopy scheduling and completion rates compared with usual care. These findings suggest that individualized health communications can increase individual motivation to obtain CRC screening.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03310892.

Analysis of Post-Colonoscopy Colorectal Cancer and Its Subtypes in a Screening Programme

Using the algorithm of the World Endoscopy Organisation (WEO), we have studied retrospectively all colorectal cancers, both detected and non-detected by the Basque Country screening programme from 2009 to 2017. In the screening programme 61,335 colonoscopies were performed following a positive Faecal Immunochemical test (FIT) (≥20 µg Hb/g faeces) and the 128 cases of post-colonoscopy colorectal cancer (PCCRC) detected were analysed. Among them, 50 interval type PCCRCs were diagnosed (before the recommended surveillance), 0.8 cases per 1000 colonoscopies performed, and 78 non-interval type PCCRCs (in the surveillance carried out at the recommended time or delayed), 1.3 per 1000 colonoscopies. Among the non-interval type PCCRCs, 61 cases were detected in the surveillance carried out at the recommended time (type A) and 17 when the surveillance was delayed (type B), 1 case per 1000 colonoscopies performed and 0.28 cases per 1000 colonoscopies performed, respectively. Interval type PCCRC is less frequent than non-interval type PCCRC. In interval type PCCRCs, CRCs detected in advanced stages (stages III-IV) were significantly more frequent than those detected in early stages, compared to those of non-interval type PCCRCs (OR = 3.057; 95% CI, 1.410-6.625; p < 0.005). Non-interval type B PCCRCs are less frequent than non-interval type A PCCRCs, but the frequency of advanced stages is higher in interval type B PCCRCs.

Increasing Cervical Cancer Prevention Through HPV Testing: Challenges in Developing Persuasive Messages

Decades of promotion of the Pap test have fallen short in persuading vulnerable women to get screened for cervical cancer. Human papillomavirus (HPV) testing provides an additional screening tool, and the task for cancer control is to promote understanding of the test and encourage its use. Ogden and colleagues investigated the effect of message framing on increasing knowledge and intention to receive HPV testing. Although both messages increased knowledge and intention, no differences were found between gain- and loss-framed messages. We explore implications of this finding and discuss needed research to expand upon and contextualize this important formative research.See related article, p. 839.

Closing the Gap: Participatory Formative Evaluation to Reduce Cancer Screening Disparities among Patients with Limited English Proficiency

Patients with limited English proficiency (LEP) have disproportionately lower rates of cancer screening than English-proficient patients. Given the multifactorial nature of screening disparities, strategies to improve screening rates must address barriers within and outside of the clinic setting. The objectives of this study were to understand local barriers from multiple stakeholder perspectives, to identify potential multilevel intervention approaches, and to mobilize community-engaged intervention decision making and planning. This participatory formative evaluation approach employed needs assessment and user engagement in order to enhance intervention usefulness and relevance. The study took place in several stages and involved clinic and community partners in a small metropolitan area of the Midwest USA. Interviews were conducted with LEP patients (n = 9) who had not completed three recommended screenings (breast, cervical, and colorectal), primary care providers (n = 5), medical interpreter (n = 5), and community members (n = 3). These highlighted multilevel barriers including limited patient understanding of preventive health, time and cost constraints, and variable roles of language interpreters. The literature was also reviewed to identify interventions used with similar populations. Findings from this review suggest that interventions are largely focused on single population groups or address single screening barriers. Finally, a community-academic summit (n = 48 participants) was held to review results and develop recommendations for community and clinic interventions. Findings from this study indicate that it is possible to engage a diverse group of stakeholders in strategies that are responsive to health care providers and patients, including LEP patients from heterogeneous backgrounds.

Interventions to Support International Migrant Women's Reproductive Health in Western-Receiving Countries: A Systematic Review and Meta-Analysis

Purpose: The reproductive health outcomes of international migrant women differ in comparison with receiving-country-born women, depending on country of birth and immigrant status. Effective interventions to support the reproductive health of international migrant women are not well known.

Methods: We conducted a systematic review and meta-analysis of studies between 2010 and 2017 evaluating interventions directly or indirectly affecting the reproductive health (as defined by the World Health Organization) of international migrant women in Western-receiving countries.

Results: Sixteen studies representing 5080 migrants were identified. Interventions consisted of linguistically (e.g., translated brochures) or culturally adapted (e.g., cultural narratives) routine care or new interventions. Meta-analysis showed that interventions increased rates of preventive reproductive health activities, including mammography, condom use, and Pap test completion, by almost 18% (95% confidence interval 7.61–28.3) compared with usual care or interventions not adapted to migrant women.

Conclusion: Culturally and linguistically adapted care practices congruent with target populations of international migrant women are effective in improving their reproductive health outcomes, particularly their participation in preventative reproductive health activities.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

The impact of monthly campaigns and other high-profile media coverage on public interest in 13 malignancies: a Google Trends analysis

It is estimated that more than 600,000 people will die of cancer in the United States in 2020. Annual cancer diagnoses throughout the country are expected to rise in the coming years, which may further strain the American healthcare system. As such, it is vital that public health campaigns intended to reduce cancer morbidity and mortality are successful. Monthly cancer awareness campaigns have been used in the past to raise awareness and funding for various malignancies. One notable example is the 'Pink October' campaign to raise awareness for breast cancer. There has been limited study, however, on the effectiveness of cancer awareness campaigns for other cancers such as colorectal cancer, prostate cancer and cervical cancer. High-profile media coverage of celebrity cancer diagnoses and/or cancer-related deaths is another method by which knowledge of common cancers is dispersed to the public. In this study, we evaluate the impact of monthly cancer awareness campaigns as well as celebrity cancer diagnoses and/or deaths on Internet search traffic regarding various malignancies. We used the Google Trends database to evaluate public interest in 13 different cancers (and their respective cancer screening methods, when applicable) from January 2010 to June 2020. Public interest in 6 of 13 cancers (cervical cancer, colorectal cancer, skin cancer, ovarian cancer, breast cancer and lung cancer) was significantly higher in their respective awareness months when compared to the rest of the year. Furthermore, peak public interest for 9 of 13 cancers was associated with a media-event such as a monthly awareness campaign or celebrity diagnoses and/or death. Our findings illustrate the important role that the media plays in facilitating public interest in common cancers and their screening methods. Cancer awareness months can serve as an effective tool to increase Internet search traffic regarding a given malignancy. In the future, public health agencies can attempt to utilise increased search traffic to better educate the public, raise funds and improve enrolment in cancer screening programmes that reduce cancer morbidity and mortality.

Organizational Transformation to Improve Breast Cancer Screening Behaviors in Iranian Women: A Qualitative Study

Breast cancer is the most common cause of premature mortality among women, and screening is one of the most important means of early diagnosis of breast cancer. This qualitative study was conducted to explore strategies for promoting breast cancer screening behaviors from the perspective of health volunteers in south-east Iran. Data collection was performed through focus groups. Using the purposive sampling method, 35 participants were selected and data were analyzed using a specific qualitative content analysis framework. By analyzing the data to provide strategies for promoting breast cancer screening behaviors, the main theme of "organizational transformation" with five subthemes including the promotion of health-centered beliefs in society, the development of culture-based training, the media revolution, financial support, and the provision of efficient health-care providers were extracted. According to the results of the study, the development of organizational transformation plays an important role in planning for the promotion of breast cancer screening.

Mailed self-sample HPV testing kits to improve cervical cancer screening in a safety net health system: protocol for a hybrid effectiveness-implementation randomized controlled trial

BACKGROUND

Almost 20% of U.S. women remain at risk for cervical cancer due to their inability or unwillingness to participate in periodic clinic-based screening. Self-sampling has been shown to be an effective strategy for screening women for high-risk human papillomavirus (HR-HPV) infection in specific contexts. However, its effectiveness among medically underserved women in safety net health systems has not been evaluated. Furthermore, it is also unclear whether implementation strategies such as patient navigation can be used to improve the success of self-sample screening programs by addressing patient-level barriers to participation.

METHODS/DESIGN

The Prospective Evaluation of Self-Testing to Increase Screening (PRESTIS) trial is a hybrid type 2 effectiveness-implementation pragmatic randomized controlled trial of mailed self-sample HPV testing. The aim is to assess the effectiveness of mailed self-sample HPV testing kits to improve cervical cancer screening participation among patients in a safety net health system who are overdue for clinic-based screening, while simultaneously assessing patient navigation as an implementation strategy. Its setting is a large, urban safety net health system that serves a predominantly racial/ethnic minority patient population. The trial targets recruitment of 2268 participants randomized to telephone recall (enhanced usual care, n = 756), telephone recall with mailed self-sample HPV testing kit (intervention, n = 756), or telephone recall with mailed self-sample HPV testing kit and patient navigation (intervention + implementation strategy, n = 756). The primary effectiveness outcome is completion of primary screening, defined as completion and return of mailed self-sample kit or completion of a clinic-based Pap test. Secondary effectiveness outcomes are predictors of screening and attendance for clinical follow-up among women with a positive screening test. Implementation outcomes are reach, acceptability, fidelity, adaptations, and cost-effectiveness.

DISCUSSION

Hybrid designs are needed to evaluate the clinical effectiveness of self-sample HPV testing in specific populations and settings, while incorporating and evaluating methods to optimize its real-world implementation. The current manuscript describes the rationale and design of a hybrid type 2 trial of self-sample HPV testing in a safety net health system. Trial findings are expected to provide meaningful data to inform screening strategies to ultimately realize the global goal of eliminating cervical cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898167 . Registered on 01 April 2019.

TRIAL STATUS

Study start data: February 13, 2020. Recruitment status: Enrolling by invitation. Estimated primary completion date: February 15, 2023. Estimated study completion date: May 31, 2024. Protocol version 1.6 (February 25, 2020).

Interventions to increase breast and cervical cancer screening uptake among rural women: a scoping review

PURPOSE

Despite widespread promotion of breast and cervical cancer (BCC) screening, uptake remains low in rural communities. Barriers to healthcare, which often result in poorer health outcomes, differentially impact residents of rural communities. Effective interventions addressing the unique needs of rural women may target these barriers and increase BCC screening participation. Our objective is to review and assess the published literature on interventions to increase BCC screening in rural communities.

METHODS

A systematic scoping review of PubMed/Medline was performed to identify BCC screening interventions conducted in rural settings. English language articles from peer-reviewed journals published from January 2006 to October 2019 were included if they reported results for BCC screening interventions in rural communities in the United States.

RESULTS

We reviewed 228 articles and identified eight articles consistent with our inclusion criteria. Studies varied in sample population characteristics, geographic location, design, and mode of intervention delivery. Interventions included patient navigation strategies, educational outreach programs, peer counseling, and small media initiatives. Interventions focused on promoting uptake of initial or one-time screening rather than targeted repeat screening, and few studies detailed the cost-effectiveness of the interventions.

CONCLUSION

This review may inform efforts to develop strategies to increase BCC screening among rural women. Additional cancer prevention and control research gaps in rural communities include the examination of the theoretical foundations, design, delivery, and cost-effectiveness of BCC screening interventions for rural communities. Future research might focus on methods to promote repeat BCC screening and effective translation of these interventions for other rural populations.

'No to unnecessary caesarean sections': Evaluation of a mass-media campaign on women's knowledge, attitude and intention for mode of delivery

Introduction

Improvement of women’s knowledge and attitude toward vaginal birth is recognized as an important strategy to control caesarean sections (CS) on maternal request. This study aimed to evaluate the effectiveness of a mass-media campaign in improving knowledge, attitude and intention of women for vaginal birth.

Methods

This was a population-based study carried out in Tehran, Iran. A national ‘No to unnecessary caesarean sections’ campaign was launched in April 2016 and was televised for ten days. A random sample of pregnant women from all defined geographical areas of Tehran were recruited and assessed for knowledge about the benefits of vaginal birth and the risk of CS, attitude and intention toward mode of delivery at two points in time: before and after the campaign. A comparison was made to evaluate outcome measures among those who had seen the campaign and those who had not.

Results

In all, 37 public and private maternity care centers were selected randomly and 702 eligible pregnant women attending these centers were entered in the study. Pre- and post-intervention data for 466 women were available for analysis. Of these, 194 women indicated that they had seen the campaign and the remaining 272 women said that they had not. A comparison of the outcome measures between the two study groups showed that there were significant differences between those who had seen the campaign and those who had not. Those who had seen the campaign reported increased knowledge, had a more positive attitude and indicated increased behavioral intention toward vaginal birth.

Conclusions

In general, the findings indicated that the mass-media campaign improved pregnant women’s knowledge, attitude and intention towards vaginal birth. However, the long-term effects of such campaigns need further investigation.

Effectiveness of Interventions to Increase Colorectal Cancer Screening Among American Indians and Alaska Natives

INTRODUCTION

Screening rates for colorectal cancer are low in many American Indian and Alaska Native (AI/AN) communities. Direct mailing of a fecal immunochemical test (FIT) kit can address patient and structural barriers to screening. Our objective was to determine if such an evidence-based intervention could increase colorectal cancer screening among AI/AN populations.

METHODS

We recruited study participants from 3 tribally operated health care facilities and randomly assigned them to 1 of 3 study groups: 1) usual care, 2) mailing of FIT kits, and 3) mailing of FIT kits plus follow-up outreach by telephone and/or home visit from an American Indian Community Health Representative (CHR).

RESULTS

Among participants who received usual care, 6.4% returned completed FIT kits. Among participants who were mailed FIT kits without outreach, 16.9% returned the kits - a significant increase over usual care (P < .01). Among participants who received mailed FIT kits plus CHR outreach, 18.8% returned kits, which was also a significant increase over usual care (P < .01) but not a significant increase compared with the mailed FIT kit-only group (P = .44). Of 165 participants who returned FIT kits during the study, 39 (23.6%) had a positive result and were referred for colonoscopy of which 23 (59.0%) completed the colonoscopy. Twelve participants who completed a colonoscopy had polyps, and 1 was diagnosed with colorectal cancer.

CONCLUSION

Direct mailing of FIT kits to eligible community members may be a useful, population-based strategy to increase colorectal cancer screening among AI/AN people.

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.

Promoting colorectal cancer screening: a systematic review and meta-analysis of randomised controlled trials of interventions to increase uptake

Colorectal cancer (CRC) represents a global public health concern. CRC screening is associated with significant reductions in CRC incidence and mortality, however, uptake is suboptimal. This systematic review and meta-analysis of randomised controlled trials explored the effectiveness of interventions designed to increase screening uptake, plus the impact of various moderators. Data from 102 studies including 1.94 million participants were analysed. Results showed significant benefit of all interventions combined (OR, 1.49, 95% CI: 1.43, 1.56, p < 0.001). The effects were similar in studies using objective versus self-reported uptake measures and lower in studies judged to be at high risk of bias. Moderator analyses indicated significant effects for aspects of behaviour (effects lower for studies on non-endoscopic procedures), and intervention (effects higher for studies conducted in community settings, in healthcare systems that are not free, and that use reminders, health-professional providers, paper materials supplemented with in-person or phone contact, but avoid remote contact). Interventions that included behaviour change techniques targeting social support (unspecified or practical), instructions or demonstration of the behaviour, and that added objects to the environment produced stronger effects. The way in which findings can inform interventions to improve CRC screening uptake is discussed.

The Effects of the Nurse Navigation Program in Promoting Colorectal Cancer Screening Behaviors: a Randomized Controlled Trial

Although screening programs are known and recommended for the early detection of colorectal cancer (CRC), the screening rates for the fecal occult blood test (FOBT) and colonoscopy are very low among adult individuals. Navigation programs, also known as individualized counseling, have recently begun to be used for increasing screening rates. The purpose of this study was to compare the efficacy of the Nurse Navigation Program versus usual care on CRC screening participation and movement in stage of adoption for CRC screening and to examine perceived benefits of and barriers to CRC screening. This study was designed in line with a pre- and posttest two-group methodology. A total of 110 participants (55 nurse-navigated and 55 non-navigated patients) were studied. Data were collected using the following three tools: a sociodemographic information form, the Harvard Colorectal Cancer Risk Assessment Tool, and Instruments to Measure Colorectal Cancer Screening Benefits and Barriers. Following the Nurse Navigation Program, the FOBT (82 and 84%, respectively) and colonoscopy completion rates (15 and 22%, respectively) were significantly higher in the nurse-navigated group than in the non-navigated group at 3 and 6 months follow-up. Following the program, the benefit perceptions of the nurse-navigated group about CRC screening were improved, and their barrier perceptions were reduced. The results showed that the Nurse Navigation Program had significant effects on CRC screening behavior and health-related beliefs concerning CRC screening. Further assessment of the Nurse Navigation Program in different groups should be performed to observe its effects.

A "Tea and Cookies" Approach: Co-designing Cancer Screening Interventions with Patients Living with Low Income

BACKGROUND

In our primary care organization, we have observed income gradients in cancer screening for our patients despite outreach. We hypothesized that outreach strategies could be improved upon to be more compelling for our patients living with low income.

OBJECTIVE

To use co-design to adapt our current strategies and create new strategies to improve cancer screening uptake for patients living with low income.

DESIGN

An exploratory, qualitative study in two phases: interviews and focus groups.

PARTICIPANTS

For interviews, we recruited 25 patient participants who were or had been overdue for cancer screening and had been identified by their provider as potentially living with low income. For subsequent focus groups, we recruited 14 patient participants, 11 of whom had participated in Phase I interviews.

APPROACH

To analyse written transcripts, we took an iterative, inductive approach using content analysis and drawing on best practices in Grounded Theory methodology. Emergent themes were expanded and clarified to create a derived model of possible strategies to improve the experience of cancer screening and encourage screening uptake for patients living with low income.

KEY RESULTS

Fear and competing priorities were two key barriers to cancer screening identified by patients. Patients believed that a warm and encouraging outreach approach would work best to increase cancer screening participation. Phone calls and group education were specifically suggested as potentially promising methods. However, these views were not universal; for example, women were more likely to be in favour of group education.

CONCLUSIONS

We used input from patients living with low income to co-design a new approach to cancer screening in our primary care organization, an approach that could be broadly applicable to other contexts and settings. We learned from our patients that a multi-modal strategy will likely be best to maximize screening uptake.

Systematic reviews as a "lens of evidence": Determinants of cost-effectiveness of breast cancer screening

Systematic reviews with economic components are important decision tools for stakeholders seeking to evaluate technologies, such as breast cancer screening (BCS) programs. This overview of systematic reviews explores the determinants of the cost-effectiveness of BCS and assesses the quality of secondary evidence. The search identified 30 systematic reviews that reported on the determinants of the cost-effectiveness of BCS, including the costs of breast cancer and BCS. While the quality of the reviews varied widely, only four out of 30 papers were considered to be of a high quality. We did not identify publication bias in the original evidence on the cost-effectiveness of mammography screening; however, we highlight a need for improved clarity in both reporting and data verification. The reviews consisted mainly of studies from high-income countries. Breast cancer costs varied widely among the studies. Factors leading to higher costs included: time (diagnosis and last months before death), later stage or metastases, recurrence of the disease, age below 64 years and type of follow-up (more intensive or more specialized). Overall, screening with mammography was considered cost-effective in the age range 50-69 years in Western European and Northern American countries but not for older or younger women. Its cost-effectiveness was questionable for low-income settings and Asia. Mammography screening was more cost-effective with biennial screening compared to annual screening and single reading using computer-aided detection vs double reading. No information on the cost-effectiveness of ultrasonography was found, and there is much uncertainty on the cost-effectiveness of CBE because of methodological limitations.

Economics of Multicomponent Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening: A Community Guide Systematic Review

CONTEXT

The Community Preventive Services Task Force recently recommended multicomponent interventions to increase breast, cervical, and colorectal cancer screening based on strong evidence of effectiveness. This systematic review examines the economic evidence to guide decisions on the implementation of these interventions.

EVIDENCE ACQUISITION

A systematic literature search for economic evidence was performed from January 2004 to January 2018. All monetary values were reported in 2016 US dollars, and the analysis was completed in 2018.

EVIDENCE SYNTHESIS

Fifty-three studies were included in the body of evidence from a literature search yield of 8,568 total articles. For multicomponent interventions to increase breast cancer screening, the median intervention cost per participant was $26.69 (interquartile interval [IQI]=$3.25, $113.72), and the median incremental cost per additional woman screened was $147.64 (IQI=$32.92, $924.98). For cervical cancer screening, the median costs per participant and per additional woman screened were $159.80 (IQI=$117.62, $214.73) and $159.49 (IQI=$64.74, $331.46), respectively. Two studies reported incremental cost per quality-adjusted life year gained of $748 and $33,433. For colorectal cancer screening, the median costs per participant and per additional person screened were $36.63 (IQI=$7.70, $139.23) and $582.44 (IQI=$91.10, $1,452.12), respectively. Two studies indicated a decline in incremental cost per quality-adjusted life year gained of $1,651 and $3,817.

CONCLUSIONS

Multicomponent interventions to increase cervical and colorectal cancer screening were cost effective based on a very conservative threshold. Additionally, multicomponent interventions for colorectal cancer screening demonstrated net cost savings. Cost effectiveness for multicomponent interventions to increase breast cancer screening could not be determined owing to the lack of studies reporting incremental cost per quality-adjusted life year gained. Future studies estimating this outcome could assist implementers with decision making.

How Is Health Literacy Related to Pap Testing Among US Women?

While Pap testing has significantly reduced the burden of cervical cancer, not all women follow prevention recommendations of cervical cancer screening every 3 years. Health literacy regarding Pap testing may influence the adoption of this behavior. The objective of this study was to assess the health literacy-related factors associated with Pap testing among a nationally representative sample of women in the USA. The Health Information National Trends Survey Cycles 4.4 and 5.1 were restricted to women 21-65 years of age (N = 2992). Questions were selected using the Integrated Model of Health Literacy domains: access (i.e., seeking cancer information), understand (i.e., HPV awareness, HPV knowledge), appraise (i.e., prevention not possible, chance of getting cancer), and apply (i.e., received a Pap in last 3 years [outcome]). Survey-weighted, logistic regression models estimated how the health literacy domains were associated with Pap testing, using SAS 9.4. In the sample, 81.1% of women received a Pap test within the last 3 years. The analysis revealed women who knew HPV is an STD (aOR = 1.64, 95% CI 1.20-2.26) were more likely to have received a Pap test in the last 3 years, while controlling for sociodemographic factors. These findings indicate that knowledge about HPV may be associated with Pap testing behavior among US women. Continued research is needed to examine the impact of health literacy on Pap testing given the changes in screening guidelines, with the ultimate goal of decreasing cervical cancer.

A Systematic Review of U.S.-Based Colorectal Cancer Screening Uptake Intervention Systematic Reviews: Available Evidence and Lessons Learned for Research and Practice

Background: We examined colorectal cancer screening (CRCS) intervention effectiveness, through the effect sizes associated with: (1) screening modality, (2) intervention level (e.g., client-directed), and (3) intervention component (e.g. client reminders) within published CRCS intervention systematic reviews (SRs).

Methods: A search of peer-reviewed CRCS SRs that were written in English was employed utilizing five databases: CINAHL, Cochrane Library, rTIPS, PubMed, and PsycINFO EBSCOHOST. SRs that included CRCS interventions with a randomized controlled trial, quasi-experimental, or single arm design were eligible. Data on effect sizes by screening modality, intervention level, and intervention component were extracted and synthesized.

Results: There were 16 eligible CRCS intervention SRs that included 116 studies published between 1986 and 2013. Reviews organized data by CRCS screening modality, or intervention component. Effect size reporting varied by format (i.e., ranges, medians of multiple studies, or effect size per study), and groupings of modalities and components. Overall, the largest effect sizes were for studies that utilized a combination of colonoscopy, fecal occult blood test (FOBT), and sigmoidoscopy as screening options (16–45 percentage point difference).

Conclusions: Evidence suggests that CRCS interventions which include a combination of screening modalities may be most effective. This is the first SR to examine effect sizes of published CRCS SRs. However, because some SRs did not report effect sizes and there were tremendous variability reporting formats among those that did, a standard reporting format is warranted. Synthesizing findings can contribute to improved knowledge of evidence-based best-practices, direct translation of findings into policy and practice, and guide further research in CRCS.

A 3-step intervention to improve adherence to cervical cancer screening: The SCAN randomized controlled trial

The aim of this study was to test the effectiveness of a stepwise intervention with an increasing level of complexity and cost to increase adherence to organized cervical cancer screening. This was a randomized (1: 1) controlled trial, conducted among 13 Portuguese primary health care units. Participants (n = 1220) were women aged 25-49 years, eligible for cervical cancer screening, with a mobile phone number available. The tested intervention was a 3-step invitation to screening, based on automated text messages/phone calls (step 1), manual phone calls (step 2) and face-to-face interviews (step 3), applied sequentially to non-adherent women after each step. Participants in the control group were invited through a written letter (standard of care). The primary outcome was the proportion of women screened, which was assessed after step 1 (45 days after the initial invitation), steps 1 + 2 (90 days after the initial invitation) and steps 1 + 2 + 3 (150 days after the initial invitation). Adherence to cervical cancer screening was significantly higher among women assigned to the intervention than those in the control group for step 1 (39.9% vs. 25.7%, p < 0.001), steps 1 + 2 (48.6% vs. 30.7%, p < 0.001) and steps 1 + 2 + 3 (51.2% vs. 34.0%, p < 0.001). In conclusion, adherence to cervical cancer screening was higher by 17% among women invited through the 3-step intervention, compared to those receiving the standard invitation letter. The former strategy has the potential to be broadly implemented due to the low requirements of technology and training. Clinical Trial Registration: NCT03122275.

Promoting Enrollment in Parenting Programs Among a Filipino Population: A Randomized Trial

BACKGROUND AND OBJECTIVES

Evidence-based parenting programs prevent the onset and escalation of youth conduct problems. However, participation rates in such programs are low among hard-to-reach populations, including Filipino individuals. Compared with other ethnic groups, Filipino adolescents have significant mental health disparities. We evaluated the effectiveness of a theory-based, culturally tailored video versus a usual-care mainstream video on enrollment in an evidence-based parenting program among Filipino caregivers of children ages 6 to 12 years and tested theoretical mediators of intervention effect.

METHODS

We randomly assigned 215 Filipino participants to view either a theory-based, culturally tailored video based on the Health Belief Model and Theory of Planned Behavior or a control video. The primary outcome was actual enrollment in an evidence-based parenting intervention. Mediators (knowledge and perceived susceptibility) were modeled as latent variables in a structural equation model.

RESULTS

After the intervention, participants in the intervention group had significantly higher knowledge of Filipino adolescent behavioral health disparities and higher perceived susceptibility to adolescent risky sexual activity and illegal drug use. Controlling for child sex, parents in the intervention group had significantly greater odds of actual enrollment in the Incredible Years program (odds ratio = 2.667; 95% confidence interval: 1.328-5.354; P = .006). The intervention effects were mediated by increased knowledge and perceived susceptibility.

CONCLUSIONS

Results demonstrated the effectiveness of a theory-based, culturally tailored intervention aimed at increasing participation of a hard-to-engage population in parenting interventions. Videos that include parents and health professionals with whom audiences can identify can be used to produce shifts in knowledge and behavior.

Randomised trial to evaluate the effectiveness and impact of offering postvisit decision support and assistance in obtaining physician-recommended colorectal cancer screening: the e-assist: Colon Health study-a protocol study

INTRODUCTION

How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening.

METHODS AND ANALYSIS

In partnership with healthcare teams, we developed 'e-assist: Colon Health', a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient-physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50-75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians.

ETHICS AND DISSEMINATION

All trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action.

TRIAL REGISTRATION NUMBER

NCT02798224; Pre-results.

Reducing ethnic inequalities in bowel screening participation in New Zealand: A randomised controlled trial of telephone follow-up for non-respondents

Objective

To test whether a telephone follow-up service for high-needs ethnic groups increases bowel screening participation in non-responders to postal invitations.

Methods

Māori, Pacific, and Asian ethnicity individuals who failed to return a bowel screening test kit within four weeks of it being posted were randomly allocated (1:1) to a telephone active follow-up service or a control group. The active follow-up service made multiple attempts to contact the invitee and provide support. Participation rates at eight weeks’ post-randomisation were compared, and the effect of the intervention on overall participation rates was imputed.

Results

A total of 3828 eligible individuals were allocated to active follow-up and 3773 to the control group. The imputed potential overall increase in participation in the active follow-up group was 2.0% (95% CI = 0.6%–3.4%); however, the impact of follow-up varied significantly by ethnicity and deprivation. The imputed increase in participation was significant for Māori (5.2; CI = 1.8%–8.5%) and Pacific (3.6%; CI = 0.7%–6.4%), but not for Asian ethnicities (0.7%; CI=−1.1%–2.4%). In addition, the imputed increase was significant among high deprivation participants (3.9%; CI = 2.0%–5.9%), but not among low deprivation participants (0.3%; CI=−1.6%–2.2%).

Conclusions

Active follow-up led to higher bowel screening participation in Māori and Pacific but not in Asian ethnicities and was more effective in high deprivation subjects. Active follow-up significantly reduced but did not eliminate ethnic inequalities in bowel screening participation.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study

OBJECTIVE

To model cost and benefit of a national community health worker workforce.

DESIGN

Modelling exercise based on all general practices in England.

SETTING

United Kingdom National Health Service Primary Care.

PARTICIPANTS

Not applicable.

DATA SOURCES

Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake.

MAIN OUTCOME MEASURES

We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients.

RESULTS

Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.

CONCLUSION

A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

Association Between Adherence to Cancer Screening and Knowledge of Screening Guidelines: Feasibility Study Linking Self-Reported Survey Data With Medical Records

BACKGROUND

It is possible that patients who are more aware of cancer screening guidelines may be more likely to adhere to them.

OBJECTIVE

The aim of this study was to determine whether screening knowledge was associated with the documented screening participation. We also assessed the feasibility and acceptability of linking electronic survey data with clinical data in the primary care setting.

METHODS

We conducted an electronic survey at 2 sites in Toronto, Canada. At one site, eligible patients were approached in the waiting room to complete the survey; at the second site, eligible patients were sent an email inviting them to participate. All participants were asked to consent to the linkage of their survey results with their electronic medical record.

RESULTS

Overall, 1683 participants responded to the survey-247 responded in the waiting room (response rate, 247/366, 67.5%), whereas 1436 responded through email (response rate, 1436/5779, 24.8%). More than 80% (199/247 and 1245/1436) of participants consented to linking their survey data to their medical record. Knowledge of cancer screening guidelines was generally low. Although the majority of participants were able to identify the recommended tests for breast and cervical screening, very few participants correctly identified the recommended age and frequency of screening, with a maximum of 22% (21/95) of screen-eligible women correctly answering all 3 questions for breast cancer screening. However, this low level of knowledge among patients was not significantly associated with screening uptake, particularly after adjustment for sociodemographic characteristics.

CONCLUSIONS

Although knowledge of screening guidelines was low among patients in our study, this was not associated with screening participation. Participants were willing to link self-reported data with their medical record data, which has substantial implications for future research.

Use of Two Self-referral Reminders and a Theory-Based Leaflet to Increase the Uptake of Flexible Sigmoidoscopy in the English Bowel Scope Screening Program: Results From a Randomized Controlled Trial in London

Background

We previously initiated a randomized controlled trial to test the effectiveness of two self-referral reminders and a theory-based leaflet (sent 12 and 24 months after the initial invitation) to increase participation within the English Bowel Scope Screening program.

Purpose

This study reports the results following the second reminder.

Methods

Men and women included in the initial sample (n = 1,383) were re-assessed for eligibility 24 months after their invitation (12 months after the first reminder) and excluded if they had attended screening, moved away, or died. Eligible adults received the same treatment they were allocated 12 months previous, that is, no reminder ("control"), or a self-referral reminder with either the standard information booklet ("Reminder and Standard Information Booklet") or theory-based leaflet designed using the Behavior Change Wheel ("Reminder and Theory-Based Leaflet"). The primary outcome was the proportion screened within each group 12 weeks after the second reminder.

Results

In total, 1,218 (88.1%) individuals were eligible. Additional uptake following the second reminder was 0.4% (2/460), 4.8% (19/399), and 7.9% (29/366) in the control, Reminder and Standard Information Booklet, and Reminder and Theory-Based Leaflet groups, respectively. When combined with the first reminder, the overall uptake for each group was 0.7% (3/461), 14.5% (67/461), and 21.5% (99/461). Overall uptake was significantly higher in the Reminder and Standard Information Booklet and Reminder and Theory-Based Leaflet groups than in the control (odds ratio [OR] = 26.1, 95% confidence interval [CI] = 8.1-84.0, p < .001 and OR = 46.9, 95% CI = 14.7-149.9, p < .001, respectively), and significantly higher in the Reminder and Theory-Based Leaflet group than in the Reminder and Standard Information Booklet group (OR = 1.8, 95% CI = 1.3-2.6, p < .001).

Conclusion

A second reminder increased uptake among former nonparticipants. The added value of the theory-based leaflet highlights a potential benefit to reviewing the current information booklet.

Trials Registry Number

ISRCTN44293755.

Evaluation of Mammogram Parties as an Effective Community Navigation Method

Women of color do not have the same level of access to mammography services as their White counterparts, and this inequity may be one of the contributing factors to the documented racial disparity in breast cancer mortality in the US. The present study sought to assess the effectiveness of the mammogram party, a promising, but under-studied approach to increasing mammography uptake, particularly among under-served populations. The program targeted mammogram-eligible women in community settings on the west and southwest sides of Chicago, gathering basic demographic information, mammography history, and interest in assistance obtaining a mammogram. Women were navigated either through traditional one-on-one navigation or to a mammogram party. Seven outcome metrics were calculated for each type of navigation. We compared navigation outcomes for those who attended to those who did not attend a mammogram party using two-tailed t tests and chi-square tests. We found that the mammography completion rate for mammogram parties was comparable to that for standard one-on-one navigation (65.8 vs. 63.7%), which is more labor-intensive as evidenced by the number of contacts needed to successfully navigate a woman to mammography (10.9 vs. 15.0). Mammogram parties offer a unique opportunity for fellowship and support for clients who are particularly fearful of mammograms or identifying breast cancer. Programmatically, mammogram parties are an efficient way to complete several mammograms in 1 day. Having the option to both navigate women to mammogram parties or one-on-one navigation allows for more flexibility for scheduling and may ensure a completed a mammogram.

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.

The "Empowering Latinas to Obtain Breast Cancer Screenings" study: Rationale and design

BACKGROUND

Latinas suffer disproportionately from breast cancer (BC) in part due to lower guideline-concordant screening. Multiple intervention approaches have been developed to promote screening through direct patient education and empowerment approaches (i.e., training community members to share BC information). This study compares the relative effects of these approaches on: 1) women's BC screening; and, 2) women's dissemination of BC information within their social networks.

DESIGN/METHODS

Our quasi-experimental trial is being implemented in community venues in two predominantly Latino neighborhoods in South and West Chicago. Eligible participants: 1) are female; 2) are 52-74 years old; 3) have not obtained a mammogram in the past 2 years; and, 4) have not previously participated in health-related volunteerism. Based on their geographic location, participants are assigned to one of two group-based interventions. Both interventions consist of three two-hour sessions, which includes BC early detection education. The education intervention sessions also covers BC prevention (diet, physical activity), whereas the empowerment intervention covers sharing information with family/friends, and health volunteerism. Navigation is provided for all women who wish to obtain mammograms. Primary outcomes include: 1) receipt of BC screening; and, 2) participants' dissemination of BC information. Secondary outcomes include positive changes in 1) participants' self-reported psychosocial facilitators; and, 2) social network members' BC behaviors.

DISCUSSION

The design of our program allows for a preliminary comparison of the effectiveness of these two approaches. This work will inform larger comparativeness trials and offers a new approach to intervention evaluation via social network analysis.

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

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Promoting colorectal cancer screening among South Asian populations: Strategies to promote access

The acceptance of colorectal cancer screening may be challenging for some South Asian groups in Canada. As oncology nurses, it is important to recognize barriers to screening, and be cognizant of culturally appropriate strategies to promote access in practice. This paper presents current research that was undertaken to understand population-based colorectal cancer screening among South Asian immigrants, and uses an access framework to outline strategies that minimize access barriers. Cultural safety principles and cultural assessment tools to support practice are also discussed.

[Not Available]

Au Canada, le dépistage du cancer colorectal peut rebuter certaines populations sud-asiatiques. En tant qu’infirmières en oncologie, il importe que nous connaissions les obstacles au dépistage de même que des stratégies culturellement appropriées pouvant être adoptées pour les surmonter. Dans cet article, nous présentons la recherche effectuée sur le dépistage du cancer colorectal chez les immigrants sud-asiatiques et utilisons un cadre sur l’accès pour dégager des stratégies permettant de lever les barrières. Nous abordons également des principes de sécurisation culturelle et examinons quelques outils d’évaluation culturelle qui peuvent être mis à profit dans la pratique infirmière.

Enhancing capacity among faith-based organizations to implement evidence-based cancer control programs: a community-engaged approach

Evidence-based interventions (EBIs) to promote cancer control among Latinos have proliferated in recent years, though adoption and implementation of these interventions by faith-based organizations (FBOs) is limited. Capacity building may be one strategy to promote implementation. In this qualitative study, 18 community key informants were interviewed to (a) understand existing capacity for health programming among Catholic parishes, (b) characterize parishes' resource gaps and capacity-building needs implementing cancer control EBIs, and (c) elucidate strategies for delivering capacity-building assistance to parishes to facilitate implementation of EBIs. Semi-structured qualitative interviews were conducted. Key informants concurred about the capacity of Catholic parishes to deliver health programs, and described attributes of parishes that make them strong partners in health promotion initiatives, including a mission to address physical and mental health, outreach to marginalized groups, altruism among members, and existing engagement in health programming. However, resource gaps and capacity building needs were also identified. Specific recommendations participants made about how existing resources might be leveraged to address challenges include to: establish parish wellness committees; provide "hands-on" learning opportunities for parishioners to gain program planning skills; offer continuous, tailored, on-site technical assistance; facilitate relationships between parishes and community resources; and provide financial support for parishes. Leveraging parishes' existing resources and addressing their implementation needs may improve adoption of cancer control EBIs.

Factors influencing participation in fecal occult blood testing to screen for colorectal cancer in Australia: a scoping review protocol

REVIEW QUESTION

The objective of this scoping review is to examine and map the evidence on the range of factors influencing a person's decision to screen or not screen for colorectal cancer using a fecal occult blood test (FOBT) in Australia, with the view to identifying gaps in the research and informing appropriate questions for future systematic reviews.The question of this review is: what evidence is available around the barriers and facilitators that influence an individual's decision to screen or not screen for colorectal cancer using a fecal occult blood test in Australia?

Breast Cancer Epidemiology, Prevention, and Screening

Globally, breast cancer is both the most commonly occurring cancer and the commonest cause of cancer death among women. Available data suggest that incidence and mortality in high-resource countries has been declining whereas incidence and mortality in low-resource countries has been increasing. This pattern is likely to be due to changing risk factor profiles and differences in access to breast cancer early detection and treatment. Risk factors for breast cancer include increasing age, race, menarche history, breast characteristics, reproductive patterns, hormone use, alcohol use, tobacco use, diet, physical activity, and body habitus. Mutations in the BRCA 1 and BRCA 2 tumor suppressor genes are significantly associated with the development of breast and ovarian cancer by the age of 70. Survival depends on both stage and molecular subtype. As there are few signs and symptoms early on, early detection is an important strategy to improve outcomes. Major professional organizations in the United States and elsewhere recommend screening with mammography with appropriate follow up for an abnormal screening test, although they differ somewhat by recommended ages and frequency of screening. Studies suggest a 15%-40% mortality reduction secondary to screening, however, there are also concerns about harms, such as overdiagnosis (5%-54%) and overtreatment leading to long term complications, and false negatives (6%-46%). Identification of women at risk for BRCA1 and BRCA 2 mutations is also recommended with referral for genetic testing. Preventive interventions, such as lifestyle, medical, and surgical options are available for women testing positive for BRCA mutations.