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

The impact of text message reminders on cryotherapy uptake among women testing positive for HPV in western Kenya: a prospective cohort study

BACKGROUND

Mobile health (mHealth) has become an increasingly popular strategy to improve healthcare delivery and health outcomes. Communicating results and health education via text may facilitate program planning and promote better engagement in care for women undergoing human papillomavirus (HPV) screening. We sought to develop and evaluate an mHealth strategy with enhanced text messaging to improve follow-up throughout the cervical cancer screening cascade.

METHODS

Women aged 25-65 participated in HPV testing in six community health campaigns (CHCs) in western Kenya as part of a single arm of a cluster-randomized trial. Women received their HPV results via text message, phone call, or home visit. Those who opted for text in the first four communities received "standard" texts. After completing the fourth CHC, we conducted two semi-structured focus group discussions with women to develop an "enhanced" text strategy, including modifying the content, number, and timing of texts, for the subsequent two communities. We compared the overall receipt of results and follow-up for treatment evaluation among women in standard and enhanced text groups.

RESULTS

Among 2368 women who were screened in the first four communities, 566 (23.9%) received results via text, 1170 (49.4%) via phone call, and 632 (26.7%) via home visit. In the communities where enhanced text notification was offered, 264 of the 935 screened women (28.2%) opted for text, 474 (51.2%) opted for phone call, and 192 (20.5%) for home visit. Among 555 women (16.8%) who tested HPV-positive, 257 (46.3%) accessed treatment, with no difference in treatment uptake between the standard text group (48/90, 53.3%) and the enhanced text group (22/41, 53.7%). More women in the enhanced text group had prior cervical cancer screening (25.8% vs. 18.4%; p < 0.05) and reported living with HIV (32.6% vs. 20.2%; p < 0.001) than those in the standard text group.

CONCLUSIONS

Modifying the content and number of texts as an enhanced text messaging strategy was not sufficient to increase follow-up in an HPV-based cervical cancer screening program in western Kenya. A one-size approach to mHealth delivery does not meet the needs of all women in this region. More comprehensive programs are needed to improve linkage to care to further reduce structural and logistical barriers to cervical cancer treatment.

The impact of text message reminders on uptake of cryotherapy among women testing positive for HPV in western Kenya

Background

Mobile health (mHealth) has become an increasingly popular strategy to improve healthcare delivery and health outcomes. Communicating results and health education via text may facilitate program planning and promote better engagement in care for women undergoing human papillomavirus (HPV) screening. We sought to develop and evaluate an mHealth strategy with enhanced text messaging to improve follow-up throughout the cervical cancer screening cascade.

Methods

Women aged 25-65 participated in HPV testing in six community health campaigns (CHCs) in western Kenya. Women received their HPV results via text message, phone call, or home visit. Those who opted for text in the first four communities received "standard" texts. After completing the fourth CHC, we conducted two focus group discussions with women to develop an "enhanced" text strategy, including modifying the content, number, and timing of texts, for the subsequent two communities. We compared the overall receipt of results and follow-up for treatment evaluation among women in standard and enhanced text groups.

Results

Among 2,368 women who were screened in the first four communities, 566 (23.9%) received results via text, 1,170 (49.4%) via phone call, and 632 (26.7%) via home visit. In the communities where enhanced text notification was offered, 264 of the 935 screened women (28.2%) opted for text, 474 (51.2%) opted for phone call, and 192 (20.5%) for home visit. Among 555 women (16.8%) who tested HPV-positive, 257 (46.3%) accessed treatment, with no difference in treatment uptake between the standard text group (48/90, 53.3%) and the enhanced text group (22/41, 53.7%). More women in the enhanced text group had prior cervical cancer screening (25.8% vs. 18.4%; p < 0.05) and reported living with HIV (32.6% vs. 20.2%; p < 0.001) than those in the standard text group.

Conclusions

Modifying the content and number of texts as an enhanced text messaging strategy was not sufficient to increase follow-up in an HPV-based cervical cancer screening program in western Kenya. A one-size approach to mHealth delivery does not meet the needs of all women in this region. More comprehensive programs are needed to improve linkage to care to further reduce structural and logistical barriers to cervical cancer treatment.

mHealth Interventions to Improve Cancer Screening and Early Detection: Scoping Review of Reviews

BACKGROUND

Cancer screening provision in resource-constrained settings tends to be opportunistic, and uptake tends to be low, leading to delayed presentation and treatment and poor survival.

OBJECTIVE

The aim of this study was to identify, review, map, and summarize findings from different types of literature reviews on the use of mobile health (mHealth) technologies to improve the uptake of cancer screening.

METHODS

The review methodology was guided by the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). Ovid MEDLINE, PyscINFO, and Embase were searched from inception to May 2021. The eligible criteria included reviews that focused on studies of interventions that used mobile phone devices to promote and deliver cancer screening and described the effectiveness or implementation of mHealth intervention outcomes. Key data fields such as study aims, types of cancer, mHealth formats, and outcomes were extracted, and the data were analyzed to address the objective of the review.

RESULTS

Our initial search identified 1981 titles, of which 12 (0.61%) reviews met the inclusion criteria (systematic reviews: n=6, 50%; scoping reviews: n=4, 33%; rapid reviews: n=1, 8%; narrative reviews: n=1, 8%). Most (57/67, 85%) of the interventions targeted breast and cervical cancer awareness and screening uptake. The most commonly used mHealth technologies for increasing cancer screening uptake were SMS text messages and telephone calls. Overall, mHealth interventions increased knowledge about screening and had high acceptance among participants. The likelihood of achieving improved uptake-related outcomes increased when interventions used >1 mode of communication (telephone reminders, physical invitation letters, and educational pamphlets) together with mHealth.

CONCLUSIONS

mHealth interventions increase cancer screening uptake, although multiple modes used in combination seem to be more effective.

Factors Promoting Breast, Cervical and Colorectal Cancer Screenings participation: A Systematic Review

Objective

The present study aims at systematically reviewing research conducted on factors promoting breast, cervical and colorectal cancer screenings participation.

Methods

A literature search in MEDLINE/PubMed and PsycInfo from January 2017 to October 2021 was performed. Data extraction, researchers' full agreement and the inclusion criteria produced 102 eligible studies. Data were narratively synthesized and critically interpreted.

Results

Multiple factors favoring or hindering breast, cervical and colorectal cancer screenings were identified and summarized as factors operating at the individual level (background information, individual characteristics, emotions related to screening procedure and to cancer, knowledge and awareness), at the relational level (relationships with healthcare staff, significant others, community members), and at the healthcare system level (systems barriers/policy, lack of staff). A critical appraisal of studies revealed a fragmentation in the literature, with a compartmentalization of studies by type of cancer screening, country and specific populations of destination.

Conclusions

Overall findings indicated that greater integration of research results obtained independently for each cancer diagnosis and within the different countries/populations could foster a more comprehensive understanding of factors potentially enhancing the participation in breast, cervical and colorectal cancer screenings worldwide. This review, which is grounded in the current context of globalization and superdiversification in population, can help to enhance a better integration between research and practices, by supporting the development of more effective and inclusive evidence‐based interventions and health‐promotion campaigns worldwide. Research and practical implications are highlighted and discussed.

Factors influencing participation in preventive interventions for gastric cancer: the results from the GISTAR study

OBJECTIVES

Search-and-treat strategy for Helicobacter pylori and surveillance of patients with precancerous lesions are recommended to decrease the burden of gastric cancer in high-risk areas. We aimed to evaluate the acceptance of the target population to these strategies.

METHODS

We applied a search-and-treat strategy combined with biomarker screening (pepsinogens I and II, gastrin-17) for atrophic gastritis to healthy individuals aged 40-64 years within the GISTAR Pilot study. Different means of invitation were evaluated - direct telephone calls, letters of invitation via the general practitioners. Participants with altered biomarker results were invited to undergo upper gastrointestinal endoscopy. H.pylori positive individuals were offered eradication therapy. Data on the compliance to the treatment and reasons for noncompliance were collected via telephone.

RESULTS

Altogether 3453 participants were enrolled. The attendance of women participants was 1.9 times higher although active invitation strategies were mainly targeting men. The yield for the telephone invitations was higher than for mail-delivered invitations (2.1 calls vs. 7.7 letters required to recruit one study subject). Out of 661 individuals reached with the invitation to undergo upper endoscopy, 520 (78.7%) attended the procedure. Out of 1185 study subjects eligible for eradication, 810 (68.4%) accepted it. Of those having received the medication, 765(94.4%) completed it. The reasons for nonparticipation were the overall misconception of the importance of screening, busy schedule and others.

CONCLUSIONS

While only the minority of the target population participated in the gastric cancer prevention strategy, relatively high compliance was seen among the participants. The acceptance rate and the identified reasons for refusing to participate in our study indicate that there is a need to raise gastric cancer awareness and its existent preventive strategies within the general population for their successful implementation in the community.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis

BACKGROUND

Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening.

METHODS

We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model.

RESULTS

We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types.

CONCLUSIONS

Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035411.

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

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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