Evaluation of a call programme for cervical cytology screening in women aged 50-60

Promoting Participation in a Population Screening Program for Breast and Cervical Cancer: A Randomized Trial of Different Invitation Strategies

Aims and background

Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.

Methods

Women eligible for invitation - 8385 for cervical and 8069 for breast cancer screening - listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A - letter signed by the GP, with a prefixed appointment; Group B - open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C - letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D - extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).

Results

Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).

Conclusions

Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored.

A systematic literature review of the effectiveness of community-based strategies to increase cervical cancer screening

OBJECTIVE

To evaluate and summarize evidence of the effectiveness of interventions available to public health staff that could be used to increase cervical cancer screening to women.

METHOD

A thorough literature review was conducted, articles screened for relevance and assessed for quality.

RESULTS

Of 42 relevant studies, 1 was rated 'strong', 18 'moderate' and 23 'weak'. Among the strong/moderate studies, 10 were aimed at disadvantaged women. The most frequently used intervention was mass media campaigns, alone or combined with individual strategies; followed by individual education using lay health educators; and last, letters of invitation. Thirteen of the moderate/strong studies evaluated strategies that reported statistically significant increases in Pap smear rates and other outcomes.

CONCLUSIONS

Strategies that combined mass media campaigns with direct tailored education to women and/or health care providers seemed most successful. The importance of accurate centralized cytology databases for recall is underscored.

A systematic literature review of the effectiveness of community-based strategies to increase cervical cancer screening

OBJECTIVE

To evaluate and summarize evidence of the effectiveness of interventions available to public health staff that could be used to increase cervical cancer screening to women.

METHOD

A thorough literature review was conducted, articles screened for relevance and assessed for quality.

RESULTS

Of 42 relevant studies, 1 was rated 'strong', 18 'moderate' and 23 'weak'. Among the strong/moderate studies, 10 were aimed at disadvantaged women. The most frequently used intervention was mass media campaigns, alone or combined with individual strategies; followed by individual education using lay health educators; and last, letters of invitation. Thirteen of the moderate/strong studies evaluated strategies that reported statistically significant increases in Pap smear rates and other outcomes.

CONCLUSIONS

Strategies that combined mass media campaigns with direct tailored education to women and/or health care providers seemed most successful. The importance of accurate centralized cytology databases for recall is underscored.

Randomized controlled study of customized preventive medicine reminder letters in a community practice

OBJECTIVE

To test the effectiveness of customized, family-oriented reminder letters in activating patients to seek appropriate preventive services.

DESIGN

Randomized clinical trial. One group received computer-generated, customized letters explaining recommended preventive procedures for each family member. A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups. A third group (control group) received no letters.

SETTING

A private medical centre, without university affiliation, in rural Quebec.

PARTICIPANTS

From 8770 patients who met study criteria, 719 families were randomly selected. Data were available for 1971 of 1998 patients in these families.

MAIN OUTCOME MEASURES

The Family Received Index is the proportion of all procedures for which a family was overdue that they received. The Family End-of-study Up-to-date Index is the proportion of procedures for which the family was eligible and for which they were up-to-date at the end of the study.

RESULTS

The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters (Kruskal-Wallis P = .0139). Comparison of the Family End-of-study Up-to-date indices also demonstrated that families of patients sent customized letters were more likely to be up-to-date than families not sent letters (Kruskal-Wallis P = .0054). No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group.

CONCLUSIONS

This study demonstrates a clinically small but statistically significant value to customizing reminder letters.

A review of cervical cancer screening intervention research: implications for public health programs and future research

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Effectiveness of a call/recall system in improving compliance with cervical cancer screening: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of a simple call/recall system in improving compliance with cervical cancer screening among women not screened in the previous 3 years.

DESIGN

Prospective randomized controlled study.

SETTING

Two family medicine clinics (1 urban, 1 rural) affiliated with Memorial University of Newfoundland, St. John's.

PARTICIPANTS

A sample of women aged 18-69 years who were listed as patients of the clinics but who had not had a Papanicolaou test (Pap test) within the 3 years before the start of the study. Of 9071 women listed as patients 1360 (15.0%) had not undergone screening in the previous 3 years. A random sample of 650 were selected, 209 of whom were excluded because they had had a hysterectomy, had had a recent Pap test, had moved or had records containing clerical errors. This left 441 women for the study.

INTERVENTION

The 221 women in the intervention group were sent a letter asking them to seek a Pap test and a reminder letter 4 weeks later. The 220 in the control group were sent no letters.

MAIN OUTCOME MEASURES

Number of women who had a Pap test within 2 months and 6 months after the first letter was sent.

RESULTS

Within 2 months, more women in the intervention group than in the control group had been screened (2.8% [5/178] and 1.9% (4/208] respectively). There was also a difference between the overall proportions at 6 months (10.7% [19/178] and 6.3% [13/208] respectively). None of the differences was statistically significant.

CONCLUSION

A letter of invitation is not sufficient to encourage women who have never or have infrequently undergone a Pap test to come in for cervical cancer screening. The effectiveness of added recruitment methods such as opportunistic screening by physicians, follow-up by telephone and the offer of a specific appointment should be evaluated.

Mass mailing campaigns to promote screening for cervical cancer: do they work, and do they continue to work?

Campaigns involving sending personally addressed letters to encourage women to have Pap smears increase Pap smear rates. The aim of this study was to assess whether this effect is maintained when campaigns are repeated regularly. In October 1992, a letter reminding women of the importance of screening was mailed to all women in three New South Wales postcode regions where a similar letter had been sent three years previously. The response was compared to the response in three regions receiving no earlier letter. The number of women attending for cervical screening during the three months after distribution of the letters was assessed from Health Insurance Commission claims for cervical cytology. These attendances were compared with expected attendances based on the attendance patterns over 28 pre-intervention quarters. Significant postintervention increases in attendance were observed in all three regions receiving an initial letter. However, in one region, the increase in attendances, around 1 per cent of eligible women, was not significantly greater than the increase in the control region (z = 0.15, P = 0.88). The second letter campaign had no measurable effect on attendances. No significant increase in screenings was observed in two of the towns. A significant increase was observed in one region, but this was not significantly greater than the increase in the control region (z = -0.05, P = 0.96). These results suggest that repeated direct-mail campaigns to promote screening for cervical cancer may be of no benefit. A one-off campaign may result in an increase in screenings in the short term.

Reminding and monitoring: new uses of administrative data for preventive care

This article illustrates how administrative data can be used to improve population health in an environment of fiscal constraint. In our universal single-payer health system, health care providers submit standardized data. This allows provinces to create health information utilities that generate population-based data that can be used for research and health care delivery. Although more study is needed to determine the cost-effectiveness of using such data to raise the rates of primary and secondary prevention, it appears that appropriately designed information systems could improve population health with relatively little additional cost.

Cervical screening: the optimum visit plan for contacting users and non-users in Scotland

OBJECTIVE

To investigate the numbers of visits required to obtain interviews with users and non-users of cervical screening, and to determine the workload involved to enable an optimum visit plan to be developed.

DESIGN

Case-control study of users and non-users of cervical screening using a flexible visit plan that involved up to eight attempts at contact. Visits were made in mornings, afternoons, and evenings, the visit pattern being determined by information gained from local sources.

PATIENTS

Altogether 660 non-users of cervical screening (cases), aged 20-64 and registered with 23 randomly selected general practitioners (GPs), were identified from the Tayside computerised register of cervical smears. These women were selected from the computerised lists of 18 GPs in Dundee and five in Perth. A total of 417 women recorded as having a smear within the previous three years (controls), matched by age and GP, were also identified from the computerised register.

RESULTS

Altogether 1834 attempts were made to contact the cases, of whom 339 were interviewed, giving a workload of 18 interviews per 100 attempts. For the controls 1359 attempts were made at contact to yield 339 interviews, a workload of 25 interviews per 100 attempts. Refusals (19%) and incorrect addresses (23%) were the two major reasons for failing to achieve interview. Only for four (0.6%) of the cases and one (0.2%) of the controls was no information gained. The proportion of attempts which led to interview remained constant with increasing numbers of call-backs (up to six for the cases and eight for the controls).

CONCLUSIONS

A flexible approach to visit scheduling that takes account of local knowledge can lead to interviews with 66% of non-users of health screening, when incorrect addresses are removed. It is preferable to plan for many (up to six) visits to achieve interview. This will minimise non-response bias without increasing the workload per successful interview.

Effectiveness of three community based strategies to promote screening for cervical cancer

OBJECTIVE

Evaluation of three potential methods for increasing Pap smear use: television media, television media combined with letter based recruitment, and television media combined with general practitioner based (GP based) recruitment.

SETTING

A trial of each intervention was carried out in three postal regions in New South Wales, Australia-a rural locality (containing about 1000 women), a country town (about 3000 women), and a major rural centre (about 10,000 women). Three control regions were selected to be demographically similar to the corresponding intervention regions.

METHODS

Outcome data on regional Pap smear rates were obtained from government health insurance claims for cervical screening, and from pathology service records. Expected Pap smear rates for the three months after the intervention were predicted from 45 pre-intervention months and were compared with observed rates for this period.

RESULTS

Television media alone was associated with a significant increase in attendances for screening in one of the three regions where a trial was carried out: 13.3% in the rural centre. The media/letter based campaign was associated with a significant increase in attendances in two out of three regions: 52.7% in the rural locality, 43.2% in the rural centre. The media/GP based campaign was associated with significant increases in attendances in all three regions: 50.2% in the rural locality, 80.8% in the country town, 15.7% in the rural centre. All three interventions were associated with significant increases in the number of women attending for cervical screening above those observed in the control regions. Furthermore, these increases were not restricted to women at low risk. They were also found for older women (aged 50-69 years) and women who had not had a Pap smear within the past three years.

Preliminary results of a general practice based call system for cervical cancer screening in The Netherlands

A study was undertaken in Nijmegen, in the Netherlands, to compare the attendance rate following a call system for cervical cancer screening organized by general practitioners, with the attendance rate resulting from the Dutch national call system. Women are invited for screening on a three yearly basis and in 1990 1616 women were identified by nine practices as being in the appropriate age group (35 to 54 years) to attend for cervical cancer screening while 10,387 women were identified by the national call system. The attendance rate among the 1101 women in the rural general practices was 58%, compared with 49% of 4154 women in the matched group receiving an invitation from the national call system. The attendance rate among the 515 women in the urban general practices was 55%, compared with 41% of 6233 women in the matched group receiving an invitation from the national call system. Invitations from general practitioners resulted in similar percentages of women in all age groups attending for screening. Four general practices sent a reminder letter or made a telephone call to non-attenders. A reminder increased the attendance rate from 58% to 70%. It is concluded that a general practice based call system for cervical screening produces a higher attendance rate than the national call system.

Recruitment methods for screening programmes: trial of a new method within a regional osteoporosis study

OBJECTIVE

To estimate the response rates and operating costs of three recruitment methods within a regional osteoporosis screening programme.

DESIGN

Randomised trial of three types of invitation letter: one offering fixed appointments with option to change time, one offering fixed appointments but requiring telephoned confirmation of intention to attend, and one inviting recipient to telephone to make an appointment.

SETTING

Osteoporosis screening unit, Aberdeen.

SUBJECTS

1200 women aged 45-49 years living within 32 km of Aberdeen and randomly selected from the community health index. 400 women were randomised to each appointment method.

MAIN OUTCOME MEASURES

Numbers attending for screening; default rate among women who confirmed appointments; social class of attenders; cost per appointment slot and per completed scan.

RESULTS

299 (75%), 277 (69%), and 217 (54%) women were scanned after fixed, confirmable, and open invitations respectively. Women who attended were given a questionnaire, and 694 (87.5%) returned it. No significant differences were found in the social class of attenders among the three methods. Of the 514 women who made or confirmed appointments, 494 attended for a scan. Total costs per scan were 25.00 pounds, 21.40 pounds, and 21.00 pounds for fixed, confirmable, and open invitations respectively.

CONCLUSIONS

The offer of a fixed appointment requiring telephoned confirmation has the potential to reduce the costs of scanning without exaggerating any social bias or significantly reducing response rates provided that empty appointments can be rebooked at short notice.

Screening for presymptomatic disease

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How complete can cervical screening be? The outcome of a call screening programme for women aged 20-60 years in Perth and Kinross

In this paper a computer system for cervical screening call and recall based on the Community Health Index (CHI) population data-base is described. It allows the unscreened population to be identified and located on an individual general practice basis. The results of the call programme on 9517 women aged 20-60 years listed on the CHI and with no record of a cervical smear is described. There was a 24% smear uptake in the call programme which meant that after the call programme the total population cover had risen from 71% to 78%. In addition, if women with a valid reason are excluded, and the data-base corrected for women no longer in the area, the true cover rises to 88%. An analysis of the percentage cover in each GP practice is described with the implications for implementation of screening targets for primary care.