What implementation interventions increase cancer screening rates? a systematic review

Examining the availability and readiness of health facilities to provide cervical cancer screening services in Nepal: a cross-sectional study using data from the Nepal Health Facility Survey

OBJECTIVE

We assessed the availability and readiness of health facilities to provide cervical cancer screening services in Nepal.

DESIGN

Cross-sectional study.

SETTING

We used secondary data from a nationally representative 2021 Nepal Health Facility Survey, specifically focusing on the facilities offering cervical cancer screening services.

OUTCOME MEASURES

We defined the readiness of health facilities to provide cervical cancer screening services using the standard WHO service availability and readiness assessment manual.

RESULTS

The overall readiness score was 59.1% (95% CI 55.4% to 62.8%), with more equipment and diagnostic tests available than staff and guidelines. Public hospitals (67.4%, 95% CI 63.0% to 71.7%) had the highest readiness levels. Compared with urban areas, health facilities in rural areas had lower readiness. The Sudurpashchim, Bagmati and Gandaki provinces had higher readiness levels (69.1%, 95% CI 57.7% to 80.5%; 60.1%, 95% CI 53.4% to 66.8%; and 62.5%, 95% CI 56.5% to 68.5%, respectively). Around 17% of facilities had trained providers and specific guidelines to follow while providing cervical cancer screening services. The basic healthcare centres (BHCCs) had lower readiness than private hospitals. Facility types, province and staff management meetings had heterogeneous associations with three conditional quantile scores.

CONCLUSION

The availability of cervical cancer screening services is limited in Nepal, necessitating urgent action to expand coverage. Our findings suggest that efforts should focus on improving the readiness of existing facilities by providing training to healthcare workers and increasing access to guidelines. BHCCs and healthcare facilities in rural areas and Karnali province should be given priority to enhance their readiness.

Implementation of Health IT for Cancer Screening in US Primary Care: Scoping Review

BACKGROUND

A substantial percentage of the US population is not up to date on guideline-recommended cancer screenings. Identifying interventions that effectively improve screening rates would enhance the delivery of such screening. Interventions involving health IT (HIT) show promise, but much remains unknown about how HIT is optimized to support cancer screening in primary care.

OBJECTIVE

This scoping review aims to identify (1) HIT-based interventions that effectively support guideline concordance in breast, cervical, and colorectal cancer screening provision and follow-up in the primary care setting and (2) barriers or facilitators to the implementation of effective HIT in this setting.

METHODS

Following scoping review guidelines, we searched MEDLINE, CINAHL Plus, Web of Science, and IEEE Xplore databases for US-based studies from 2015 to 2021 that featured HIT targeting breast, colorectal, and cervical cancer screening in primary care. Studies were dual screened using a review criteria checklist. Data extraction was guided by the following implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework; the Expert Recommendations for Implementing Change taxonomy; and implementation strategy reporting domains. It was also guided by the Integrated Technology Implementation Model that incorporates theories of both implementation science and technology adoption. Reporting was guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews).

RESULTS

A total of 101 studies met the inclusion criteria. Most studies (85/101, 84.2%) involved electronic health record-based HIT interventions. The most common HIT function was clinical decision support, primarily used for panel management or at the point of care. Most studies related to HIT targeting colorectal cancer screening (83/101, 82.2%), followed by studies related to breast cancer screening (28/101, 27.7%), and cervical cancer screening (19/101, 18.8%). Improvements in cancer screening were associated with HIT-based interventions in most studies (36/54, 67% of colorectal cancer-relevant studies; 9/14, 64% of breast cancer-relevant studies; and 7/10, 70% of cervical cancer-relevant studies). Most studies (79/101, 78.2%) reported on the reach of certain interventions, while 17.8% (18/101) of the included studies reported on the adoption or maintenance. Reported barriers and facilitators to HIT adoption primarily related to inner context factors of primary care settings (eg, staffing and organizational policies that support or hinder HIT adoption). Implementation strategies for HIT adoption were reported in 23.8% (24/101) of the included studies.

CONCLUSIONS

There are substantial evidence gaps regarding the effectiveness of HIT-based interventions, especially those targeting guideline-concordant breast and colorectal cancer screening in primary care. Even less is known about how to enhance the adoption of technologies that have been proven effective in supporting breast, colorectal, or cervical cancer screening. Research is needed to ensure that the potential benefits of effective HIT-based interventions equitably reach diverse primary care populations.

An Exploratory Analysis of the Cost-Effectiveness of a Multi-cancer Early Detection Blood Test Compared with Standard of Care Screening in Ontario, Canada

BACKGROUND

Determining whether multi-cancer early detection (MCED) tests are cost effective is important in deciding whether they should be included in the clinical path of cancer care, especially for cancers where screening tools do not exist.

RESEARCH OBJECTIVE

The main objective of this study is to determine the cost effectiveness of including a MCED screening regimen together with existing provincial screening protocols for selected cancers that are prevalent in Ontario, Canada, among average risk persons aged 50-75 years. The selected cancers include breast, colorectal, lung, esophageal, liver, pancreatic, stomach, and ovarian.

METHODS

Cost effectiveness was estimated from a provincial Ministry of Health perspective. A state-transition Markov model representing the decision path of both the proposed and existing screening strategies along the natural history of the selected types of cancers was implemented. The incremental cost-effectiveness ratio (ICER) was calculated using data from available literature and the guidelines published by the Canadian Agency for Drugs and Technologies in Health (CADTH) for conducting a cost-effectiveness analysis, which included a discount rate of 1.5% applied to all costs and outcomes. Costs were also converted to 2022 Canadian dollars. To test the robustness of the model, both univariate and probabilistic sensitivity analyses were conducted.

RESULTS

MCED screening resulted in more diagnosed cases of each type of cancer, even at an earlier stage of disease. This was also associated with fewer related deaths compared with standard of care. Notwithstanding, the analysis revealed that the MCED intervention was not cost effective [ICER: CAD$143,369 per quality-adjusted life year (QALY)], given a willingness to pay (WTP) threshold of $100,000 per QALY. The probabilistic sensitivity analyses revealed that the MCED intervention strategy was preferred to standard of care no more than 2% of the time at this WTP for both males and females. The model was most sensitive to the cost of MCED screening, and the levels of specificity of the MCED and colorectal cancer screening tests.

CONCLUSION

The main contribution of the study is to present and execute a methodological approach that can be adopted to test the cost effectiveness of an MCED tool in the Canadian setting. The model is also sufficiently generic that it could be adapted to other jurisdictions, and with consideration for increasing the WTP threshold beyond the common $100,000 per QALY limit, given the life-threatening nature of cancer, to ensure that MCED interventions are cost-effective.

Cancer care and treatment during homelessness

People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.

Improving Guideline-Recommended Colorectal Cancer Screening in a Federally Qualified Health Center (FQHC): Implementing a Patient Navigation and Practice Facilitation Intervention to Promote Health Equity

BACKGROUND

Colorectal cancer (CRC) screening is effective in the prevention and early detection of cancer. Implementing evidence-based screening guidelines remains a challenge, especially in Federally Qualified Health Centers (FQHCs), where current rates (43%) are lower than national goals (80%), and even lower in populations with limited English proficiency (LEP) who experience increased barriers to care related to systemic inequities.

METHODS

This quality improvement (QI) initiative began in 2016, focused on utilizing patient navigation and practice facilitation to addressing systemic inequities and barriers to care to increase CRC screening rates at an urban FQHC, with two clinical locations (the intervention and control sites) serving a diverse population through culturally tailored education and navigation.

RESULTS

Between August 2016 and December 2018, CRC screening rates increased significantly from 31% to 59% at the intervention site (p < 0.001), with the most notable change in patients with LEP. Since 2018 through December 2022, navigation and practice facilitation expanded to all clinics, and the overall CRC screening rates continued to increase from 43% to 50%, demonstrating the effectiveness of patient navigation to address systemic inequities.

CONCLUSIONS

This multilevel intervention addressed structural inequities and barriers to care by implementing evidence-based guidelines into practice, and combining patient navigation and practice facilitation to successfully increase the CRC screening rates at this FQHC.

Health literacy and breast cancer screening adherence: results from the population of Tuscany, Italy

Mammographic screening can reduce breast cancer (BC) mortality in women. In Italy, although attendance rates increased recently, they are still far from the recommended levels internationally. Inadequate health literacy (HL) may be a reason for poor awareness and/or knowledge about the importance of completing cancer screening. This study examined the relationship between HL, other sociodemographic determinants, and their influence on participation in both opportunistic and organized BC screenings among women aged 50-69 in Tuscany. The study analyzed 2017-2019 data from the Tuscan population subsample in the Italian Behavioral Risk Factor Surveillance System PASSI (Progressi delle Aziende Sanitarie per la Salute in Italia). HL was assessed using the Italian version of the six-item European Health Literacy Survey Questionnaire (HLS-EU-Q6). Among the 2250 interviewees, 75.3% underwent the organized BC screening and 9.4% on voluntary basis. Although to a different extent, HL was significantly associated to compliance rates with both opportunistic and organized screenings. Among sociodemographic factors, only occupational status was associated with opportunistic screening attendance rates. As expected, being invited by letter resulted to be strongly associated with participation to organized screening programs and the medical advice predicts for participating to both opportunistic and organized screening. This study highlights the relevant role that HL plays in BC, opportunistic and organized, screening adherence in a universal healthcare system. To increase BC screening participation rates, healthcare systems would benefit by implementing interventions for improved HL at population level or within healthcare organizations.

Measuring implementation outcomes in the context of scaling up possible serious bacterial infection guidelines: Implications for measurement and programs

BACKGROUND

Reducing the burden of neonatal sepsis requires timely identification and initiation of suitable antibiotic treatment in primary health care (PHC) settings. Countries are encouraged to adopt simplified antibiotic regimens at the PHC level for treating sick young infants (SYI) with signs of possible serious bacterial infection (PSBI). As countries implement PSBI guidelines, more lessons on effective implementation strategies and outcome measurements are needed. We document pragmatic approaches used to design, measure and report implementation strategies and outcomes while adopting PSBI guidelines in Kenya.

METHODS

We designed implementation research using longitudinal mixed methods embedded in a continuous regular systematic learning and adoption of evidence in the PHC context. We synthesized formative data to co-create with stakeholders, implementation strategies to incorporate PSBI guidelines into routine service delivery for SYIs. This was followed by quarterly monitoring for learning and feedback on the effect of implementation strategies, documented lessons learned and tracked implementation outcomes. We collected endline data to measure the overall effect on service level outcomes.

RESULTS

Our findings show that characterizing implementation strategies and linking them with implementation outcomes, helps illustrate the pathway between the implementation process and outcomes. Although we have demonstrated that it is feasible to implement PSBI in PHC, effective investment in continuous capacity strengthening of providers through blended approaches, efficient use of available human resources, and improving the efficiency of service areas for managing SYIs optimizes timely identification and management of SYI. Sustained provision of commodities for management of SYI facilitates increased uptake of services. Strengthening facility-community linkages supports adherence to scheduled visits. Enhancing the caregiver's preparedness during postnatal contacts in the community or facility will facilitate the effective completion of treatment.

CONCLUSION

Careful design, and definition of terms related to the measurement of implementation outcomes and strategies enable ease of interpretation of findings. Using the taxonomy of implementation outcomes help frame the measurement process and provides empirical evidence in a structured way to demonstrate causal relationships between implementation strategies and outcomes. Using this approach, we have illustrated that the implementation of simplified antibiotic regimens for treating SYIs with PSBI in PHC settings is feasible in Kenya.

Primary care provider interventions for addressing cancer screening participation with marginalised patients: a scoping review protocol

INTRODUCTION

Cancer screening is an integral component of primary care, and providers can play a key role in facilitating screening. While much work has focused on patient interventions, there has been less attention on primary care provider (PCP) interventions. In addition, marginalised patients experience disparities in cancer screening which are likely to worsen if not addressed. The objective of this scoping review is to report on the range, extent and nature of PCP interventions that maximise cancer screening participation among marginalised patients. Our review will target cancers where there is strong evidence to support screening, including lung, cervical, breast and colorectal cancers.

METHODS AND ANALYSIS

This is a scoping review conducted in accordance with the framework by Levac et al. Comprehensive searches will be conducted by a health sciences librarian using Ovid MEDLINE, Ovid Embase, Scopus, CINAHL Complete and the Cochrane Central Register of Controlled Trials. We will include peer-reviewed English language literature published from 1 January 2000 to 31 March 2022 that describes PCP interventions to maximise cancer screening participation for breast, cervical, lung and colorectal cancers. Two independent reviewers will screen all articles and identify eligible studies for inclusion in two stages: title and abstract, then full text. A third reviewer will resolve any discrepancies. Charted data will be synthesised through a narrative synthesis using a piloted data extraction form informed by the Template for Intervention Description and Replication checklist.

ETHICS AND DISSEMINATION

Since this is a synthesis of digitally published literature, no ethics approval is needed for this work. We will target appropriate primary care or cancer screening journals and conference presentations to publish and disseminate the results of this scoping review. The results will also be used to inform an ongoing research study developing PCP interventions for addressing cancer screening with marginalised patients.

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.

Dissemination and implementation research for oral and craniofacial health: Background, a review of literature and future directions

Oral conditions are highly prevalent globally and have profound consequence on individuals and communities. Clinical (e.g. dental treatments, behavioural counselling) and non-clinical (e.g. community-based programming, water fluoridation, oral health policy) evidence-based interventions have been identified, recommended and applied at the clinic, community and policy levels. Still, the burden of oral conditions persists, with inequitable distribution across populations. A major driver of this lack of progress is poor translation of research findings, which results in an evidence-to-practice gap. Dissemination and implementation science (DIS) has emerged to address this gap. A relatively new field, application of DIS represents an important avenue for achieving good dental, oral and craniofacial health for all. The goal of this introductory article is to provide a brief background on DIS relevant to researchers in dentistry and oral health. The problem of knowledge translation, basic concepts and terminology in DIS, and approaches to doing dissemination and implementation research-including implementation strategies, key outcomes, and implementation theories, models and frameworks-are discussed. Additionally, the article reviews literature applying DIS to dentistry and oral health. Results of published studies and their implications for the field are presented. Drawing on the literature review and contemporary thinking in DIS, current gaps, opportunities and future directions are discussed. Resources for understanding and applying DIS are provided throughout. This article serves as a primer on DIS for dental and oral health researchers of all types working across a range of contexts; it also serves as a call to action for increased application of DIS to address the burden of oral conditions globally.

Knowledge and awareness of oral cancer: A cross-sectional survey in Trieste, Italy

The aim of the study was to verify the knowledge on oral cancer and to assess possible differences in awareness and information basing on different demographic and subject-related factors. An anonymous survey was provided to 750 random subjects using online-based questionnaires. Statistical analysis was performed in order to evaluate the influence of demographic variables (gender, age, education) on knowledge of oral cancer and its risk factors. 68.4% of individuals knew about the existence of oral cancer, mostly from media and family/friends. Awareness was significantly influenced by gender and higher education, but not by age. Most participants recognized smoking as a risk factor, but alcohol abuse and sunlight exposure are less known, especially among less educated subjects. On the contrary, our study shows a diffusion of false information: more than 30% of the participants indicated the possible role of amalgam fillings in oral cancer onset, independently of gender, age or education. The results of our study suggest the need for oral cancer awareness campaigns, where school and healthcare professionals should be actively involved in promoting, organizing and finding methods to monitor the medium and long-term efficacy with proper methodological quality.

Applying implementation frameworks to the clinical trial context

BACKGROUND

Clinical trials advance science, benefit society, and provide optimal care to individuals with some conditions, such as cancer. However, clinical trials often fail to reach their endpoints, and low participant enrollment remains a critical problem with trial conduct. In these ways, clinical trials can be considered beneficial evidence-based practices suffering from poor implementation. Prior approaches to improving trials have had difficulties with reproducibility and limited impact, perhaps due to the lack of an underlying trial improvement framework. For these reasons, we propose adapting implementation science frameworks to the clinical trial context to improve the implementation of clinical trials.

MAIN TEXT

We adapted an outcomes framework (Proctor's Implementation Outcomes Framework) and a determinants framework (the Consolidated Framework for Implementation Research) to the trial context. We linked these frameworks to ERIC-based improvement strategies and present an inferential process model for identifying and selecting trial improvement strategies based on the Implementation Research Logic Model. We describe example applications of the framework components to the trial context and present a worked example of our model applied to a trial with poor enrollment. We then consider the implications of this approach on improving existing trials, the design of future trials, and assessing trial improvement interventions. Additionally, we consider the use of implementation science in the clinical trial context, and how clinical trials can be "test cases" for implementation research.

CONCLUSIONS

Clinical trials can be considered beneficial evidence-based interventions suffering from poor implementation. Adapting implementation science approaches to the clinical trial context can provide frameworks for contextual assessment, outcome measurement, targeted interventions, and a shared vocabulary for clinical trial improvement. Additionally, exploring implementation frameworks in the trial context can advance the science of implementation through both "test cases" and providing fertile ground for implementation intervention design and testing.

Measuring the effects of misinformation exposure and beliefs on behavioural intentions: a COVID-19 vaccination study

Misinformation has been a pressing issue since the beginning of the COVID-19 pandemic, threatening our ability to effectively act on the crisis. Nevertheless, little is known about the actual effects of fake news on behavioural intentions. Does exposure to or belief in misinformation about COVID-19 vaccines affect people's intentions to receive such a vaccine? This paper attempts to address this question via three preregistered experiments (N = 3463). In Study 1, participants (n = 1269) were exposed to fabricated pro- or anti-vaccine information or to neutral true information, and then asked about their intentions to get vaccinated. In Study 2, participants (n = 646) were exposed to true pro- and anti-vaccine information, while Study 3 (n = 1548) experimentally manipulated beliefs in novel misinformation about COVID-19 vaccines by increasing exposure to the information. The results of these three studies showed that exposure to false information about the vaccines had little effect on participants' intentions to get vaccinated, even when multiple exposures led them to believe the headlines to be more accurate. An exploratory meta-analysis of studies 1 and 3, with a combined sample size of 2683, showed that exposure to false information both supporting and opposing COVID-19 vaccines actually increased vaccination intentions, though the effect size was very small. We conclude by cautioning researchers against equating exposure to misinformation or perceived accuracy of false news with actual behaviours.

Building implementation science capacity among practitioners of cancer control: development of a pilot training curriculum

PURPOSE

Cancer control interventions are difficult to implement with fidelity, while tailoring to fit contexts. Engaged approaches are suggested to advance equity. On-the-ground practitioners are needed to serve as collaborators in the implementation process with research teams, but few trainings are designed with them in mind.

METHODS

The Cancer Control Implementation Science Base Camp (CCISBC) was created to improve capacity among cancer control practitioners when implementing evidence-based cancer screening programs in specific contexts. Development of the curriculum included the following: (1) performing a literature review assessing extant curricula, (2) comparing competencies of these curricula, (3) user-centered design, (4) producing learning materials, (5) recruiting two teams to test a pilot, (6) running the pilot, and (7) evaluating results.

RESULTS

Nine competencies overlapped between four of the curricula scanned in this study, all of which served as the basis for learning objectives. Principles that emerged from design sessions included staying clear about terminology, supporting the brokerage of knowledge, reframing theories, models, and frameworks as tools, and including equity in everything. Pilot testing showed that the average learner increased 74.5% in knowledge and 75% in confidence regarding implementing evidence-based cancer screening. Evidence suggests that the training increased the skill of implementing evidence-based interventions (EBIs) with a health equity lens.

CONCLUSION

In order to scale practice-based evidence, practitioners will need to be engaged. This engagement is optimized when practitioners are trained to collaborate on implementation research. The CCISBC is a feasible program to develop capacity among practitioners in comprehensive cancer control in order to optimize EBIs tailored to context.

Improving intervention design to promote cervical cancer screening among hard-to-reach women: assessing beliefs and predicting individual attendance probabilities in Bogotá, Colombia

Background

Despite being a preventable disease, cervical cancer continues to be a public health concern, affecting mainly lower and middle-income countries. Therefore, in Bogotá a home-visit based program was instituted to increase screening uptake. However, around 40% of the visited women fail to attend their Pap smear test appointments. Using this program as a case study, this paper presents a methodology that combines machine learning methods, using routinely collected administrative data, with Champion’s Health Belief Model to assess women’s beliefs about cervical cancer screening. The aim is to improve the cost-effectiveness of behavioural interventions aiming to increase attendance for screening. The results presented here relate specifically to the case study, but the methodology is generic and can be applied in all low-income settings.

Methods

This is a cross-sectional study using two different datasets from the same population and a sequential modelling approach. To assess beliefs, we used a 37-item questionnaire to measure the constructs of the CHBM towards cervical cancer screening. Data were collected through a face-to-face survey (N = 1699). We examined instrument reliability using Cronbach’s coefficient and performed a principal component analysis to assess construct validity. Then, Kruskal–Wallis and Dunn tests were conducted to analyse differences on the HBM scores, among patients with different poverty levels. Next, we used data retrieved from administrative health records (N = 23,370) to fit a LASSO regression model to predict individual no-show probabilities. Finally, we used the results of the CHBM in the LASSO model to improve its accuracy.

Results

Nine components were identified accounting for 57.7% of the variability of our data. Lower income patients were found to have a lower Health motivation score (p-value < 0.001), a higher Severity score (p-value < 0.001) and a higher Barriers score (p-value < 0.001). Additionally, patients between 25 and 30 years old and with higher poverty levels are less likely to attend their appointments (O.R 0.93 (CI: 0.83–0.98) and 0.74 (CI: 0.66–0.85), respectively). We also found a relationship between the CHBM scores and the patient attendance probability. Average AUROC score for our prediction model is 0.9.

Conclusion

In the case of Bogotá, our results highlight the need to develop education campaigns to address misconceptions about the disease mortality and treatment (aiming at decreasing perceived severity), particularly among younger patients living in extreme poverty. Additionally, it is important to conduct an economic evaluation of screening options to strengthen the cervical cancer screening program (to reduce perceived barriers). More widely, our prediction approach has the potential to improve the cost-effectiveness of behavioural interventions to increase attendance for screening in developing countries where funding is limited.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01800-3.

Interventions for cancer screening among Chinese Americans: A systematic review and meta-analysis

Background

Cancer is the leading cause of death among Chinese Americans (CAs). Although death rates of cancers can be significantly reduced by screening cancers at an early stage, cancer screening (CS) rates are low among CAs. Interventions on CS may increase the uptake rates of CS and help to decrease the death rates of cancers in CAs.

Objectives

This study aims to summarize the intervention methods on CS among CAs and compare effects of various intervention methods on the outcomes of CS, including knowledge levels of CS, intentions to complete CS, and actual completions of CS.

Methods

A systematic review and meta-analysis design was used. Keyword searching was conducted on PubMed, Google Scholar, PsycINFO, and CINAHL. Inclusion and exclusion criteria were applied. The PEDro scale was used to evaluate the quality of the studies. Data was analyzed using Review Manager Version 5.4 software. Random effect model and subgroup analyses were conducted.

Results

The search yielded 13 eligible studies. All of the reviewed interventions were culturally tailored. Systematic review results were categorized by intervention delivery objects, intervention led, intervention contact, intervention types, and intervention focus according to group consensus. Meta-analysis results showed that the interventions on CS had a positive effect on all outcomes, including a 1.58 (95% CI, 1.17–2.14; P = 0.003), 1.78 (95% CI, 1.27–2.48; P = 0.0007), and 1.72 (95% CI, 1.22–2.42; P = 0.002) effect on knowledge of CS, intentions to complete CS, and completions of CS, respectively, compared to the control group. The subgroup analysis suggested that physician-led, individual-based, face-to-face client-focused interventions with multiple components increased CS among CAs, with the OR ranging from 1.60 (95% CI, 1.08–2.39; P = 0.02) to 3.11 (95%CI, 1.02–9.49; P = 0.05).

Discussion

Interventions on CS significantly increased CAs’ knowledge of CS, intentions to complete CS, and completions of CS. Physician-led, individual-based, face-to-face client-focused interventions with multiple components should be utilized for CAs.

The "case" for case studies: why we need high-quality examples of global implementation research

Rigorous and systematic documented examples of implementation research in global contexts can be a valuable resource and help build research capacity. In the context of low- and middle-income countries (LMICs), there is a need for practical examples of how to conduct implementation studies. To address this gap, Fogarty’s Center for Global Health Studies in collaboration with the Cincinnati Children's Hospital Medical Center and the National Cancer Institute is commissioning a collection of implementation science case studies in LMICs that describe key components of conducting implementation research, including how to select, adapt, and apply implementation science models, theories, and frameworks to these settings; develop and test implementation strategies; and evaluate implementation processes and outcomes. The case studies describe implementation research in various disease areas in LMICs around the world. This commentary highlights the value of case study methods commonly used in law and business schools as a source of “thick” (i.e., context-rich) description and a teaching tool for global implementation researchers. It addresses the independent merit of case studies as an evaluation approach for disseminating high-quality research in a format that is useful to a broad range of stakeholders. This commentary finally describes an approach for developing high-quality case studies of global implementation research, in order to be of value to a broad audience of researchers and practitioners.

Cancer Screening Among Current and Former U.S. Military Personnel Compared to Civilians: A Cross-Sectional Analysis of the Behavioral Risk Factor Surveillance System

INTRODUCTION

Approximately 3% of invasive U.S. cancer diagnoses are made among veterans in a Veterans Affairs (VA) clinic each year, while VA patients only comprise about 1.9% of the U.S. population. Although some research has shown that veterans have higher incidence rates of cancer compared to civilians, evidence is sparse regarding possible disparities in rates of cancer screening between these populations. Thus, the purpose of this study is to compare differences in rates of screening for colorectal, lung, breast, and cervical cancers between current and former U.S. Military service members and civilians.

METHODS

Using the data extracted from the Behavioral Risk Factor Surveillance System, we assessed the rates of cancer screening among current and former U.S. Military service members compared to civilians from self-reported surveys assessing when individuals had been screened for colorectal or lung cancer among all participants and breast and cervical cancer among women participants. Persons greater than 25 years of age were included in the cervical cancer screening, 50 years of age for colon cancer screening, and 40 years of age for the breast cancer screening-the latter based on recommendations from the American Cancer Society. We used multivariate logistic regression models to determine the adjusted risk ratios (ARRs) of current and former U.S. Military service members receiving screening compared to civilians, adjusting for age, gender, race, education, and health care coverage.

RESULTS

Current and former U.S. Military service members accounted for 2.6% of individuals included for the cervical cancer screening analysis, 2.2% for the breast cancer screening analyses, nearly 10% of the lung cancer screening, and 15% of the colorectal cancer (CRC) screening analyses. Prevalence of screening was higher for current and former U.S. Military service members among lung cancer and CRC. When controlling for age, race, education, and health care coverage, current and former U.S. Military service members were statistically more likely to be screened for CRC (ARR: 1.05; 95% confidence interval: 1.04-1.07) and lung cancer (ARR: 1.32; 95% confidence interval: 1.15-1.52). The odds of having completed a cervical or breast cancer screening were not significantly different between groups.

CONCLUSION

Our study showed that current and former U.S. Military service members were more likely to complete CRC and lung cancer screenings, while no significant difference existed between each population with regard to cervical and breast cancer screenings. This is one of the few studies that have directly compared cancer screening usage among civilians and current and former U.S. Military service members. Although current and former U.S. Military service members were more likely to receive several cancer screenings, improvements can still be made to remove barriers and increase screening usage due to the disproportionate rates of cancer mortality in this population. These solutions should be comprehensive-addressing personal, organizational, and societal barriers-to improve prognosis and survival rates among current and former U.S. Military service members.

Feasibility of a multifaceted implementation intervention to improve attendance at diabetic retinopathy screening in primary care in Ireland: a cluster randomised pilot trial

OBJECTIVES

Diabetic retinopathy screening (DRS) uptake is suboptimal in many countries with limited evidence available on interventions to enhance DRS uptake in primary care. We investigated the feasibility and preliminary effects of an intervention to improve uptake of Ireland's national DRS programme, Diabetic RetinaScreen, among patients with type 1 or type 2 diabetes.

DESIGN/SETTING

We conducted a cluster randomised pilot trial, embedded process evaluation and cost analysis in general practice, July 2019 to January 2020.

PARTICIPANTS

Eight practices participated in the trial. For the process evaluation, surveys were conducted with 25 staff at intervention practices. Interviews were conducted with nine staff at intervention practices, and 10 patients who received the intervention.

INTERVENTIONS

The intervention comprised practice reimbursement, an audit of attendance, electronic prompts targeting professionals, General Practice-endorsed patient reminders and a patient information leaflet. Practices were randomly allocated to intervention (n=4) or wait-list control (n=4) (usual care).

OUTCOMES

Staff and patient interviews explored their perspectives on the intervention. Patient registration and attendance, including intention to attend, were measured at baseline and 6 months. Microcosting was used to estimate intervention delivery cost.

RESULTS

The process evaluation identified that enablers of feasibility included practice culture and capacity to protect time, systems to organise care, and staff skills, and workarounds to improve intervention 'fit'. At 6 months, 22/71 (31%) of baseline non-attenders in intervention practices subsequently attended screening compared with 15/87 (17%) in control practices. The total delivery cost across intervention practices (patients=363) was €2509, averaging €627 per practice and €6.91 per audited patient. Continuation criteria supported proceeding to a definitive trial.

CONCLUSIONS

The Improving Diabetes Eye screening Attendance intervention is feasible in primary care; however, consideration should be given to how best to facilitate local tailoring. A definitive trial of clinical and cost-effectiveness is required with preliminary results suggesting a positive effect on uptake.

TRIAL REGISTRATION NUMBER

NCT03901898.

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND

Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016.

OBJECTIVE

To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions.

DESIGN

A quality improvement project led by a multidisciplinary group of healthcare providers.

PARTICIPANTS

Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population.

INTERVENTION

Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period.

MAIN MEASURES

Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients.

KEY RESULTS

After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention.

CONCLUSIONS

The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

The integrated screening action model (I-SAM): A theory-based approach to inform intervention development

Screening can reduce deaths if the people invited participate. However, good uptake is hard to achieve, and our current approaches are failing to engage the most vulnerable. A coherent model of screening behaviour to guide our understanding and intervention development is yet to be established. The present aim was to propose an Integrated Screening Action Model (I-SAM) to improve screening access. The I-SAM synthesises existing models of health behaviour and empirical evidence. The I-SAM was developed following: i) an appraisal of the predominant models used within the screening literature; ii) the integration of the latest knowledge on behaviour change; with iii) the empirical literature, to inform the development of a theory-based approach to intervention development. There are three key aspects to the I-SAM: i) a sequence of stages that people pass through in engaging in screening behaviour (based on the Precaution Adoption Process Model); ii) screening behaviour is shaped by the interaction between participant and environmental influences (drawing from the Access Framework); and iii) targets for intervention should focus on the sources of behaviour - 'capability', 'opportunity', and 'motivation' (based on the COM-B Model). The I-SAM proposes an integrated model to support our understanding of screening behaviour and to identify targets for intervention. It will be an iterative process to test and refine the I-SAM and establish its value in supporting effective interventions to improve screening for all.

Multiple approaches to enhancing cancer communication in the next decade: translating research into practice and policy

Communicating risk and other health information in a clear, understandable, and actionable manner is critical for the prevention and control of cancer, as well as the care of affected individuals and their family members. However, the swift pace of development in communication technologies has dramatically changed the health communication landscape. This digital era presents new opportunities and challenges for cancer communication research and its impact on practice and policy. In this article, we examine the science of health communication focused on cancer and highlight important areas of research for the coming decade. Specifically, we discuss three domains in which cancer communication may occur: (a) among patients and their healthcare providers; (b) within and among families and social networks; and (c) across communities, populations, and the public more broadly. We underscore findings from the prior decade of cancer communication research, provide illustrative examples of future directions for cancer communication science, and conclude with considerations for diverse populations. Health informatics studies will be necessary to fully understand the growing and complex communication settings related to cancer: such works have the potential to change the face of information exchanges about cancer and elevate our collective discourse about this area as newer clinical and public health priorities emerge. Researchers from a wide array of specialties are interested in examining and improving cancer communication. These interdisciplinary perspectives can rapidly advance and help translate findings of cancer communication in the field of behavioral medicine.

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

Economic Evaluation of Web- versus Telephone-based Interventions to Simultaneously Increase Colorectal and Breast Cancer Screening Among Women

Screening for colorectal and breast cancer is considered cost effective, but limited evidence exists on cost-effectiveness of screening promotion interventions that simultaneously target both cancers. Increasing Colorectal and Breast Cancer Screening (Project COBRA), a randomized controlled trial conducted in the community, examined the cost-effectiveness of an innovative tailored web-based intervention compared with tailored telephone counseling and usual care. Screening status at 6 months was obtained by participant surveys plus medical record reviews. Cost was prospectively measured from the patient and provider perspectives using time logs and project invoices. Relative efficiency of the interventions was quantified by the incremental cost-effectiveness ratios. Nonparametric bootstrapping and net benefit regression analysis were used to assess statistical uncertainty of the results. The average cost per participant to implement the Phone counseling, Web-based, and Web + Phone counseling interventions were $277, $314, and $337, respectively. Comparing Phone counseling with usual care resulted in an additional cost of $300 (95% confidence interval [CI]: $283-$320) per cancer screening test and $421 (95% CI: $400-$441) per additional person screened in the target population. Phone counseling alone was more cost-effective than the Web + Phone intervention. Web-based intervention alone was more costly but less effective than the Phone counseling. When simultaneously promoting screening for both colorectal and breast cancer the Web-based intervention was less cost-effective compared with Phone and Web + Phone strategies. The results suggest that targeting multiple cancer screening may improve the cost-effectiveness of cancer screening interventions. PREVENTION RELEVANCE: This study informs researchers, decision makers, healthcare providers, and payers about the improved cost-effectiveness of targeting multiple cancer screenings for cancer early detection programs.

Breast cancer screening adherence rates and barriers of implementation in ethnic, cultural and religious minorities: A systematic review

Breast cancer is the most common cancer affecting women worldwide. Adherence to breast cancer screening guidelines is frequently lower in racial, ethnic and cultural minority populations and is affected by potential inequities or barriers to screening that these minorities face. Therefore, the aim of the present study was to collect information from different minority groups worldwide, assess adherence to breast cancer screening and evaluate barriers or limitations causing non-adherence, which should facilitate the development of effective interventions. A search was conducted through PubMed and Web of Science. Studies were considered as eligible if they met the following criteria: i) Female patients; ii) breast cancer screening program implemented in the country; iii) minority groups; iv) asymptomatic; v) report written in Portuguese or English; vi) study published from 2015 onwards. The Critical Appraisal Skills Programme checklist was used for qualitative studies and the Strengthening The Reporting of Observational Studies in Epidemiology checklist for cross-sectional studies. From the 348 initial articles, 86 were removed due to duplication and 19 were selected, analyzed and summarized, accordingly. Of the 19 studies included, 5.3% were classified as high quality, 52.6% as moderate to high and 42.1% as moderate. A total of 15 studies were cross-sectional and 4 were qualitative, collectively including 250,733 women. The rate of adherence to mammogram in different minorities was evaluated, obtaining a mean value of 49.7% in the last 2 years, and statistically significant barriers were selected and divided into sociodemographic; personal; ethnic, cultural and religious; and external factors. The characteristics of each population play a major role in the population's breast health practices. If the population, adherence rates, barriers and inequities are carefully studied, screening models may be customized and participation to breast cancer screening can be optimized, thereby reducing the high breast cancer-associated mortality.

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.

A lay health worker intervention to improve breast and cervical cancer screening among Latinas in El Paso, Texas: A randomized control trial

INTRODUCTION

We examined the effectiveness of a lay health worker (promotora)-delivered intervention on increasing breast and cervical cancer screening among low-income, primarily uninsured Latinas living in El Paso, Texas.

METHODS

In 2015, Breast and Cervical Cancer Screening (BCCS) program promotoras recruited Latinas overdue for breast and/or cervical cancer screening in community settings. Promotoras consented eligible women and conducted baseline surveys before individually randomizing women into control (n = 313) or intervention (n = 314) groups. Control participants received printed material providing basic information about breast and cervical cancer screening.Intervention participants received promotora-delivered one-on-one breast and cervical cancer screening education followed by navigation calls, providing assistance to address personal and logistic barriers to accessing clinical services. We assessed breast and cervical cancer screening outcomes using a 6-month follow-up survey. Per protocol (PP) and intent to treat (ITT) analyses are reported.

RESULTS

At follow-up, among women in need of breast cancer screening, those in the intervention group were significantly more likely to complete a mammogram than those in the control group (PP: 53.4% vs. 40.1%, p = .013; ITT: 47.9% vs. 35.2%, p = .011). Among women in need of Pap screening, only intervention group women 50 years and older were more likely to complete a Pap screening compared with control group women (PP: 64.5% vs. 43.5%, p = .019).

CONCLUSIONS

A promotora-delivered behavioral intervention, embedded in a community-based organization, increased mammography uptake in all women and Pap uptake among women 50 years and older in a sample of low-income Latinas. NCT04397744.

Increasing hepatitis virus screening uptake at worksites in Japan using nudge theory and full subsidies

BACKGROUND

Despite the importance of hepatitis screening for decreasing liver cancer mortality, screening rates remain low in Japan. Previous studies show that full subsidies increase screening uptake, but full subsidies are costly and difficult to implement in low-resource settings. Alternatively, applying nudge theory to the message design could increase screening at lower costs. This study examined the effects of both methods in increasing hepatitis virus screening rates at worksites.

METHODS

1496 employees from a Japanese transportation company received client reminders for an optional hepatitis virus screening before their general health checkups. Groups A and B received a client reminder designed based on the principles of "Easy" and "Attractive," while the control group received a client reminder not developed using nudge theory. Additionally, hepatitis virus screening was offered to the control group and group A for a co-payment of JPY 612, but was fully subsidized for group B. The hepatitis virus screening rates among the groups were compared using a Chi-square test with Bonferroni correction, and the risk ratios of group A and group B to the control group were also calculated. To adjust for unobservable heterogeneity per cluster, the regression analysis was performed using generalized linear mixed models.

RESULTS

The screening rate was 21.2%, 37.1%, and 86.3% for the control group, group A, and group B, respectively. And the risk ratio for group A was 1.75 (95% confidence interval [CI] 1.45-2.12) and that of group B was 4.08 (95% CI 3.44-4.83). The parameters of group A and group B also were significant when estimated using generalized linear mixed models. However, the cost-effectiveness (incremental cost-effectiveness ratio (ICER)) of the nudge-based reminder with the full subsidies was lower than that of only the nudge-based reminder.

CONCLUSIONS

While fully subsidized screening led to the highest hepatitis screening rates, modifying client reminders using nudge theory significantly increased hepatitis screening uptake at lower costs per person.

Factors affecting patient adherence to publicly funded colorectal cancer screening programmes: a systematic review

OBJECTIVES

Colorectal cancer (CRC) is the third most common cancer. Many countries in Europe have already implemented systematic screening programmes as per the recommendations by the European Union. The impact of screening is highly dependent on participation rates. The aim of the study was to identify barriers, facilitators and modifiers to participation in systematised, stool sample-based, publicly financed CRC screening programmes.

STUDY DESIGN

Systematic review.

METHODS

A systematic search in PubMed, Embase, MEDLINE, CINAHL, Cochrane CENTRAL, Google Scholar and PsycINFO was undertaken. We included both qualitative and quantitative studies reporting on barriers and facilitators (excluding sociodemographic variables) to participation in stool sample-based CRC screening. Barriers and facilitators to participation were summarised and analysed.

RESULTS

The inclusion criteria were met in 21 studies. Reported barriers and facilitators were categorised into the following seven themes (examples): psychology (fear of cancer), religion (believing cancer is the will of God), logistics (not knowing how to conduct the test), health-related factors (mental health), knowledge and awareness (lack of knowledge about the test), role of the general practitioner (being supported in taking the test by the general practitioner), and environmental factors (knowing someone who has participated in a screening programme). Six studies reported that non-participation was not due to a negative attitude towards screening for CRC.

CONCLUSION

Many barriers to screening were found. It is important to work with peoples' fear of screening. Moreover, this review suggests that it might be possible to increase participation rates, if the population-wide awareness and knowledge of potential health benefits of CRC screening are increased and proper logistical support is provided.

Increasing Cancer Screening Rates in Primary Care

Screening for cancer has contributed to substantial reductions in death from several cancers and is one of the most cost-effective preventive interventions in all of health care. In the United States, primary care clinicians, their clinical teams, and the systems in which they work are primarily responsible for ensuring that screening occurs. In order to achieve the highest possible population-wide screening rates, primary care clinicians must embrace the responsibility to screen their entire enrolled patient population, institute several overarching general approaches to screening, and implement a combination of evidence-based interventions.

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).

The role of health education on cervical cancer screening uptake at selected health centers in Addis Ababa

Introduction

Cervical cancer is one of the most common causes of morbidity and mortality among women in developing countries including Ethiopia. Unlike other types of cancers, the grave outcomes of cervical cancer could be prevented if detected at its early stage. However, in Ethiopia, awareness about the disease and the availability of screening and treatment services is limited. This study aims to determine the role of health education on cervical cancer screening uptake in selected health facilities in Addis Ababa.

Methods

Two-pronged clustered randomized controlled trial was conducted in 2018 at eight public health centers that provide cervical cancer screening services using visual inspection with acetic acid (VIA) in Addis Ababa, Ethiopia. Each of the eight health centers were randomly assigned to serve as either an intervention or a control center. A two-pronged clustered randomized controlled trial was conducted in eight public health care centers. All the selected facilities provided cervical cancer screening services using visual inspection with acetic acid (VIA). Four health centers were randomly assigned to the intervention and control arms. The study participants were women aged 30–49 years who sought care at maternal and child health clinics but who had never been screened for cervical cancer. In the intervention health centers, all eligible women received one-to-one health education and educational brochures about cervical cancer and cervical cancer screening. In the control health centers, participants received standard care. Baseline data were collected at recruitment and follow-up data were collected two months after the baseline. For the follow-up data collection, participants (both in the intervention and control arms) were interviewed over the phone to check whether they were screened for cervical cancer.

Result

From the 2,140 women who participated in the study, 215 (10%) screened for cervical cancer, where 152(71%) were from the intervention health centers. Seventy-four percent of these participants reported that they learned about the benefits of screening from the one-to-one health education or the brochure. Women from the intervention health centers had higher odds of getting screened (AOR = 2.43,95%CI;1.58–2.90) than the controls. Women with the educational status of the first degree and those who have a history of sexually transmitted infections (STIs) had higher odds of getting screened (AOR = 2.03,95%CI;(1.15–2.58) and (AOR = 1.55,95%CI;1.01–2.36), respectively.

Conclusion and recommendation

Providing focused health education supported by printed educational materials increased the uptake of cervical cancer screening services. Integrating one-to-one health education and providing a take-home educational material into the existing maternal and child health services can help increase cervical cancer screening uptake.

Effectiveness of Mass and Small Media Campaigns to Improve Cancer Awareness and Screening Rates in Asia: A Systematic Review

PURPOSE

The main objective of this systematic review was to identify whether mass and small media interventions improve knowledge and attitudes about cancer, cancer screening rates, and early detection of cancer in Asia.

METHODS

The review was conducted according to a predefined protocol. Medline, EMBASE, CINAHL, Web of Science, Cochrane Library, and Google Scholar were searched in September 2017, and data extraction and rating of methodologic study quality (according to Joanna Briggs Institute rating procedures) were performed independently by reviewers.

RESULTS

Twenty-two studies (reported across 24 papers) met the inclusion criteria. Most studies (n = 21) were conducted in high or upper-middle income countries; targeted breast (n = 11), cervical (n = 7), colorectal (n = 3), or oral (n = 2) cancer; and used small media either alone (n = 15) or in combination with mass media and other components (n = 5). Studies regarding cancer screening uptake were of medium to high quality and mainly reported positive outcomes for cervical cancer and mixed results for breast and colorectal cancer. The methodologic strength of research that investigated change in cancer-related knowledge and the cost effectiveness of interventions, respectively, were weak and inconclusive.

CONCLUSION

Evidence indicated that small media campaigns seemed to be effective in terms of increasing screening uptake in Asia, in particular cervical cancer screening. Because of the limited number of studies in Asia, it was not possible to be certain about the effectiveness of mass media in improving screening uptake and the effectiveness of campaigns in improving cancer-related knowledge.

Implementation Strategies for Web-Based Apps for Screening: Scoping Review

Background

Screening is an effective primary prevention strategy in health care, as it enables the early detection of diseases. However, the uptake of such screening remains low. Different delivery methods for screening have been developed and found to be effective in increasing the uptake of screening, including the use of web-based apps. Studies have shown that web-based apps for screening are effective in increasing the uptake of health screening among the general population. However, not much is known about the effective implementation of such web-based apps in the real-world setting. Implementation strategies are theory-based methods or techniques used to enhance the adoption, implementation, and sustainability of evidence-based interventions. Implementation strategies are important, as they allow us to understand how to implement an evidence-based intervention. Therefore, a scoping review to identify the various implementation strategies for web-based apps for screening is warranted.

Objective

This scoping review aims to identify (1) strategies used to implement web-based apps for health screening, (2) frameworks used for implementing web-based apps for health screening, (3) outcome measures of implementation strategies, and (4) effective implementation strategies.

Methods

This scoping review was conducted based on Arksey and O’Malley’s framework. After identifying the review question, two researchers independently screened and selected relevant literature from PubMed, Embase, Cochrane, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, International Standard Randomised Controlled Trial Number Registry, OpenGrey, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform, and Web of Science. This was followed by charting the data using a standardized form. Finally, we collated, summarized, and reported the results quantitatively and qualitatively based on the review objectives.

Results

A total of 16,476 studies were retrieved, of which 5669 were duplicates. From a total of 10,807 studies, 10,784 studies were excluded based on their titles and abstracts. There were 23 full-text articles reviewed, and 4 articles were included in the final analysis. Many studies were excluded because they focused on the effectiveness and not on the implementation of web-based apps. Facilitation was the most cited implementation strategy used, followed by reminders, clinical champions, and educational meetings and materials. Only 2 studies used implementation frameworks to guide the evaluation of their studies. Common outcome measures for implementation strategies were feasibility, fidelity, and penetration. Implementation strategies reported to be effective were quality improvement meetings, facilitation, educational meetings, and clinical champions.

Conclusions

There is a dearth of literature on the implementation of web-based apps for health screening. Implementation strategies were developed without any reported use of implementation theories or frameworks in most studies. More research on the development and evaluation of web-based screening app implementations is needed.

Ready, set, go!: exploring use of a readiness process to implement pharmacy services

Background

Readiness is an essential precursor of successful implementation; however, its conceptualization and application has proved elusive. R = MC² operationalizes readiness for use in practice. The purpose of this study was to (1) describe the application of R = MC² to assess and build readiness in nine healthcare sites responsible for implementing medication management services and (2) gain insights into the sites’ experience.

Methods

This mixed methods exploratory study used data collected as part of a process evaluation. Understanding application of the readiness process (Aim 1) involved examining team members’ involvement (who?), readiness challenges and readiness building strategies (what?), strategy execution (how much?), and resulting changes (for what purpose?). To understand the sites’ experience with the R = MC² system (Aim 2), interviews were conducted with six of the sites to identify facilitators, barriers, and lessons learned. Data sources included a document review (e.g., sites’ action plans), survey results, and interview data.

Results

Sites included primary care and specialty clinics, pharmacies within health systems, and community pharmacies. Teams consisted of 4–11 members, including a lead pharmacist. The teams’ readiness activities clustered into five broad categories of readiness building strategies (e.g., building the operational infrastructure for service integration). Of the 34 strategies identified across sites, 68% were still in progress after 4 months. Engaging in the readiness process resulted in a number of outputs (e.g., data management systems) and benefits (e.g., an opportunity to ensure alignment of priorities and fit of the intervention). Based on the interviews, facilitators of the readiness process included assistance from a coach, internal support, and access to the readiness tools. Competing priorities and lack of resources, timely decision-making, and the timing of the readiness process were cited as barriers. The importance of service fit, stakeholder engagement, access to a structured approach, and rightsizing the readiness process emerged as lessons learned.

Conclusions

These findings provide valuable insights into the application of a readiness process. If readiness is to be integrated into routine practice as part of any implementation effort, it is critical to gain a better understanding of its application and value.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Effect of a Mammography Screening Decision Aid for Women 75 Years and Older: A Cluster Randomized Clinical Trial

IMPORTANCE

Guidelines recommend that women 75 years and older be informed of the benefits and harms of mammography before screening.

OBJECTIVE

To test the effects of receipt of a paper-based mammography screening decision aid (DA) for women 75 years and older on their screening decisions.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial with clinician as the unit of randomization. All analyses were completed on an intent-to-treat basis. The setting was 11 primary care practices in Massachusetts or North Carolina. Of 1247 eligible women reached, 546 aged 75 to 89 years without breast cancer or dementia who had a mammogram within 24 months but not within 6 months and saw 1 of 137 clinicians (herein referred to as PCPs) from November 3, 2014, to January 26, 2017, participated. A research assistant (RA) administered a previsit questionnaire on each participant's health, breast cancer risk factors, sociodemographic characteristics, and screening intentions. After the visit, the RA administered a postvisit questionnaire on screening intentions and knowledge.

INTERVENTIONS

Receipt of the DA (DA arm) or a home safety (HS) pamphlet (control arm) before a PCP visit.

MAIN OUTCOMES AND MEASURES

Participants were followed up for 18 months for receipt of mammography screening (primary outcome). To examine the effects of the DA, marginal logistic regression models were fit using generalized estimating equations to allow for clustering by PCP. Adjusted probabilities and risk differences were estimated to account for clustering by PCP.

RESULTS

Of 546 women in the study, 283 (51.8%) received the DA. Patients in each arm were well matched; their mean (SD) age was 79.8 (3.7) years, 428 (78.4%) were non-Hispanic white, 321 (of 543 [59.1%]) had completed college, and 192 (35.2%) had less than a 10-year life expectancy. After 18 months, 9.1% (95% CI, 1.2%-16.9%) fewer women in the DA arm than in the control arm had undergone mammography screening (51.3% vs 60.4%; adjusted risk ratio, 0.84; 95% CI, 0.75-0.95; P = .006). Women in the DA arm were more likely than those in the control arm to rate their screening intentions lower from previsit to postvisit (69 of 283 [adjusted %, 24.5%] vs 47 of 263 [adjusted %, 15.3%]), to be more knowledgeable about the benefits and harms of screening (86 [adjusted %, 25.5%] vs 32 [adjusted %, 11.7%]), and to have a documented discussion about mammography with their PCP (146 [adjusted %, 47.4%] vs 111 [adjusted %, 38.9%]). Almost all women in the DA arm (94.9%) would recommend the DA.

CONCLUSIONS AND RELEVANCE

Providing women 75 years and older with a mammography screening DA before a PCP visit helps them make more informed screening decisions and leads to fewer women choosing to be screened, suggesting that the DA may help reduce overscreening.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02198690.

Feasibility of an implementation intervention to increase attendance at diabetic retinopathy screening: protocol for a cluster randomised pilot trial

BACKGROUND

Diabetic retinopathy screening (DRS) leads to the earlier detection of retinopathy and treatment that can prevent or delay the development of diabetes-related blindness. However, uptake continues to be sub-optimal in many countries, including Ireland. Routine management of type 2 diabetes largely takes place in primary care. As such, there may be an opportunity in primary care to introduce interventions to improve DRS uptake. However, few studies test the feasibility of interventions to enhance DRS uptake in this context. Our aim is to investigate the feasibility of an implementation intervention (IDEAs (Improving Diabetes Eye screening Attendance)) delivered in general practice to improve the uptake of the national DRS programme, RetinaScreen.

METHODS

The IDEAs study is a cluster randomised pilot trial with an embedded process evaluation and economic evaluation. Following stratification by practice size, eight general practices (clusters) will be randomly allocated to intervention (n = 4) or wait-list control groups (n = 4). The intervention will be delivered for 6 months, after which, it will be administered to wait-list control practices. The intervention is multi-faceted and comprises provider-level components (training, audit and feedback, health care professional prompt, reimbursement) and patient-level components (GP-endorsed reminder with information leaflet delivered opportunistically face-to-face, and systematically by phone and letter). Patient inclusion criteria are type 1 or type 2 diabetes and DRS programme non-attendance. A multi-method approach will be used to determine screening uptake, evaluate the trial and study procedures and examine the acceptability and feasibility of the intervention from staff and patient perspectives. Quantitative and qualitative data will be collected on intervention uptake and delivery, research processes and outcomes. Data will be collected at the practice, health professional and patient level. A partial economic evaluation will be conducted to estimate the cost of delivering the implementation intervention in general practice. Formal continuation criteria will be used to determine whether IDEAs should progress to a definitive trial.

DISCUSSION

Findings will determine whether IDEAsis feasible and acceptable and will be used to refine the intervention and study procedures. A definitive trial will determine whether IDEAs is a cost-effective intervention to improve DRS uptake and reduce diabetes-related blindness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03901898. Registered 3rd April 2019.

A Telephone and Mail Outreach Program Successfully Increases Uptake of Hepatocellular Carcinoma Surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer‐related death worldwide. Society guidelines recommend surveillance with abdominal ultrasound with or without serum alpha‐fetoprotein every 6 months for adults at increased risk of developing HCC. However, adherence is often suboptimal. We assessed the feasibility of a coordinated telephone outreach program for unscreened patients with cirrhosis within the Veteran’s Affairs (VA) health care system. Using a patient care dashboard of advanced chronic liver disease in the VA Greater Los Angeles Healthcare System, we identified veterans with a diagnosis of cirrhosis, a platelet count ≤ 150,000/uL, and no documented HCC surveillance in the previous 8 months. Eligible veterans received a telephone call from a patient navigator to describe the risks and benefits of HCC surveillance. Orders for an abdominal ultrasound and alpha‐fetoprotein were placed for veterans who agreed to surveillance. Veterans who were not reached by telephone received an informational letter by mail to encourage participation. Of the 129 veterans who met the eligibility criteria, most were male (96.9%). The most common etiology for cirrhosis was hepatitis C (64.3%), and most of the patients had compensated cirrhosis (68.2%). The patient navigators reached 32.5% of patients by phone. Patients in each group were similar across clinical and demographic characteristics. Patients who were called were more likely to undergo surveillance (adjusted odds ratio = 2.56, 95% confidence interval: 1.03‐6.33). Most of the patients (72.1%) completed abdominal imaging when reached by phone. Conclusion: Targeted outreach increased uptake of HCC surveillance among patients with cirrhosis in a large, integrated, VA health care system.

Leveraging the Mammography Setting to Raise Awareness and Facilitate Referral to Lung Cancer Screening: A Qualitative Analysis

PURPOSE

Despite compelling support for the benefits of low-dose CT (LDCT) screening for lung cancer among high-risk individuals, awareness of LDCT screening and uptake remain low. The aim of this project was to explore the perspectives of ACR mammography screening program directors (MPDs) regarding efforts to raise LDCT screening awareness and appropriate referrals by identifying high-risk individuals participating in routine mammography.

METHODS

MPDs were recruited from ACR-accredited mammography facilities to participate in semistructured interviews after the completion of an online survey. Interviews were conducted over the telephone, recorded, transcribed, and subsequently reviewed for accuracy. Twenty MPDs were interviewed, and 18 interviews were transcribed and included in the thematic analysis. A theme codebook was developed, and all interviews were coded using NVivo by two trained reviewers.

RESULTS

Key themes were organized into four broad domains: (1) general attitudes toward the integration of LDCT screening, (2) identifying mammography patients at high risk for lung cancer, (3) counseling about LDCT screening, and (4) strategies to identify high-risk women and increase awareness and knowledge of LDCT screening. Overall, MPDs recognized the benefits of integrating mammography and LDCT screening and were receptive to educating and referring women for LDCT screening. However, training and workflow changes are needed to ensure successful implementation.

CONCLUSIONS

Qualitative data suggest that MPDs are amenable to leveraging the mammography setting to engage women about LDCT screening; however, additional tools, training, and/or staffing may be necessary to leverage the full potential of reaching women at high risk for lung cancer within the context of mammographic screening.

Social media and mobile health technology for cancer screening: a systematic review and meta-analysis protocol

INTRODUCTION

Cancer is one of the leading causes of death globally and many jurisdictions have developed population-based cancer screening programmes to reduce the public health burden of disease. However, screening participation remains suboptimal. Social media and other mobile health (mHealth) technologies are increasingly being used for health promotion and behaviour change. This paper reports on the protocol for a systematic review exploring the effect of social media and other mHealth interventions on cancer screening participation and intention.

METHODS AND ANALYSIS

This protocol is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. We will include any randomised controlled trials or quasi-experimental studies with a pre/post design conducted in adults ≥18 years of age that report on the effectiveness of a social media or mHealth intervention on screening participation or intention (inclusive of breast, cervical, colorectal, prostate and lung cancer). Interventions will be inclusive of those delivered online or through a computer using an established social media platform or a new purpose-built platform, or those delivered through cellphones or other wireless technologies. Any comparator will be acceptable (control group, alternate intervention or pre/post design). We will search Medline, EMBASE, PsycINFO, Scopus, CINAHL, the Cochrane Central Register of Controlled Trials, and Communication and Mass Media Complete from 1 January 2000 to 31 May 2019. Two independent reviewers will screen titles, abstracts and full-text articles with conflicts resolved through discussion or by a third reviewer, as needed. The two reviewers will also independently complete risk of bias assessments for each included study. We will report on the characteristics of the studies, participants and interventions in descriptive narrative form and report the absolute and relative differences in screening and intention attributable to social media and mobile technology interventions.

ETHICS AND DISSEMINATION

As this is a systematic review, ethical approval for conduct of this study is not required. We will pursue publication of study results in a relevant peer-reviewed journal and report our findings according to the PRISMA checklist.

TRIAL REGISTRATION NUMBER

CRD42019139615.

Age, Race, and Income Are Associated With Lower Screening Rates at a Safety Net Hospital

BACKGROUND

While lung cancer screening improves cancer-specific mortality and is recommended for high-risk patients, barriers to screening still exist. We sought to determine our institution's (an urban safety net hospital) screening rate and to identify socioeconomic barriers to lung cancer screening.

METHODS

We identified 8935 smokers 55 to 80 years of age evaluated by a primary care physician between March 2015 and March 2017 at our institution. We randomly selected one-third of these (n = 2978) to review for eligibility using the U.S. Preventive Services Task Force criteria for lung cancer screening. Using our institution's Lung Cancer Screening Program clinical tracking database, we identified patients who were screened from March 2015 to March 2017. We collected demographic information (race, primary language, education status, and median income) and evaluated possible associations with screening.

RESULTS

Among our institution population, 99 patients meeting U.S. Preventive Services Task Force screening criteria underwent screening computed tomography, whereas 516 eligible patients were not screened, making our institution's estimated screening rate 16.1%. Comparing the unscreened population with those who received screening at our institution, the unscreened population was significantly older (median age of screened patients was 63 years, of unscreened patients was 66 years; P < .001). African Americans had a lower screening rate (37.6% of the screened population and 47.5% of the unscreened population; P < .001). Unscreened patients had a lower annual household income.

CONCLUSIONS

The lung cancer screening rate at our hospital is 16.1%. Unscreened patients were older, were more likely to be African American, and had a lower median income. These findings highlight possible screening barriers and potential areas for targeted strategies to decrease disparities in lung cancer screening.

Transient elastography for screening of liver fibrosis: Cost-effectiveness analysis from six prospective cohorts in Europe and Asia

BACKGROUND & AIMS

Non-alcoholic fatty liver disease and alcohol-related liver disease pose an important challenge to current clinical healthcare pathways because of the large number of at-risk patients. Therefore, we aimed to explore the cost-effectiveness of transient elastography (TE) as a screening method to detect liver fibrosis in a primary care pathway.

METHODS

Cost-effectiveness analysis was performed using real-life individual patient data from 6 independent prospective cohorts (5 from Europe and 1 from Asia). A diagnostic algorithm with conditional inference trees was developed to explore the relationships between liver stiffness, socio-demographics, comorbidities, and hepatic fibrosis, the latter assessed by fibrosis scores (FIB-4, NFS) and liver biopsies in a subset of 352 patients. We compared the incremental cost-effectiveness of a screening strategy against standard of care alongside the numbers needed to screen to diagnose a patient with fibrosis stage ≥F2.

RESULTS

The data set encompassed 6,295 participants (mean age 55 ± 12 years, BMI 27 ± 5 kg/m², liver stiffness 5.6 ± 5.0 kPa). A 9.1 kPa TE cut-off provided the best accuracy for the diagnosis of significant fibrosis (≥F2) in general population settings, whereas a threshold of 9.5 kPa was optimal for populations at-risk of alcohol-related liver disease. TE with the proposed cut-offs outperformed fibrosis scores in terms of accuracy. Screening with TE was cost-effective with mean incremental cost-effectiveness ratios ranging from 2,570 €/QALY (95% CI 2,456-2,683) for a population at-risk of alcohol-related liver disease (age ≥45 years) to 6,217 €/QALY (95% CI 5,832-6,601) in the general population. Overall, there was a 12% chance of TE screening being cost saving across countries and populations.

CONCLUSIONS

Screening for liver fibrosis with TE in primary care is a cost-effective intervention for European and Asian populations and may even be cost saving.

LAY SUMMARY

The lack of optimized public health screening strategies for the detection of liver fibrosis in adults without known liver disease presents a major healthcare challenge. Analyses from 6 independent international cohorts, with transient elastography measurements, show that a community-based risk-stratification strategy for alcohol-related and non-alcoholic fatty liver diseases is cost-effective and potentially cost saving for our healthcare systems, as it leads to earlier identification of patients.

Colorectal Cancer in Brunei Darussalam: An Overview and Rationale for National Screening Programme

Colorectal cancer (CRC) is the third most common cancer worldwide after lung and breast cancers, and ranks second in terms of cancer mortality globally. Brunei Darussalam reports high incidence of CRC in the Southeast Asian region and has no formal national screening programme for CRC. Screening for CRC in Brunei Darussalam is offered in an opportunistic fashion for individuals with average or above average risks for CRC, that is, the individual has a positive family history of CRC or neoplasms and is more than 50 years old. Opportunistic screening is widely practiced but this is not standardised. The Ministry of Health in Brunei Darussalam is currently in the process of implementing a CRC screening programme as part of a larger national health screening based on the increasing incidence of non-communicable diseases (NCDs). This review article assesses the situation of CRC in Brunei Darussalam from the 1980s to present day, including incidence of CRC in different age groups, ethnicities and genders; relevant non-modifiable and modifiable risk factors of CRC in Brunei Darussalam setting; and common CRC screening techniques used in Brunei Darussalam as well as other Asia-Pacific countries. The review also discusses the merits of a national CRC screening programme. With the increasing incidence of CRC worldwide and in Brunei Darussalam, national screening for CRC in Brunei Darussalam is an important strategy to lower morbidity and mortality rates. A review of the progress and outcome of the national screening programme will be available a few years after rollout.

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.

Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the World Health Organization's World Mental Health International College Student Initiative

BACKGROUND

The majority of university students with mental health problems are untreated. Only a small empirical literature exists on strategies to increase mental health service use.

AIMS

To investigate the effects and moderators of a brief acceptance-facilitating intervention on intention to use mental health services among university students.

METHOD

Within the German site of the World Health Organization's World Mental Health International College Student (WMH-ICS) initiative, 1,374 university students were randomized to an intervention condition (IC; n = 664) or a control condition (CC; n = 710) that was implemented in the survey itself. Both conditions received the questions assessing mental disorders and suicidality that were included in other WMH-ICS surveys. The IC group then additionally received: Internet-based personalized feedback based on subject symptom severity in the domains of depression, anxiety, substance use, suicidal thoughts and behaviors, and nonsuicidal self-injury; psychoeducation tailored to the personal symptom profile; and information about available university and community mental health services. The primary outcome was reported intention to use psychological interventions in the next semester, which was the last question in the survey. A broad range of potential moderating factors was explored.

RESULTS

There was a significant main effect of the intervention with students randomized to IC, reporting significantly higher intentions to seek help in the next semester than students in the CC condition (d = 0.12, 95% CI: 0.02 to 0.23). Moderator analyses indicated that the intervention was more effective among students that fulfilled the criteria for lifetime (d = 0.34; 95% CI: -0.08 to 0.7) and 12-month panic-disorder (d = 0.32; 95% CI: -0.10 to 0.74) compared with those without lifetime (d = 0.11; 95% CI: 0.00 to 0.22) or 12-month panic disorder (d = 0.11; 95% CI: 0.00 to 0.22), students with lower (d = 0.37; 95% CI: -0.77 to 1.51) than higher (d = -0.01; 95% CI: -0.36 to 0.34) self-reported physical health, and students with nonheterosexual (d = 0.38; 95% CI: 0.08 to 0.67) compared with heterosexual (d = 0.06; 95% CI: -0.06 to 0.17) sexual orientation. The intervention had no effects among students who reported that they recognized that they had an emotional problem and "are already working actively to change it" (Stage 4 "stages of change").

CONCLUSIONS

A simple acceptance-facilitating intervention can increase intention to use mental health services, although effects, are on average, small. Future studies should investigate more personalized approaches with interventions tailored to barriers and clinical characteristics of students. In order to optimize intervention effects, the development and evaluation should be realized in designs that are powered to allow incremental value of different intervention components and tailoring strategies to be evaluated, such as in multiphase optimization designs.

Colorectal Cancer: Applying the Value Transformation Framework to increase the percent of patients receiving screening in Federally Qualified Health Centers

Background

Colorectal cancer is the second leading cause of cancer death in the U.S. and third-most common cancer in both men and women. Colorectal cancer screening (CRCS) rates remain low, particularly among vulnerable patients receiving care at federally qualified health centers. Through its Value Transformation Framework, the National Association of Community Health Centers provides a systematic approach to improving CRCS by transforming health center infrastructure, care delivery, and people systems—to improve health outcomes, patient and staff experiences, and lower costs (Quadruple Aim).

Methods

We combined the Value Transformation Framework, evidence-based CRCS interventions, and the Learning Community Model to drive system improvements and implement evidence-based practices. Multi-disciplinary teams at 8 health centers in Georgia and Iowa participated for 1-year with Primary Care Association support.

Results

Pre−/post- 1-year-intervention data showed, within health centers, raw percentage of eligible patients screened for CRC increased from 33.2% (13.5%–61.7%) in January 2017 to 46.5% (14.2%–81.5%) in December 2017, with an overall 13.3 percentage point average increase. This translates into an average increase of 3.3 (95% CI: 1.7, 5.0) eligible patients screened per month per health center over the year or 317 additional patients meeting CRCS guidelines. Specific interventions associated with higher CRCS rates included standing orders, sharing performance data, and electronic health record alerts.

Conclusion

Findings support a three-pronged approach for improving CRCS: The Value Transformation Framework's evidence-based recommendations, with actionable CRC interventions, offered in a learning community. These results guide methodological approaches to improving CRCS in health centers through a multi-level, multi-modality quality improvement and transformation approach.

A systematic review of the effectiveness of health education interventions to increase cervical cancer screening uptake

Background

Cervical cancer screening reduced cancer morbidity and mortality in developed countries. Health education interventions are expected to enhance screening and early detection. Thus, this review is aimed to see the effectiveness of the interventions in cervical cancer screening uptake.

Methods

Online databases (PubMed/MEDLINE/PubMed Central, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science and Google Scholar) were searched for all published eligible research articles in the past 12 years (as of January 2005-2017). A total of 17 research articles were included. The interventions were classified as 'individual level', 'community level' and 'cultural sensitive educations' which contains various interventions in their content as compared with usual care. A quality coding system was assessed using Cochrane checklists and rated by each researcher independently and the average score was given accordingly. This study was registered in PROSPERO 2017: CRD42017060405.

Results

The review dovetailed 17 studies. Ten studies (58.82%) were conducted in the United States, three in Iran (17.65%) and one each in Malaysia, China, Cameroon and Nigeria (23.53%). Almost all levels of the interventions boosted the screening uptake and the Pap test. However, the individual level health education interventions were prioritized in many of the studies.

Conclusion

The review indicated that health education interventions have immense contributions in boosting the screening uptake. However, the effectiveness varies with study setting, populations and the way of delivery. Therefore, the limited quality of the studies indicated that further research is required to develop a simple and effective intervention to boost cervical cancer screening uptake.

What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis

BACKGROUND

Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal.

OBJECTIVES

To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS.

DATA SOURCES AND REVIEW METHODS

Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components.

RESULTS

Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals.

LIMITATIONS

Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement.

CONCLUSIONS

Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.