ArticleClient-Directed Interventions to Increase Community Demand for Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review
Introduction
Cancer is a major public health problem in the U.S. In 2003, more than 1,290,000 people were diagnosed with cancer and more than 556,000 died of cancer.1,a This included more than 55,000 men and women who died from colorectal cancer, 41,000 women from breast cancer, and nearly 4000 women from cervical cancer. According to a 2003 report from the Institute of Medicine's National Cancer Policy Board,2 each year 4475 deaths from breast cancer, 3644 deaths from cervical cancer, and 9632 deaths from colorectal cancer could be prevented if all eligible Americans received appropriate cancer screening services. Yet the 2005 National Health Interview Survey of U.S. adults3 found that only 67% of women aged ≥40 years reported having had mammograms within the previous 2 years, and 78% of women aged ≥18 years reported Pap tests within the previous 3 years. Among adults aged ≥50, only 50% reported ever having screening endoscopies and only 17% reported having fecal occult blood tests (FOBT) within the previous 2 years. Lower rates were observed among American Indians and Alaska Natives; people of Asian, Latino, or Hispanic ethnicity; African Americans (endoscopy, only); and among poor and less-educated populations. Rates for recommended screenings tend to be lower among individuals without a usual source of health care, without health insurance, and among recent immigrants to the U.S.4 At the same time, efforts to maximize control of breast, cervical, and colorectal cancers through screening face the additional challenge of assuring that cancer screening, once initiated, is repeated at recommended intervals.5, 6 Increasing use of these screening tests at recommended intervals and reducing inequalities in screening use are important steps toward reducing cancer morbidity and mortality.2
An array of community- and systems-based interventions are available to programs and planners for use in promoting cancer screening.7, 8 These interventions can target clients (client-directed), providers (provider-directed), or both, each either directly or through the healthcare system. Many of these interventions also have been applied in other areas of public health, but their effectiveness, applicability, and cost effectiveness in increasing cancer screening rates are either not clearly established or not completely understood.
The Guide to Community Preventive Services (Community Guide), developed by the independent, nonfederal Task Force on Community Preventive Services (Task Force), has conducted systematic reviews on the effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of community interventions to increase screening for breast, cervical, and colorectal cancers.7 The conceptual approach to and selection of interventions for these reviews focused on three primary strategies to close screening-related gaps: increasing community demand for cancer screening services, reducing barriers to access, and increasing delivery of these services by healthcare providers. The first two strategies encompass client-directed approaches intended to influence client knowledge, motivation, access, and decision to be screened at appropriate intervals. The third strategy encompasses provider-directed approaches to reduce missed opportunities to recommend, order, or deliver cancer screening services at appropriate intervals. Evidence from these reviews provides the basis for Task Force recommendation of interventions in each of these strategic areas as well as for identifying additional research needs.
In this report, evidence is reviewed on the effectiveness of classes of client-directed interventions intended to increase community demand for screening recommended for early detection of breast cancer (mammography), cervical cancer (Pap test), and colorectal cancer (guaiac-based FOBT, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema).9, 10, 11, 12 Client-directed interventions designed to increase community access to these services are reviewed in an accompanying article,13 as are two types of provider-directed interventions.14 An additional provider-directed intervention and multicomponent (combinations of) interventions will be reviewed in future publications.
The use of community will usually refer to a group of individuals who share one or more characteristics,15 in this case the potential to benefit from one or more cancer screening services. Community is also used in reference to a setting or in combination with “community healthcare worker,” in which case the intent is locale, neighborhood, or other geopolitical unit.
Section snippets
Methods
General methods for conducting Community Guide systematic reviews have been described in detail.16, 17 Specific methods for conducting reviews of interventions to increase breast, cervical, and colorectal cancer screening are described elsewhere in this supplement.8 That description includes the overall literature search of primary scientific publications through November 2004, selection of the 244 candidate studies satisfying general inclusion criteria for the cancer screening reviews, and
Results: Client Reminders
Client reminder or recall (referred to collectively as client reminders) included in this review are printed (letter or postcard) or telephone messages advising people that they are due (reminder) or late (recall) for screening. Client reminders, as defined by our team, may be enhanced by one or more of the following: a follow-up printed or telephone reminder; additional text or discussion with information about indications for, benefits of, and ways to overcome barriers to screening; or
Results: Client Incentives
Client incentives are small, noncoercive rewards (e.g., cash or coupons) to motivate people to seek cancer screening for themselves or to encourage others (e.g., family members, close friends) to seek screening. Incentives are distinct from interventions designed to improve access to services (e.g., transportation, child care, reducing out-of-pocket client costs), reviewed elsewhere in this supplement.13
Results: Mass Media
Mass media—including television, radio, newspapers, magazines, and billboards—are used to communicate educational and motivational information in community or larger-scale intervention campaigns. Mass media interventions, however, almost always include other components or attempt to capitalize on existing interventions and infrastructure. For example, such interventions have been shown to be effective in reducing alcohol-related motor vehicle crashes when implemented with ongoing law
Results: Small Media
Small media include videos or printed materials (e.g., letters, brochures, pamphlets, flyers, or newsletters). These can be distributed from healthcare systems or other community settings, and can convey educational or motivational information to promote cancer screening in target populations. Messages may describe screening tests and procedures and include indications for, benefits of, and ways to overcome barriers to screening. Messages are often based on behavior theories which posit that
Results: Group Education
Group education conveys information on indications for, benefits of, and ways to overcome barriers to screening with the goal of informing, encouraging, and motivating participants to seek recommended screening. Group education is usually conducted by health professionals or by trained laypeople who use slide presentations or other teaching aids in a lecture or interactive format, and often incorporate role modeling or other methods.84 Because group education can be given to a variety of
Results: One-on-One Education
One-on-one education conveys information to individuals by telephone or in person on indications for, benefits of, and ways to overcome barriers to screening with the goal of informing, encouraging, and motivating them to seek recommended screening. These messages are delivered by healthcare workers or other health professionals, lay health advisors, or volunteers, and are conducted in medical, community, worksite, or household settings. Interventions can be untailored to address a general
Other Positive or Negative Effects of Interventions to Increase Community Demand
No reports were found of other positive or negative effects of interventions to increase community demand for breast, cervical, or colorectal cancer screening services on use of other healthcare services (e.g., blood pressure monitoring or adult immunization) or health behaviors (e.g., on smoking or physical activity) or on informed decision making (e.g., in reducing patient autonomy by offering incentives).
Potential Barriers to Implementing Interventions to Increase Community Demand
Limited resources and infrastructure constitute the primary barriers to implementing interventions to increase community demand for breast, cervical, and colorectal cancer screening services. Healthcare delivery systems with limited computer or staffing support may have difficulty tracking, identifying, and notifying clients eligible for reminders or recall. Cost may be a major barrier to obtaining adequate exposure, dose, intensity, and quality of mass media campaigns. Access to effective
Research Issues for Increasing Community Demand for Screening
For the six intervention approaches, the team identified key research issues that had not been answered in the review. Researchers are encouraged to consider which of these questions might be answered as part of studies already underway, through studies being planned, or through new studies. Research questions are grouped within each of the two effectiveness ratings (i.e., effective based on strong or sufficient evidence or undetermined based on insufficient evidence).
Discussion
These reviews summarize the evidence base that supports Task Force recommendations161 for interventions to increase community demand for breast, cervical, and colorectal cancer screening services. Interventions to increase community demand are strategically distinct from interventions to overcome barriers to access13 or to encourage providers to deliver these services,14 both of which have been reviewed separately. Demand-enhancing interventions concentrate on promoting awareness, knowledge,
References (161)
- et al.
Prevalence and correlates of repeat mammography among women aged 55-79 in the Year 2000 National Health Interview Survey
Prev Med
(2004) - et al.
Introducing the Community Guide's reviews of evidence on interventions to increase screening for breast, cervical, and colorectal cancers
Am J Prev Med
(2008) - et al.
Methods for conducting systematic reviews of evidence on effectiveness and economic efficiency of interventions to increase screening for breast, cervical, and colorectal cancers
Am J Prev Med
(2008) - et al.
Client-directed interventions to increase community access to breast, cervical, and colorectal cancer screening: a systematic review
Am J Prev Med
(2008) - et al.
Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: systematic reviews of provider assessment and feedback and provider incentives
Am J Prev Med
(2008) - et al.
Developing the Guide to Community Preventive Services—overview and rationale
Am J Prev Med
(2000) - et al.
Developing an evidence-based Guide to Community Preventive Services—methods
Am J Prev Med
(2000) - et al.
Data collection instrument and procedure for systematic reviews in the Guide to Community Preventive Services
Am J Prev Med
(2000) - et al.
Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults
Am J Prev Med
(2000) The effectiveness of mailed patient reminders on mammography screenings: a meta-analysis
Am J Prev Med
(1998)
Impact of a mailed intervention on annual mammography and physician breast examinations among women at high risk of breast cancer
Cancer Epidemiol Biomarkers Prev
Improving preventive care at a medical clinic: how can the patient help?
Am J Prev Med
A randomized trial of the impact of risk assessment and feedback on participation in mammography screening
Prev Med
Evaluation of three methods for improving mammography rates in a managed care plan
Am J Prev Med
A randomized trial of general practitioner-written invitations to encourage attendance at screening mammography
Community Health Stud
Facility-based inreach strategies to promote annual mammograms
Am J Prev Med
A randomised trial of invitations to attend for screening mammography
Aus J Public Health
Pap smear screening at an urban aboriginal health service: report of a practice audit and an evaluation of recruitment strategies
Aust N Z J Public Health
Pap smear outreach: a randomized controlled trial in an HMO
Am J Prev Med
Cervical screening in general practice
Aust J Public Health
Cost-effectiveness of interventions to promote cervical screening in general practice
Aust N Z J Public Health
Effectiveness of mass media campaigns for reducing drinking and driving and alcohol-involved crashes: a systematic review
Am J Prev Med
Reviews of evidence regarding interventions to increase use of child safety seats
Am J Prev Med
The effectiveness of interventions to increase physical activity: a systematic review
Am J Prev Med
Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke
Am J Prev Med
Evaluation of an intervention to increase mammography screening in Los Angeles
Prev Med
Tailored risk notification for women with a family history of breast cancer
Prev Med
Comparison of tailored interventions to increase mammography screening in nonadherent older women
Prev Med
Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data
Patient Educ Couns
Can tailored interventions increase mammography use among HMO women?
Am J Gastroenterol
United States cancer statistics
Fulfilling the potential of cancer prevention and early detection
Summary health statistics for U.S. adults: National Health Interview Survey, 2005
Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey
Cancer
Repeat mammography: prevalence estimates and consideration for assessment
Ann Behav Med
Guide to clinical preventive services: cancer
Screening for breast cancer
Screening for colorectal cancer
Screening for cervical cancer
Criteria for the systematic review of health promotion and public health interventions
Health Promot Int
Strategies for increasing the participation of women in community breast cancer screeningThe Cochrane Library, Issue 3
Interventions that increase use of adult immunization and cancer screening services: a meta-analysis
Ann Intern Med
Efficacy of patient letter reminders on cervical cancer screening: a meta-analysis
J Gen Intern Med
A randomized study of cancer screening in a family practice setting using a recall model
J Fam Pract
Computer-generated physician and patient reminders: tools to improve population adherence to selected preventive services
J Fam Pract
Cancer screening and prevention in rural Wisconsin: the Greater Marshfield Experience
Wis Med J
Recruitment activities and sociodemographic factors that predict attendance at a mammographic screening program
Am J Public Health
Participation in breast cancer screening: randomized controlled trials of doctors' letters and of telephone reminders
Aust J Public Health
Mammography screening credit card and compliance
Cancer
Improving breast screening uptake: persuading initial non-attenders to attend
J Med Screen
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Author affiliations are shown at the time the research was conducted.
The names and affiliations of the Task Force members are listed at the front of this supplement and at www.thecommunityguide.org.
Address reprint requests to Shawna L. Mercer, MSc, PhD, The Guide to Community Preventive Services, CDC, 1600 Clifton Road NE, MS E-69, Atlanta GA 30333. E-mail: [email protected].