Article
Client-Directed Interventions to Increase Community Demand for Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review

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Abstract

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

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,

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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].

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