SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
November, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
World-wide, cervical cancer is the second most common cancer in women and more than 85% of women dying from cervical cancer live in the developing world. Increasing the uptake of screening, alongside increasing informed choice, is key to controlling this disease through prevention and early detection. Methods of encouraging women to undergo cervical screening include invitations to screening; reminders to attend screening; education to increase knowledge of screening programmes or of cervical cancer; message framing (positive or negative messages about screening); counselling regarding barriers to screening; risk factor assessment of individuals; procedures, such as making the screening process easier; and economic interventions, such as incentives to attend screening.
Key messages
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
A woman's risk of developing cervical cancer by the age of 65 ranges from 0.8% in developed countries to 1.5% in developing countries. The Papanicolau, or Pap smear, screening test is the most widely used and is primarily aimed at detecting pre-cancerous changes within the cervix (i.e. abnormalities in the cells of the cervix known as dysplasia) before they have an opportunity to progress to more advanced disease. Pap smear uptake and coverage not only varies between countries, but differences also exist within countries between different socio-demographic groups, according to ethnic origin, age, education and socio-economic status. Women from ethnic minorities and deprived sub-groups in the population have shown consistently lower uptake over decades of screening in countries worldwide.
| Review objectives: To assess the effectiveness of interventions aimed at women, to increase the uptake of cervical cancer screening | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials assessing universal, selective or opportunistic cervical cancer screening. |
38 randomised trials, including 6 cluster randomised trials assessed invitations (17 studies), education (6), message framing (1), counselling (2), risk factor assessment (2), procedures (1), use of a photo comic book (1) and intensive recruitment (1). |
| Participants | Women eligible to participate in cervical cancer screening. |
Women receiving care in community clinics, primary care practices and Health Maintenance Organisations, mostly located in urban areas. |
| Settings | Community, workplace, health centre and hospital settings. |
USA (16 studies), Australia (9), UK (7), Canada (2), Sweden (2), South Africa (1) and Italy (1). |
| Outcomes |
Primary outcomes: Uptake of cervical screening as recorded by health service records and via self-report. Secondary outcomes: booking of appointments; reported intentions to attend screening; satisfaction with screening service, attitudes and knowledge about screening; costs of the interventions. |
All primary outcomes, booking of appointments (1 study), acceptability of the intervention (1) and costs of the interventions (5). |
| Date of most recent search: March 2009 | ||
| Limitations: This is well-conducted systematic review with only minor limitations. | ||
Everett T, Bryant A, Griffin MF, Martin-Hirsch PP, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. The Cochrane database of systematic reviews. 2011(5):CD002834.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The 38 included studies assessed varied interventions (invitations, education, counselling, risk factor assessment, message framing, procedures, photo comic book and intensive recruitment). Secondary outcomes, including cost data, were incompletely documented.
Seventeen studies compared the effects of invitations to women to attend cervical screening programmes to usual care or no invitation. Diverse types (face-to-face, letter, telephone, celebrity letter, letter with fixed appointment, letter with open invitation to make an appointment) and sources of invitations (general practitioners, health clinics, programme coordinators) were examined. Effects were found to vary by types and sources of the invitations.
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Effect of invitations compared to usual care on uptake of cervical screening |
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People Women eligible to participate in cervical cancer screening Settings Community clinics, primary care practices Intervention Invitations Comparison Usual care or no invitation |
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|
Outcomes |
Usual care or no invitation |
Invitations |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Absolute effect (95% CI) |
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Uptake of screening |
55 per 1000 |
91 per 1000 (79 to 105) |
RR 1.65 (1.44 to 1.90) |
Moderate |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Six studies compared the effects of education interventions to usual care or no education. Educational interventions were also compared with other interventions, such as invitation letters and risk assessment, to increase the uptake of cervical screening (these studies showed that educational interventions probably lead to little or no difference in cervical screening uptake, compared to other interventions).
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Effect of education compared to usual care on uptake of cervical screening |
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People Women eligible to participate in cervical cancer screening Settings Community clinics, primary care practices Intervention Educational interventions for women Comparison Usual care or no invitation |
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Outcomes (for specific educational interventions) |
Control |
Education |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Absolute effect (95% CI) |
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|
Uptake of screening with printed material |
301 per 1000 |
334 per 1000 |
RR 1.11 |
Moderate |
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Uptake of screening with educational exercises or materials |
187 per 1000 |
359 per 1000 |
RR 1.92 (1.24 to 2.97) |
Moderate |
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Uptake of screening with face-to-face home visits |
215 per 1000 |
502 per 1000 |
RR 2.33 (1.04 to 5.23) |
Moderate |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Two studies compared the effects of telephone or face-to-face counselling to usual care or no counselling. Telephone counselling to increase awareness of cervical screening programme probably leads to little or no difference compared to provider prompts.
| Effect of counselling compared to usual care on uptake of cervical screening | ||||||
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People Women eligible to participate in cervical cancer screening Settings Community clinics, primary care practices Intervention Counselling Comparison Usual care or no counselling |
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|
Outcomes |
Usual care or no invitation |
Counselling |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Absolute effect (95% CI) |
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|
Uptake of screening |
533 per 1000 |
656 per 1000 |
RR 1.23 (1.04 to 1.45) |
Moderate |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Two studies compared the effects of providing enhanced risk factor assessment (a personally tailored assessment followed by a discussion with the healthcare provider about the woman’s personal risk factors for developing cervical cancer) to usual care or no risk factor assessment.
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Effect of enhanced risk factor assessment compared to usual care on uptake of cervical screening |
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People Women eligible to participate in cervical cancer screening Settings Community clinics, primary care practices Intervention Risk factor assessment Comparison Usual care or no risk factor assessment |
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Outcomes |
Usual care or no invitation |
Risk factor assessment |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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|
Absolute effect (95% CI) |
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|
Uptake of screening |
431 per 1000 |
654 per 1000 |
RR 1.52 (0.58 to 3.95) |
Very low |
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Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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The review identified a number of other interventions to increase the uptake of cervical screening. Each of these was assessed by one study only. The findings were as follows:
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Effect of ‘other’ interventions compared to usual care on uptake of cervical screening |
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People Women eligible to participate in cervical cancer screening Settings Community clinics, primary care practices Intervention Risk factor assessment Comparison Usual care or no risk factor assessment |
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|
Outcomes (for specific interventions) |
Usual care or no intervention |
interventions to increase the uptake of cervical screening |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
|
|
Absolute effect (95% CI) |
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|
Uptake of screening through access to a health promotion nurse |
431 per 1000 |
509 per 1000 |
RR 1.18 (1.10 to 1.26) |
Moderate |
|
|
Uptake of screening with photo-comic book |
69 per 1000 |
66 per 1000 |
RR 0.96 (0.53 to 1.73) |
Low |
|
|
Uptake of screening with intensive recruitment |
185 per 1000 |
294 per 1000 |
RR 1.59 (1.24 to 2.06) |
Moderate |
|
|
Uptake of screening with message framing |
514 per 1000 |
406 per 1000 |
RR 0.79 (0.48 to 1.30) |
Very low |
|
|
Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| All except one of the included studies were conducted in high-income countries. One study was conducted in a middle-income country. |
When assessing the transferability of these findings to low-income countries, the following factors should be considered: − Literacy levels (e.g. for printed materials) − Population migration, and access to remote areas − Availability of resources for the intervention or devices, such as mobile phones, to disseminate messages Acceptability and costs of the interventions |
| EQUITY | |
|
There was little information in the included studies regarding the differential effects of the interventions on resource-disadvantaged populations. Amongst ethnic minority groups, lay members of the community could be useful in presenting culturally-tailored information, particularly when performed "face-to-face". |
In many settings, women from ethnic minorities and deprived sub-groups in the population have lower uptake of cervical screening. Resources needed for interventions may be less available in disadvantaged populations. The interventions may increase inequity if they are not applied or adapted to these populations. |
| ECONOMIC CONSIDERATIONS | |
| No trials assessing cost-effectiveness were identified. Five trials presented cost data, but all were conducted in high-income countries. |
Scaling up of these interventions will require resources, and this should be considered when making decisions regarding implementation. Local costings studies are desirable before scaling up these interventions. |
| MONITORING & EVALUATION | |
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Sending invitations to women to attend cervical screening programmes is the intervention that has received most evaluation. It is uncertain which type of interventions, for each categories of interventions are most effective. |
Larger and more rigorous studies are required to determine the effects and the cost-effectiveness of interventions, particularly in resource-poor settings. For each category of intervention, studies should identify which types are the most effective. Future trials should also consider combination of interventions and ongoing changes in screening technology. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: |
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Glick SB, Clarke AR, Blanchard A, Whitaker AK. Cervical cancer screening, diagnosis and treatment interventions for racial and ethnic minorities: a systematic review. Journal of general internal medicine. 2012;27(8):1016-1032.
Camilloni L, Ferroni E, Cendales BJ, et al. Methods to increase participation in organised screening programs: a systematic review. BMC public health. 2013; 13:464.
Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services. American journal of preventive medicine. 2012;43(1):97-118.
Brouwers MC, De Vito C, Bahirathan L, et al. What implementation interventions increase cancer screening rates? A systematic review. Implementation science: IS. 2011;6:111.
Baron RC, Rimer BK, Breslow RA, et al. Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review. American journal of preventive medicine. 2008;35(1 Suppl):S34-55.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Thomas Everett and Lize Maree.
Everett T, Bryant A, Griffin MF, Martin-Hirsch PP, Forbes CA, Jepson RG. Interventions targeted at women to encourage the uptake of cervical screening. The Cochrane database of systematic reviews. 2011(5):CD002834.
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care.
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