A large population-based randomized controlled trial to increase attendance at screening for cervical cancer. A randomised controlled trial of strategies to prompt attendance for a Pap smear. Improving uptake of cervical cancer screening in women with prolonged history of non-attendance for screening: a randomized trial of enhanced invitation methods. Promoting participation in a population screening program for breast and cervical cancer: a randomized trial of different invitation strategies. Mass mailing campaigns to promote screening for cervical cancer: do they work, and do they continue to work? Computerized reminders to encourage cervical screening in family practice. Media interventions to increase cervical screening uptake in South Africa: an evaluation study of effectiveness. A randomized controlled trial of interventions to promote cervical cancer screening among Chinese women in North America. Cervical screening in general practice. Do personalised letters in Vietnamese increase cervical cancer screening among Vietnamese women? A randomised trial of invitations to attend for screening mammography. The safety net: a cost-effective approach to improving breast and cervical cancer screening. Tailored messages for breast and cervical cancer screening of low-income and minority women using medical records data. Effectiveness of a call/recall system in improving compliance with cervical cancer screening: a randomized controlled trial. Effectiveness of three community based strategies to promote screening for cervical cancer. Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls. Randomised controlled trial of the effect of evidence based information on women's willingness to participate in cervical cancer screening. Promotion of cervical screening among nonattendees: a partial cost-effectiveness analysis. Can health education increase uptake of cervical smear testing among Asian women? A randomised trial of general practitioner-written invitations to encourage attendance at screening mammography. Prospective randomised controlled trial of methods of call and recall for cervical cytology screening. The impact of tailored interventions on a community health center population. Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial. How much does a reminder letter increase cervical screening among under-screened women in NSW? Using an office system intervention to increase breast cancer screening. Does the offer of cervical screening with breast screening encourage older women to have a cervical smear test? Comparison of tailored interventions to increase mammography screening in nonadherent older women. Message framing and mammography screening: a theory-driven intervention. A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives. Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders. Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study. Does feedback improve the quality of cervical smears? A randomized controlled trial. Effective lay health worker outreach and media-based education for promoting cervical cancer screening among Vietnamese American women. Encouraging underscreened women to have cervical cancer screening: the effectiveness of a computer strategy. Effect on survey response rate of hand written versus printed signature on a covering letter: randomised controlled trial [ISRCTN67566265].
Although cervical cancer is one of the potentially most preventable malignancies, it is still fairly common. In settings with established screening programs, increased compliance is important for future reduction in cervical cancer incidence, but it is presently unclear how this can be effectively achieved.
                We conducted a randomized controlled trial including all 12,240 women invited to organized screening in Sweden. To increase compliance, three successive interventions were tested: (a) modified invitation versus the standard invitation letter, (b) reminder letter to nonattenders after the first intervention versus no reminder letter, and (c) phone reminder to nonattenders after the reminder letter versus no phone reminder. We analyzed the proportion of women attending screening after each intervention and the cumulative proportion after the interventions as well as the cumulative proportions of cytologic abnormalities.
                The modified invitation did not increase attendance compared with the standard invitation letter [difference 1.3% 95% confidence interval (CI) -0.3 to 2.9]. In contrast, a reminder letter increased the proportion of women attending with 9.2% (95% CI 7.9-10.5) compared with women who did not receive a reminder letter, and a phone reminder increased the proportion of women attending with 31.4% (95% CI 26.9-35.9). Combinations of modified invitation, written reminder, and phone reminder almost doubled attendance within 12 months, and the number of detected cytologic abnormalities was more than tripled.
                Simple reminders by mail and phone can drastically increase women's participation in Papanicolaou smear screening and increase the number of detected precursor lesions and thereby save lives. To assess the comparative efficacy, by randomised controlled trial, of three interventions designed to encourage "at risk" women to have a Pap smear: an educational pamphlet; letters inviting attendance at a women's health clinic; and letters from physicians.
                Subjects at risk for cervical cancer who had not been adequately screened were identified by a random community survey and randomly allocated to one of the intervention groups or a control group. Six months after intervention implementation, a follow up survey assessed subsequent screening attendance. Self report was validated by comparison with a national screening data base.
                A significantly greater proportion of women (36.9%) within the group receiving a physician letter reported screening at follow up than in any other group (P = 0.012). The variables most strongly predicting screening attendance were: age, perceived frequency of screening required, use of oral contraceptives, and allocation to receive the physician letter intervention.
                The relative efficacy of the GP letter in prompting screening attendance shows that this strategy is worthy of further investigation. There remains a need to examine the barriers to screening for older women, and to develop tailored strategies for this population. To compare the effectiveness and cost-effectiveness of three methods of inviting women with a long history of non-attendance to undergo cervical screening.
                Randomized controlled trial and cost-effectiveness analysis. In all, 1140 women were identified from routine NHS screening records as having no smear for at least 15 years and randomly allocated to receive a telephone call from a nurse, a letter from a well-known celebrity (Claire Rayner) or letter from the local NHS Cervical Screening Commissioner. Uptake of screening was measured using routine data and attributed to interventions if occurring within three months. Uptake was compared with a control group. Costs of carrying out the interventions were noted from the perspective of the NHS and cost-effectiveness, as cost per additional attender, calculated.
                Uptake following all interventions was low: telephone call (1.4, 95% confidence interval [CI] 0.38-3.6%); celebrity letter (1.8, 95% CI 0.57-4.0%); commissioner letter (4.6, 95% CI 2.5-7.7%); control group (1.8, 95% CI 0.57-4.0%). There were no significant differences between groups. Telephone intervention was not possible in a quarter of women whose numbers were unlisted. Telephone intervention was the most expensive and least effective of the interventions. The commissioner letter yielded an additional attender within three months at an incremental cost of 23.21 pounds compared with taking no action.
                Neither a telephone call from a nurse nor a letter from a celebrity to encourage attendance for cervical screening were effective or cost-effective in women with a prolonged history of non-participation in the screening programme. A letter from the local cervical screening programme commissioner resulted in a small, non-significant increase in uptake. The low cost and ease of implementation of this intervention supports further research into its use in routine practice. Attendance level has been identified as a major determinant of cost-effectiveness of organized screening programs. We tested the effectiveness of 4 different invitation systems in the context of an organized population screening program for cervical and breast cancer.
                Women eligible for invitation--8385 for cervical and 8069 for breast cancer screening--listed in the rosters of 43 and 105 general practitioners (GP), respectively, who had accepted to collaborate in the program, were randomized to 4 invitation groups: Group A--letter signed by the GP, with a prefixed appointment; Group B--open-ended invitation, signed by the GP, prompting women to contact the screening center to arrange an appointment; Group C--letter (same as for group A), signed by the program coordinator, with a prefixed appointment; Group D--extended letter (highlighting the benefits of early cancer detection) signed by the GP, with a prefixed appointment. Assignment to the interventions was based on a randomized block design (block=GP).
                Assuming Group A as the reference, the overall compliance with cervical cancer screening was reduced by 39% in Group B (RR=0.61; 95% CI, 0.56-0.68) and by 14% in Group C (RR=0.86; 95% CI, 0.78-0.93); no difference was observed for Group D (RR=1.03; 95% CI, 0.95-1.1). The response pattern was similar for breast screening (Group B: RR=0.71; 95% CI, 0.65-0.76; Group C: RR=0.87; 95% CI, 0.81-0.94; Group D: RR=1.01; 95% CI, 0.94-1.08).
                Personal invitation letters signed by the woman's GP, with preallocated appointments, induce a significant increase in compliance with screening. Efficiency can be ensured through the adoption of overbooking, provided that attendance levels are regularly monitored. Campaigns involving sending personally addressed letters to encourage women to have Pap smears increase Pap smear rates. The aim of this study was to assess whether this effect is maintained when campaigns are repeated regularly. In October 1992, a letter reminding women of the importance of screening was mailed to all women in three New South Wales postcode regions where a similar letter had been sent three years previously. The response was compared to the response in three regions receiving no earlier letter. The number of women attending for cervical screening during the three months after distribution of the letters was assessed from Health Insurance Commission claims for cervical cytology. These attendances were compared with expected attendances based on the attendance patterns over 28 pre-intervention quarters. Significant postintervention increases in attendance were observed in all three regions receiving an initial letter. However, in one region, the increase in attendances, around 1 per cent of eligible women, was not significantly greater than the increase in the control region (z = 0.15, P = 0.88). The second letter campaign had no measurable effect on attendances. No significant increase in screenings was observed in two of the towns. A significant increase was observed in one region, but this was not significantly greater than the increase in the control region (z = -0.05, P = 0.96). These results suggest that repeated direct-mail campaigns to promote screening for cervical cancer may be of no benefit. A one-off campaign may result in an increase in screenings in the short term. In a randomized trial three ways of increasing rates of cervical screening were compared for women attending a family medicine center. Working from computerized medical records, 1,587 women aged 18 to 35 years who were overdue for a screening test were included in the study. In a control group, no formal method was used to encourage patients to attend for screening, and 13.7 percent obtained a test within the trial year. In one intervention group the physician was issued a message identifying those women visiting the center for a routine appointment who were due for screening; 16.1 percent were screened. Sending a letter to patients in a second group yielded a 25.9 percent compliance rate. In a third group the practice nurse called patients on the telephone to advise them to obtain the test, and 20.0 percent complied. Reminders issued to the physician provide a low-cost, opportunistic approach to reach women who happen to visit the practice, but this approach should be supplemented by telephoning or sending a letter to those women who do not attend regularly. Successful cervical cancer prevention depends on reaching, screening and treating women with pre-invasive disease. We aimed to evaluate the effectiveness of two media interventions-a photo-comic and a radio-drama-in increasing cervical screening uptake. A randomized controlled trial compared a photo-comic on cervical cancer screening with a placebo comic. One month after the comics were distributed a radio-drama paralleling the photo-comic was broadcast on the community radio station and a retrospective evaluation was carried out. The trial was set in Khayelitsha, a peri-urban squatter community near Cape Town, South Africa. A random sample consisted of 658 women between the ages of 35 and 65 years, from a stratified sample of census areas. The main outcome measure was self-reported cervical screening uptake 6 months after distribution of the comics. Seven percent (18 of 269) of women who received the intervention photo-comic reported cervical screening during the 6 months follow-up, compared with 6% (25 of 389) of controls (P = 0.89). Women who recalled hearing the radio-drama were more likely to report attending screening (nine of 53, 17%) than those who did not (19 of 429, 4%; P < 0.001). We conclude that the photo-comic was ineffective in increasing cervical screening uptake in this population. The radio-drama may have had more impact, but only a minority of women recalled being exposed to it. Future research must concentrate not only on achieving high level of exposure to health messages, but also on investigating the links between exposure and action. North American Chinese women have lower levels of Papanicolaou (Pap) testing than other population subgroups. We conducted a randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.
                Four hundred and eighty-two Pap testing underutilizers were identified from community-based surveys of Chinese women conducted in Seattle, Washington, and Vancouver, British Columbia. These women were randomly assigned to one of two experimental arms or control status. Several Chinese-language materials were used in both experimental arms: an education-entertainment video, a motivational pamphlet, an educational brochure, and a fact sheet. Women in the first experimental group (outreach worker intervention) received the materials, as well as tailored counseling and logistic assistance, during home visits by trilingual, bicultural outreach workers. Those in the second experimental group (direct mail intervention) received the materials by mail. The control group received usual care. Follow-up surveys were completed 6 months after randomization to ascertain participants' Pap testing behavior. All statistical tests were two-sided.
                A total of 402 women responded to the follow-up survey (83% response rate). Of these women, 50 (39%) of the 129 women in the outreach group, 35 (25%) of the 139 women in the direct mail group, and 20 (15%) of the 134 women in the control group reported Pap testing in the interval between randomization and follow-up data collection (P<.001 for outreach worker versus control, P =.03 for direct mail versus control, and P =.02 for outreach worker versus direct mail). Intervention effects were greater in Vancouver than in Seattle.
                Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America. This study examined the effect of three interventions for encouraging women to have a Pap smear in a general practice: tagging the medical record to remind the doctor to offer a Pap smear, sending an invitation to make an appointment for a Pap smear, and sending an invitation with an appointment to attend for a Pap smear at a special screening clinic staffed by women. The study took place in a university general practice at Lockridge, near Perth. A computerised practice age-sex register provided 2139 women in the age range 36 to 69 inclusive. Of these, 757 were eligible for inclusion in the study and were allocated randomly to one of three intervention groups or a control group. In total, 177 women had a Pap smear during the study. Significantly more Pap smears were taken for the appointment-letter and letter-only groups than the control group (odds ratio (OR) 2.13, 95% confidence interval (CI) 1.34 to 3.57, and OR 1.67, CI 1.01 to 2.77 respectively), but there was no significant difference between the tagged-notes and the control groups. Women who attended the screening clinic rated the experience positively. Attendance, however, was inadequate for the clinic's viability in a private practice. In Australia, Vietnamese women are at greater risk of cervical cancer than other Australian women. To increase their participation in cervical screening, the Vietnamese community was exposed to a media campaign about the advantages of cervical smear screening which was delivered in Vietnamese through Vietnamese newspapers and radio. In addition, 689 Vietnamese (18-67 years) were selected from the electoral roll. They were randomly assigned to either receive a personal letter written in Vietnamese promoting cervical screening, or not. We report on the effect of the letter on smear rates. Being randomised to be sent such a letter was not associated with any increase in screening (relative rate of appropriate screening in the intervention versus the control group was 0.85, 95% CI 0.55-1.3). It is important to carefully evaluate untested health promotion interventions. The aim of this study was to evaluate the effectiveness of invitations for mammographic screening. Women aged 45 to 69 who had not attended for screening at the mobile Breast X-Ray Programme of the Central Sydney Area Health Service were randomly selected from the 1989 electoral listing. In the geographical area in which the study was conducted (Drummoyne local government area), 36 per cent of women had attended for screening before the intervention, indicating that the invitations were aimed at the reluctant participant. Women were randomly allocated to a control group who did not receive invitations (n = 80), and an intervention group who received letters from the Program inviting them to attend at a specified time (n = 163). Overall 33 per cent of women (53 of 163) who were sent invitations attended for screening compared to 9 per cent of those not invited (7 of 80) (P less than 0.001). Older women responded at least as well as younger women. In addition, the distribution of language spoken at home was similar for electoral listing attenders and the community as a whole, suggesting that this intervention works as well for women of English- and non-English-speaking backgrounds. The results suggest that the response to an invitation for screening from a source not personally known to women achieves comparable attendance to an invitation from their general practitioner, as assessed in a previous study. The purposes of the study were (1). to assess the cost-effectiveness of three interventions to deliver breast and cervical cancer screening to women unscreened for >or=3 years and (2). to determine the relation of an invasive cervical cancer diagnosis to the interval since the last true screening test.
                In a randomized trial, women were randomly assigned to (1). usual care, (2). letter plus follow-up letter, (3). letter plus follow-up phone call, (4). phone call plus follow-up phone call. Screening within 12 weeks was the outcome. A 5-year retrospective review of cervical cancer cases and screening histories was done.
                The 8% of women not screened for >or=5 years had 62% of the invasive cervical cancer cases. Mammography outreach led to screening in 10%, 24%, 51%, and 50% of controls, letter/letter, letter/phone, and phone/phone interventions groups, respectively. Cervical cancer screening outreach led to screening in 17%, 22%, 54%, and 50% of the respective groups. Letter reminders alone produced fewer tests at substantially higher costs than did personalized telephone notification.
                For cervical cancer, only 1 person in 12 was not screened in the preceding 5 years, but these accounted for nearly two thirds of invasive cancers. Aggressive outreach to the rarely screened is an important part of screening programs. Letter reminder, followed by a telephone appointment call, was the most cost-effective approach to screening rarely screened women. Lack of accurate information on prior hysterectomy adds substantial unnecessary costs to a screening reminder program. Barriers to screening and early detection often result in cancers in low-income and minority women diagnosed at stages too advanced for optimal treatment. This randomized controlled trial examined whether a personalized form (PF) letter containing generic cancer information and a personalized tailored (PT) letter containing minimally tailored individualized risk factor information based on medical records data affected breast and cervical cancer screening among 1574 urban low-income and minority women. The personalized form-letter group was significantly more likely to schedule a screening appointment and to have undergone a Pap test and mammography within 1 year after the intervention than were the tailored letter and control groups (P<0.001 for all comparisons). Personalized tailored letters that contain individualized cancer risk factor information may decrease the likelihood of receiving cancer screening among medically underserved low-income and minority women, but personalized form letters that contain generic cancer information may improve these rates in this disadvantaged population. To determine the effectiveness of a simple call/recall system in improving compliance with cervical cancer screening among women not screened in the previous 3 years.
                Prospective randomized controlled study.
                Two family medicine clinics (1 urban, 1 rural) affiliated with Memorial University of Newfoundland, St. John's.
                A sample of women aged 18-69 years who were listed as patients of the clinics but who had not had a Papanicolaou test (Pap test) within the 3 years before the start of the study. Of 9071 women listed as patients 1360 (15.0%) had not undergone screening in the previous 3 years. A random sample of 650 were selected, 209 of whom were excluded because they had had a hysterectomy, had had a recent Pap test, had moved or had records containing clerical errors. This left 441 women for the study.
                The 221 women in the intervention group were sent a letter asking them to seek a Pap test and a reminder letter 4 weeks later. The 220 in the control group were sent no letters.
                Number of women who had a Pap test within 2 months and 6 months after the first letter was sent.
                Within 2 months, more women in the intervention group than in the control group had been screened (2.8% [5/178] and 1.9% (4/208] respectively). There was also a difference between the overall proportions at 6 months (10.7% [19/178] and 6.3% [13/208] respectively). None of the differences was statistically significant.
                A letter of invitation is not sufficient to encourage women who have never or have infrequently undergone a Pap test to come in for cervical cancer screening. The effectiveness of added recruitment methods such as opportunistic screening by physicians, follow-up by telephone and the offer of a specific appointment should be evaluated. Evaluation of three potential methods for increasing Pap smear use: television media, television media combined with letter based recruitment, and television media combined with general practitioner based (GP based) recruitment.
                A trial of each intervention was carried out in three postal regions in New South Wales, Australia-a rural locality (containing about 1000 women), a country town (about 3000 women), and a major rural centre (about 10,000 women). Three control regions were selected to be demographically similar to the corresponding intervention regions.
                Outcome data on regional Pap smear rates were obtained from government health insurance claims for cervical screening, and from pathology service records. Expected Pap smear rates for the three months after the intervention were predicted from 45 pre-intervention months and were compared with observed rates for this period.
                Television media alone was associated with a significant increase in attendances for screening in one of the three regions where a trial was carried out: 13.3% in the rural centre. The media/letter based campaign was associated with a significant increase in attendances in two out of three regions: 52.7% in the rural locality, 43.2% in the rural centre. The media/GP based campaign was associated with significant increases in attendances in all three regions: 50.2% in the rural locality, 80.8% in the country town, 15.7% in the rural centre. All three interventions were associated with significant increases in the number of women attending for cervical screening above those observed in the control regions. Furthermore, these increases were not restricted to women at low risk. They were also found for older women (aged 50-69 years) and women who had not had a Pap smear within the past three years. A randomized trial was conducted to evaluate the combined impact of a physician reminder letter and a telephone contact on the use of Pap tests and mammograms in a low-income managed care program. Women 40 to 79 years of age who were past due for cancer screening were randomly assigned to an intervention or control group. Medical claims were reviewed after 6 months to determine intervention effectiveness. The odds of receiving all needed cancer screening tests during follow-up were four times higher in the intervention group. Women who reported having to take time off from work to see a doctor had lower odds of getting screened. To assess whether providing women with additional information on the pros and cons of screening, compared with information currently offered by the NHS, affects their intention to attend for screening.
                Randomised controlled trial. Participants were randomly assigned to receive either the control, (based on an NHS Cervical Screening Programme leaflet currently used), or the intervention leaflet (containing additional information on risks and uncertainties).
                Three general practices in Birmingham.
                300 women aged 20 to 64 attending the practices during a one month period.
                Intention to attend for screening. Main results: 283 women (94.3%) completed the study. Fewer women in the intervention (79%) than the control group (88%) expressed intention to have screening after reading the information leaflet (difference between groups 9.2%, 95% confidence intervals (CI) 3.2% to 21.7%). The crude odds ratio (OR) and 95% CI was 0.50 (0.26 to 0.97). After adjusting for other factors, the trend persisted (OR 0.60, 95% CI 0.28 to 1.29). Having a previous Pap smear was the only significant predictor of intention to have screening (adjusted OR 2.54, 95% CI 1.03 to 6.21). Subgroup analysis showed no intervention effect in intended uptake between women at higher and lower risk of cervical cancer (p=0.59).
                Providing women with evidence based information on the risks, uncertainties, and the benefits of screening, is likely to deter some, but not differentially those at higher risk. Measures to increase attendance rate in cervical screening programmes have been suggested, but few have been evaluated in terms of value for money. The aim of this study was to describe the cost-effectiveness of a resource-intensive intervention to promote attendance at cervical screening among women with no registered cervical smear during the last 5 years. Among all 56 644 women (28-65 years) in Kalmar County, January 2004, a total of 6565 women had no registered cervical smear during the last 5 years. From this population, 400 women were randomly selected to a study group and another 400 women to a control group. The intervention was composed of a variety of efforts intended to promote attendance at cervical screening. We included, for example, all costs for identifying the women, sending out invitation letters, making phone calls and helping to make arrangements. Data on registered cervical smears at follow-up were collected from a data register within 1 year. In the study group, 118 women had a registered cervical smear compared with 74 in the control group (P=0.000). In the study group, the cost per cervical smear taken was 66.87 euro compared with 16.63 euro in the ordinary screening programme. The incremental cost per additional registered cervical smear was calculated at 151.36 euro in an area with high coverage, efforts to promote attendance at cervical screening were related to high costs per extra cervical smear gained and is not considered as reasonable from a cost-effectiveness perspective. To determine the effects of three different methods of providing health education on the uptake of cervical smear testing among Asian women, and to evaluate the acceptability of different health education materials.
                Prospective cohort study over one year of effects of written materials by post, personal visit to give written materials, and personal visit to show a video on the uptake of smear testing. Techniques included a personally administered questionnaire.
                Leicester, a city with a large Asian population.
                737 randomly selected Asian women aged 18 to 52 who were not recorded on the central cytology laboratory's computer as ever having had a cervical smear test. 159 declined to participate or were not contactable.
                Women were randomised into four groups: visited and shown a video (263), visited and shown a leaflet and fact sheet (219), posted a leaflet and fact sheet (131), not contacted at all (124).
                Cervical smear test recorded on computer within four months after intervention.
                57 (37%, 26% of group) of the women visited and given leaflets and 80 (47%, 30% of group) shown the video attended for cervical smears. Only six (5%) of those who were not contacted and 14 (11%) of those sent leaflets had a smear test during the study.
                Health education interventions increased the uptake of cervical cytology among Asian women in Leicester who had never been tested. Personal visits were most effective irrespective of the health education materials used, but there was some evidence that home viewed videos may be particularly effective in one of the most hard to reach groups: Urdu speaking, Pakistani Moslems. Written translated materials sent by post were ineffective. The aim of this study was to examine the effectiveness of general practitioner-written invitations to the Breast X-Ray Programme of the Central Sydney Area Health Service. Five out of six randomly selected general practices in Drummoyne participated. Within each practice, women aged 45 to 70 were individually randomised to receive or not receive a letter from their general practitioner (GP). Thirty-two per cent of women attended if invited compared to 7 per cent if they were not sent an invitation. An attendance of 38 per cent was obtained for women whose GP chose to send a letter with an appointment compared to 24 per cent for women whose GP chose to send a general invitation without an appointment. Combining all practices, women who consulted their GP within the previous 6 months were more likely to attend in response to the invitation (38 per cent) than women whose last consultation was more remote, dropping to 15 per cent in those who last attended that GP over 2 years earlier. Women aged 65 to 70 years old were at least as likely to respond to the invitation as women aged 45 to 64. Reminder letters were subsequently sent to a random half of nonrespondents who had attended the practice in the previous 12 months. A further 18 per cent of women attended after the reminder letter was sent (8/45), compared with 2 per cent in the control group (1/48). Twenty-seven per cent of women in Drummoyne had already attended for screening mammography before the trial.(ABSTRACT TRUNCATED AT 250 WORDS) To discover whether systematic methods of call and recall are more effective than a non-systematic method and to see which of the two systematic methods was more effective.
                Prospective randomised controlled trial over a year.
                One group general practice.
                416 Women over 35 eligible for a smear test who had never had a cervical smear test or in whom a smear test was overdue (previous test more than five years before).
                One group received written invitations to have a smear taken. The second group had their notes tagged so that the doctor would remind them (when they attended for another reason) to have a smear test. No special intervention was made in the third group.
                Performance of a cervical smear test during the year of the study.
                32% (45/140) of the screened group, 27% (39/142) of the tagged group, and 15% (20/134) of the control group had a smear test during the year. The percentage of women having a smear test in the screened group was not significantly different from that in the tagged group, but the percentages in the two groups were significantly different from that in the control group. Whether a woman had had a previous smear test significantly affected the uptake of the invitation to have a smear test independently of the method of invitation.
                The systematic methods of call and recall were more effective than a non-systematic method. There was no significant difference between the two systematic methods (sending letters or tagging the notes) at one year. We conducted a 4-year randomized study in a community health center that serves primarily low income Blacks in Durham, North Carolina. Patients (1318 at baseline) were assigned randomly to one of three study groups: provider prompting intervention alone, provider prompting and tailored print materials or the previous group and tailored telephone counseling. The purpose of the study was to determine whether increasingly intensive, tailored print and telephone interventions also were increasingly effective in promoting adherence to mammograms, Pap tests and overall cancer screening compliance. Thus, the combination of tailored print interventions (print and telephone) should have been more effective than the provider prompting intervention alone, or the print intervention and prompting combination. This is one of the few studies to examine a measure of overall cancer screening compliance and to assess the benefit of combinations of tailored interventions in promoting adherence to cancer screening. Patients gave extremely high ratings to the interventions. At the bivariate level, we found a significant effect of the most intensive group (provider prompting intervention, tailored print communications and tailored telephone counseling) on Pap test compliance (P = 0.05) and borderline significance at the multivariate level (P = 0.06) as well on overall screening compliance (P = 0.06). There was not a significant effect on mammography, probably because a majority of the patients were receiving regular mammograms. We also found some important subgroup differences. For example, a larger proportion of women reported Pap tests in the tailored print and counseling group when they believed the materials were 'meant for me.' These results show that a combination of tailored interventions may have potential for reaching the women who have too often been labeled the 'hard to reach.' Our objective was to evaluate the efficacy and acceptability of two interventions designed to increase opportunistic cervical cancer screening. We designed a randomized trial of two interventions additional to usual care. We recruited 17 male general practitioners selected at random from the inner metropolitan region of Sydney, Australia. The patients were 202 women, between 20 and 65 years of age, eligible for a Pap smear. We allocated minimal and maximal interactional interventions to obtain consent for a Pap smear. Our main outcome measure was women's having a Pap smear during the consultation or within one month. We also measured acceptability of interventions to practitioners and women. These were our results: minimal: 55% of women had a Pap smear; maximal: 67% of women had a Pap smear; total when both approaches are combined: 61%. We conclude that brief advice is as effective as maximal persuasion in increasing women's compliance with opportunistic screening in routine consultations. Both interventions were acceptable to women. Practitioners preferred the minimal intervention. We demonstrate opportunistic screening is an effective and acceptable way to encourage women at risk to have a Pap smear. To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months.
                Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups.
                After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups.
                Being sent a reminder letter is associated with higher Pap testing rates in under-screened women. To evaluate an innovative approach to continuing medical education, an outreach intervention designed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practices.
                Randomized, controlled trial with primary care practices assigned to either the intervention group or control group, with the practice as the unit of analysis.
                Twenty mostly rural counties in North Carolina.
                Physicians and staff of 62 randomly selected family medicine and general internal medicine practices, primarily fee-for-service, half group practices and half solo practitioners.
                Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance, and to assist these primary care practices in developing office systems tailored to increase breast cancer screening.
                Physician questionnaires were obtained at baseline and follow-up to assess the presence of five indicators of an office system. Three of the five indicators of office systems increased significantly more in intervention practices than in control practices, but the mean number of indicators in intervention practices at followup was only 2.8 out of 5. Cross-sectional reviews of randomly chosen medical records of eligible women patients aged 50 years and over were done at baseline (n = 2,887) and follow-up (n = 2,874) to determine whether clinical breast examinations and mammography, were performed. Results for mammography were recorded in two ways, mention of the test in the visit note and actual report of the test in the medical record. These reviews showed an increase from 39% to 51% in mention of mammography in intervention practices, compared with an increase from 41% to 44% in control practices (p = .01). There was no significant difference, however, between the two groups in change in mammograms reported (intervention group increased from 28% to 32.7%; control group increased from 30.6% to 34.0%, p = .56). There was a nonsignificant trend (p = .06) toward a greater increase in performance of clinical breast examination in intervention versus control practices.
                A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography, but had little impact on actual performance of breast cancer screening. At follow-up, few practices had a complete office system for breast cancer screening. Outreach approaches to assist primary care practices implement office systems are promising but need further development. The aim was to determine what effect the offer of a cervical smear test when attending for breast screening has on the uptake of cervical and breast screening.
                The study involved randomisation to compare uptake in those women invited for cervical screening in advance with their breast screening invitation (group 1) with those invited for breast screening only and then offered a smear test upon arrival for breast screening (group 2). The main outcome measure was improvement in the uptake of cervical screening among older women without detriment to the breast screening service.
                The study took place at the Northern Hospital in North Manchester.
                Participants were 2131 women aged 50-64 years invited for breast screening at the Northern Hospital in the summer of 1990.
                Overall, 54% of the women who were eligible attended for breast screening, 52% attended from group 1 and 55% from group 2. Of those attending for breast screening, 957 were eligible for cervical screening and 193 (20%) had a smear test. There was a difference in the proportion tested from each group (p < 0.001), 28% had a smear test from group 1 and 13% from group 2. Forty five percent of the 193 had not had a cervical smear for at least five years.
                The cervical screening facility did attract some women who were overdue for a smear test and who might not normally have attended for cervical screening, and there was no evidence to suggest that it had a detrimental effect on the breast screening uptake. An advanced cervical screening invitation seemed preferable to an invitation upon arrival at the breast screening unit. Recent increases in mammography use have led to a decrease in mortality from breast cancer.
                Building on the Health Belief Model, the Transtheoretical Model, and past effectiveness of tailored interventions, we conducted a prospective randomized trial (n = 773) to test the efficacy on mammography adherence of tailored interventions delivered by five different methods, i.e., telephone counseling, in-person counseling, physician letter, and combinations of telephone with letter and in-person with letter.
                All five interventions increased mammography adherence significantly relative to usual care (odds ratios, 1.93 to 3.55) at 6 months post intervention. The combination of in-person with physician letter was significantly more effective than telephone alone or letter alone. Women thinking about getting a mammogram at baseline were more likely to be adherent by 6 months; even those in usual care achieved 48% adherence compared with 50-70% in the intervention groups. In contrast, women not thinking about getting a mammogram needed the interventions to increase their adherence from 13% to over 30%.
                All five interventions were effective at increasing mammography adherence. Women not thinking about getting a mammogram were most likely to benefit from these tailored interventions while other women might need less intensive interventions. Although the rising incidence of breast cancer has prompted a surge of intervention strategies aimed at increasing women's use of mammography screening, the majority of patient-directed interventions have not been driven by relevant theoretical work on persuasive health communication. The authors evaluated an intervention derived from prospect theory that was designed to increase women's adherence to recommendations for annual mammography screening. They sent 1 of 3 reminder letters (positive frame, negative frame, or standard hospital prompt) to 929 randomly selected women who were due for mammography screening and had been identified as having either a positive or negative family history of breast cancer. The primary hypothesis that women with a positive history would be more responsive to negatively framed messages, whereas women with a negative history would be more responsive to positively framed letters, was not confirmed. The lack of support for predictions derived from prospect theory raises important questions about the generalizability of laboratory research to natural settings. First-degree relatives (FDRs) of people diagnosed with colorectal cancer (CRC) have a two- to threefold increased risk of developing the same disease. Tailored print interventions based on behavior change theories have demonstrated considerable promise in facilitating health-promoting behaviors. This study compared the impact of two mailed print interventions on CRC screening outcomes among FDRs.
                This randomized trial compared effects of two mailed print interventions--one tailored and one nontailored--on participation in CRC screening among FDRs of CRC survivors. Data collected via phone interviews from 140 FDRs at baseline, 1 week post-intervention, and 3 months post-intervention.
                At 3 months, both the tailored and nontailored interventions yielded modest but statistically insignificant increases in adherence to any CRC screening test (14% vs. 21%, respectively; p=0.30). While there were no main effects for tailored versus nontailored interventions, there were significant interactions that showed that the tailored print intervention had significantly greater effects on forward stage movement for CRC screening depending on stage of adoption at baseline, race, and objective CRC risk. Receipt of the tailored intervention was 2.5 times more likely to move baseline precontemplators and contemplators forward in stage of adoption for colonoscopy (95% CI: 1.10-5.68) and was three times more likely to move Caucasians forward in stage of adoption for FOBT (95% CI: 1.00-9.07). In addition, the tailored intervention was 7.7 times more likely to move people at average risk forward in stage of adoption for colonoscopy (95% CI: 1.25-47.75).
                The tailored print intervention was more effective at moving Caucasians, those in precontemplation and contemplation at baseline, and those at average risk forward in their stage of adoption for CRC screening.
                Both tailored and nontailored print interventions showed moderate effects for increasing CRC screening participation. Tailored print interventions may be more effective for certain subgroups. To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally.
                Controlled trial, randomised by general practice.
                Inner London borough of Newham.
                2064 women aged 50-64 years who had failed to attend for breast screening. Women came from 26 of 37 eligible practices, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported.
                Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation.
                Attendance in the intervention group was significantly better than in the control group (9% v 4%). The response was best in Indian women--it was 19% in the intervention group and 5% in the control group.
                This simple, low cost intervention improved breast screening rates modestly. Improvement was greatest in Indian women--probably because many practice staff shared their cultural and linguistic background. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates. This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening.
                Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors.
                Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant.
                Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend. In a randomized controlled trial three methods of feedback of increasing intensity, directed at 183 doctors taking cervical smears, were compared with respect to their effects on the sampling quality of smears. Overall, feedback was found to have no influence on quality criteria in the crude data analysis. However, a significantly larger decrease in the percentage of smears lacking endocervical cells was found in the groups receiving monthly overviews of their results with peer comparison, when compared with the groups not receiving this type of feedback (odds ratio 0.75). Moreover, feedback appeared to have a clear effect on the presence of endocervical cells among doctors submitting a substantial number of smears in the intervention period, as opposed to those who submitted fewer smears. A positive correlation was also observed between the increase in the group mean of the proportions of smears containing pathological cells and the intensity of the feedback. However, this increase did not reach statistical significance. This study suggests that monthly feedback with peer comparison may have a positive relationship with some aspects of quality improvement in cervical screening. We sought to promote cervical cancer screening among Vietnamese American women in Santa Clara County, Calif.
                In 2001-2004, we recruited and randomized 1005 Vietnamese American women into 2 groups: lay health worker outreach plus media-based education (combined intervention) or media-based education only. Lay health workers met with the combined intervention group twice over 3 to 4 months to promote Papanicolaou (Pap) testing. We used questionnaires to measure changes in awareness, knowledge, and Pap testing.
                Testing increased among women in both the combined intervention (65.8% to 81.8%; P<.001) and media-only (70.1% to 75.5%; P<.001) groups, but significantly more in the combined intervention group (P=.001). Among women never previously screened, significantly more women in the combined intervention group (46.0%) than in the media-only group (27.1%) obtained tests (P<.001). Significantly more women in the combined intervention group obtained their first Pap test or obtained one after an interval of more than 1 year (became up-to-date; 45.7% to 67.3%, respectively; P<.001) than did those in the media-only group (50.9% to 55.7%, respectively; P=.035).
                Combined intervention motivated more Vietnamese American women to obtain their first Pap tests and to become up-to-date than did media education alone. Computers that collect data from patients and provide both patients and practitioners with printed feedback on a range of health risks are a tool for assisting general practitioners with preventive care. This study assessed the impact of computer-generated printed feedback on cervical screening among women who were underscreened for cervical cancer.
                Female attenders at two Australian general practices were randomly allocated to Experimental or Control groups. Women in both groups completed a health risk survey on a touch screen computer prior to their consultation. Those in the Experimental group received printed pages summarizing their results, including their eligibility for cervical screening and last Pap test, for themselves and their doctor. The number and proportion of underscreened women who had a Pap test in the 6 months after completing the computer survey, as determined by pathology records, were examined.
                Of the 679 participants, 139 were classified as underscreened on the basis of self-report (74 Experimental, 65 Control) and 272 on the basis of their pathology records (148 Experimental, 124 Control). Overall about one-third of women had a test in the 6-month period, and the differences between the groups were not significant for women overall (18-70 years) or for women 18-49 years. Among women 50-70 who were underscreened based on self-report, those receiving the printout were more likely to have a Pap test in the next 6 months (P < 0.05). This pattern was also evident, but did not reach statistical significance, for older women who were underscreened based on pathology records.
                We are unable to draw conclusions regarding the effectiveness of the computer system due to the modest proportions of women screened, the small numbers, and the fact that the computer survey may have created an intervention effect in the Control group. As the study suggests the computer system is acceptable to women and may be effective for encouraging screening among older women, further exploration of the system is desirable. It is important that response rates to postal surveys are as high as possible to ensure that the results are representative and to maximise statistical power. Previous research has suggested that any personalisation of approach helps to improve the response rate. This experiment tested whether personalising questionnaires by hand signing the covering letter improved the response rate compared with a non-personalised group where the investigator's signature on the covering letter was scanned into the document and printed.
                Randomised controlled trial. Questionnaires about surgical techniques of caesarean section were mailed to 3,799 Members and Fellows of the Royal College of Obstetricians and Gynaecologists resident in the UK. Individuals were randomly allocated to receive a covering letter with either a computer printed signature or a hand written signature. Two reminders were sent to non-respondents. The outcome measures were the proportion of questionnaires returned and their time to return.
                The response rate was 79.1% (1506/1905) in the hand-signed group and 78.4% (1484/1894) in the scanned and printed signature group. There was no detectable difference between the groups in response rate or time taken to respond.
                No advantage was detected to hand signing the covering letter accompanying a postal questionnaire to health professionals.
There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.