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Interventions targeted at women to encourage the uptake of cervical screening

RHL Commentary by Germar MJV

1. EVIDENCE SUMMARY

Cervical cancer is a preventable disease. At the present time cervical screening is acknowledged to be the most effective approach to controlling this cancer. Central to the success of any screening programme is its ability to identify, reach and screen the defined target population.

Thirty-five studies published from 1987 to 1999 fulfilled the inclusion criteria for the review. Each study was thoroughly examined for its methodological quality. Of these, 19 studies had evaluated the effectiveness of sending letters that invited women to come for cervical screening. Eight of the 9 studies for which relative risks could be calculated, found a statistically significant improvement in screening uptake in the groups of women who were sent invitation letters compared with those who were not (control groups). Owing to statistical heterogeneity among the studies, however, a pooled summary estimate was not calculated. The authors' conclusions were therefore based on individual study quality and should be interpreted with caution.

Six studies evaluated the effectiveness of different educational interventions. Although 5 of the 6 found these interventions to be beneficial compared with controls the benefit was neither statistically nor clinically significant. Furthermore, it was not clear which particular educational intervention-i.e. print, video/slides, interpersonal communication-was most effective. Evidence with regard to telephone invitations, interpersonal communication, counseling and providing transportation incentives was limited owing to lack of good-quality studies.

Sub-group analyses of the included studies would have been useful in terms of setting (general practice clinic, community or health management organization), age group and access to care of those screened.

The authors concluded that there was some evidence supporting support of the use of invitation letters. They also found limited evidence to support educational interventions in increasing the uptake of cervical screening.

The authors looked into informed uptake of cervical screening as an outcome, but this was not considered by any study.

This Cochrane review was last updated in 2001. The search strategy of Jepson et al. (1) was used, which was comprehensive and included unpublished studies without any language restrictions. Two reviewers screened the studies while one of the authors extracted the data, which were presented clearly. However, following additional information would have been useful: (i) literacy rate of countries where studies were done, (ii) level of education of the women studied; (iii) language used in writing the intervention letters; (iv) cost per woman screened of the particular intervention; and (v) the insurance status of the women screened.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Worldwide, more than 238,000 women die each year from cervical cancer; over 80 % these women live in developing countries (2). In the Philippines, cancer ranks third among the leading causes of morbidity and mortality. Cervical cancer is the 2nd most common type of cancer in women, next only to breast cancer. The incidence of cervical cancer in the Philippines has remained unchanged since 1980, with an overall survival rate of 51.7 %, or about 10 per 100,000 women dying from the disease over 5 years. In 2005, an estimated 7,277 new cases and 3,807 deaths will occur (3) in that country. About two-thirds of cervical cancer cases in the Philippines are diagnosed at an advanced stage; owing to inadequate radiotherapy facilities in the country, mortality is high.

At the present time cervical cytology is considered to be the only way to reduce cervical cancer incidence. However, it has been effective only in developed countries as the existence of a reliable health infrastructure is a prerequisite for this approach (4). An organized screening programme would be difficult to implement in developing countries like the Philippines where resources are scarce. Although cytological screening is being carried out in developing countries, this is mostly done in the context of opportunistic screening. Such screening is often of poor quality: it is performed inadequately and is inefficient in terms of population coverage (5).Particularly in the Philippines, which is composed of 7,100 islands, some of which are so remote there are no physicians on them, screening programmes for cervical cancer have consistently failed to access the target population owing to lack of manpower and funds (6). Thus, the issue of interventions to increase screening uptake would become relevant only after suitably planned and well-funded screening programmes have been established.

2.2. Applicability of the results

All of the studies included in the review were conducted in developed countries. Most of these countries have well organized cervical screening programmes or, at the very least, have a functioning health care system funded by the government. This is not the situation in most developing countries, where basic health care services are either lacking or inaccessible and where there are significant barriers to receiving preventive care.

The interventions studied in the trials included in the review required the existence of functioning databases of women in the target population, an efficient postal system, adequate funding, and a high literacy rate in the target population. These factors may not exist in developing countries. Also, in developing countries the screening process in itself may be unaffordable. Moreover, in developing countries there is a lack of necessary human expertise and a screening method suitable for under-resourced settings does not exist (7). In view of this, interventions to increase uptake of cytological screening may not be immediately relevant.

2.3. Implementation of the intervention

Any intervention to increase uptake of cervical screening must be tailored to the baseline knowledge, perceptions, culture, and attitudes unique to the target population.

In the "Philippine knowledge, attitude and practices behavior modification study" (5), the following factors were shown to be the causes of failure of cervical screening methods: (i) lack of knowledge among women about symptoms that may be associated with cervical cancer; (ii) a fatalistic attitude towards cancer in general and lack of awareness that cervical cancer can be cured; (iii) lack of cytological screening facilities and expertise and of treatment facilities in rural areas; and (iv) lack of patient compliance with follow-up for check-up and treatment.

Hence, successful implementation a cytological screening programme in the Philippines would involve: (i) a well-funded screening programme; (ii) an organized database of the identified target population; (iii) a baseline study of the target population in terms of knowledge, attitudes practices, and cultural norms; and (iv) education of health care providers as to these factors, so that they can come up with a tailored intervention tool for the particular population. The provision of accurate, comprehensive, socioculturally appropriate and relevant information on cervical cancer and screening must therefore be the basis of any intervention to promote uptake.

3. RESEARCH

Trials are currently ongoing to identify the ideal method for cervical screening in developing countries (8). With limited resources and infrastructure, implementation of an organized screening programme will depend on the extent of its coverage of the target population. Research should therefore be directed towards determining the knowledge, perceptions, attitudes and cultural beliefs of women in developing countries so that tailored interventions to increase informed uptake could be implemented even with meager resources. To increase informed uptake, the tailored intervention should include information on the likely harms and risks, as well as the benefits of screening (1). More importantly, research should also look into the most cost-effective screening tool and intervention to increase uptake of screening in developing countries.

Sources of support: none

Acknowledgements: none

References

• Jepson R, Clegg A, Forbes C, Lewis R et al. The determinants of screening uptake and interventions for increasing uptake: a systematic review. Health Technology Assessment 2000;4:14.
• World Health Report 2004. Geneva, World Health Organization;2004.
• Laudico AV, Esteban DB, Reyes L. Philippine cancer facts and estimates. Manila. Philippine Cancer Society;1998.
• Cervical cancer screening in developing countries. Report of a WHO Consultation, Geneva. World Health Organization;2004.
• Department of Health Cervical Cancer Screening Study Group. Knowledge, attitudes and practices-behavior study. Manila. University of the Philippines;2001.
• Department of Health Cervical Cancer Screening Study Group. Delineation of an appropriate and replicable cervical cancer screening program for Filipino women. Manila. University of the Philippines,;2001.
• Cronje HS. Screening for cervical cancer in developing countries. International Journal of Gynecology and Obstetrics 2004;84:101-108.
• Sankaranarayanan R, Parkin DM. The current work of the International Agency for Research on Cancer (WHO/IARC) in cervical cancer control in developing countries. Lyon. International Agency for Research on Cancer;2003 (unpublished document).

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This document should be cited as: Germar MJV. Interventions targeted at women to encourage the uptake of cervical screening: RHL commentary (last revised: 7 October 2004). The WHO Reproductive Health Library; Geneva: World Health Organization.

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