Increasing women's compliance with opportunistic cervical cancer screening: a randomized trial.

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.     

Promoting screening for cervical cancer: realising the potential for recruitment by general practitioners

This paper explores the potential for general practitionersto promote screening for cervical cancer and describes one exampleof an effective general practitioner-based (GP-based) programmeto improve community screening rates. The GP-based programmewas designed to improve general practitioners' involvement inrecruiting women in their communities to have Pap smears. Theaim was to raise doctors' awareness of the fact that many womenare not adequately screened, to encourage them to consider whythese women are not being recruited, to assist them to developstrategies to overcome these problems, and to support them inthe use of these strategies by providing information and resources,feedback on performance, and peer support. The effectivenessof the GP-based programme was assessed as part of a multi-centretrial to compare the differential effectiveness of three community-basedstrategies to promote screening for cervical cancer: a televisioncampaign, a television campaign combined with personally addressedletters sent to all women in the community, and a televisioncampaign combined with the GP-based programme. Each interventionwas delivered to three postal regions in New South Wales, Australia,and time-series data on Pap smear rates were obtained. Threecontrol regions were included for comparison. Of all three strategies,the combined television campaign and GP-based programme hadthe most potential, with up to an additional 8% of previouslyunscreened women being screened during each quarter of the combinedtelevision campaign and GP-based programme. This compares withscreening of 2–4% of previously unscreened women in associationwith television combined with letters, and only 1–3% ofpreviously unscreened women when television was used alone.However, the impact of the GP-based programme was highly variable.This variation in effectiveness points to a need for furtherresearch to determine the general practitioner, community andprogramme factors associated with programme success.     

Randomised trial of intensive academic detailing to promote opportunistic recruitment of women to cervical screening by general practitioners

OBJECTIVE: To evaluate a multifaceted intervention involving intensive academic detailing for general practitioners (GPs) to improve recruitment of women for cervical screening. METHODS: We conducted a cluster randomisation trial involving 39 general practices in inner-metropolitan Sydney. GPs' knowledge, propensity to an opportunistic approach, competence and confidence were assessed by self-report before and after the intervention. To measure GP behaviour, recall of an opportunistic discussion about cervical screening was determined in cross-sectional samples of female patients at baseline (n = 1,090) and post-test (n = 1,062). RESULTS: Knowledge improved marginally in both groups but there were no changes in other GP self-reported measures. At post-test, women attending GPs in the intervention group were no more likely than those in the control group to recall an opportunistic inquiry about their cervical screening status (OR 0.65, 95% CI 0.40-1.08). Women in the intervention group who were overdue for cervical screening were no more likely than their control group counterparts at post-test to recall advice about cervical screening (OR 2.16, 95% CI 0.75-6.14) or written information (OR 0.34, 95% CI 0.04-26.5). CONCLUSIONS: Intensive academic detailing does not improve an opportunistic approach to cervical screening in general practice. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: In an evidence-based climate, implementation of academic detailing as a strategy to improve cervical screening rates in general practice would be premature.     

A general practice-based recruitment strategy for colorectal cancer screening

OBJECTIVE: To determine whether a screening recruitment strategy for first degree relatives of people with colorectal cancer is effective in enabling eligible relatives to request screening from their general practitioner (GP) and to assess acceptability to GPs and patients. METHODS: Thirty GPs, from 26 practices, and 303 of their patients aged over 50 who were first degree relatives of a person with colorectal cancer, participated in a randomised controlled trial of a GP-based recruitment strategy, in the Newcastle Area of New South Wales, Australia. RESULTS: The proportion of relatives requesting screening was statistically significantly higher in the intervention group than in the control group (18% compared to 4%, respectively; p = 0.01). CONCLUSIONS: Interest in the study by GPs was low, however for GPs who were involved, the recruitment strategy did prompt first degree relatives to discuss screening. The strategy may be even more effective when combined with other interventions such as a media campaign. The results may be generalizable to feasibility studies of general population screening for colorectal cancer in Australia. IMPLICATIONS: The results of this work are potentially informative to public health practice in Australia given the ensuing pilot programs of colorectal cancer screening.     

城市女性宫颈癌机会性筛查接受障碍原因及影响因素

目的 分析城市女性宫颈癌机会性筛查接受障碍原因及影响因素,提出促进女性宫颈癌筛查的策略与建议。方法 对2009年1月-2015年3月随机抽取的重庆市内8家医院就诊的女性进行宫颈癌筛查接受意愿问卷调查。结果 有效问卷11 965（98.9%）份,16.77%受访者不愿意接受宫颈癌机会性筛查,接受障碍前3位原因为"认为没有必要,相信自己没有问题"占44.44%,"不愿意或害怕妇科检查"占30.39%,"不知道筛查的意义"占10.71%。多因素logistic回归分析结果显示,年龄越小,文化程度越低越不愿意接受筛查;无业、未生育和生产次数≥ 3者,没有听说过宫颈癌、不知道宫颈癌筛查目的者均不愿意接受筛查。结论 缺乏健康意识为筛查接受障碍的主要原因,建议增强宫颈癌筛查相关知识传播及认知,重点在青年女性、低学历、无业及未生育者、不了解宫颈癌及筛查者。     

Cost-effectiveness of interventions to promote cervical screening in general practice

Abstract: A cost-effectiveness study of three different interventions to promote the uptake of screening for cervical cancer in general practice was carried out in Perth in 1991. Women eligible for a Pap smear were randomly allocated to one of four groups: one receiving letters with specific appointments to attend a screening clinic staffed by female doctors, one receiving letters informing them of the availability of the clinic and suggesting they make an appointment, one whose files were tagged to remind a doctor to offer a smear during a consultation, and a comparison control group that received opportunistic screening only. Variable and fixed costs for each group were itemised and summarised to give an average cost per smear taken. The cost and effectiveness of each intervention were then compared with those of the control group. Sensitivity analysis was performed on the major component of the costs, the doctor's time. Opportunistic screening cost $14.60 per smear and attained 16 per cent recruitment. Tagging files was the cheapest intervention ($14.75 per smear) although it was the least effective in recruiting women (20 per cent). This result held true for different scenarios of doctor's time allocated. Intervention by invitation letter with no appointment cost $45.35 per smear and attained 26 per cent recruitment, and intervention with a specific appointment cost $48.21 per smear and attained 30 per cent recruitment. Compared with the control group, the incremental cost-effectiveness for the tagged group was $15.40, for the letter-without-appointment group $97.75 and for the letter-with-appointment group $86.50.     

Improving population-based cervical cancer screening in general practice: effects of a national strategy.

OBJECTIVE: To assess the effects of a Dutch national prevention programme, aimed at general practitioners (GPs), on the adherence to organizational guidelines for effective cervical cancer screening in general practice. To identify the characteristics of general practices determining success. DESIGN: A prospective questionnaire study with pre- and post-measurement (before and 15 months after the introduction of the national programme). SETTING AND STUDY PARTICIPANTS: A random sample of one-third of all 4758 Dutch general practices. One GP was asked to participate per practice. INTERVENTION: A national GP prevention programme to improve population-based prevention of cervical cancer combining various methods for quality improvement in general practice, performed on a national, district and practice level. Outreach visitors were a key strategy in bringing about behavioural changes. MAIN OUTCOME MEASURES: The proportion of practices adhering to 10 recommendations (in four guidelines) to organize effective cervical cancer screening. RESULTS: After 15 months, all Dutch practices showed significant improvement in adherence to nine out of 10 recommendations. Two recommendations, in particular 'identifying women who should be medically excluded from screening' and 'sending a reminder to non-compliers' showed the largest absolute increases of 26% and 33%, respectively. Besides more intensive support of outreach visitors, practice characteristics such as 'computerization' and 'delegation of many clinical tasks to the practice assistant' were important in improving the adherence to guidelines. CONCLUSION: The national programme, with a combination of various methods for quality improvement, appeared to be effective in improving the organization of cervical screening in general practice. Computerization and, to a lesser extent, delegation of many clinical tasks to the practice assistant and more intensive support to practices, positively influenced the effectiveness of the national programme.     

Reliability and validity of women's recall of mammographic screening

Objective : To assess the reliability and validity of self‐reported attendance for mammographic screening. Methods : To assess reliability of recall of attendance for a screening mammogram, 100 women selected at random were interviewed twice (approximately one week apart). To assess validity, 127 women who reported having a mammogram within the national breast screening program (BreastScreen Australia) consented to having their reports verified by the national program. Results : Test‐retest reliability for the question “Have you ever had a mammogram?” was perfect (agreement 100%, kappa 1). Validity was also high. About one‐quarter of women (24.4%) recalled the exact date of their last mammogram and a further third (39.4%) correctly reported the month in which the mammogram was done. Almost all (91.3%) women reported the mammogram date accurately to within 12 months of the recorded date. Conclusions : These data suggest that Australian women provide reliable and valid information in relation to mammographic screening attendance. Implications : Self‐reported data about attendance for mammographic screening are likely to provide reliable and valid estimates for research and health services evaluation purposes.     

妇女对乳腺癌、宫颈癌筛查的知晓及意愿调查

目的 了解妇女对 "宫颈癌、乳腺癌"筛查的意愿,评估"两癌"筛查健康传播的效果,为全国顺利开展"两癌"筛查工作提供参考.方法 采用横断面调查,在2009年9月对北京市各级妇幼保健院门诊就医妇女700人进行问卷调查.结果 北京市户籍人口对北京市开展"两癌"筛查行动知晓率达到90.3%,高于非户籍人口的62.9%.86.9%的妇女"两癌"筛查信息来自于社区街道、村里、医院、媒体宣传.知晓"两癌"筛查信息者比不知道筛查信息者更愿意接受"两癌"筛查.44.4%的人明确表示,如果没有政府的"两癌"免费筛查,自己不会花钱去做检查.结论 "两癌"筛查受到群众欢迎,获知信息有助于提高筛查率,北京市"两癌"筛查健康传播策略取得较好效果.     

Costs and remuneration for cervical screening in general practice in the west of Scotland

OBJECTIVES: To investigate associations between costs and remuneration for cervical screening in general practice in relation to skill mix, features of practice structure and deprivation levels in the local area; and, to identify efficient policies for organising cervical screening in general practice. METHOD: Questionnaire survey and interview study in 87 general practices in Greater Glasgow Health Board an area in the west of Scotland which covers a socio-economically varied population. The main outcome measures were remuneration to cost ratios (RCRs) for cervical screening and their natural logarithms (logRCRs). RESULTS: Both the costs of cervical screening and RCRs varied widely between the 87 practices taking part. RCRs ranged from 0.29 to 14.67 (mean 2.64, median 2.18, interquartile range 1.15-2.98). Twenty-one per cent (18) of practices earned less than they spent on the organisation of screening, whilst 9% (8) of practices had PCRs of more than 5:1. RCRs were significantly lower if medical staff were involved in either taking smears or dealing with results. RCRs did not vary by social deprivation score, despite uptake being lower in practices in more deprived areas. This was explained by nurses working in practices in deprived areas being more likely to take smears than nurses working in more affluent areas. Sensitivity analyses were undertaken, altering key time and cost assumptions. As a result, the absolute values of the RCRs changed, although the overall pattern of association did not, with the exception of doctor involvement in processing results which was no longer significant when average general practitioners' income was substituted for locum rates. CONCLUSIONS: Practices in deprived areas may be responding to greater pressure of work by making optimal use of skill mix within the primary health care team. A more graduated incentive payment scheme may more fairly reward practices in deprived areas which are less likely to achieve 80% uptake due to relatively intractable features of practice structure. Assuming that practice nurses provide an equivalent quality of service to that provided by general practitioners, results suggest that doctor-nurse substitution would be cost-effective for general practice based cervical screening. Resource savings (principally doctor's time) could be redeployed to other areas of primary health care.     

广东省龙川县1620例宫颈癌机会性筛查结果分析

目的研究龙川县接受宫颈癌机会性筛查的妇女宫颈癌及癌前病变的发病状况,并探讨液基细胞学检查（TCT）及阴道镜等在宫颈癌筛查和诊断中的临床意义及应用价值。方法收集分析龙川县人民医院2008年1月-2013年6月妇科门诊进行宫颈癌机会性筛查的1620例病例,对TCT阳性者进行阴道镜下宫颈活检及病理检查,确诊宫颈病变及宫颈癌。结果 1620例受检者中,TCT阳性为258例（15.9%）,活检证实为宫颈上皮内瘤变（CIN）者64例（3.95%）,宫颈浸润癌2例（0.12%）。在TCT阳性（258例）病例中,阴道镜检出异常者130例（50.4%）,其中活检结果为湿疣17例、CIN或浸润癌72例,阴道镜与活检诊断符合率为68.4%（89/130）。此外,不同年龄组对比发现宫颈癌发病率差异有显著性（P〈0.05）,定期筛查组（各机关事业单位及部分企业计划定期普查发现宫颈癌前病变及宫颈癌患者）阳性检出率显著低于非定期筛查组（随机抽查同期来龙川县人民医院就诊发现宫颈癌前病变及宫颈癌患者）（P〈0.05）。结论宫颈癌前病变及早期宫颈癌高发年龄在30~49岁,TCT结合阴道镜检查是较好的宫颈癌筛查手段之一。开展宫颈癌前病变定期筛查工作能显著降低宫颈癌的发生和发展机率。     

General practice intervention to increase opportunistic screening for chlamydia

We describe an 18-month intervention that was designed to improve opportunistic screening for chlamydia in General Practice. Key strategies included engaging and informing general practitioners, adopting a simplified screening protocol, providing feedback on practice testing performance and developing resources for use with patients. This uncontrolled before and after study found that the overall impact on testing was modest and largely transient, and was insufficient to impact on the current chlamydia epidemic. Major additional measures would be required to further substantially increase testing levels. These could include financial incentives linked to screening performance and increased community awareness to increase patient demand for testing.     

Understanding the role of violence in incarcerated women's cervical cancer screening and history

In this exploratory study the authors investigated characteristics, including reported experiences of violence, related to incarcerated women's self-report of cervical cancer screening and cancer history and treatment. During a four month period in 2010, 204 women in Kansas City jails were surveyed. Multiple logistic regression models were used to examine the relations of socio-demographic and community characteristics and history of violence among the women to their cervical cancer screening, diagnosis, and treatment histories. Forty percent of the women in the current sample reported abnormal Pap histories, though only 6% of all Pap smears done in the U.S. are abnormal. Women who reported abuse histories in this study were found to be more likely to report having ever had an abnormal Pap smear (for physical abuse Odds Ratio [OR] = 6.05; CI 2.36, 15.54 and for past year intimate partner violence OR = 2.41; CI 1.09, 5.31). Participants who did not fear neighborhood violence were less likely to report an abnormal Pap history (OR = 0.57; CI 0.34, 0.96) and more likely to visit a family doctor for their Pap screenings (OR = 1.91; CI 1.01, 3.60). Women who perceived greater neighborhood violence had increased odds of reporting that they received Pap screenings in a hospital setting (OR = 1.47; CI 1.08, 2.00). Frequency of Pap screening did not differ in women who did and did not have fear of neighborhood violence. This study highlights the heightened cervical cancer risk experienced by women with criminal justice histories and suggests that violence at several levels has implications for cervical cancer prevention for these women.     

A computer-managed call and recall system for cervical screening

In order to maximine the response of women to cervical screening the service needs to be re-oriented towards the needs of the consumer, with a greater initiative coming from the service provider. These considerations imply that the system should take account of various barriers and in order to do so systematically and comprehensively requires a database and a management system. This paper described the development of a computer-managed scheme for cervical screening using the Family Practitioner Committee (FPC) register as a database to identify women for screening. This system can be used for calling previously unscreened women as well as for recall.     

The cost of cervical cancer screening provided by a women's health nurse

Abstract: This study examines the cost of cervical cancer screening provided by a women's health nurse. Methods used to estimate the cost of taking a Pap smear were based on the economic principle of opportunity cost. Techniques for estimating the magnitude of some costs were developed specifically for this study because the cost of taking a Pap smear had to be isolated from the costs of other services provided by the women's health nurse. The cost of taking a Pap smear in 1989 was estimated to be between $17.68 and $17.95. A sensitivity analysis was carried out so that the results of this study could be adapted for practices which differ from the women's health nurse's practice in the Mount Druitt and Hawkesbury area of New South Wales. As a result of this analysis, the cost of taking a Pap smear ranged from $14.16 to $38.88, depending on whether the women's health nurse was a Clinical Nurse Consultant or Clinical Nurse Specialist, the number of Pap smears taken, the proportion of clients who come for postnatal examinations, length of consultations and the distance travelled. It should be noted that the cost of taking a Pap smear would rise considerably above $38.88 for women's health nurses working in remote areas.     

Accuracy of patients' recall of Pap and cholesterol screening

OBJECTIVES: This study was undertaken in mid-1994 and assessed how accurately patients recall the recency and result of their most recent cholesterol and Papanicolaou (Pap) tests. METHODS: A cross-sectional, door-to-door community survey was used to gather self-report and, subsequently, pathology laboratory data for 195 individuals. RESULTS: In regard to cholesterol screening, 30% of individuals who reported being adequately screened were actually inadequately screened, 45% who reported normal cholesterol levels actually had elevated levels, and 21% of inadequately screened individuals and 56% of individuals with elevated levels were not identified by self-report. In terms of Pap screening, 28% of women who reported being adequately screened were actually inadequately screened, 11% of patients who reported a normal Pap test actually had abnormal or inadequate results, and 55% of inadequately screened individuals and 53% of individuals with abnormal or inadequate results were not identified by self-report. CONCLUSIONS: This study revealed self-report to be a less-than-adequate measure of individuals' recall of cholesterol and Pap screening. Relying exclusively on self-report surveys as indicators of screening coverage is likely to result in significant underestimations of the proportion of people who are inadequately screened or whose results indicate a need for intervention.     

Diagnosing type 2 diabetes before patients complain of diabetic symptoms--clinical opportunistic screening in a single general practice

In the UK, patients normally see their general practitioner first and 86% of the health needs of the population are managed in general practice, with 14% being referred to specialist/hospital care. Early diagnosis is the privilege of general practice since general practitioners make most medical diagnoses in the NHS. Their historic aim has been to diagnose as early as possible and if possible before patients are aware of symptoms. Over time, diagnoses are being made earlier in the trajectory of chronic diseases and pre-symptomatic diagnoses through tests like cervical screening. Earlier diagnosis benefits patients and allows earlier treatment. In diabetes, the presence of lower HbA1c levels correlates with fewer complications. Methodologically, single practice research means smaller populations but greater ability to track patients and ask clinicians about missing data. All diagnoses of type 2 diabetes, wherever made, were tracked until death or transfer out. Clinical opportunistic screening has been undervalued and is more cost-effective than population screening. It works best in generalist practice. Over 19 consecutive years, all 429 patients with type 2 diabetes in one NHS general practice were analysed. The prevalence of type 2 diabetes rose from 1.1% to 3.0% of the registered population. Since 2000, 95.9% were diagnosed within the general practice and the majority (70/121 = 57.9%) of diagnoses were made before the patients reported any diabetes-related symptom. These patients had median HbA1c levels 1.1% lower than patients diagnosed after reporting symptoms, a clinically and statistically significant difference (P = 0.01).     

Cervical screening in general practice

Abstract: 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.