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Implications for practice and research
Client reminders and one-on-one education are effective community-based interventions for improving screening rates for colorectal cancer (CRC), breast and cervical cancers.
Group education is now shown to be an effective approach for improving breast cancer screening rates.
Needs particular to the target population should be considered in conjunction with published recommendations when choosing interventions to improve screening rates.
Studies which address interventions for increasing CRC screening other than with faecal occult blood test are needed.
An important area to address in future research is the effectiveness of electronic communications in improving screening rates.
Although screening rates have improved overall for CRC, breast and cervical cancer during the last decades, interval-appropriate screening rates remain low. The Guide to Community Preventive Services (Community Guide), supervised by The Community Preventive Services Task Force (Task Force), previously used a systematic review (SR) approach to evaluate intervention studies designed to increase screening rates for these cancers.1 Because of continued low-screening rates and a lack of strong evidence for some community interventions, an updated SR was conducted by the Task Force in conjunction with the Cancer Prevention and Control Research Network to ascertain updated evidence for screening interventions.
MEDLINE, the Cumulative Index to Nursing and Allied Health database, the Chronic Disease Prevention Database, PsycINFO and the Cochrane Library were researched for eligible studies. Studies published between January 2004 and October 2008 were selected if they were: (1) primary studies addressing one of the three strategies: increasing community demand for screening; reducing access barriers and increasing service delivery by healthcare providers; (2) conducted in a country with high income; (3) addressed screening for breast, cervical or CRC and (4) provided screening rate data either prior to the intervention or from a control group. Consistent with the previous Task Force SR, studies meeting inclusion criteria were evaluated by two reviewers, and quality was rated as good, fair or limited. Effectiveness of the study intervention was rated by comparing change in a particular screening behaviour compared with either the control group or baseline behaviour, using methods reported elsewhere.2
From more than 18 000 citations, 45 studies met the inclusion criteria. New recommendations were related only to the strategy of increasing community demand for screening and included: (1) group education for breast cancer screening, (2) one-on-one education for CRC screening and (3) client reminders for CRC screening. Other recommendations consistent with previous results reported by the Task Force included reducing structural barriers for breast and CRC screening as well as decreasing out-of-pocket costs for breast cancer screening and delivering provider feedback for all the three types of cancer screening. Client incentives and mass media use to increase screening rates across all the three malignancies remained inconclusive and therefore were not recommended for use in any screening group.
Findings from this updated SR provide important information about how screening rates for breast, cervical and CRCs might be enhanced through community interventions. A major strength of this study is the SR process established in a previous work by the Task Force and developed explicitly for determining evidence for screening intervention effectiveness. As such, the generalisability of these recommendations is considerable. The applicability of recommendations to the underserved or particular ethnic minority populations may be limited; however, recommendations are designed to guide screening interventions in the general population. As with all systematic reviews and other reviews, limitations of individual publications, including bias in analysing and reporting findings, may have influenced SR ratings and subsequent recommendations.
Findings revealed that studies utilising one-on-one education and client reminders may be recommended for all the three cancers of interest. Furthermore, a new finding that breast cancer screening rates are responsive to group education interventions offers an opportunity for reaching clients in the community through both individual-targeted and group-targeted approaches.
Recommendations made within the two other strategy categories (reducing access barriers and increasing healthcare provider service delivery) remained unchanged, reaffirming the importance of reducing structural barriers (breast and CRC) and out-of-pocket costs (breast). The continued recommendation of provider assessment and feedback underscores the long-understood important role of healthcare providers in encouraging screening uptake and potential for improvement in that regard. In summary, this SR is a comprehensive update of evidence-based community interventions, which should lead to increased screening rates for an early diagnosis of the three highly curable diseases.
Competing interests None.
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