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Cited by 332Cervical Cancer and HPV ResearchWomen's cancer prevention and managementGlobal Cancer Incidence and Screening

Interventions targeted at women to encourage the uptake of cervical screening

Open access
Everett, Thomas, Bryant, Andrew, Griffin, Michelle F, Martin-Hirsch, Pierre PL, Forbes, Carol A, Jepson, Ruth G·2011·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd002834.pub2PMC PMC4163962
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Abstract

BACKGROUND: This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease. OBJECTIVES: To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology. MAIN RESULTS: Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard scr

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  • Mass media campaigns are more effective when complemented with letter campaigns.

    “and they are more effective when complemented with letter campaigns [39].”

    From Improving cancer screening uptake: A behavioural and cultural insights perspective and rapid review (2026) · cites this paper as [39]

    In Results > Effects of interventions (page unavailable), the review reports that television media plus letters significantly increased cervical-screening attendance in two regions, while television media alone did so in one. It does not report a direct comparison establishing that adding letters makes mass-media campaigns more effective generally. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Awareness raising usually relies on one-way information provision through small media (booklets, videos, letters) and less often mass media.

    “Awareness raising usually relies on one-way information provision through small media e.g., booklets, videos, letters [9,38,39], and less often mass media [38].”

    From Improving cancer screening uptake: A behavioural and cultural insights perspective and rapid review (2026) · cites this paper as [39]

    The Results (Description of studies; page not provided) describe 17 trials of invitation letters and three of printed educational materials, while the Results (Effects of interventions; page not provided) describe a television-media trial. This supports the examples of letters and printed materials and suggests less coverage of mass media in this review. It does not establish that awareness raising usually relies on one-way provision, or specifically identify videos as a commonly used small medium. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • A Cochrane review found insufficient evidence to support any particular type of educational intervention for CC.

    “A Cochrane review found insufficient evidence to support any particular type of educational intervention for CC (types include media education, brief educational sessions, and educational courses) [39].”

    From Improving cancer screening uptake: A behavioural and cultural insights perspective and rapid review (2026) · cites this paper as [39]

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Research works printed but not linked: 6

  1. Greene PG Smith DE Kratt PP Mayo MS Harrison R Partridge E Promoting cervical cancer screening in a rural minority primary care setting Annals of Behavioral Medicine 1999 21 SO57
  2. Torres Mejía G Salmerón Castro J Téllez Rojo MM Lazcano Ponce EC Juárez Márquez SA Torres Torija I Call and recall for cervical cancer screening in a developing country: a randomised field trial International journal of cancer. Journal international du cancer 2000 87 6 869 73 10956399
  3. Jemal A Siegel R Ward E Hao Y Xu J Murray T Thun MJ Cancer Statistics CA Cancer J Clin 2008 58 71 96 18287387
  4. La Vecchia C Franceschi S Decarli A Sexual factors, venereal diseases and the risk of intraepithelial and invasive cervical neoplasia Cancer 1986 58 935 3755077
  5. Walters S Nur U Rachet B Gordon E Jakomis N Edgar G Coleman MP Cancer survival in England:one-year and five-year survival for 21 common cancers, by sex and age Patients diagnosed 2003-2007 and followed up to 2008 2010 Statistical Bulletin, Office of National Statistics
  6. Ries LAG Kosary CL Hankey BE SEER cancer statistics review, 1973-1996 1999 US Department of Health and Human Services, National Cancer Institute Bethesda, MD

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Authors
Everett, T., Bryant, A., Griffin, M. F., Martin-Hirsch, P. P., Forbes, C. A., & Jepson, R. G.
Affiliations
  • Addenbrooke's Hospital (GB)
  • Newcastle University (GB)
  • Royal Preston Hospital, Lancashire Teaching Hospital NHS Trust; Gynaecological Oncology Unit; Sharoe Green Lane Fullwood Preston Lancashire UK PR2 9HT
  • University of York (GB)
  • Scottish Collaboration for Public Health Research and Policy (GB)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2011-05-11
Volume
9
Issue
5
Pages
CD002834-CD002834
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd002834.pub2
PMC
PMC4163962
OpenAlex
W1933814988
Cited by
332
References
214
Citations by year
2026: 5 · 2025: 8 · 2024: 11 · 2023: 36 · 2022: 20 · 2021: 22 · 2020: 17 · 2019: 15 · 2018: 22 · 2017: 20 · 2016: 38 · 2015: 20 · 2014: 14 · 2013: 17 · 2012: 11
FWCI
1.84
Type
journal article
Language
en
Update notices
new_version (2021-09-06)
Open access
Licence
other-oa
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion, other-oa)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Stirling Online Research Repository (University of Stirling) (submittedVersion, public-domain)
  • Newcastle University ePrints (Newcastle Univesity)
Topics
  • Health Sciences › Medicine › Epidemiology › Cervical Cancer and HPV Research
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
  • Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
Keywords
cervical cancer screening, screening uptake, women, health education intervention, educational intervention, informed consent, cervical cancer prevention, HPV vaccination, screening programs, barriers to screening, cervical cancer mortality, socioeconomic status, ethnic differences, screening coverage, opportunistic screening
MeSH terms
Uterine Cervical Neoplasms, Female, Humans, Mass Screening, Patient Acceptance of Health Care, Precancerous Conditions, Vaginal Smears, Randomized Controlled Trials as Topic, Reminder Systems

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