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O’Flaherty M, Lloyd-Williams F, Capewell S, et al. Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users. Southampton (UK): NIHR Journals Library; 2021 May. (Health Technology Assessment, No. 25.35.)

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Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users.

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Chapter 3Updating the evidence base to inform scenario design and model

How do the best-performing local authorities commission and implement the Health Check programme?

There has been national monitoring and publication of each LA’s performance on the NHS HCP since 2013. It was therefore possible to identify and contact the best-performing LAs from across England to potentially identify and share best practice. Variation in practice is common, as well as achievement against the key performance indicators of the programme. The overarching aim of this survey of best-performing LAs was to inform the workshops and scenario design features that the model needs to accommodate to support ‘what-if’ types of scenarios assessing the impact of locally adapting those best practices. For instance, if several best-performing LAs had outreach services in pharmacies, then we would want the workHORSE tool to be able to model these services.

Context

From April 2013, LAs became responsible for commissioning the risk assessment component of the NHS HCP. LAs can commission the risk assessment from any provider of their choice, but must work closely with their CCGs to ensure that there is a joined-up approach to the risk assessment, clinical follow-up and management. Although the NHS HCP is a national programme, there is variation in the implementation and delivery of NHS Health Checks within different LAs. Commissioners have some scope to adjust their delivery model to ensure that the programme is reaching their high risk and vulnerable communities. Therefore, different forms of delivery may have an impact on the uptake of NHS Health Checks among the eligible population.

Aim

We aimed to contact the best-performing LAs to find out how they were delivering the NHS HCP. This included identifying their success stories to develop best practice narratives and, if possible, templates for the workHORSE tool.

Methods

Sampling local authorities

We selected the best-performing LAs based on data from the NHS Health Checks Fingertips website [URL: https://fingertips.phe.org.uk/profile/nhs-health-check-detailed (accessed 4 November 2019)]. For the original sample, we looked at the performance of LAs during the complete 5-year cycle, from 2013 to 2017.

When considering the 5-year cycle, including the new quarters in 2018, the top-performing LAs remained the same. In addition, Gateshead joined the top-performing LAs, having improved most in the previous year, and was also included. The best-performing LAs were judged based on the percentage of eligible people who received an NHS Health Check. The percentage of eligible people who received an NHS Health Check varied from 17% to 95% across all LAs. PHE had an initial target for LAs to work towards 66% uptake of NHS Health Checks to improve coverage.

We used the 66% cut-off point for the best-performing LAs. In 2018, 12 LAs were reaching this target (Table 2), mapping well to the workHORSE model parameters and enabling scenario analysis, as described in Chapter 5.

TABLE 2

TABLE 2

Best-performing LAs

Additionally, we wanted to ensure that we had a representative sample of best-performing LAs. We identified five additional LAs that improved most over the previous year/four quarters (2017/18) compared with the previous year (2016/17) using the percentage of eligible people who received an NHS Health Check (Table 3).

TABLE 3

TABLE 3

Top five most improved LAs

Model parameters and inclusion criteria

An objective was to produce real-world input parameters of NHS Health Checks for the workHORSE model. The model had six input parameters related to NHS Health Checks, including interventions, implementations or deliveries affecting:

  1. eligibility criteria
  2. coverage
  3. uptake
  4. average risk profile
  5. diagnosis and treatment
  6. referrals for brief interventions and lifestyle services.

To inform our workHORSE model, we selected the best-performing LAs based on their performance concerning coverage and uptake. These parameters were selected because what happens during and after an NHS Health Check is not routinely published. Only patchy data relating to the other parameters exist, and these are discussed in each LA summary in Results. Further information on the methodology can be found in Appendix 1.

Results

Each LA (n = 16) was contacted by e-mail with a request for a telephone call to explain the project. A telephone call was completed with all LAs apart from one (n = 15). After the telephone call, the questions were e-mailed and the LAs were asked to return them electronically. Thirteen LAs responded (81% response rate). One responding LA (LA C) was responsible for two LAs and provided combined information, as the same approach was utilised in both LAs.

Coverage

Invited population

Local authorities invited all 40- to 74-year-olds who had not already been diagnosed with heart disease, stroke, diabetes or kidney disease or were known to be at higher risk owing to already receiving treatment for high blood pressure or high blood lipid levels.

One LA, LA C, noted that, if possible, the focus should be on inviting high-risk patients, whereas LA K reported that invitations are stratified based on estimated QRISK®2 (ClinRisk Ltd, University of Nottingham, Nottingham and EMIS Health, Leeds; URL: https://qrisk.org/2017/). In the latter case, practices are responsible for running searches that had been developed to group people into priority groups for invitations (first QRISK 2 ≥ 20% and then QRISK 2 ≥ 15% < 20%). In addition, LA K developed searches to identify those who were eligible, but had never been invited to an NHS Health Check.

Local authority F provided their strategy for identifying people to invite. More manageable annual cohorts were obtained by inviting participants by birth month. In this way, all eligible participants were invited over the 5-year cycle.

Invitation methods

The LAs reported that their GPs tended to use a mix of invitation methods, depending on what worked for different practices. Common invitation methods used included letters, telephone calls, texts and e-mail. Seven LAs (A, B, D, E, G, J and L) also reported that their practices were using opportunistic methods, including on-screen reminders on general practice systems. Three LAs (E, G and L) used this as the primary method of invitation.

Six LAs (B, E, F, G, H and K) reported that some practices had changed their method of invitation since the beginning of the programme. LAs E and G had switched to opportunistic invitations, as using letters resulted in low uptake. They felt that the change in approach had improved uptake. However, LA E reported that it was more challenging to monitor invitations when using the opportunistic model. Other changes included using texts, e-mail, a standardised short letter and re-inviting those who were still eligible but had not had an NHS Health Check in the last 4 years.

Case examples

Local authority B

After changing to more opportunistic screening, coverage in LA B increased.

2017/18

As of the end of 2017/18, 26.4% of the eligible population had been offered an NHS Health Check. This was significantly better than the overall England figure of 17.3%.

2013–18 (5-year period)

A total of 73,211 patients had been offered an NHS Health Check, which was 125% of the eligible population of 58,649. This was significantly better than the England figure of 90.9%.

Local authority F

In the final year of the cycle, searches were developed to re-invite all those who had not had a Health Check in the previous 4 years and remained eligible to increase the number of NHS Health Checks completed over the 5-year cycle.

Take-up

Approaches used to increase uptake

Local authorities reported a wide variety of different approaches to increase the uptake of NHS Health Checks.

Local authority A

Uptake increased by 17% (from 47% in 2013–14 to 64% in 2017–18).

In 2017/18, the number of NHS Health Check invitations was 14,672 and the number of NHS Health Checks completed was 9425. Twenty-eight health-care assistants/nurses attended NHS Health Checks training delivered in April 2018.

This LA had several approaches to increase uptake:

  • Free annual training for general practices (including refreshers training).
  • Systems and processes were in place to run reports for invoicing and make payments for NHS Health Checks more streamlined.
  • The public health team provided practices with eligible population reports, clinical templates, referral forms, information leaflets and associated crib sheets.
  • Practices were incentivised to reach their annual target by offering bonus payments according to their uptake.

In 2014, the public health team changed the way payments were made. Payments were split by Health Check invite, Health Check completed and Health Check bonus payment for achieving the target to increase uptake. The performance target for NHS Health Checks in this LA area was also increased in line with national targets.

Local authority B

In 2012/13, uptake varied between practices from 7% to 57%. The CCG average performance at this time was 24.3% (quartile 3). Slow uptake reflected a lack of resource and poor coding.

An increase in uptake was seen in 2013/14 from 27.2% to 40.6% of eligible individuals. In 2017/18, of the 15,478 people offered an NHS Health Check, 64.9% accepted. This was significantly better than the overall England figure of 47.9% and represented a relative increase of 35% from 2016/17 (48.1%).

The following numbers were reported over the 5-year period (2013–18):

  • Of the 73,211 people offered an NHS Health Check, 55.0% accepted. This was significantly better than the overall England figure of 48.7%.
  • Of the listed eligible population of 58,649 people, 68.7% (n = 40,270) received a Health Check, which was significantly better than the overall England figure of 44.3%.

Five approaches were used to increase uptake:

  1. A joint initiative with the CCG to improve performance of the lowest-performing practices together with recognising the need to increase the number of NHS Health Checks for all of the LA B population. All practices developed an action plan focusing on two or three quality indicators. Actions within practices included NHS Health Checks training delivered by public health, use of point-of-care testing machines, holding additional clinics (including weekends), inclusion as a regular feature in practice newsletters and on the website, and working with practices to improve coding.
  2. Use of a master template on the general practice clinical system.
  3. Quarterly feedback on performance and key messages were sent to all providers.
  4. An NHS Health Check Implementation Group to provide oversight to the programme.
  5. A health and well-being intervention lead post, which provided training and support visits to Health Check providers to improve the quality of NHS Health Checks.
Local authority C

Local authority C reported on their approaches to increasing uptake of NHS HCP, but did not quantify that change. Their NHS HCP was delivered through primary care, primarily by health-care assistants. A three-pronged approach achieved this:

  1. The LA developed a local template within the general practice clinical system and the associated reports. Alongside this, the LA provided all of its practices with point-of-care blood testing and developed a training programme. It also produced promotional materials and guidance on running the programme for practice managers and health-care assistants.
  2. The LA actively engaged with their general practice teams, including attending quarterly CCG meetings and GP network meetings to promote the programme. It then visited general practices identified as needing additional support, providing training on using the template, equipment and running searches.
  3. The LA’s payment structure ensured that practices were well remunerated for work delivery (recognising the financial pressures general practices face). Initially, it also offered a range of bonus incentive payments. Targets were set for practices and quarterly performance reports were produced. This helped to encourage natural competitiveness.
Local authority D

Local authority D had an eligible population of 75,038, of whom 53,434 (71.2%) had a Health Check over 5 years.

Several approaches were implemented to increase uptake, including:

  • practice visits
  • NHS Health Check events
  • health trainers
  • advertisements on buses
  • practice websites
  • campaigns using local celebrities (new since 2018).
Local authority E

The percentage of uptake increased from 8% of those eligible in 2010/11 to 30% of those eligible in 2012/13. Total number of screens completed increased from 7403 patients to 24,048 patients in 2012/13.

This LA altered their model of delivery and:

  • met with GPs to fully understand the barriers they faced
  • commissioned focus groups with the public to understand why people did not take up an invite
  • conducted a marketing campaign to increase awareness of the service.
Local authority F

Local authority F did not quantify recent changes. However, they did report the approaches they had used to increase uptake:

  • Pharmacies and optical practices were trained to undertake NHS Health Checks.
  • Three third-party providers and a team of sessional workers provided community and workplace NHS Health Checks.
  • In the final year, a pilot, using a private company formed by local practice clinicians, went into general practices where capacity was an issue to carry out NHS Health Checks.

In the year from April 2017 to March 2018, a performance-related bonus payment for practices was introduced. Practices reaching 66% coverage of the 5-year cohort received a bonus payment of £5 extra per check for all checks completed after that. To incentivise the practices to complete Health Checks, those that reached 75% coverage received a bonus payment of £10 for each check completed.

Local authority G

Local authority G did not report a precise percentage change, only their approaches to increase uptake. These had evolved and included:

  • professional training
  • general practice support
  • travelling NHS HCP sofas
  • a series of short NHS HCP promotional films
  • card-making project with children for loved ones
  • presentations at GP locality meetings
  • presenting to the local medical committee
  • practice meetings
  • promotion at local football matches
  • radio campaigns (both local and regional).
Local authority H

This LA provided monthly support to practices by (1) training clinical staff, (2) ringing patients to make an appointment and (3) sending out monitoring reports to practice managers to inform them of their completion and uptake figure. This information was benchmarked against other practices.

Local authority H did not report a specific percentage change in uptake.

Local authority I

Local authority I introduced a new model in April 2017, designed to increase activity, utilise the local system and integrate working across the LA and CCG.

Local authority I commission the NHS HCP through the broader primary care standards contract managed by their CCG. Public health was a specific domain area and to receive payment practices had to complete all areas within the domain. As a financial incentive to complete the whole domain, there was a threshold for each area, with a detailed performance management system for practices to monitor activity.

Local authority I did not report a specific percentage change in uptake.

Local authority J

During 2008–13, 45,275 NHS Health Checks were completed, and during 2013–18, 52,196 NHS Health Checks were completed, representing an increase of 15.3%.

The following approaches were introduced in 2014 and achieved a sharp increase in performance:

  • Introduction of monthly ‘activity’ dashboards that monitor invite and uptake, which are shared with GPs by e-mail. At quarterly ‘cluster meetings’, these data were presented to groups of GPs, comparing performances across practices, clusters and against neighbouring boroughs.
  • ‘Outcome’ and ‘quality’ dashboards were presented at cluster meetings. For example, the number of diagnoses of type 2 diabetes, CVD and other conditions that had arisen in NHS Health Check patients within 3 months of a check (or year to date).
  • The quality dashboard monitored outcomes such as referrals into appropriate services for eligible patients, measures completed within a Health Check and invitation method.

The dashboards were feasible because (1) all GPs in LA J were on an electronic patient record system and (2) the LA had commissioned a third party that had data-sharing agreements in place with all GPs, and the analytical and technical capacity to offer the service.

Local authority J commented that the critical factors for improving uptake were access to regular high-quality data for purposes of contract monitoring and data sharing with GPs so that they could view their performance against their peers, thereby encouraging competition.

Local authority K

Between 2010 and 2015, 42,113 NHS Health Checks were delivered:

  • GPs delivered 64% of all NHS Health Checks.
  • Pharmacies delivered 6% of all NHS Health Checks.
  • Community outreach delivered 30% of all NHS Health Checks.

Local authority K reported that community outreach delivered the highest proportion of checks to younger age groups (i.e. those aged 35–49 years), accounting for 64% of all community NHS Health Checks delivered. However, the highest uptake rate was found in older age groups (i.e. those aged 60–74 years), with 53% of the eligible population receiving an NHS Health Check.

Local authority K had a multifaceted approach to NHS Health Check delivery. The approach was based on local analysis of where the most significant impact in reducing CVD-related inequalities could be achieved:

  • GPs focused on people with (1) a high estimated CVD risk (i.e. a QRISK 2 score of ≥ 10%) and (2) mental health/learning disabilities.
  • Pharmacies focused on (1) people who were not engaged with primary care and (2) deprived neighbourhoods.
  • Community outreach focused on (1) deprived communities, (2) ethnic minorities and (3) men.

Changes to the payment structure were implemented at the start of 2012/13 to incentivise GPs to target increasing uptake among people with a high estimated QRISK 2 score and those on mental health registers.

Local authority L

A total of 50,650 NHS Checks were carried out from 2009 to 2012, reaching in equal measure the local South Asian population, the socially deprived and the older-age population. In 2011/12 the uptake was 73%.

Individual general practices and GP networks organised how to invite their local patients to the NHS Health Check, resulting in a steady number of eligible registered people attending over the period. The GP networks were given a target to meet each year, which resulted in the LA continuing to meet the delivery targets for NHS Health Checks across the borough.

Community outreach

Approximately half of the LAs used community outreach activities for NHS Health Checks. Most of the community outreach activities were focused on improving uptake, specifically in more deprived communities where uptake was low. Three LAs (B, C and I) reported events in local community venues as their only community outreach activities. LAs F, G and K had more extensive outreach programmes with various activities.

Local authority F
  • NHS Health Checks in pharmacies and optical practices with ‘out-of-office’ hours appointments.
  • NHS Health Checks in local workplaces.
  • Third-party contracts offering NHS Health Checks. Advertised in local venues around boroughs of low uptake or high deprivation.
Local authority G
  • A travelling NHS HCP sofa visited local parks, supermarkets, general practices and town centres.
  • A series of short NHS HCP promotional films were developed to promote the programme.
  • A card-making project with children for loved ones who may be eligible for a check.
  • Promotion at football matches.
  • Radio campaigns (both local and regional).
Local authority K
  • A comprehensive communication programme to increase public awareness of availability and locations of NHS Health Checks delivery.
  • Programme delivery at accessible, high footfall locations, such as supermarkets and community events.

Half of the LAs included did not have any community outreach activities for NHS Health Checks (LAs A, D, E, H and J).

Lifestyle services

All but one LA had a directly commissioned lifestyle referral service. However, the one LA without a directly commissioned lifestyle referral service offered to signpost to a lifestyle service. Nine LAs reported the components of their lifestyle referral services, including health trainers, smoking cessation, weight management, physical activity, healthy eating, alcohol services, diabetes prevention and social prescribing. Two LAs (C and L) did not specify the components.

Cost per NHS Health Check

Nine LAs (A, B, C, E, F, G, H, J and K) paid practices for a completed NHS Health Check, varying from £18 to £47 per Health Check. Of these nine LAs, five indicated that they provided bonus payments if specific criteria were met (£4–28 per Health Check). Criteria included meeting the invite (100%) and uptake (66%) targets, placing patients on a management plan (one off) and testing high-risk patients. Only one LA (A) paid practices for sending out invites. LA E previously paid practices for invites but found it ineffective, with a very low percentage uptake. LAs D, I and L did not pay per NHS Health Check completed. However, they did have a fixed allocation budget, which depended on practices delivering on targeted numbers. LA I specified that this could amount to £37 per NHS Health Check completed.

Conclusions

The approaches adopted for improving coverage and uptake of NHS HCP varied across all of the top-performing LAs we contacted. The LAs varied in terms of population profile and numbers, and levels of social deprivation. These factors influenced how the LAs designed and implemented strategies to increase coverage and uptake. It was therefore not possible to establish a typical pattern to identify a set of effective approaches that can be recommended to LAs that are not performing as well. However, it was apparent that all of the LAs had taken a strategic and sometimes innovative approach based on their population profile to achieve the targets set.

In terms of the workHORSE project, the information obtained provided valuable case examples for possible scenarios. The information also suggested that uptake-based scenarios for analysis will provide support to model different ‘implementations’ or optimisation of the programme to analyse with the workHORSE tool and to inform the content of the stakeholder engagement workshops.

Umbrella review of approaches used to increase screening uptake

Introduction

Among the strategies developed to tackle the preventable burden of NCDs, screening programmes are proposed and in place for many conditions: primarily cancers and infectious diseases. Screening programmes are used to detect diseases in an earlier stage in asymptomatic people who may have an increased risk of disease and can lead to better chances of successful treatment. In turn, earlier diagnosis reduces premature morbidity and mortality.44 However, several biases, relating to screening programmes, have been identified, including overdiagnosis, length time bias, lead time bias and reaching the worried well.44

The introduction of screening programmes depends on the effectiveness, acceptability and cost of the intervention. Globally, there are many types of screening programmes that target different populations. Screening programmes for adults are mainly cancer related, including breast, cervical and colorectal cancer, as feasible and efficient evidence-based strategies exist for these diseases, which are cost-effective.45,46 However, variability exists in approaches to screening in different countries, as shown in a report on cancer screening in the European Union.47 Differences exist concerning the level at which the screening takes place (regional or national), the screening test used [i.e. an immunochemical faecal occult blood test (FOBT) vs. a guaiac-based FOBT for colorectal screening], the interval at which screening takes place and the population targeted (age range).47

For screening programmes to be successful, there needs to be a system and not just a test. Programmes need to have an infrastructure to provide support throughout the entire process, from inviting people to attend the screening through to treatment and follow-up.44 However, to maximise the impact of screening programmes, high uptake, compliance and diagnosis are also essential. Uptake represents the most important factor in determining the success of screening programmes. Unfortunately, for breast and cervical cancer screening, a trend is emerging internationally that a smaller proportion of eligible women are being screened. This trend is also observed in the UK, with none of the cancer screening programmes meeting its agreed standard targets in 2017/18.48

Reasons for low uptake included low awareness of screening benefits, low acceptability of certain screening tests [e.g. Pap (Papanicolaou) test], difficulty in accessing services, language or cultural barriers, perceived costs and structural barriers.44,48 Some ethnic minority groups have significantly lower uptake and people with disabilities or mental health problems also tend to have lower uptake than the general population. Screening has the potential to reduce health inequalities. However, this is not certain with the current design and therefore it is crucial to promote equitable access for underserved groups.11,48,49

High participation rates in screening programmes targeting NCDs are instrumental in achieving full screening benefits; however, uptake enhancement in screening programmes remains underused, especially among vulnerable populations.

We conducted an umbrella review to assess the type of approaches screening programmes use to maximise uptake, the effectiveness of the approaches and the impact on equity.

Methods

Study design

We conducted an umbrella literature review (i.e. a review of systematic reviews and meta-analyses) of strategies intended to increase the uptake of screening programmes. To ensure proper conduct, we adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist (see Appendix 2, Figure 22).50 A narrative synthesis was used to present the data by strategy, type of screening programme and strength of evidence. The protocol for this review was registered as PROSPERO CRD42019132087 [see the NIHR Journals Library project web page; URL: www.journalslibrary.nihr.ac.uk/programmes/hta/1616501/#/ (accessed 10 March 2020)].

Search strategy

Exemplar papers were used to develop the search terms and inform the search strategy. A pilot was conducted to determine appropriate databases, identify relevant papers and highlight potential issues to be addressed. Based on this, limits were applied to publication date only (1999–2019). Search terms included screening, uptake, participation, systematic reviews and meta-analysis. A full search strategy can be found in the file PROSPERO protocol [see the NIHR Journals Library project web page; URL: www.journalslibrary.nihr.ac.uk/programmes/hta/1616501/#/ (accessed 10 March 2020)].

We searched the following electronic bibliographic databases from 1999 to 2019 for both published and unpublished reports: MEDLINE, Cochrane Database of Systematic Reviews (CDSR), Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Web of Science, Healthcare Management Information Consortium (HMIC), Database of Promoting Health Effectiveness Reviews (DoPHER) (EPPI Centre) and the NIHR Journals Library. Targeted searches were also conducted in Google Scholar (Google Inc., Mountain View, CA, USA). The final search was conducted on 27 March 2019. Reference lists of included studies were screened for potential eligible papers and study authors were contacted if we were unable to access the paper.

Eligibility criteria and study selection

We included studies if they evaluated strategies to improve the uptake of screening programmes. We excluded studies focusing on shared decision-making or patient navigation interventions. Owing to time limitations and budget restrictions, only studies in English were included. The retrieved studies were evaluated using the PICOS (Participants, Interventions, Comparators, Outcomes and Study design) approach, summarised in Table 4.

TABLE 4

TABLE 4

The PICOS approach: review of strategies to increase the uptake of screening programmes

The main outcome of this umbrella review was uptake of screening programmes (i.e. participation rate).

Michelle Maden conducted the searches and all papers identified by the searches were imported into Covidence (Melbourne, VIC, Australia) for screening. Duplicates were removed. Titles and abstracts were screened for eligibility independently by two reviewers (LH and FLW) and full-text papers were retrieved if papers were deemed potentially eligible. A full-text review was also carried out independently by two reviewers (LH and FLW). Any discrepancies were resolved by consensus or involving the senior author.

Data extraction and management

Data extraction forms were developed based on the recommendations made by Aromataris et al.51 for the proper conduct of an umbrella review. These forms were pre-piloted and adapted for this review. The data extraction form included the following elements:

  • citation details
  • objectives of the included review
  • type of review
  • participant details
  • setting and context
  • number of databases sourced and searched
  • date range of database searching
  • publication date range of studies included in the review that inform each outcome of interest
  • the number of studies, types of studies and country of origin of studies included in each review
  • instruments used to appraise the primary studies and the quality rating
  • outcomes reported that are relevant to the umbrella review question
  • method of synthesis/analysis employed to synthesise the evidence
  • comments or notes the umbrella review authors may have regarding any included study.

The data extraction was initially carried out by one reviewer (LH). Each study was then checked by a second reviewer (AB or MO’F) for correctness and any potential missing information.

Risk of bias

The ROBIS (Risk of Bias in Systematic Reviews) tool was used to assess the risk of bias for each study. The tool assessed eligibility criteria, identification and selection of studies, data collection and study appraisal, and synthesis and findings. One reviewer (LH) assessed the risk of bias for all studies. A random sample (50%) of the studies was assessed independently by a second reviewer (MM or FLW). A second reviewer checked the remaining 50% of the studies for correctness (MM or ES). Discrepancies in the quality assessment were reconciled by consensus or involving a third senior member of the team.

Data synthesis

The evidence was summarised as a narrative synthesis according to intervention type, screening programme and strength of evidence to facilitate comparisons between the different interventions and screening programmes. (For summary tables of the studies included in this review, see Table 6.) The full data extraction tables are available in Appendix 3 with full references.

TABLE 6

TABLE 6

Summary of the studies included in the review

Results

In total, 5286 records were identified through the database searches. After removing 2207 duplicates, 3133 records were left for the title and abstract screening. During that process, 2955 records were excluded, leaving 178 records for full-text review. We included a total of 61 reviews in this umbrella literature review. Of these 61 reviews, 38 included more than two interventions or screening programmes (detailing 180 outcomes).

The main interventions identified included patient education, patient invitations and reminders, provider interventions, reducing out-of-pocket client costs, reducing structural barriers and multiple interventions. Definitions are provided in Table 5.

TABLE 5

TABLE 5

Definitions for the interventions included in the review

Most screening programmes identified focused on breast, cervical or colorectal cancer, with a few examples of other cancers (e.g. testicular) or infectious conditions [e.g. human immunodeficiency virus (HIV)].

Most of the systematic reviews and systematic reviews with meta-analyses included were reviewing RCTs, quasi-experimental and observational designs. In general, the individual reviews were at high risk of bias. The outcomes reported included screening uptake, participation, adherence and utilisation, test utilisation and some looked at guidelines’ adherence and compliance. A summary of the main findings is provided in Table 6.

Patient invitations

Thirteen studies46,52–63 investigated the effect of patient invitations, with two studies46,56 reporting outcomes on more than one screening programme separately (n = 17).

Breast cancer

Five reviews46,56,59,61,63 assessed the effect of different types of patient invitations on breast cancer screening uptake. All five reviews found patient invitations to be effective (one systematic review and meta-analysis,56, one meta-analysis59 and three systematic reviews46,61,63). Effective patient invitations included a letter of invitation or telephone call or both. The combination was the most effective intervention. Furthermore, adding appointments to invitation letters further increased uptake. One meta-analysis,59 deemed to have a low risk of bias, found a smaller intervention effect in underutilising populations than in the general population.

Cervical cancer

All reviews46,55–57,60 (three systematic reviews and meta-analyses,55–57 and two systematic reviews46,60) found invitation letters to be effective in increasing cervical cancer screening. Furthermore, open invitation letters, appointments on invitation letters, telephone invitations and personal invitations were also found to be effective. Invitation letters with a reminder telephone call were reported as the most effective intervention.

Colorectal cancer

Participation was increased by all invitation methods, including postal and telephone reminders, scheduled appointments on invitation letters, the addition of a kit to the invitation letter and GP involvement in two systematic reviews and meta-analyses.56,58 Two further systematic reviews46,52 showed some positive impact of advance notification letters.

Multiple screening programmes

One systematic review,62 rated as having a low risk of bias, reported that invitation letters were more effective in cervical cancer screening than in breast cancer screening. One systematic review and meta-analysis,53 rated as having a high risk of bias, found that patient invitation was effective in increasing screening uptake.

Cardiovascular disease risk factor screening

Only one systematic review and meta-analysis,54 rated as having a high risk of bias, was included. This study54 suggested that patient invitations were not effective in increasing CVD risk factor screening.

Conclusions

Overall, there is strong evidence that patient invitations are effective in increasing screening uptake for breast, cervical and colorectal cancer. The combination of invitation letters plus a telephone reminder was even more effective. Evidence on the equity impact was limited and merits further research.

Patient reminders

Fourteen reviews52,62–74 were identified. Two systematic reviews67,69 presented outcomes for two screening programmes separately (n = 17).

Breast cancer

One systematic review and meta-analysis,71 one meta-analysis74 and one systematic review62 all found some evidence of the effectiveness of patient reminders. One systematic review,69 rated as having a high risk of bias, reported strong evidence of effectiveness. Finally, another systematic review67 investigated the effect of reminder letters on non-responders and reported consistent findings of increased uptake.

Cervical cancer

One meta-analysis,73 rated as having a high risk of bias, suggested significant effectiveness of reminder letters. They also found that those in lower socioeconomic groups had a lower uptake than those using mixed populations. A systematic review,66 rated as having a low risk of bias, and two systematic reviews,68,69 rated as having a high risk of bias,68,69 also found favourable results among lower socioeconomic groups.

Colorectal cancer

Five reviews52,64,65,67,69 were included, all of which were rated as having a low risk of bias, apart from Sabatino et al.69 One systematic review and meta-analysis65 and one systematic review64 showed modest improvements in screening rates. Larger effects were seen among interventions with a telephone component (alone or in combination with a letter) (one systematic review and meta-analysis65 and two systematic reviews52,69).

Multiple screening programmes

Patient reminders appear to be effective in increasing breast, cervical and colorectal cancer based on one meta-analysis72 and one systematic review,70 both of which were rated as having a high risk of bias. Using text reminders appeared to have a moderate effect only.67

Conclusions

Patient reminders were effective in increasing the uptake of breast, cervical and colorectal cancer screening. Patient reminders also seemed to increase uptake in non-responders for breast cancer screening. More research is needed, particularly to determine the effects on equity.

Reducing structural barriers

Reducing structural barriers for patients included five different types of interventions: (1) access-enhancing interventions, (2) mailing kits, (3) organisational change and procedures, (4) using dedicated personnel and (5) tailoring the interventions for individuals.

Access-enhancing interventions

Seven reviews63,69,70,75–78 were identified that included access-enhancing interventions, of which one systematic review69 presented outcomes for breast, cervical and colorectal cancer screening separately (n = 9).

Breast cancer

Both meta-analyses,76,78 rated as having a low and high risk of bias, respectively, found that access-enhancing interventions had the largest effectiveness compared with individual-directed interventions, community education and mass media. One of the interventions targeted ethnic minority women. One systematic review,63 rated as having a high risk of bias, found no sufficient evidence, whereas another systematic review,69 also rated as having a high risk of bias, found strong evidence of effectiveness. Some evidence of effectiveness was found on mobile onsite mammography screening in certain Asian ethnic women in a systematic review,75 which was rated as having a high risk of bias.

Cervical cancer

Mixed results were found in one meta-analysis,77 rated as having a low risk of bias, which reported that access-enhancing interventions were more effective in increasing cervical cancer screening in ethnic minority women than other interventions. However, another systematic review,69 rated as having a high risk of bias, found insufficient evidence to determine the effectiveness on cervical cancer screening uptake because of the small number of studies.

Colorectal cancer

Only one systematic review,69 rated as having a high risk of bias, was identified. Strong evidence was found for the effectiveness of access-enhancing interventions on colorectal cancer screening.

Multiple screening programmes

Only one systematic review70 included the effect of access-enhancing interventions on breast, cervical and colorectal screening combined. The review70 concluded that this intervention appears effective, but its role in cervical and colorectal cancer screening is less established.

Conclusions

Strong evidence was found that access-enhancing interventions increased breast cancer screening. Two meta-analyses76,78 even suggested that these interventions were more effective than other interventions (e.g. education, reminders, letters and mass media). Some evidence was found for effect on cervical and colorectal cancer; however, the number of reviews was limited and their role was less established. More research is needed to determine the effectiveness for cervical and colorectal cancer. Furthermore, some evidence suggested that these interventions may be effective in ethnic minority women for breast and cervical cancer. However, more research is needed to confirm this effect.

Mailed kits

For cervical and colorectal cancer, part of the screening programme can include sending out ‘do-it-yourself’ kits, as opposed to visiting a health-care professional to complete the screening.

Breast cancer

Not applicable.

Cervical cancer

Three systematic reviews and meta-analyses,55,56,79 one rated as having a low risk of bias and two rated as having a high risk of bias, and one systematic review66 rated as having a high risk of bias, all showed an increase in cervical screening rates after mailing kits to patients homes, including in underscreened women and non-responders.55,56

Colorectal cancer

Three studies52,64,65 were rated as having a low risk of bias and one study80 was rated as having a low/unclear risk of bias. All four studies52,64,65,80 found an increase in colorectal cancer screening after mailing screening kits compared with controls. A similar effect was seen in underserved and minority populations.

Conclusions

Mailing kits to increase cervical cancer screening seems to be consistently effective in women invited for screening, underscreened women and non-responders. Similarly, mailing kits increased the uptake of colorectal cancer screening, with a potentially similar effect for underserved/minority populations.

Organisational change and procedures

Three reviews,53,72,81 all rated as having a high risk of bias, evaluated the effect of organisational change and procedures.

Breast cancer

One meta-analysis81 found a modest effect of the reorganisation of the clinic and using nurse-based interventions.

Cervical cancer

No studies identified.

Colorectal cancer

No studies identified.

Multiple screening programmes

One meta-analysis72 investigated the effect of organisational change to improve screening attendance for breast, cervical and colorectal cancer screening. Organisational change is most likely to improve cancer screening behaviour, compared with financial patient incentives, patient reminders, patient education and provider assessment and feedback, and it was the most potent intervention. A further systematic review and meta-analysis53 found clinical practice improvements to be effective in improving men’s screening uptake.

Conclusions

Organisational change may improve breast, cervical and colorectal screening. However, this reflects just three reviews,53,72,81 each rated as having a high risk of bias. More research is needed.

Using dedicated personnel
Breast cancer

No studies identified.

Cervical cancer

No studies identified.

Colorectal cancer

No studies identified.

Cardiovascular disease risk factor screening

One systematic review and meta-analysis54 found that using dedicated personnel significantly increased the uptake of CVD risk factor screening compared with the control groups.

Conclusions

The effect of using dedicated personnel to increase screening uptake remains unproven. Only one review54 of CVD risk factor screening was identified, with none on breast, cervical or colorectal cancer. More research is needed.

Interventions tailored for individuals
Breast cancer

Mixed results were presented. One systematic review and meta-analysis82 and one systematic review,83 both rated as having high risk of bias, found a small effect on the uptake when using either simple interventions, or community education, clinical engagement and tailoring, respectively. Compared with other interventions, two meta-analyses76,78 found individual-directed interventions (e.g. counselling, letters and reminders) to be effective. One meta-analysis76 reported that the intervention effect was significant in one ethnic minority group, but not in others.

Cervical cancer

One meta-analysis,77 rated as having a low risk of bias, found individual-directed interventions (e.g. counselling, letters and reminders) to be effective; however, they were less effective when compared with access-enhancing and community education interventions. Combined intervention effects appeared significant for some ethnic minority groups, but not for others. A systematic review,84 rated as having a high risk of bias, found that individual-level interventions (e.g. education, letters and reminders) boosted uptake. In-reach interventions targeting both health-care professionals and patients seemed to moderately improve screening rates (low risk of bias).66

Conclusions

Individual-directed interventions may have the potential to be effective. Further research is needed, particularly on equity.

Patient education

Patient education interventions were categorised based on their delivery mode, either at individual or group level. Interventions delivered to individuals included decision aids, one-on-one education or counselling, home visits and personalised risk communication or tailored messaging. Interventions delivered to groups of people included community health-based workers, group education, community education, small media and mass media. Small media are smaller-sized campaigns and include videos or printed materials (e.g. flyers, letters, newsletters and brochures) that contain educational messages to promote screening. Mass media includes larger-scale interventions (e.g. radio, television, newspapers, magazines and billboards). Some reviews combined individual and subpopulation interventions, and these are presented separately.

Individual level: decision aids
Colorectal cancer

One systematic review and meta-analysis,85 rated as having an unclear risk of bias, was identified, which found that decision aids had a similar impact on colorectal cancer screening rates as general colorectal cancer screening information.

Prostate cancer

Three systematic reviews and meta-analyses,86–88 rated as having a high risk of bias, suggested that patients who received decision aids were less likely than controls to undergo screening. This perhaps reflected patients acquiring a better understanding of the associated uncertainties and limitations.

Conclusions

Evidence from all reviews indicated that decision aids have no impact on colorectal cancer screening rates and may even discourage uptake for prostate cancer.

Individual: one-on-one education and counselling

In total, nine reviews53,57,69–71,81,82,89,90 presented results on individual education interventions, of which one systematic review69 reported results for breast, cervical and colorectal cancer separately.

Breast cancer

All four reviews69,71,74,82 were assessed as having a high risk of bias. Two systematic reviews and meta-analyses71,82 and one meta-analysis74 suggested moderate effectiveness at best for one-on-one education in improving breast cancer screening rates. One systematic review69 suggested more robust evidence of effectiveness.

Cervical cancer

One systematic review and meta-analysis,57 rated as having a low risk of bias, and one systematic review,69 rated as having a high risk of bias, found that one-on-one education can be effective in increasing cervical cancer screening rates.

Colorectal cancer

Only one systematic review,69 rated as having a high risk of bias, was identified. It suggested sufficient evidence to support the use of one-on-one education in improving colorectal cancer screening.

Multiple screening programmes

One systematic review and meta-analysis53 and three systematic reviews,70,89,90 all rated as having a high risk of bias, reported on the effectiveness of one-on-one education for multiple screening programmes combined [including breast, cervical, colorectal, prostate, testicular and skin cancer, HIV, sexually transmitted infections (STIs) and hepatitis B virus]. Each review was slightly different in their target population and the way in which the intervention was structured. One systematic review and meta-analysis53 suggested educational interventions to be effective in men, but only when low methodological studies were excluded. Strong evidence was found for one-on-one education in Asian populations,90 but another systematic review89 found no link to ethnicity and reported inconsistent findings.

Conclusions

One-on-one education has the potential to be modestly effective for breast cancer and perhaps for cervical and colorectal cancer. However, the evidence is based on a limited number of studies. More research is needed, particularly to determine the impact on equity.

Individual: home visits

Three studies57,61,75 specified one-on-one education as home visits.

Breast cancer

Only one systematic review,61 rated as having a high risk of bias, was identified for breast cancer screening and found home visits to be ineffective.

Cervical cancer

A systematic review and meta-analysis,57 rated as having a low risk of bias, found that home visits increased uptake significantly, whereas a systematic review75 found that home visits were effective in some Asian populations, but not in others.

Conclusions

There is insufficient evidence to determine the impact of home visits on breast cancer. Home visits may be effective in increasing rates of cervical cancer screening; however, this was based on a small number of studies and more research is needed.

Individual: personalised risk communication/tailored messaging

Five reviews57,64,91–93 investigated the effect of personalised risk communication or tailored messaging on screening uptake, of which one systematic review93 presented results for breast, cervical and colorectal cancer separately (n = 7). All studies were rated as having a low risk of bias, apart from Usher-Smith et al.91

Breast cancer

One systematic review93 investigated different types of tailoring risk and found indicative findings for behavioural construct tailoring, but no effect for risk factor tailoring.

Cervical cancer

Findings from both studies57,93 suggested that tailoring messages and enhanced risk assessment were ineffective, as no differences were found between the intervention and control or comparison groups.

Colorectal cancer

Both systematic reviews64,93 found no effect on screening uptake.

Multiple screening programmes

Two systematic reviews and meta-analyses91,92 investigated the effect of personalised risk communication on more than two screening programmes (breast and colorectal cancer; breast, cervical and colorectal cancer). A study91 rated as having a low risk of bias found weak evidence of effectiveness, whereas a study91 rated as having a high risk of bias study found no effectiveness.

Conclusions

Personalised risk communication and tailored messaging do not appear to be effective for increasing the uptake of breast, cervical or colorectal screening.

Mass campaign: community-based health workers

Two systematic reviews and meta-analyses,94,95 rated as having a high risk of bias, and two systematic reviews,66,96 rated as having a low risk of bias, investigated the effect of community-based health workers.

Breast cancer

Only one systematic review and meta-analysis95 was included. The review suggested a significantly increased uptake in breast cancer screening.

Cervical cancer

Only one systematic review66 was identified. This study found that community-based health worker interventions significantly increased the uptake of screening in lower socioeconomic groups.

Colorectal cancer

One systematic review96 evaluated the use of community-based health worker interventions among Latino men. The review reported increased colorectal cancer screening uptake.

Multiple screening programmes

One systematic review and meta-analysis,94 rated as having a high risk of bias, combined findings for breast, cervical and colorectal cancer, and suggested a higher uptake after using community-based health workers and a larger effect in previously non-adherent patients.

Conclusions

Community-based health workers appear to be effective in increasing screening uptake for breast, cervical and colorectal cancer.

Mass campaign: group education

Eight reviews69,76–78,84,89,97,98 included group education, of which one systematic review69 presented results for breast, cervical and colorectal cancer separately (n = 10).

Breast cancer

Five studies69,76,78,97,98 focused on breast cancer and mixed findings were found for the effectiveness of group education. Both meta-analyses,76,78 rated as having a low risk of bias and high risk of bias, respectively, reported modest effect at best. One systematic review,69 rated as having a high risk of bias, reported sufficient evidence for the effectiveness of group education, whereas limited effects were reported by another systematic review97 that was rated as having a high risk of bias. One systematic review,98 rated as having a low risk of bias, investigated the effect of group education in Turkish women and found some effectiveness.

Cervical cancer

The effectiveness of group education on cervical cancer screening rates generated mixed findings in a meta-analysis,77 which was rated as having a low risk of bias, and in a systematic review,69 which was rated as having a high risk of bias. One systematic review,84 rated as having a high risk of bias, found more favourable outcomes.

Colorectal cancer

Only one systematic review,69 rated as having a high risk of bias, focused on colorectal cancer and found limited effect based on a small number of studies.

Multiple screening programmes

One systematic review,89 rated as having a high risk of bias, included breast, cervical, colorectal and prostate cancer, and hepatitis B virus screening programmes. The review89 suggested that most studies increased screening uptake in minority groups.

Conclusions

The effectiveness of group education on cancer screening uptake produced mixed and modest findings for breast cancer and cervical cancer. Insufficient evidence was available for colorectal cancer screening. Further research is needed.

Mass campaign: mass media

Seven studies60,69,76–78,89,99 investigated the effect of mass media on screening uptake.

Breast cancer

Two meta-analyses,76,78 one rated as having a low risk of bias76 and one rated as having a high risk of bias,78 reported limited effectiveness of mass media on breast cancer screening.

Cervical cancer

Limited effectiveness was found for using mass media to increase cervical cancer screening based on one meta-analysis77 and two systematic reviews.60,99

Colorectal cancer

No review was identified that focused solely on colorectal cancer.

Multiple screening programmes

Two systematic reviews69,89 considered the effect of mass media on multiple screening programmes (breast, cervical, colorectal and prostate cancer, and hepatitis B virus). Both reviews69,89 were rated as having a high risk of bias. Sabatino et al.69 reported insufficient evidence to determine effectiveness. Conversely, Kelly et al.89 reported apparent effectiveness in ethnic minority groups.

Conclusions

Mass media to increase uptake has limited effectiveness in breast and cervical cancer screening. No evidence was identified for its effect on colorectal cancer screening. More research is needed, particularly to determine equity impact.

Mass campaign: small media

Seven reviews52,57,61,70,90,96,99 focused on the effect of small media, of which one systematic review99 reported outcomes for breast, cervical and colorectal cancer separately.

Breast cancer

Two systematic reviews,61,99 rated as having a high risk of bias, suggested favourable effectiveness of small media on breast cancer screening uptake.

Cervical cancer

One systematic review and meta-analysis,57 rated as having a low risk of bias, reported mixed findings for using small media to highlight educational materials to increase cervical cancer screening. A systematic review,69 rated as having a high risk of bias, suggested a positive effect on screening.

Colorectal screening

Mixed findings were reported for systematic reviews,52,96 both of which were rated as having a low risk of bias. One review52 found no effectiveness, whereas the other review96 found mixed and inconsistent results. Conversely, a systematic review69 that was rated as having a high risk of bias found a positive effect of small media on colorectal cancer screening.

Multiple screening programmes

Two systematic reviews,70,90 rated as having a high risk of bias, reviewed multiple screening programmes (breast, cervical and colorectal cancer), with one70 suggesting that small media appeared to be effective in all three cancers. The other review90 suggested that small media might also be effective in Asian communities.

Conclusions

Modest effectiveness of small media was reported for breast cancer, and perhaps for cervical cancer. Results for colorectal cancer were mixed. More research is needed, especially examining equity.

Individual and mass campaign combined

Eleven reviews65,72,75,79,90,97,100–104 addressed the combination of two or more individual and mass campaign interventions. One meta-analysis72 and one systematic review102 focused on more than one screening programme (n = 14). All reviews were rated as having a high risk of bias, apart from one study by Dougherty et al.65

Breast cancer

One systematic review and meta-analysis,100 one meta-analysis72 and one systematic review97 all combined individual with mass campaign interventions (individual plus group education; individual education plus mass media; and education, message framing plus telephone calls, respectively). All studies indicated a low to moderate effect. The systematic review and meta-analysis found that Hispanic people had lower uptake levels than non-Hispanic white people. The use of culturally sensitive strategies produced inconsistent results.102

Cervical cancer

One systematic review and meta-analysis,79 one meta-analysis72 and two systematic reviews75,101 suggested some effectiveness of combining mass media or small media with either individual or group education. Education and mass media did not seem effective among Latino populations.103 Consistent results were reported for using culturally sensitive strategies.102

Colorectal cancer

One systematic review and meta-analysis,65 one meta-analysis72 and one systematic review104 found some evidence to indicate the effectiveness of combining individual with mass campaign interventions.

Multiple screening programmes

One systematic review suggested that lay health workers and mass education campaigns could be successful in some Asian populations.90

Conclusions

Combining individual and mass campaign educational interventions achieved low to moderate effectiveness for increasing the uptake of breast, cervical and colorectal cancer screening. More research on equity is needed.

Provider interventions

Several interventions were targeted at providers and included reminders, education and incentives. Each will be presented separately below.

Provider reminders

Nine reviews were included.46,54,64,65,81,89,99,105,106 One systematic review106 presented outcomes for multiple screening programmes (n = 11).

Breast cancer

Both a meta-analysis81 and a systematic review,106 each rated as having a high risk of bias, suggested increases in uptake after provider reminders.

Cervical cancer

One systematic review,106 rated as having a high risk of bias, suggested that provider reminders modestly increased cervical screening rates.

Colorectal cancer

All four reviews (i.e. two systematic reviews and meta-analyses65,105 and two systematic reviews64,106) found provider reminders to be effective in increasing colorectal cancer screening rates.

Multiple screening programmes

Three systematic reviews, all rated as having a high risk of bias, combined the effect of provider reminders on multiple screening outcomes (breast, cervical, colorectal and prostate cancer, Hepatitis B) and all were in favourable directions.46,89,106 One focused on minority groups and found significant increases in uptake.89

Cardiovascular disease risk factor screening

Provider reminders were stated to be effective in both pessimistic and optimistic scenarios in one meta-analysis and systematic review,54 which was rated as having a high risk of bias.

Conclusions

Provider reminder interventions seem to be effective in increasing breast, cervical and colorectal screening rates. Providers have the potential to increase uptake in minority groups, although the number of studies included was small and further research is needed to determine the impact on equity.

Education of health-care professionals
Breast cancer

No studies were identified.

Cervical cancer

No studies were identified.

Colorectal cancer

Only one systematic review and meta-analysis,65 rated as having a low risk of bias, found that clinician education improved screening uptake.

Multiple screening programmes

One systematic review and meta-analysis,53 rated as having a high risk of bias, focused on improving screening rates in men (e.g. prostate cancer, HIV, STIs, melanoma) and reported some effectiveness of health-care professional training in increasing men’s uptake compared with usual care.

Conclusions

No evidence was identified for breast and cervical cancer. Health-care professional training appeared to increase the uptake of colorectal cancer screening and health screening for men (prostate, HIV, STIs, melanoma). However, both reviews included only a small number of studies and were rated as having a high risk of bias. Further evidence is therefore needed.

Provider assessment and feedback

Four reviews69,70,72,81 were included, all of which were rated as having a high risk of bias. One systematic review69 provided outcomes for several screening programmes (n = 7).

Breast cancer

One meta-analysis81 and one systematic review69 both indicated sufficient evidence that provider assessment and feedback increased uptake of breast cancer screening.

Cervical cancer

One systematic review69 suggested effectiveness.

Colorectal cancer

One systematic review69 was included and offered evidence of effectiveness.

Multiple screening programmes

Three studies combined the effect of provider assessment and feedback on multiple screening programmes (i.e. breast, cervical and colorectal cancer). One meta-analysis72 found some effectiveness of provider feedback. However, this intervention was considered to be the least effective intervention when compared with other interventions, such as organisational change, patient reminders and patient education. The other two systematic reviews69,70 also reported sufficient evidence that this is an effective intervention.

Conclusions

Provider assessment and feedback interventions usually increase uptake of breast, cervical and colorectal cancer screening.

Incentives for providers
Breast cancer

No studies identified.

Cervical cancer

No studies identified.

Colorectal cancer

No studies identified.

Multiple screening programmes

Only one systematic review69 looked at the effect of provider interventions on breast, cervical and colorectal cancer screening. Insufficient evidence was found for each of the screening programmes because of the generally small and inconsistent results.

Conclusions

More evidence is needed to determine the effectiveness of provider incentives on breast, cervical and colorectal cancer screening uptake.

Combination of two or more provider interventions
Breast cancer

No studies were identified that reported multiple provider interventions.

Cervical cancer

No studies identified.

Colorectal cancer

Only one systematic review,52 rated as having a low risk of bias, investigated the effect of multiple provider interventions (e.g. GP involvement through reminders, letters and education) on the uptake of colorectal cancer screening. The review suggested limited effectiveness, reporting inconsistent findings and a small number of studies overall.

Conclusions

More research on multiple provider interventions is needed.

Reducing out-of-pocket client costs and other financial incentives

Four studies54,65,69,72 were identified in this domain, with one systematic review69 reporting on outcomes for breast, cervical and colorectal cancer separately (n = 6). All studies were rated as having a high risk of bias, apart from Dougherty et al.65

Breast cancer

Only one systematic review69 found sufficient evidence for reducing out-of-pocket client costs, but it found insufficient evidence for client incentives.

Cervical cancer

One systematic review69 found insufficient evidence for both reducing out-of-pocket client costs and client incentives.

Colorectal cancer

One systematic review and meta-analysis,65 rated as having a low risk of bias, found that providing small financial incentives (US$5) slightly increased uptake. However, this effect did not occur with the financial incentive of US$10 and pooling both groups found no effectiveness. An earlier systematic review69 had failed to identify any studies.

Multiple screening programmes

One meta-analysis72 suggested that financial incentives for breast, cervical and colorectal cancer screening after an organisational change was effective.

Cardiovascular disease risk factor screening

One systematic review and meta-analysis54 reported that financial incentives significantly increased the uptake of CVD risk factor screening.

Conclusions

Financial incentives may increase the uptake of cancer screening and CVD risk factor screening; however, more research is needed.

Multiple component interventions

This section is divided into two subcategories. A distinction is made between the use of two or more interventions combined and studies combining the effect of several distinct single interventions.

Interventions with two or more components

Eighteen reviews54,60,61,65,66,74,78,79,81,82,89,90,104,107–111 investigated the effect of multiple component interventions and a wide variety of intervention combinations were evaluated. One review108 reported on outcomes for multiple screening programmes separately (n = 21).

Breast cancer

Nine reviews were identified.61,74,78,81,82,103,107–109 Mixed results were found for breast cancer screening rates, with some reviews indicating no to low effectiveness (one systematic review and meta-analysis,103 one meta-analysis74 and one systematic review61) and others reporting modest to high effectiveness (two systematic review and meta-analyses,82,107 two meta-analyses78,81 and one systematic review108). One systematic review109 reported the effect of multiple interventions being larger than that of single interventions.

Cervical cancer

Four reviews60,66,79,108 were included and all were rated as having a low risk of bias, apart from Musa et al.79 A mix of interventions was evaluated (i.e. provider recommendations, in-reach and out-reach interventions with community education, mass media combined with invitation letters and/or education and education with reducing structural barriers or out-of-pocket client costs). Two systematic reviews60,108 found that multiple interventions were effective in increasing cervical cancer screening rates. The other systematic review and meta-analysis66 and systematic review79 found a modest positive effect.

Colorectal cancer

One systematic review and meta-analysis,65 rated as having a low risk of bias, reported that multiple interventions were associated with larger increases in colorectal cancer screening rates (vs. single interventions). A systematic review108 that was rated as having a low risk of bias found mixed results, with some effectiveness of education, reducing structural barriers and out-of-pocket client costs. One systematic review104 that was rated as having a high risk of bias found mixed findings depending on the interventions identified. Patient mailings and telephone outreach were found to be effective, whereas multimedia interventions were not.104

Multiple screening programmes

Four systematic reviews89,90,108,110 investigated the effectiveness of multiple interventions on breast, cervical, lung, prostate and colorectal cancer, and hepatitis B virus. All four systematic reviews89,90,108,110 reported some effectiveness of multicomponent interventions (e.g. education, small media and reminders; and special events reducing structural barriers, group and individual education, small media and reducing out-of-pocket client costs). For Asian groups, a range of interventions was identified to be effective, including the use of social networks, lay health workers, media education, community-based education, reminder notices, health-care provider assistance and health system changes.90

Cardiovascular disease risk factor screening

Only one systematic review and meta-analysis54 was identified. The systematic review and meta-analysis54 investigated the effectiveness of both provider and patient interventions and reported a low to moderate level of effectiveness, depending on the pessimistic or optimistic scenario, respectively.

Conclusions

Despite the heterogeneity in the multiple interventions used, modest to high effectiveness was found for increasing breast, cervical and colorectal cancer screening uptake. Furthermore, some reviews60,109 reported that multiple interventions were more effective than single interventions. The impact on equity has not been adequately investigated and merits further study.

Single interventions combined
Breast cancer

Mixed results were presented and were rated as having a high risk of bias. One systematic review and meta-analysis82 and one systematic review83 found a small effect on uptake when using simple interventions or community education, clinical engagement and tailoring, respectively. Two meta-analyses76,78 found individual-directed interventions (e.g. counselling, letters and reminders) to be effective compared with other interventions, with one meta-analysis76 reporting that the intervention effect was significant in one ethnic minority group, but not in others.

Cervical cancer

A meta-analysis77 that was rated as having a high risk of bias found individual-directed interventions (e.g. counselling, letters and reminders) to be effective. However, the interventions were less effective when compared with access-enhancing and community education interventions. Combined intervention effects appeared significant for some ethnic minority groups, but not for others. Another systematic review84 that was rated as having a high risk of bias found that individual-level interventions (e.g. education, letters and reminders) boosted uptake. In-reach interventions targeting both health-care professionals and patients seemed to moderately improve screening rates (low risk of bias).66

Conclusion

Most interventions were heterogenous and therefore it was difficult to draw conclusions. Individual-directed interventions may have the potential to be effective. Further research is needed to determine the impact on equity.

Discussion

Summary of findings

This umbrella literature review identified 61 systematic reviews of interventions intended to increase the uptake of screening programmes. Almost all of the screening programmes that were identified focused on one of just three diseases – breast, cervical or colorectal cancer – and very few addressed screenings for high levels of cardiovascular risk factors.

The main targets spanned a spectrum from individuals and groups to communities, organisations or entire populations.

The potential interventions were numerous and diverse. Patient-focused interventions included education, media campaigns, invitations, reminders, mailed self-test kits, home visits, enhanced access or reduced costs. Provider-focused interventions included reminders, incentives, professional training, dedicated personnel, assessment and feedback, plus organisational changes to address structural barriers. Crucially, many involved multiple interventions targeted at multiple targets.

Surprisingly, few authors appeared to recognise that they were addressing complex, adaptive systems. In a review of the evidence, the Health Foundation advocate a complex adaptive systems approach in health care.112 They suggest that doing so can challenge assumptions, focus on relationships rather than simple cause and effect models, provide a framework for categorising and analysing knowledge and agents, suggest new possibilities for change and provide a better picture of influences affecting change. The review also provides evidence of how patients can be understood as complex adaptive systems. By understanding the non-linear dynamics of internal and external features, patients can improve how health is defined; enhance professionals’ understanding of patients, disease and the systems in which they meet; help to develop future monitoring systems; and be used to support change.113

The evidence on uptake effectiveness was often patchy and inadequate, and often rated as having a high risk of bias. The summary below is therefore tentative.

interventions considered in isolation

The most effective interventions considered in isolation were as follows:

  • There was strong and consistent evidence that patient invitations alone or reminders alone consistently increased screening uptake for breast, cervical and colorectal cancer. The combination of invitation letters plus a telephone reminder was even more effective.
  • Mailing kits to patients enhanced uptake for cervical and colorectal cancer screening.
  • Access-enhancing interventions increased screening in breast cancer.
  • Community-based health workers delivering patient education was effective in increasing screening uptake for breast, cervical and colorectal cancers.

Multiple interventions in combination

Multiple interventions involving very diverse combinations consistently appeared effective in increasing breast, cervical and colorectal cancer screening uptake. Furthermore, some reviews were able to make direct comparisons and report that multiple interventions were more effective than single interventions.

The ineffective interventions considered in isolation included:

  • decision aids and personalised risk communication/tailored messaging interventions.

Interventions with modest effectiveness included:

  • one-to-one patient education and counselling
  • group education
  • mass media and small media campaigns alone
  • media campaigns combined with individual education
  • financial incentives for patients.

Effective provider interventions included:

  • reminders to providers
  • provider assessment and feedback
  • training of health-care professionals.

The effectiveness evidence on several other interventions (i.e. individual home visits, provider incentives, using dedicated personnel, and organisational change and procedures) was inconclusive and requires further research.

Findings in the context of other literature

This review indicates the complexity of the evidence regarding interventions to encourage and increase the uptake of a specific screening programme. Interventions at the individual, health-care provider and the health-care system level all demonstrate varying degrees of success in different populations.

Interventions are used to promote uptake and optimal use of health-care services, including screening programmes. As demonstrated here, there are examples of successful interventions, those that have the potential to succeed and those that, although anticipated to be effective, did not prove successful.

Our review is very timely. The October 2019 Review of National Cancer Screening Programmes in England48 recently set out key recommendations for increasing the uptake and coverage of screening programmes. The review emphasised a high priority for spreading the implementation of evidence-based initiatives to increase uptake.48 The review recommends an integrated system approach, including (1) implementing text message reminders for all screening programmes; (2) further pilots of social media campaigns, with formal evaluation and rollout if successful; (3) spreading good practice on physical and learning disabilities; (4) encouraging links with faith leaders, community groups and relevant voluntary, community and social enterprise organisations that work with the NHS at national, regional and local levels to reduce health inequalities and advance equality of opportunity; (5) increasing awareness of trans and gender-diverse issues among screening health professionals; and (6) consideration of financial incentives for providers to promote out-of-hours and weekend appointments.

Inequalities

Many studies have consistently reported lower uptake rates in disadvantaged individuals, groups and communities. However, our review found a striking lack of equity research comparing the differential response to an intervention intended to increase screening uptake. Some US studies76,77,89 did focus on equity in minority populations, but with no comparison population. Further research is required into the equitable uptake of screening programmes.

Research of interventions to increase the uptake of CVD screening programmes is also scarce and, likewise, necessitates further research.

The NHS England report48 also highlighted a current lack of equity in the uptake of NHS screening programmes. This was previously demonstrated by a review by Javanparast et al.114 The review focused on the equity of participation in colorectal cancer screening among different population subgroups. The authors found that the provision of a single screening guideline for all groups within the population did not support equitable access, and individuals and some population subgroups may face a range of barriers hindering their actual utilisation of services. Interventions that resulted in improved participation rates included those that increased knowledge and influenced attitudes, engaged providers, and improved tracking, communication and support systems.

Might some interventions increase uptake more in affluent groups and therefore widen inequalities,115,116 for instance the recommendation to implement text message reminders by NHS England?48 This issue has been discussed by Asaria et al.,117 who suggest a new methodological framework for undertaking distributional cost-effectiveness analysis to combine the objectives of maximising health and minimising unfair variation in health when evaluating population health interventions. The authors take the NHS bowel cancer screening programme as a case example, which was expected to improve population health, but had worsened population health inequalities associated with deprivation and ethnicity. The authors demonstrated the distributional cost-effectiveness analysis framework by examining two redesign options for the bowel cancer screening programme: (1) the introduction of an enhanced targeted reminder aimed at increasing screening uptake in deprived and ethnically diverse neighbourhoods and (2) the introduction of a basic universal reminder aimed at increasing screening uptake across the whole population. Asaria et al.117 found that the universal reminder maximised population health, whereas the targeted reminder screening strategy minimised unfair variation in health. The framework can be used to demonstrate how the two objectives can be traded off against each other, and how alternative social value judgements can influence the assessment of which strategy is best, including judgements about which dimensions of health variation are considered unfair and societal levels of inequality aversion.

Behaviour change and nudge

We found that multiple interventions involving very diverse combinations consistently appeared effective in increasing cancer screening uptake. Furthermore, some reviews reported that multiple interventions appeared more effective than single interventions, consistent with current thinking regarding the need for multiple interventions that target key nodes within a complex system.118

Behavioural approaches have therefore been highlighted to potentially help improve the translation of research into practice and enable the identification of interventions with maximum impact. Michie et al.119 developed a framework called the ‘behaviour change wheel’. Elements of the behaviour change wheel provide a potential framework for the development of interventions to increase uptake and effectiveness of screening programmes at the health-care system, health-care provider and individual levels.

At the centre of Michie et al.’s framework is a ‘behaviour system’ that involves three essential conditions: (1) capability, (2) opportunity and (3) motivation. This system forms the hub of the wheel, around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions: (1) education, (2) persuasion, (3) incentivisation, (4) coercion, (5) training, (6) enablement, (7) modelling, (8) environmental restructuring and (9) restrictions. Around this are placed seven categories of policy that could enable those interventions to occur: (1) communication/marketing, (2) legislation, (3) service provision, (4) regulation, (5) fiscal measures, (6) guidelines and (7) environmental/social planning.

Perry et al.120 reviewed nudge-type interventions that have potential for changing behaviours in the broader context of increasing efficiency and reducing waste in health care. Perry et al.120 suggest several approaches with potential, including framing health messages according to specific characteristics of a target audience; better information design, both in terms of text and language; framing and planning to enhance reminder content; financial micro-incentives; audit and feedback; and planning interventions, including ‘planning prompts’, action plans and implementation intentions.

Similar to our findings of the range of interventions with various degrees of effectiveness, the authors120 conclude that developing effective behaviour change interventions likely benefits from theory-based behavioural analysis, an appreciation of context, and structured selection of possible interventions, with consideration of acceptability and equity. However, what makes for effective combinations of nudge-type interventions remains mostly unexplored.

Strengths

The literature on interventions on improving screening programmes is extensive, complex and challenging. However, our umbrella literature review managed to identify and analyse 61 relevant reviews successfully. To our knowledge, this is the first comprehensive review of the evidence on invitation methods to improve uptake of screening programmes. It is particularly strong on interventions targeting breast, cervical and colorectal cancer screening programmes, and offers potentially valuable principles cautiously generalisable to CVD risk factor screening.

Limitations

This umbrella review has several limitations. First, we took the main message from the 61 reviews as published. We, therefore, did not go back to extract information related to individual studies. For some reviews, only one study was found for a specific intervention and we excluded this information in the summary tables and results section of this review. However, this more detailed information is available and is presented in the data extraction tables in Appendix 3. Second, we were unable to conduct a meta-analysis because the data were strikingly heterogeneous. Future researchers might wish to conduct a meta-analysis on a subgroup of interest. Third, we excluded two intervention areas during the pilot phase: (1) patient navigation interventions and (2) shared decision-making interventions. However, both were considered to fall outside our focus. Fourth, the evidence on interventions to increase the uptake of CVD screening was particularly patchy and poor. However, one might cautiously extrapolate some general principles from the ‘best-buy’ options that generally increased the uptake of three very different cancer screening programmes. Fifth, we did not consider economic analyses. However, substantial work might merit a separate review.

Conclusions

Strategies to improve the uptake of screening programmes have the potential to be effective. However, there are many components within these complex systems, at the individual, health-care professional or health-care system levels, that can influence the uptake of screening programmes. Single interventions may appear both plausible and attractive. However, within each screening programme, it is very likely that practitioners will need to implement multiple interventions to improve uptake maximally and therefore generate the most significant health gain.

Implications for the workHORSE model and tool

Our umbrella review is one approach that users can employ to interrogate the evidence base to design scenarios to use with the model. For parametrisation purposes, more detailed systematic reviews with meta-analysis may be required.

As a result of this umbrella review, we encourage users of the workHORSE tool to consider the costs of those methods of delivery that were found to be most effective and how these methods might enhance uptake for the NHS HCP. For example, users may model the impact of increasing text reminders or of having community outreach workers who would educate people on the benefits of participating in the NHS HCP. Furthermore, it is important to assess the studies’ outcomes to ensure that they match the model parameters used to set up scenarios (see Chapter 4, The graphical user interface).

Image 16-165-01-fig22
Copyright © Queen’s Printer and Controller of HMSO 2021. This work was produced by Flaherty et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Bookshelf ID: NBK570881
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