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Health Technol Assess. 2016 Sep;20(68):1-138. doi: 10.3310/hta20680.

A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC).

Author information

1
Institute of Cancer Sciences, University of Manchester, St Mary's Hospital, Manchester, UK.
2
Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK.
3
National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
4
Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
5
Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, UK.
6
Department of Health Sciences, University of York, York, UK.
7
Virology Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.

Abstract

BACKGROUND:

Falling participation by young women in cervical screening has been observed at a time that has seen an increase in the incidence of cervical cancer in the UK in women aged < 35 years. Various barriers to screening have been documented, including fear, embarrassment and inconvenience.

OBJECTIVES:

To measure the feasibility, clinical effectiveness and cost-effectiveness of a range of interventions to increase the uptake of cervical screening among young women.

DESIGN:

A cluster randomised trial based on general practices performed in two phases.

SETTING:

Primary care in Greater Manchester and the Grampian region in Scotland.

PARTICIPANTS:

Phase 1: 20,879 women receiving their first invitation for cervical screening. Phase 2: 10,126 women who had not attended by 6 months.

INTERVENTIONS:

Phase 1: pre-invitation leaflet or not, and access to online booking (Manchester only). Phase 2: (1) vaginal self-sampling kits (SSKs) sent unrequested (n = 1141); or (2) offered on request (n = 1290); (3) provided with a timed appointment (n = 1629); (4) offered access to a nurse navigator (NN) (n = 1007); or (5) offered a choice between a NN or a SSK (n = 1277); and 3782 women in control practices.

MAIN OUTCOME MEASURES:

Uplift in screening compared with control practices, cost-effectiveness of interventions, and the women's preferences explored in a discrete choice experiment.

RESULTS:

The pre-invitation leaflet and offer of online booking were ineffective when compared with control practices at 3 months, 18.8% versus 19.2% [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.88 to 1.06; p = 0.485] and 17.8% versus 17.2% (OR 1.02, 95% CI 0.87 to 1.20; p = 0.802), respectively. The uptake of screening at 3 months was higher among previously human papillomavirus (HPV)-vaccinated women than unvaccinated women, 23.7% versus 11% (OR 2.07, 95% CI 1.69 to 2.53; p < 0.001). Among non-attenders, the SSK sent intervention showed a statistically significant increase in uptake at 12 months post invitation, 21.3% versus 16.2% (OR 1.51, 95% CI 1.20 to 1.91; p = 0.001), as did timed appointments, 19.8% versus 16.2% (OR 1.41, 95% CI 1.14 to 1.74; p = 0.001). The offer of a NN, a SSK on request, and a choice between timed appointments and NN were ineffective. Overall, there was a gradual rather than prompt response, as demonstrated by uptake among control practices. A discrete choice experiment indicated that women invited who had not yet attended valued the attributes inherent in self-sampling. The health economic analysis showed that both timed appointments and unsolicited SSK sent were likely to be cost-effective at a cost per quality-adjusted life-year (QALY) gained of £7593 and £8434, respectively, if extended across the national 25-year-old cohort throughout the duration of screening. The certainty of these being cost-effective at a ceiling ratio of £20,000 per QALY gained was > 90%.

CONCLUSION:

Women receiving their initial screening invitation frequently delay taking up the offer and the net impact of interventions was small. Timed appointments and SSKs sent to non-attenders at 6 months are likely to be a cost-effective means of increasing uptake and should be considered further. HPV vaccination in the catch-up programme was associated with an increased uptake of cervical screening. Future work should focus on optimising self-sampling in terms of age range, timing of offer for non-attenders and use of urine testing instead of vaginal samples.

TRIAL REGISTRATION:

Current Controlled Trials ISRCTN52303479.

FUNDING:

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 68. See the NIHR Journals Library website for further project information.

PMID:
27632816
PMCID:
PMC5046076
DOI:
10.3310/hta20680
[Indexed for MEDLINE]
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