Effectiveness of Mass and Small Media Campaigns to ImproveCancer Awareness and Screening Rates in Asia: A SystematicReviewSchliemann, D., Su, T. T., Paramasivam, D., Treanor, C., Dahlui, M., Loh, S. Y., & Donnelly, M. (2019).Effectiveness of Mass and Small Media Campaigns to Improve Cancer Awareness and Screening Rates in Asia:A Systematic Review. Journal of Global Oncology, 5. https://doi.org/10.1200/JGO.19.00011
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reviewarticle
Effectiveness of Mass and Small MediaCampaigns to Improve Cancer Awareness andScreening Rates in Asia: A Systematic ReviewDesiree Schliemann, PhD1; Tin Tin Su, PhD2,3; Darishiani Paramasivam, MMedSc3; Charlene Treanor, PhD1; Maznah Dahlui, PhD3;
Siew Yim Loh, PhD3; and Michael Donnelly, PhD1
abstract
PURPOSE The main objective of this systematic review was to identify whether mass and small media in-terventions improve knowledge and attitudes about cancer, cancer screening rates, and early detection ofcancer in Asia.
METHODS The review was conducted according to a predefined protocol. Medline, EMBASE, CINAHL, Web ofScience, Cochrane Library, and Google Scholar were searched in September 2017, and data extraction andrating of methodologic study quality (according to Joanna Briggs Institute rating procedures) were performedindependently by reviewers.
RESULTS Twenty-two studies (reported across 24 papers) met the inclusion criteria. Most studies (n = 21) wereconducted in high or upper-middle income countries; targeted breast (n = 11), cervical (n = 7), colorectal(n = 3), or oral (n = 2) cancer; and used small media either alone (n = 15) or in combination withmassmedia andother components (n = 5). Studies regarding cancer screening uptake were of medium to high quality andmainly reported positive outcomes for cervical cancer and mixed results for breast and colorectal cancer. Themethodologic strength of research that investigated change in cancer-related knowledge and the cost effec-tiveness of interventions, respectively, were weak and inconclusive.
CONCLUSION Evidence indicated that small media campaigns seemed to be effective in terms of increasingscreening uptake in Asia, in particular cervical cancer screening. Because of the limited number of studies inAsia, it was not possible to be certain about the effectiveness of mass media in improving screening uptake andthe effectiveness of campaigns in improving cancer-related knowledge.
J Global Oncol. © 2019 by American Society of Clinical Oncology
Licensed under the Creative Commons Attribution 4.0 License
INTRODUCTION
According to the Global Cancer Observatory (GLO-BOCAN; April 10, 2018), Asia accounts for almost onehalf of newly detected cancer cases (48.4%) andmorethan one half of cancer deaths globally (57.3%). Themost common cancers are lung, colorectal, breast,stomach, and liver cancer.1 Asia is a continent com-posed of diverse countries in terms of cultures andreligions as well as economies. Most Asian countrieshave developing economies and are classified as low-or middle-income countries (LMICs).2 The strong as-sociation between the Human Development Index andage-standardized cancer incidence is reflected in thehigh cancer incidence rates in Asia given that mostAsian countries are LMICs.3 LMICs experience highcancer mortality rates, and many deaths could beavoided through improved screening services thatwould facilitate early presentation and treatment.4
Population-based screening programs are lacking inmost Asian countries, and the often less than optimum
availability of screening facilities contributes to latedetection.4 One of the priorities of theWHO is to reducepremature mortality from noncommunicable diseasesincluding cancer by 25% by 2020.5 According to theWHO and other experts, one of the first steps towardsearly diagnosis is to raise awareness about cancersigns and symptoms and to encourage the seeking ofhelp.5 Therefore, there is a priority need for programsthat raise awareness about the warning signs andsymptoms of cancer and the benefits of early de-tection. This form of secondary prevention should beimplemented in countries in which resources forpopulation-based screening are lacking, particularlyfor cancers such as colorectal and breast cancer.6
Evaluations of mass and small media programs inWestern countries have reported promising results interms of promoting healthy behaviors,7 increasingcancer-related knowledge,8 improving screeningrates,9,10 and diagnosing cancer at an earlier stage.11
However, there is a need to identify, appraise, and
ASSOCIATEDCONTENT
Appendix
Author affiliationsand supportinformation (ifapplicable) appear atthe end of thisarticle.
Accepted on January17, 2019 andpublished atascopubs.org/journal/jgo on April 10, 2019:DOI https://doi.org/10.1200/JGO.19.00011
1
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summarize available evidence about the effectiveness ofmedia campaigns to improve health-seeking behavior forcancer-related symptoms in Asia.12 Mass media includecommunication channels such as television, radio, news-papers, billboards, posters, the Internet, and smart media(ie, smartphones, smart TVs, and tablets) intended to reachlarge numbers of people.7,13,14 Small media are generallyaimed at individuals rather than groups (eg, mailed lettersand/or other mailed information [eg. brochures and leaflets],telephone calls, e-mails, text messages [Short MessageSystem], and CDs or videos intended for individuals or smallgroup viewings).15 The aim of this systematic review was toidentify whether mass and/or small media campaigns in-creased knowledge and awareness about signs andsymptoms of cancer, improved attitudes towards cancerscreening, and increased screening attendance, self-screening, and detection rates of cancer in Asian countries.
METHODS
This systematic review was conducted according toPRISMA guidelines and the protocol was preregistered withPROSPERO.16
Search Strategy
A search strategy was developed in consultation with aninformation specialist with experience in devising electronicsearch strategies for systematic reviews. In September2017, D.S. conducted the search, according to the pre-defined search terms (Appendix Table A1) and protocol, inthe following databases: MEDLINE, Embase, CINAHL, Webof Science, PsycINFO, Scopus, Cochrane Library, Greyliterature (ie, government reports and conference ab-stracts), and Google Scholar. In addition, reference lists ofrelevant reviews and studies were hand searched, and anindividual search was conducted of relevant journals. Theabstract and full-text screening of every paper was con-ducted by two pairs of reviewers (D.S. and M. Donnelly, T.T.S.or D.P.), and any discrepancies were resolved by a thirdreviewer (M. Donnelly).
Study Selection
Publications that reported findings from campaigns usingmass media (TV, radio, Internet, mobile telephone, socialmedia, newsletters, or magazine or print advertisement), smallmedia (brochures, leaflets, newsletters, letters, or videos), orboth, were included in this systematic review if they includedone of the primary outcomes under investigation: (1) cancerawareness, (2) cancer knowledge, (3) attitudes and beliefsabout cancer, (4) self-efficacy to self-screen and/or seea doctor, (5) actual self-screening behavior, (6) clinical at-tendance because of cancer-related symptoms, (7) cancerscreening attendance, and (8) numbers of cancer cases de-tected. Secondary outcome measures under review were thecost effectiveness of campaigns and downstaging of cancer.
Inclusion criteria. Randomized and nonrandomized studies,cohort studies, quasi-experimental studies (QESs), inter-rupted time series, and pilot studies were eligible for inclusionif they met the following criteria: (1) were in a peer-reviewedpublication, (2) were written in the English language, (3) werepublished before September 2017, (4) included adults18 years of age or older, (5) were set in Asia, (6) targeted thegeneral population or a subpopulation, (7) included massand/or small media components that addressed at least oneoutcome, (8) kept individual and/or group interventioncomponents to a minimum, and (9) investigated any cancer.
Exclusion criteria. We excluded (1) interventions that weretargeted at minority Asian populations (eg, Chinese living inthe United States); (2) systematic reviews and cross-sectional studies, as well as conference abstracts andbrief communications if sufficient details could not be ob-tained; and (3) studies of patients with diagnosed cancer and/or health professionals alone (studies targeting both healthprofessionals and general populations were considered).
Data Extraction
Heterogeneity among the studies under review did not allowfor a meta-analysis to be conducted as originally planned.Instead, we systematically extracted data independentlyfrom included full-text papers into a data capture template.As with the search strategy, two pairs of reviewers (D.S. and
CONTEXT
Key ObjectiveThis research systematically reviewed studies that used mass or small media to prevent cancer in Asia.Key FindingsHigh- and middle-income Asian countries tend to focus on prevention and early detection regarding mainly breast cancer and
cervical cancer. Cervical cancer small media campaigns seem to be effective in increasing screening uptake.RelevanceResearch in low-income Asian countries is sparse due to inadequate resources. There is a need to increase empirical studies
in Asia and to advance the use of research to inform and target the efficiency of prevention efforts such as public healthmedia campaigns and plans towards reducing the significant cancer burden throughout Asia.
Schliemann et al
2 © 2019 by American Society of Clinical Oncology
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D.P., M. Dahlui, S.Y.L. or M. Donnelly) extracted data anddiscrepancies between reviewers were resolved by dis-cussion with M. Donnelly.
Methodological Quality Assessment
We applied the relevant critical appraisal tool by the JoannaBriggs Institute (JBI) to assess the quality of each includedstudy. Randomized controlled trials (RCTs) were scored on13 questions and QESs were scored on nine items. D.S.and C.T. conducted the quality review, and any dis-agreement was resolved in discussion with M. Donnelly.
RESULTS
The search generated 18,374 studies, of which 22 studies(published in 24 papers) met the eligibility criteria for in-clusion in this systematic review (Fig 1). According to theJBI study criteria, 11 of 22 studies were RCTs (published in13 papers) and 11 of 22 studies were QESs.
Study Quality
RCTs were of medium to high quality (Table 1; ie, all studiesmet seven to 1017,18 JBI criteria). Criteria that were not metrelatedmainly to blinding of participants, individuals deliveringthe intervention, and outcome assessors. In addition, somepapers were unclear about whether random assignment hadtaken place or treatment allocation had been concealed. QESs
were of mixed quality and ranged from meeting two of ninecriteria19 to nine of nine criteria20,21 (Table 2).
Study Characteristics
Study characteristics are outlined in Tables 1 and 3.
Study population. The majority of studies focused onbreast cancer,17,20,28-30,33,34,36,37,39,41 followed by cervicalcancer,20-23,31,32,35,41,42 colorectal cancer,25-27 oral cancer,38,40
and gastric cancer.27 The countries in which the studieswere conducted included Japan,20,21,26,28,41 Malaysia,22,23,40,42
Korea,27,37,39 Taiwan,17,31,32 Israel,25,36 Lebanon,19,29
Singapore,30,33 India,34 Turkey,35 and Iran38 (Fig 2).
Individual studies targeted between 45 and 75,559 par-ticipants. Studies that aimed to increase awareness aboutbreast and cervical cancer included women only, with theexception of two studies, one of which targeted the parentsof adult daughters20 and another study that targeted bothmothers and daughters.37 A study focusing on colorectaland gastric cancer targeted men only,27 and four studies(either targeting colorectal or oral cancer) included bothmen and women.25,26,38,40 The age range of includedparticipants differed among studies and the type of canceraddressed (ie, cervical cancer awareness studies generallytargeted women 20 years of age and older, breast cancerawareness studies targeted those 30 years of age and older,and some included women 50 years of age and older (with
Scre
en
ing
Elig
ibilit
yId
en
tifi
cati
on
Inclu
ded
Studies included inqualitative synthesis(n = 22 in 24 papers)
Records after duplicates removed(n = 10,676)
Abstracts screened(n = 481)
Records excluded(n = 428)
Full-text articles assessedfor eligibility
(n = 53)
Full-text articles excluded, with reasons
Study designIntervention componentsSettingOutcomeAbstract onlyStudy Population
Records identified through database searching CINAHLEmbaseMEDLINEPsycINFOScopusWeb of ScienceGrey literature & hand-searchTotal
(n = 1,647)(n = 3,646)(n = 3,644)(n = 5,296)(n = 2,768)(n = 1,373)
(n = 6)(N = 18,374)
(n = 10)
(n = 29)
(n = 10)
(n = 2)(n = 2)(n = 4)(n = 1)
FIG 1. PRISMA flowchart of study selection.
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 3
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TABLE1.
Stud
yQua
lityof
Ran
domized
Con
trolledTrialsAccording
toJB
Icriteria
FirstAu
thor
True RA
Concea
led
Alloca
tionto
TGs
Simila
rity
Between
TGsat
Baselin
eBlinding
ofPa
rticipants
Blinding
ofTh
ose
Delivering
Treatmen
tBlinding
ofOA
s
Iden
tical
Treatmen
tof
Grou
ps(oti)
Complete
Follo
w-Up
Analysis
ofPa
rticipantsin
Grou
psto
Which
They
Were
Rand
omly
Assign
ed
Same
Mea
suremen
tsforTG
sRe
liable
Mea
sures
Approp.
Statistic
s
Approp
.Trial
Design
Overall
Ratin
g
Abd
ulRashid2
2,23
+?
+?
?+
++
++
++
+10
+
Abd
ullah2
4+
++
−−
−?
+−
+−
++
7+
Hag
oel25
??
++
?+
++
−+
++
+9+
Hira
i26
??
+?
?+
++
+?
++
+8+
Hon
g27
??
??
−+
?+
++
++
+7+
Ishika
wa2
8+
?−
?+
+−
++
++
++
9+
Lakkis29
+?
??
+?
++
++
++
+9+
Lin1
7+
++
?+
?+
+?
++
++
10+
Ng3
0?
??
+?
?+
++
++
?+
7+
Hou
31,32
−−
+?
??
++
−+
++
+7+
Seow
33
+?
??
−?
+−
++
++
+7+
Abb
reviations:App
rop.,ap
prop
riate;+,yes;
−,no
;?,un
clea
r;JB
I,Joan
naBrig
gsInstitu
te;n/a,
notap
plicab
le;OAs,
outcom
eassessors;
oti,othe
rthan
interven
tion;
RA,rand
omassign
men
t;TG
s,treatm
entgrou
ps.
Schliemann et al
4 © 2019 by American Society of Clinical Oncology
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE2.
Stud
yQua
lityof
Qua
si-Experim
entalS
tudies
Acc
ording
toJB
ICriteria
FirstAu
thor
Clea
rCa
use
and
Effect
ParticipantsWere
Includ
edin
Any
Comparis
onsSimila
r
Simila
rTrea
tmen
tof
Grou
psOthe
rTh
anthe
Interven
tionofInterest
Control
Grou
pPresen
t
Multip
leMea
suremen
tsof
Outcom
e
CompleteFollo
w-Up
andAd
equa
teDe
scrip
tionof
Diffe
renc
es
Outcom
esof
ParticipantsIncluded
Comparis
onsMea
sured
intheSa
meWay
Relia
ble
Mea
suremen
tof
Outcom
es
Approp
riate
Statistic
alAn
alysis
Total
Score
Adib1
9+
−−
−−
n/a
n/a
—+
2+
Gad
gil34
++
+−
+n/a
n/a
++
6+
Guven
c35
++
+−
+−
n/a
——
4+
Heyman
n36
+?
++
++
n/a
+?
6+
Heo
37
++
+−
−−
n/a
+—
4+
Motallebn
ejad
38
++
+−
−n/a
n/a
+—
4+
Park3
9+
−+
+−
n/a
++
+6+
Saleh4
0+
−+
−−
n/a
n/a
++
4+
Tabu
chi41
++
++
−n/a
++
+7+
Ued
a21
++
++
++
++
+9+
Yagi
20
++
++
++
++
+9+
Abb
reviations:+,yes;
−,no
;?,un
clear;JB
I,Joan
naBrig
gsInstitu
te;n/a,
notap
plicab
le.
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 5
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TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Ran
domized
controlledtrials
Breastca
ncer
Ishika
wa2
3
Japa
nCha
racteristics:
wom
en51
-59yearsold(excep
t55
yearsold),listedin
loca
lhea
lthde
partmen
tda
taba
se,n
oscreen
ingin
past
2years
Sample:
n=8,10
0eligible
andco
ntac
ted;
n=3,23
6replied(rec
ontacted
)Se
tting
:co
mmun
ity
Smallm
edia
IG:(1)individu
alassessmen
t;(2)
assessmen
t-ba
sedtailoredlette
rto
prom
ptstud
ypa
rticipan
tsto
participate
inmam
mograph
yscreen
ing(divided
into
3segm
ents:high
intention;
low
intentionan
dhigh
brea
stca
ncer
worry;
lowintentionan
dlow
brea
stca
ncer
worry);(3)pa
rticipan
tsthen
hadto
return
postcard
toreceiveticke
tsforfree
screen
ing,
which
they
coulduseat
loca
lclinics
CG:no
ntailoredreminde
r
Interven
tionde
livered
durin
gNovem
ber20
09Fo
llow-up:
data
were
collected
for5mon
ths
Prim
ary:
mam
mog
ram
uptake
Seco
ndary:
cost
effectiven
ess
Outco
mes
wereco
llected
from
med
ical
reco
rds
from
health
clinics
Lakkis24
Leba
non
Cha
racteristics:
wom
en40
-75yearsold,with
health
insuranc
eplan
andce
llph
onenu
mbe
r;no
screen
ingin
thepa
st2
years
Sample:
n=38
5pa
rticipated
;IG1=19
2,IG2=19
3Se
tting
:family
med
icine
center
Smallm
edia
IG1:
SMSscreen
inginvitationfor
amam
mog
ram
IG2:
sameas
IG1an
dad
ditiona
lSMS
includ
inginform
ationab
out
mam
mog
rams;
3iden
tical
message
ssent
toea
chgrou
p(with
4wee
ksin
betweenea
chSM
S);co
stof
mam
mog
ram
coveredby
insuranc
e
Interven
tionde
livered
from
Aprilto
June
2010
Follow-up:
data
were
collected
for6mon
ths
Prim
ary:
mam
mog
ram
uptake
Outco
mewas
collected
from
med
ical
recordsfrom
Family
Med
icineCen
tre
Lin2
5
Taiwan
Cha
racteristics:
wom
en35
-69yearsold,
noscreen
ingexpe
rienc
ean
dno
intentionto
have
screen
ing,
neverha
dbrea
stca
ncer,Interne
tat
homeor
work+co
mpu
ter
expe
rienc
eSa
mple:
n=14
4recruited;
n=12
8completed
(IG:64
;CG:64
)Se
tting
:co
mmun
ity
Smallm
edia
Allde
livered
throug
hco
mpu
ter:
IG:(1)mini-lecture
vide
oshow
ing
mam
mog
ram
proc
edure;
(2)vide
oclips
with
person
altestim
oniesof
survivors
andawom
enwho
regu
larly
wen
tfor
mam
mog
raph
y;(3)role
mod
elingvia
audiovisua
lpresentationof
storiesof
brea
stca
ncer
survivors(note:
issues
relatedto
person
ality
andTa
iwan
ese
custom
sweread
dressedin
vide
os)
CG:stan
dard
interven
tion(edu
cationa
lbroc
hure,also
publishe
don
Web
site)
Interven
tiondu
rationwas
between15
and40
min
Follow-up:
mea
suremen
tstake
ndirectlybe
fore
and
afterinterven
tion
Prim
ary:
percep
tions
and
intentions
toob
tain
mam
mog
ram
Outcomes
wereself-repo
rted
throug
h3validated
tools:
Stageof
Ado
ptionof
Mam
mog
ram;Dec
isiona
lBalan
cefor
Mam
mog
raph
yinventory;
Dem
ograph
icInventory
(Con
tinue
don
followingpa
ge)
Schliemann et al
6 © 2019 by American Society of Clinical Oncology
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Ng2
6 Sing
apore
Cha
racteristics:
wom
enfrom
Sing
aporepo
pulation
registry
50-64yearsold,
noscreen
ingin
thepa
st1year
orbiop
sywith
in6mon
ths,
noca
ncer
history,
notpreg
nant
Sample:
n=67
,656
eligible
wom
enrece
ived
invitations,n=28
,231
respon
ded(IG);n=
97,294
wereno
tinvited
(CG)
Setting
:na
tionw
ide
Smallm
edia
Sing
aporeBreastCan
cerSc
reen
ing
Project
IG:letterinvitationfora
free
mam
mogram;if
noreply:
2follow-uplette
rsCG:Noinvitationsent
Invitations
wereissued
over
2years,
startin
gOctob
er19
94;on
e-offlette
r,follow-uplette
rssent
the
following2mon
ths
Follow-up:
data
were
collected
for2years
Prim
ary:
effectiven
essor
mam
mog
raph
yscreen
ingtech
niqu
eSe
cond
ary:
detectionof
canc
er;size
andstag
edistrib
utionof
canc
er,
interval
canc
errates
Prim
aryou
tcom
ewas
collected
from
med
ical
recordsfrom
Nationa
lBreastCarcino
ma
Registry
Seow
29
Sing
apore
Cha
racteristics:
wom
en50
-64yearsold,
nona
ttend
ingwom
enwho
wereinvitedon
cebe
fore
forscreen
ing
Sample:
n=1,50
0were
targeted
(n=50
0in
each
grou
p)Se
tting
:na
tionw
ide
Smallm
edia
Sing
aporebrea
stca
ncer
screen
ing
projec
t(wom
enwho
didno
trespo
ndto
firstinvitationweredu
etheirsecond
reminde
r,as
repo
rted
inNget
al26)
IG1:
lette
r(invitationwith
screen
ingda
tefor
afree
mam
mog
ram
andpa
mph
letwith
screen
inginfo)
IG2:
sameas
IG1+ed
ucationa
lfolde
rmailed
IG3:
sameas
IG2de
livered
bytraine
dfemalefieldworke
r
Interven
tionwas
aon
e-off
contac
tin
Decem
ber
1996
Follow-up:
data
were
collected
5wee
ksafter
design
ated
appo
intm
ent
date
Prim
ary:
mam
mog
ram
uptake
Outco
mewas
collected
from
med
ical
recordsfrom
Nationa
lBreast
Carcino
maRegistry
Cervica
lcan
cer
Rashid1
7,18
Malaysia
Cha
racteristics:
wom
en20
-65yearsold,
nega
tive
Pap
anicolau
testprevious
year
Sample:
n=1,00
0(n
=25
0in
each
grou
p)Se
tting
:co
mmun
ityclinics
Smallm
edia
IG1:
postal
lette
rIG2:
registered
lette
rIG3:
SMS
IG4:
teleph
oneca
ll(allIGsco
ntaine
dthe
date
forafree
Pap
anicolau
test
and
teleph
onenu
mbe
rto
resche
dule)
Interven
tionwas
aon
e-off
contac
tin
June
2011
Follow-up:
data
were
collected
for8weeks
afterinterven
tion
Prim
ary:
Pap
anicolau
test
uptake
Seco
ndary:
cost
effectiven
ess
Outco
mewas
collected
from
med
ical
reco
rdsfrom
the
Pap
anicolau
testprog
ram
inform
ationsystem
(Con
tinue
don
followingpa
ge)
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 7
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Abd
ullah1
9
Malaysia
Cha
racteristics:
female
teac
hers
who
didno
tattend
Pap
anicolau
test
inthepa
st3years,
reprod
uctiveag
eSa
mple:
n=40
3at
baseline;
n=39
8at
follow-up(IG:
n=19
9;CG:n=19
9)Se
tting
:workp
lace
(pub
licsecond
aryscho
ols)
Smallm
edia
IG:(1)lette
r(in
vitationforafree
Pap
anicolau
test)an
dpa
mph
let
(inform
ationab
outcervical
canc
eran
dPap
anicolau
test)ha
ndde
livered
byscho
olprincipa
l;(2)teleph
oneca
llreminde
r(1×)
after4wee
ksto
reiterate
impo
rtan
ceof
Pap
anicolau
test
CG:no
interven
tion(opp
ortunistic
screen
ing)
Preda
taco
llectionan
dinterven
tionwere
cond
uctedbe
tween
Janu
aryan
dNovem
ber
2010
Follow-up:
data
were
collected
for24
wee
ksafterinitial
contac
t
Prim
ary:
Pap
anicolau
test
uptake
Outco
mewas
collected
throug
haself-repo
rted
questionn
aire
Hou
27,28
Taiwan
Cha
racteristics:wom
en≥30
yearsold(you
nger
ifmarrie
d),n
oscreen
ingin
past
1year,family
mem
berof
inpa
tients
admitted
toon
eof
teac
hing
hospitalsin
Taiwan
(Aug
ust-
Septem
ber19
99)
Sample:
n=42
4(baseline
IG:n
=21
2;CG:n
=21
2;follow-upIG:n
=12
3;CG:
n=12
4)Se
tting
:ho
spital
Smallm
edia
IG:mon
th1:
welco
melette
r,mailed
educ
ationa
lbroch
ure,
quotes
from
wom
enwho
completed
Pap
anicolau
test,screen
ingsche
dule;mon
th2:
invitationlette
rforafree
Pap
anicolau
test
andmailedmaterials:factsheet,
screen
ingsche
dule,role
mod
elstories;
mon
th3:
teleph
oneca
llfrom
health
educ
ator
toofferba
rriers
coun
seling
and/or
assistan
cewith
appo
intm
ent
sche
duling
CG:m
onthlyne
wsletterwith
gene
ralh
ealth
inform
ationfrom
hospital
Rec
ruitm
enttook
plac
ebe
tweenAug
ustan
dSe
ptem
ber19
99;
interven
tiondu
rationwas
3mon
ths
Follow-up:
IG:du
ringteleph
oneca
ll(pre)an
dmailedsurvey
(post)
CG:m
ailedsurvey
(postonly)
Prim
ary:
Pap
anicolau
test
uptake
Second
ary:
diffe
renc
ebe
twee
nea
rlyad
opters
andno
nearlyad
opters
Outco
mes
wereco
llected
throug
haself-repo
rted
questionn
aire
Colorec
talc
ance
r
Hag
oel20
Israel
Cha
racteristics:
men
and
wom
en50
-74yearsold
from
nationa
ldatab
ase,
nohistoryofinflam
matory
bowel
diseaseor
bowel
maligna
ncy,
noco
lono
scop
yin
past
3years;
noFO
BTin
previous
1year
Sample:
n=48
,091
(IG1:
n=9,63
1;IG2:
n=9,59
6;IG3:
n=9,63
0;IG4:
n=9,63
2;IG5:
n=9,60
2)Se
tting
:na
tionw
ide
Smallm
edia
Allpa
rticipan
tsrece
ived
(1)amailed
lette
r,asking
them
tomailbackan
FOBT
test
orde
rform
orpick
upafree-of-
charge
FOBTat
aloca
lclinican
d(2)a
nSM
Sreminde
r.Five
type
sof
lette
rswere
sent
todiffe
rent
grou
ps:
IG1:
interrog
ativereminde
rs+no
social
contextreferenc
eIG2:
interrog
ativereminde
rs+socialco
ntext
referenc
eIG3:
noreminde
rIG4:
noninterrogativereminde
r+no
social
contextreferenc
eIG5:
noninterrogativereminde
r+social
context
One
-offlette
rwas
sent,
followed
byaon
e-offS
MS
1wee
klater,in
2013
Follow-up:
data
were
collected
for6mon
ths
afterinterven
tion
Prim
ary:
FOBTup
take
Outco
mes
wereco
llected
from
med
ical
reco
rds
from
Nationa
lIsraeli
Colorec
talC
ancerEa
rlyDetec
tionda
taba
se
(Con
tinue
don
followingpa
ge)
Schliemann et al
8 © 2019 by American Society of Clinical Oncology
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Hira
i21
Japa
nCha
racteristics:
men
and
wom
en,46
-66yearsold,
noFO
BTin
past
1year,
mem
bershipin
Japa
n’s
nationa
lhealth
insuranc
eprog
ram
Sample:
n=2,14
0eligible
participan
ts(IG1:
n=
356;
IG2:
n=35
5;CG1:
n=71
7;CG2:
n=71
2)Se
tting
:co
mmun
ity
Smallm
edia
Mailedlette
rforsubstituted
screen
ing
(4type
s):
IG1:
tailoredmatch
edmessage
cond
ition
,tailoredan
dprintrem
inde
rfor
screen
ing
IG2:
tailoredun
match
edmessage
cond
ition
andprintrem
inde
rfor
screen
ing(for
IG1
andIG2:
3diffe
rent
message
sba
sedon
screen
ingintention)
CG1:
typica
lmessage
,profession
ally
design
ed,an
dprintreminde
rfor
screen
ingCG2:
typicalm
essage
,no
tprofession
allyde
sign
ed,an
dprint
reminde
rforscreen
ing
Firstcon
tactwas
mad
einOct
2010
,asecond
contac
t(rem
inde
r)was
mad
ein
Novem
ber20
10Fo
llow-up:
data
were
collected
for5mon
ths
Prim
ary:
FOBTup
take
Second
ary:
cost-
effectiven
ess
Outco
mes
wereco
llected
from
med
ical
reco
rds
from
health
care
facilities
Colorec
tala
ndga
stric
canc
er
Hon
g22
Korea
Cha
racteristics:
men
50-59
yearsold,
inthelowest
50%
oftheNationa
lHea
lthInsuranc
eCorpo
rationPremium,
hadno
treceived
canc
erscreen
ingtestspreviously
Sample:
n=92
3in
total(CG:
n=22
3;IG1:
n=23
0;IG2:
n=24
3;IG3:
n=22
7Se
tting
:co
mmun
ity
Smallm
edia
IG1:
lette
rplus
mailedinform
ation
(screening
eligibility,a
ndfree
screen
ing
availability;
inform
ationab
outca
ncer
andscreen
ing;
fina
nciala
idprog
rams
forpa
tientswith
canc
er)
IG2:
teleph
oneca
ll(cou
nseling,
same
inform
ationas
inIG1conveyed
,called
upto
3tim
es)
IG3:
IG1plus
IG2(le
ttersweresent
2weeks
afterteleph
oneca
lls)
CG:no
interven
tion
Interven
tionwas
delivered
durin
gSe
ptem
ber20
12Fo
llow-up:
data
were
collected
for4mon
ths(1
mon
thdu
ring
interven
tionan
dfor3
mon
thsafterintervention)
Prim
ary:
screen
ingof
stom
achan
dco
lorectal
canc
erOutco
mewas
collected
from
med
ical
recordsfrom
clinics
Qua
si-experim
entalstudies
Breastca
ncer
Adib3
1
Leba
non
Cha
racteristics:wom
en≥40
yearsoldforsurvey1an
d2an
d≥
35yearsoldfor
surveys3-5from
selected
clusters
Sample:
n=1,20
0wom
en(survey1an
dsurvey
2;diffe
rent
forsurveys3-5)
Setting
:co
mmun
ity
Smallm
edia
+massmed
ia+othe
rs(1)discou
nted
priceformam
mog
raph
y(in
160ce
nters);(2)pa
mph
lets
insupe
rmarke
ts,ph
armac
ies,
waitin
groom
s,salons,with
clinicsofferin
gredu
cedpricescreen
ing;
(3)
educ
ationa
lCDforhe
alth
care
profession
als;
(4)billboa
rds,
street
sign
s,pink
ribbo
ns;(5)TV
andradio
advertisem
ents;T
Vtalk
show
s;(6)SM
Sad
vertisem
ent;(7)ca
mpa
ignba
nners
onho
mep
ages
ofmainInternet
providers
Interven
tionwas
delivered
once
ayear
(throu
ghou
tOctob
er)20
02-200
5Dataco
llection:
data
were
collected
once
ayear
inJanu
aryin
2004
,20
05,
and20
06
Prim
ary:
mam
mog
ram
uptake
Outco
mewas
collected
throug
haself-repo
rted
,tested
questionn
aire
(Con
tinue
don
followingpa
ge)
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 9
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Gad
gil34
India
Cha
racteristics:
wom
en30
-69yearsoldem
ployed
atBhaba
Atom
icResearch
Cen
tre(and
family
mem
bers),en
rolledin
occu
pationa
lhealth
care
sche
me
Sample:
n=22
,500
Setting
:workp
lace
Smallm
edia
+othe
rs(1)mailedaw
aren
ess
brochu
reson
annu
alba
sis(4×)
abou
tbreast
anatom
y,sign
san
dsymptom
sof
breastcanc
er;(2)
breastclinicsby
trained
nurses:e
ducation,
coun
seling,
BSE
;and
physicians:clinical
breast
exam
ination;
(3)walk-in
clinicsto
teachab
outbreast
chan
geswith
silicon
mod
el(allhe
alth
care
costscoveredby
employer)
Interven
tionwas
delivered
once
ayear
inJune
from
2013
to20
16Dataco
llection:
Pre:Janu
ary20
05-M
ay20
13Post:June
2013
-Jun
e20
16
Prim
ary:
mam
mog
ram
uptake
Outco
mewas
collected
from
med
ical
recordsfrom
occu
pationa
lhea
lthca
resche
me
Heyman
n36
Israel
Cha
racteristics:
female
mem
bers
ofMacca
biHea
lthca
reSe
rvices,40
-65
yearsold
Sample:
n=12
0,23
1Se
tting
:co
mmun
ity
Smallm
edia
+massmed
ia+othe
rs(1)mailedinform
ationpa
cksthat
discussedhe
alth,includ
ingbrea
stca
ncer;(2)
lette
rinc
lude
dininform
ation
pack
asking
participan
tto
visitprim
ary
care
physicianwho
wou
lddiscuss
health
preven
tionissues
andreferh
erto
approp
riate
tests;
(3)mailedince
ntive:
substantialdiscoun
tonface
cream
whe
nvisitin
gph
ysician;
(4)75
×15
-sTV
ads
Interven
tionwas
delivered
durin
gMarch
2001
Dataco
llection:
Pre:March
-April19
98,
1999
,20
00Post:March
-April20
02,
2003
Prim
ary:
mam
mog
ram
uptake
Outco
mewas
collected
from
med
ical
recordsfrom
Macca
biHea
lthCare
Services
Heo
37
Korea
Cha
racteristics:
female
stud
ents,worke
rs,loca
lreside
nts;≥19
yearsold,
nohistoryof
brea
stca
ncer,sm
artpho
neow
ner
Sample:
n=45
Setting
:workp
lace
orun
iversity
Massmed
iaSm
artpho
neap
plication:
reminde
rof
optim
alda
yto
perform
breast
self-
exam
ination,
motivationa
ltoo
lsinclud
ingpa
rticipan
t’smothe
r,record
keep
ing,
educ
ationa
lcon
tent
Interven
tionwas
delivered
from
mid-Julyto
mid-
Septem
ber20
12(app
roximately2mon
ths)
Dataco
llection:
directlyafter
interven
tioncompletion
Prim
ary:
brea
stself-
exam
inationprac
tice
Outco
mewas
collected
throug
hself-repo
rted
questionn
aire
Park3
9
Korea
Cha
racteristics:
female,
30-69yearsold,
perm
anen
treside
ntsin
interven
tioncity
Sample:n=48
0(IG:n
=24
0an
dCG:n=24
0)Se
tting
:co
mmun
ity
Smallm
edia
+massmed
ia+othe
rsGun
poCan
cerSc
reen
ingProject
IG:(1)
posterson
apartm
entb
illbo
ards
and
inclinic
waitin
groom
san
dph
armac
y;(2)leaflets(han
dde
livered
)distrib
uted
atstreet
even
ts;(3)lette
rsto
prom
ote
brea
stca
ncer
screen
ing(freeof
charge
toall);
(4)street
prom
otion;
(5)
outbou
ndteleph
oneca
llstowom
enwho
sign
edap
plicationform
atstreet
prom
otions;(6)mon
thlyne
ighb
orho
odmee
tings;(7)sm
allg
roup
educ
ationa
lsessions;(8)on
lineblog
onbrea
stca
ncer
screen
ing
CG:no
interven
tion
Interven
tiondu
rationwas
6-7mon
ths
Dataco
llection:
Pre:June
2008
Post:7mon
thslater
Prim
ary:
addressba
rriers
towardbrea
stca
ncer
screen
ing,
improve
attitud
esan
dbe
liefs;
mam
mog
ram
uptake
Outco
mes
wereco
llected
throug
hself-repo
rted
questionn
aire
(based
onHea
lthBeliefMod
elan
dTran
sthe
oretical
Mod
el)
(Con
tinue
don
followingpa
ge)
Schliemann et al
10 © 2019 by American Society of Clinical Oncology
Downloaded from ascopubs.org by Queen's University Belfast on April 18, 2019 from 143.117.193.021Copyright © 2019 American Society of Clinical Oncology. All rights reserved.
TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Cervica
lcan
cer
Guven
c35
Turkey
Cha
racteristics:wom
en≥21
yearsof
age,
nogyne
cologicca
ncer
history,
noscreen
ingin
past1year,livinginstud
yarea,literate,
sexually
active,
have
teleph
one
numbe
rSa
mple:
stageI:n=2,50
0;stageII:
n=30
2;stag
eIII:
n=54
Setting
:co
mmun
ity
Smallm
edia
+othe
rsTh
reeStag
esof
Nursing
Interven
tion:
Stag
eI:maileded
ucationa
lbroch
ures
andinvitationto
attend
afree
Pap
anicolau
test
Stag
eII:
teleph
oneinterviews
StageIII:face-to-face
interviews
Interven
tionwas
cond
ucted
in20
08Dataco
llection:
prean
dpo
st(notim
epe
riodor
datesgiven)
Prim
ary:
Pap
anicolau
test
uptake
,kn
owledg
ean
dbe
liefs
abou
tPap
anicolau
test
Outco
mes
wereco
llected
throug
haself-repo
rted
questionn
aire
(sociode
mograph
icinform
ation;
Kno
wledg
e,Hea
lthBeliefM
odelSc
ale
forCervica
lCan
cer;an
dPap
anicolau
test)
Ued
a33
Japa
nCha
racteristics:
wom
en20
-49
yearsold,
reside
ntsof
stud
yarea
(IG:20
,25
,30
,35,
and40
yearsold;
CG:21
,26
,31
,36
,an
d41
yearsold)
Sample:
n=1,50
0-3,50
0wom
enin
everyag
eca
tegory,ea
chyear
Setting
:na
tionw
ide
Smallm
edia
IG:mailedfree
cervical
canc
erscreen
ing
coup
onCG:no
interven
tion
Aon
e-offc
oupo
nwas
sent
toallw
omen
inthe
applicab
leag
eca
tegory
each
year
(200
9-20
12)
Dataco
llection:
Pre:20
08Post:20
09-201
2
Prim
ary:
Pap
anicolau
test
uptake
Outco
mewas
collected
from
med
ical
records
Yagi
32
Japa
nCha
racteristics:
IG1:
wom
en20
yearsold;
IG2:
parents
with
daug
hters20
years
old,
stilllivingatho
me,no
historyof
Pap
anicolau
test;C
G:w
omen
21years
old
Sample:
IG1:
n=1,97
6;IG2:
n=1,91
6Se
tting
:na
tionw
ide
Smallm
edia
IG1:
mailedfree
screen
ingco
upon
and
reminde
rpo
stca
rdIG2:
sameas
IG1+leafl
etto
parents
enco
urag
ingthem
toshow
their
daug
htersaca
rtoo
n(enc
ourage
dgirls
toha
veaPap
anicolau
test)
CG:ne
verrece
ived
interven
tion
Interven
tionforIG1was
cond
uctedin
May
2013
andJan20
14;
interven
tionforIG2was
cond
uctedin
May
2014
andJanu
ary20
13Dataco
llection:
data
were
collected
for3mon
ths
Prim
ary:
Pap
anicolau
test
uptake
Outco
mewas
collected
from
med
ical
records
Breastan
dce
rvical
canc
er
(Con
tinue
don
followingpa
ge)
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 11
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TABLE3.
Stud
yCha
racteristicsof
Ran
domized
Con
trolledTrialsan
dQua
si-Experim
entalS
tudies
(Con
tinue
d)
FirstAu
thor
andCo
untry
Populatio
n
Classifica
tionof
Interven
tion
(smallmed
ia,massmed
ia,
orothe
rs)an
dInterven
tion
Timeline
Outcom
e(s)
Tabu
chi41
Japa
nCha
racteristics:
IG:wom
en20
,25
,30
,35
,an
d40
yearsoldforPap
anicolau
test
and40
,45
,50
,55
,an
d60
yearsoldfor
mam
mog
raph
y;CG:
female,
≥1year
old;
IG:
≥2yearsold
Sample:
IG:be
tween
n=1,46
5an
dn=2,00
0;CG:be
tweenn=5,63
8an
dn=8,24
7Se
tting
:na
tionw
ide
Smallm
edia
IG:free
cervical
orbrea
stscreen
ing
vouc
hers
weredistrib
uted
(usuallyby
mailb
utoc
casion
allyby
hand
)an
dmailedinform
ationleaflets
CG:no
interven
tion
One
-offvouc
her(+
leaflet)
was
sent
betwee
nSe
ptem
ber20
09an
dMarch
2010
Dataco
llection:
Pre:20
07Post:20
10
Prim
ary:(1)P
apan
icolau
test
uptake
;(2)mam
mog
ram
uptake
Seco
ndary:
cost
perup
take
Outco
mes
wereco
llected
throug
haself-repo
rted
questionn
aire
(Com
preh
ensive
Survey
ofLiving
Con
ditions
ofPeopleon
Hea
lthan
dWelfare)
Oralc
ance
r
Motallebn
ejad
38
Iran
Cha
racteristics:
participan
tslivingin
selected
clusters
(noothe
rcriteria
stated
)Sa
mple:
pre:
n=40
0;po
st:
n=22
6Se
tting
:co
mmun
ity
Smallm
edia
Inform
ationbrochu
reon
oral
canc
erfacts(han
dde
livered
bystud
ents)after
briefba
selinequ
estionn
aire
was
completed
with
participan
ts
One
-offbroc
hure
was
delivered
in20
05Dataco
llection:
Pre:directlybe
fore
broc
hure
was
given
Post:1mon
thafter
interven
tion
Prim
ary:
know
ledg
eab
out
oral
canc
erOutco
mewas
collected
throug
hself-repo
rted
questionn
aire
Saleh4
0
Malaysia
Cha
racteristics:
registered
e-maila
ddress
with
med
iaco
mpa
ny(datab
aseof
.2millionco
ntac
ts)
Sample:
contac
tedpre:
n=75
,559
;po
st:
n=40
,351
;respo
nden
ts:
n=66
9(pre)a
ndn=75
7(post)
Setting
:na
tionw
ide
Massmed
ia(1)20
-sTV
ads(aire
dfor32
days,2
-3×
perd
ayon
TV3,
NTV
7);(2)
TVtalkshow
(2×)
bysurgeo
nat
theen
dof
interven
tionpe
riodtoad
dressem
otiona
lba
rriers
facedby
patientsin
seeking
treatm
ent
Interven
tionwas
delivered
from
May
23to
June
23,
2010
(32da
ys)
Dataco
llection:
directly
before
andafter
interven
tion
Prim
ary:
awaren
essof
oral
canc
erOutco
mewas
collected
throug
hself-repo
rted
onlinesurvey
Abb
reviations:BSE
,brea
stself-exam
ination;
CG,co
ntrolg
roup
;FO
BT,
feca
locc
ultbloo
dtest;IG,interven
tiongrou
p;SM
S,shortmessage
service(textmessage
).
Schliemann et al
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one exception37). Colorectal and gastric cancer studiesincluded participants between 46 and 74 years of age, andoral cancer studies did not use age as an exclusion cri-terion. Most studies that aimed to increase screening ratesincluded participants who did not attend screening in thepast 1 to 3 years.
Intervention. All RCTs of interventions used small mediaonly (Table 3). The most common channel of communi-cation was mailed letters, generally with the purpose ofinviting participants to cancer screening. Sometimes theletters were mailed with brochures or other educationalmaterials regarding cancer. Other small media communi-cation channels were telephone calls and text messages(Short Message System). The RCTs included between oneand four intervention groups (IGs), either comparing dif-ferent channels of communication to a control group (CG)or comparing different types of messages delivered throughthe same channel of communication.
Included QESs used bothmass and small media channels, aswell as intervention components such as counseling or groupeducation (Table 3). Two studies evaluated the impact ofTV advertisements and a TV talk show,40 as well asa smartphone application.37 Three studies combined massmedia (ie, TV ads, billboards, posters, street signs, radioadvertisements, and a Web site) and small media com-munication channels, together with intervention compo-nents such as counseling, group education, discounted orfree-of-charge screening, and neighborhood meetings.19,36,39
Four studies included small media only,20,21,38,41 and twostudies included small media and other communicationchannels.34,35 Small media channels used in QESs in-cluded mailed letters or postcards, mailed coupons, mailedbrochures or other educational materials, mailed cartoons,telephone calls, and an educational CD or video.
The few interventions that seemed to be informed by be-havior change theory used constructs from the HealthBelief Model,31,32,35,39 the Transtheoretical Model,17,39 and
FIG 2. Map of Asia, highlighting countries included in interventions identified as part of this systematic review.
Systematic Review of Cancer Media Campaigns in Asia
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the Theory of Planned Behavior.26,28 One intervention wasbased on the Question–Behavior Effect technique,25 andanother was developed according to the PRECEDE/PROCEEDmodel.39 Few studies described the involvementof their target population in designing the intervention,although the needs assessment of the target populationwas described mainly in studies that used a behaviorchange theory.17,35,39
Small media studies generally targeted people in their homes,with the exception of one study that invited participants to theresearch center.17 Addresses were commonly obtained fromhealth and population registries targeting large numbers ofpeople (Tables 1 and 3). Other recruitment methods includedconvenience sampling within housing areas,38,39 hospitals(visiting relatives),31,32 or workplaces,34,36,37 or an e-mail listheld by a mass media organization.40
The intervention duration and follow-up period differedamong types of studies and outcomes of interest (Tables 1and 3). Most small media interventions delivered a one-offletter or text message or followed up with a second letter,text message, or telephone call between 1 week and3 months later and collected data on cancer screeninguptake between 5 weeks and 12 months after the in-tervention. Other interventions posted annual brochures forup to 3 years.34 Small media campaigns focusing on im-proving cancer knowledge and perceptions conductevaluations directly after the intervention or 1 month after.38
Mass media campaigns lasted from 1month for TV only40 to3 months for a smartphone application intervention only.37
Researchers, staff working in clinics and governmentscreening programs, or students delivered the in-terventions. Trained nurses, physicians, and other clini-cians undertook the screening, which was free of chargewith the exception of two studies in which screening wasdiscounted.19,26 Most of the studies were funded by uni-versities and research centers.22,23,26,33,34,37,39,42 Otherfunding bodies were a pharmaceutical company,19 a na-tional cancer association (nongovernmental organization[NGO]),25 a nursing association,17 a media company,40
a Ministry of Health (government),20,21,26-28,30,41 a healthinsurance plan,a hospital,31,32 and one campaign wasretail-pharmacy sponsored.36 The funding source wasunclear in two studies.35,38
Study Findings
All findings are reported in Table 4.
Cancer-related knowledge, attitudes to cancer screening,and self-examination practice. Change in cancer-relatedknowledge was assessed in one RCT and four QESs, all ofmedium quality.31,32,35,38-40 Findings from the RCT con-ducted by Hou et al31 found no between-groups differencein knowledge regarding cervical cancer and Papanicolautests at follow-up. Conversely, Park et al39 found thata mixedmedia campaign (small andmassmedia plus othercomponents) demonstrated a greater decrease in beliefs
about breast cancer–related myths in Korea (non-significant). Furthermore, a before-and-after evaluation ofa mass media campaign in Malaysia found an increase inawareness about oral cancer (ie, having heard of oralcancer), but there was no increase in knowledge aboutsymptoms.40 Findings across five studies (two RCTs andthree QESs) of attitudes toward screening concerningbreast17,37,39 or cervical cancer were mixed.31,32,35 Studiesaddressing attitudes or beliefs about cancer generallydescribed an underlying theory for the intervention design.For example, Park et al reported that a mixed media in-tervention based on the Transtheoretical Model, resulted inan increase in the proportion of intervention participantswho progressed to the action stage (+23% in the in-tervention city v −5% in the control city) and an increase inintention to undergo mammography screening in the next2 years (+14% in the intervention city v +7% in the controlcity).39 The small media intervention (combined with face-to-face interviews in stage III) that was based on the HealthBelief Model did not find a change in beliefs related tocervical cancer and H tests.35 A small study usinga smartphone application did not find a change in breastself-examination practice in general, although there wasa significant increase in the number of women 30 years ofage or younger conducting breast self-examination (36% to82%, P = .002).37
Screening attendance, cancer diagnosis, and downstaging.Screening uptake was the most commonly reported out-come measure (n = 17) for breast, cervical, and colorectalcancer. Findings from RCTs were mixed for breast (n = 4[medium quality]) and colorectal cancer screening (n = 3[medium quality]) and positive for cervical cancerscreening (n = 3 [medium to high quality]). Only one RCTlooked at gastric cancer screening.27 Ishikawa et al26 re-ported that a tailored letter about free breast cancerscreening was significantly more effective than a non-tailored reminder (odds ratio, 4.02 [95% CI, 2.67 to 6.06];P , .001). Conversely, a repeated text message screeninginvitation combined with information about mammo-grams was as effective as receiving a screening invitationthrough text message alone.29 Medium-and low-qualityQESs reported weak positive effects on breast cancerscreening.131,34,36,41 According to one QES, breast cancerscreening uptake increased over a 4-year period (notsignificant),19 and Heymann et al36 reported a small in-crease, from 3.2% to 3.8%, in another QES. High- andmedium-quality QESs reported significant positive effectsfor cervical cancer screening,20,21,35,41 which were sup-ported by high- and medium-quality RCTs.22,24,31 For ex-ample, Abdul Rashid et al22 reported a significantly greateruptake of Papanicolau tests in the IG invited by telephonecompared with a mailed letter, a registered letter, or a textmessage (50.9%, 23.9%, 23.0%, and 32.93%, re-spectively; P, .05). Similarly, a mailed screening invitationand information followed by a telephone reminder yielded
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TABLE 4. Findings Regarding Cancer-Related Knowledge, Attitudes, and Beliefs and Screening Uptake
First AuthorChange inKnowledge
Change in Attitudesand Beliefs Screening Uptake
Cancer CasesDetected
Downstaging ofCancer
CostEffectiveness
Randomized controlled trials
Breast cancer
Ishikawa28a — — IG v CGb — — IG v CGc
Lakkis29a — — IG1 v IG2d — — —
Lin17e — IG v CGb — — — —
Ng30a — — f IG v CGb IG v CGb —
Seow33a — — IG3 v IG1b
IG3 v IG2b
IG3 v IG2b
— — —
Cervical cancer
Abdul Rashid22,23e — — IG4 v allb — — IG4 v allc
Abdullah24a — — IG v CGb — — —
Hou31,32a IG v CGd IG v CGb (more pros)IG v CG (fewer cons)c
IG v CGb — — —
Colorectal cancer
Hagoel25a — — IG1 and IG2 v allc — — —
Hirai26a — — IG1 v CGsb
IG1 v IG2d
— — Not justifiedd
Colorectal and gastriccancer
Hong27a — — IG2 v CGb
IG3 v CGb
IG1 v CGd
— — —
Quasi-experimentalstudies
Breast cancer
Adib19g — — S3 and S4 v S1 andS2c
— — —
Gadgil34a — — f f Post v prec —
Heymann36a — — IY v other Ysc — — —
Park39a IG v CGc IG v CGb — — — —
Heo37a — Pre v postd
Age ≤ 30 yearsb
Age . 30 yearsh
— f — —
Cervical cancer
Guvenc35a After S1b d b — — —
Ueda21e — — IY v other Ysb — — —
Yagi20e — — IG v CGb — — —
Breast and cervicalcancer
Tabuchi41a — — IG v CGb — — d
Oral cancer
Motallebnejad38a Pre v postb — — — — —
(Continued on following page)
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 15
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a significantly higher Papanicolau test uptake comparedwith no intervention (opportunistic screening; odds ratio,2.44 [95% CI, 1.29 to 4.62]).24 High-quality QESs founda significant increase in Papanicolau test uptake amongIG participants compared with the CG (8.7% v 3.6%;P , .001)20 and an increase in the first-time participationscreening rate21 as a result of small media interventions(mailed screening coupons) in Japan. RCT participantswho received a telephone call alone or a call combined withmailed information were significantly more likely to attendgastric and colorectal cancer screenings compared withthe respective CGs (gastric cancer: telephone, 31.7% v17.9%, P = .01; telephone plus post, 40.5% v 17.9%,P , .01; Colorectal cancer: telephone, 24.3% v 13.5%,P , .01; telephone plus post, 27.8% v 13.5%, P , .01).27
Detected cancer cases were reported in three studies. Amedium-quality RCT of a small media intervention founda significant between-group difference in terms of breastcancer cases detected (IG, 4.8 of 1,000 cases v CG, 1.3 of1,000 cases),30 whereas the interventions in two medium-quality QESs did not increase cancer case detection.34,37
Two medium-quality studies assessed downstaging ofdetected cancers as an outcome. Ng et al30 demonstrateda significant difference in stage of breast cancer diagnosisas a result of a small media intervention in Singapore (IG,64% v CG, 26% of cases were stage 0 or 1, P , .001),whereas Gadgil et al34 reported that the proportion ofsmaller-sized tumors detected was higher (85.3% v 89.5%,P = .390) and the proportion of large-sized tumors detectedwas smaller (14.7% v 10.5%, P = .390) after the in-tervention. Furthermore, the proportion of cancer deathsdecreased from 8.3% to 0% within 3 years from diagnosisover the study period.
Cost effectiveness. Four studies reported intervention costs,with mixed findings. An intervention using assessment-based, tailored screening reminder letters to improvebreast cancer screening was cost effective compared withnontailored reminders (IG, 30 USD v CG, 52 USD),28
whereas a tailored message condition was not more cost
effective than an unmatched message condition for co-lorectal cancer screening.26 Abdul Rashid et al23 compareddifferent small media campaigns to increase cervical cancerscreening and found that a telephone call was themost cost-effective method. An intervention that paid out-of-pocketcosts for breast and cervical cancer screenings in Japanimproved cancer screening uptake, although the in-tervention was not cost saving because of the high cost ofscreening.41
DISCUSSION
Findings from this systematic review suggest that smallmedia interventions (eg, interventions using mailed ma-terials, text messages, and telephone calls) may be effectivein improving screening uptake for breast, cervical, co-lorectal, and gastric cancer in Asian countries. The numberof studies usingmassmedia channels was too small to drawconclusions about their effectiveness. There was also in-sufficient evidence to indicate that small or mass mediacampaigns improved knowledge or attitudes toward can-cer. The lack of mass media campaigns is likely to berelated to (1) the high costs involved in running campaignsusing TV and radio advertisements and (2) the lack ofcampaign evaluation of campaigns run by the governmentand NGOs. The only nationwide mass media campaignsincluded here received funding frommedia channels for TVadvertisements.
The findings regarding screening were mainly fromstudies conducted in high or higher middle-incomecountries (Japan, South Korea, Taiwan, Singapore,Malaysia, Israel, Turkey, Lebanon, and Iran). The absenceof studies in low and lowermiddle-income countries may beexplained by a lack of resources to conduct screeningprograms, as well as a lack of screening facilities. Moststudies reported a one-off follow-up, and only a few studiesevaluated the impact of such programs in the long term.Studies from Western countries suggest that screeningprograms have to be run repeatedly to maintain uptake overtime.43
TABLE 4. Findings Regarding Cancer-Related Knowledge, Attitudes, and Beliefs and Screening Uptake (Continued)
First AuthorChange inKnowledge
Change in Attitudesand Beliefs Screening Uptake
Cancer CasesDetected
Downstaging ofCancer
CostEffectiveness
Saleh40a Awareness oforal cancerb
Symptomawarenessd
— — — — —
Abbreviations: CG, control group; IG, intervention group; IY, intervention year; S1, stage I; S2, stage II; Y, year; —, not applicable (not reported).aMedium quality.bSignificant positive difference.cPositive difference (not significant).dNo difference.eHigh quality.fFindings not conclusive.gLow quality.hNegative difference.
Schliemann et al
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Surprisingly, the two most common cancers in Asia, lungand liver cancer, were not addressed by any study in thesystematic review. The majority of lung and liver cancerprograms tend to focus on prevention (ie, smoking ces-sation and hepatitis B vaccination) instead of symptomeducation and early detection. However, the high numberof lung and liver cancer cases suggests that there is a needfor early detection and awareness programs to supple-ment prevention programs and to detect and treat thesecancers early. The under-researched number of cancercases detected and downstaging of cancer may be relatedto the poor quality or absence of adequate data collectionsystems in LMICs. Bhoo-Pathy et al44 reported that onlyone in three Asian countries collected data on cancerincidence, and only one in six countries monitored cancermortality. In turn, inadequate or absent routine datacollection is likely to hinder cost-effectiveness analysis ofinterventions.
Eight studies (40%) reported implementation issues.Findings highlighted that between 21.2% and 34.4% ofletters, mailed brochures, or text messages were neverreceived because of incorrect addresses or telephonenumbers22,29 and that approximately 43.5% of targetedparticipants never read the brochure they received.38 Onestudy using mass and small media highlighted that 50% ofparticipants reported that they had heard about thecampaign.19 Reasons why women refused free cervicalcancer screening after the first contact included no timeand embarrassment during screening.35
Findings presented in this systematic review are in line withthe findings of two systematic reviews focused mainly onWestern countries.15,43 Furthermore, Hou et al12 concludedthat small media were effective in improving screeninguptake among Asians (including Asians living abroad). Tothe best of our knowledge, the systematic review presentedin this article is the first review focusing on Asians living inAsia and takes account of the different health care systemsand resources in Asian countries compared with Westerncountries. In addition, the review extracted informationabout small and mass media campaigns specifically, ratherthan educational interventions in general; these data will beinformative for the design and development of early de-tection cancer programs that plan to use this mode ofdelivery.
To the best of our knowledge, this systematic review de-livers the best available up-to-date reliable evidence aboutsmall and mass media cancer screening interventions inAsia. Most studies in this systematic review were deemed tobe of medium quality according to the results of the ap-plication of the JBI methodologic checklists. However,a consideration of individual studies in the context of thetarget interventions might suggest that some may be higherin methodologic quality. For example, the scoring of criteriasuch as blinding may not be realistic for these types ofpopulation-based educational interventions.
Often, data collected from medical records or cancerregistries in LMICs are not complete or reliable because ofa lack of resources. For example, the cancer registry inMalaysia relies on voluntarily supplied information,45 andbecause of the dual-tiered health care system, evidencefrom private clinics and hospitals is often lacking. Manyinterventions and campaigns run by governments andNGOs in LMICs are evaluated internally and are not pub-lished in scientific journals and, therefore, may be missed.
Few of the studies included offered minimal contact withparticipants (eg, neighborhood meetings, telephone con-tact, and so forth) and we do not know the extent to whichthis personal contact is important for intervention success.Due to the limited number of studies, no conclusions canbe drawn about whether interventions that applied a theorywere more effective than atheoretical studies or whetherthere are differences in effectiveness between screeningtests. However, a recent systematic review by Senore et al43
suggested that different colorectal cancer screeningmethods yielded different results regarding screeninguptake.
Because some studies compared one intervention withanother intervention (eg, tailored messages v nontailoredmessages), no conclusions can be drawn from some in-terventions regarding the effectiveness of the interventioncompared with no intervention. Our review covered a lim-ited number of high and higher middle-income countries,and findings may not be applicable to other LMICs in Asia(Fig 2). Furthermore, few studies looked at using differentmethods to target different age groups. However, it wassuggested that younger women may be better disposed tosmartphone applications37 as well as to being influenced bytheir parents.
Mailed information and an invitation for a free screening, aswell as mailed information combined with a telephonereminder, seem to be effective in increasing screeninguptake. High-quality studies in this review may serve asimportant resources to inform screening interventions inAsian countries. A limited number of interventions in thissystematic review evaluated screening programs over anextended time period, and future studies should investigatescreening engagement in the long term.43
Few studies addressed knowledge and attitudes regardingcancer and cancer screening. However, in some LMICs,lack of knowledge, misbeliefs, negative attitudes towardcancer treatment, and distrust in Western medicine are stillsignificant barriers toward screening,46,47 and these bar-riers must be addressed to improve screening uptake inAsia. Understanding barriers toward screening in the targetpopulation is a key research goal,43 and basing in-terventions on theoretical components may improve ef-fectiveness. The two most commonly applied theories incancer education programs in Asia are the TranstheoreticalModel and the Health Belief Model.12
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Mass media campaigns are run yearly by NGOs andindustry,48 but they do not seem to be subject to rigorousevaluation. To identify whether mass media are cost ef-fective and worthwhile to be used by policy makers andpublic health practitioners for public education in Asia,there would be considerable merit in NGOs and cam-paigning bodies exploring collaboration with academicianswith a view to rigorously evaluating public health improve-ment programs.
Findings from this systematic review suggest that smallmedia cancer awareness–raising campaigns are effectivein increasing cancer screening rates for breast and cervicalcancer, and limited evidence is available for colorectalcancer. Evaluation of mass media campaigns is required toimprove understanding about the importance (or other-wise) of these campaigns in public health education. Ad-ditional research is needed to assess the cost effectivenessof media interventions for cancer screening in Asia.
AFFILIATIONS1Queen’s University Belfast, Belfast, United Kingdom2Monash University Malaysia, Bandar Sunway, Malaysia3University of Malaya, Kuala Lumpur, Malaysia
The views expressed in the submitted article represent the work andthoughts of the authors and are not an official position of the institution orfunder.
CORRESPONDING AUTHORDesiree Schliemann, Queen’s University Belfast Centre for Public Health,Grosvenor Rd, Institute for Clinical Sciences, Block B, Belfast, NorthernIreland BT12 6BA,United Kingdom; e-mail: [email protected].
PRIOR PRESENTATIONPresented in part (short oral presentation) at the World Cancer Congress2018, Kuala Lumpur, Malaysia.
SUPPORTSupported by UK MRC-Newton Ungku Omar Funding. The collaborativegrant application was subjected to peer-review by individual academicreviewers and the final decision about funding was made by anexpert panel.
AUTHOR CONTRIBUTIONSConception and design:Desiree Schliemann, Tin Tin Su, Michael DonnellyAdministrative support: Tin Tin Su, Maznah Dahlui, Siew Yim Loh
Provision of study material or patients: Darishiani ParamasivamCollection and assembly of data: Desiree Schliemann, Tin Tin Su,Darishiani Paramasivam, Maznah Dahlui, Siew Yim LohData analysis and interpretation: Desiree Schliemann, Tin Tin Su, CharleneTreanor, Siew Yim Loh, Michael DonnellyManuscript writing: All authorsFinal approval of manuscript: All authorsAccountable for all aspects of the work: All authors
AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTERESTThe following represents disclosure information provided by authors ofthis manuscript. All relationships are considered compensated.Relationships are self-held unless noted. I = Immediate Family Member,Inst =My Institution. Relationshipsmay not relate to the subject matter ofthis manuscript. For more information about ASCO's conflict of interestpolicy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc.
No potential conflicts of interest were reported.
ACKNOWLEDGMENT
We thank Richard Fallis (information specialist at Queen’s UniversityBelfast) for assisting the team in devising the electronic search strategyfor this systematic review.
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n n n
Systematic Review of Cancer Media Campaigns in Asia
Journal of Global Oncology 19
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APPENDIX
TABLE A1. Concepts Searched in the Databases
Concept 1: Cancer, neoplasm
Concept 2: Screening, breast health, awareness, knowledge, self-screening, beliefs, attitudes, self-efficacy, self-examination, attendance,health behavior
Concept 3: Mass media, small media, campaigns, health promotion, health education, public health, interventions, programs, TV, radio, mail,brochures, (print) advertisement, social media, Internet, online
Concept 4: Asia, Afghanistan, Armenia, Azerbaijan, Bahrain, Bangladesh, Bhutan, Brunei, Cambodia, China, Cyprus, Georgia, India,Indonesia, Iran, Iraq, Israel, Japan, Jordan, Kazakhstan, Kuwait, Kyrgyzstan, Laos, Lebanon, Malaysia, Maldives, Mongolia, Myanmar(Burma), Nepal, North Korea, Oman, Pakistan, Palestine, Philippines, Qatar, Russia, Saudi Arabia, Singapore, South Korea, Sri Lanka, Syria,Taiwan, Tajikistan, Thailand, Timor-Leste, Turkey, Turkmenistan, United Arab Emirates, Uzbekistan, Vietnam, Yemen
NOTE. Search terms for each concept were combined with OR. All four search concepts were combined with AND.
Schliemann et al
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