effectiveness of mass and small media campaigns to improve cancer awareness … · summarize...

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


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


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



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.




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



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)




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



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)




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



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)




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

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Schliemann et al



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.




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

Schliemann et al



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)




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



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




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




https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=76731

http://ghdx.healthdata.org/record/malaysia-national-cancer-registry-report-malaysia-cancer-statistics-data-and-figure-2007

http://ghdx.healthdata.org/record/malaysia-national-cancer-registry-report-malaysia-cancer-statistics-data-and-figure-2007

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



effectiveness of mass and small media campaigns to improve cancer awareness … · summarize...

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