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Journal of Public Health Advance Access originally published online on March 27, 2007
Journal of Public Health 2007 29(2):165-172; doi:10.1093/pubmed/fdm003
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© The Author 2007, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

Comparison of a community outreach service with opportunity screening for cervical cancer using Pap smears



Huan-Cheng Chang, Lecturer in Health Care Management and President of Li-Shin Hospital1,2

Hui-Yin Hsiung, Chair of Training and Research Center3

Shu-I Chen, Project Officer3

Amy Ming-Fang Yen, Assistant Professor4,6

Tony Hsiu-Hsi Chen, Professor4,5,6,
1 Department of Health Care Management, Chang-Gung University, Taoyuan, Taiwan
2 Department of Community Medicine, Li Shin Hospital, Taoyuan, Taiwan
3 Training and Research Center, Li Shin Hospital, Tao-Yuan, Taiwan
4 Institute of Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
5 Division of Biostatistics, Graduate Institute of Epidemiology, College of Public Health, National Taiwan University
6 Centre of Biostatistics Consultation, College of Public Health, National Taiwan University

Address correspondence to Tony Hsiu-Hsi Chen, E-mail: chenlin{at}ntu.edu.tw

We sought to compare the take-up of cervical screening with Pap smears in a new outreach and pre-existing hospital-based setting (1) to assess the extent to which the two means of provision would overlap; (2) to establish how the utilization rate is influenced by demographic features and geographical distance from the point of provision; and (3) to access whether an outreach service would lead to increased utilization. We used a pre-test–post-test design and used multiple linear regression to assess the effect an outreach service has on utilization after adjusting for participants age, education and martial status. We found that the outreach service independently provided screening to 89% of eligible women and that coverage was inversely associated with distance from the pre-existing hospital provision. After controlling for age, education and martial status, there was a statistically significant increase (53%; 95% CI: 25, 80%) in utilization. There was little overlap between the outreach and hospital-based cervical screening services so that overall accessibility was enhanced, particularly for the elderly, widowed and less well educated. The outreach service also reduced inequalities due to geography.

Keywords: cervical cancer screening, accessibility, preventive service utilization


   Introduction
TOP
 Introduction
Materials and methods
 Results
 Discussion
 References
 
Cervical cancer is the most common female cancer in Taiwan. The age-standardized incidence rate there was estimated to be 24.23 per 100,000 in 1998,1,2 which is approximately twice that seen in the USA.3 In Western countries, screening with Papanicolaou (Pap) smears has been shown to reduce both cervical cancer incidence and mortality,4–7 but its success, from the public health perspective, depends on the degree of coverage and attendance rates attained.8–11

A nationwide screening programme for cervical cancer, using Pap smears, was initiated in Taiwan in 1995, with women aged over 30 years, prior to 1999, being eligible for annual screening. Thereafter, the policy changed to three-yearly regime. Although this was a nationwide programme, financially supported by National Health Insurance in Taiwan, its execution was essentially opportunistic because in most areas women were informed and invited to have routine Pap smear examination in an assigned hospital by local public health nurses by telephone or mail in accordance with population household lists that were routinely updated and provided by the Bureau of Health Promotion, Department of Health. Since this approach may result in inequitable health care access,12,13 the take-up of cervical screening in Taiwan has been somewhat lower than desired, and strategies to increase coverage are being considered. Unlike certain nationwide organized programmes (e.g. in the UK) that contribute to a reduction in the incidence of and mortality from cervical cancer, our nationwide programme may not achieve this goal because different infrastructures of primary medical care may discount the accessibility attributed to the organized screening programme. One option would be to introduce a community-based education programme, as was found to increase the uptake of screening services among black minority ethnic groups.14 An alternative would be to increase accessibility by making the current screening service community- rather than hospital and clinic-based, by creating an outreach service in other words (defined below).10,12 Little is known, however, about how well this would work since coverage is likely to vary with distance from the nearest screening provider and demographic characteristics such as age and socio-economic status. Furthermore, there are concerns that having a mixture of both hospital and outreach screening services (defined below) would lead to an unacceptably high ‘double coverage’ rate. This is relatively common in this country due to the unique phenomenon of ‘hospital shopping’, where patients may visit several hospitals or clinics for a single test or clinical condition. Therefore, to minimize the wasting of resources, the duplicate coverage should always be monitored. By assessing the take-up of Pap smear testing, before and after the addition of an outreach service to an existing hospital-oriented national screening programme, we will be able to answer the following questions:

  1. Does the provision of an outreach service enhance attendance for Pap smear examinations?
  2. To what extent, if at all, would a community-based outreach overlap with a pre-existing hospital and clinic based service?
  3. To what extent would increases in attendance, due to the introduction of an outreach service, be attributable to demographic characteristics and distance from nearest hospital?


   Materials and methods
TOP
 Introduction
 Materials and methods
Results
 Discussion
 References
 
Subjects and design
The study subjects are women who participated in the cervical screening programme at Li-shin hospital (Pingjen, Taoyuan, Northern Taiwan) between 1999 and 2004. Table 1 shows the utilization rates in the area served by the hospital (i.e. Taoyuan county). It comprises 13 townships, with the highest take-up having been in Pingjen, the second highest in Jungli, third highest in Yangmei, and so on. We used a ‘pre-test and post-test’ design to compare the utilization rates in two time periods, 1999–2001 and 2002–2004, which represent the pre- and post-outreach service periods. Note that the outreach service was defined as having offered mobile clinics with Pap smear examination in a local setting such as schools or local curriculum centres in the neighbourhood of each community, defined as ‘Li’, the smallest geographical unit for administrative management in Taiwan and containing around 4000 inhabitants with roughly 1100 eligible women per Li in Taoyuan. Regarding the invitation method, all women in the community eligible for Pap smear examination according to the population household list and no history of Pap smear examination for the previous three years were invited to have an outreach Pap smear examination by telephone and mail.


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  		Table 1 The distribution, by township, of women attending for Pap smears at Li-shin hospital between 1999 and 2004

 
After excluding ineligible subjects (those with an unknown identification number, those registered in other counties and foreigners), the total number of Pap smear examinations available for analysis was 29,073, including 14,000 relating to 10,802 women screened during the first period and 15,073 relating to 12,078 women screened during the second. The figures for the first period therefore relate only to opportunity screening (the hospital- and clinic-based service) whereas the figures from the second include 2403 Pap smears, relating to 2270 women who attended the outreach service. As the national cervical cancer screening programme offers testing every three years, the data from these two periods can also be used to estimate the repeated attendance rate, i.e. the proportion of women who, having attended for the first screen, re-attended for the second.

Venn diagram
To assess the degree of overlap between the new outreach service and pre-existing national programme, a Venn diagram was sketched (Fig. 1). This shows the 7558 women who were only tested in the first period (1999–2001), 9808 who were tested only in the second, and 3244 who were tested in both (part B). Of 12,078 women tested during the second period, 2270 were served by the outreach service (part A). The overlap between parts B and A represents the degree of duplication between the outreach service and pre-existing screening programme. The size of the overlap represents the proportion of women taking advantage of both screening services.


Figure 1
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  		Fig. 1 Venn diagram showing the degree of overlap between the pre-existing opportunistic screening provision and new outreach service between 1999 and 2004.

 
Accessibility by demographic features and distance
The demographic features, particularly age and education, of those attending for screening before and after the introduction of the outreach service were also compared. Accessibility (as judged by geographical distance from local hospital) is illustrated in Fig. 2, which shows how the utilization rate decreases with increased distance from Li-Shin hospital.


Figure 2
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  		Fig. 2 Average coverage of the pre-existing and new outreach services for cervical screening with Pap smears in Pingjen City.

 
Statistical analysis
The denominator for calculating the utilization rate (take-up of Pap smear testing) was 1,735,457, the number of eligible subjects according to the population registry records for Taoyuan in 2001. Changes in the various rates (utilization, positive, pre-cancerous and cancer, etc.) were expressed as percentages (SD). Multiple linear regression models were used to assess the effect the outreach service had on utilization after adjusting for the demographic factors age, education and martial status.


   Results
TOP
 Introduction
 Materials and methods
 Results
Discussion
 References
 
Figure 1 shows the overlap between the outreach and pre-existing screening services. Of the 2270 who attended the outreach service only 267 (11.7%; part A) were found to have previously attended for screening (between 1999 and 2001) at Li-shin hospital. This suggests that up to 89% of the women attending the outreach service were not adequately served by or able to access the pre-existing screening service. We also found that 33% of the women taking advantage of the hospital-based screening programme attended regularly (part B).

Table 2 shows the number of Pap smears examined before and after the outreach service was introduced. There were 14,000 Pap smears taken between 1999 and 2001, and 15,073 between 2002 and 2004, including 2403 smears derived from the outreach services. Clearly, the elderly, widowed and less educated women were more inclined to take up Pap smear screening offered through the outreach service.


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  		Table 2 Characteristics of women attending for Pap smears at Li-shin hospital between 1999 and 2004

 
Table 3 shows change in utilization following the introduction of the outreach service. After controlling for age, education and martial status, there was a statistically significant 53% increase (95% CI: 25–80%) in take-up of Pap smear testing.


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  		Table 3 Multiple linear regression estimates for the effect of outreach screening on the utilization of Pap smear screening

 
Although the outreach service can have only a limited effect on overall coverage in such a short period of time, its impact on local attendance patterns can already be seen, with the outreach service providing a greater proportion of the overall coverage as the distance from Li-shin hospital increases, ranging from 25.6% at the lowest to 48.9% at the highest.

Since the highest coverage was observed in Pingjen City (the town nearest to Li-Shin hospital) and, as illustrated in Figure 2, in general coverage is inversely proportional to distance from Li-Shin, there is evidence to suggest that geographical factors do influence the uptake of Pap smear screening.


   Discussion
TOP
 Introduction
 Materials and methods
 Results
 Discussion
References
 
Main finding of this study
Given existing nationwide organized Pap smear screening for cervical cancer in Taiwan, this study demonstrates that outreach Pap smear screening services may be a means of enhancing accessibility and thereby increasing attendance. Approximately 90% women attending outreach service had not previously accessed the pre-existing Pap smear examination provided in hospital. The enhancement of accessibility was particularly significant for certain subgroups of women (the elderly, the widowed and less well educated).

What is already known on this topic
Equality of access ensures that screening is made available to everyone and that no population subgroup is excluded by virtue of geographic location, socioeconomic status or ethnic background.12 Doing so may increase participation rate, which, in turn, reduces the incidence of cervical cancer. To achieve this goal, an organized screening programme instead of opportunistic screening may be required. With high coverage and attendance rate, a nationwide organized screening programme for cervical cancer with Pap smear has led to a significant decrease in cervical cancer between the late 1980s and the early 1990s in the UK. Similar findings have been seen in Nordic countries like Denmark, Finland and Icelands.15–17 As only one-third of women have routinely taken up Pap smear testing in Taiwan, measures to improve accessibility (the outreach service, for example) are likely to be instrumental in increasing long-term participation. The outreach service can be seen as a means of reducing the barriers that prevent women who would like to be screened from actually attending. In the area served by Li-Shin hospital, 89% of those attending the outreach service for Pap smear testing had not previously accessed the pre-existing service. This finding is in keeping with the principle of equity and access in primary health care18 and suggests that outreach services may be a way of both increasing availability and improving accessibility; two known determinants of underutilization in cervical screening. In addition, an outreach service may also enhance user satisfaction by better meeting the expectations of the target community,19 another factor that has been shown to predict uptake in Pap smear screening.

From the viewpoint of efficiency, since the overlap between outreach and pre-existing services is small, there is a low double coverage rate, which is to be expected when the medical care system consists of both national (government-funded) and private health services.20

Our finding on demographic features was consistent with the results of previous studies,21 which indicated that low utilization was common amongst the elderly and less educated women. Age and education level are well documented as being highly associated with uptake in Pap smear screening.22–28 The under-use of cervical screening services by older women may be due to the fact that such women are more difficult to reach with the relevant information and are therefore less aware of the benefits of their being screened. The negative impact of socioeconomic inequality on preventive medicine has been studied and reported previously by Lorant et al.29 Another study, targeted at Mexican-American women found that older women, and those below the poverty line, underutilized Pap smear testing by 50%.30 Our findings suggest that low take-up due to age or socioeconomic status can be improved with the introduction of an outreach service.

We found the coverage was inversely associated with distance from Li-Shin hospital. This finding was consistent with the results of Maxwell et al., who found that each 1 km increase in distance from the point of screening provision leads to a 2% reduction in attendance.31 Our findings also support the view reported in the same study that lack of transportation and medical care infrastructure create barriers to cervical cancer screening in rural areas.32 In our study, the women residing in the townships distant from Li-shin hospital would have less comprehensive medical services available to them in their local areas and be unable (or unwilling) to make the journey to Li-Shin hospital.

It is also very interesting to note that the overall coverage of Pap smear testing in Taoyuan county was 52.5%,31 whereas at Lin-Shin hospital it was only 2.82%. This suggests that the Pap smear screening service in Taoyuan is largely primary care- rather than hospital-based. This again emphasizes the importance of health screening in primary care. In addition, since even with the outreach service participation was only around 50%, further improvements to accessibility and a sustained community-based education programme may still be required to bring attendance up to Western levels.

What this study adds
Although the previous study has demonstrated that a nationwide organized screening programme can lead to reduce cervical cancer, accessibility to Pap smear examination within an organized screening programme may also depend on infrastructure of primary medical care, which varies from country to country. In the UK, a nationwide cervical cancer screening programme with Pap smear may achieve high coverage/attendance rate through long-existing general practice in primary medical care. By contrast, in Taiwan, primary medical care has evolved from a privately based payment system to being publicly funded from the national health insurance programme after 1995. It is reasonable that accessibility to Pap smear, common practice in primary care in our country, cannot be as favourable as the UK organized Pap smear service programme implemented through general practice. Outreach service given an organized screening programme may provide a means of enhancing participation rates.

This study on the impact of introducing an outreach service for cervical screening has significant implications with regard to tackling inequalities in health service provision and take-up. The outreach service improved attendance amongst those demographic subgroups least inclined to attend and also those living furthest from the pre-existing point of provision. This is important because overcoming health inequalities is a prerequisite to reducing both the incidence and mortality of cervical cancer. Similar arguments support the view that inequalities in health can be significantly reduced through primary health care interventions such as organized cervical cancer screening programmes.

Limitations of this study
This study has limitations, most obviously that the data was derived from one hospital catchment area only, which means that the results must be interpreted with caution. Further clarification is needed in the form of a multi-centre study.

In conclusion, the Li-Shin outreach service complements the pre-existing opportunistic cervical screening service in Taoyuan, Taiwan and has been demonstrated to enhance accessibility and participation amongst eligible women, particularly the elderly, widowed and less well educated. The provision of an outreach service may also reduce inequalities due to geography.


   References
TOP
 Introduction
 Materials and methods
 Results
 Discussion
 References
 

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This Article
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