Statistical Databases

Background This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease. Objectives To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Selection criteria Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening. Data collection and analysis Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology. Main results Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases. Authors' conclusions There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

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Interventions targeted at women to encourage the uptake of cervical screening

A growing number of empirical studies have revealed that diaphragmatic breathing may trigger body relaxation responses and benefit both physical and mental health However, the specific benefits of diaphragmatic breathing on mental health remain largely unknown The present study aimed to investigate the effect of diaphragmatic breathing on cognition, affect, and cortisol responses to stress Forty participants were randomly assigned to either a breathing intervention group or a control group The breathing intervention group received intensive training for 20 sessions, implemented over 8 weeks, employing a real-time feedback device, and an average respiratory rate of 4 breaths/minute, while the control group did not receive this treatment All participants completed pre- and post-tests of sustained attention and affect Additionally, pre-test and post-test salivary cortisol concentrations were determined in both groups The findings suggested that the breathing intervention group showed a significant decrease in negative affect after intervention, compared to baseline In the diaphragmatic breathing condition, there was a significant interaction effect of group by time on sustained attention, whereby the breathing intervention group showed significantly increased sustained attention after training, compared to baseline There was a significant interaction effect of group and time in the diaphragmatic breathing condition on cortisol levels, whereby the breathing intervention group had a significantly lower cortisol level after training, while the control group showed no significant change in cortisol levels In conclusion, diaphragmatic breathing could improve sustained attention, affect, and cortisol levels This study provided evidence demonstrating the effect of diaphragmatic breathing, a mindbody practice, on mental function, from a health psychology approach, which has important implications for health promotion in healthy individuals

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The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults

guvenc g., akyuz a. & acikel c.h. (2011) Health Belief Model Scale for Cervical Cancer and Pap Smear Test: psychometric testing. Journal of Advanced Nursing 67(2), 428–437.

Abstract
Aim.  This study is a report of the development and psychometric testing of the Health Belief Model Scale for Cervical Cancer and the Pap Smear Test.

Background.  While the Champion Health Belief Model scales have been tested extensively for breast cancer and screening for this, evaluation of these scales in explaining the beliefs of women with regard to cervical cancer and the Pap Smear Test has only received limited attention.

Methods.  This methodological research was carried out in Turkey in 2007. The data were collected with 237 randomly selected women who met the criteria for inclusion and agreed to participate in this study. The Champion Health Belief Model scales were translated into Turkish, adapted for cervical cancer, validated by professional experts, translated back into English and pilot-tested.

Findings.  Factor analysis yielded five factors: Pap smear benefits and health motivation, Pap smear barriers, seriousness, susceptibility and health motivation. Cronbach’s alpha reliability coefficients for the five subscales ranged from 0·62 to 0·86, and test–retest reliability coefficients ranged from 0·79 to 0·87 for the subscales.

Conclusion.  The Health Belief Model Scale for Cervical Cancer and the Pap Smear Test was found to be a valid and reliable tool in assessing the women’s health beliefs. Understanding the beliefs of women in respect of cervical cancer and the Pap Smear Test will help healthcare professionals to develop more effective cervical cancer screening programmes.

Health Belief Model Scale for Cervical Cancer and Pap Smear Test: psychometric testing

Background Acupuncture has been used during IVF treatment as it may improve outcome, however, there are concerns about the true efficacy of this approach. This randomized double blind study aimed to compare real acupuncture with placebo acupuncture in patients undergoing IVF treatment. Methods On the day of embryo transfer (ET), 370 patients were randomly allocated to either real or placebo acupuncture according to a computer-generated randomization list in sealed opaque envelopes. They received 25 min of real or placebo acupuncture before and after ET. The endometrial and subendometrial vascularity, serum cortisol concentration and the anxiety level were evaluated before and after real and placebo acupuncture. Results The overall pregnancy rate was significantly higher in the placebo acupuncture group than that in the real acupuncture group (55.1 versus 43.8%, respectively, P = 0.038; Common odds ratio 1.578 95% confidence interval 1.047-2.378). No significant differences were found in rates of ongoing pregnancy and live birth between the two groups. Reduction of endometrial and subendometrial vascularity, serum cortisol concentration and the anxiety level were observed following both real and placebo acupuncture, although there were no significant differences in the changes in all these indices between the two groups. Conclusions Placebo acupuncture was associated with a significantly higher overall pregnancy rate when compared with real acupuncture. Placebo acupuncture may not be inert. Trial registered with HKClinicalTrials.com: number HKCTR-236.

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A randomized double blind comparison of real and placebo acupuncture in IVF treatment

Objective: Despite high incidence rates of cervical cancer in Korea, Papanicolaou (Pap) tests are not utilized as a preventive behavior. This study examined the effects of an emotion-cognition focused program on the decision of taking Pap tests in Korean women. Design: A non-equivalent control group post-test only design was utilized. Sample: A convenience sample was randomly assigned to either experimental (N = 48) or control group (N = 48) after matching for education and age. Measurements: Knowledge of Cervical Cancer and Pap Smear Test, Champion's Health Belief Model, and Self-Efficacy Scale were used. Intention and stage of adoption to take a Pap test were measured with single items. Results: Women in the experimental group had significantly higher scores on knowledge of cervical cancer (t = 6.99, p < .001) and perceived benefits of Pap tests (t = 2.91, p < .05), lower scores on procedural (t = −2.45, p < .05) and cognitive (t = −2.66, p < .01) barriers to testing. Improvement in self-efficacy (t = 3.38, p < .01), strong intention to have the test (t = 2.99, p < .01), and advanced stages of behavior adoption (χ2 = 12.93, p < .01) were also found. Conclusions: Women's perspectives, attitudes of health care practitioners, and clinical environment need to be considered if change is to happen in women's preventive behavior related to Pap test screening.

Effects of a Cognition‐Emotion Focused Program to Increase Public Participation in Papanicolaou Smear Screening

Effects of acupressure on dysmenorrhea and skin temperature changes in college students: A non-randomized controlled trial

Results and Conclusion. Paired t-test showed significant changes in scores of maternal-fetal attachment (t=6.91. p<.001) and self-efficacy related to childbirth (t=10.19, p<.001). Taegyo opens the possibility of integrating Western ideas with Korean traditional health behavior. Incorporation of Taegyo into existing prenatal classes is recommended.

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Effect of Taegyo-focused prenatal education on maternal-fetal attachment and self-efficacy related to childbirth.

Purpose: This study was done to examine the effects of abdominal breathing on VAS-Anxiety (VAS-A), blood pressure, peripheral skin temperature and saturation oxygen in pregnant women in preterm labor. Method: The study design was a matched control group interrupted time series. Forty-six women matched to gestational age were assigned to either the experimental group (26) or control group (20). Data were collected between March 2007 and May 2008. For the experimental treatment the women performed abdominal breathing 30 times, which took 5 minutes, and did one set of 5-minute abdominal breathing daily for three days. Data collection was done before and after the abdominal breathing to measure VAS-A, blood pressure, peripheral skin temperature and oxygen saturation. Descriptive, , Mann-Whitney U tests were used to analyze the data with the SPSS/PC+Win 15.0 program. Result: For the experimental group there were significant decreases in VAS-A (Z=-4.37, p=.00), systolic blood pressure (Z=-3.38, p=.00), and an increase in skin temperature (Z=-4.50, p=.00) and oxygen saturation (Z=-3.66, p=.00). Conclusion: These findings suggest that abdominal breathing in pregnant women in preterm labor results in decreases in anxiety(VAS-A) including biological evidences such as systolic blood pressure, and increases in peripheral skin temperature and oxygen saturation. Further longitudinal study is needed on the lasting effects and obstetric and neonatal outcomes following abdominal breathing.

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SoonBok Chang

Papers

Effects of a Cognition‐Emotion Focused Program to Increase Public Participation in Papanicolaou Smear Screening

Effects of acupressure on dysmenorrhea and skin temperature changes in college students: A non-randomized controlled trial

Effect of Taegyo-focused prenatal education on maternal-fetal attachment and self-efficacy related to childbirth.

Effects of Abdominal Breathing on Anxiety, Blood Pressure, Peripheral Skin Temperature and Saturation Oxygen of Pregnant Women in Preterm Labor

Context of barriers to Pap testing in Korean women.