European Journal of Public Health, 1–7

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.........................................................................................................
A systematic review of health promotion interventions
to increase breast cancer screening uptake: from the
last 12 years

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Feleke Doyore Agide1,2, Roya Sadeghi3, Gholamreza Garmaroudi3, Bereket Molla Tigabu4

1 Department of Health Education and Promotion, School of Public Health, International Campus, Tehran University of
Medical Sciences, Tehran, Iran
2 Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia
3 Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences
(TUMS), Tehran, Iran
4 Department of Pharmaco-economics and Pharmaceutical Administration, International Campus, Tehran University of
Medical Sciences, Tehran, Iran

Correspondence: Roya Sadeghi, Department of Health Education and Promotion, School of Public Health, Tehran
University of Medical Sciences, Tehran, Iran, Tel: +98 (0) 2188955888, Fax: +98 (0) 188989129, e-mail: [email protected]

Background: The outcome of breast cancer treatment largely depends on the timing of detection. The health
promotion interventions have an immense contribution to early detection and improved survival. Therefore, this
review aimed to provide evidence on the efficacy of the health promotion interventions to increase the uptake of
breast cancer screening and to develop effective interventions targeting women. Methods: Online databases
(PubMed/MEDLINE/PubMed Central, Ovid/MEDILINE, EMBASE, Web of Science and Google Scholar) were
searched for studies published between January 2005 and January 2017. A quality coding system was assessed
using Cochrane checklists for randomized controlled trial (RCT) and Downs and Black checklists for non-RCT. The
score was rated for the included articles by each researcher independently and the average score is given accord-
ingly. This study was registered in PROSPERO as [PROSPERO 2017: CRD42017060488]. Results: The review
dovetailed 22 studies. Thirteen studies (59.10%) were conducted in the Unite States, 4 in Iran (18.18%), 2 in
India (9.09%) and 1 each in Turkey, Saudi Arabia and Israel. The interventions were classified as ‘individual-
based’, ‘community-based’, ‘group-based teachings and training’ and ‘behavioral model based’. The majority of
the studies showed favorable outcomes after health promotion interventions, including improvements in women’s
view of breast screening, breast self-examination and knowledge of breast screening. Conclusion: The review
confirmed that most of the health promotion interventions targeting women boosted the breast screening in one
or another way. However, the limited quality of the included studies showed that further research is needed to
improve the trials in the next future.
.........................................................................................................

Introduction variation of incidence between developed and developing countries

can partly be explained by dietary effects combined with later first
he global burden of breast cancer in women is enormous in the
Tdeveloped and the developing world. It is estimated that over 508 childbirth, lower parity and shorter breast feeding as well as the
effect of globalization.7–9
000 women were died in 2011 globally due to breast cancer. Its A holistic approach that integrates prevention of modifiable risk
incidence is increasing in the developing world due to increased factors for both breast cancer and other non-communicable diseases
life expectancy, urbanization and adoption of western lifestyles.1 includes promoting a healthy diet, physical activity, control of
Although breast cancer is thought to be a disease of the developed alcohol intake, overweight and obesity could eventually have an
world, almost 50% of breast cancer cases and 58% of deaths occur in impact in reducing the incidence of breast cancer in the long
less developed countries.2 According to the American Cancer Society term.10,11
in 2011, approximately 230 480 females in the United States were Many literatures confirmed the improvement in breast cancer
diagnosed with breast cancer. The death toll for that same year was outcome after self-examination, early detection, early diagnosis
estimated at 39 520 deaths.3 and mammography screening method.12 Mammography screening
Breast cancer survival rate varies in various parts of the world. is very complex and resource intensive and no research of its effect-
It is over 80% in North America and around 60% in Sweden and iveness has been conducted in low resource settings.13
Japan but below 40% in low-income countries.2 The very low Therefore, this systematic review helps to provide evidence on the
survival rate in less developed countries could be marked by a lack efficacy of health promotion interventions on breast cancer
of awareness and the lack of early detection programs, which results screening uptake targeting women in the various parts of the world.
in a high proportion of women presenting with late-stage disease, as
well as by the shortage of adequate diagnosis and treatment
facilities.1,2 Methods
Various risk factors for breast cancer have been well-docu-
mented.4 Prolonged exposure to endogenous estrogens such as Data sources, search engines and key words
early menarche, late menopause and late age at first childbirth and A comprehensive search was carried out using PubMed/MEDLINE/
behavior-related factors such as oral contraceptive and hormone PubMed Central, EMBASE, Ovid/MEDILINE, Web of Science and
replacement therapy lead women to breast cancer.4–6 In fact, the Google Scholar. Search terms were ‘breast’ AND ‘cancer’ AND
2 of 7 European Journal of Public Health

‘behavioral’ AND ‘intervention’ OR ‘health promotion’ AND ‘mam- the study (59.10%) were conducted in the United States (13/22), 4 in
mography’ AND ‘screening’ AND ‘uptake’. Studies published as of Iran (18.18%), 2 in India (9.09%) and 1 each in Turkey, Saudi
January 2005–2017 were searched. Reference lists of included studies Arabia and Israel (13.64%). Half of the studies were conducted
were also scanned to identify additional relevant papers. All articles at the community level and one at a religious institution.
were published in English language. Finally, a total of 22 articles were Majority of study populations were migrant women. The interven-
identified. We limited our review to start from 2005 since the tion period ranges from 3 months to 8 years with a total sample
previous review was included the articles up to 2005 in one or size of 16 231. The individual sample ranges from 67 to 5144.
another way.14 (((((((health[tiab]) AND promotion[tiab]) OR edu- Diverse intervention strategies were used including phone calls,
cation[tiab]) OR intervention[tiab]) AND breast[tiab]) AND framed messages, training, lectures, self-test instructions, videos,

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cancer[tiab]) AND screening[tiab]) AND uptake[tiab] DVD, pamphlets, booklets, flip charts, demonstrations, group dis-
cussions, audiovisuals, education by lay health workers, home-based
Study selection education and home visits, cultural promoters education, social
workers workshops, model-based personal education and
Inclusion and exclusion criteria screening campaigns. Most studies used multiple strategies
All published eligible research articles in past 12 years (as of January (table 1). The quality of RCTs was assessed using Jadad method17
2005–2017) were included. Criteria for the inclusion of articles were: and Downs and Black checklists18 were used non-RCT. The rate was
(i) articles that provided behavioral intervention or health given using the scores 1–5. However, the RCTs scored 2 or 3,
promotion and/or education intervention to increase uptake of pointing that the RCTs included in this review, but, cannot be
breast cancer screening were included; (ii) eligible participants classified as being of the highest quality and are therefore subject
were women of any age groups; (iii) the study involved experimental to some degree of bias (table 2) and low quality was reported for
or quasi-experimental designs. The study sought to improve breast non-RCT in table 3.
cancer screening rates and/or breast cancer knowledge and screening In this review, multiple and highly diversified interventions
intentions and/or self-examinations. Exclusion criteria (i) focused were included. Thus, explaining or estimating the effects of each inter-
on survivors of breast cancer (biomedical treatment and rehabilita- vention strategy might be difficult in such cases. Therefore, evidence
tion). (ii) Studies that focused on assessment/descriptive research, that supports the overall effectiveness of the intervention programs
non-intervention studies, drugs research and studies that did not and strategies were reported instead of individual interventions. The
report valid outcome measures. All age groups were included in highlight of each intervention was discussed as follows.
this study review since the recommendation of cancer screening
test varies in developing countries to developed countries; even
there is even no guideline in some countries. Two investigators Individual-based interventions
then independently reviewed all located articles to confirm Phone calls and message-framed interventions
whether inclusion criteria were met. The rest investigators also A study from USA found that there was dramatically significant
reviewed to check its consistency. increase in mammography use among medically un- or under-
insured women to support the evidence of loss-framed message
Synthesis of results and quality assessment and phone calls ([OR] = 1.914 [95%CI 1.20–3.05], P =0 .0063).19
In this systematic review, the authors followed the PRISMA statement Similarly, the studies from Portland Oregon and Iran, indicated
rule.15 The authors reviewed all abstracts for inclusion. In cases of that phone calls with lay health advisors and phone call with
doubt based on abstracts, the articles were included for full-text education intervention had significantly increased in interventional
articles review. The authors independently reviewed all full-text group and correlated with making breast self-examination (BSE) as a
articles to confirm whether inclusion criteria were met or not. The part of a regular schedule (r = 0.57, P = 0.001) and with performing
data were synthesized in two ways: first, the study design and inter- BSEs on an irregular basis (r = 0.38, P = 0.02).20,21 Health education
vention strategies were presented for all 22 studies that met inclusion delivered in person (one to one education) by community health
criteria. Second, the findings of each study were analyzed. The quality
assessment/outcome measure criteria were imposed and the evidence
on intervention effectiveness was reported for a subset of studies
that reported valid outcome measures as indicated in the PRISMA
flow diagram of studies15 (figure 1). Study designs were classified
into randomized controlled trials (RCTs; including cluster RCT
and randomized controlled crossover trial), quasi-experimental
study or non-equivalent control group. In order to present reliable
evidence on intervention effectiveness, quality assessments were
conducted following the criteria Data Collection Checklist from the
Cochrane EPOC guidelines.16 The Jadad scoring system was applied
to the assessment of the quality of the included RCTs17 and the feasi-
bility of creating a checklist for the assessment of the methodological
quality both of randomized and non-randomized studies of health
care interventions to non-RCTs.18 Finally, the interventions were
classified as ‘individual-based’, ‘community-based’, ‘group-based
teachings and training’ and ‘behavioral model based.’

Results
The initial literature search resulted in 1194 records through
database searching for a total of 1085 unique citations. Of the 77
abstracts, 22 studies were included in this review. Ten were RCTs
and 12 Quasi-RCT and non-RCT. A systematic search was detailed Figure 1 PRISMA flow diagram for breast cancer screening articles’
in PRISMA flow diagram as indicated in figure 1. The majority of selection and evaluation
 Systematic review of health promotion interventions 3 of 7

Table 1 Characteristics of health promotion intervention studies and summary of findings

First author & year Country Setting Study population Study design and Intervention and its descriptions Outcome (Intervention
sample size vs. control, if applicable)

Abood et al. (2005)19 USA Population Women Nonequivalent ex- Phone calls and framed messages Odds ratio [OR] = 1.914,
based perimental for intervention groups (Two 2 = 7.48 [95%CI 1.20–
design; 1104 female staff members on site 3.05], P = 0.0063
who received all phone
inquiries at the experimental
public health unit and

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delivered the scripted loss-
framed message
telephonically.)
Rao et al. (2005)24 India Community Rural women Non-randomized Health education on breast Self-examination of the
based intervention cancer and BSE by trained breast increased from 0
study; 360 health workers. to 93% (z = 15.807;
P< 0.001)
Fry et al. (2005)34 USA School based Female students Randomized 90 min intervention consisted of BSE a part of a regular
education inter- an essay, lecture, video routine (r = 0.57, P =
vention study; portraying of breast cancer, 0.001)
197 group discussions, self-test and
instructions on performing
BSEs for a total of 48 h.
Consedine et al. (2007)21 USA Community Black and white Intervention Telephone intervention, Intervention vs. Control =
based women study; 5144 education and training 65.6% vs. 48.9%
Vernon et al. (2008)50 USA Population women veterans RCT; 184 A folder containing (1) a set of No significant difference
based four educational booklets, (2) between intervention
a letter for the woman to group and control
discuss mammography with group (P>0.05)
health-care provider, and (3) a
pamphlet about mammog-
raphy screening through the
Veterans Administration
Gupta et al. (2009)35 India Community Women Pre-post Lecture, pamphlets, flip charts 90.7% practiced (BSE)
based Intervention and demonstration of the five compared with 0% pre-
study; 1000 step method of BSE using test. and over all 53%
audio-visual aids were vs. 43% of BSE practice
administrated.
Nguyen et.al. (2009)25 USA population Vietnamese- RCT; 1100 The intervention group received Mammography use OR =
based American two LHW educational sessions 3.14 (95% CI = 1.98,
women and two telephone calls. Both 5.01) P < 0.001)
groups received targeted
Media education.
Kim et al. (2009)30 USA Community Korean women Quasi-experimen- Stage model based 45-min inter- No statistically significant
based tal study; 300 active breast cancer early intervention effect was
screening health education noted on upward shift
session (GO EARLY) in mam- in stage of readiness
mography use. for mammography use
post intervention (P >
0.05)
Lindberg et al. (2009)20 USA Health care Women RCT, 616 A 30–45 min individual BSE intervention (0–59%
setting counseling session featuring vs. 0–12.2%, P< 0.001)
BSE instruction, training and
practice with silicon models,
identification of barriers to
BSE, and problem-solving. This
intervention was followed by
two brief follow-up telephone
calls.
Akhtar et al. (2010)26 Saudi Health care Arabic women Quasi-experimen- Breast screening program/ 18% of the total
Arabia setting tal study; 1766 campaigns via media channels, population
newspapers, exhibitions, participated in
lectures, information stalls, mammogram
and posters. Awareness with screening, with high
interactive educational recall rate (31.6 %)
sessions.
Arshad et al. (2011)37 USA Community American-Arabic Quasi-experimen- Educational interventions are BSE and mammogram use
based women tal study; 100 delivered by community health regardless of their
workers at their home language preference
together with their adult [OR = 0.15; 95% CI =
female family members 0.04–0.50; (OR = 0.15;
95% CI = 0.04, 0.54, P <
0.05)]

(continued)
4 of 7 European Journal of Public Health

Table 1 Continued

First author & year Country Setting Study population Study design and Intervention and its descriptions Outcome (Intervention
sample size vs. control, if applicable)

Cohen et al. (2010)38 Israel Community Israeli-Arabic Quazi experimen- A religious and cultural Intervention group vs.
based Women tal controlled promoter’s involved training control group (48 % vs.
before and was given for six months by 12.5%)
after design; 67 trained social worker on
culture-specific barriers and
misconceptions.
Bowen et al. (2011)23

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USA Population- women RCT; 1354 Telephone calls.; Web/Internet Mammography in the last
based intervention year intervention (69–
82% vs. 71% as it is)
and BSE Intervention
(40–62% vs. 41–41%)
Engelman et al. (2011)22 USA Health care Women RCT, N = 290 One to one education delivered Intervention group vs.
setting in person by community health control (25–30% vs.
workers. Follow-up telephone 15% to no change )
calls.
Hajian et al. (2011)31 Iran Community Women RCT; 100 HBM constructs based interven- Intervention group vs.
based tion (well-known psychological control [41–82%; vs.
theories health education for 31–62%; P = 0.021 and
breast cancer screening) (x2= 5.6, P = 0.12)]
Ayash et al. (2011)27 USA Community Women Quasi-experimen- Workshops, community-based 68% reported increased
based tal study; 597 participatory approach and understanding of
cultural responsiveness cancer screening, and
trainings sticking to individual 29% increase in
level risks in Arabic language. screening
Dallo et al. (2011)38 USA Health care Women Quasi-experimen- Bilingual educational interven- Cancer knowledge
setting tal study, 866 tion along with physical increased after inter-
examination and screening vention compared with
prior to the interven-
tion (P<0.05)
Eskandari-Torbaghan Iran University Female Staffs Randomized Educational intervention and Behavior scores increased
et al. (2014)28 controlled trial; training based on health belief by 18% [1.21 (2.54)
130 model (perceived susceptibil- vs. 0.15(2.94), P <
ity, perceived benefits, and 0.05]
perceived barriers as well as in
practice)
Khalili et al. (2014)39 Iran Community Women Quasi experimen- Three sessions of training were Cases to control mean
based tal study, 144 held for case group and every score of knowledge
session contained 1 h training. improved (11.7–21.81;
P < 0.001)
Rahman et al. (2014)33 USA Religious Korean Americans RCT; 428 The intervention group slogan There is no significant
institutions Women couple was ‘Healthy Family, Healthy difference between the
Wife’ and the control group two groups (P > 0.05).
slogan was ‘Healthy Family, Both intervention
Healthy Diet’ emphasize on groups have signifi-
breast screening or healthy cantly increased
diet. The intervention group (P<0.05)
30-minute Korean-language
DVD on breast screening,
group discussion immediately
after the video; couple to
complete a discussion activity
at home
Taymoori, et al. (2015)32 Iran Community Iranian women RCT; 184 Health belief model and theory A significant intervention
based of planned behavior based effect was identified (P
health education < 0.0001)
Tuzcu et al. (2016)29 Turkey Community Migrant women Quasi-experimen- Health behavior models based Increased the rate of BSE
based tal study; 200 training in BSE and mammog- 0.8 times and the rate
raphy was displayed visually in of mammography 0.7
the film. TRAINING: times. An increase of
demonstrated proper each unit in health
palpation using the breast motivation increased
model. Two different reminder the rate of clinical
cards BSE card, breast cancer breast examination 1.3
screening methods card) and times and the rate of
an invitation card and mammography 1.5
demonstrated proper times
palpation using the breast
model
 Systematic review of health promotion interventions 5 of 7

Table 2 Jadad assessment criteria for quality assessment of RCTs

Articles Jadad quality criteria Total scores

Randomization Method of Double Method of Withdrawals and

Randomization blinded double blinded dropouts described
described described

Bowen et al. (2011)23 1 1 NR NR 1 3

Engelman et al. (2011)22 1 1 NR NR 1 3
Eskandari-Torbaghan et al. (2014)28 1 NR NR NR 1 2

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Fry (2005)34 1 1 NR NR 1 3
Hajian et al. (2011)31 1 NR NR NR 1 2
Lindberg et al. (2009)20 1 1 NR NR 1 3
Rahman et al. (2014)33 1 1 NR NR 1 3
Vernon et al. (2008)50 1 NR NR NR 1 2
Taymoori et al. (2015)32 1 1 NR NR 1 3
Nguyen et al. (2009)25 1 1 NR NR 1 3

Note: 1= Yes; 0 = No; NR, not reported.

Table 3 Shows downs and black checklist for assessing the quality of non-randomized trials and quazi-experimental studies

Articles Downs and black criteria for non-RCT Total score

(Total points/27)
Reporting External validity Bias Confounding Power
(10 points) (3 points) (7 points) (6 points) (1 point)

Abood et al. (2005)19 8 1 3 3 0 0.56

Akhta et al. (2010)26 4 2 2 3 0 0.41
Arshad et al. (2011)37 6 1 4 2 0 0.48
Ayash et al. (2011)27 7 1 2 2 0 0.44
Cohen (2010)36 6 1 3 2 0 0.44
Consedine et al. (2007)21 5 1 3 1 0 0.37
Dallo et al. (2011)38 7 3 3 4 0 0.63
Gupta et al. (2009)35 7 3 4 4 0 0.67
Khalili et al. (2014)39 7 1 3 2 0 0.48
Kim (2009)30 6 1 3 2 0 0.44
Rao et al. (2005)24 7 2 4 2 0 0.52
Tuzcu et al. (2016)29 7 1 3 2 0 0.48

Note: 1= Yes; 0 = No; 0 = unable to determine.

worker through follow up telephone calls and web based interven- Group-based teachings and training
tion had significantly increased the screening uptake.22,23
Health education model-based interventions
Health belief model and theory of planned behavior based health
education on BSE and mammography displayed visually in the film
Community-based interventions
and demonstrated proper palpation using the breast model increased
A community-based educational intervention through demonstra- behavior scores by 18% (1.21 (+ 2.54) vs. 0.15(+2.94), P < 0.05).28,29
tion of BSE stressing on thoroughness and the recommended However, stage model based interactive breast cancer early screening
technique significantly increased the overall awareness regarding health education session (GO EARLY) in mammography use had no
breast cancer screening (z = 15.807; P < 0.001) as well as in the statistically significant effect on the upward shift in stage of readiness
performance of self-examination of the breast increased from 0% for mammography use post intervention (P > 0.05) in Korean
to93% in Indian women.24 In contrast, an intervention through the women, USA and other countries like Iran.28,30–32
targeted component consisted of a folder containing educational
booklets, a letter for the woman from health-care provider, and a
pamphlet about mammography screening services had resulted in no
significant difference between intervention group and control group
Interventions using video, visuals and audio-visuals
by Cox modeling; however, analysis using logistic regression The intervention including couples vs. diet emphasizing the
produced odds ratios (ORs) that were consistently higher than the importance of the husband’s support in promoting family health
corresponding hazard rate ratios for both coverage and compliance by encouraging breast cancer screening or healthy diet through
(ORs = 1.15–1.29).21 mass media plus DVD plus late group discussions at home did
Integrating multiple methods to convey breast cancer screening not show significant effect in screening (P > 0.05).33,34 An Indian
campaign such as newspapers, exhibitions, lectures, information study revealed the use of lecture, pamphlets, flip charts and demon-
stalls and posters had significantly increased mammography use in stration of the five-step method of BSE using audio-visual increased
2009 study (OR= 3.14 (95% CI = 1.98, 5.01) and in numerical BSE practice by 90.7% compared to 0% pre-test and the BSE
screening values.25–27 practice overall increment was 53–43%.35
6 of 7 European Journal of Public Health

Religious, cultural promoters and lay workers A community level educational intervention emphasizing
religious, cultural promoters and lay workers boosted overall
A study from Israel on Arabic women found that culture-based
awareness regarding breast cancer screening as well as the perform-
interventions increased the rate of attending for clinical examination
ance of self-examination (in Indian women, USA migrants).24 For
and mammography [intervention group vs. the control group (48%
breast cancer screening, evidence was found to support the effect-
vs. 12.5%)].36 The training involving both religious and cultural
iveness of the following intervention strategies: community-based
health promoters by trained social and community health workers
group education plus culturally sensitive educational materials
at home together with adult female members had a significant effect
plus physician consultations.10,40,44,49 In contrast, an intervention
on BSE and mammography use [OR = 0.15; 95% CI = 0.04–0.50;
based on the targeted component consisted of a folder containing
(OR = 0.15; 95% CI = 0.04, 0.54, P < 0.05)].37–39

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a set of four educational booklets, a letter for the woman to use to
Thus, the overall aim of the interventions to increase the uptake of
discuss mammography with her health-care provider, and a
screening through a variety of health promotion strategies by
pamphlet about mammography screening services had no significant
integrating and increasing the awareness of health care professionals,
difference between intervention group and control group.50
community, lay health workers and community stakeholders was
However, compared with the literature of screening intervention
almost successful.
on general Caucasian population, the patterns of intervention
design and results of effectiveness with those observed from the
Discussion literature targeting general Caucasian population tend to be more
heterogeneous. This is in line with the complexity and challenges in
The review confirmed that the most common health promotion interventions targeting ethnic groups.45,49 For sure, many western
interventions in breast cancer initiatives targeting women boosted group and community-based interventions did not show a clear
the breast cancer screening in one or another way. However, het- recommendation for further use.10,44,51,52 Surprisingly, almost all
erogeneity between the trials limited the statistical pooling of data. studies included were from western countries, but no studies
Evidence regarding the effectiveness of other interventions such as appeared in search engine from African countries. The African
behavioral interventions, counseling and risk factor assessment was studies might focus more on problem definition than recognizing
limited by the number of included trials and their moderate or high the value of interventions. If so, health promotion researchers
risk of bias. should appreciate the value of the interventions rather than giving
Tables 2 and 3 show the evaluation criteria reported from the problem definition and simply assessing the already answered
selected studies. These characteristics must be interpreted with questions.
caution, as they by no means give the full picture of indicators This review has several limitations. Primarily, it includes only
used in health promotion interventions. Therefore, it is difficult to English language published articles and it did not give any room
arrive at a conclusive and generalizable conclusion on the effective- for studies published in other languages and also did not include
ness of any particular intervention.17,18 gray literature that may have overlooked this valuable information.
To this end, the evidence shows that effectiveness in boosting Secondly, the majority of the researches were conducted in the
screening uptake is greatest for the simple to administer interven- United States on migrant women. This might lead us to refrain
tions, rather than in depth ones.10 These tend to be the ‘individual- from generalizing the specific countries set-up and might be
based’ category, e.g. methods of invitation women. Indeed, most different in permanent residents of the countries linked to cultural
interventions were of the individual based category.19,20,22,29–32 differences, access to services and health care system especially issues
This might be, partly, because these interventions are easier to related to access to breast cancer screening and even affordability of
carry out and evaluate than those of the other categories. the cost.
The different categories of intervention such as individual-based, In conclusion, although there were noted differences across
community-based and mixed or multi-strategy were taken to con- studies, most studies in this review noted favorable outcomes after
ceptualize these interventions in understanding the effectiveness of health promotion interventions including improvements in partici-
them and how they fit into the present screening system. A review of pants’ view of breast screening, BSE skill, and satisfaction with breast
interventions to increase breast screening focused on women cancer screening educational interventions. Benefits were seen in
lifespan and ethnicity issues in the United States studies had different resident populations and using both general and specific
shown similar implications.40 scenarios. Our results confirmed that the most common health
Individual level framed message and phone calls are contempor- promotion intervention in breast cancer initiatives targeting
ary technologies used in facilitating several interventions and noted women boosted the breast cancer screening in one or another way.
in boosting of screening uptake in this review in USA and Indian It is likely that other methods are advantageous, but the evidence is
studies.19,20,22,29–32,37 This is also supported by Lu et al. systematic not as strong. Research on breast screening uptake has clearly moved
review of interventions to increase breast and cervical cancer on from the problem definition stage to the next phase of assessing
screening uptake among Asian women.10 Behavioral model based the value of interventions. However, the limited quality of the
behavioral interventions like stage model and health belief model included studies showed that further research is required to
mainly developed to intrapersonal communication in their develop simple and effective intervention to improve the trials in
intention but further explicit implication seen in individual level the next future.
intervention boosted screening in this review.28–32 and in various
findings.41–44 Supplementary data
The intervention including couples with diet emphasizing the
importance of the husband’s support by encouraging breast cancer Supplementary data are available at EURPUB online.
screening uptake was more effective than the interventions focusing
on healthy diet through mass media at home did not show an effect Conflicts of interest: None declared.
in screening (Korean women).33 The evidence from the other studies
did not support the effectiveness of complex community level inter-
ventions.10,41–46 Lecture, pamphlets, flip charts and demonstration Key points
of the method of BSE using audio-visuals were increased BSE.35 This
evidence was supported by a number of western groups and  To provide evidence on the effectiveness of the health
individual model-based intervention studies though their focus promotion interventions.
was not only on primary prevention.10,44,47,48
 Systematic review of health promotion interventions 7 of 7

17 Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized
 To find research gap and to improve knowledge in the field clinical trials: is blinding necessary? Controlled Clin Trials 1996; 17: 1–12.
of health education. 18 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
 To develop effective interventions targeting women. methodological quality both of randomised and non-randomised studies of health
 To develop guidelines important for breast screening uptake. care interventions. J Epidemiol Commun Health 1998; 52: 377–84.
 To see professional contribution in the field of health 19 Abood DA, Black DR, Coster DC. Loss-framed minimal intervention increases
promotion. mammography use. Women’s Health Issues 2005; 15: 258–64.
20 Lindberg NM, Stevens VJ, Smith KS, et al. A brief intervention designed to increase
breast cancer self-screening. Am J Health Promotion 2009; 23: 320–3.
Acknowledgements

Downloaded from https://academic.oup.com/eurpub/advance-article-abstract/doi/10.1093/eurpub/ckx231/4812600 by guest on 18 October 2018

21 Consedine NS, Horton D, Magai C, et al. Breast screening in response to gain, loss,
We would like to acknowledge all staff members of department of and empowerment framed messages among diverse, low-income women. J Health
Care Poor Underserved 2007; 18: 550–66.
health education and health promotion, school of public health,
International Campus of Tehran University of Medical Sciences 22 Engelman KK, Cupertino AP, Daley CM, et al. Engaging diverse underserved
for their unreserved administrative support during this manuscript communities to bridge the mammography divide. BMC Public Health 2011; 11: 47.
writing. Special thanks go to the Tehran University of Medical 23 Bowen DJ, Robbins R, Bush N, et al. Effects of a Web-based intervention on
Sciences digital library for available search there in the library. women’s breast health behaviors. Transl Behav Med 2011; 1: 155–64.
24 Rao R, Nair S, Nair NS,. et al. Acceptability and effectiveness of a breast health
awareness programme for rural women in India. Indian J Med Sci 2005; 59: 398.
25 Nguyen TT, Le G, Nguyen T, et al. Breast cancer screening among Vietnamese
References Americans: a randomized controlled trial of lay health worker outreach. Am J
1 Fitzmaurice C, Dicker D, Pain A, et al. The global burden of cancer 2013. JAMA Prevent Med 2009; 37: 306–13.
Oncol 2015; 1: 505–27. 26 Akhtar S, Nadrah H, Al-Habdan M, et al. First organized screening mammography
2 Coleman MP, Forman D, Bryant H, et al. Cancer survival in Australia, Canada, programme in Saudi Arabia: preliminary analysis of pilot round/Premier
Denmark, Norway, Sweden, and the UK, 1995–2007 (the International Cancer programme de mammographie de depistage en Arabie saoudite: rapport
Benchmarking Partnership): an analysis of population-based cancer registry data. preliminaire de l’operation pilote. East Mediterr Health J 2010; 16: 1025.
The Lancet 2011; 377: 127–38. 27 Ayash C, Axelrod D, Nejmeh-Khoury S, et al. A community intervention: AMBER:
3 Alteri R, Bandi P, Brinton L, et al. Breast Cancer Facts & Figures 2011–2012. Arab American breast cancer education and referral program. J Immigr Minority
American Cancer Society, Atlanta, Georgia 2011. Health 2011; 13: 1041.

4 Boyle P, Levin B. World Cancer Report 2008. IARC Press, International Agency for 28 Eskandari-Torbaghan A, Kalan-Farmanfarma K, Ansari-Moghaddam A, et al. Improving
Research on Cancer, Lyon, 2008. breast cancer preventive behavior among female medical staff: the use of educational
intervention based on health belief model. Malay J Med Sci: MJMS 2014; 21: 44.
5 Danaei G, Vander Hoorn S, Lopez AD, et al. Causes of cancer in the world: com-
parative risk assessment of nine behavioural and environmental risk factors. The 29 Tuzcu A, Bahar Z, Gözüm S. Effects of interventions based on health behavior
Lancet 2005; 366: 1784–93. models on breast cancer screening behaviors of migrant women in Turkey. Cancer
nursing 2016; 39: E40–50.
6 Lacey JV, Kreimer AR, Buys SS, et al. Breast cancer epidemiology according to
recognized breast cancer risk factors in the Prostate, Lung, Colorectal and Ovarian 30 Kim JH, Menon U. Pre-and postintervention differences in acculturation,
(PLCO) Cancer Screening Trial Cohort. BMC Cancer 2009; 9: 84. knowledge, beliefs, and stages of readiness for mammograms among Korean
American women. Oncol Nurs Forum 2009, 36:E80–92.
7 Kratzke C, Vilchis H, Amatya A. Breast cancer prevention knowledge, attitudes, and
behaviors among college women and mother–daughter communication. J Commun 31 Hajian S, Vakilian K, Najabadi KM, et al. Effects of education based on the health
Health 2013; 38: 560–8. belief model on screening behavior in high risk women for breast cancer, Tehran,
Iran. Asian Pac J Cancer Prev 2011; 12: 49–54.
8 Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA: a cancer journal for
clinicians 2015; 65: 5–29. 32 Taymoori P, Molina Y, Roshani D. Effects of a randomized controlled trial to increase
repeat mammography screening in Iranian women. Cancer Nurs 2015; 38: 288.
9 Peto J. Cancer epidemiology in the last century and the next decade. Nature 2001;
411: 390–5. 33 Rahman SM, Harris CM, Mitchell M, KF Soliman KE. Perceptions related to breast
cancer prevention and behavioral practices in underserved women participated in a
10 Lu M, Moritz S, Lorenzetti D, et al. A systematic review of interventions to increase
CBPR intervention. Cancer Research 2014; 74(19 Suppl): 5056–5056.
breast and cervical cancer screening uptake among Asian women. BMC public health
2012; 12: 413. 34 Fry RB, Prentice-Dunn S. Effects of a psychosocial intervention on breast self-
examination attitudes and behaviors. Health Educ Res 2005; 21: 287–95.
11 Corkum M, Hayden JA, Kephart G, et al. Screening for new primary cancers in
cancer survivors compared to non-cancer controls: a systematic review and meta- 35 Gupta SK, Pal D, Garg R, et al. Impact of a health education intervention program
analysis. J Cancer Survivorship 2013; 7: 455–63. regarding breast self examination by women in a semi-urban area of Madhya
Pradesh, India. Asian Pac J Cancer Prev 2009; 10: 1113–7.
12 Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast examination: pre-
liminary results from a cluster randomized controlled trial in India. J Natl Cancer 36 Cohen M, Azaiza F. Increasing breast examinations among Arab women using a
Inst 2011; 103: 1476–80. tailored culture-based intervention. Behav Med 2010; 36: 92–9.

13 Yip C-H, Cazap E, Anderson BO, et al. Breast cancer management in middle- 37 Arshad S, Williams KP, Mabiso A, et al. Evaluating the knowledge of breast cancer
resource countries (MRCs): consensus statement from the Breast Health Global screening and prevention among Arab-American women in Michigan. J Cancer
Initiative. The Breast 2011; 20:S12–9. Educ 2011; 26: 135–8.

14 Masi CM, Blackman DJ, Peek ME. Interventions to enhance breast cancer screening, 38 Dallo FJ, Zakar T, Borrell LN, et al. Cancer knowledge increases after a brief
diagnosis, and treatment among racial and ethnic minority women. Med Care Res intervention among Arab Americans in Michigan. J Cancer Educ 2011; 26: 139–46.
Rev 2007;64:195S–242S. 39 Khalili S, Shojaiezadeh D, Azam K, et al. The effectiveness of education on the health
15 Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic beliefs and practices related to breast cancer screening among women referred to
reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097. Shahid Behtash Clinic, Lavizan area, Tehran, using health belief model. J Health
2014; 5: 45–58.
16 Mowatt G, Grimshaw JM, Davis DA, et al. Getting evidence into practice: the work
of the Cochrane Effective Practice and Organization of Care Group (EPOC). 40 Rimer BK. Interventions to increase breast screening: lifespan and ethnicity issues.
J Contin Educ Health Prof 2001; 21: 55–60. Cancer 1994; 74: 323–8.