João Firmino-Machado

Cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening

Abstract Background Cervical cancer screening is effective in reducing mortality, but adherence is generally low. We aimed to investigate the cost-effectiveness of a stepwise intervention to promote adherence to cervical cancer screening in Portugal. Methods We developed a decision tree model to compare the cost-effectiveness of four competing interventions to increase adherence to cervical cancer screening: (i) a written letter (standard-of-care); (ii) automated short message service text messages (SMS)/phone calls/reminders; (iii) automated SMS/phone calls/reminders + manual phone calls; (iv) automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. The main outcome measure was cost per quality-adjusted life year (QALY) measured over a 5-year time horizon. Costs were calculated from the societal and provider perspectives. Results From the societal perspective, the optimal strategy was automated SMS/phone calls/reminders, below a threshold of €8171 per QALY; above this and below €180 878 per QALY, the most cost-effective strategy was automated SMS/phone calls/reminders + manual phone calls and above this value automated SMS/phone calls/reminders + manual phone calls + face-to-face interviews. From the provider perspective, the ranking of the three strategies in terms of cost-effectiveness was the same, for thresholds of €2756 and €175 463 per QALY, respectively. Conclusions Assuming a willingness-to-pay threshold of one time the national gross domestic product (€22 398/QALY), automated SMS/phone calls/reminders + manual phone calls is a cost-effective strategy to promote adherence to cervical cancer screening, both from the societal and provider perspectives.

How can cervical screening meet the needs of vulnerable women? A qualitative comparative study with stakeholder perspectives from seven European countries

Objective This study explored and compared stakeholder perspectives on enhancements to cervical cancer screening for vulnerable women across seven European countries. Design In a series of Collaborative User Boards, stakeholders were invited to collaborate on identifying facilitators to improve cervical cancer screening. Setting This study was part of the CBIG-SCREEN project which is funded by the European Union and targets disparities in cervical cancer screening for vulnerable women ( www.cbig-screen.eu ). Data collection took place in Bulgaria, Denmark, Estonia, France, Italy, Portugal and Romania. Participants Represented stakeholders at various levels, including user representatives (vulnerable women), healthcare professionals, social workers, programme managers and decision makers. Methods 14 meetings lasting 2 hours each were held in these seven countries between October 2021 and June 2022. The meetings were audio or video recorded, transcribed and translated into English for qualitative framework analysis. Results We engaged 120 participants in the Collaborative User Boards. Proposed solutions targeted both provider and system levels. In all countries, fostering trusting relationships between vulnerable women and social or healthcare professionals, coupled with community outreach for awareness and access to testing was a consistent recommendation. Participants in Estonia, Denmark, France, Italy, Portugal and Romania advocated for tailoring healthcare services to meet the unique needs of vulnerable populations through a holistic approach. In Bulgaria and Romania, participants advocated for the need to secure free access, from screening to follow-up, and emphasised the need for organised screening with target population screening registries. Conclusion The study offers insights into stakeholders' recommendations for enhancing cervical cancer screening services for vulnerable women across seven European countries. Despite variations in the implementation level of population-based screening programmes, the imperative to optimise outreach and proximity work to improve cervical cancer screening resonated across all countries.

What are the barriers towards cervical cancer screening for vulnerable women? A qualitative comparative analysis of stakeholder perspectives in seven European countries

Objectives The aim of this study was to map and compare stakeholders’ perceptions of barriers towards cervical cancer screening for vulnerable women in seven European countries. Design In Collaborative User Boards, stakeholders were invited to participate to identify barriers towards participation in cervical cancer screening. Setting The study is nested in the European Union-funded project CBIG-SCREEN which aims to tackle inequity in cervical cancer screening for vulnerable women ( www.cbig-screen.eu ). Data collection took place in Bulgaria, Denmark, Estonia, France, Italy, Portugal and Romania. Participants Participants represented micro-level stakeholders covering representatives of users, that is, vulnerable women, meso-level stakeholders covering healthcare professionals and social workers, and macro-level stakeholders covering programme managers and decision-makers. Methods Across the seven countries, 25 meetings in Collaborative User Boards with a duration of 2 hours took place between October 2021 and June 2022. The meetings were video recorded or audio recorded, transcribed and translated into English for a qualitative framework analysis. Results 120 participants took part in the Collaborative User Boards. Context-specific barriers were related to different healthcare systems and characteristics of vulnerable populations. In Romania and Bulgaria, the lack of a continuous screening effort and lack of ways to identify eligible women were identified as barriers for all women rather than being specific for women in vulnerable situations. The participants in Denmark, Estonia, France, Italy and Portugal identified providers’ lack of cultural and social sensitivity towards vulnerable women as barriers. In all countries, vulnerable women’s fear, shame and lack of priority to preventive healthcare were identified as psychological barriers. Conclusion The study provides an overview of stakeholders’ perceived barriers towards vulnerable women’s cervical cancer screening participation in seven European countries. The organisation of healthcare systems and the maturity of screening programmes differ between countries, while vulnerable women’s psychological barriers had several similarities.