Background

The review focuses on two types of screening: risk factor screening (cholesterol) and screening for early disease (breast and cervical cancer). Risk factor screening involves a strategy for primary prevention, whereas early or preclinical disease screening is secondary prevention.

Screening can be delivered as a systematic programme, an 'opportunistic' programme or an 'open-access' programme. A systematic programme is provider led and will actively seek out the eligible population and invite them to participate in screening. Opportunistic screening occurs when a patient consults a health professional about an unrelated problem, and the opportunity is taken (by a healthcare provider) to offer and conduct the screening. Open-access screening is user led, where the screened population is self-selected.

Objectives

To carry out a systematic review to examine the effects of cholesterol, breast and cervical cancer screening on actual or intended health-promoting behaviours and health-related beliefs.

In particular, the review addressed the following questions:

• What are the effects of screening for hypercholesterolaemia, breast cancer and cervical cancer on future health beliefs and behaviours?
• What are the implications for the NHS?

Methods

Results

The study designs used in the three screening types differed. The cholesterol studies used prospective designs more frequently. This may be explained by differing research agendas as the majority of the cholesterol papers were interested in observing changes in lifestyle following screening. However, participants who went for breast or cervical screening were not offered advice on lifestyle changes and most of the research into cancer screening programmes investigated issues related to uptake of screening services, explanations of why people are or are not screened and interventions to improve uptake.

All three screening programmes are associated with high levels of favourable health behaviours and beliefs that have been measured, although there is evidence that recommended follow-up after screening is often not adhered to. However, most of the research has been restricted to outcomes related to the condition being screened for (e.g. cancer-related beliefs as related to cancer screening). To explore fully the effects of screening on future health behaviours and beliefs a much wider range of outcomes should be studied. There were very few qualitative studies that could have provided a better understanding of how and why participants in screening are affected by the processes they have undergone.

There was no literature on the cost-effectiveness regarding the wider implications of screening (only on reduction of disease-specific mortality/morbidity). This is possibly due to the outcomes being very broad and not easily categorised and classified.

Conclusions

Recommendations for research

To answer the question posed by the review, further research needs to be undertaken to include:

• measuring a much wider range of behaviours and beliefs (including long-term lifestyle changes) before and after screening is accepted or declined, to measure changes that could be attributed to screening
• specifically in cholesterol screening: the subgroup of participants who receive 'desirable' results and the impact of this on health beliefs and health-promoting behaviour
• qualitative research into the experiences of screening and how this interacts with knowledge and beliefs about other aspects of health, not simply those relating to the condition being screened for.

Publication

• Bankhead CR, Brett J, Bukach C, Webster P, Stewart-Brown S, Munafo M, et al. The impact of screening on future health-promoting behaviours and health beliefs: a systematic review. Health Technol Assess 2003;7(42). [PubMed: 14670217]

NHS R&D HTA Programme

The NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS.

Initially, six HTA panels (pharmaceuticals, acute sector, primary and community care, diagnostics and imaging, population screening, methodology) helped to set the research priorities for the HTA Programme. However, during the past few years there have been a number of changes in and around NHS R&D, such as the establishment of the National Institute for Clinical Excellence (NICE) and the creation of three new research programmes: Service Delivery and Organisation (SDO); New and Emerging Applications of Technology (NEAT); and the Methodology Programme.

This has meant that the HTA panels can now focus more explicitly on health technologies ('health technologies' are broadly defined to include all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care) rather than settings of care. Therefore the panel structure was replaced in 2000 by three new panels: Pharmaceuticals; Therapeutic Procedures (including devices and operations); and Diagnostic Technologies and Screening.

The HTA Programme will continue to commission both primary and secondary research. The HTA Commissioning Board, supported by the National Coordinating Centre for Health Technology Assessment (NCCHTA), will consider and advise the Programme Director on the best research projects to pursue in order to address the research priorities identified by the three HTA panels.

The research reported in this monograph was funded as project number 96/23/56.

The views expressed in this publication are those of the authors and not necessarily those of the HTA Programme or the Department of Health. The editors wish to emphasise that funding and publication of this research by the NHS should not be taken as implicit support for any recommendations made by the authors.

Criteria for inclusion in the HTA monograph series

Reports are published in the HTA monograph series if (1) they have resulted from work commissioned for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors.

Reviews in Health Technology Assessment are termed 'systematic' when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.

HTA Programme Director: Professor Kent Woods

Series Editors: Professor Andrew Stevens, Dr Ken Stein, Professor John Gabbay, Dr Ruairidh Milne, Dr Chris Hyde and Dr Rob Riemsma

Managing Editors: Sally Bailey and Sarah Llewellyn Lloyd

The editors and publisher have tried to ensure the accuracy of this report but do not accept liability for damages or losses arising from material published in this report. They would like to thank the referees for their constructive comments on the draft document.