Cancer Prevention & Control, Client-Oriented Screening Interventions: Reducing Structural Barriers

Structural barriers are non-economic burdens or obstacles that make it difficult for people to access cancer screening. Interventions designed to reduce these barriers may facilitate access to cancer screening services by:

• Reducing time or distance between service delivery settings and target populations
• Modifying hours of service to meet client needs
• Offering services in alternative or non-clinical settings (e.g., mobile mammography vans at worksites or in residential communities)
• Eliminating or simplifying administrative procedures and other obstacles (e.g., scheduling assistance, patient navigators, transportation, dependent care, translation services, limiting the number of clinic visits)

Such interventions often include one or more secondary supporting measures, such as:
• Printed or telephone reminders
• Education about cancer screening
• Information about screening availability (e.g., group education, pamphlets, or brochures)
• Measures to reduce out-of-pocket costs to the client (though interventions principally designed to reduce client costs are considered to be a separate class of approaches)

Summary of Task Force Recommendations & Findings

The Community Preventive Services Task Force recommends interventions to reduce structural barriers to increase screening for breast and colorectal cancers (by mammography and FOBT, respectively) on the basis of strong evidence of effectiveness. Evidence is insufficient, however, to determine whether reducing structural barriers is effective in increasing colorectal cancer screening by flexible sigmoidoscopy or colonoscopy because only one study using these screening procedures were identified. Evidence is also insufficient to determine the effectiveness of the intervention in increasing screening for cervical cancer because only three relevant studies were identified, and these had some methodological limitations.

Task Force Finding & Rationale Statement

Results from the Systematic Reviews

The Task Force findings are based on evidence from a previously completed review (search period 1966-2004) and an updated review (search period 2004-2008). Updates of reviews are conducted to incorporate more recent evidence.

Read a summary of findings from the previous review or visit the Cancer Prevention and Control section of our publications page to access the complete articles.

Breast Cancer

Results of the Original Review

The original breast cancer screening review included seven studies.

• Mammography screening: median increase of 17.7 percentage points (interquartile interval [IQI]: 11.5 to 30.5 percentage points).

Results of the Updated Review

One additional study qualified for the updated review.

• Mammography screening: increase of 18 percentage points
• Clinical breast examinations: increase of 34 percentage points

The Task Force recommendation should apply across a range of populations and settings, provided that the program is adapted to the target population and delivery context.

Find a Research-Tested Intervention Program (RTIP) about reducing structural barriers to increase breast cancer screening (What is an RTIP?).

Cervical Cancer

Three studies qualified for the review.

• Pap screening: median increase of 13.6 percentage points (range: 5.9-17.8)
• While these results were in the favorable direction, the studies had some methodological limitations.

Colorectal Cancer

Results of the Original Review

The original colorectal cancer screening review included seven studies.
• Screening by FOBT: median increase of 16.1 percentage points (IQI: 12.1 to 22.9 percentage points)

Results of the Updated Review

Five additional studies qualified for the updated review.
• Colorectal cancer screening: median increase of 36.9 percentage points (range: 16.3 to 41.1 percentage points; 4 study arms)
• The larger intervention effect during the update period imay be at least partially due to differences in target populations, baseline rates of screening, and study designs.

The Task Force recommendation should be applicable across a range of settings where target populations may have limited physical access to FOBT.

These findings were based on a systematic review of all available studies, conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to cancer prevention and control.

Publications

More Community Guide publications about Cancer Prevention and Control, including articles for the original review.

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Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation:
Guide to Community Preventive Services. Cancer prevention & control, client-oriented screening interventions: reducing structural barriers. www.thecommunityguide.org/cancer/screening/client-oriented/ReducingStructuralBarriers.html. Last updated: MM/DD/YYYY.

Review completed: March 2010