The effects of screening on health behaviour: a summary of the results of randomized controlled trials

Journal of Public Health, Mar 2011

Background Screening aims to improve health by early detection of disease or risk factors for disease. It may also influence health behaviour, either by intention or as a side effect. The aim of this review was to summarize evidence of the effects of screening, either risk factor screening or screening for early detection of disease, on health behaviour: smoking habits, diet, exercise, alcohol consumption and adherence to guidelines for healthy living.

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The effects of screening on health behaviour: a summary of the results of randomized controlled trials

Journal of Public Health | The effects of screening on health behaviour: a summary of the results of randomized controlled trials Marije Deutekom 1 2 3 Fleur Vansenne 1 2 Kirsten McCaffery 0 2 Marie-Louise Essink-Bot 2 3 Karien Stronks 2 3 Patrick M.M. Bossuyt 1 2 0 Screening and Test Evaluation Program, School of Public Health, University of Sydney , Sydney , Australia 1 Department of Clinical Epidemiology and Biostatistics from the Academic Medical Centre , Amsterdam , The Netherlands 2 Marije Deutekom , Senior Researcher, Public Health Fleur Vansenne , Researcher , Clinical Epidemiology Kirsten McCaffery, Assistant Professor, Public Health Marie-Louise Essink-Bot , Assistant Professor, Public Health Karien Stronks , Professor, Public Health Patrick M.M. Bossuyt , Professor , Clinical Epidemiology 3 Department of Public Health , Room K2-207, Meibergdreef 9, 1105 AZ Amsterdam , The Netherlands A B S T R AC T Background Screening aims to improve health by early detection of disease or risk factors for disease. It may also influence health behaviour, either by intention or as a side effect. The aim of this review was to summarize evidence of the effects of screening, either risk factor screening or screening for early detection of disease, on health behaviour: smoking habits, diet, exercise, alcohol consumption and adherence to guidelines for healthy living. Methods This review included randomized controlled trials (RCTs) comparing the effects of screening on health behaviour in a screened group and an unscreened group. Systematic searches of Medline, CCTR and Embase between 1970 and May 2008 were conducted. Results Seven trials were included, five on screening for risk factors (four cardiovascular; one ALDH2) and two on screening for early detection of disease (colorectal cancer and hearing loss). In trials of screening for risk factors, health behaviour was on average significantly more favourable in screened individuals. The number of trials on screening for early detection of disease was too small to allow for conclusions on effects on health behaviour. Conclusion The number of trials studying the effect of population-based screening programmes on health behaviour is limited. The trials on screening for risk factors suggest a positive effect on health behaviour, while the number of trials on screening for early detection of disease was too low to draw conclusions on subsequent health behaviour. Future RCTs of screening interventions should systematically include health behaviour effects in their study design. exercise; health behaviour; risk factors; screening; smoking Background Methods Search strategy This review included RCTs studying the effects of screening on health behaviour in a screened group and an unscreened group. Systematic searches of electronic databases were conducted, including National Library of Medicine (Medline; 1966 onwards), Cochrane Controlled Trial Register (CCTR) and Embase (1980 onwards). The searches were conducted in May 2008. The following search strategies were used: (health AND behaviour) OR lifestyle OR diet OR exercise OR smoking OR life style mesh OR risk reduction behaviour mesh OR health behaviour mesh AND mass screening mesh AND (Clinical trialpt OR randomizedtiab OR placebotiab OR clinical trialsmh OR randomlytiab OR trialti) NOT (animalsmh NOT (animalsmh AND humansmh)) (Medline) (diet or smoking or exercise or (health and behaviour) or lifestyle).mp AND mass screening/AND (Clinical tria$ or randomized or randomized or placebo or control or randomly or trial).mp (Embase) and (health AND behaviour) OR lifestyle OR diet OR exercise OR smoking OR life style OR risk reduction behaviour) AND mass screening mesh in Clinical Trials (CCTR). No language restrictions were used. The reference sections of the obtained articles were also studied and requests for unpublished studies were circulated among colleagues. A methodological filter to identify RCTs was used.12 Possibly eligible papers were downloaded into Reference Manager. Inclusion criteria were: randomized study on screening in healthy adults (aged 18 and above), measurement of health behaviour. Health behaviour was defined as any data on smoking habits, diet, exercise, alcohol consumption or adherence to guidelines of healthy living. Studies were not included when they investigated health intentions only, when they focused solely on improving the uptake of screening, or reattendance at screening when next invited, or when they investigated the effect on families (significant others) and social environment. When RCTs were found compared screened and unscreened individuals on clinical variables but did not mention any health behaviour variables, the corresponding author was contacted and asked whether he and his colleagues had collected such data. If so, these unpublished data were also included in the review. Study selection potentially eligible trial were then obtained for further assessment of eligibility by two authors (M.D. and F.V.). Any disagreements were resolved by discussion. Data extraction Data regarding inclusion criteria, study characteristics and results (study design, participants, interventions and outcomes) were extracted. Data analysis Due to the small number of included studies and marked heterogeneity in the type of screening, study population, length of follow-up and outcome assessment measures, we made no attempts at statistically pooling the data in a meta-analysis. Instead a qualitative synthesis of the results is presented. All dichotomous variables were analyzed, if possible, with Chi-square statistics to compare differences between the screened and unscreened groups. For all statistical tests P-values ,0.05 were considered to represent statistically significance. Results Retrieval of papers In total 1953 manuscripts were retrieved, of which 621 were duplicates. The remaining 1332 manuscripts were assessed for eligibility by reading title and abstract. This resulted in 107 potentially eligible trials. Based on the complete manuscripts 100 of these studies could not be included. In total, seven trials13 – 19 met our inclusion criteria (see Fig. 1). Medline (n = 1128) CCTR (n = 438) Embase (n = 360) Cinahl (n = 0) Retrieved papers (n = 1953) Assessed eligibility (n = 1332) Full citations (n = 107) Total included (n = 7) Duplicates (n = 621) Exclusion (n = 1225) Exclusion (n = 100) Fig. 1 Search strategy. place,14,16 in one study14 individuals were randomly drawn from the population registry. The follow-up length varied from 3 months19 to 5 years.15 Different forms of health behaviour were studied: smoking in three studies,13,17,18 diet in three studies,13,16,18 exercise in two studies,13,18 alcohol consumption in two studies,14,18 and adherence to given advice (testing for cholesterol and avoidance of noise) in two studies.15,19 ed ed .r s s a u u e s l y p p ro 1 3 -u u t r r w lrgo lcon .w ftae ftae llfoo trno rean irvee ltssu ltssu fso se co itn is re r-e th to ow tu th ts tso no N T b in Po P m 5 U Pa in % ): 1 , p ).1 :3 % -u 0 C 2 w .0 ,% I:2 lloo P(¼ I:32 i.ren ilf-en 2% li;k rag sea 2 a b Effects of early detection of disease screening Only two studies dealt with screening for early detection of disease.13,15 The study of Larsen et al.13 investigated the effects of screening for colorectal cancer on smoking, diet and exercise. The study of Karlsmose et al.15 investigated the effects of screening for hearing loss on exposure to noise. In the trial of colorectal cancer smoking,13 and diet were measured on a scale from 1 (never) to 6. For smoking ‘6’indicated ‘.20 cigarettes per day’ and for diet ‘consumption .3 times per day’. Exercise was measured on a scale from 2 to 12. Unscreened individuals showed a decline in smoking of 0.14 points (baseline score: 2.49) versus 0.11 in the screened group (baseline score: 2.56) (P ¼ 0.013; P-value from original article and derived from linear regression analyses). Diet was measured with various variables: servings of fruit, berries and vegetables, consumption of boiled potatoes, poultry, meat, fatty fish and chocolate. The screened group lowered their consumption of fruit, berries and vegetables with 0.13 points (baseline score: 2.28), whereas the unscreened group increased their intake with 0.04 points (baseline score: 2.15; difference between screened and unscreened group: 0.17: P ¼ 0.001; derived from linear regression analyses). No difference in intake was detected between the screen negatives and the screen positives (P ¼ .346). The improvement in the amount of exercise in the screened group was significantly lower (P , 0.001) than in the unscreened group (þ0.01 (baseline: 6.09) versus þ 0.21 (baseline: 5.89)). The study of screening for hearing loss found that after screening15 there was a significant change in exposure to leisure noise between screened and unscreened individuals (42 and 49%, respectively; P ¼ 0.045) after 5 years. However, no differences were detected for exposure to occupational noise (screened: 46%; unscreened: 50%: 95% CI of difference: 210.6 to 2.6) and to the use of hearing protection (screened: 42%; unscreened: 47%: 95% CI of difference: 24.0 to 14.7). Summary of the results In table 2 a summary of the results is shown. For all five health behaviour variables (smoking, diet, exercise, alcohol consumption and adherence) we list whether the outcome was better, equal or worse in the screened group compared with the unscreened group. Discussion Table 2 Summary of results per outcome variable Exercise Alcohol consumption Adherence Risk factor screening Hutchison OXCHECK18 Strychar Komiya et al.14 Authors’ contributions Marteau TM, Kinmonth AL, Thompson S et al. The psychological impact of cardiovascular screening and intervention in primary care: a problem of false reassurance? British Family Heart Study Group. Br J Gen Pract 1996;46:577 – 82. 1 Barlow J. Psychological consequences of hypercholesterolaemia . Br J Gen Pract 1993 ; 43 : 435 - 6 . 2 Jones A , Davies DH , Dove JR et al. Identification and treatment of risk factors for coronary heart disease in general practice: a possible screening model . BMJ (Clin Res Ed) . 1988 ; 296 : 1711 - 4 . 3 4 Miles A , Wardle J , McCaffery K et al. The effects of colorectal cancer screening on health attitudes and practices . Cancer Epidem Biomar 2003 ; 12 : 651 - 5 . Kinlay S , Heller RF. Effectiveness and hazards of case finding for a high cholesterol concentration . BMJ 1990 ; 300 : 1545 - 7 . 6 Stewart-Brown S , Farmer A. Screening could seriously damage your health . BMJ 1997 ; 314 : 533 - 4 . 7 Tijmstra T , Bieleman B. The psychosocial impact of mass screening for cardiovascular risk factors . Fam Pract 1987 ; 4 : 287 - 90 . 8 Bankhead CR , Brett J , Bukach C et al. The impact of screening on future health-promoting behaviours and health beliefs: a systematic review . Health Technol Assess 2003 ; 7 : 1 - 92 . 9 Irwig L , McCaffery K , Salkeld G et al. Informed choice for screening: implications for evaluation . BMJ 2006 ; 332 : 1148 - 50 . 10 Hoff G , Thiis-Evensen E , Grotmol T et al. Do undesirable effects of screening affect all-cause mortality in flexible sigmoidoscopy programmes? Experience from the Telemark Polyp Study 1983 - 1996 . Eur J Cancer Prev 2001 ; 10 : 131 - 7 . 11 Marteau TM , Lerman C. Genetic risk and behavioural change . BMJ 2001 ; 322 : 1056 - 9 . 12 Glanville JM , Lefebvre C , Miles JN et al. How to identify randomized controlled trials in MEDLINE: ten years on . J Med Libr Assoc 2006 ; 94 : 130 - 6 . 13 Larsen IK , Grotmol T , Almendingen K et al. Impact of colorectal cancer screening on future lifestyle choices: a three-year randomized controlled trial . Clin Gastroenterol Hepatol 2007 ; 5 : 477 - 83 . 14 Komiya Y , Nakao H , Kuroda Y et al. Application of aldehyde dehydrogenase 2 (ALDH2) genetic diagnosis in support of decreasing alcohol intake . J Occup Health 2006 ; 48 : 161 - 5 . 15 Karlsmose B , Lauritzen T , Engberg M et al. A randomised controlled trial of screening for adult hearing loss during preventive health checks . Br J Gen Pract 2001 ; 51 : 351 - 5 . 16 Strychar IM , Champagne F , Ghadirian P et al. Impact of receiving blood cholesterol test results on dietary change . Am J Prev Med 1998 ; 14 : 103 - 10 . 17 Wood DA , Kinmonth AL , Davies GA et al. Randomised controlled trial evaluating cardiovascular screening and intervention in general practice: principal results of British family heart study . BMJ 1994 ; 308 : 313 - 20 . 18 OXCHECK Study Group. Effectiveness of health checks conducted by nurses in primary care: final results of the OXCHECK study . Imperial Cancer Research Fund OXCHECK Study Group. BMJ 1995 ; 310 : 1099 - 104 . 19 Hutchison B , Birch S , Evans CE et al. Screening for hypercholesterolaemia in primary care: randomised controlled trial of postal questionnaire appraising risk of coronary heart disease . BMJ 1998 ; 316 : 1208 - 13 . 20 Toronto Working Group on Cholesterol Policy. Detection and Management of Asymptomatic Hypercholesterolaemia: A Policy Document . Toronto, Ontario: Ministry of Health , 1989 . 21 Thornton A , Lee P. Publication bias in meta-analysis: its causes and consequences . J Clin Epidemiol 2000 ; 53 : 207 - 16 . 22 Aitken JF , Youl PH , Janda M et al. Increase in skin cancer screening during a community-based randomized intervention trial . Int J Cancer 2006 ; 118 : 1010 - 6 . 23 Sankaranarayanan R , Ramadas K , Thomas G et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomised controlled trial . Lancet 2005 ; 365 : 1927 - 33 . 24 Andriole GL , Levin DL , Crawford ED et al. Prostate Cancer Screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial . J Natl Cancer Inst 2005 ; 97 : 433 - 8 . 25 Zick CD , Mathews CJ , Roberts JS et al. Genetic testing for Alzheimer's disease and its impact on insurance purchasing behavior . Health Aff 2005 ; 24 : 483 - 90 . 26 Chrissidis T , Saliangas K , Economou A et al. Mass screening for colorectal cancer: compliance in Almopea Region . Tech Coloproctol 2004 ; 8 ( Suppl 1 ): s193 - s195 . 27 Taylor KL , Shelby R , Gelmann E et al. Quality of life and trial adherence among participants in the prostate, lung, colorectal, and ovarian cancer screening trial . J Natl Cancer Inst 2004 ; 96 : 1083 - 94 . 28 Faivre J , Dancourt V , Lejeune C et al. Reduction in colorectal cancer mortality by fecal occult blood screening in a French controlled study . Gastroenterol 2004 ; 126 : 1674 - 80 . 29 Vardulaki KA , Walker NM , Couto E et al. Late results concerning feasibility and compliance from a randomized trial of ultrasonographic screening for abdominal aortic aneurysm . Br J Surg 2002 ; 89 : 861 - 4 . 30 Niv Y , Lev-El M , Fraser G et al. Protective effect of faecal occult blood test screening for colorectal cancer: worse prognosis for screening refusers . Gut 2002 ; 50 : 33 - 7 . 31 Jorgensen OD , Kronborg O , Fenger C. A randomised study of screening for colorectal cancer using faecal occult blood testing: results after 13 years and seven biennial screening rounds . Gut 2002 ; 50 : 29 - 32 . 32 Engberg M , Christensen B , Karlsmose B et al. Can systematic general health screening and patient-physician health discussions improve the cardiovascular profile of the population? A randomized controlled trial in general practice with a 5-year follow-up . Ugeskr Laeger 2002 ; 164 : 3354 - 60 . 33 Thorogood M , Coulter A , Jones L et al. Factors affecting response to an invitation to attend for a health check . J Epidemiol Community Health 1993 ; 47 : 224 - 8 . 34 Griffiths C , Cooke S , Toon P. Registration health checks: inverse care in the inner city? Br J Gen Pract 1994 ; 44 : 201 - 4 . 35 Waller D , Agass M , Mant D et al. Health checks in general practice: another example of inverse care? BMJ 1990 ; 300 : 1115 - 8 . 36 Kim LG , Thompson SG , Marteau TM et al. Screening for abdominal aortic aneurysms: the effects of age and social deprivation on screening uptake, prevalence and attendance at follow-up in the MASS trial . J Med Screen 2004 ; 11 : 50 - 3 . 37 Maheswaran R , Pearson T , Jordan H et al. Socioeconomic deprivation, travel distance, location of service, and uptake of breast cancer screening in North Derbyshire , UK. J Epidemiol Community Health 2006 ; 60 : 208 - 12 . 38 McCaffery K , Wardle J , Nadel M et al. Socioeconomic variation in participation in colorectal cancer screening . J Med Screen 2002 ; 9 : 104 - 8 . 39 Sutton S , Wardle J , Taylor T et al. Predictors of attendance in the United Kingdom flexible sigmoidoscopy screening trial . J Med Screen 2000 ; 7 : 99 - 104 .


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Marije Deutekom, Fleur Vansenne, Kirsten McCaffery, Marie-Louise Essink-Bot, Karien Stronks, Patrick M.M. Bossuyt. The effects of screening on health behaviour: a summary of the results of randomized controlled trials, Journal of Public Health, 2011, 71-79, DOI: 10.1093/pubmed/fdq050