{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T19:17:00Z","timestamp":1775071020747,"version":"3.50.1"},"reference-count":71,"publisher":"National Institute for Health and Care Research","issue":"68","license":[{"start":{"date-parts":[[2016,9,1]],"date-time":"2016-09-01T00:00:00Z","timestamp":1472688000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/non-commercial-government-licence\/non-commercial-government-licence.htm"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["09\/164\/01"],"award-info":[{"award-number":["09\/164\/01"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title><jats:p>Falling participation by young women in cervical screening has been observed at a time that has seen an increase in the incidence of cervical cancer in the UK in women aged &lt;\u200935 years. Various barriers to screening have been documented, including fear, embarrassment and inconvenience.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-2\"><jats:title>Objectives<\/jats:title><jats:p>To measure the feasibility, clinical effectiveness and cost-effectiveness of a range of interventions to increase the uptake of cervical screening among young women.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-3\"><jats:title>Design<\/jats:title><jats:p>A cluster randomised trial based on general practices performed in two phases.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-4\"><jats:title>Setting<\/jats:title><jats:p>Primary care in Greater Manchester and the Grampian region in Scotland.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-5\"><jats:title>Participants<\/jats:title><jats:p>Phase 1: 20,879 women receiving their first invitation for cervical screening. Phase 2: 10,126 women who had not attended by 6 months.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-6\"><jats:title>Interventions<\/jats:title><jats:p>Phase 1: pre-invitation leaflet or not, and access to online booking (Manchester only). Phase 2: (1) vaginal self-sampling kits (SSKs) sent unrequested (<jats:italic>n<\/jats:italic>\u2009=\u20091141); or (2) offered on request (<jats:italic>n<\/jats:italic>\u2009=\u20091290); (3) provided with a timed appointment (<jats:italic>n<\/jats:italic>\u2009=\u20091629); (4) offered access to a nurse navigator (NN) (<jats:italic>n<\/jats:italic>\u2009=\u20091007); or (5) offered a choice between a NN or a SSK (<jats:italic>n<\/jats:italic>\u2009=\u20091277); and 3782 women in control practices.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-7\"><jats:title>Main outcome measures<\/jats:title><jats:p>Uplift in screening compared with control practices, cost-effectiveness of interventions, and the women\u2019s preferences explored in a discrete choice experiment.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-8\"><jats:title>Results<\/jats:title><jats:p>The pre-invitation leaflet and offer of online booking were ineffective when compared with control practices at 3 months, 18.8% versus 19.2% [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.88 to 1.06;<jats:italic>p<\/jats:italic>\u2009=\u20090.485] and 17.8% versus 17.2% (OR 1.02, 95% CI 0.87 to 1.20;<jats:italic>p<\/jats:italic>\u2009=\u20090.802), respectively. The uptake of screening at 3 months was higher among previously human papillomavirus (HPV)-vaccinated women than unvaccinated women, 23.7% versus 11% (OR 2.07, 95% CI 1.69 to 2.53;<jats:italic>p<\/jats:italic>\u2009&lt;\u20090.001). Among non-attenders, the SSK sent intervention showed a statistically significant increase in uptake at 12 months post invitation, 21.3% versus 16.2% (OR 1.51, 95% CI 1.20 to 1.91;<jats:italic>p<\/jats:italic>\u2009=\u20090.001), as did timed appointments, 19.8% versus 16.2% (OR 1.41, 95% CI 1.14 to 1.74;<jats:italic>p<\/jats:italic>\u2009=\u20090.001). The offer of a NN, a SSK on request, and a choice between timed appointments and NN were ineffective. Overall, there was a gradual rather than prompt response, as demonstrated by uptake among control practices. A discrete choice experiment indicated that women invited who had not yet attended valued the attributes inherent in self-sampling. The health economic analysis showed that both timed appointments and unsolicited SSK sent were likely to be cost-effective at a cost per quality-adjusted life-year (QALY) gained of \u00a37593 and \u00a38434, respectively, if extended across the national 25-year-old cohort throughout the duration of screening. The certainty of these being cost-effective at a ceiling ratio of \u00a320,000 per QALY gained was &gt;\u200990%.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-9\"><jats:title>Conclusion<\/jats:title><jats:p>Women receiving their initial screening invitation frequently delay taking up the offer and the net impact of interventions was small. Timed appointments and SSKs sent to non-attenders at 6 months are likely to be a cost-effective means of increasing uptake and should be considered further. HPV vaccination in the catch-up programme was associated with an increased uptake of cervical screening. Future work should focus on optimising self-sampling in terms of age range, timing of offer for non-attenders and use of urine testing instead of vaginal samples.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-10\"><jats:title>Trial registration<\/jats:title><jats:p>Current Controlled Trials ISRCTN52303479.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-11\"><jats:title>Funding<\/jats:title><jats:p>This project was funded by the NIHR Health Technology Assessment programme and will be published in full in<jats:italic>Health Technology Assessment<\/jats:italic>; Vol. 20, No. 68. See the NIHR Journals Library website for further project information.<\/jats:p><\/jats:sec>","DOI":"10.3310\/hta20680","type":"journal-article","created":{"date-parts":[[2016,9,20]],"date-time":"2016-09-20T10:40:22Z","timestamp":1474368022000},"page":"1-138","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":40,"title":["A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC)"],"prefix":"10.3310","volume":"20","clinical-trial-number":[{"clinical-trial-number":"isrctn52303479","registry":"10.18810\/isrctn","type":"results"}],"author":[{"given":"Henry C","family":"Kitchener","sequence":"first","affiliation":[{"name":"Institute of Cancer Sciences, University of Manchester, St Mary\u2019s Hospital, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Matthew","family":"Gittins","sequence":"additional","affiliation":[{"name":"Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Oliver","family":"Rivero-Arias","sequence":"additional","affiliation":[{"name":"National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Apostolos","family":"Tsiachristas","sequence":"additional","affiliation":[{"name":"Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Margaret","family":"Cruickshank","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alastair","family":"Gray","sequence":"additional","affiliation":[{"name":"Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Loretta","family":"Brabin","sequence":"additional","affiliation":[{"name":"Institute of Cancer Sciences, University of Manchester, St Mary\u2019s Hospital, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Torgerson","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of York, York, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emma J","family":"Crosbie","sequence":"additional","affiliation":[{"name":"Institute of Cancer Sciences, University of Manchester, St Mary\u2019s Hospital, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexandra","family":"Sargent","sequence":"additional","affiliation":[{"name":"Virology Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chris","family":"Roberts","sequence":"additional","affiliation":[{"name":"Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"6221","published-online":{"date-parts":[[2016,9]]},"reference":[{"key":"key20160916100118649_ref1-bib1","volume-title":"Cervical Cancer Incidence Statistics","author":"Cancer Research UK"},{"key":"key20160916100118649_ref1-bib2","volume-title":"Cervical Screening Programme, England. 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