• Vol. 27 No. 6, 838–842
  • 15 November 1998

A Randomized Trial of the Use of Print Material and Personal Contact to Improve Mammography Uptake Among Screening Non-attenders in Singapore



The Singapore Breast Screening Project was a nationwide study inviting a random sample of women between the ages of 50 and 64 years for mammography at one of two hospital-based screening centres over two years. The current study was undertaken to determine if (1) mailed health educational material alone, or (2) the same material delivered during a home visit made to the subject and her family would increase the uptake among Singapore women who had not responded to two previous invitations for mammographic screening as part of the Project.

This randomized trial employed a standard second reminder letter (R), the same letter packaged with health education material designed for the project (RP) and the addition of a home visit to make contact with the woman and her family (RV). The outcome measure of interest was the proportion of women in each group subsequently attending for screening. The study population comprised 1500 non-attenders whose names appeared consecutively in the database of the larger screening centre in this Project. These were randomized into three groups of 500 each. In total, they broadly resembled the national population in ethnic composition (72.3% Chinese, 17.8% Malays, 9.0% Indians and 0.8% Others).

By the end of the project, 7.0% of women in group R and 7.6% in group RP responded to the invitation. In group RV, 428 homes were visited at least once and contact was made with the subject and her family member in 306 (71.5%) cases. Subsequently, 13.3% of the women visited attended for screening. The rate ratio for attendance in group RP compared with group R was 1.09 (95% CI 0.70 to 1.70) and for group RV compared with R, 1.90 (1.27 to 2.84). When analyzed by groups originally assigned to, women in group RV remained significantly more likely to attend than those in groups R or RP. The marginal cost of a home visit, based on this study, was $25.04 per additional woman screened.

Our results suggest that the response to a second reminder is generally low and that additional print material does not improve screening attendance in this group of initial non-attenders. Personal contact with the family through a home visit appears to increase uptake, and may be helpful particularly among women who have less frequent contact with the health care system.

Breast cancer is the most common cancer among females in Singapore. Although lower than incidence rates in North America and the United Kingdom the incidence of breast cancer here has doubled from 20 to 38.8 per 100,000 women per year over the past 2 decades, and the disease is currently of major public health concern.

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