Evolution of multiple disease screening in Keelung: a model for community involvement in health interventions?

OBJECTIVE Screening for cancer and other chronic conditions tends to be conducted in independent programmes; that is, screening for one disease at a time. The Keelung community-based multiple disease screening programme, developed in Keelung city, Taiwan, is a notable exception. Here, we report on the Keelung programme's ethos and development within the community, focusing on equity of delivery of the service, and community involvement. In addition, we present some preliminary cost-effectiveness analyses of multiple disease screening. METHODS The Keelung programme offers screening for breast, colorectal and liver cancers, cervical and oral neoplasia, all of which have an evidence base for their efficacy, and for diabetes, hypertension, osteoporosis and hyperlipidaemia, which are of unknown efficacy. We assessed variability of coverage rates of the Keelung Community-based Integrated Screening (KCIS) programme with age and socioeconomic status, availability of facilities for referral of positive screenees, and numbers of community social workers, general practitioners and local hospitals involved in the programme. We also assessed in qualitative terms how the programme interacts with non-health agencies. Finally, we simulated activities and costs for a variety of single- and multiple-disease screening situations. RESULTS Between 1999 and 2003, coverage increased overall from 14.7 to 34.4%, and increased most dramatically in people aged 60-79 years (from around 30 to 60%) and in those of lower educational status (from around 40 to 70%). There was a significant growth in the involvement of social workers and volunteers in the programme, and an increase in the availability of local diagnostic and care facilities for those screened positive. In addition, there was substantial involvement of non-health agencies in publicizing the programme. In the health economic simulations, compared with no screening, the extra costs to gain an additional life year were estimated as 667 US dollars, 608 US dollars, 4227 and 4789 US dollars for multiple screening with 100% attendance, multiple screening with 70% attendance, single disease screening with 100% attendance and single disease screening with 30% attendance at each programme (i.e. 74% attendance for at least one out of four programmes), respectively. CONCLUSIONS The innovative design and outreach procedures of the KCIS have led to a growth in delivery of screening services to groups sometimes overlooked (equity), community involvement in health care (participation) and the use of non-health organizations for publicity and health education (collaboration). Simulation studies indicate that multiple disease screening may be more cost-effective than single disease screening.