Use of patient reminder letters to promote cancer screening services in women: A population-based study in Wisconsin.

BACKGROUND: Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking. METHODS: Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year. RESULTS: Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively. CONCLUSIONS: Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.     

PAP SMEAR USAGE IN NEW SOUTH WALES - IMPACT OF ACTIVE PROMOTION

Less than 25 per cent of eligible Australian women have cervical (‘Pap’) smear tests in any year. Rates are particularly low (<8%) for women over 55 years, the group at highest risk of cervical cancer. A regional program, actively promoting Pap smears by widespread direct community intervention and attention to service needs, targeting women over 55 years and under 25 years, was conducted on the North Coast (population 132,000 women) immediately after a New South Wales State-wide media campaign in February 1988. The number of Pap smears done in the region increased 119 per cent for women over 55 years and 44 per cent for 15–24 year-olds during the promotion (63% overall) compared to New South Wales increases of 58 per cent for women over 55 years and 23 per cent for 15–24 year-olds (31% overall). Differences between the North Coast and New South Wales were statistically significant for all age groups in March and in April for women over 55 years. Differences between New South Wales and Australia (no active promotion) were significant for women over 55 years in March and April. Records from a sample of 152 women attending clinics during the campaign showed 63 per cent had not had a smear test for three or more years, 10 per cent never. The results indicate that an intensive, low-cost public health program, working in conjunction with general practitioners, can be effective in increasing smear rates and that well-designed strategies will have an impact on older women, a high risk group who traditionally are poor users of Pap smear services. The combined impact of the two campaign strategies on Pap smear usage was significantly greater than media alone. A Central New South Wales cervical screening database is essential for evaluation of screening promotion.     

How much does a reminder letter increase cervical screening among under‐screened women in NSW?

OBJECTIVE: To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months. METHODS: Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups. RESULTS: After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups. CONCLUSIONS AND IMPLICATIONS: Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.     

A RANDOMISED TRIAL OF GENERAL PRACTITIONER-WRITTEN INVITATIONS TO ENCOURAGE ATTENDANCE AT SCREENING MAMMOGRAPHY

The aim of this study was to examine the effectiveness of general practitioner-written invitations to the Breast X-Ray Programme of the Central Sydney Area Health Service. Five out of six randomly selected general practices in Drummoyne participated. Within each practice, women aged 45 to 70 were individually randomised to receive or not receive a letter from their general practitioner (GP). Thirty-two per cent of women attended if invited compared to 7 per cent if they were not sent an invitation. An attendance of 38 per cent was obtained for women whose GP chose to send a letter with an appointment compared to 24 per cent for women whose GP chose to send a general invitation without an appointment. Combining all practices, women who consulted their GP within the previous 6 months were more likely to attend in response to the invitation (38 per cent) than women whose last consultation was more remote, dropping to 15 per cent in those who last attended that GP over 2 years earlier. Women aged 65 to 70 years old were at least as likely to respond to the invitation as women aged 45 to 64. Reminder letters were subsequently sent to a random half of non-respondents who had attended the practice in the previous 12 months. A further 18 per cent of women attended after the reminder letter was sent (8/45), compared with 2 per cent in the control group (1/48). Twenty-seven per cent of women in Drummoyne had already attended for screening mammography before the trial. Two invitations with appointments from GPs had the potential to attract 49 per cent of the remaining women, resulting in 63 per cent attendance overall.     

Who has Pap smears in New South Wales? Patterns of screening across sociodemographic groups

Abstract: The aim of this study was to determine whether Pap smear screening at adequate intervals is associated with area of residence, frequency of consultations with a general practitioner, socioeconomic status and non-English-speaking background. A representative 10 per cent sample of women from New South Wales and the Australian Capital Territory, aged 25 to 69 years and registered with the Health Insurance Commission (Medicare) (N = 155 281) was used to obtain age, postcode, frequency of Pap smears and frequency of consultations with general practitioners in the three-year period from February 1985 to January 1988. Census data for each postcode area were used as an indicator of other sociodemographic characteristics. Age-specific screening rates did not vary between Sydney, Newcastle/Wollongong, Canberra, and nonmetropolitan areas. In all age groups, having had a smear was most strongly associated with the frequency with which a woman consulted a general practitioner. Women who visited a general practitioner at least four times a year on average were about twice as likely to have had a recent Pap smear as those who averaged less than one visit per year. Screening rates were lowest among women living in areas with the most non-English-speakers and the lowest socioeconomic status. Sociodemographic factors and health service usage patterns influence the proportion of women who are currently being screened. Evaluation of interventions to improve Pap smear screening rates should consider whether the percentage of women screened increases overall, and also whether the imbalances in screening rates between different groups are diminishing.     

Mammography rescreening among women of diverse ethnicities: patient, provider, and health care system factors

This study identified patient, provider, and health care system factors that influenced mammography rescreening among non-insured, racial/ethnic minority women. Data were collected using a stratified-clustered random sample survey of 1,050 women of five racial/ethnic groups (Latina, Chinese, Filipina, African American, and Caucasian) and 102 primary care clinical sites. Women received screening services through two no-cost screening programs in California. Chi-square tests were used to assess bivariate associations and multiple logistic regressions were used to compute adjusted odds ratios and 95% confidence intervals. Mammography rescreening was associated with living in the United States longer; having higher education levels, better health care access, a history of breast problems, and favorable perceptions of mammography; obtaining regular Pap screening and hormone replacement therapy; having had better communication with clinicians; and attending clinics that conducted in-reach activities. This study suggests that simply removing financial barriers is not enough to improve mammography rescreening among underserved women.     

Mass mailing campaigns to promote screening for cervical cancer: do they work,and do they continue to work?

Abstract: Campaigns involving sending personally addressed letters to encourage women to have Pap smears increase Pap smear rates. The aim of this study was to assess whether this effect is maintained when campaigns are repeated regularly. In October 1992, a letter reminding women of the importance of screening was mailed to all women in three New South Wales postcode regions where a similar letter had been sent three years previously. The response was compared to the response in three regions receiving no earlier letter. The number of women attending for cervical screening during the three months after distribution of the letters was assessed from Health Insurance Commission claims for cervical cytology. These attendances were compared with expected attendances based on the attendance patterns over 28 pre-intervention quarters. Significant postintervention increases in attendance were observed in all three regions receiving an initial letter. However, in one region, the increase in attendances, around 1 per cent of eligible women, was not significandy greater than the increase in the control region ( z = 0.15, P = 0.88). The second letter campaign had no measurable effect on attendances. No significant increase in screenings was observed in two of the towns. A significant increase was observed in one region, but this was not significandy greater than the increase in the control region ( z = -0.05, P = 0.96). These results suggest that repeated direct-mail campaigns to promote screening for cervical cancer may be of no benefit. A one-off campaign may result in an increase in screenings in the short term.     

Comparative effectiveness of two outreach strategies for cervical cancer screening

ObjectiveTest-specific reminder letters can improve cancer screening adherence. Little is known about the effectiveness of a reminder system that targets the whole person by including multiple screening recommendations per letter.MethodsWe compared the effectiveness of a Pap-specific reminder letter sent 27 months after a woman's last Pap, to a reminder letter that included up to seven preventive service recommendations sent before a woman's birthday (“birthday letter”) on Pap smear adherence from a natural experiment occurring in routine clinical care. Participants included 82,016 women from Washington State who received 72,615 Pap-specific letters between 2003 and 2007 and 100,218 birthday letters between 2009 and 2012. We defined adherence as having a Pap test within a six month window around the Pap test due date. Using logistic regression, we calculated adjusted odds ratios (OR) for adherence with 95% confidence intervals (CI) following the birthday letter with 1–2 recommendations, 3–5 recommendations, and 6–7 recommendations compared to the Pap-specific letter. All analyses were stratified by whether a woman was up-to-date or overdue for screening at the time she received a letter.ResultsAdjusted ORs showed reduced adherence following the birthday letter compared with the Pap-specific letter for up-to-date women whether the letter had 1–2 recommendations (OR = 0.37, 95%CI = 0.36–0.39), 3–5 recommendations (OR = 0.44, 95%CI = 0.42–0.45), or 6–7 recommendations (OR = 0.36, 95%CI = 0.32–0.40). We noted no difference in Pap-test adherence between letter types for overdue women.ConclusionsIn conclusion, for women regularly adherent to screening, an annual birthday letter containing reminders for multiple preventive services was less effective at promoting cervical cancer screening compared with a Pap-specific letter.     

Improving Rescreening In Community Clinics: Does A System Approach Work?

Abstract Community clinics provide inadequate breast cancer screening services to low-income, racially- and ethnically-diverse communities. This study develops and evaluates the effectiveness of multifaceted organizational system interventions—operational assessments, tracking systems, reminder calls, tailored education, physician prompts and a tailored counseling call—on mammography rescreening rates within three community clinics. We used the Chronic Care Model and Put Prevention Into Practice framework to redesign breast screening delivery services within the California Cancer Detection Programs: Every Woman Counts(CDP:EWC), community clinic settings. We used a quasi-experimental design with a random selection of 400 patients at pre-intervention. To establish a post-intervention clinic’s rescreening rate a new comparable cross-sectional random sample of 347 women was drawn.Measures A chart abstraction instrument was used to establish clinics’ rescreening rates.Subjects Participants at pre and post-intervention were low-income women 50 years of age and older who had received normal mammography results and had not been diagnosed with breast cancer in the last five years. General linear mixed model analysis revealed significant improvements for the organizational system redesign condition [pre-intervention rescreening rate: 32.1 percent v. post-intervention rescreening rate 50.2 percent, (p < .001)]. For the organizational system redesign plus tailored counseling call condition, there was maintenance in the rescreening rate following the intervention [pre-intervention: 44.4 percent v. post-intervention: 45.1 percent, (p > 0.05)]. Multilevel interventions directed at redesigning community clinics primary care breast cancer screening services, can improve mammography rescreening rates.This study was funded by the California Department of Health Services, Cancer Detection Section. Contract # 00-90917.     

Facilitators and barriers to cervical cancer screening among Chinese Canadian women

BACKGROUND: Chinese Canadian women have higher cervical cancer incidence, and lower Pap testing, rates than the general Canadian population. Predisposing, enabling and reinforcing factors associated with ever having a Pap test, and having a recent Pap test within the last 2 years, were assessed in Chinese women in British Columbia using the PRECEDE-PROCEED model. METHOD: Chinese women (n=512) between the ages of 20 and 79 years and residing in Greater Vancouver were interviewed about Pap testing, health care, traditional health beliefs, acculturation and sociodemographic characteristics. Two analyses were done, comparing women who had ever and never had a Pap test, and comparing women who had and had not received a recent Pap test. Focus groups and qualitative interviews ensured cultural sensitivity in the survey questionnaire. RESULTS: Seventy-six percent reported ever having a Pap test and 57% reported having a Pap test within the last 2 years. Traditional health beliefs were not associated with ever or recent Pap testing. However, belief that Pap testing prevented cancer and general knowledge about the Pap test were associated with screening. Concern about pain/discomfort with the test, availability of time, culturally sensitive health care services and recommendation for Pap testing by a physician were also associated with screening. Factors differed for ever, and recently, having a Pap test. INTERPRETATION: Pap testing is less common among Chinese Canadian women. Continuing education about Pap testing is recommended for physicians serving underscreened Chinese women. Culturally and linguistically appropriate educational materials are needed for the Chinese community.     

Pap smear screening at an urban Aboriginal health service: report of a practice audit and an evaluation of recruitment strategies

A culturally appropriate women's health service was established at an Aboriginal community-controlled health service in Darwin in 1994. An initial file audit found that 48% of included women had ever been screened with a Pap smear and 37% of women were considered to have been adequately screened. The enhancement of opportunistic screening by file tagging had a modest effect on screening coverage over a 12-month period for women who attended the health service. The proportion of these women who were adequately screened increased from 43% to 48% and of those ever screened increased from 54% to 62%. A randomised trial of recruitment interventions including personal approach, letter and control groups was subsequently performed for women for whom Pap smears were overdue or not recorded. The impact of both interventions on the number of Pap smears performed was low, with 7% of women in the personal approach group, 2% of women in the letter group and no women in the control group having Pap smears during the three-month follow-up period. Low rates of abnormalities were observed for women having Pap smears over a two-year period. The minimal effect of a formal reminder system and letters at this urban Aboriginal health service has resulted in a re-orientation of activities towards strengthening opportunistic screening and the continued promotion of Pap smears in a range of clinic and community settings. It is important to place Pap smear screening in the context of other social, economic and health priorities for Aboriginal women and health workers.     

Breast and Cervical Cancer Screening Among South Asian Women in New York City

The purpose of this paper is to document the breast and cervical cancer screening practices of a community sample of South Asian women living in the New York City area. A convenience sample of 98 women was engaged in face-to-face interviews regarding their socio-demographic characteristics and cancer screening utilization. Sixty-seven percent of women had ever had a Pap test; 54% had one in the last 3 years. Seventy percent of women over 40 had ever had a mammogram; 56% had one in the last 2 years. Sixty-six percent of women had knowledge of breast self-exam (BSE); 34% of women ever practiced BSE. Multiple logistic regression analysis indicated that insurance status was a significant predictor of ever having a Pap test or mammogram, receiving timely Pap tests, and ever practicing BSE. Education was a significant predictor of ever having a Pap test and having knowledge of BSE. Marital status was a predictor of receiving timely Pap tests, and having spent more time in the U.S. was a predictor of ever practicing BSE. The study concludes that increased educational efforts must be developed targeting immigrant South Asian women of low socioeconomic status with limited access to healthcare.     

Increasing response rates of gynaecologists to a survey: a randomised trial of telephone prompts

Abstract: This study used a randomised controlled trial to evaluate the effectiveness of telephone prompts to increase the response rate of gynaecologists to a survey. A nine-page questionnaire about management of women with abnormal Pap smears was mailed to Fellows of the Royal Australian College of Obstetricians and Gynaecologists. A random sample was contacted in advance by telephone, and nonrespondents received a telephone reminder 14 days after the initial mail-out. The control group was mailed questionnaires and a reminder letter conventionally. On Day 25, nonresponders in both groups were mailed a second questionnaire. Of the intervention group, 84 per cent responded to the survey compared to 69 per cent of the control group (P = 0.005). A telephone call in anticipation of a mailed questionnaire is highly recommended.     

Predictors of cervical Pap smear screening awareness,intention, and receipt among Vietnamese-American women

BACKGROUND: Compared with white women, Vietnamese women in the United States have a higher rate of cervical cancer and lower Papanicolau (Pap) test utilization. We evaluated factors associated with awareness of the Pap test, intention to obtain it, and its receipt in Vietnamese-American women. METHODS: In 2000, we conducted a telephone survey of Vietnamese-American women aged >or=18 years living in Santa Clara County, California, and Harris County, Texas. We collected data on sociodemographics, healthcare system access and attitudes, as well as Pap test awareness, attitudes, intentions, and practices. RESULTS: Of 1566 subjects, 74% had heard of the Pap test, and 76% had had at least one. Only 42% of those who never had a Pap test had considered obtaining one. There were no significant differences between the two sites. Women aged >or=65 had the lowest rates for all three outcomes. For all women, younger age, being married, having requested a Pap test, physician recommendation, and preferring a female standby if the doctor was male were associated with Pap test intention. Being married, higher level of education, having a female doctor, having a respectful doctor, having requested the test, and physician recommendation were associated with Pap test receipt. CONCLUSION: Vietnamese-American women have low rates of Pap test awareness, intention, and receipt. The patient-doctor interaction is an important determinant. Efforts to increase Pap test utilization in this population need to be directed at encouraging physicians to offer the Pap test and empowering women to ask for the test.     

Cervical cancer screening beliefs among young Hispanic women

OBJECTIVES: This study examined beliefs, attitudes, and personal characteristics that correlated with self-reported cervical cancer screening history among Hispanic women aged 18 to 25 years old in El Paso, TX, a large metropolitan area on the U.S.-Mexico border. METHODS: Data were collected through a cross-sectional, face-to-face survey. The study questionnaire was based primarily on the Health Belief Model, and included scales that measured perceived susceptibility and seriousness of cervical cancer, and perceived benefits and barriers to Pap test screening. The study questionnaire also included measures of acculturation, Pap test history, pregnancy and sexual history, use of birth control, type of medical insurance, and educational attainment. RESULTS: Sixty-nine percent reported ever having had a Pap test and 56% reported having had a test in the past year. Eighty percent reported that they were sexually active, and of these, 63% reported using birth control. Respondents understood the seriousness of cervical cancer, their susceptibility to cervical cancer, and the benefits of Pap testing; however, only 61% agreed that most young women whom they know have Pap tests. Greater acculturation and the belief that most young unmarried women have Pap tests were positively associated with ever having screening. The perception that the test would be painful and not knowing where to go for the test were negatively associated with ever having a Pap test. CONCLUSIONS: This study found suboptimal rates of screening for cervical cancer in a sample of young Hispanic women residing along the U.S.-Mexico border. Although women may understand the seriousness of cervical cancer and the benefits of screening, perceptions about Pap tests may pose barriers to undergoing screening. Efforts to increase screening also may need to focus specifically on women who are least acculturated, as they also were least likely to have had prior Pap tests.     

Three-year follow-up study of women who participated in a cervical cancer screening intervention while in prison

OBJECTIVE: This study describes rescreening following a prison cervical cancer screening intervention: the numbers of women who received rescreening during the three-year follow-up period; their timing of rescreening in relationship to intervention follow-up recommendations; and socio-demographic factors associated with rescreening. METHODS: Socio-demographic information was collected from Corrections Branch records. Clinical and risk factor information was obtained by a self-administered questionnaire. Pap screening histories were collected from Cervical Cancer Screening Program (CCSP) client records using the client ID number for Pap smears taken during the intervention period, during the three-year follow-up period, and during the 30-month period preceding the intervention period. Results were entered in Excel and responses summarized with frequency tables; bivariate analysis of categoric variables was done using chi-square tests of independence. RESULTS: During the three-year follow-up period, only 28 (21%) of 138 women who participated in a prison cervical cancer screening intervention were rescreened within 6 months of the recommendation received at intervention Pap test. Women with fewer than 5 multiple names (aliases) were more likely to be rescreened (p = 0.02). Educational level approached statistical significance (p = 0.05), with women with least education receiving highest rescreening. There was no relationship between rescreening and ethnicity, injection drug use, having borne children and current methadone treatment. CONCLUSION: Only 50% of women who participated in a specifically designed prison screening intervention were rescreened during the subsequent three years. Further work is needed to design, implement and evaluate follow-up initiatives of community cervical cancer screening programs for women who are at higher risk of developing cervical dysplasia.     

Predictors of early rescreening in the National Cervical Screening Program, Australia

OBJECTIVE: To identify variables that predict early rescreening after a negative Pap smear report. METHODS: Cohort study using the records of a statewide Cervical Cytology Registry in Victoria, Australia. The cohort comprised 31,082 women who had a negative Pap smear report during the first half of 1996 and who were rescreened within the subsequent 36 months. Early rescreening was defined as a further Pap smear within 21 months. RESULTS: The strongest predictor of early rescreening was a recommendation at the time of issuing the negative Pap smear report by the laboratory for retesting before two years (adjusted odds ratio = 3.81, 95% confidence interval (CI) 3.58-4.05). Mention of reactive or inflammatory change as part of the negative Pap smear report was also a powerful predictor (adjusted odds ratio = 1.67, 95% CI 1.50-1.85). Significant predictors associated with the women were young age, high socio-economic status and residence in the capital city. Significant predictors associated with the practitioner were if either the index or subsequent smear was collected by an obstetrician/ gynaecologist or a hospital-based clinic, or if the practitioner collecting the index smear was a female. The population-attributable risk per cent associated with the laboratory recommendation was 27%. CONCLUSIONS: This data suggests that a multifaceted strategy targeting pathology laboratories, practitioners and women may be needed to reduce early rescreening. IMPLICATIONS: Early rescreening is wasteful of health resources. New screening programs should be designed to avoid this problem.     

Factors associated with obtaining health screening among women of reproductive age.

Death and disability associated with breast and cervical cancer and hypertension can be reduced by early detection and treatment. The authors examined the rates for having obtained a Papanicolaou (Pap) test or pelvic examination, a breast physical examination, and a blood pressure test within the last 12 months among women of reproductive age in the United States in 1988, as reported by the 8,450 women interviewed for the 1988 National Survey of Family Growth. Overall, the annual rates of screening for women ages 15-44 years for those tests were 67 percent for a Pap test or pelvic examination, 67 percent for a breast examination, and 82 percent for a blood pressure test. Standard recommendations for the frequency of screening and survey data were examined to see whether actual screening practice was consistent with those recommendations. More than 90 percent of women who had a family planning service visit within 12 months received each of the tests, regardless of who provided the service or who paid for the visit. Women who were not sexually active, women with little education or low income, American Indian women, Hispanic women, and women of Asian or Pacific Islander descent had lower rates of screening than others, regardless of their risk status. These findings strongly suggest that the likelihood of having obtained screening among women 15-44 years old is determined primarily by how often a woman uses health care, rather than by her risk of disease.     

Breast and cervical cancer screening in a low-income managed care sample: the efficacy of physician letters and phone calls.

A randomized trial was conducted to evaluate the combined impact of a physician reminder letter and a telephone contact on the use of Pap tests and mammograms in a low-income managed care program. Women 40 to 79 years of age who were past due for cancer screening were randomly assigned to an intervention or control group. Medical claims were reviewed after 6 months to determine intervention effectiveness. The odds of receiving all needed cancer screening tests during follow-up were four times higher in the intervention group. Women who reported having to take time off from work to see a doctor had lower odds of getting screened.     

Health risks and behaviour of out–of–school 16–year–olds in New South Wales

Abstract: This study describes the health risks and health behaviour of a sample of 283 out–of–school 16–year–olds in New South Wales. We sampled study participants through the Commonwealth Employment Service offices in 1994 using a multistage sampling procedure. Of those surveyed, 129 responded to a letter inviting them to participate and 154 were recruited opportunistically. This paper describes the study methods and results for self–reported binge drinking, weekly use of tobacco and marijuana, sexual abuse, physical abuse, drink–driving, violence, and use of health services, by sex and method of recruitment. High rates of substance use were observed. Reported substance use in the out–of–school group was consistently higher than for 16–year–olds in school, except for binge drinking for girls recruited by letter. Of the out–of–school group, 34 per cent reported weekly use of tobacco, marijuana and also binge drinking. Boys were more likely to report drink–driving than girls (28 per cent and 13 per cent respectively). Having been in trouble with police ranged from 32 per cent for girls recruited by letter to 75 per cent for boys recruited opportunistically. A high proportion of girls reported sexual abuse (34 per cent of the 'letter' group and 41 per cent of the 'opportunistic' group). Overall, 87 per cent of respondents had used health services in the previous year. The results indicate that this is a disadvantaged group of young people who are an important target for health service provision and interventions.