Interventions to improve access to care for abnormal uterine bleeding: A systematic scoping review

Abstract Background Women with abnormal uterine bleeding (AUB) experience barriers to accessing healthcare services. Objectives To identify and describe the evidence on interventions to improve healthcare access of women with AUB. Search strategy A systematic search of databases including Medline, CINAHL, EMBASE, Scopus, and Cochrane register for clinical trials on February 26, 2021. Selection criteria Studies including women with AUB and investigating an intervention to improve access at the levels of individual patient, community, organization, health system, or medical education. Data collection and analysis Data extraction and descriptive analysis of the country, study design, settings, participant characteristics, intervention, outcome measures, and key findings. Main results We identified 20 studies and most interventions (13 studies) targeted organizational changes. Creating a multidisciplinary team, bringing services together and developing a care pathway improved the availability of services. Management of AUB in an outpatient setting improved the affordability. The use of decision aids improved patient engagement in consultations. There is a lack of interventions at an individual or community level targeting health literacy, health beliefs, social acceptability, and opportunity to reach and pay for services. Conclusions Community‐based culturally‐adapted interventions focusing on access to women with different socio‐economic and cultural backgrounds should be investigated.


| BACKG ROU N D
Abnormal uterine bleeding (AUB), is the term used to describe any change from normal menstruation or a normal menstrual cycle pattern, including changes in the regularity, frequency, heaviness, or duration of blood flow of the normal menstrual pattern. 1 The prevalence of AUB is common, affecting 10%-30% of women, and a spectrum of underlying conditions related to structure (endometrial cancer, polyps, fibroids, pregnancy complication), hormonal function (menopause) and contraceptive methods contribute to AUB. 2 Abnormal bleeding can reduce quality of life. Women often experience AUB symptoms for years before seeking care or receiving treatment. [3][4][5][6] In a UK national audit including 14 545 women with heavy menstrual bleeding (HMB) attending secondary care, 74% of women had symptoms for more than 1 year before seeking treatment and 30.4% reported no previous treatment in primary care. 5 A multinational survey across women with HMB in Canada, the USA, Brazil, France, and Russia showed that the mean time from first symptoms to seeking help was 2.9 (±3.1) years. Forty percent of women had not seen a health care professional about their HMB. Furthermore, over half (54%) had never been diagnosed or treated and only 20% had been diagnosed and received appropriate treatment. 6 Some of the barriers to healthcare access identified include taboo or stigma that prevented women from disclosing menstrual problems, embarrassment from exposing private body parts, discomfort with gynecologic examination, and fear of the possible diagnosis or gaps in health literacy resulting in normalizations of symptoms. Lack of trust, rapport, and shared decision making in doctor-patient relationships can make communication about sensitive gynecologic issues difficult.
For women who did engage with primary healthcare providers, dismissal of symptoms 4 and health providers' lack of procedural skills for AUB management were problematic. 7 Health system issues like long waiting lists and delays in assessment and diagnosis were also identified. 4 Barriers to access could lead to delayed management and racial disparities in gynecologic examinations, diagnosis, and healthcare outcomes. 8 Interventions or programs that address the barriers and health needs of women may be able to improve the access to health care for women with AUB, and then improve outcomes.
Levesque et al. 9 define access to health care as the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care. Access is considered to be dependent on features of health systems, organizations, and providers; and also on features of the population such as characteristics of individuals, households, and physical and social environments. Based on Levesque et al.'s literature-informed conceptual framework, accessibility to health services is categorized into five dimensions comprising approachability, acceptability, availability and accommodation, affordability, and appropriateness. Five corresponding abilities of populations that interact with the dimensions of accessibility include the ability to perceive, ability to seek, ability to reach, ability to pay, and ability to engage. The aim of this systematic scoping review is to identify and describe the evidence on the effectiveness of interventions to improve healthcare access of women with AUB. As access is multifactorial, this review focuses on interventions addressing factors at personal, household, community, population, and health system levels that target improving access for women with AUB.

| Identifying the research question
Our previous review identified barriers to healthcare access for women with AUB. 3 Our qualitative study then provided further insights into barriers to women's journey of care for AUB at a tertiary medical center in New Zealand. 4 Before planning an intervention aimed to improve access to care for AUB, we proposed a scoping review to examine the existing evidence for such interventions and identify gaps in the intervention literature. The scoping review protocol is available on request. The review addresses the following research questions: (1) What are the types of population or AUB conditions included in the studies? (2) In which settings are these interventions provided? (3) Which types of studies are available in the literature? (4) What type of interventions or programs have been successful or unsuccessful in improving access to care for women with AUB? (5) What access-related outcome measures have been used?  2 To search for studies on access to health care, we used terms based on the conceptual framework of "Patientcentred Access to Health Care". 9 These included terms related to health services dimensions and population dimensions. The search strategy and specific search terms are provided in a supplementary online file (Appendix S1).

| Identifying relevant studies
Our librarian executed the search strategy and provided data to the primary author (PSK) as a compressed Endnote library.

| Study selection
A study was included if it: (1) included patients (service users) with AUB with any underlying cause; (2) involved healthcare/service providers, health administrators, or support staff as participants; (3) was an intervention or program evaluation study with quantitative, qualitative, or mixed-method study methodology; (4) included interventions or programs at an individual patient level, health provider level, administration level, system level (policies) or medical education level; and (5) was in English. Exclusion criteria included studies investigating diagnostic, medical, or surgical interventions/procedures.
We also excluded opinion pieces, commentary, letters, and theses.
Using the eligibility criteria, the primary author (PSK) performed the title and abstract screening. At the full-text screening stage, another author (SF) was involved to discuss articles for inclusion in the final review. Additionally, this author (SF) reviewed a sample of 11 full-text articles.

| Data collection/Charting the data
A data collection instrument (spreadsheet) was used to extract the study characteristics of included studies. Data were extracted under the following headings: author, year of publication, country of study, study design, participant characteristics and study settings, intervention, access-related outcome measure, and key findings related to either the effect of an intervention (quantitative studies) or the experience of intervention (qualitative studies). Charting was an iterative process and the data collection form was categorized or sectioned based on the type of interventions.

| Data summary and synthesis of results
Data obtained were synthesized to map the research evidence available and provide information on literature, particularly the main type of interventions available and intervention settings. We grouped the data based on the type of intervention and the dimensions of access according to Levesque et al. 9 Health services-based interventions are at an organizational, policies, or health-provider level.
Population-based interventions could be programs at an individual patient, household, or community level.

| Optional consultation
We did not perform any consultation with stakeholders because of time constraints.

| RE SULTS
Our search resulted in 14 526 records with 5849 remaining after the removal of duplicates. Figure 1 illustrates the selection process.
Following title screening, we included 314 records, which was reduced to 91 after abstract screening. After full-text screening, 21 papers 12-32 were included. Two papers 29,30 were from one study, so the total number of included studies was 20. We have cited Vuorma et al. 29 to represent both papers. Reasons for exclusion at full-text screening were the type of publication (e.g. protocol, commentary, conference proceedings), studies without access outcomes, and cost analyses of diagnostic or treatment interventions. Cost analysis studies (52 in total) compared the cost-effectiveness of various medical or surgical treatments and diagnostic procedures rather than financial interventions to improve accessibility such as providing incentives or capitation fees to patients. Questionnaires Medical records Treatment decision within 3 months was made more often in the intervention group than in the control group. No between-group differences were detected in the change in anxiety, satisfaction or knowledge level. There were no marked disparities in treatment costs between groups.

| Description of study type, setting, and population
Ten studies 13

| Type of interventions
Thirteen of 20 studies investigated interventions to improve access that focused on changes at the healthcare service (organizational) level. Organizational interventions included one study creating a multidisciplinary team, 12 six bringing services together, 13-18 one developing a care pathway, 19 and five creating an outpatient setting for procedures. [20][21][22][23][24] Population-based interventions comprised six studies targeting patient education and engagement using decision aids for shared decision making in physician consultations. [25][26][27][28][29]31 A single study piloted an educational intervention to improve awareness among school children regarding AUB and bleeding disorders. 32

| Description and outcomes of health servicebased interventions
Studies investigating one-stop menstrual or postmenopausal clinics where diagnosis and management services were co-localized showed improvement in access measures including a reduced number of hospital visits, avoidance of hospital admissions, decreased waiting time for appointments, and increased coordination and continuity of care. [13][14][15][16][17][18] Collectively, these studies suggested that 68%-89% of patients were evaluated and managed in the first one-stop clinic visit. A collaborative hysteroscopy clinic with women's health nurse and gynecologist improved service "availability" by increasing the number of appointment slots by more than 50% and reducing the waiting time for Abbreviations: AUB, abnormal uterine bleeding; BD, bleeding disorder; GP, general practitioner; HMB, heavy menstrual bleeding, PMB, postmenopausal bleeding; RCT, randomized controlled trial.

TA B L E 1 (Continued)
appointments. 12 A prospective study, that interviewed 22 women with AUB, confirmed that a one-stop clinic was suited to the needs of these women. 16 A general practitioner-led "Bridges pathway" for access to appropriate secondary care showed improvements in getting choice of appointment slot, choice of doctor, and coordination between primary and secondary care. 19 This "Bridges pathway" involved the use of evidencebased guidelines by the general practitioner for the management of AUB and access to booking for investigations and surgical treatment.
Interventions such as changing a diagnostic procedure to the outpatient setting, creating an outpatient assessment and treatment unit, outpatient microwave endometrial ablation, outpatient polyp treatment, or office hysteroscopy, reduced the cost per patient when compared with procedures in the inpatient setting, and saved theater time. 20-4

| Description and outcomes of patient-or population-based interventions
Interventions targeting patient information using bespoke interactive computerized decision aids such as "The clinical guidance tree" 28 or "option grid encounter decision aid" 25 improved shared decision making between physician and the patients. An iPod Touch device with access to period information, provider contact information for questions, and record details of menstrual cycles and medications improved compliance with medications resulting in fewer hospital days due to missed medications. 26 Information booklets provided before the consultation resulted in quicker decision making in treatment. 29,31 One study showed cost savings in treatment with an information booklet, videotape, and preference elicitation (interview to elicit the preferences), 31 but another study showed no cost savings in treatment with patient information booklet alone. 29 Information booklet alone was found to make no difference to the anxiety, satisfaction, or knowledge level of women. 29 A single communitylevel pilot study "Let's talk periods" with 75 minutes of class presentation showed improved knowledge of menorrhagia and bleeding disorders. 32

| DISCUSS ION
This scoping review identified 20 studies that aimed at improving aspects of access to care for women with AUB. Given the high • Caregiver support -prevalence of AUB in women across countries 2 and consistent reporting of barriers for women with AUB to accessing care over the past two decades, 3,5,6 it is concerning that there is such a limited number of intervention studies focusing on this topic.

TA B L E 2 Dimensions of access targeted by interventions in included studies
Our results show that organizational interventions such as developing collaborative services appeared to improve the availability, coordination, and continuity of healthcare services for AUB provided in hospital settings. Assessment and management of AUB in an outpatient setting seemed to reduce service costs when compared with an inpatient setting. Patient engagement (shared decision making) in patient-physician consultations improved with patient information booklets, videotapes, and computer-based decision tools.
There were no studies targeting other health service-based access dimensions including approachability, acceptability, appropriateness and population-based access dimensions such as the ability to perceive, seek, reach, and pay. Hence, many evidence gaps need to be addressed to enable research-informed programs that can improve access to care and the quality of life for women with AUB.
This review found that intervention studies were commonly conducted in western or high-income countries and in a hospital setting.
We found only one study targeting availability and coordination of services at primary care. 19  training general practitioners with procedural skills such as insertion of intrauterine devices and AUB guidelines would be helpful for the initial management of AUB. 5 However, this requires increased resources, time, and financial costs. 34 We did not find any study directly exploring acceptability, which includes cultural and social acceptance of services. Two studies did show improved satisfaction with choice of doctor with the one-stop menstrual clinic 16 and the general practitioner-led Bridges pathway. 19 Cultural competency in health care generally influences improved access and health outcomes in racial/ethnic minority groups in the community by increasing awareness, knowledge, and skills of healthcare providers or patients as well as modifying policies and practices of organizations. 35 Organizational cultural competency such as the use of bilingual community health workers, interpreters, and patient navigators has been found to improve access in health service-based settings. At the health provider level, some of the interventions include training, workshops to improve the understanding of cultural beliefs in the community, and interpersonal skills for delivering culturally-sensitive care. 35 A strength of this study is that we used a broad range of search terms for AUB and healthcare access in our search strategy. The database search was conducted from inception until the recent date for the current review. A limitation is that we did not search gray literature and studies published in languages other than English.
In conclusion, interventions to improve access to women with abnormal uterine bleeding are restricted to organizational interventions targeting mainly the availability and affordability of services in a hospital setting. Future research should aim at interventions in the primary care setting and community setting. Interventions with a focus on approachability, acceptability, appropriateness of services, and ability to perceive, seek, reach, and pay for services is required.
Interventions targeting education for general practitioners, culturallytailored information resources, and a culturally-safe and supported environment could improve access to health care for women with different cultural backgrounds and improve equitable health outcomes.

ACK N OWLED G M ENTS
We thank Megan Ferris (Reference librarian) and the Wellington [Correction added on 08-May-2022, after first online publication: CRUI-CARE funding statement has been added].

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interests.

AUTH O R CO NTR I B UTI O N S
All the authors have contributed to the review design. PSK and SF were involved in the screening and selection of articles. PSK led the manuscript writing. All authors contributed to the review of the manuscript and approval of the final draft of the manuscript.