title: Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women's Health Demonstration Project.
abstract: BACKGROUND
  The Boston Racial and Ethnic Approaches to Community Health (REACH) 2010 Breast and Cervical Cancer Coalition developed a case management intervention for women of African descent to identify and reduce medical and social obstacles to breast cancer screening and following up abnormal results.
  
  
  METHODS
  We targeted black women at high risk for inadequate cancer screening and follow-up as evidenced by a prior pattern of missed clinic appointments and frequent urgent care use. Case managers provided referrals to address patient-identified social concerns (e.g., transportation, housing, language barriers), as well as navigation to prompt screening and follow-up of abnormal tests. We recruited 437 black women aged 40-75, who received care at participating primary care sites. The study was conducted as a prospective cohort study rather than as a controlled trial and evaluated intervention effects on mammography uptake and longitudinal screening rates via logistic regression and timely follow-up of abnormal tests via Cox proportional hazards models.
  
  
  RESULTS
  A significant increase in screening uptake was found (OR 1.53, 95% CI 1.13-2.08). Housing concerns (p < 0.05) and lacking a regular provider (p < 0.01) predicted poor mammography uptake. Years of participation in the intervention increased odds of obtaining recommended screening by 20% (OR 1.20, 95% CI 1.02-1.40), but this effect was attenuated by covariates (p = 0.53). Timely follow-up for abnormal results was achieved by most women (85%) but could not be attributed to the intervention (HR 0.95, 95% CI 0.50-1.80).
  
  
  CONCLUSIONS
  Case management was successful at promoting mammography screening uptake, although no change in longitudinal patterns was found. Housing concerns and lacking a regular provider should be addressed to promote mammography uptake. Future research should provide social assessment and address social obstacles in a randomized controlled setting to confirm the efficacy of social determinant approaches to improve mammography use.
authors.affiliation: Center for Community Health and Health Equity, Brigham and Women's Hospital, Division of General Medicine and Primary Care, Center for Community Health and Health Equity, 1620 Tremont Street, Boston, MA 02120, USA. crclark@partners.org
authors.forename: Cheryl R
authors.initials: CR
authors.lastname: Clark
authors.forename: Nashira
authors.initials: N
authors.lastname: Baril
authors.forename: Marycarmen
authors.initials: M
authors.lastname: Kunicki
authors.forename: Natacha
authors.initials: N
authors.lastname: Johnson
authors.forename: Jane
authors.initials: J
authors.lastname: Soukup
authors.forename: Kathleen
authors.initials: K
authors.lastname: Ferguson
authors.forename: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.forename: JudyAnn
authors.initials: J
authors.lastname: Bigby
mesh_terms: D000328:Adult; D000368:Aged; D044383:Black People / Q000523:psychology / Q000706:statistics & numerical data*; D001900:Boston; D001943:Breast Neoplasms / Q000208:ethnology* / Q000517:prevention & control / Q000523:psychology; D016504:Breast Self-Examination / Q000523:psychology / Q000706:statistics & numerical data*; D015331:Cohort Studies; D016001:Confidence Intervals; D005260:Female; D015438:Health Behavior / Q000208:ethnology*; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion / Q000706:statistics & numerical data*; D006801:Humans; D008327:Mammography / Q000523:psychology / Q000706:statistics & numerical data; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D016387:Women's Health; D001741:Black or African American