title: Case management intervention in cervical cancer prevention: the Boston REACH coalition women's health demonstration project.
abstract: BACKGROUND
  The Boston REACH Coalition developed a case management intervention for Black women in primary care settings to identify and reduce medical and social obstacles to cervical cancer screening and following up abnormal results.
  
  
  METHODS
  The 5-year intervention was evaluated among 732 Black women aged 18 to 75 who were at high risk for inadequate Pap smear screening and follow-up. Case managers provided social services referrals to address patient-identified social concerns (e.g., transportation, housing), as well as navigation to prompt screening and follow-up of abnormal tests. The three study aims were to (1) identify the social factors associated with Pap smear screening at baseline before intervention, (2) evaluate the correlation between exposure to case management intervention and achieving recommended Pap screening intervals, and (3) evaluate the correlation between exposure to case management intervention and having timely follow-up of abnormal Pap smear tests.
  
  
  RESULTS
  We found that a lack of a regular clinical provider, concerns communicating with providers, poor self-rated health, and having less than a high school education were important correlates of recent Pap smear screening before the case management intervention. During the case management intervention, we found a significant increase in achieving recommended Pap smear screening intervals among women with a recent Pap smear at study entry (increasing from 52% in the first year to 80% after 4 or more years; p < .01), but not among women who entered the study without a recent Pap smear (increasing from 31% in the first year to 44% after 4 or more years; p = .39). During case management intervention, having social support for childcare was associated with regular screening among women without a recent Pap smear (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.28-9.69). Insurance status was the key factor in timely clinically indicated follow-up of abnormal results (uninsured OR, 0.27; 95% CI, 0.08-0.86), rather than case management intervention.
  
  
  CONCLUSIONS
  Exposure to case management was associated with regular Pap smear screening among women who recently engaged in screening. Future research should focus on systems changes to address social determinants of health, including strategies to facilitate screening for Black women without social support for childcare. To improve follow-up of abnormal results, financial access to care should be addressed.
authors.affiliation: Center for Community Health Equity, Brigham and Women's Hospital, Commonwealth of Massachusetts, USA.
authors.forename: Cheryl R
authors.initials: CR
authors.lastname: Clark
authors.forename: Nashira
authors.initials: N
authors.lastname: Baril
authors.forename: Angela
authors.initials: A
authors.lastname: Hall
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: Stuart
authors.initials: S
authors.lastname: Lipsitz
authors.forename: Judyann
authors.initials: J
authors.lastname: Bigby
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American; D000368:Aged; D001900:Boston / Q000453:epidemiology; D019090:Case Management / Q000458:organization & administration* / Q000592:standards; D005260:Female; D006265:Health Care Coalitions / Q000458:organization & administration* / Q000592:standards; D006297:Health Services Accessibility / Q000191:economics / Q000592:standards; D054625:Healthcare Disparities / Q000191:economics / Q000208:ethnology*; D006801:Humans; D008875:Middle Aged; D065006:Papanicolaou Test; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D015397:Program Evaluation; D012959:Socioeconomic Factors; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000208:ethnology / Q000517:prevention & control*; D014626:Vaginal Smears / Q000191:economics / Q000706:statistics & numerical data*; D055815:Young Adult