title: Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges.
abstract: BACKGROUND
  Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey.
  
  
  METHODS
  Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients' electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests.
  
  
  RESULTS
  We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts.
  
  
  CONCLUSIONS
  While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty.
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. aisha.lofters@utoronto.ca.|Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada. aisha.lofters@utoronto.ca.|Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. aisha.lofters@utoronto.ca.|Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. aisha.lofters@utoronto.ca.|Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada. aisha.lofters@utoronto.ca.
authors.forename: A K
authors.identifier: http://orcid.org/0000-0002-7322-0894
authors.initials: AK
authors.lastname: Lofters
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Schuler
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Slater
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.|Department of Surgery, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: N N
authors.initials: NN
authors.lastname: Baxter
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.|Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: N
authors.initials: N
authors.lastname: Persaud
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.|Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.
authors.forename: A D
authors.initials: AD
authors.lastname: Pinto
authors.affiliation: Cancer Care Ontario, 620 University Avenue, Toronto, ON, M5G 2L7, Canada.
authors.forename: E
authors.initials: E
authors.lastname: Kucharski
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Davie
authors.affiliation: Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Nisenbaum
authors.affiliation: Department of Family & Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Department of Family & Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada.|Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
authors.forename: T
authors.initials: T
authors.lastname: Kiran
mesh_terms: D000328:Adult; D000368:Aged; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000458:organization & administration*; D008875:Middle Aged; D009017:Morbidity / Q000639:trends; D009369:Neoplasms / Q000175:diagnosis / Q000453:epidemiology*; D009864:Ontario / Q000453:epidemiology; D011320:Primary Health Care / Q000592:standards*; D057566:Self Report; D064890:Social Determinants of Health / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D055815:Young Adult
keywords: Breast cancer; Cervical cancer; Colorectal cancer; Screening; Social determinants of health