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

J Womens Health (Larchmt). 2009 May;18(5):677-90. doi: 10.1089/jwh.2008.0972.


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.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Black People / psychology
  • Black People / statistics & numerical data*
  • Boston
  • Breast Neoplasms / ethnology*
  • Breast Neoplasms / prevention & control
  • Breast Neoplasms / psychology
  • Breast Self-Examination / psychology
  • Breast Self-Examination / statistics & numerical data*
  • Cohort Studies
  • Confidence Intervals
  • Female
  • Health Behavior / ethnology*
  • Health Knowledge, Attitudes, Practice*
  • Health Promotion / statistics & numerical data*
  • Humans
  • Mammography / psychology
  • Mammography / statistics & numerical data
  • Middle Aged
  • Odds Ratio
  • Prospective Studies
  • Surveys and Questionnaires
  • Women's Health