Addressing
g Social Determinants
of Health in Cervical Cancer
Screening: The Women’s
Women s Health
Demonstration Project
Cheryl
y Clark,, Nashira Baril,, Marycarmen
y
Kunicki,,
Jane Soukup, Natacha Johnson, Stuart Lipsitz,
JudyAnn Bigby
for the Boston REACH Coalition
June 29,, 2010
T d ’ T
Today’s
Talk
lk

Introduction to the Boston REACH
Women’s Health Demonstration
Project:
j
CBPR Partnership
p

Intervention study

Successes and challenges
REACH 2010: Community Engaged
Health Interventions

Boston Racial and Ethnic Approaches to
Community Health (REACH 2010)
– CommunityCommunity-based coalition of partners
– Health disparities/
Health equity focus
– Women’s health focus
foc s
Infant mortality
 Women’s
’ health
h l h status

REACH 2010 Breast and Cervical
Cancer Coalition

Mission: “to eliminate racial and ethnic
disparities in breast and cervical cancer
in Boston by creating, with the
community, a culturally competent
system
y
which p
promotes screening,
g,
education, prevention, treatment and
access to care for Black women and
women of African descent”
Women s Health Demonstration
Women’s
Project Approach

Comprehensive approach to women’s
health
– Perform social and medical assessments
– Provide advocates to interface with
systems
– Address barriers to cervical cancer
screening
Bigby 2003
S d H
Study
Hypotheses
h

Does exposure to comprehensive social
and medical case management
– facilitate onon-schedule Pap smear screening?
– facilitate timelyy follow up
p of abnormal Pap
p
smear results?
S d D
Study
Design
i

Feasibility study
– Case management in social assessment
– Intervention delivered to all participants

Data collection
– Enrollment
E ll
t and
d intervention
i t
ti (2002 – 2006)
– Baseline survey assessment
– Medical record review (1999 – 2007)
– Follow up
p through
g 2007
Participants and Setting

African descent/Black women (18(18-75yrs)
– At risk for fragmented primary care delivery
 No PCP appointment in 2 years
 Missed
Mi d screening
i appointments
i t
t
 Repeated use of urgent care

Six primary care sites
– Free
F
standing
t di community
it h
health
lth centers
t
(CHCs)
(CHC )
– Hospital licensed CHCs
– Academic hospital clinic
Intervention: Comprehensive
Case Management

Case managers
– Lay community health worker
– Women
Women’ss health focus
– Social services focus

Case manager training & support
– 12 month women
women’ss health curriculum
– Cultural competency training
– Social work support
Case Management
a age e Intervention
e e o
Components

Assess and address social determinants
– Connect to tailored social services

Facilitate culturally competent care
– Patient advocacy, interpreters

Systems navigation
– Logistic support, tracking abnormal results

Social support and community building
Survey: Women
Women’s
s Health
Questionnaire
62--item baseline assessment survey (1 hr)
62

Social determinants of health
– Social barriers (e.g., domestic violence, lack
of social support, housing concerns)

Health care access

Health beliefs & intentions
O
Outcome
Measures
M
Medical record review

Pap smear screening guideline adherence
– 2001 American Cancer Societyy ((ACS))
– liquid cytology

Timely indicated followfollow-up (Bethesda 2001)
– ASCUS (12 months)
– Dysplasia (3 months)
– Insufficient sample (6 months)
Analysis

Odds of adherence to 2001 ACS Pap
smear screening
i guidelines
id li
– Recent Pap vs. NonNon-recent Pap
– Years of exposure to case management

Odds of timely follow up of abnormal
results
– Before intervention vs. during intervention
– Exact logistic regression
Study Participants Due for
Pap Smear Screening N=578
Years of Case Management
Exposure and Guideline Adherence
Effect of Case Management
on Guideline Adherence
Table 1. Odds of Adhering to ACS Pap Smear Screening Guidelines (N = 578) Recent Pap Smear No Recent Pap at Baseline Smear at Baseline Years of Case Management Intervention
Intervention Unadjusted 1.41 (1.16 ‐ 1.72)
1.41 (1.16 1.72)* 1.37 (1.07 1.37 (1.07 ‐ 1.75)
1.75)*
1.15 (0.76 ‐ 1.75)
1.15 (0.76 Uninsured 0.56 (0.28 ‐ 1.11) 2.64 (0.70 ‐ 9.89) No child care 0.62 (0.39 ‐ 1.01)
0.28 (0.10 ‐ 0.78)*
Odds Ratio (95% CI) adjusted for socioeconomic status (education), provider communication. Reference groups: Private insurance, has access to child care * P < 0.05
f
i
i
h
hild
*
Abnormal Results Requiring
Follow Up (N = 108)
Effect of Case Management
Intervention on Timely Follow up
Table 2. Odds of Timely Clinical Follow Up for Abnormal Pap Smear Results Results
All abnormal ASCUS (N = 44) Dysplasia (N = 41) results (N = 108)
results (N 108)
Found During Case Management 1 49 (0 64 ‐ 3.50)
1.49 (0.64 3 50) 1.01 (0.22 1 01 (0 22 ‐ 4.61)
4 61) 5.18 (0.82 5 18 (0 82 ‐ 47.14) 47 14)
Intervention U i
Uninsured d
0 31 (0 10 0.99)*
0.31 (0.10 ‐
0 99)* 0.44 (0.05 ‐
0 44 (0 05 3.21)
3 21) 0.09 (0.004 ‐
0 09 (0 004 1.03) 1 03)
Odds Ratio (95% CI) adjusted for socioeconomic status (education), Bethesda criteria. Reference Odds
Ratio (95% CI) adjusted for socioeconomic status (education), Bethesda criteria. Reference
groups: Result found prior to case management; private insurance * P < 0.05 E l
Evaluation
i
Processes
P

Case managers provided
successful advocacy and
social support
pp
Women reported that case
managers helped them with:
 Getting
housing
 Getting assistance with food needs
 Coping
p g with death of loved ones
 Court eviction
Limitations and Challenges




No control group or randomization
Evolving recommendations for Pap
smear usage during study
Process measures qualitative not
quantitative
Cost determination/effectiveness
beyond scope of study
Conclusions and Successes


Success in assessing social determinants
of health in primary care settings
Case management intervention effects
– Evidence of improved screening patterns
– Consider case management in care team
– Future directions – social support

CBPR principles in research
– Trust,
Trust long term partnership
partnership, commitment
N
Next
Steps
S


REACH US Coalition work on Social
Determinants of Health
Qualitative research on communication
i
inequality
li around
d HPV vaccination
i i
((National Cancer Institute))
Summary and Challenge for
CBPR

Promise of community engaged
research
– Ask the right questions
– Act on the information to make change

Need for strong science
– Apply our energies in the right direction

Need for action
– Disseminate and act for change
Acknowledgements

REACH Coalition
– Nashira
N hi Baril,
B il Erline
E li Achille,
A hill Marycarmen
M
Kunicki, Natacha Johnson

Ms. Jane Soukup

Dr. Stuart Lipsitz

D JJudyAnn
Dr.
d A Bigby
Bi b

Dr Barbara Ferrer
Dr.
Thank you
Principles of Social
Determinants of Health

Fundamental Causes
– Contribution to any single disease small
– Effect on health amplified by contribution
to several diseases affected by the
pathway

S i ll modifiable
Socially
difi bl
– Strongest
g
interventions alter social or
environmental factors
Challenges
Ch ll
iin CBPR

Funding

Timing and process

Trust and relationship building

Scientific analysis
y and ways
y of
knowing
Screening and Vulnerable
Populations

Recent vs. Regular Screening

“Hidden”
Hidden populations