Investigators may have uncovered the social determinants of health hindering breast cancer screening in the United States, according to a recent systematic review published by Jhumkhawala et al in Frontiers in Public Health.
Background
Health disparities have consistently been associated with delayed screening, which contribute to higher mortality rates among Hispanic and Black populations. Moreover, poverty, lack of education, neighborhood disadvantage, residential segregation, racial discrimination, lack of social support, and social isolation may also play a role in the breast cancer stage at diagnosis. As a result, there has been a critical need to better understand which social determinants of health and health inequities may influence lower rates of breast cancer screening behaviors in the United States.
“One of the most influential roles of social determinants of health lies within the realm of equitable access,” explained senior study author Lea Sacca, PhD, Assistant Professor in the Department of Population Health and Social Medicine at the Florida Atlantic University Schmidt College of Medicine.
Study Methods and Results
In the recent systematic review, investigators conducted a scoping review of 72 peer-reviewed observational studies published between 2013 and 2023. They focused on social determinants of health such as race and ethnicity, employment, education, food security, insurance status, housing, and access to quality health care.
The investigators found that the social determinants of health related to socioeconomic status—specifically income, education level, employment status, birthplace and citizenship, acculturation and years lived in the United States, marital status, social support, and number of children—were most common among the patients.
Access to health care with subcategories such as insurance status, accessibility of health care services and providers, insurance coverage, access to mammography facilities, insurance copayments, time from breast cancer diagnosis to first treatment, travel time to clinic, and county uninsured rate emerged as a statistically significant factor that was incorporated into 61% of the studies included in the review.
Insurance status was the most reported subcategorical factor of access to quality health care. Many of the studies demonstrated a strong correlation between a lack of health insurance and a lower rate of breast cancer screening.
Race and ethnicity, sex and gender, and sexual orientation were additional factors reported. The investigators revealed that 58% of the studies showed statistical significance in the social and community context category, with the highest subcategories being age and ethnicity. Ethnic minority women—with the exception of those identifying as Asian—had a lower likelihood of undergoing breast cancer screening, and Black women experienced a higher risk of diagnosis upon first breast cancer screening. White bisexual women had significantly lower mammography rates compared with White heterosexual women, whereas Black bisexual women had higher mammography rates compared with Black heterosexual women.
Language was the third most prevalent factor, underscoring its significance as an issue influencing breast cancer screening behavior. Additionally, 38% of the studies exhibited statistical significance in the economic stability category, with income level (27%) being the most common subcategorical factor emphasized. Women with estimated household incomes greater than $38,100 were also found to have rates of repeat mammography higher than those of women whose estimated household incomes were below $25,399. The investigators emphasized that high levels of poverty and impoverished rural regions were associated with lower screening rates.
Food security was another influential factor of mammography rates. “When women are forced to choose between feeding their families and pursuing preventive care, mammography becomes more of a luxury than life-saving care. Women facing food insecurity have a 54% lower likelihood of [undergoing mammography],” stated Dr. Sacca.
Further, 33% of the articles showed statistical significance in education access and quality as strong indicators of mammography rates, with the highest level of education completed acting as the greatest subcategorical factor.
Location, transportation, housing, county poverty rate, internet access, area deprivation index, diversity index, perceived discrimination, health beliefs and trust in health care providers and systems, and cultural and religious beliefs also were cited in the review. For instance, fatalism-emphasizing religions were associated with less breast cancer screening adherence and maintenance of modesty did not prove a significant limitation for women undergoing mammography.
Conclusions
“Results from our research could inform future evidence-based interventions aimed at addressing the underlying factors contributing to low screening rates for breast cancer in the country,” Dr. Sacca highlighted. “Improving patient-provider communication, addressing perceived discrimination, and improving trust in the health care system is necessary to improve screening rates across all demographics. Additionally, structural efforts to improve health insurance coverage, language proficiency, and transportation services could be beneficial. These steps will need to involve the local community to develop community-tailored educational campaigns to reinforce the importance of establishing regular [breast cancer] screenings,” she concluded.
Disclosure: For full disclosures of the study authors, visit frontiersin.org.
