Social determinants of health and US cancer screening interventions: A systematic review

Abstract

There remains a need to synthesize linkages between social determinants of health (SDOH) and cancer screening to reduce persistent inequities contributing to the US cancer burden. The authors conducted a systematic review of US-based breast, cervical, colorectal, and lung cancer screening intervention studies to summarize how SDOH have been considered in interventions and relationships between SDOH and screening. Five databases were searched for peer-reviewed research articles published in English between 2010 and 2021. The Covidence software platform was used to screen articles and extract data using a standardized template. Data items included study and intervention characteristics, SDOH intervention components and measures, and screening outcomes. The findings were summarized using descriptive statistics and narratives. The review included 144 studies among diverse population groups. SDOH interventions increased screening rates overall by a median of 8.4 percentage points (interquartile interval, 1.8-18.8 percentage points). The objective of most interventions was to increase community demand (90.3%) and access (84.0%) to screening. SDOH interventions related to health care access and quality were most prevalent (227 unique intervention components). Other SDOH, including educational, social/community, environmental, and economic factors, were less common (90, 52, 21, and zero intervention components, respectively). Studies that included analyses of health policy, access to care, and lower costs yielded the largest proportions of favorable associations with screening outcomes. SDOH were predominantly measured at the individual level. This review describes how SDOH have been considered in the design and evaluation of cancer screening interventions and effect sizes for SDOH interventions. Findings may guide future intervention and implementation research aiming to reduce US screening inequities.

Keywords: United States; cancer screening; early detection of cancer; health equity; implementation science; social determinants of health.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Figure 2.

Intervention components grouped by SDOH domain and construct. A component may represent >1 SDOH construct (e.g., state health insurance mandate addresses health insurance coverage and health policy).

Figure 3A-C.

Summary of associations between SDOH and (A) all cancer screening outcomes, (B) screening behavior, and (C) behavioral precursors to screening. Favorable associations (blue) indicate that the SDOH (e.g., having health insurance) was associated with better screening outcomes, whereas unfavorable associations (red) indicate that the SDOH (e.g., having a higher education level) was associated with worse outcomes. Overall, 31 studies reported mixed associations (e.g., favorable and null) for a single SDOH construct due to multiple analyses and/or screening outcomes; each association is reported separately. Two associations were excluded from the summary: a favorable association between a SES index (including poverty, income, income support, education, employment) and screening behavior, and an association with screening behavior that could not discern directionality between categorical health insurance types.