Cancer Screening: Patient Navigation Services to Increase Colorectal Cancer Screening and Advance Health Equity

Snapshot What the CPSTF Found Supporting Materials Considerations for Implementation

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends patient navigation services to increase colorectal cancer screening by colonoscopy, fecal occult blood test (FOBT) or fecal immunochemical test (FIT), among historically disadvantaged racial and ethnic populations and people with lower incomes.

Patient navigation services are expected to advance health equity when implemented among these populations who often have lower screening rates (Sabatino et al. 2021). With timely and appropriate follow-up care and treatment, patient navigation services may improve health for these groups.

The CPSTF has related findings for patient navigation interventions to increase screenings for the following:

Breast cancer (recommended)
Cervical cancer (recommended)

The CPSTF finds patient navigation services to increase colorectal cancer screenings are cost-effective. Systematic review evidence shows estimates of cost per quality-adjusted life year (QALY) gained are below a conservative threshold of $50,000. In addition, the CPSTF finds that the return on investment is favorable for patient navigation services to increase colorectal cancer screening by colonoscopy, as estimated values for colonoscopy reimbursement exceed the cost of the intervention.

Intervention

Patient navigation services provided through healthcare systems help patients overcome barriers to accessing colorectal cancer screening. Services are offered to populations experiencing greater disparities in cancer screening, including people from historically disadvantaged racial and ethnic populations and people with lower incomes. Patient navigation services do one or more of the following:

Provide client reminders
Reduce structural barriers (e.g., modify administrative processes; assist with appointment scheduling, transportation, translation, or childcare; arrange alternative screening sites or hours)
Reduce patients’ out-of-pocket costs

Services may also provide one-on-one or group education to inform patients’ understanding of cancer and cancer screening.

Services may be delivered by community health workers (CHWs), healthcare professionals, nurses, patient navigators, social workers, or others. They are often designed to be culturally- and language-appropriate.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

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About The Systematic Review

The CPSTF finding is based on evidence from a systematic review that examined intervention effectiveness in increasing breast, cervical, or colorectal cancer screening. The review included 34 studies identified from an existing systematic review (Nelson et al. 2020; search period January 1996 to July 2019) and an updated search (search period through November 2021).

Of the 34 included studies, 27 evaluated intervention effects on colorectal cancer screening.

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control.

Context

Screening for colorectal cancer, combined with appropriate follow-up diagnosis and treatment, can reduce cancer incidence and mortality (USPSTF 2021). In 2018, colorectal cancer screening rates in the United States were below the Healthy People 2020 targets, and Healthy People 2030 adjusted their targets based on 2018 data. Rates are even lower among people from historically disadvantaged racial and ethnic groups, people qualifying for Medicaid, and people who do not have health insurance (Sabatino et al. 2021). Identifying and expanding the use of evidence-based interventions to increase screenings can help reduce screening disparities.

Patient navigation services were designed to eliminate barriers and promote access to timely diagnosis and treatment of cancer (Freeman et al. 2011). These services guide patients through healthcare system barriers from pre-diagnosis through all phases of the cancer treatment (Freeman et al. 2011). Barriers may be financial or structural or associated with communication or access to information (CDC 2021). Barriers may also include patients’ mistrust of the healthcare system or fear of possible cancer diagnoses (CDC 2021; Freeman et al. 2011).

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 27 studies. Patient navigation interventions increased colorectal cancer screening for all types of screening.

Received colorectal cancer screening using any colorectal cancer screening test recommended by USPSTF
- Colorectal cancer screening increased by a median of 13.6 percentage points or 76.2% (26 studies)
- Meta-analysis: risk ratio of 1.82, 95% CI 1.50 to 2.21 (26 studies)
Received colorectal cancer screening using colonoscopy
- Colorectal cancer screening increased by a median of 13.9 percentage points or 109.9% (12 studies)
- Meta-analysis: risk ratio of 1.97, 95% CI 1.34 to 2.89 (11 studies)
Received colorectal cancer screening using FOBT or FIT
- Colorectal cancer screening increased by a median of 12.4 percentage points or 57.3% (12 studies)
- Meta-analysis: risk ratio of 1.65, 95% CI 1.38 to 1.99 (12 studies)

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

A systematic review of economic evidence shows patient navigation services to increase colorectal cancer screening are cost-effective. In addition, the CPSTF finds that the return on investment is favorable for patient navigation services to increase colorectal cancer screening by colonoscopy as estimated values for colonoscopy reimbursement exceed the cost of the intervention.

The economic review (search period through December 2022) included studies of screening for colorectal cancer (17 studies). All but one study was conducted in the United States, and monetary values are reported in 2022 dollars.

Intervention Cost

The median intervention cost per person for colorectal cancer screening: $150 (Interquartile Interval (IQI): $66, $338; 16 studies).
The median intervention cost per additional person screened for colorectal cancer: $663 (IQI: $202, $1711; 17 studies).

Economic Benefit

An increase in colorectal cancer screenings is expected to raise healthcare costs initially due to an associated increase in diagnostic tests and follow up treatment costs. Over time, however, earlier detection of cancer is expected to lower treatment costs that lead to economic benefits.

Three colorectal cancer screening studies modeled long-term treatment cost net of intervention cost.

Net savings per person for colorectal cancer screening intervention: $173 and $1,442 (2 studies)
Net cost per person for colorectal cancer screening intervention: $42 (1 study)

Cost-effectiveness

The systematic economic review finds patient navigation services to increase colorectal cancer screening are cost-effective with three studies’ estimates of cost per QALY gained falling below the conservative threshold of $50,000. Two studies showed that when using patient navigation services, cost declined, and quality-adjusted life year (QALY) increased for colorectal cancer screening. One study showed the cost per life year gained when using patient navigation services with colorectal cancer screening was $3,231, and when converted to QALY, this estimate was below $50,000 per QALY gained.

Rate of Return on Investment (ROI)

The median ROI: 2.3% (IQI: 1.7%, 6.9%; 5 estimates, 2 studies).

Applicability

Based on results from the systematic review, findings are applicable to adults and older adults with different baseline screening status, across educational levels, employment, and insurance status.

Evidence suggests programs can be offered in urban or rural settings, include different intervention components, and be delivered by a range of providers who work alone or as part of a team.

Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. Evidence gaps were identified for breast, cervical, and colorectal cancer screenings. (What are evidence gaps?)

CPSTF identified the following questions as priorities for research and evaluation:

How effective are patient navigation services in increasing the following?
- Repeat screenings (the U.S. Preventive Services Task Force recommends repeating breast, cervical, and colorectal cancer screenings at appropriate intervals [USPSTF 2016, 2018, 2021]); the included studies examined one-time screenings
- The proportion of patients with positive screening tests who receive follow-up diagnostic tests
- Cervical cancer screening for younger females (USPSTF recommends females start regular cervical cancer screening at age 21 years [USPSTF 2018]); the included studies recruited participants with a median age of 59.5 years.
What is the cost-effectiveness of patient navigation services to increase cervical cancer screening?
What is the cost-effectiveness of patient navigation services to increase colorectal cancer screening for populations that were underrepresented in the economic review, including African Americans?

Remaining questions for research and evaluation identified by CPSTF:

How effective are patient navigation services in increasing the following?
- Cervical cancer screening that includes HPV tests (following the 2018 update from USPSTF that recommended high risk HPV testing alone or in combination with cytology for women aged 30 to 65 years)
- Colorectal cancer screening for adults aged 45-49 years (following the 2021 update from USPSTF that lowered the starting age for colorectal cancer screenings)
- Colorectal cancer screening using other USPSTF-recommended tests such as the stool DNA test, flexible sigmoidoscopy, or computed tomography colonography
Does intervention effectiveness vary by the following?
- Participants’ health literacy
- Number of interactions between service deliverers and participants
What is the precise economic impact of patient navigation services within comprehensive health promotion interventions?
What is the cost-effectiveness of patient navigation services to increase FOBT/FIT followed by diagnostic colonoscopy?

Study Characteristics

The following characteristics describe the 34 included studies across all three cancer types.

All included studies were conducted in the United States.
Studies were conducted in clinic (22 studies) or clinic and community (12 studies) settings, and in urban (26 studies), rural (5 studies), or a mix of urban and rural areas (2 studies).
Study participants had a mean age of 59.5 years (25 studies), self-identified as American Indian or Alaska Native (1 study), Asian (4 studies), Black or African American (15 studies), Hispanic or Latino (11 studies), Native Hawaiian (1 study), or White (14 studies).
Among studies that reported on income and education, the majority of study participants had annual incomes below 150% of the federal poverty level (16 studies), and had a high school education or less (14 studies).
Interventions offered one to six services including assistance with appointment scheduling (20 studies) or transportation (13 studies), reductions in administrative barriers (23 studies), and one-on-one education (24 studies).
Services were delivered remotely (15 studies) or both remotely and face-to-face (18 studies); no services were delivered face-to-face only.
Services were most often delivered by CHWs or dedicated patient navigators who worked alone (CHWs, 6 studies; navigator, 14 studies) or on a team (CHWs, 3 studies; navigator, 6 studies).

Analytic Framework

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

The economic review team develops an analytic framework to align economic outcomes with each stage of the effectiveness review analytic framework. It informs the economic research questions and may be used to summarize the evidence for intervention cost, economic benefit, cost-effectiveness, and cost-benefit.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 492 KB]

Economic Review

Summary Evidence Table – Economic Review [PDF – 303 KB]

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies, or one study may be explained in several publications).

Effectiveness Review

Baker DW, Brown T, Buchanan DR, et al. Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial. JAMA Internal Medicine 2014;174(8):1235-41.

Blumenthal D, Smith S, Majett C, et al. A trial of three interventions to promote colorectal cancer screening in African Americans. Cancer 2010;116(4):922-9.

Braun KL, Thomas Jr WL, Domingo JLB, et al. Reducing cancer screening disparities in Medicare beneficiaries through cancer patient navigation. Journal of American Geriatric Society 2015;63(2):365-70.

Christie J, Itzkowitz S, Lihau-Nkanza I, et al. A randomized controlled trial using patient navigation to increase colonoscopy screening among low-income minorities. Journal of the National Medical Association 2008;100(3):278-84.

Coronado GD, Petrik AF, Vollmer WM, et al. Effectiveness of a mailed colorectal cancer screening outreach program in community health clinics: the STOP CRC Cluster Randomized Clinical Trial. JAMA Internal Medicine 2018;178(9):1174-81.

Davis T, Arnold C, Rademaker A, et al. Improving colon cancer screening in community clinics. Cancer 2013;119(21):3879-86.

DeGroff A, Schroy III PC, Morrissey KG, et al. Patient navigation for colonoscopy completion: results of an RCT. American Journal of Preventive Medicine 2017;53(3):363-72.

Dietrich A, Tobin J, Cassells A, et al. Telephone care management to improve cancer screening among low-income women: a randomized, controlled trial. Annals of Internal Medicine 2006;144(8):563-71.

Dietrich AJ, Tobin JN, Robinson CM, et al. Telephone outreach to increase colon cancer screening in Medicaid managed care organizations: a randomized controlled trial. Annals of Family Medicine 2013;11(4):335-43.

Enard K, Nevarez L, Hernandez M, et al. Patient navigation to increase colorectal cancer screening among Latino Medicare enrollees: a randomized controlled trial. Cancer Causes & Control 2015;26(9):1351-9.

Fiscella K, Humiston S, Hendren S, et al. A multimodal intervention to promote mammography and colorectal cancer screening in a safety-net practice. Journal of the National Medical Association 2011;103(8):762-8.

Ford ME, Havstad S, Vernon SW, et al. Enhancing adherence among older African American men enrolled in a longitudinal cancer screening trial. Gerontologist 2006;46(4):545-50.

Fortuna RJ, Idris A, Winters P, et al. Get Screened: a randomized trial of the incremental benefits of reminders, recall, and outreach on cancer screening. Journal of General Internal Medicine 2014;29(1):90-7.

Goldman SN, Liss DT, Brown T, et al. Comparative effectiveness of multifaceted outreach to initiate colorectal cancer screening in community health centers: a randomized controlled trial. Journal of General Internal Medicine 2015;30(8):1178-84.

Hardin V, Tangka FK, Wood T, et al. The effectiveness and cost to improve colorectal cancer screening in a federally qualified homeless clinic in eastern Kentucky. Health Promotion Practice 2020;21(6):905-9.

Haverkamp D, English K, Jacobs-Wingo J, et al. Effectiveness of interventions to increase colorectal cancer screening among American Indians and Alaska Natives. Preventing Chronic Disease 2020;17:E62.

Honeycutt S, Green R, Ballard D, et al. Evaluation of a patient navigation program to promote colorectal cancer screening in rural Georgia, USA. Cancer 2013;119(16):3059-66.

Jandorf L, Gutierrez Y, Lopez J, et al. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. Journal of Urban Health 2005;82(2):216-24.

Lasser KE, Murillo J, Lisboa S, et al. Colorectal cancer screening among ethnically diverse, low-income patients: a randomized controlled trial. Archives Internal Medicine 2011;171(10):906-12.

Leone LA, Reuland DS, Lewis CL, et al. Reach, usage, and effectiveness of a Medicaid patient navigator intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011. Preventing Chronic Disease 2013;10:E82.

Ma GX, Shive S, Tan Y, et al. Community-based colorectal cancer intervention in underserved Korean Americans. Cancer Epidemiology 2009;33:381-6.

Ma GX, Lee M, Beeber M, et al. Community-clinical linkage intervention to improve colorectal cancer screening among underserved Korean Americans. Cancer Health Disparities 2019;3:e1-5.

Myers RE, Sifri R, Daskalakis C, et al. Increasing colon cancer screening in primary care among African Americans. Journal of the National Cancer Institute 2014;106(12):dju344.

Myers RE, Stello B, Daskalakis C, et al. Decision support and navigation to increase colorectal cancer screening among Hispanic patients. Cancer Epidemiology Biomarkers and Prevention 2019;28(2):384-91.

Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. Journal of General Internal Medicine 2009;24(2):211-7.

Percac‐Lima S, López L, Ashburner JM, et al. The longitudinal impact of patient navigation on equity in colorectal cancer screening in a large primary care network. Cancer 2014;120(13):2025-31.

Reuland DS, Brenner AT, Hoffman R, et al. Effect of combined patient decision aid and patient navigation vs usual care for colorectal cancer screening in a vulnerable patient population: a randomized clinical trial. JAMA Internal Medicine 2017;177(7):967-74.

Economic Review

Baker DW, Brown T, Buchanan DR, Weil J, Balsley K, Ranalli L, et al. Comparative effectiveness of a multifaceted intervention to improve adherence to annual colorectal cancer screening in community health centers: a randomized clinical trial. JAMA Intern Med 2014;174(8):1235-1241.

Davis T, Arnold C, Rademaker A, Bennett C, Bailey S, Platt D, et al. Improving colon cancer screening in community clinics. Cancer 2013;119(21):3879-86.

Davis MM, Nambiar S, Mayorga ME, Sullivan E, Hicklin K, O’Leary MC, et al. Mailed FIT (fecal immunochemical test), navigation or patient reminders? Using microsimulation to inform selection of interventions to increase colorectal cancer screening in Medicaid enrollees. Prev Med 2019;129:105836.

De Mil R, Guillaume E, Guittet L, Dejardin O, Bouvier V, Pornet C, et al. Cost-effectiveness analysis of a navigation program for colorectal cancer screening to reduce social health inequalities: a French cluster randomized controlled trial. Value Health 2018;21(6):685-691.

Elkin EB, Shapiro E, Snow JG, Zauber AG, Krauskopf MS. The economic impact of a patient navigator program to increase screening colonoscopy. Cancer 2012;118(23):5982-5988.

Hardin V, Tangka FK, Wood T, Boisseau B, Hoover S, DeGroff A, et al. The effectiveness and cost to improve colorectal cancer screening in a federally qualified homeless clinic in eastern Kentucky. Health Promot Pract 2020;21(6):905-909.

Herman PM, Bucho-Gonzalez J, Menon U, Szalacha LA, Larkey L. Cost-Effectiveness of Community-to-Clinic Tailored Navigation for Colorectal Cancer Screening in an Underserved Population: Economic Evaluation Alongside a Group-Randomized Trial. Am J Health Promot 2022;36(4):678-686.

Jandorf L, Stossel LM, Cooperman JL, Graff Zivin J, Ladabaum U, Hall D, et al. Cost analysis of a patient navigation system to increase screening colonoscopy adherence among urban minorities. Cancer 2013;119(3):612-620.

Kim KE, Randal F, Johnson M, Quinn M, Maene C, Hoover S, et al. Economic assessment of patient navigation to colonoscopy‐based colorectal cancer screening in the real‐world setting at the University of Chicago Medical Center. Cancer 2018;124(21):4137-4144.

Ladabaum U, Mannalithara A, Jandorf L, Itzkowitz SH. Cost‐effectiveness of patient navigation to increase adherence with screening colonoscopy among minority individuals. Cancer 2015;121(7):1088-1097.

Lairson DR, Kim J, Byrd T, Salaiz R, Shokar NK. Cost-effectiveness of community interventions for colorectal cancer screening: low-income Hispanic population. Health Promot Pract 2018;19(6):863-872.

Percac-Lima S, Grant RW, Green AR, Ashburner JM, Gamba G, Oo S, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med 2009;24:211-217.

Percac‐Lima S, López L, Ashburner JM, Green AR, Atlas SJ. The longitudinal impact of patient navigation on equity in colorectal cancer screening in a large primary care network. Cancer 2014;120(13):2025-2031.

Qian F, Gates M, Bisner S, Collins E, Vora S, Dacus H. Benefits, cost, and activities of patient navigation (PN) program for colorectal cancer screening at the Charles B. Wang Community Health Center (CBWCHC). J Immigr Minor Health 2020;22:476-483.

Rice K, Sharma K, Li C, Butterly L, Gersten J, DeGroff A. Cost‐effectiveness of a patient navigation intervention to increase colonoscopy screening among low‐income adults in New Hampshire. Cancer 2019;125(4):601-609.

Wilson FA, Villarreal R, Stimpson JP, Pagán JA. Cost-effectiveness analysis of a colonoscopy screening navigator program designed for Hispanic men. J Cancer Educ 2015;30:260-267.

Wolf HJ, Dwyer A, Ahnen DJ, Pray SL, Rein SM, Morwood KD, et al. Colon cancer screening for Colorado’s underserved: a community clinic/academic partnership. Am J Prev Med 2015;48(3):264-270.

Additional Materials

Reaching Communities through Patient Navigation: Evidence for Action (May 2, 2023)
Hosted by the American Cancer Society National Navigation Roundtable, the webinar features speakers from The Community Guide, the Professional Oncology Navigation Task Force, and CDC’s Community Guide Program and Division of Cancer Control and Prevention

Oncology Navigation Standards of Professional Practice
These standards provide clinical oncology nurse navigators, social work navigators, and patient navigators clear information about best practices in the provision of professional care.
Developed by the Academy of Oncology Nurse & Patient Navigators and other organizations of the Professional Oncology Navigation Task Force

New Hampshire Colorectal Cancer Screening Program Patient Navigation Model Replication Manual
This manual describes how to implement the patient navigation model developed by the New Hampshire Colorectal Cancer Screening Program.
Funded and evaluated by CDC’s Colorectal Cancer Control Program

National Navigation Roundtable (NNRT) Resource Center
NNRT offers resources to support the patient navigation services community.
Hosted by the American Cancer Society

Search Strategies

Effectiveness Review

The review included studies from a published systematic review (Nelson et al. 2020, 29 studies; search period January 1, 1996, to July 6, 2019) and an updated search (5 studies; search period July 1, 2019, to November 30, 2021). The updated search used the same search strategy from Nelson et al., with detailed search strategy and results listed below. Two team members independently screened each paper identified to determine eligibility. Uncertainties and disagreements were resolved by consensus among review team members.

Overall Search Results:
Databases	Date	Results	Duplicates	Final Results
Medline (OVID) 1946 –	11/24/21	2,735	0	2,735
APA PsycInfo (OVID)	11/24/21	907	91	816
Sociology Database Sogicolocial Abstracts (Proquest Central) 1952-	11/27/21	132	41	91
Scopus 1960	11/29/21	666	371	295
Cochrane Library	11/24/21	205	70	135
Total		4,645	572	4,073

Appendix A. Literature Search Strategies

Database: Ovid MEDLINE® July 2019 thru Nov 2021

Broad search:

1 Healthcare Disparities/

2 “Health Services Needs and Demand”/

3 exp Health Services Accessibility/

4 exp Socioeconomic Factors/

5 Minority Groups/

6 exp Population Groups/

7 vulnerable populations/ or working poor/

8 exp Disabled Persons/

9 exp Sexual Minorities/

10 Minority Health/

11 cultural competency/ or cultural diversity/

12 1 or 2 or 3

13 or/4-11

14 13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw.

15 12 or 14

16 exp Preventive Health Services/

17 exp Mass Screening/

18 exp Health Promotion/

19 (“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.

20 or/16-19

21 exp diabetes mellitus, type 2/ or prediabetic state/

22 exp Cardiovascular Diseases/

23 Aspirin/

24 exp breast neoplasms/ or exp colorectal neoplasms/ or exp lung neoplasms/ or uterine cervical neoplasms/

25 exp Obesity/

26 Smoking/

27 exp “Tobacco Use Cessation”/

28 21 or (22 and 23) or 24 or 25 or 26

29 27 or 28

30 29 and pc.fs.

31 20 or 30

32 15 and 31

33 exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new york city/ or san francisco/

34 (“united states” or “u.s.” or alabama or alaska or arizona or arkansas or california or colorado or connecticut or delaware or florida or georgia or hawaii or idaho or illinois or indiana or iowa or kansas or kentucky or louisiana or maine or maryland or massachusetts or michigan or minnesota or mississippi or missouri or montana or nebraska or nevada or “new hampshire” or “new jersey” or “new mexico” or “new york” or “north carolina” or “north dakota” or ohio or oklahoma or oregon or pennsylvania or “rhode island” or “south carolina” or “south dakota” or tennesee or texas or utah or vermont or virginia or washington or “west virginia” or wisconsin or wyoming).ti,ab,kw.

35 32 and (33 or 34)

36 africa/ or caribbean region/ or central america/ or canada/ or greenland/ or mexico/ or south america/ or exp asia/ or exp europe/

37 35 not 36

38 limit 37 to (meta analysis or systematic reviews)

39 (medline or systematic or metaanalysis or “meta analysis”).ti,ab.

40 37 and 39

41 38 or 40

42 limit 41 to english language

43 37 not 42

44 (201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.

45 43 and 44 867

Focused search: evidence gaps

1 Healthcare Disparities/ 20269

2 “Health Services Needs and Demand”/ 54678

3 exp Health Services Accessibility/ 120117

4 exp Socioeconomic Factors/ 481169

5 Minority Groups/ 15822

6 exp Population Groups/ 321010

7 vulnerable populations/ or working poor/ 12188

8 exp Disabled Persons/ 69810

9 exp Sexual Minorities/ 10967

10 Minority Health/ 861

11 cultural competency/ or cultural diversity/ 17597

12 1 or 2 or 3 180299

13 or/4-11 849167

14 13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw. 120769

15 12 or 14 275025

16 exp Preventive Health Services/ 636769

17 exp Mass Screening/ 137402

18 exp Health Promotion/ 81963

19 (“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au. 3039

20 or/16-19 650299

21 exp diabetes mellitus, type 2/ or prediabetic state/ 154697

22 exp Cardiovascular Diseases/ 2555761

23 Aspirin/ 46715

24 exp breast neoplasms/ or exp colorectal neoplasms/ or exp lung neoplasms/ or uterine cervical neoplasms/ 833088

25 exp Obesity/ 235735

26 Smoking/ 145101

27 exp “Tobacco Use Cessation”/ 1324

28 21 or (22 and 23) or 24 or 25 or 26 1340617

29 27 or 28 1341591

30 29 and pc.fs. 119957

31 20 or 30 737319

32 15 and 31 31442

33 exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new york city/ or san francisco/ 1413746

35 32 and (33 or 34) 12684

36 “Social Determinants of Health”/ 4973

37 35 or 36 17553

38 37 and (gap* or limit* or lack* or barrier*).ti,ab. 4878

39 (201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt. 3543456

40 38 and 39 857

41 limit 40 to english language 849

849

Focused search: breast cancer screening

CG Nelson Updated CGO 112621 breast cancer final”

Healthcare Disparities/
“Health Services Needs and Demand”/
exp Health Services Accessibility/
exp Socioeconomic Factors/
Minority Groups/
exp Population Groups/
vulnerable populations/ or working poor/
exp Disabled Persons/
exp Sexual Minorities/
Minority Health/
cultural competency/ or cultural diversity/
1 or 2 or 3
or/4-11
13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw.
12 or 14
exp Preventive Health Services/
exp Mass Screening/
exp Health Promotion/
(“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.
prevent*.ti,ab.
16 or 17 or 18 or 19 or 20
15 and 21
exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new orleans/ or new york city/ or philadelphia/ or san francisco/
exp africa/ or caribbean region/ or central america/ or latin america/ or canada/ or greenland/ or mexico/ or south america/ or exp antarctic regions/ or exp arctic regions/ or exp asia/ or exp europe/ or exp islands/ or exp oceania/
exp Breast Neoplasms/pc [Prevention & Control]
((breast adj3 cancer) or mammogram or mammography or “clinical breast exam” or (breast adj3 self)).ti,ab,kw.
exp Mass Screening/ or exp early diagnosis/
screen*.ti,ab,kw.
(25 or 26) and (27 or 28)
12 and 21 and 29
14 and 21 and 29
30 or 31
23 and 32
32 not 24
33 or 34
(201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.
35 and 36
limit 37 to english language

Focused search: cervical cancer screening

Healthcare Disparities/
“Health Services Needs and Demand”/
exp Health Services Accessibility/
exp Socioeconomic Factors/
Minority Groups/
exp Population Groups/
vulnerable populations/ or working poor/
exp Disabled Persons/
exp Sexual Minorities/
Minority Health/
cultural competency/ or cultural diversity/
1 or 2 or 3
or/4-11
13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw.
12 or 14
exp Preventive Health Services/
exp Mass Screening/
exp Health Promotion/
(“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.
prevent*.ti,ab.
16 or 17 or 18 or 19 or 20
15 and 21
exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new orleans/ or new york city/ or philadelphia/ or san francisco/
exp africa/ or caribbean region/ or central america/ or latin america/ or canada/ or greenland/ or mexico/ or south america/ or exp antarctic regions/ or exp arctic regions/ or exp asia/ or exp europe/ or exp islands/ or exp oceania/
Uterine Cervical Neoplasms/
((cervical or cervix) adj3 cancer).ti,ab,kw.
exp Mass Screening/ or exp early diagnosis/
screen*.ti,ab,kw.
(25 or 26) and (27 or 28)
12 and 21 and 29
14 and 21 and 29
30 or 31
23 and 32
32 not 24
33 or 34
(201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.
35 and 36
limit 37 to english language

Focused search: colon cancer screening

CG Nelson Updated CGO 112621 colon cancer screenings”

Healthcare Disparities/
“Health Services Needs and Demand”/
exp Health Services Accessibility/ or health status disparities/ or “social determinants of health”/
exp Socioeconomic Factors/
Minority Groups/
exp Population Groups/
vulnerable populations/ or working poor/
exp Disabled Persons/
exp Sexual Minorities/
Minority Health/
cultural competency/ or cultural diversity/
1 or 2 or 3
or/4-11
13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw.
12 or 14
exp Preventive Health Services/
exp Mass Screening/
exp Health Promotion/
(“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.
prevent*.ti,ab.
or/16-20
15 and 21
exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new orleans/ or new york city/ or philadelphia/ or san francisco/
exp africa/ or caribbean region/ or central america/ or latin america/ or canada/ or greenland/ or mexico/ or south america/ or exp antarctic regions/ or exp arctic regions/ or exp asia/ or exp europe/ or exp islands/ or exp oceania/
exp Colorectal Neoplasms/pc [Prevention & Control]
(((colon or colorectal) adj3 cancer) or colonoscopy).ti,ab,kw.
exp Mass Screening/
screen*.ti,ab,kw.
(25 or 26) and (27 or 28)
12 and 21 and 29
14 and 21 and 29
30 or 31
23 and 32
32 not 24
33 or 34
(201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.
35 and 36
limit 37 to english language

Systematic reviews:

CG Nelson Updated CGO 112621 systematic reviews

Healthcare Disparities/
“Health Services Needs and Demand”/
exp Health Services Accessibility/ or health status disparities/ or “social determinants of health”/
exp Socioeconomic Factors/
Minority Groups/
exp Population Groups/
vulnerable populations/ or working poor/
exp Disabled Persons/
exp Sexual Minorities/
Minority Health/
cultural competency/ or cultural diversity/
1 or 2 or 3
or/4-11
13 and (equity or equitable or equal* or fair or parity or unequal* or inequal* or inequit* or undertreat* or under-treat* or access* or disparit* or discriminat*).ti,ab,kw.
12 or 14
exp Preventive Health Services/
exp Mass Screening/
exp Health Promotion/
(“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.
or/16-19
exp diabetes mellitus, type 2/ or prediabetic state/
exp Cardiovascular Diseases/
Aspirin/
exp breast neoplasms/ or exp colorectal neoplasms/ or exp lung neoplasms/ or uterine cervical neoplasms/
exp Obesity/
exp “Tobacco Use Cessation”/
21 or (22 and 23) or 24 or 25
26 or 27
28 and pc.fs.
15 and 29
exp united states/ or baltimore/ or boston/ or chicago/ or “district of columbia”/ or los angeles/ or new york city/ or san francisco/
(“united states” or “u.s.” or alabama or alaska or arizona or arkansas or california or colorado or connecticut or delaware or florida or georgia or hawaii or idaho or illinois or indiana or iowa or kansas or kentucky or louisiana or maine or maryland or massachusetts or michigan or minnesota or mississippi or missouri or montana or nebraska or nevada or “new hampshire” or “new jersey” or “new mexico” or “new york” or “north carolina” or “north dakota” or ohio or oklahoma or oregon or pennsylvania or “rhode island” or “south carolina” or “south dakota” or tennesee or texas or utah or vermont or virginia or washington or “west virginia” or wisconsin or wyoming).ti,ab,kw.
30 and (31 or 32)
africa/ or caribbean region/ or central america/ or canada/ or greenland/ or mexico/ or south america/ or exp asia/ or exp europe/
33 not 34
limit 35 to (meta analysis or systematic reviews)
(medline or systematic or metaanalysis or “meta analysis”).ti,ab.
36 and 37
36 or 38
(201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.
39 and 40
limit 41 to english language

Database: Ovid MEDLINE® Epub Ahead of Print , In-Process & Other Non-Indexed Citations to July 2019 to Nov 2021

((health or healthcare or “health care” or care) and (equit* or disparit* or inequal* or accessibilit*)).ti,ab,kw.
(socioeconomic or economic or poor or vulnerable or disenfranchis* or (social adj3 class)).ti,ab,kw.
(divers* or minorit* or ethnicit* or race or racial or black* or “african american*” or asian* or “native american*” or indian or hispanic or latin*).ti,ab,kw.
(disabled or challenged or handicapped).ti,ab,kw.
(“sexual adj3 minorit*” or homosexual* or bisexual* or gay* or lesbian* or transgender* or queer or lbg*).ti,ab,kw.
(“cultural competency” or “cultural diversity”).ti,ab,kw.
(preventive or prevention or prevent).ti,ab,kw.
screen*.ti,ab,kw.
(“United States Preventive Services Task Force” or “U.S. Preventive Services Task Force” or “U.S.P.S.T.F.” or “USPSTF”).ti,ab,kw,au.
or/2-6
10 and (equit* or disparit* or inequal* or accessibilit*).ti,ab,kw.
1 or 11
12 and (7 or 8 or 9)
(diabetes or glucose or aspirin or cardiovascular or heart or coronary or “myocardial infarction” or stroke or colorectal or colon or breast or cervical or human papillomavirus or HPV or diet or exercise or “physical activity” or overweight or obese or obesity or metabolic or hypertension or “blood pressure” or lung or tobacco or smoke* or smoking).ti,ab,kw.
13 and 14
(“united states” or “u.s.” or alabama or AL or alaska or AK or arizona or AZ or arkansas or AR or california or CA or Colorado or CO or Connecticut or CT or delaware or DE or florida or FL or georgia or GA or hawaii or HI or Idaho or ID or Illinois or IL or indiana or iowa or IA or Kansas or KS or kentucky or KY or Louisiana or LA).ti,ab,kw,in.
(maine or ME or maryland or MD or Massachusetts or MA or michigan or MI or Minnesota or MN or mississippi or MS or missouri or MO or montana or MT or nebraska or NE or Nevada or NV or “new hampshire” or NH or “new jersey” or NJ or “new mexico” or NM or “new york” or NY or “north carolina” or NC or “north dakota” or ND).ti,ab,kw,in.
(ohio or OH or oklahoma or OK or oregon or pennsylvania or PA or “rhode island” or RI or “south carolina” or SC or “south dakota” or SD or tennesee or TN or texas or TX or Utah or UT or vermont or VT or Virginia or VA or Washington or WA or “west virginia” or WV or wisconsin or WI or Wyoming or WY).ti,ab,kw,in.
15 and (16 or 17 or 18)
(201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).dt.
19 and 20
limit 21 to english language

Database: PsycINFO 1806 to July 2019 thru Nov 2021

CG Nelson Updated CGO 112621 PsycINFO”

1 health disparities/ or treatment barriers/

2 (equit* or disparit* or inequal* or accessibilit*).ti,ab.

3 exp sociocultural factors/

4 exp group differences/

5 minority groups/ or alaska natives/ or american indians/ or asians/ or blacks/ or cultural sensitivity/ or hawaii natives/ or indigenous populations/ or “latinos/latinas”/ or pacific islanders/ or “race and ethnic discrimination”/ or “racial and ethnic groups”/

6 exp disabilities/

7 exp gender identity/

8 exp sexual orientation/

9 (divers* or minorit* or ethnicit* or race or racial or black* or “african american*” or asian* or “native american*” or indian or hispanic or latin*).ti,ab.

10 (“sexual adj3 minorit*” or homosexual* or bisexual* or gay* or lesbian* or transgender* or queer or lbg*).ti,ab.

11 (disabled or challenged or handicapped).ti,ab.

12 (1 or 2) and (or/3-11)

13 exp health promotion/

14 exp DIABETES/

15 exp cardiovascular disorders/

16 exp ASPIRIN/ 517

17 exp breast neoplasms/

18 cancer screening/

19 exp overweight/

20 tobacco smoking/ or smoking cessation/

21 (diabetes or glucose or aspirin or cardiovascular or heart or coronary or “myocardial infarction” or stroke or colorectal or colon or breast or cervical or human papillomavirus or HPV or diet or exercise or “physical activity” or overweight or obese or obesity or metabolic or hypertension or “blood pressure” or lung or tobacco or smoke* or smoking).ti,ab.

22 or/13-21

23 12 and 22

24 (“united states” or “u.s.” or alabama or AL or alaska or AK or arizona or AZ or arkansas or AR or california or CA or Colorado or CO or Connecticut or CT or delaware or DE or florida or FL or georgia or GA or hawaii or HI or Idaho or ID or Illinois or IL or indiana or iowa or IA or Kansas or KS or kentucky or KY or Louisiana or LA).ti,ab,in.

25 (maine or ME or maryland or MD or Massachusetts or MA or michigan or MI or Minnesota or MN or mississippi or MS or missouri or MO or montana or MT or nebraska or NE or Nevada or NV or “new hampshire” or NH or “new jersey” or NJ or “new mexico” or NM or “new york” or NY or “north carolina” or NC or “north dakota” or ND).ti,ab,in.

26 (ohio or OH or oklahoma or OK or oregon or pennsylvania or PA or “rhode island” or RI or “south carolina” or SC or “south dakota” or SD or tennesee or TN or texas or TX or Utah or UT or vermont or VT or Virginia or VA or Washington or WA or “west virginia” or WV or wisconsin or WI or Wyoming or WY).ti,ab,in.

27 24 or 25 or 26

28 23 and (24 or 25 or 26)

29 (201907* or 201908* or 201909* or 201910* or 201911* or 201912* or 2020* or 2021*).up.

30 28 and 29

31 limit 30 to english language 907

Database ProQuest Sociological Abstracts July 2019 to Nov 021 ( Ebsco Soc Index not available)

((((noft(((health OR healthcare OR “health care” OR care) AND (equit* OR disparit* OR inequal* OR accessibilit*))) OR ((noft((socioeconomic OR economic OR poor OR vulnerable OR disenfranchis* OR (social NEAR/3 class))) OR noft((divers* OR minorit* OR ethnicit* OR race OR racial OR black* OR “african american*” OR asian* OR “native american*” OR indian OR hispanic OR latin*)) OR noft((disabled OR challenged OR handicapped)) OR noft((“cultural competency” OR “cultural diversity”)) OR noft(((sexual NEAR/3 minorit*) OR homosexual* OR bisexual* OR gay* OR lesbian* OR transgender* OR queer OR lbg*))) AND noft((equit* OR disparit* OR inequal* OR accessibilit*)))) AND (noft((preventive OR prevention OR prevent)) OR noft((“United States Preventive Services Task Force” OR “U.S. Preventive Services Task Force” OR “U.S.P.S.T.F.” OR “USPSTF”)) OR noft(screen*.))) AND noft((diabetes OR glucose OR aspirin OR cardiovascular OR heart OR coronary OR “myocardial infarction” OR stroke OR colorectal OR colon OR breast OR cervical OR human papillomavirus OR HPV OR diet OR exercise OR “physical activity” OR overweight OR obese OR obesity OR metabolic OR hypertension OR “blood pressure” OR lung OR tobacco OR smoke* OR smoking))) AND noft((“United States” OR USA OR “u.s.” OR Alabama OR Alaska OR Arizona OR Arkansas OR California OR Colorado OR Connecticut OR Delaware OR “District of Columbia” OR Florida OR Georgia OR Hawaii OR Idaho OR Illinois OR Indiana OR Iowa OR Kansas OR Kentucky OR Louisiana OR Maine OR Maryland OR Massachusetts OR Michigan OR Minnesota OR Mississippi OR Missouri OR Montana OR Nebraska OR Nevada OR “New Hampshire” OR “New Jersey” OR “New Mexico” OR “New York” OR “North Carolina” OR “North Dakota” OR Ohio OR Oklahoma OR Oregon OR Pennsylvania OR “Rhode Island” OR “South Carolina” OR “South Dakota” OR Tennessee OR Texas OR Utah OR Vermont OR Virginia OR Washington OR “West Virginia” OR Wisconsin OR Wyoming OR “Puerto Rico”))) NOT (stype.exact(“Magazines” OR “Books”) AND pd(20190701-20211129))

Scopus

( ( ( ( ( ( TITLE-ABS-KEY ( ( health OR healthcare OR “health care” OR care ) AND ( equit* OR disparit* OR inequal* OR accessibilit* ) ) ) OR ( ( TITLE-ABS-KEY ( equit* OR disparit* OR inequal* OR accessibilit* ) ) AND ( ( TITLE-ABS-KEY ( socioeconomic OR economic OR poor OR vulnerable OR disenfranchis* OR “social class” ) ) OR ( TITLE-ABS ( divers* OR minorit* OR ethnicit* OR race OR racial OR black* OR “african american*” OR asian* OR “native american*” OR indian OR hispanic OR latin* ) ) OR ( TITLE-ABS ( disabled OR challenged OR handicapped ) ) OR ( TITLE-ABS-KEY ( “cultural competency” OR “cultural diversity” ) ) OR ( TITLE-ABS ( “sexual W/3 minorit*” OR homosexual* OR bisexual* OR gay* OR lesbian* OR transgender* OR queer OR lbg* ) ) ) ) ) ) AND ( ( TITLE-ABS-KEY ( preventive OR prevention OR prevent ) ) OR ( TITLE-ABS-KEY ( screen* ) ) OR ( TITLE-ABS-KEY ( “United States Preventive Services Task Force” OR “U.S. Preventive Services Task Force” OR “U.S.P.S.T.F.” OR “USPSTF” ) ) ) ) AND ( TITLE-ABS-KEY ( diabetes OR glucose OR aspirin OR cardiovascular OR heart OR coronary OR “myocardial infarction” OR stroke OR colorectal OR colon OR breast OR cervical OR human AND papillomavirus OR hpv OR diet OR exercise OR “physical activity” OR overweight OR obese OR obesity OR metabolic OR hypertension OR “blood pressure” OR lung OR tobacco OR smoke* OR smoking ) ) ) ) AND ( TITLE-ABS-KEY ( “United States” OR usa OR “u.s.” OR alabama OR alaska OR arizona OR arkansas OR california OR colorado OR connecticut OR delaware OR “District of Columbia” OR florida OR georgia OR hawaii OR idaho OR illinois OR indiana OR iowa OR kansas OR kentucky OR louisiana OR maine OR maryland OR massachusetts OR michigan OR minnesota OR mississippi OR missouri OR montana OR nebraska OR nevada OR “New Hampshire” OR “New Jersey” OR “New Mexico” OR “New York” OR “North Carolina” OR “North Dakota” OR ohio OR oklahoma OR oregon OR pennsylvania OR “Rhode Island” OR “South Carolina” OR “South Dakota” OR tennessee OR texas OR utah OR vermont OR virginia OR washington OR “West Virginia” OR wisconsin OR wyoming OR “Puerto Rico” ) ) AND ( PUBDATETXT ( “July 2019” OR “August 2019” OR “September 2019” OR “October 2019” OR “November 2019” OR “December 2019” ) OR PUBYEAR = 2020 OR PUBYEAR = 2021 ) AND ( LIMIT-TO ( LANGUAGE , “English” ) ) …

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