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Achieving Health Equity in Preventive Services

Systematic Review

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Purpose of Review

To summarize research on achieving health equity in 10 preventive services for cancer, cardiovascular disease, and diabetes in adults by identifying effects of impediments and barriers that create disparities and effectiveness of interventions to reduce them.

Key Messages

  • No eligible studies evaluated effects of provider barriers.
  • Evidence is low or insufficient for effects of population barriers, including insurance, access, age, rural location, income, language, health literacy, country of origin, and attitudes.
  • Screening rates are higher with patient navigation for colorectal, breast, and cervical cancer; telephone calls and prompts for colorectal cancer; and reminders with lay health workers for breast cancer.
  • Evidence is low or insufficient for other interventions due to lack of studies or their limitations.

Structured Abstract

Objectives. To summarize research on achieving health equity in 10 preventive services for cancer, cardiovascular disease, and diabetes in adults for a National Institutes of Health Pathways to Prevention Workshop by identifying the effects of impediments and barriers that create disparities, and the effectiveness of interventions to reduce them.

Data sources. Ovid® MEDLINE®, PsycINFO®, SocINDEX (January 1, 1996, to July 5, 2019); Veterans Affairs Health Services database; manual review of reference lists.

Review methods. Eligible abstracts and full-text articles were independently dual-reviewed for inclusion using pre-established criteria. Data were abstracted into evidence tables and verified for accuracy. Risk of bias and applicability of studies were independently dual-rated using established criteria; disagreements were resolved by consensus. Strength of evidence and applicability for each Key Question and outcome were assessed using established methods. Meta-analysis used a profile likelihood random effects model.

Results. No eligible studies evaluated effects of provider-specific barriers; 18 studies of population barriers provided low or insufficient evidence regarding insurance coverage, access, age, rural location, low income, language, low health literacy, country of origin, and attitudes. In 12 studies of clinician interventions, screening was higher for colorectal cancer with patient navigation, risk assessment and counseling, educational materials, and decision aids; breast and cervical cancer with reminders involving lay health workers; and cervical cancer with outreach and health education. Clinician-delivered interventions were effective for smoking cessation and weight loss. In 11 studies of health information technologies, automated reminders and electronic decision aids increased colorectal cancer screening, and web- or telephone-based self-monitoring improved weight loss, but other technologies were not effective. In 88 studies of health system interventions, evidence was strongest for patient navigation to increase screening for colorectal (risk ratio [RR] 1.64; 95% confidence interval [CI] 1.42 to 1.92; 22 trials), breast (RR 1.50; 95% CI 1.22 to 1.91; 10 trials), and cervical cancer (RR 1.11; 95% CI 1.05 to 1.19). Screening was also higher for colorectal cancer with telephone calls, prompts, other outreach methods, screening checklists, provider training, and community engagement; breast cancer with lay health workers, patient education, screening checklists, and community engagement; cervical cancer with telephone calls, prompts, and community engagement; and lung cancer with patient navigation. Trials of smoking cessation and obesity education and counseling had mixed results.

Conclusions. In populations adversely affected by disparities, evidence is strongest for patient navigation to increase colorectal, breast, and cervical cancer screening; telephone calls and prompts to increase colorectal cancer screening; and reminders including lay health workers encouraging breast cancer screening. Evidence is low or insufficient to determine effects of barriers or effectiveness of other interventions because of lack of studies and methodological limitations of existing studies.

Citation

Suggested citation: Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Fu R, Stillman L, Kondo K. Achieving Health Equity in Preventive Services. Comparative Effectiveness Review No. 222. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20-EHC002-EF. Rockville, MD: Agency for Healthcare Research and Quality; December 2019. Posted final reports are located on the Effective Health Care Program search page.
DOI: https://doi.org/10.23970/AHRQEPCCER222.