An Evaluation of Access and Policy Initiatives for Breast Cancer Screening in Ontario
Michael J. E. Smith, RN, BScN, MN1 | Erin Heynemans, RN, BScN, MN(c)1 | Deanne Drover, MCISc, BSc, BEd, BN, RN1 | Ashley Lagleva, RN, BScN1 | Paige Lau, BSc, MCISc, MRT(T)1 | Mary Ndu, MPH, PhD (ABD)1
Abstract
Early disease detection is important to increase positive outcomes for patients with breast cancer. In Ontario, routine breast cancer screening through mammography is offered to women over the age of 50 (CCO, n.d. b). The program offers two streams of surveillance: routine screening for those at average risk of breast cancer and enhanced screening for those at high-risk (CCO, n.d.c). Despite providing screening without needing physician referral, recent program analysis demonstrated that only 65% of the eligible population participates in screening (Lofters et al., 2018). This disparity in screening suggests that the Ontario Breast Screening Program (OBSP) falls short of meeting population needs. The current policy was evaluated using the Policy Triangle Framework. The results highlight the existing inequities in access and screening quality. To address these issues, the OBSP policy can be enhanced by increasing access to screening and improving public and healthcare provider knowledge. Utilizing mobile clinics, media campaigns, creating clear guidelines for vulnerable populations, and standardizing digital mammography across screening sites are examples of how the provincial policy can be enhanced. Although cost, risk, and obstacles accompany policy change, improving BCS in Ontario will address inequities in accessibility and ensure all eligible Ontario residents receive high-quality BCS.
Key Words: breast cancer screening, Ontario Cancer Plan, policy, Cancer Care Ontario, Ontario Breast Screening Program.
Citation: Smith, Michael J. E., et al (2023). An Evaluation of Access and Policy Initiatives for Breast Cancer Screening in Ontario. Canadian Health Policy, FEB 2023. https://doi.org/10.54194/QPBG4764, www.canadianhealthpolicy.com
- Western University, Faculty of Health Sciences, Department of Applied Health Sciences.
Introduction
In Canada, one in every eight women will be diagnosed with breast cancer in their lifetime (Lofters et al., 2019). Receiving an early cancer diagnosis, using routine screening such as mammography and other imaging modalities has been correlated with a greater likelihood of positive outcomes for patients (Lofters et al., 2019). Canadian screening policies vary between provinces. Breast cancer screening (BCS) in Ontario is conducted through the Ontario Breast Screening Program (OBSP), which follows the policies and guidelines of Cancer Care Ontario (CCO) (Sayani, 2019). CCO is responsible for allocating funding, determining access, and improving cancer care to meets the needs of patients and their families (Sayani, 2019). Even though the Ontario Cancer Plan (OCP) aims to improve screening access and quality screening practices, pervasive inequities continue to exist (CCO, n.d. a).
Sayani (2019) analyzed the OCP and its alignment in addressing health inequities and determined that equity, as defined by policymakers, has a direct influence on policy implementation. The OCP directly influences equity to access, therefore, highlighting the importance of social support services and funding in efforts to increase accessibility to high-risk populations (Sayani, 2019). Marginalized populations facing inequities in BCS in Ontario include the indigenous population, immigrants, low-income neighbourhoods, and the transgender population (Tobias et al., 2020; Vahabi et al., 2015). This paper will review the current literature on BCS, explore the effectiveness of the current OBSP policies, and recommend changes to the OBSP policy to incorporate evidence-based practices to address inequities.
Abdel-Raham (2021) analyzed the Canadian Community Health Survey (CCHS) to evaluate current trends in cancer screening. The CCHS is an annual cross-sectional survey that is conducted to better understand the health needs and behaviors of Canadians. This study identified three cohorts including a breast screening cohort of women aged 40-74 years with knowledge of mammography use and the current BCS policy. It was determined that 35% of women who did not have timely mammography screening were more likely to be unmarried, a self-identified visible minority, and/or have a lower income (Abdel-Raham, 2021).
Social factors contributing to discrepancies in BCS participation include immigration status, cultural and language barriers, literacy levels, financial resources, and knowledge of the disease (Raynault, 2019). Despite having lower incidences of breast cancer, immigrant women have higher breast cancer mortality rates, suggesting inequities in BCS (Vahabi et al., 2015). Vahabi et al. (2015) found that 64% of eligible women who were screened had lower BCS rates, which was highly associated with immigration status. Contributing factors for lower BCS rates in immigrant populations include living in a low-income neighborhood, having a male and or internationally trained physician, or not being enrolled in a primary care model (Vahabi et al., 2015).
The Canadian Indigenous population is also less likely to participate in cancer screening due to a lack of access to services, cost of transportation, lack of education, and a generalized distrust of the entire healthcare system caused by intergenerational trauma (Tobias et al., 2020). An embedded multiple-case study design was conducted to address health policy as a barrier to the Indigenous population’s access to cancer screening. Tobias et al. (2020) identified three areas of improvement for cancer screening, including cancer screening initiatives tailored towards Indigenous populations, increased cultural competency, and clarification of jurisdictional health services.
Inequities in BCS are further reflected in the 2SLGBTQIA+ population. A literature review conducted in 2020 demonstrated that lesbian, gay, bisexual, transgender, or queer (2LGBTQIA+) individuals are less likely to participate in cancer screening, especially in BCS as compared to the heterosexual population (Haviland et al, 2020). Transgender individuals and bisexual women were also found to be less likely to follow mammography screening guidelines (Haviland et al., 2020). While this marginalized population is typically medically underserved and underrepresented in literature, they also experience unique barriers to health access including a lack of patient and provider knowledge of screening practices and perceived discrimination (Haviland et al, 2020).
Trends in mammography utilization have mirrored breast cancer incidence since its adopted use as the front-line imaging modality for screening in the early 1990s (Canadian Cancer Society). CCO (2010) reports that female breast cancer rates are now stable, with mortality rates decreasing since 1986. While mammography is the most common form of image screening for breast cancer, there is low-certainty evidence for this modality due to overdiagnosis, false positives, and unnecessary cancer treatments (Klarenbach et al, 2018). Other modalities that are used for BCS include tomosynthesis, magnetic resonance imaging (MRI), and ultrasound, but are not recommended for women who are of average breast cancer risk (Klarenbach et al, 2018). In Ontario, only high-risk women are offered MRI or ultrasound (CCO, n.d.c). While image-based technologies such as mammography, MRI, and ultrasound are the current standard for BCS, they do not come without limitations, including image resolution quality resulting in discrepancies in diagnostic accuracy (Barba et al., 2021). A critical review by Barba et al. (2021) appraised current and emerging BCS and diagnostic tools including tissue rigidity, optical imaging, and digital infrared thermography (Barba et al., 2021). Limitations of technological advancements in BCS include financial constraints, lack of data collection, and skilled specialists (Barba et al., 2021). The goal of future screening methods should move toward more accurate and non-invasive data collection that is accessible and enables data sharing while remaining secure and protecting patient privacy (Barba et al., 2021).
Policy Issues
Ontario Breast Screening Program Policy
Currently, in Ontario, there are two primary BSC policies within the OBSP supported by CCO, which include recommendations for both average and high-risk populations and include an overarching recommendation for trans and nonbinary people. The OBSP recommends that eligible women, transgender, and nonbinary people between the ages of 50-74 years receive mammography screening every two years if they belong to an average risk category (CCO, n.d. b). Other inclusion criteria for this risk category include no new breast cancer symptoms, no personal history of breast cancer, no current breast implants, no history of mastectomy, and no previous screening mammogram within the last 11 months (CCO, n.d. b). In addition to a primary care referral, requirements for those in the higher risk category include no current breast issues, the presence of either a gene mutation that increases the risk for breast cancer in the patient or a first-degree relative, a history of chest radiation therapy (to treat another cancer or condition before age 30 and at least 8 years ago), or a 25% or greater lifetime risk of breast cancer based on family history based on genetic assessment (CCO, n.d. c). For women who are considered to be at a higher risk of developing breast cancer, the age criteria expand to include women aged 30 to 69 and increasing the frequency of mammograms to once per year along with a breast MRI or breast ultrasound (CCO, n.d. c).
Ontario Breast Screening Program (OBSP) Performance and Effectiveness
In addition to directing the process of BCS in Ontario, CCO also evaluates program performance. In the most recent review, the findings from the Ontario Cancer Screening Performance Report 2020 demonstrated that the OBSP has varying levels of effectiveness (Ontario Health, 2021). OBSP successfully increased the percentage of early detection of breast cancers from 61% to 65% between 2013-2016 (Ontario Health, 2021). Report findings also indicate that once an individual has entered the program, the rate of follow-up exceeds Canadian targets (Ontario Health, 2021). Data from 2000-2018 shows that OBSP consistently follows up on abnormal screenings in over 90% of cases (Ontario Health, 2021). However, overall program participation rates fall short of national targets (Ontario Health, 2021). Only 61-66% of eligible persons participated in the OBSP from 2000 to 2018 – both the Canadian and European Union guidelines are set to a target of 70% (Ontario Health, 2021). For patients who require biopsy after an abnormal mammogram, the rate of follow-up within seven weeks fell below the national target of 90%, highlighting an additional area of improvement for the OBSP (Ontario Health, 2021). The variance in the efficacy of the current program suggests that the current policy requires reform.
Analysis of Ontario Breast Screening Policy (OBSP)
In order to fully examine the effectiveness of the current OBSP policy, a thorough analysis of the policy is required. In Walt and Gilson’s (1994) seminal article, the Policy Triangle Framework was introduced as a means of healthcare policy analysis. The authors contend that when exploring policy, the focus cannot rest solely on the content of the policy but must also include the actors and context in which the policy is set; failure to do so results in ineffective policy and policy implementation (Walt & Gilson, 1994). Walt & Gilson (1994) claim that the purpose of policy analysis is to both influence the outcome of policies and ensure that healthcare reform is effectively implemented (Walt & Gilson, 1994). Applying this framework to critique the OBSP policy provides an understanding of the role of context, content, process, and actors within the current guidelines. Additionally, the framework provides a lens with which to view the current literature on BCS thereby identifying solutions that can address the shortcomings of the current screening policies.
Context of Policy
Within the Policy Triangle Framework, the context of a policy refers to the impact of government, society, and culture on the setting to which the policy will be executed (Walt & Gilson, 1994). According to the framework, the government can have either a central or minor role in the development of policy (Walt & Gilson, 1994). Studying the current OBSP policy through this lens, the context of the current policy places the Ontario Ministry of Health in a central role. Within practice, the Ontario Ministry of Health is enacting its central role with the intent of providing what is best for public interest. Current practice is to invite all women aged 50 years and older to participate in screening but does not provide information on the risks or benefits of mammography, nor does it address the needs of those who do not identify as cis-gender. Early detection of cancer reduces the burden of disease on the health system and improves health outcomes, all of which are in the public’s best interest. However, current policy fails to incorporate the context of society and culture in relation to BCS access.
With readily available health information, there is a societal trend towards incorporating individual choice into healthcare. A qualitative study using citizen deliberations by Abelson et al. (2018) noted that women want the opportunity to make an informed choice regarding routine mammography screening. Participants indicated that receiving clear information regarding benefits and risks of screening is important (Abelson et al., 2018). In order to incorporate the context of society and culture, it is necessary for the OBSP to integrate the role of informed choice into the current policy. The OBSP must share information to build trust and transparency while allowing the process of shared decision-making to occur (Abelson et al., 2018).
The OBSP policy requires acknowledgment of the unique care needs of the 2SLGBTQIA+ community, particularly the gender non-conforming population. The current OBSP policy does not provide clear guidelines for healthcare providers to effectively screen this population. At baseline, the transgender population is medically underserved and existing research is ambiguous regarding whether the use of cross-sex hormones increases risk of breast cancer (Meggetto et al., 2019). This leads to unclear screening guidelines, which creates inconsistent screening practices (Meggetto et al., 2019). A study conducted by Kiran et al. (2019) in a multisite family health team found that transgender patients had lower rates of screening for breast cancer. Researchers noted that transgender patients’ eligibility for screening was often misidentified, and many choose not to proceed with screening due to the gender dissonance it caused (Kiran et al., 2019). Transgender individuals and bisexual women were also found to be less likely to follow mammography screening guidelines (Haviland et al., 2020). The OBSP policy must incorporate the needs of this population by creating clear guidelines for practitioners and removing barriers to access. Incorporating culture into the context of the OBSP policies requires measures to address inequities for the 2SLGBTQIA+ community and integrate informed patient choice into current practices.
Considering the impact of culture on policy context requires an exploration of the inequities faced by Indigenous, immigrant, and racialized groups. Current OBSP policy fails to acknowledge the healthcare barriers that these marginalized populations experience. These marginalized groups are less likely to participate in BCS than the general population (Nnorom et al., 2021; Tobias et al., 2020). Indigenous people face unique structural barriers to accessing BCS services due to the remote locations of many reserves and turnover of health care workers who are often contract employees in these remote locations (Jacklin et al., 2017). Furthermore, due to the historical trauma endured by Indigenous people, many Indigenous people distrust and are reluctant to engage with the healthcare system (Jacklin et al., 2017; Tobias et al., 2020). Tobias et al. (2020) also noted that there are lower rates of preventative screening measures for the Indigenous population due to competing healthcare priorities, such as food security and a lack of culturally competent care. Nnorom et al. (2021) identified that screening rates within the immigrant and racialized populations improved with a culturally-centered approach to patient education. When this approach was used, practitioners were able to better explain the importance of cancer screening and address barriers regarding misconceptions surrounding breast cancer (Nnorom et al., 2021). To provide better access for these populations, the OBSP policy requires the integration of cultural safety and competency into guidelines for practitioners and improved access to screening.
The impact of the COVID-19 pandemic further compounded cultural and societal issues and exacerbated the gaps in BCS (Walker et al, 2021). The pandemic resulted in a reduction of cancer screening in most programs by greater than 40% in 2020 in order to reduce the transmission of COVID-19 (Walker et al., 2021). This decrease produced a provincial backlog of cancer screenings in spite of screening resumption during the pandemic (Walker et al., 2021). The OBSP policy failed to provide guidance to practitioners for extenuating circumstances that interrupted screening practices and it was not prepared to prioritize cancer screenings during the recovery phase. Furthermore, research on the impact and implications as a result of the pandemic is crucial to addressing inequities in cancer screening and treatment.
Content of Policy
Content in the Policy Triangle Framework refers to the objectives, guidelines, and methods by which a policy is carried out (O’Brien et al., 2020). The current guidelines are in line with many of the recommendations for screening found within the literature. The Canadian Task Force on Preventive Health Care reviewed the OBSP process in 2018 and found that the current process aligned with available research evidence but recommended that screening should be a collaborative process between patient and provider with informed choice as a priority (Klarenbach et al., 2018). Canadian guidelines for screening are also predominantly based on two trials conducted in the 1980s to determine the efficacy of BCS (Yaffe et al., 2022). Recently, the study methods of these seminal research trials have been called into question. Findings of a review from the studies conducted by Yaffe et al. (2022) suggest that the trials were significantly flawed, thereby raising skepticism of the results. Yaffe et al. (2022) recommends that these trials not be included in any further BCS policies.
Process of Policy
In the context of the Policy Triangle Framework, process of policy refers to the resources needed to implement a policy as well as the development, communication, and evaluation of policy (O’Brien et al., 2020; Walt & Gilson, 1994). The OBSP offers screening at regional breast assessment centers, breast assessment affiliates, and diagnostic imaging clinics (Jiang et al., 2018). Jiang et al. (2018) indicated that those who have screening completed at a diagnostic assessment unit, such as a regional center, have reduced waiting periods for a diagnosis. This is significant as decreasing wait times can improve access to treatment and reduce the psychosocial stress associated with a delayed cancer diagnosis (Jiang et al., 2018).
Varying methods of BCS also correlate to the geographical location of the testing site. While the OBSP recommends digital mammography as the standard of care, nearly 60% of testing sites within Ontario continue to use conventional film mammography (Ontario Association of Radiologists, 2022.). Further, emerging evidence demonstrates that digital breast tomosynthesis increases the detection of breast cancer by 33-53% while also reducing false positives by 30-40% (Seely & Alhassan, 2018). According to the Ontario Radiology Association (2022), digital breast tomosynthesis can be used on the same scanner as a standard mammogram, however, this technology is only available at two urban hospital locations in Ontario. The OBSP would be strengthened by incorporating this technology into standard care guidelines and expanding access to Ontario citizens living throughout the province.
Only 65% of the eligible population participates in BCS (Lofters et al., 2018), suggesting that recommendations from healthcare providers are not consistent. A study exploring patient knowledge of cancer screening by Lofters et al. (2018), demonstrated that 22% of patients could correctly identify the test, age, and frequency of cancer screening in Ontario. This demonstrates a significant knowledge gap, resulting in poor BCS rates. Improved patient education and routine screening recommendations by primary care providers (PCP) could increase the rate of BCS participation (Lofters et al., 2018). The OBSP could lead this education initiative through a public education campaign by providing clear and consistent guidelines to PCPs.
Actors of Policy
According to Walt and Gilson (1994), the actors, within the Policy Triangle Framework, are defined as those who influence the outcome of policy. Actors are often thought to be limited to government, politicians, and bureaucrats; however, particularly within the healthcare sector, it is important to identify the medical professionals, advocacy groups, and organizations that also influence policy development (O’Brien et al., 2020, Walt & Gilson, 1994). OBSP policy actors include the Ontario Ministry of Health, CCO, Ontario Health, Canadian Cancer Society, physicians, allied health professionals, hospital systems, and patients. Each actor, or stakeholder, brings a unique set of values and goals for policy formation. Current OBSP policy does not incorporate the outlooks of all actors into the guidelines and processes of BCS. The perspectives of vulnerable populations have been overlooked in the development of the current OBSP policy. Walt and Gilson (1994) suggest that evaluation of policy outcomes require an understanding of the historical context and the influence of the actors at the time of writing. Studies have identified the gaps that exist since the implementation of the OBSP. Current policy should be amended to include the goals and values of vulnerable populations, as well as expand the guidelines for practitioners who find themselves practicing in unconventional settings, such as a pandemic. Ultimately, cultural considerations and safety should be incorporated into the screening process in order to provide inclusive and comprehensive care.
Recommendations
Our analysis of the current OBSP policies demonstrates that amendments are required to enhance the current policies in order to address existing gaps, specifically, improvements to access, education, and technology. We recommend integrating cultural safety practices to break down barriers for vulnerable populations and increasing access to screening through the use of mobile screening clinics. In order to enhance the general public’s understanding of the importance of breast screening, we suggest that regular media campaigns be undertaken by the OBSP for both the public and healthcare providers and that clear guidelines for screening practices be widely disseminated to all healthcare providers. The OBSP could also provide breast density results to participants, and standardize technology at all screening locations. These recommendations are not without costs, obstacles and risks; however, the benefits of enhancing the OBSP to support women in BCS outweighs many of these issues.
BCS in Ontario requires evidence-based policy recommendations. Proposed recommendations should be presented to relevant stakeholders including policymakers, patients, Ontario residents, and healthcare professionals. Political, systematic and financial constraints and barriers should be well-noted as the feasibility for these recommendations require provincial support and funding.
Improved Access to Screening
Creating a healthcare policy in Ontario that helps to improve BCS accessibility to all people, especially the vulnerable communities, is strongly recommended. Structural inequalities faced by some of the marginalized populations in Ontario cause low incidences of BCS, which results in late detection of cancers, leading to a greater risk of mortality (Hanna et al., 2020). Delays in cancer treatment caused by late access to screening can increase the risk of patient death by 6-8% for every delay of four weeks (Hanna et al., 2020). Ontario’s move from traditional fee-for-service to an enhanced fee-for-service and capitation-based model has disproportionately impacted Ontario’s vulnerable population with regard to accessing BCS (Lofters et al., 2018). In order for the province to increase the uptake of BCS by these populations, provincial healthcare strategies should be implemented, which includes increasing breast cancer awareness campaigns, introduction of mobile health units, and enhanced cultural competency.
Previous research conducted in the United Kingdom found that breast cancer awareness campaigns were effective at reducing breast cancer-associated deaths caused by late diagnoses by increasing knowledge and screening uptake (Anastasi & Lusher, 2017). While the Canadian Cancer Society hosts a breast cancer awareness month each October, social media efforts could be an effective supplemental vector for increasing BCS awareness. As of 2018, 67% of the 14.2 million Ontario residents were using social media (Sherpa, 2018). If a policy was implemented that required social media platforms to promote BCS education and eligibility criteria, more women could be reached regardless of geographical limitations (Sherpa, 2018).
Mobile health units have been employed within the United States to address the barriers to accessing BCS faced by vulnerable populations (Brooks et al., 2013). The mobile health unit is a portable vehicular system that can seek and serve vulnerable populations (Brooks et al., 2013). These health units include a PCP, registered nurses, community health workers, and technical staff (Brooks et al., 2013). Services include educational counseling, a focused history, physical examination, and a mammogram, if required (Brooks et al., 2013). A mobile health unit in Louisville, Kentucky was able to travel to more than 200 locations in five years and perform approximately 4,000 mammograms in underserved communities (Brooks et al., 2013). We recommend that Ontario leverages allocated healthcare tax funds to invest in mobile health units for BCS, based on the previous empirical evidence. Due to the immense size and disproportionate distribution of residents within Ontario, a mobile health unit would be beneficial in providing access to those living in more rural locations (Ge et al., 2021). Research conducted by Ge et al. (2021) found that many patients living in Southern Ontario are able to reach hospitals within a 30-minute drive, but most patients in Northern Ontario cannot reach hospitals within a similar time frame due to geographical disparities in hospital coverage zones (Ge et al., 2021). Provincial policy implementation of a mobile health unit would be an effective method of delivering BCS services to vulnerable populations that have difficulty physically accessing a screening center.
Another recommendation is enhanced cultural competency in BCS programs. Cultural competency is the ability to appreciate, understand, and interact with another culture that is different from one’s own (Tobias et al., 2020). Tobias et al. (2020) found that cultural competency is one of the areas of improvement needed to improve BCS among Indigenous communities. Policymakers must work collaboratively with the Indigenous population and other racialized communities to create change in the screening process that will enact cultural competency (Tobias et al., 2020). As part of our recommendations, policies that can be enacted to improve cultural competency in OBCP includes recruiting and retaining more Indigenous and minority healthcare staff, greater utilization of community health workers, a willingness to make screening centres more accessible, and providing interpreter services for those who require it (Health Policy Institute, 2019). These recommendations are applicable to other marginalized populations as well, although it is important to note these vulnerable populations may face healthcare barriers unique to their respective groups.
Breast Density Notification
To improve BCS awareness, patients should be provided with their breast density results, which are determined from mammograms. Breast density results have been associated with one’s risk of developing breast cancer (Aziz, 2021). Mammographic breast density is currently the best diagnostic indicator of breast cancer risk for both premenopausal and postmenopausal women (Kim et al., 2020). Currently, Ontario does not reveal this result to patients (Aziz, 2021). Research has determined a correlation between women with dense breast tissue of greater than 50% have a greater risk of developing breast cancer (Kim et al., 2020). Awareness of breast density values and the associated risk for developing breast cancer may result in modifications in lifestyle choices made by women with dense breasts. Some of these modifiable lifestyle choices that can reduce breast cancer risk includes reducing alcohol consumption, loss of excess weight, and avoiding a sedentary lifestyle (CCO, n.d. d). Implementing a provincial policy that recommends notifying patients of their initial breast density results and using those results to recommend additional screenings that were outlined previously for the high-risk category could help prevent hospital admissions. Patients who receive an early cancer diagnosis as a result could undergo timely treatments and procedures, therefore resulting in decreased hospitalization rates caused by advanced cancer treatment. Potential obstacles to this initiative include producing unnecessary anxiety and testing for patients as medical guidelines for treatment of dense breasts are currently ambiguous (Eggertson, 2020).
Policy evaluation will be required following the implementation of any recommended initiatives. The development of an evaluation plan to identify the specific activities, methods, and outcomes of the recommendations would help improve the effectiveness of BCS. Implementing a reporting system for key stakeholders and enhancing communication with regards to project plans will be pivotal in strengthening and amending the proposed recommendations.
Conclusion
While the OBSP remains a relatively successful program for BCS in Ontario, there are blatant areas of improvement. Policy actors and stakeholder involvement, particularly those from marginalized populations, are imperative to the policy making process to reduce BCS disparities. The current OBSP guidelines lack cohesive and inclusive care across social stratifications and for patients of different marginalized backgrounds. Improvements in language, standardization of care, and quality assurance of care are necessary to increase accessibility for all populations. These improvements would help increase awareness for all stakeholders, including health care providers, policy makers, patients, and patient caregivers. The recommendations for improved access to screening, breast density notification, and enhanced technological changes aim to improve participation rates and equitable delivery of care for the OBSP. Effective change in BCS requires an in-depth understanding of the systematic issues and social disparities of health that lead to preventable issues.
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