Strategies for Accessible Breast Screening for People With Intellectual Disability

Abstract

Introduction:

People with intellectual disability are less likely to participate in breast screening than people without intellectual disability. They experience a range of barriers to accessing breast screening, however, there is no consensus on strategies to overcome these barriers. Our objective was to reach consensus on the strategies required for accessible breast screening for people with intellectual disability.

Methods:

Fourteen experts participated in a modified on-line Delphi that used Levesque’s model of health care access as the theoretical framework. At the end of each round descriptive and thematic analyses were completed. Data was then triangulated to determine if consensus was reached.

Results:

After 3 rounds, 9 strategies were modified, 24 strategies were added and consensus was reached for 52 strategies across the 5 dimensions of access. Key areas of action related to (i) decision making and consent, (ii) accessible information, (iii) engagement of peer mentors, (iv) service navigators, and (v) equipping key stakeholders.

Conclusions:

The resulting strategies are the first to articulate how to make breast screening accessible and can be used to inform health policy and quality improvement practices.

Cancer is one of the leading causes of potentially avoidable deaths of people with intellectual disability. ¹ However, there is emerging evidence that people with intellectual disability are less likely to participate in cancer screening compared to people without intellectual disability, including breast screening. ² For breast screening, research suggests that people with intellectual disability are less likely to have ever been screened, and less likely to adhere to ongoing breast screening guidelines than people without intellectual disability.^{3 -9} There are a range of factors that may be associated with these low rates of participation, including individual, environmental, support network capacity, workforce capacity, and service design.^{10 -12} Known barriers to breast screening for people with intellectual disability include poor awareness of risk factors for breast cancer, being underprepared to participate in screening, needing decision making support, and requiring reasonable adjustments to participate in screening.^{10 -12} However, to date there is no consensus from experts on the strategies required to ensure breast screening is accessible to people with intellectual disability, nor is there a way for services to audit their accessibility. A recent systematic review by Chan et al ¹³ highlights the importance of addressing this gap and developing strategies that allow cancer screening services to meet the needs of people with intellectual disability.

Breast screening aims to identify breast cancer at an early stage to improve survival rates. Mammography is considered to be the gold standard of breast screening, however, alternatives such as ultrasound, magnetic resonance imaging, and physical exams are also available but less reliable at detecting cancer. ¹⁴ Delivery of breast screening programs vary from country to country. For example, in Australia and Canada a national program invites women aged between 50 and 74 years of age to have a mammogram every 2 years.^15,16 While in United Kingdom the breast screening program invites women from 50 to 70 years old for screening every 3 years. ¹⁷ However, globally there is no overarching consensus on the strategies to enable accessible breast screening services for people with intellectual disability.

This research aims to address this gap by being the first to reach consensus on the strategies required for accessible breast screening for people with intellectual disability.

Methodology

Study Design

This study used the Delphi method, which included mixed methods, to identify, and reach consensus on the strategies required for accessible breast screening services for people with intellectual disability. A Delphi method was selected because it is an iterative process of consultation that has been shown to make best use of existing evidence, professional experience,^18,19 and provides a structured approach to reach group consensus. ²⁰ We elected to use a modified Delphi method that deviates from the traditional Delphi approach by (i) being delivered online, (ii) commencing with a proposed list of items, and (iii) using unique participant codes to ensure complete participant anonymity. This modified approach has been found to address some of the common limitations of a traditional Delphi method including high dropout rates, moulding of opinions, and incomplete participant anonymity. ²¹ For the Delphi method a sample size between 8 and 23 members is recommended. ²²

This study used Levesque’s model of person-centered health care access as the theoretical framework to help participants to identify factors that may influence access to breast screening services. Levesque’s model includes 5 key dimensions of health care access including (i) approachability, (ii) acceptability, (iii) availability and accommodation, (iv) affordability, and (v) appropriateness. ²³ Within each of these dimensions the model considers the individual and structural factors that may influence health care access. This theoretical model of access was chosen for this study because it has demonstrated utility in understanding the health care access needs of people from diverse backgrounds, including people with intellectual disability. ²⁴

Ethical Consideration

This research was designed to ensure that (i) participants were able to make informed consent to participate, (ii) were able to participate anonymously, and (iii) the data provided was used and stored in a way that upheld best practice standards in data management.

This research project received ethics approval from UNSW Sydney Human Ethics Committee (HC220111).

Delphi Survey Tools

Each of the Delphi survey tools stated the aim of the research, the definition of consensus, and the rules that will guide decisions to add, delete, or modify items in during the Delphi.

Round 1

The research team initially used their expertise and findings from a literature review on breast screening for people with intellectual disability to propose potential strategies for accessible breast screening. disability. The team then collated the strategies and categorized their relationship to the domains of Levesque’s theoretical model of patient centered access to health care. ²³ All collated strategies mapped onto Levesque’s model domains of (i) approachability, (ii) acceptability, (iii) availability and accommodation, (iv) affordability, and (v) appropriateness.

The round 1 survey tool asked the participants to (i) provide demographic information, (ii) generate a unique participant code, (iii) rate their level of agreement that each proposed items will contribute to breast screening services being accessible to people with intellectual disability (using a 5 point Likert scale—strongly disagree to strongly agree), (iv) provide comments on the wording of the proposed item, and (v) propose additional items that they thought were important.

Rounds 2 and 3

From round 2 onwards the results from the previous round were used to inform the content of the survey tool. Items presented in round 2 onwards indicated if items were new, or if they had been edited between rounds, including how they had been edited. Participants were also provided with a summary of the results from the previous round and a list of items that had reached consensus.

The round 2 and 3 survey tools asked participants to (i) rate their level of agreement that each proposed items will contribute to breast screening services being accessible to people with intellectual disability (using a 5 point Likert scale—strongly disagree to strongly agree), (ii) provide comments on the wording of the proposed item, and (iii) propose additional items that they thought were important.

The survey tool for each round was implemented using Qualtrics software.

Participant Recruitment and Eligibility

A convenience sample of experts (n = 60) were invited to participate in the Delphi. These experts were identified through: professional networks of the research teams; those actively involved in service provision or advocacy in this space; and those who have published in the area.

Potential participants were emailed from a generic email account. The email invitation (i) invited them to participate in the Delphi, and (ii) asked them to invite other relevant experts to participate in the Delphi. Interested experts completed an online form to assess their eligibility, and consent to participating in the study.

Inclusion criteria for participants to take part in this study included self-identifying as:

1. Being 18 years of age or older

2. Having expertise in breast screening, breast cancer treatment or support, decision making support tools for breast screening/cancer screening, accessible health screening services for people with intellectual disability, accessible healthcare for people with intellectual disability, or health advocacy for people with intellectual disability.

Only participants who completed the eligibility and consent form were sent the Delphi survey. A total of 18 people registered and consented to participate in the Delphi. Once the Delphi process had commenced no further participants were recruited to the study. However, registered participants did not need to participate in a round to be able to participate in a subsequent round.

Delphi Implementation and Timeframe

The study was conducted between May 2022 and July 2022.

For each round the recruited participants were sent an email inviting them to participate and providing them with a link to the online survey.

Each round was open for 2 weeks and participants were sent 2 reminder emails about participating in the round. This timeframe was selected for pragmatic reasons, to provide participants with enough time to contribute and to keep project momentum.

Data Analysis

The authors used descriptive statistics and measures of central tendency to analyze the quantitative data and Braun and Clarkes ²⁵ thematic analysis for the qualitative results. The quantitative data was analyzed using SPSS and the qualitative data was analyzed in NVivo. Qualitative data were analyzed by the first and second authors who are allied health professionals with expertise in health service design for people with intellectual disability. When there was disagreement about qualitative responses, the authors discussed the reasons for differences in opinion and developed a strategy for continuing with the analysis.

Data triangulation was then used to make decisions on whether to keep, discard, or modify the proposed items. Group consensus was defined as 70% or more participants agreeing or strongly agreeing on an item, and a median of 3.5 or higher, where the qualitative feedback did not contradict the quantitative results. Proposed items were removed if either 70% or more participants disagreed or strongly disagreed on an item and/or the qualitative feedback indicated that the items needed to be removed. Items were also added and modified based on the qualitative feedback.

Results

Demographics

The majority of the participants identified as female (78.6%), between 35 and 54 years of age (64.3%), and half had a health care professional background. The majority had a primary area of expertise in accessible healthcare and health advocacy for people with intellectual disability (78.6%), and 21.4% had expertise in breast screening, treatment, or support. The majority of participants had 11 or more years of experience in their area of expertise (64.3%) (see Table 1).

Table 1.

Participant Demographics (N = 14).

Variable	Category	n (%)
Gender	Male	3 (21.4)
	Female	11 (78.6)
Age (years)	35-54	9 (64.3)
	55+	5 (35.7)
Professional background	Health care professional	7 (50.0)
	Academic	4 (28.6)
	Other	3 (21.4)
What is your primary area of expertise related to this project?	Breast screening, treatment, or support	3 (21.4)
	Accessible healthcare and health advocacy for people with intellectual disability	11 (78.6)
How many years of experience do you have in this area of expertise?	10 or less years	5 (35.7)
	11-15 years	4 (28.6)
	16 years or more	5 (35.7)

Delphi rounds

Three rounds of the Delphi were conducted to reach consensus on 52 strategies required for accessible breast screening for people with intellectual disability (see Table 2).

Table 2.

Strategies Required for Accessible Breast Screening for People With Intellectual Disability—Final Items.

Stage 1: perception of need and desire to participate in breast screening
1.1	Working with people with intellectual disability and their support networks to raise breast health awareness.
1.2	Working with people with intellectual disability and their support networks to raise awareness of the breast cancer risk profile of people with intellectual disability.
1.3	Provide accessible information on routine breast screening guidelines.
1.4	Provide accessible information on available breast screening services and how to access them.
1.5	Provide accessible information on the different types of breast screening options available and the potential benefits and risks of each option.
1.6	Provide accessible information on care pathways that articulate all stages of breast screening from identification, referral, through to what happens after screening.
1.7	Equip health professionals involved in conducting health assessments for people with intellectual disability on breast cancer risk in people with intellectual disability.
1.8	Equip health professionals involved in conducting health assessments for people with intellectual disability on the potential risks and benefits of different breast screening options.
1.9	Development of strategies to reach and raise awareness of breast cancer and screening options for people with intellectual disability across the lifespan who have been excluded from services or identify as being from other diverse groups. For example, First Nations, culturally and linguistically diverse, complex health profiles, LGBTQIA+.
1.10	Equip health professional involved in conducting health assessments for people with intellectual disability on the gaps in accessibility to breast screening and impact of late breast cancer diagnosis on outcomes.
1.11	Share self-advocate experiences of participating in breast screening with people with intellectual disability and their support networks.
1.12	Use peer mentors to educate people with intellectual disability and their support networks about breast screening.
1.13	Provide opportunities for people with intellectual disability and their support network to observe how breast screening is carried out.
1.14	Breast screening services to promote their availability and how they make their service accessible to people with intellectual disability.
1.15	A centralized liaison officer to facilitate access to breast screening services.
1.16	Develop and implement a strategy that links breast screening to other preventive health care.
1.17	Primary care to use electronic medical records to identify people with intellectual disability who are candidates for breast screening.
Stage 2: seeking breast screening
2.1	Educating people with intellectual disability about their right to access breast screening.
2.2	Educating people with intellectual disability and their support networks on what a breast cancer diagnosis could mean for the person.
2.3	Providing people with intellectual disability and their support networks with strategies to manage their fear and anxiety about the person participating in breast screening.
2.4	Equip health professional involved in conducting health assessments for people with intellectual disability on how to facilitate access to breast screening that will meet a person’s needs.
2.5	Provide accessible information on signs of breast cancer and what to do if the person or their support network identifies one of these signs.
2.6	Provide accessible information on what breast screening involves.
2.7	Provide support networks with information on how they can use the accessible information on breast screening with the person with intellectual disability.
2.8	Identify barriers and facilitators for people with intellectual disability to seeking breast screening and use these to guide service and workforce development.
2.9	Provide tailored guidance to those supporting a person with severe/profound intellectual disability on seeking breast screening.
2.10	Equipping people with intellectual disability and their support networks around the consent, and withdrawal of consent process for participating in breast screening.
Stage 3: reaching breast screening
3.1	Equipping breast screening staff to adjust their communication to meet the needs of people with intellectual disability, including the use of augmentative and alternative communications.
3.2	Adapting the environment to meet the needs of the person with intellectual disability. Including their physical and sensory needs.
3.3	Auditing breast screening services in relation to their accessibility to people with intellectual disability and use this information to develop and implement an action plan to address identified barriers.
3.4	Work with breast screening staff to identify their knowledge, skills, confidence, and attitudes towards providing breast screening to people with intellectual disability. If required, use the findings to develop a workforce capacity building action plan.
3.5	Work with breast screening staff to adjust their communication and ways of working with the person’s support network during the screening process.
3.6	Educating breast screening staff on intellectual disability, including the needs of people with mild to profound intellectual disability.
3.7	Education breast screening staff on consent and withdrawal of consent process. Including process for people who use alternate decision makers.
3.8	Identifying and educating health professionals on breast screening options that can meet the needs of the person with intellectual disability (noting the mammography is the gold standard of breast screening).
3.9	Equipping the breast screening sector to implement education, training, and mentorship to equip breast screening staff (clinical and clerical) on meeting the needs of people with intellectual disability.
3.10	Educating supporting health agencies about the capacity of their local screening service to meet the needs of people with intellectual disability.
Stage 4: affordability of breast screening
4.1	Funding to facilitate transport to and from breast screening and any follow up appointment.
4.2	If required, funding for a support persons time to prepare the person for the screening and to attend the screening and any follow up appointment.
Stage 5: appropriateness of breast screening services
5.1	Equipping the service to facilitate supported decision making for people with intellectual disability to participate in the service.
5.2	Improving capacity of breast screening services to work with alternate decision makers.
5.3	Developing and implementing an accessible version of the breast cancer screening: it’s your choice document. 2017 updated breast screening DA (Hersch et al26).pdf (usyd.edu.au)
5.4	Ability to adapt the length of the appointment to meet the needs of the person.
5.5	Work with the person with intellectual disability and their support network to prepare the person for the screening process.
5.6	Working with the person with intellectual disability and their support network to determine the best breast screening option for them (noting the mammography is the gold standard of breast screening).
5.7	Breast screening services to review referral and to liaise with the person and their support network to identify their needs.
5.8	Breast screening services have clear guidelines on consent and withdrawal of consent for people with intellectual disability. Including people with alternate decision makers.
5.9	A resource for people with intellectual disability to acknowledge their participation in breast screening and what the next steps are.
5.10	Appoint a local champion to assist services with service delivery.
5.11	Breast screening services confirm if a person has an intellectual disability at the time of referral.
5.12	Educating breast screening staff about high rates of trauma experienced by people with intellectual disability and how this may impact on their ability to participate in breast screening.
5.13	Develop and implement tailored decision-making support tools.

The quantitative and qualitative results were triangulated and used to modify 9 strategies and add 24 strategies (see Table 3).

Table 3.

Summary of the Development of the Strategies Over the 3 Delphi Rounds.

	Round 1 (n = 14)	Round 2 (n = 12)	Round 3 (n = 9)	Total
Items deleted	0	0	0	0
Items modified	5	4	0	9
Items added	21	3	0	24
Items that reached consensus	23	22	7	52

In round 1 the level of quantitative agreement (agree and strongly agree) ranged from 64.3% to 100% (Supplemental Table 1). The level of agreement increased over the subsequent rounds and ranged from 66.7% to 100% in round 2 (Supplemental Table 2) to 77.7% to -100% in round 3 (Supplemental Table 3).

The qualitative feedback in round 1 and round 2 is summarized in Table 4 and identified a range of additional strategies across Levesque’s domains including for example, considerations of the needs of people with severe to profound disability, the need for trauma informed care, the role of alternative screening options if mammography is not possible for the person and equipping the health sector on breast screening.

Table 4.

Summary of Qualitative Feedback From Round 1 and Round 2.

Round	Suggestions from qualitative feedback	Supporting examples from what the participants wrote
1	Consider the needs of people with severe or profound intellectual disability.	There was a need to think “through how these approaches would work for people with profound and multiple intellectual disabilities”
	The important role of self-advocates, peer mentors, and local champions to facilitate access to breast screening	We need to share “self-advocate stories of successful screening”
	The need for more detailed information on consent.	More information was needed on “how consent is granted and/or withdrawn”
	The need for further details on equipping the sector and workforce to meet the needs of people with intellectual disability.	In “educational and workforce development strategies, adopt a trauma informed approach to care”
	The need to acknowledge that mammography is the gold standard for breast screening.	“Mammography is the only reliable/gold standard of breast screening”
2	Consider the use of other screening options if the person is unable to tolerate mammography.	“I think it is important to consider less good alternatives if it isn’t possible to go with the gold standard. Better than doing nothing”
	Consider using electronic primary care medical records to identify candidates for breast screening.	“Develop EMR <electronic medical records> search strategies for family MD <medical doctor> practices to identify breast cancer screening candidates with intellectual and developmental disabilities in their practices and employ outreach strategies above.”
	Educate others about the capacity of local breast screening services to meet the needs of people with intellectual disability.	“Educating supporting health agencies about the capacity of their local screening service to meet the needs of a woman with ID.”
	Use tailored decision-making support tools.	“Tailored decision support tools.”

Discussion

Over 3 rounds a panel of clinical and academic experts reached consensus on 52 strategies that may contribute to making breast screening services accessible for people with intellectual disability. Strategies were identified across each of the 5 dimensions of Levesque’s conceptual model of patient centered access to health care (approachability, acceptability, availability and accommodation, affordability, and appropriateness). ²³ The study highlights the need for diverse strategies to ensure accessibility of breast screening including for example (i) decision making and consent, (ii) accessible information, (iii) engagement of peer mentors and self-advocates, (iv) service navigators, and (v) equipping key stakeholders. The findings are the first to our knowledge to articulate the overarching strategies required to enable accessible breast screening services for people with intellectual disability. The strategies have international utility to inform service development and practice.

Equipping breast screening services and their associated workforces in decision making and consent were identified as strategies to make breast screening services accessible for people with intellectual disability. Consensus was reached that clear service guidelines are required around consent, including withdrawal of consent, and working with alternative decision makers. This finding aligns with previous research which has found that the inability for a person with intellectual disability to provide their own consent as an access barrier to breast screening.^13,27,28 Gaining consent to participate in breast screening, like in other areas of health care can be complex for people, including people with intellectual disability. The ability to facilitate supported decision making about participation in breast screening will be key to breast screening services upholding article 12 of the United National Convention on the Rights of Persons with Disabilities (UNCRPD). ²⁹ Key features of supported decision include prioritising a person’s will, preferences and rights. While debate remains around the best approach to supported decision-making recent work by Douglas and Bigby ³⁰ articulates a framework that encompasses 7 key steps. These steps include: (i) knowing the person, identifying, and describing the decision, (ii) understanding the person’s will and preferences, (iii) refining the decision and taking account of constraints, (iv) considering whether a self-generate, shared, or substitute decision is to be made, (v) reaching the decision and associated decisions, and (vi) implementing a decision and seeking out advocates if necessary. Their work also highlights important practice strategies that may assist breast screening services. These include attention to communication, education about consequences and practicalities, listening and engaging to ensure all options are considered, creating opportunities, and breaking things down. ³⁰ Further work is required to consider how to implement these strategies into breast screening service practice.

Another key finding from this study was the need for strategies that make information about breast cancer and breast screening accessible to people with intellectual disability. Accessible health information is a right held by people with disability under articles 9 and 21 of the UNCRPD ²⁹ and is one of the key aspects of health literacy, and more specifically functional health literacy. ³¹ To our knowledge, there is no available research on the accessibility of breast screening information, however, a broader review of health information shows low levels of accessibility, and lack of adaptation to meet the diverse communication needs of people with intellectual disability. ³² Future research is needed to audit existing breast screening information to determine information accessibility and options if the person is unable to tolerate mammography. Consideration also needs to be given about how to best present breast screening information because of the diverse communication needs and preferences of people with intellectual disability. ³³ While there has been a shift to using Easy Read to support the communication of health information further research is needed to evaluate its effectiveness.^34,35

This study also suggests that peer mentors have an important role in facilitating access to breast screening for people with intellectual disability. There is a growing use of peer mentors in both the mainstream mental and physical health spaces and the available research suggests that they have a positive impact on patient experience. ³⁶ For the general population, there has also been suggestions about the utility of peer mentors in cancer screening.^37,38 However, to date there is no available research on the role and utility of peer mentors in cancer screening for people with intellectual disability, and to our knowledge for people with disability. There is however emerging evidence in the broader health literature to suggest that peer mentoring is helpful for people with intellectual disability, particularly when mentee centered, and outcome focused. ³⁹ This work suggests potential utility of peer mentors in supporting people with intellectual disability to engage with breast screening. An important next step would be to develop, trial, and evaluate a peer mentor program to facilitate access to breast screening for this group.

In addition to peer mentors, this study highlighted the key role that centralized liaison officer may have in improving access through assistance with service navigation and care coordination. This finding is supported by previous research which identified care coordination as a facilitator to accessing breast screening services for people with intellectual disability.^11,12 Wilkinson et al ¹¹ suggest that care coordinators may have an important role in prompting health care providers to initiate cancer screening, advocating for access to breast screening, and problem solving logistical access issues. To date there has not been an evaluation of the role of a centralized liaison officer, nor more broadly care coordination, in improving access to breast screening services for people with intellectual disability. However, work by Ruiz et al ⁴⁰ suggest the potential benefits of health care coordination to the individual and health care system. These benefits included, for example, timeliness of care, patient safety, and reduced claims for health care use. There is also evidence from the United Kingdom around the positive impact of learning disability liaison nurses, including person centered care, and service coordination. ⁴¹ However, debate remains about the best way to deliver health care coordination, including health care coordination for people with intellectual disability.^40,42 The trial of a care coordination role within the breast screening context could provide important insights into this emerging body of knowledge.

Equipping key stakeholders, including people with intellectual disability, their support networks, breast screening providers, and primary care professionals were identified as important strategies for accessible breast screening services. Tailoring capacity building strategies for each of these groups, and their roles, was also identified as being important in this study. For example, for people with intellectual disability there was a focus on equipping them with knowledge about (i) their rights to access breast screening, (ii) breast cancer and what a breast cancer diagnosis means, and (iii) breast screening and the benefits and risks of participating. Lessons can be learnt from initiatives that aim to improve health care communication such as hospital passports, ⁴³ and accessible information on breast screening. ⁴⁴ For example, hospital passports have been shown to improve safety, communication, and person centered care. ⁴³ It will also be important that resources assist in equipping a person’s support network, as they play a critical role in accessing health care and may have low levels of knowledge about breast screening. While for breast screening staff the study identified a need for them to be able to adapt their communication and consent processes to meet the needs of all people with intellectual disability, including those with severe and profound levels of disability. These workforce capabilities are similar those that have been articulate in other areas of health for people with intellectual disability, such as mental health. ⁴⁵ The strategies articulated in this study could be used to guide (i) the development of tools that can be used to measure how equipped each of the key stakeholders are in this area, and if required a workforce development strategy.

Strengths and Limitations

Strengths of this study include participant anonymity (as the lack of anonymity is a limitation of the traditional Delphi method), years of experience in the field, and high levels of consensus for the proposed items. The use of Levesque’s model of access facilitated participants and the research team to think of access through a person centered, multi-dimensional lens.

There are also some limitations including the drop out of participants over rounds, however this rate of drop out is similar to other Delphi studies. ¹⁹ We also note that the majority of participants identified their primary area of expertise as being accessible health care and health care advocacy for people with intellectual disability, and the limited number of people with primary expertise in the area of breast screening, treatment, and support. This may have influenced our results and subsequent uptake of the findings; and further work with breast screening staff could be undertaken to confirm the identified strategies. There was also a high number of errors in the unique code generated by participants meant the authors were unable to track participants reliably over rounds and the stability of their response. We also did not ask participants to report on their country of origin. The strategies identified in this study were also not tested to see if they positively influence access to breast screening and ongoing adherence to breast screening guidelines. However, this provides an opportunity for further research to assess the impact of these strategies on the accessibility of services. It will be important to see how these strategies resonate with people involved more broadly in making accessible screening services.

Implications for Policy and Practice

The strategies for accessible breast screening for people with intellectual disability articulated in this study has the potential to inform the development of an accessibility auditing tool. An auditing tool would allow for the measurement and reporting of the accessibility of breast screening services which in turn can be used to inform a cycle of quality improvement. However, given the number of strategies identified further work may be warranted to simplify and prioritize areas for action. This may include learning from what is being done to make screening services accessible for women with disability.

The strategies articulated in this study may also have utility to policy makers, as they consider how to make health services accessible for people with intellectual disability.

Conclusion

This study reached consensus on 52 strategies for accessible breast screening for people with intellectual disability. These strategies relate to the approachability, acceptability, availability and accommodation, affordability, and appropriateness of breast screening services. These strategies can be used to inform quality improvement practices to ensure the accessibility of breast screening services for people with intellectual disability.