Mammography screening, the only population-based method for the early detection of breast cancer, has been shown to be effective in reducing breast cancer mortality in women aged 50-74 years. In the United States, continuing racial/ethnic and socioeconomic disparities in access to preventive health services, including but not limited to mammography screening, pose a major public health challenge. Over the last decade, two macro-level events had a formidable impact on health care access, with profound implications for persistent disparities in cancer screening. In 2007, the recession led to a sharp increase in unemployment and a decline in employer-sponsored insurance nationwide. After implementation of the Affordable Care Act in 2010, the expansion of Medicaid in 2014 had the potential to reduce the mammography screening disparities in low- income and minority women. Few studies have hitherto systematically examined the impact of these two events in relation to mammography screening utilization rates within a nationally representative data set while taking into account a large number of multilevel confounding factors at individual and geographic levels. Among women aged 50 to 64 years and participating in the National Health Interview Survey, our specific aims are to: assess potential variations in mammography screening rates by comparing rates before, during, and after the recession due to increases in unemployment (Aim 1a); examine if any associations vary across race/ethnicity or socioeconomic position (Aim 1b); evaluate potential variations in mammography screening rates, comparing rates before and after the ACA Medicaid expansion (Aim 2a), and examine if any associations vary across race/ethnicity, or socioeconomic position (Aim 2b). The proposed work is significant in that it will uncover the impact of these macro-level events on mammography screening?information that will be useful to policymakers and researchers. Our work will be a unique contribution to the breast cancer screening literature, with important implications for informing public policy. Major strengths are: (1) a large, representative and socioeconomically and racially/ethnically diverse sample of women aged 50 to 64 years; (2) assessment of mammography screening rates before, during and after the recession and the ACA Medicaid expansion; (3) innovative hypotheses focusing on important gaps in screening research since no information exists on the impact of these two events on mammography screening utilization; and (5) multilevel data have been collected on a wide range of potential confounding factors that might modify any associations of the recession and the ACA Medicaid expansion with mammography screening utilization. The interdisciplinary training environment for this proposal will provide the applicant an opportunity to enhance methodological skills, build research competency, and augment content expertise, in order to become an expert in the intersection of cancer screening and social determinants of health.
While mammography screening is a proven preventive method to detect breast cancer earlier and reduce breast cancer mortality in women aged 50-74 years, there are consistent barriers to accessing screening that disproportionately impact minority, low-income and uninsured persons in the United States. Over the last decade, two macro-level events had a formidable impact on health care access with profound implications on the persistent disparities in mammography screening. The proposed study intends to uncover the impact of these macro-level events on mammography screening, and determine how these events affect the persistent racial/ethnic and socioeconomic inequalities in mammography screening.
