Contextual analysis of breast and cervical cancer screening and factors associated with health care access among United States women, 2002.

This research explored the relationships between race/ethnicity and area factors affecting access to health care in the United States. The study represents an advance on previous research in this field because, in addition to including data on rurality, it incorporates additional contextual covariates describing aspects of health care accessibility. Individual-level data were obtained from the 2002 Behavioral Risk Factor Surveillance System (BRFSS). The county of residence reported by BRFSS respondents was used to link BRFSS data with county-level measures of health care access from the 2004 Area Resource File (ARF). Analyses of mammography were limited to women aged 40 years with known county of residence (n=91,492). Analyses of Pap testing were limited to women aged 18 years with no history of hysterectomy and known county of residence (n=97,820). In addition to individual-level covariates such as race, Hispanic ethnicity, health insurance coverage and routine physical exam in the previous year. We examined county-level covariates (residence in health professional shortage area, urban/rural continuum, racial/ethnic composition, and number of health centers/clinics, mammography screening centers, primary care physicians, and obstetrician-gynecologists per 100,000 female population or per 1000 square miles) as predictors of cancer screening. Both individual-level and contextual covariates are associated with the use of breast and cervical cancer screening. In the current study, covariates associated with health care access, such as health insurance coverage, household income, Black race, and percentage of county female population who were non-Hispanic Black, were important determinants of screening use. In multivariate analysis, we found significant interactions between individual-level covariates and contextual covariates. Among women who reside in areas with lower primary care physician supply, rural women are less likely than urban women to have had a recent Pap test. Black women were more likely than White women to have had a recent Pap test. Women with a non-rural county of residence were more likely to have had a recent mammogram than rural women. A significant interaction was also found between individual-level race and number of health centers or clinics per 100,000 population (p-value=0.0187). In counties with 2 or more health centers or clinics per 100,000 female population, Black women were more likely than White women to have had a recent mammogram. A significant interaction was also observed between the percentage of county female population who were Hispanic and the percentage who were non-Hispanic Black.