Short Communication Breast and Cervical Cancer Screening among Appalachian Women

Medical service shortages, rural residence, and socioeconomic and cultural factors may pose barriers to breast and cervical cancer screening among women living in the Appalachian region of the United States. This study determined the rates of breast and cervical cancer screening in Appalachia and identified factors associated with screening. Data from the Behavioral Risk Factor Surveillance System, 1996 to 1998, for the Appalachian region were analyzed to determine the percentage of women >40 years of age who had had a mammogram or clinical breast examination (CBE) within the past 2 years and the percentage of women >18 years of age who had had a Pap test within the past 3 years. Screening rates were compared with those for women living elsewhere in the United States. Screening rates were further assessed according to demographic, socioeconomic, and physical and behavioral health factors. Multiple logistic regression analyses were conducted to examine the predictors of screening. Overall, 14,520 Appalachian women >18 years of age reported on Pap tests; 13,223 women >40 years of age reported on mammogram screening, and 13,124 women reported on CBE screening. Among Appalachian women, 68.8% [95% confidence interval (CI), 67.8–69.9] had a mammogram, 75.1% (95% CI, 74.1–76.1) had a CBE in the past 2 years, and 82.4% (95% CI, 81.5–83.3) had a Pap test in the past 3 years. These rates were at most 3% lower than those for women living elsewhere in the United States, but these differences were statistically significant. Older women and women with less education or income were screened less commonly. Women who had visited a doctor within the past year were more likely to have been screened. Additional interventions are needed to increase breast and cervical cancer screening rates for Appalachian women to meet the goals of Healthy People 2010, targeting in particular population groups found to have lower screening rates. Introduction Appalachia historically has been underserved by the health care system (1, 2). In addition, rural residence, geographic isolation, poverty, unemployment, lack of education, lack of child care services, and attitudinal and cultural factors may pose barriers to cancer screening among Appalachian women (2–6). The United States Department of Health and Human Services (7) sets nationwide target goals for breast and cervical cancer screening. In addition, a primary goal is to achieve equity in health to eliminate disparities. Race, ethnicity, education, income, and rural location have been found to be associated with less use of preventive screening services and lack of health insurance (7). There is little published information about screening rates among women in the Appalachian region. Similar to studies among the United States population, small studies within Appalachia found lower rates of breast and cervical cancer screening among women who were older, less educated, or unemployed; lived in rural settings; had lower incomes; lacked health insurance; or were covered by public health insurance (4, 5). We used data from the Centers for Disease Control and Prevention BRFSS to determine the prevalence and to characterize the correlates of breast and cervical cancer screening among Appalachian women. The Appalachian region comprises all 55 counties of West Virginia and a total of 351 counties in Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. Materials and Methods The BRFSS collects data on behavioral risk factors for the adult population 18 years of age and living in households. State health departments identify a probability sample of all households with telephones, administer the interviews, and transmit the information to Centers for Disease Control and Prevention for editing, processing, weighting, and additional analysis. Telephone coverage ranges from 87 to 98% across states and varies by subgroups but was not available specifically for the Appalachian region. The estimated median response rate for 1998 was 59.2% but ranged from 32.5 to 76.7% across states. To determine whether women 40 years of age received breast cancer screening in the recommended time frame, we determined the percentages of women who had received a Received 3/12/01; revised 10/5/01; accepted 10/23/01. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 1 To whom requests for reprints should be addressed, at Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Mailstop K 53, 4770 Buford Highway NE, Atlanta, GA 30341. Phone: (770) 488-3001; Fax: (770) 488-4759; E-mail: [email protected]. 2 The abbreviations used are: BRFSS, Behavioral Risk Factor Surveillance System; CBE, clinical breast exam; BMI, body mass index; CI, confidence interval; OR, odds ratio. 3 Appalachian Regional Commission. List of counties in the Appalachian Region. Internet address: http://www.arc.gov/aboutarc/region/regmap.htm. 4 Centers for Disease Control and Prevention. Overview of the BRFSS 1998 survey data. Internet address: http://www.cdc.gov/nccdphp/brfss. 5 Centers for Disease Control and Prevention. Estimated telephone coverage: current population survey, March 1998. Internet address: http://www.cdc.gov/ nccdphp/brfss/pdf/telecov98.pdf. 6 Centers for Disease Control and Prevention. BRFSS summary quality control report. Internet address: http://www.cdc.gov/nccdphp/brfss, 1998. 137 Vol. 11, 137–142, January 2002 Cancer Epidemiology, Biomarkers & Prevention on September 6, 2017. © 2002 American Association for Cancer Research. cebp.aacrjournals.org Downloaded from mammogram or a CBE within the past 2 years. For cervical cancer screening, we determined whether a Pap test had been received within the past 3 years among women 18 years of age who had not had a hysterectomy. Other information obtained from BRFSS included age, race, marital and employment status, education, household income, number of persons living in the household, number of dependent children in the household who were 18 years of age, health insurance, health status, height, weight, smoking, doctor visit within the past year, and diabetes. BMI [weight (in kilograms) divided by height (in meters squared)] was categorized according to the International Obesity Task Force classification (BMI 25, 25– 29, and 30; Ref. 8). We combined data for 1996–1998 to obtain adequate sample sizes for subgroup analyses. We calculated the percentage of Appalachian women receiving the screening tests and 95% CIs overall and by demographic and other potential correlates (univariate analyses with 2 statistic; P 0.05). To compare screening rates between Appalachian and other United States women, we calculated age-adjusted percentages, using the age distribution for women from intercensal estimates for 1996, 1997, and 1998 (9). The age-adjusted rates were compared by calculating a Z statistic (P 0.05). All analyses were weighted to adjust for differences in probability of selection, nonresponse, and noncoverage. Multivariate logistic regression analyses were conducted to Table 1 Percentage of Appalachian women 40 years of age who received a mammogram or CBE in the past 2 years and the difference between Appalachian and other United States women, Behavioral Risk Factor Surveillance System, 1996-1998 Demographic or health characteristic Mammogram in past 2 years CBE in past 2 years n % 95% CI % D P n % 95% CI % D P Age, yr 40–49 3941 63.7 61.8–65.7 63.8 1.9 0.084 3930 78.8 77.0–80.5 78.8 1.8 0.063 50–59 3017 76.0 73.8–78.1 75.9 2.0 0.087 3008 80.0 78.0–82.0 80.0 1.4 0.201 60–69 2771 72.8 70.5–5.0 72.8 4.8 0.00