title: Association of contextual factors and breast cancer screening: finding new targets to promote early detection.
abstract: BACKGROUND
  Disparities in breast cancer screening (BCS) exist within the United States. Although such factors as a woman's income and insurance status explain some differences, additional contributions related to local healthcare system characteristics or the social and economic context in which women live have not been fully explored.
  
  
  METHODS
  Using data from a cross-sectional survey of Ohio residents, we assessed BCS in a state-representative sample of 2231 women between the ages of 50 and 69 years. Urbanization, the proportion of female-headed households (FHH), managed care activity, the number of primary care physicians (PCPs) per capita, and county designation as being medically underserved represented some of the contextual characteristics we examined. Using nested hierarchical logistic regression models, we evaluated the association of these characteristics with BCS before and after adjusting for respondents' characteristics.
  
  
  RESULTS
  The proportion of age-eligible women screened for breast cancer was 61.9% (n = 1383); county screening rates varied from 12.9% to 100% (mean 60.3%). Failure to complete high school, lower family income, and absence of continuous insurance, a usual source of care, or current employment were associated with lower BCS. After accounting for these characteristics, per capita PCPs (adjusted odds ratio [AOR] 1.05 (1.01, 1.10), p = 0.02) and the proportion of FHH (AOR 0.66 (0.44, 0.99), p = 0.045) remained independently associated with BCS.
  
  
  CONCLUSIONS
  Contextual characteristics independently associated with BCS identify areas in which women are at increased risk for delayed breast cancer diagnosis. The approach described here can inform the planning phase of regional, state, or federal initiatives to enhance BCS and reduce subsequent disparities in treatment outcomes.
authors.affiliation: Department of Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio 44106, USA. David.Litaker@med.va.gov
authors.forename: David
authors.initials: D
authors.lastname: Litaker
authors.forename: Anne
authors.initials: A
authors.lastname: Tomolo
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D018672:Community Health Planning / Q000706:statistics & numerical data*; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D042241:Early Diagnosis; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008327:Mammography / Q000706:statistics & numerical data; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D016017:Odds Ratio; D009820:Ohio / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011322:Primary Prevention / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D016387:Women's Health; D014932:Women's Health Services / Q000706:statistics & numerical data