title: Healthcare access and mammography screening in Michigan: a multilevel cross-sectional study.
abstract: BACKGROUND
  Breast cancer screening rates have increased over time in the United States. However actual screening rates appear to be lower among black women compared with white women.
  
  
  OBJECTIVE
  To assess determinants of breast cancer screening among women in Michigan USA, focusing on individual and neighborhood socio-economic status and healthcare access.
  
  
  METHODS
  Data from 1163 women ages 50-74 years who participated in the 2008 Michigan Special Cancer Behavioral Risk Factor Survey were analyzed. County-level SES and healthcare access were obtained from the Area Resource File. Multilevel logistic regression models were fit using SAS Proc Glimmix to account for clustering of individual observations by county. Separate models were fit for each of the two outcomes of interest; mammography screening and clinical breast examination. For each outcome, two sequential models were fit; a model including individual level covariates and a model including county level covariates.
  
  
  RESULTS
  After adjusting for misclassification bias, overall cancer screening rates were lower than reported by survey respondents; black women had lower mammography screening rates but higher clinical breast examination rates than white women. However, after adjusting for other individual level variables, race was not a significant predictor of screening. Having health insurance or a usual healthcare provider were the most important predictors of cancer screening.
  
  
  CONCLUSIONS
  Access to healthcare is important to ensuring appropriate cancer screening among women in Michigan.
authors.affiliation: Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA. tomiaki@umich.edu.
authors.forename: Tomi F
authors.initials: TF
authors.lastname: Akinyemiju
authors.forename: Amr S
authors.initials: AS
authors.lastname: Soliman
authors.forename: May
authors.initials: M
authors.lastname: Yassine
authors.forename: Mousumi
authors.initials: M
authors.lastname: Banerjee
authors.forename: Kendra
authors.initials: K
authors.lastname: Schwartz
authors.forename: Sofia
authors.initials: S
authors.lastname: Merajver
mesh_terms: D000368:Aged; D044383:Black People / Q000706:statistics & numerical data; D001943:Breast Neoplasms / Q000175:diagnosis; D003430:Cross-Sectional Studies; D055088:Early Detection of Cancer / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data*; D006801:Humans; D008327:Mammography / Q000706:statistics & numerical data*; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D012923:Social Class; D044465:White People / Q000706:statistics & numerical data; D001741:Black or African American