title: Area-level Socioeconomic Inequalities in the Use of Mammography Screening: A Multilevel Analysis of the Health of Houston Survey.
abstract: BACKGROUND
  An emerging literature reports that women who reside in socioeconomically deprived communities are less likely to adhere to mammography screening. This study explored associations between area-level socioeconomic measures and mammography screening among a racially and ethnically diverse sample of women in Texas.
  
  
  METHODS
  We conducted a cross-sectional, multilevel study linking individual-level data from the 2010 Health of Houston Survey and contextual data from the U.S. Census. Women ages 40 to 74 years (n = 1,541) were included in the analyses. We examined tract-level poverty, unemployment, education, Hispanic and Black composition, female-headed householder families, and crowding as contextual measures. Using multilevel logistic regression modeling, we compared most disadvantaged tracts (quartiles 2-4) to the most advantaged tract (quartile 1).
  
  
  RESULTS
  Overall, 64% of the sample was adherent to mammography screening. Screening rates were lower (p < .05) among Hispanics, those foreign born, women aged 40 to 49 years, and those with low educational attainment, unemployed, and without health insurance coverage. Women living in areas with high levels of poverty (quartile 2 vs. 1: odds ratio [OR], 0.50; 95% CI, 0.30-0.85), Hispanic composition (quartile 3 vs. 1: OR, 0.54; 95% CI, 0.32-0.90), and crowding (quartile 4 vs. 1: OR, 0.53; 95% CI, 0.29-0.96) were less likely to have up-to-date mammography screening, net of individual-level factors.
  
  
  CONCLUSIONS
  Our findings highlight the importance of examining area-level socioeconomic inequalities in mammography screening. The study represents an advance on previous research because we examined multiple area measures, controlled for key individual-level covariates, used data aggregated at the tract level, and accounted for the nested structure of the data.
authors.affiliation: Department of Management, Policy and Community Health, The University of Texas School of Public Health, Houston, Texas. Electronic address: wacalo@live.unc.edu.
authors.forename: William A
authors.initials: WA
authors.lastname: Calo
authors.affiliation: Center for Health Promotion and Prevention Research, The University of Texas School of Public Health, Houston, Texas.
authors.forename: Sally W
authors.initials: SW
authors.lastname: Vernon
authors.affiliation: Center for Health Services Research, The University of Texas School of Public Health, Houston, Texas.
authors.forename: David R
authors.initials: DR
authors.lastname: Lairson
authors.affiliation: Institute for Health Policy, The University of Texas School of Public Health, Houston, Texas.
authors.forename: Stephen H
authors.initials: SH
authors.lastname: Linder
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis* / Q000208:ethnology; D003430:Cross-Sectional Studies; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005006:Ethnicity / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000208:ethnology*; D006801:Humans; D016015:Logistic Models; D008327:Mammography / Q000706:statistics & numerical data*; D008403:Mass Screening / Q000706:statistics & numerical data*; D008875:Middle Aged; D055361:Multilevel Analysis; D011203:Poverty; D012959:Socioeconomic Factors; D013781:Texas / Q000453:epidemiology; D014478:Unemployment
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