Factors Associated with Self-Reported Mammography Use for Women With and Women Without a Disability

Abstract

Background:

Although their risk of breast cancer is similar to that of women without a disability, women with a disability might be less likely to obtain a mammogram within the recommended time frame. The purpose of this study was to expand our knowledge of the association between mammography use and having a disability by controlling for sociodemographic and health variables.

Methods:

Data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) were used to obtain prevalence of self-reported mammography use in the past 2 years among U.S. women ≥40 years of age (n=204,981) as well as women 50–74 years of age (n=122,374). Logistic regression was used to estimate associations between disability and obtaining a mammogram for each age cohort, controlling for sociodemographic factors.

Results:

Prevalence of self-reported mammography use is lower for women with a disability (72.2% for women ≥40 years of age and 78.1% for women 50–74 years of age) than women without a disability (77.8% and 82.6%, respectively). Women with a disability had lower odds of mammography use than women without a disability for both age cohorts (≥40, adjusted odds ratio [aOR] 0.92, p=0.01; 50–74 years, aOR 0.92, p=0.03).

Conclusions:

Disparities in obtaining a mammogram at recommended screening intervals persist for women with disabilities. This demonstrates the need for continued health promotion and prevention activities directed toward women with a disability to improve their accessibility to obtaining a mammogram.

Introduction

Breast cancer is the most frequent type of cancer among women and the second leading cause of cancer-related deaths among women. Early detection of breast cancer through preventive screening is important in reducing mortality.^1,2 Until November 2009, the U.S. Preventive Services Task Force (USPSTF) recommended that women ≥40 years of age obtain a mammogram every 1–2 years to screen for breast cancer.¹ An updated review of the evidence at that time resulted in breast cancer screening guidelines being revised to recommend routine screening for women 50–74 years of age and individualized (not routine) screening for women 40–49 years of age.¹ Numerous articles in the medical literature have noted that black or African American women, Hispanic white women, and Native American women with breast cancer seek medical help with more advanced cancer stages and have poorer survival rates than non-Hispanic white women.^3
–5 In addition to these disparities being attributed to to limited screening access, they have also been associated with socioeconomic and lifestyle factors.⁶

Much of the policy focus on healthcare disparities has centered on reducing racial and ethnic disparities, and relatively little attention has been paid to disability. Empirical evidence has shown that women with disabilities diagnosed with early stage breast cancer may have lower rates of breast conserving surgery and higher breast cancer mortality than women without a disability.⁷ Although women with a disability share the same risk for breast cancer as women without a disability,⁸ they are less likely to obtain a mammogram at recommended screening intervals.^9
–11 However, these studies examining mammography use among women with a disability use either national data collected in the mid-1990s that is now dated^9,11 or small, not nationally representative samples.¹⁰ Given that as many as 30% of women in the United States have a disability,¹² efforts to reduce disparities in breast cancer screening might be more effective if they target all segments of the population and explicitly include women with a disability.

The aim of this study was to use recent national data to increase our understanding of the association between mammography use and disability. Our study also controls for socioeconomic and lifestyle factors that might influence this association. Given the updated age recommendations by the USPSTF for biennial screening for women 50–74 years of age,¹ we completed separate analyses for all women ≥40 years of age and for women 50–74 years of age.

Materials and Methods

Data source

The data for this study were obtained from the 2008 Behavioral Risk Factor Surveillance System (BRFSS).¹³ The BRFSS is a random-digit dialed telephone survey, conducted by all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands, with assistance from the Centers for Disease Control and Prevention (CDC). The survey data are collected by trained interviewers on a variety of areas, including socioeconomic characteristics, health risks, and preventive health behaviors among the civilian, noninstitutionalized population ≥18 years of age. In 2008, a total of 414,509 respondents completed the survey. The median response rate (the percentage of partial and completed interviews among all eligible sample units) for the 2008 BRFSS was 53.3%, and the median cooperation rate (the percentage of completed interviews among all potential respondents who were selected and contacted) was 75.0%. Our analysis was limited to women who reported their age as being ≥40 years, which was a total of 204,981 respondents. We also completed a comparative analysis that was limited to women 50–74 years of age, which included 122,374 respondents. In addition, we limited our analysis to the 50 states and the District of Columbia. A detailed description of the data and data collection methods can be found at www.cdc.gov/brfss.

Statistical analyses

Prevalence estimates of self-reported mammography use within the past 2 years were determined for women with and without a disability. Prevalence of mammography use was also estimated after further stratifying the sample for each selected sociodemographic characteristic. Logistic regression was used to estimate the association between mammography use and disability while controlling for sociodemographic and health characteristics. For mammography use, all women who answered affirmatively to the question: “A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?” were asked: “How long has it been since your last mammogram?” Responses were recoded, and the dependent variable was a binomial indicator variable denoting respondents who had a mammogram within the past 2 years and those who had not.

The key independent variable of interest, disability, was measured using the Healthy People 2010 ¹⁴ definition; that is, respondents were defined as having a disability if they answered yes to either of the following questions: “Are you limited in any way in any activities because of physical, mental or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?” Respondents who answered no to both questions were considered not to have a disability. Respondents who answered don't know, refused to answer, had missing responses to both questions or a missing response on one and a no response on the other were counted as having missing data.

Other independent variables included in the multivariate model were respondent age¹⁵ (40–49 years, 50–64 years, and ≥65 years for the first model; 50–64 years and 65–74 years for the second model), race or ethnicity (non-Hispanic white, non-Hispanic black or African American, Hispanic, or other non-Hispanic),^16
–18 and marital status¹⁹ (never married, previously married, or married or part of a couple). The independent variable household income categorized respondents as having an annual income of <$25,000, $25,000–$49,999, or ≥$50,000.²⁰ Educational attainment information was stratified to distinguish between respondents having less than a high school education, having a high school education or some college, and having a college education.¹¹ Employment status was categorized as employed, unemployed, unable to work, or other (retired, student, or homemaker). Body mass index (BMI) was categorized into underweight (<18.5), healthy weight (18.5–24.9), overweight (25–29.9), and obese (≥30).²¹ Whether or not the respondent was receiving emotional support (always, usually or sometimes, or rarely or never) was included. Finally, indicator variables for having health insurance,^15,17 having a primary healthcare provider,²² being unable to see a doctor due to cost,⁶ and self-rated health status of excellent or very good vs. good or fair or poor also were included, as was information on the region of the country where the respondent lived.

All statistical analyses were performed using SAS-callable SUDAAN software, version 10.0 (Research Triangle Institute, Research Triangle Park, NC), and SAS software, version 9.2 (SAS Institute, Cary, NC), survey procedures to account for the complex sampling design of the BRFSS. Statistical significance between age-adjusted percentages (disability vs. no disability) was assessed using a t test, with corresponding p values and 95% confidence intervals (CIs). Using multivariate analyses, we calculated adjusted odds ratios (ORs) with 95% CIs. Prevalence estimates were age-adjusted to the 2000 U.S. standard population.²³ Finally, the data were weighted to account for noncoverage, nonresponse, and the race, sex, and age characteristics of the population.

Results

In the United States in 2008, an estimated 29.3% of women ≥40 years of age and 31.3% of women 50–74 years of age had a self-reported disability (Table 1). Among women ≥40 years of age, the prevalence of disability ranged from 22.1% in Hawaii to 39.4% in West Virginia. Among women 50–74 years of age, the prevalence of disability ranged from 24.5% in Hawaii to 40.7% in West Virginia.

Table 1.

State-Level, Age-Adjusted Prevalence of Self-Reported Disability for Women ≥40 Years of Age and Women 50–74 Years of Age: 50 States and the District of Columbia, 2008 Behavioral Risk Factor Surveillance System

	Aged ≥40 years		Aged 50–74 years
State	%	±95% CI	%	±95% CI
Alabama	36.8	2.1	38.3	2.6
Alaska	34.4	4.4	35.8	5.6
Arizona	29.9	3.0	35.5	4.3
Arkansas	34.9	2.3	35.9	2.7
California	28.2	1.5	30.3	2.0
Colorado	28.7	1.3	30.9	1.8
Connecticut	25.8	1.9	27.1	2.6
Delaware	28.0	2.5	31.0	3.2
DC	30.9	2.4	34.0	3.2
Florida	26.4	1.8	31.1	2.6
Georgia	29.3	2.0	33.9	2.6
Hawaii	22.1	1.8	24.5	2.5
Idaho	32.5	2.3	32.7	2.9
Illinois	27.4	1.9	28.9	2.7
Indiana	28.7	2.3	31.6	3.1
Iowa	24.1	1.7	25.7	2.3
Kansas	29.7	1.5	31.2	2.0
Kentucky	34.4	1.8	36.2	2.3
Louisiana	30.4	1.9	32.3	2.3
Maine	27.2	1.7	29.9	2.2
Maryland	29.6	1.7	31.6	2.3
Massachusetts	25.5	1.2	26.6	1.6
Michigan	31.8	1.5	34.2	2.0
Minnesota	30.6	2.1	32.5	2.8
Mississippi	34.5	1.7	37.6	2.1
Missouri	32.8	2.4	33.8	3.0
Montana	32.5	2.1	32.2	2.4
Nebraska	26.6	1.6	27.4	2.2
Nevada	30.2	2.8	32.9	3.5
New Hampshire	29.6	1.8	28.6	2.3
New Jersey	24.7	1.4	26.2	2.0
New Mexico	31.1	2.1	32.6	2.6
New York	29.9	1.8	31.2	2.4
North Carolina	31.6	1.3	33.3	1.7
North Dakota	23.8	1.8	25.3	2.4
Ohio	29.8	1.5	31.6	1.8
Oklahoma	35.8	1.7	38.3	2.2
Oregon	33.0	2.1	35.0	2.7
Pennsylvania	28.8	1.6	29.0	2.0
Rhode Island	27.3	2.0	27.5	2.5
South Carolina	30.7	1.9	31.7	2.4
South Dakota	26.2	1.8	25.9	2.3
Tennessee	34.3	2.5	34.6	2.8
Texas	28.9	1.7	29.3	2.2
Utah	32.6	2.6	32.8	3.3
Vermont	26.9	1.7	26.4	2.1
Virginia	26.0	2.1	29.3	3.1
Washington	32.8	1.1	34.9	1.3
West Virginia	39.4	2.4	40.7	2.9
Wisconsin	26.6	2.2	26.9	3.0
Wyoming	26.9	1.5	29.0	2.0
Total	29.3	0.4	31.3	0.5

Age adjusted to the 2000 U.S. standard population.

CI, confidence interval.

Overall, 76.2% of women ≥40 years of age (Table 2) reported having had a mammogram within the past 2 years, although women with a disability had a lower prevalence of mammography use than women without a disability (72.2% vs. 77.8%, p<0.001). For all women 50–74 years of age (Table 3), 81.2% reported having had a mammogram within the past 2 years; women with a disability reported a lower prevalence than did women without a disability (78.1% vs. 82.6%, p<0.001). For both age groups, a lower prevalence of mammography use was found among women with a disability compared to women without a disability for those who were white/non-Hispanic (72.0% vs. 78.4% ≥40 years; 77.7% vs. 83.3%, 50–74 years), previously married (67.5% vs. 72.9% ≥40 years; 74.1% vs. 77.7%, 50–74 years), high school graduate or having some college (70.7% vs. 76.3% ≥40 years; 76.8% vs. 81.5%, 50–74 years) and usually or sometimes receiving emotional support (72.5% vs. 77.4% ≥40 years; 78.6% vs. 82.0%, 50–74 years). Similar differences were observed between women with a disability compared to women without by characteristics reflective of access to care. These include: having health insurance (74.8% vs. 80.7%, ≥40 years; 80.3% vs. 85.4%, 50–74 years), having at least one usual source of healthcare (74.3% vs. 81.1% ≥40 years; 79.6% vs. 86.0%, 50–74 years) and reporting no barnors to care due to cost (76.2% vs. 79.9% ≥40 years; 81.5% vs. 84.6%, 50–74 years).

Table 2.

Age-Adjusted Prevalence of Receiving a Mammogram Within Past 2 Years for Women ≥40 Years of Age, by Disability Status and Sociodemographic Characteristic: 2008 Behavioral Risk Factor Surveillance System

	Total			Has disability			No disability
	%	±95% CI	n	%	±95% CI	n	%	±95% CI	n	p value ^a for difference
Total^b	76.2	0.4	195,299	72.2	0.7	64,905	77.8	0.4	130,394	<0.001
Race/ethnicity
Non-Hispanic black or African American	78.3	1.3	15,122	74.8	2.5	5,359	80.0	1.5	9,763	<0.001
Hispanic	75.1	1.7	8,748	75.8	3.5	2,516	74.7	2.0	6,232	0.5972
Other	71.0	2.0	8,663	65.4	3.5	3,068	73.2	2.5	5,595	<0.001
Non-Hispanic white	76.5	0.4	161,091	72.0	0.8	53,292	78.4	0.4	107,799	<0.001
Household income
<$25,000	65.5	0.9	54,529	64.6	1.4	26,570	66.3	1.3	27,959	0.074
$25,000–$49,999	74.6	0.8	46,976	73.0	1.6	14,494	75.2	0.9	32,482	0.020
≥$50,000	82.8	0.5	64,479	80.7	1.2	13,640	83.3	0.6	50,839	<0.001
Employment status
Employed	78.0	0.6	87,658	75.2	1.3	17,307	78.5	0.7	70,351	<0.001
Unemployed	67.1	2.1	6,669	64.7	3.3	2,796	68.5	2.8	3,873	0.084
Unable to work	68.8	1.6	15,066	68.4	1.6	13,258	70.7	5.0	1,808	0.395
Other	75.4	0.9	85,490	73.4	1.6	31,408	76.3	1.0	54,082	0.003
Marital status
Never married	71.4	1.4	13,054	69.5	2.4	4,759	72.5	1.8	8,295	0.056
Previously married	70.9	0.8	80,032	67.5	1.3	33,362	72.9	0.9	46,670	<0.001
Married/couple	79.3	0.4	101,649	76.1	1.0	26,601	80.3	0.5	75,048	<0.001
Education level
Less than high school	67.0	1.6	19,089	67.4	2.3	8,834	67.1	2.2	10,255	0.859
High school graduate/some college	74.6	0.5	116,998	70.7	1.0	40,383	76.3	0.6	76,615	<0.001
College graduate	81.8	0.6	58,919	78.6	1.3	15,592	82.7	0.6	43,327	<0.001
Health insurance
Has insurance	79.0	0.4	179,478	74.8	0.8	59,715	80.7	0.4	119,763	<0.001
No insurance	53.4	2.2	15,546	54.1	2.8	5,080	53.1	2.8	10,466	0.632
Age group, years
40–49	69.8	0.8	42,197	64.6	1.7	9,543	71.2	0.9	32,654	<0.001
50–64	80.3	0.5	77,275	77.1	0.9	25,016	81.7	0.6	52,259	<0.001
≥65	79.1	0.5	75,827	75.7	0.8	30,346	81.3	0.6	45,481	<0.001
Emotional support
Always	78.8	0.5	96,726	75.8	1.1	27,643	79.9	0.6	69,083	<0.001
Usually/some	75.8	0.5	79,696	72.5	1.0	28,976	77.4	0.7	50,720	<0.001
Rarely/never	64.5	1.7	14,275	61.6	2.3	6,722	66.5	2.3	7,553	0.003
Self-rated health
Excellent/very good	79.7	0.5	93,237	78.7	1.2	14,168	79.9	0.5	79,069	0.076
Good	74.8	0.7	59,012	72.7	1.3	20,760	75.6	0.8	38,252	<0.001
Fair/poor	69.5	1.0	42,143	68.8	1.1	29,561	71.0	1.8	12,582	0.041
Healthcare provider
>1 usual source of healthcare	79.1	0.4	178,838	74.3	0.7	60,697	81.1	0.4	118,141	<0.001
No usual source of healthcare	48.5	1.5	16,104	49.1	2.8	4,074	48.1	1.8	12,030	0.565
BMI level
Underweight	67.0	2.9	3720	64.3	4.9	1464	69.0	3.5	2256	0.124
Healthy weight	77.3	0.6	69782	70.7	1.4	17553	78.9	0.6	52229	<0.001
Overweight	77.6	0.7	59,816	75.5	1.3	18,510	78.6	0.8	41,306	<0.001
Obese	74.6	0.7	51,312	72.0	1.2	23,828	76.4	1.0	27,484	<0.001
Access to care
Cost barrier to care	60.0	1.4	21,413	59.8	1.7	10,761	60.1	2.2	10,652	0.817
No cost barrier to care	78.9	0.4	173,499	76.2	0.8	53,960	79.9	0.4	119,539	<0.001
U.S. region
Northeast	79.1	0.8	40,624	76.1	1.7	12,470	80.4	0.9	28,154	<0.001
Midwest	75.7	0.7	44,489	70.5	1.4	14,422	77.7	0.8	30,067	<0.001
West	75.8	0.9	46,469	72.6	1.7	15,520	77.2	1.0	30,949	<0.001
South	75.2	0.6	63,717	71.2	1.2	22,493	76.9	0.7	41,224	<0.001

Age adjusted to the 2000 U.S. standard population.

p value reflects a t test of age-adjusted percentage differences between disability and no disability.

The total number of respondents may differ in each group because of excluding respondents with unknown responses or refusals to answer.

BMI, body mass index.

Table 3.

Age-Adjusted Prevalence of Receiving a Mammogram in Past 2 Years for Women 50–74 Years of Age, by Disability Status and Sociodemographic Characteristics: 2008 Behavioral Risk Factor Surveillance System

	Total			Has disability			No disability
	%	±95% CI	n	%	±95% CI	n	%	±95% CI	n	p value ^a for difference
Total^b	81.2	0.4	116,985	78.1	0.7	39,017	82.6	0.5	77,968	<0.001
Race/ethnicity
Non-Hispanic black or African American	82.4	1.6	9,349	80.1	2.6	3,456	83.6	1.9	5,893	0.039
Hispanic	81.3	2.2	4,864	85.1	3.2	1,560	79.9	2.7	3,304	0.015
Other	74.5	2.7	5,051	70.8	4.1	1,934	76.2	3.6	3,117	0.052
Non-Hispanic white	81.5	0.4	96,826	77.7	0.7	31,706	83.3	0.5	65,120	<0.001
Household income
<$25,000	71.4	1.1	30,993	70.6	1.4	15,416	72.0	1.6	15,577	0.188
$25,000–$49,999	80.2	0.9	29,574	79.1	1.6	9,113	80.7	1.0	20,461	0.085
≥$50,000	86.8	0.6	40,046	85.4	1.2	9,267	87.2	0.7	30,779	0.014
Employment status
Employed	81.8	0.7	54,617	80.7	1.3	11,966	82.1	0.8	42,651	0.06
Unemployed	73.0	2.5	4,225	70.4	3.7	1,839	74.4	3.3	2,386	0.112
Unable to work	72.5	1.7	10,767	72.0	1.7	9,501	75.7	5.9	1,266	0.238
Other	82.4	0.8	47,160	80.7	1.3	15,644	83.2	0.9	31,516	0.002
Marital status
Never married	76.1	1.9	7,371	73.3	3.1	2,818	77.8	2.3	4,553	0.024
Previously married	76.3	0.8	44,422	74.1	1.2	17,982	77.7	1.1	26,440	<0.001
Married/couple	83.8	0.5	64,817	81.1	0.9	18,091	84.9	0.6	46,726	<0.001
Education level
Less than high school	72.7	1.9	10,243	73.2	2.3	4,784	72.5	2.8	5,459	0.708
High school graduate/some college	80.0	0.5	70,540	76.8	1.0	24,207	81.5	0.6	46,333	<0.001
College graduate	86.1	0.6	36,048	83.5	1.2	9,979	87.0	0.8	26,069	<0.001
Health insurance
Has insurance	83.8	0.4	107,369	80.3	0.7	35,631	85.4	0.5	71,738	<0.001
No insurance	56.3	3.3	9,487	59.5	3.5	3,341	55.1	4.3	6,146	0.112
Age group, years
50–64	80.3	0.5	77,275	77.1	0.9	25,016	81.7	0.6	52,259	<0.001
65–74	83.3	0.7	39,710	80.4	1.1	14,001	84.7	0.8	25,709	<0.001
Emotional support
Always	83.4	0.6	58,128	80.4	1.1	16,135	84.4	0.7	41,993	<0.001
Usually/some	80.8	0.6	48,775	78.6	1.0	18,356	82.0	0.8	30,419	<0.001
Rarely/never	70.5	1.9	7,788	67.4	2.7	3,816	72.7	2.8	3,972	0.007
Self-rated health
Excellent/very good	84.2	0.5	56,522	84.5	1.2	8,630	84.2	0.6	47,892	0.641
Good	80.8	0.8	34,820	79.8	1.3	12,341	81.3	1.0	22,479	0.078
Fair/poor	75.1	1.1	25,190	73.7	1.2	17,847	77.8	2.1	7,343	<0.001
Healthcare provider
>1 usual source of healthcare	84.0	0.4	107,611	79.6	0.7	36,513	86.0	0.5	71,098	<0.001
No usual source of healthcare	51.1	2.1	9,214	55.3	3.6	2,440	49.7	2.5	6,774	0.012
BMI level
Underweight	69.1	3.9	1801	61.9	7.4	686	73.1	4.2	1115	0.01
Healthy weight	82.0	0.7	38145	77.0	1.4	9080	83.4	0.8	29065	<0.001
Overweight	82.3	0.7	36,502	79.9	1.4	10,760	83.2	0.9	25,742	<0.001
Obese	80.1	0.8	33,800	78.3	1.1	16,165	81.6	1.1	17,635	<0.001
Access to care
Cost barrier to care	64.3	1.8	12,934	65.0	2.0	7,027	63.5	3.0	5,907	0.423
No cost barrier to care	83.7	0.4	103,859	81.5	0.8	31,909	84.6	0.5	71,950	<0.001
U.S. region
Northeast	83.8	0.9	23,543	81.5	1.6	7,166	84.8	1.0	16,377	0.001
Midwest	80.4	0.8	25,755	77.0	1.4	8,218	82.0	0.9	17,537	<0.001
West	81.3	1.0	28,528	78.4	1.7	9,658	82.7	1.3	18,870	<0.001
South	80.3	0.7	39,159	77.0	1.2	13,975	81.9	0.9	25,184	<0.001

Age adjusted to the 2000 U.S. standard population.

p value reflects a t test of age-adjusted percentage differences between disability and no disability.

The total number of respondents may differ in each group because of excluding respondents with unknown responses or refusals to answer.

The logistic regression results showed that women with a disability had statistically significant lower odds than women without a disability of having obtained a mammogram within the previous 2 years, when controlling for sociodemographic factors (Table 4). This was consistent among women ≥40 years of age (adjusted OR [aOR] 0.92, p=0.01) and for those women 50–74 years of age (aOR 0.92, p=0.03). Furthermore, both multivariate models indicated lower odds for women who were multiracial or of another, unspecified race compared with non-Hispanic white women; those who reported never having been married or having been married previously compared with married women; women with lower education levels, lower household income levels, and lower self-rated health status; and women who were identified as being underweight. In contrast, higher odds of mammography use were observed among non-Hispanic black or African American and Hispanic women; those living in the Northeast; those with health insurance, emotional support, and at least one primary healthcare provider; and in older age groups. The coefficients for employment status were not statistically significant. We conducted a sensitivity analysis by excluding women who never had a mammogram from the models instead comparing women who had a mammogram in the past 2 years to women who had their last mammogram >2 years ago. We obtained similar results for disability with an even smaller (aOR 0.84, p<0.001 for women ≥40 years; aOR 0.86, p<0.001 for women 50–74 years). Additional results are available from the authors on request.

Table 4.

Results of Logistic Regression Models for Having a Mammogram in Past 2 Years Compared to >2 Years Ago or Never for Women ≥40 Years of Age and for Women 50–74 Years of Age, Adjusting for Sociodemographic Variables, Adjusted Odds Ratios, and 95% Confidence Intervals: 2008 Behavioral Risk Factor Surveillance System

	Aged ≥40 years		Aged 50–74 years
	aOR estimate	95% CI	aOR estimate	95% CI
Disability status
Has disability	0.92	0.87-0.98	0.92	0.85-0.99
No disability	Referent		Referent
Race/ethnicity
Non-Hispanic black or African American	1.58	1.43-1.75	1.62	1.4-1.87
Hispanic	1.88	1.64-2.16	2.27	1.85-2.77
Other	0.86	0.77-0.98	0.79	0.66-0.95
Non-Hispanic white	Referent		Referent
Household income
<$25,000	0.65	0.60-0.71	0.69	0.62-0.76
$25,000–$49,999	0.78	0.73-0.83	0.77	0.71-0.84
≥$50,000	Referent		Referent
Employment status
Employed	1.00	0.93-1.07	0.88	0.81-0.96
Unemployed	0.97	0.85-1.11	0.89	0.75-1.07
Unable to work	0.96	0.86-1.07	0.76	0.66-0.88
Other	Referent		Referent
Marital status
Never married	0.84	0.76-0.93	0.81	0.71-0.93
Previously married	0.85	0.80-0.90	0.85	0.78-0.92
Married/couple	Referent		Referent
Education level
Less than high school	0.81	0.73-0.90	0.78	0.68-0.91
High School graduate/some college	0.85	0.81-0.90	0.84	0.78-0.91
College graduate	Referent		Referent
Health insurance
Has insurance	Referent		Referent
No insurance	0.51	0.46-0.56	0.45	0.40-0.51
Age group, years
40–49	Referent		N/A	N/A
50–64	1.88	1.78-1.99	Referent
≥65^a	1.75	1.62-1.91	1.01	0.92-1.11
Emotional support
Always	1.35	1.23-1.48	1.42	1.23-1.62
Usually/some	1.22	1.12-1.34	1.28	1.12-1.47
Rarely/never	Referent		Referent
Self-rated health
Excellent/very good	Referent		Referent
Good	0.91	0.86-0.96	0.91	0.85-0.99
Fair/poor	0.87	0.80-0.94	0.88	0.79-0.98
Healthcare provider
>1 usual source of healthcare	3.04	2.80-3.31	3.68	3.30-4.11
No usual source of healthcare	Referent		Referent
BMI level
Underweight	0.70	0.60-0.82	0.54	0.44-0.68
Healthy weight	Referent		Referent
Overweight	1.10	1.03-1.16	1.03	0.95-1.12
Obese	0.98	0.93-1.05	0.96	0.89-1.05
Access to care
Cost barrier to care	0.70	0.65-0.75	0.65	0.59-0.73
No cost barrier to care	Referent		Referent
U.S. region
Northeast	1.12	1.04-1.20	1.12	1.02-1.23
Midwest	0.95	0.90-1.01	0.93	0.86-1.01
West	1.02	0.95-1.09	1.07	0.97-1.18
South	Referent		Referent
Likelihood ratio chi-square	5,048,991.0	<0.001	2,708,078.0	<0.001

For the analytic group of women between 50 and 74 years of age, this group represents women 65–74 years of age.

aOR, adjusted odds ratio; N/A, not available.

Discussion

Our results are consistent with previous empirical evidence suggesting that women with a disability are less likely to receive a mammogram than women without a disability.^9,11,24 However, many of these studies have used older datasets^9,11 or focused on a specific type of disability (e.g., cognitive limitation).²⁴ Although women with a disability in our study reported a higher prevalence of receiving a mammogram in the previous 2 years than did women with a disability in a study conducted using data from 1994–1995,⁹ they continue to report lower levels than women without a disability. In addition, our findings were consistent across both age groups (i.e., women ≥40 years of age and women 50–74 years of age). Because approximately 30% of women have a disability and women with a disability also have been found to have higher breast cancer mortality,⁷ even when diagnosed at the same stage,²⁵ identifying and reducing barriers to breast cancer screening are key from a public health policy standpoint.

Lack of health insurance frequently has been associated with lowered mammography use.^15,17,26 In addition, women with a disability, who are disproportionately poor,²⁷ also have noted cost concerns as a barrier²⁸ to seeking a mammogram. We found that not having health insurance and having cost-related access-to-care difficulties were significant barriers to obtaining a mammogram. On the other hand, women in our study with a disability who reported having insurance, at least one usual source of healthcare, or no lack of access to care because of cost reported a statistically significantly lower prevalence of mammography use in the last 2 years than did women without a disability. When controlling for these and other factors typically associated with health disparities (such as household income and financial barriers), however, disability continues to be associated with lower levels of mammography use. This suggests that health disparities resulting from less frequent access to mammograms might be associated with barriers not identified in our data that discourage people with a disability from receiving periodic preventive care.²⁹

Barriers to mammography use for women with disabilities include physical inaccessibility of office space and medical equipment; limited transportation and parking options; provider discomfort in providing care to these women or recommending a mammogram less frequently than to women without disabilities; and time and assistance constraints associated with undressing, transferring, and positioning for medical examinations.^30

–34 These barriers that limit mammography use for women with a disability might be reduced through interventions aimed at improving environmental access, enhancing provider training and education, increasing outreach efforts to women with a disability, and improving overall health education. Given the regional differences found, it is also possible that variations in healthcare in these areas may be driving these differences. These findings were consistent with results of other work in the literature that included region as a covariate, where women in the Northeastern United States reported the highest prevalence of mammography use.¹¹

Resources and materials are available to assist healthcare professionals in implementing cancer screening programs for women with a disability (e.g., Breast Cancer Screening: The Right to Know³⁵). To promote health and wellness, health agencies, providers, and healthcare plans must promote cancer prevention and educational programs that are inclusive and responsive to the special needs of women with a disability. To reach these women, cancer screening programs might require such additional information as where to find accessible screening sites, or health information might need to be presented in alternative formats, such as large print, Braille, or American Sign Language (ASL).^36,37

There were limitations to the study. First, the disability questions in the BRFSS do not measure duration or severity of disability, so it is possible that they might capture people with a short-term disability (e.g., a broken ankle). We also do not have any information on underlying condition or cause of the disability, so we are unable to stratify our analysis by type of disability. It is possible that we could obtain different results by looking at mammography use by type of disability. Second, there are several populations the BRFSS does not be reach. The BRFSS includes only the civilian noninstitutionalized population, so people residing in group homes or institutions are not included, which likely causes an underestimation of people with a disability. In addition, the BRFSS is not accessible to people who use a TTY/TDD, and the limited number of rings allowed before discontinuing the call might not allow people with mobility impairments adequate time to answer the telephone.³⁸ People with cognitive limitations might not be able to participate in a telephone survey, such as the BRFSS. Third, the BRFSS mammography questions do not specify if the mammogram was for screening or diagnostic purposes, so we could not assume all reported mammograms were obtained solely for screening purposes. Fourth, the BRFSS contains self-reported data, and reliability of the data cannot be determined. However, research has found that national estimates using the BRFSS are reliable when compared with analogous surveys, where the reliability of mammography related responses was found to be moderate to high.³⁹ Although some of the statistically significant results could be an artifact of a large sample size, our findings are in line with older findings using other data sources.

Conclusions

Using updated national data, we found that disparities in obtaining a mammogram during recommended intervals continue to persist for women with a disability. Given the documented decrease in mammography use for women,^15,17 coupled with previous findings that women with a disability are more likely to have higher rates of breast cancer mortality,⁷ it is important to increase mammography availability for women with a disability. Social marketing campaigns, such as Breast Cancer Screening: The Right to Know,³⁵ can help facilitate the inclusion of women with disabilities in public health breast cancer prevention programs.

Footnotes

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Disclosure Statement

No competing financial interests exist.

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