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Int. J. Environ. Res. Public Health 2018, 15(9), 1961; https://doi.org/10.3390/ijerph15091961

What Explains Education Disparities in Screening Mammography in the United States? A Comparison with The Netherlands

1
Tinbergen Institute, 3062 PA Rotterdam, The Netherlands
2
Department of Applied Economics, Erasmus School of Economics, 3062 PA Rotterdam, The Netherlands
3
Department of Balkan, Slavic and Oriental Studies, University of Macedonia, 546 36 Thessaloniki, Greece
*
Author to whom correspondence should be addressed.
Received: 13 July 2018 / Revised: 31 August 2018 / Accepted: 5 September 2018 / Published: 8 September 2018
(This article belongs to the Special Issue Socioeconomic Inequality of Health)
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Abstract

Background: In the U.S., less educated women are substantially less likely to receive screening mammography. It is not clear whether this is due to differences in access to screening or in perceptions of breast cancer risks and the effectiveness of screening. We weigh the plausibility of these two explanations by examining how the dependence of mammography on education changes after conditioning on indicators of access and perceptions. We also compare estimates for the U.S. with those for the Netherlands where there is universal access to a publicly financed screening program. Method: Cross-sectional and cross-country comparable individual level data from the American Life Panel (n = 646) and the Netherlands Longitudinal Internet Studies for the Social Sciences (n = 1398) were used to estimate and explain education disparities in screening mammograms given to American and Dutch women aged 40+. The education gradient was estimated using logit models. Controls were sequentially added to detect whether disparities were explained by differences in access or perceptions of risks and effectiveness. Results: In the United States, high school graduates were 11.5 percentage points (95% CI: 1–22 percentage points) less likely than college graduates to receive a screening mammogram in the previous two years. This education gradient was largely explained by differences in income, insurance coverage and receipt of medical advice. It was not explained by educational differences in the perceived risk of breast cancer and the effectiveness of mammography. There were no education disparities in receipt of mammography among Dutch women within the 50–75 age range covered by the national screening program. Conclusion: In the absence of a universal screening program in the U.S., determinants of access—income, insurance coverage and receipt of medical advice—appear to drive the education disparities in screening mammography. View Full-Text
Keywords: breast cancer; screening mammogram; education gradient; screening program; health insurance breast cancer; screening mammogram; education gradient; screening program; health insurance
This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. (CC BY 4.0).
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Koç, H.; O’Donnell, O.; Van Ourti, T. What Explains Education Disparities in Screening Mammography in the United States? A Comparison with The Netherlands. Int. J. Environ. Res. Public Health 2018, 15, 1961.

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