Demographic Predictors of
Mammography and Pap Smear
Screening in US Women
:. ---------- --------------- ............................................
1..Im Eugenia E. Calle, PhD, W. Dana Flanders, MD, ScD, Michael J. Thun,
.1
MD, MPH, and Linda M. Martin, MS
Introduction
Reductions in mortality from breast
and cervical cancer depend on early detec-
tion and treatment. Proven screening tech-
nologies exist for both these cancers,'-5 but
they are underused by many women, and
screening behavior varies among women
from different age, race, and socioeco-
nomic groups.6'5 Recent efforts to remedy
this situation have begun at national, state,
and local levels.1-'9
Using data from a nationwide survey
of US women, this article examines the
demographic characteristics that predict
underuse of mammography and Pap
smear screening. These characteristics
are then examined in combination to pro-
duce profiles of women who are severely
underserved by such technologies and
who are most likely to benefit from inter-
vention programs.
Methods
We used data from the 1987 National
Health Interview Survey Cancer Control
Supplement to identify variables that pre-
dict underuse of mammography and Pap
smear screening. The National Health In-
terview Survey is a cross-sectional, an-
nual, household interview survey of the
civilian, noninstitutionalized population of
the United States, conducted by the Na-
tional Center for Health Statistics.20 Rep-
resentative households are selected con-
tinuously throughout the year using a
multistage probability sampling design.
The survey questionnaire consists of a set
of basic health and demographic items,
and of one or more sets of supplemental
questions on current health topics. The
Cancer Control Supplement included de-
tailed questions related to cancer screen-
ing and was completed by 12 868 women
18 years of age and older.
For the present study, we based anal-
yses of Pap smear screening on 12 252
women aged 18 and older who reported no
history of cancer (except nonmelanoma
skin cancer). We further restricted analy-
ses of mammography use to 6353 women
aged 40 and older with no history of can-
cer.
We employed two measures of un-
deruse of both Pap smear screening and
mammography: never having been
screened and not having been screened in
the past year. We examined eight demo-
graphic variables as potential predictors of
underuse of screening: age (18 to 39, 40 to
64, 65 + for Pap smear; 40 to 49, 50 to 64,
65+ for mammography); race/ethnicity
(White, Black, Hispanic, other); income
(below poverty level, poverty level to
200% of poverty level, 200% to 300% of
poverty level, greater than 300% of pov-
erty level); education (fewer than 12 years,
12 years, more than 12 years); marital sta-
tus (married, widowed, divorced, never
married); type of urban area (central city,
other metropolitan statistical area, non-
metropolitan statistical area); region
(Northeast, Midwest, South, West); and
employment (in the labor force, not in the
labor force). The income variable was
constructed based on the reported house-
hold income and family size, and using the
Eugenia E. CaHle, Michael J. Thun, and Linda
M. Martin are with the American Cancer So-
ciety, and W. Dana Flanders is with the Emory
University School of Public Health, Atlanta,
Ga.
Requests for reprints should be sent to Dr.
Eugenia E. Calle, American Cancer Society,
1599 Clifton Rd, Atlanta, GA 30329.
This paper was submitted to the Journal
July 1, 1991, and accepted with revisions June
8, 1992.
American Journal of Public Health 53
Calk et aL
1987 poverty income guidelines21 to iden-
tify those people living below the poverty
level, which was defined as a household
income of about $11 000 for a family of
four. Women with missing income data
(about 12% of all women) were excluded
from estimates by income but were in-
cluded in all other estimates.
We calculated frequencies of screen-
ing underuse and 95% confidence intervals
(CIs) for levels of each potential predictor
using SESUDAAN,= a user-defined Sta-
tistical Analysis System procedure that in-
corporates the National Health Interview
Survey sampling weights and the charac-
teristics of the complex sample design to
54 American Joumal of Public Health
estimate appropriate standard errors. Sim-
ple and multiple logistic regression were
used to evaluate the individual and the si-
multaneous impact of all predictors. Crude
and adjusted odds ratios (ORs) and 95%
CIs were calculated using RTILOGrT,3
another Statistical Analysis System proce-
dure that incorporates the National Health
Interview Survey weights and sample de-
sign. We did not test for statistical signifi-
cance of interactions; rather, we evaluated
two-way interactions between age, race,
and income by examining the differences
between stratum-specfic ORs.
All variables that were significant
predictors of underuse in the multiple lo-
gistic regression model were further em-
ployed to produce profiles of high-risk
women. We calculated frequencies of un-
deruse within each stratum defined by ev-
ery combination of pairs and then triplets
of signifcant predictors. The profiles cre-
ated by these variable combinations were
sorted by degree of underuse of screening,
and the profiles of women at highest risk
were identified. In each profile, the num-
ber of US women who were not screened
was estimated using SESUDAAN and in-
corporating the National Health Interview
Survey samplingweights. Because of their
small numbers, women of other races
were excluded from the profile analyses.
Reslts-
Mammography
Table 1 shows the univariate distri-
butions of mammography use by levels of
demographic predictors. More than 60%o
of all women over the age of 40 reported
never having had a mammogram and 86%
had not had one in the past year. There
were substantial differences in underuse
within levels of vitually all demographic
variables. In the univariate analyses, the
strongest predictor of underuse of mam-
mography screening was low income. Al-
most 80%o of women below the poverty
level had never had a mammogram, com-
pared with 50%o of women in the highest
income category (crude OR = 3.5; 95% CI
= 2.8, 4.4). In addition to income, fewer
than 12years ofeducation, other race, and
age greater than 65 years significantly pre-
dicted underuse of mammography screen-
ing. Weaker associations were seen for
women living in rural (non-metropolitan
statistical area) areas, widows and women
who had never married, Hispanicwomen,
Blackwomen, women living in the South,
and women not in the labor force.
After simultaneously controlling for
all predictors in the multivariate logistic
model, five characteristics remained sig-
nificantly associated with underuse of
mammography screening (Table 1). Other
race strongly predicted underuse (adjust-
ed OR = 2.3, 95% CI = 1.3, 4.1 for never
having had a mammogram; OR = 3.4,
95% CI = 1.3, 9.0 for not having had one
in the past year). Income remained a
strong predictor; women at low and mod-
erate income levels were less likely to
have received screening services than
women in the highest income category.
The magnitude of this association in-
creased as income level decreased, with
women below the poverty level at greatest
January 1993, Vol. 83, No. 1
 Mammography and Pap Smear Screening

risk of underuse (OR = 2.3; 95% CI = 1.8,

2.9 for never having had a mammogram).
A similar gradient existed for education.
Hispanic ethnicity, age greater than 65,
and residence in a rural area also remained
significant in the multivariate model; how-
ever, Black race did not predict underuse
in this model. In both the multivariate and
univariate analyses, the patterns of risk
across levels of demographic variables
were very similar for never having had a
mammogram and for not having had one
within the past year.
We studied 102 profiles of women
based on all pairwise combinations of lev-
els of the five significant predictors. In the
group of women at highest risk (those with
income below poverty level and living in a
rural area), 82% had never had a mammo-
gram. In the group at lowest risk (those
with income above 300% of PL and with
more than 12years of education), 44% had
never had a mammogram. In each of the
17 highest risk profiles (Table 2), at least
74% of the women reported never having
had a mammogram. For each profile, Ta-
ble 2 shows both the percentage of women
who reported never having had a mam- Percent~M
mogram and the number of women in the 10Percent
100
United States within the given profile es-
timated to have never had a mammogram. 90_
The profiles are not mutually exclusive;
women may be represented in more than a 70
one. Because of their small numbers,
women ofother races were not subdivided
further in the profile analysis. Over 74% of so _
all such women-an estimated 686 523
women nationwide-had never had a White BSlak Hispanic
mammogram.
More than 80% of White women be- Percent
100
low the poverty level had never had a
mammogram (profile 3). Nationwide, this
represents over 2 million women. Women
with less than a high school education
(profiles 4, 8, and 10) were in a high-risk
profile at all income levels except the high-
est. Rural women who are poor (profiles 1
and 5), aged 65 years or older (profile 14), Hispanic
or have little education (profile 6) were
76 White lack
greatly underserved. The largest single
group was women aged 65 or older with
less than a high school education (profile _income 'PL _Income 200% PL EJincome 800% PL innccue 4300% PLe
11); this proffile represents more thanS mil- NI. PL = povery leb.
lion women estimated to have never had a
mammogram. FIGURE 1- Women aged 40 and olderwho had never had a mammogram and who had
The influence of income on use of not had a mammogram in the pastyear, by race and income level, National
Heafth Inberview Survey, 1987.
mammography services differed some-
what by race, making White women be-
low the poverty level less likely to be ever, among Black and Hispanic women, peared to offer less of an advantage for
screened than Black and Hispanic women women below the poverty level appeared Hispanic women than for White or Black
to be less underserved than women just women (Figure 1). No substantive inter-
below the poverty level (Figure 1). Among
White women, as income decreased, above the poverty level. Also, high in- actions were observed between income
(above 300%o of poverty level) ap- and age or between age and race.
screening consistently decreased. How- come

American Journal of Public Health 55

January 1993, Vol. 83, No. 1
Cale et aL
Table 3 lists all the three-way profiles
in which 80%o or more of the women re-
ported never having had a mammogram.
As the profiles are more narrowly defined,
the number of US women in each one is
smaller than in the two-way profiles, but
the proportion of women who had never
been screened is higher. In the most un-
derserved profile (women at 200% of pov-
erty level, aged 40 to 49, and rural), more
than 85% had never had a mammogram.
The largest single group was White
women below the poverty level with fewer
than 12 years of education (profile 8); 83%
of this group had never been screened.
The characteristics of women who had no
mammogram in the past year were very
similar to those of women who had never
had a mammogram.
Pap Smear Screening
Among all women over the age of 18,
9% reported never having had a Pap
smear; however, 62% had not had a Pap
smear in the past year (Table 4). As with
mammography screening, usage varied
greatly across levels of the demographic
variables examined. More than 20% of
Hispanic women and 35% of women of
other races, as well as 25% of never-mar-
ried women, had never had a Pap smear.
In the univariate analysis, the strongest
predictors of never having been screened
were race (other: crude OR = 7.0,95% CI
56 American Journal of Public Health
= 5.1,9.8; Hispanic: crude OR = 3.4,95%
CI = 2.6, 4.4); marital status (never mar-
ried: crude OR = 6.8, 95% CI = 5.4, 8.6;
widowed: crude OR = 4.2,95% CI = 3.4,
5.0); and income (below poverty level:
crude OR = 3.8, 95% CI = 3.1, 4.8).
Weaker associations were seen for fewer
than 12years of education, 65 years of age
or older, unemployment, and residence in
the central city or the Northeast.
Screening patterns across levels of
demographic variables were quite differ-
ent for never having had a Pap smear and
not having had a Pap smear in the past
year (Table 4). Never having been married
and being of other race were strong pre-
dictors of never having been screened but
were not signifcant predictors of not hav-
ing had a recent Pap smear. Older age-
both 40 to 64 years and, most importantly,
65 years and older-were important pre-
dictors of not having had a recent Pap
smear. And association of income with
screening in the past year was not as
strong as it was with never having been
screened.
When all demographic predictors
were included in the multivariate model,
five remained significantly associated
with underuse of Pap smear screening
(Table 4). Other race (OR = 9.1; 95% CI
= 5.7, 14.6) and never-married marital
status (OR = 8.4; 95% CI = 6.5, 10.8)
remained the strongest independent pre-
dictors of never having had a Pap smear;
Hispanic ethnicity, age 65 years or older,
and education of fewer than 12 years
were also strong independent predictors.
Income below the poverty level remained
significantly associated with never hav-
ing had a Pap smear (OR = 1.6; 95% CI
= 1.2, 2.2), but it appears to be a weaker
predictor than the other variables in the
model. In the multivariate model, Black
women were significantly more likely to
have had a Pap smear in the past year
than White women (OR = 0.7; 95% CI =
0.6, 0.9).
The two-way profiles for never hav-
ing had a Pap smear were strongly influ-
enced by the two strongest predictors,
marital status and race (Table 5). Thirty-
nine percent of never-married Hispanic
women reported never having had a Pap
smear (profile 1). The high risk for never-
married women was relatively constant
across income levels (profiles 9, 15, 16,
and 18) and existed for both White
women (profile 12) and Hispanic women
(proffle 1). (Never-married Black women
did not appear to be at high risk; only 12%
had never had a Pap smear.) Both Black
women and Hispanic women aged 65 and
older were at high risk of never having
had a Pap smear (profiles 5 and 8). The
largest groups of high-risk women were
never-married women aged 18 to 39 (pro-
file 14) and never-married White women
(profile 12).
The disadvantage of Hispanic
women compared with White and Black
women can be seen at every income level
(Figure 2). As with mammogaphy use,
poor White women were more likely to
have never had a Pap smear than poor
Black women. No substantive interac-
tions were observed between income and
age or between age and race.
While women of other races were not
subdivided further in the profile analysis,
they are a severely underserved group re-
gardless of income or age. Nearly 35% of
all such women-an estimated 898 036
women nationwide-had never had a Pap
smear.
The large group of never-married
women aged 18 to 39 was further subdi-
vided into smaller age ranges to see if the
risk was constant across age within this
group. In fact, the high risk was limited to
the youngest women, those aged 18 to 24;
33% of these women had never had a Pap
smear yersus about 10%of women aged
25 to 39. This relationship of highest risk
with young age was seen in each race
January 1993, Vol. 83, No. 1
 amogapy and Pap Smear Saeeng
group, although the absolute levels of risk
varied considerably across races.
Table 6 shows all three-way profiles
in which at least 34% of the women in the
group had never had a Pap smear. The
group at highest risk (profile 1) was His-
panic, aged 65 and older, and living below
the poverty level. The largest high-risk
group was never-married White women
living below the poverty level (profile 20).
Profiles showing groups at highest
risk of having had no Pap smear in the past
year were strongly influenced by older
age. More than 91% of women aged 65
years or older and living below the pov-
erty level had not had a Pap smear in the
past year. Older women hving at 200%
and 300%o of the poverty levelwere also at
high risk, as were olderwomen of all races
and all marital statuses. The largest single
group was White women aged 65 years or
older; close to 11 million USwomeninthis
profile had not had a Pap smear in the past
year.

Discussion
This study identifies great variability
across levels of basic demographic char-
acteristics in the tendency of women to
underuse screening technologies. It also
shows that the importance of these char-
acteristics differs for mammography
screening versus Pap smear screening, as
well as for women who have never been
screened versus women who have not re-
cently been screened.
Income is an important predictor of
mammography use; women below the
poverty level are at greatest risk of under-
use, but women of low and moderate in-
come are also underserved. Although
White race alone is not a risk factor for
underuse, White women below the pov-
erty level are less likely to be screened
than poor women of other races. Among
non-White women, those below the pov- the disease.24 Screening services need to Although guidelines for breast cancer
erty level are better screened than those be extended to include women with low to screening differ for women aged 40 to 49
just above the poverty level. This may re- moderate income. and women aged 50 to 64,25 there are no
flect greater availability of screening serv- Although Black race appears to be a differences in use between these two age
ices to minority women with income low risk factor in the univariate analysis, this is groups for ever having been screened or
enough to meet program-related poverty not the case in the multivariate analysis. for having been recently screened. It is
criteria. It may also reflect a greater em- When other potential confounders are in- possible that women over age 50 have
phasis on providing services to poor mi- cluded in the model, Black women are been screened more frequently than
nority women, under the assumption that very similar to White women in their use women under age 50; the available data do
White women are not underserved. While of mammography, both ever and recent. not allow an estimate of total lifetime fre-
the overall incidence of breast cancer is However, Hispanicwomen andwomen of quency of screening. However, the data
higher among women of high socioeco- other races are not receiving mammogra- may mean that the screening behavior of
nomic status, there is evidence to suggest phy services at levels comparable to those these two age groups is, in fact, the same.
that women of low socioeconomic status of White or Black women. These women Older women (aged 65 and older and es-
are less likely to be diagnosed with early- appear to be relatively underserved re- pecially those living below the poverty
stage disease and are more likely to die of gardless of income level. level, those with low education, or those

January 1993, Vol. 83, No. 1 American Joumal of Public Health 57

CaRe et aL

tivity. If underuse ofscreening is limited to

never-married women who are not sexu-
ally active, it may not represent a public
health problem. The fact that the high risk
among never-married women aged 18 to
39 is actually limited to those aged 18 to 24
supports this possibility. However, esti-
mates from national surveys indicate that
more than 50%o of White women, 80% of
Black women, and 40% of Hispanic
women are sexually active by the age of
19.27 28 Moreover, 75% of never-married
women between the ages of 20 and 24 are
sexually active.29 Studies of sexually ac-
tive adolescent females have found evi-
dence of cervical human papillomavirus
DNAin 10% to 38% of women tested.3-32
Higher rates of this infection are typically
found in younger women and in women
who have had greater numbers ofsex part-
ners. Both the importance of human pap-
illomavirus infection as a precursor of cer-
vical neoplasia and the frequency of this
infection in young female populations sug-
gest that women should begin regular
screening programs while in their teens or
as soon as they become sexually active. It
is clear from the results of the present
study that never-married women in gen-
eral and, more specifically, never-married
so
Percent White women, Hispanic women, women
under age 25, and women aged 65 and
older are not receiving Pap smears. These
25 _ women deserve further study both to de-
termine whether their marital status is a
a
0
a 20 _ surrogate for sexual activity and/or access
to screening in conjunction with obstetric
i. care, and to target them for intervention if
161
s
appropriate.
Hispanic and other-race women ofall
101- ages and all income levels are at vety high
risk of never having had a Pap smear. Un-
5
fortunately, Hispanic and Native Ameri-
can women of all ages are also at high risk
of invasive cervical cancer when com-
OL pared with White women.33-34 These se-
White Black Hispanic
verely underserved women at high risk of
Income 'PL aIncome 200% PL riIncome 800S% PL inIncome 400% PL disease should also be targeted for appro-
R PL povrty Wm.
= priate intervention programs.
Women aged 65 and older are an-
FIGURE 2-Women aged 18 and older who had never had a Pap smear, by race and other group needing focused, effective in-
Income level, Natonal Health I r Survey, 1987. tervention programs to increase their lev-
els of Pap smear screening. Such women
in rural areas) are less likely to receive than 40%1 in very poorly served groups. represent a very large target group in the
services. At the same time, they are at One of the strongest predictors of never United States (close to 15 million)who are
higher risk of developing breast cancer. having been screened is never having been also at high risk of cervical cancer.35
Thus, there is a special need to develop married. The interpretation of this predic- Within this group, older Blackwomen are
screening programs to reach these tor is problematic. Major risk factors for extremely disadvantaged relative to their
women. cervical cancer include multiple sexual young counterparts and are also at great
While 9% of all women have never partners and early age at first inter- risk of disease. Older age is a stronger risk
had a Pap smear, this percentage varies course.26 Unfortunately, the 1987 Na- factor for not being screened in the past
substantially by demographic group, from tional Health Institute Survey supplement year than it is for never having been
less than 1% inwell-served groups to more does not contain information on sexual ac- screened. This implies a decrease in reg-

58 American Journal of Public Health January 1993, Vol. 83, No. 1


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n.S:
S~t
..:Z.raul
i>N
.::S
-:Z :ES>;Z;s;,'s-Z>..
2.S:S.>:;
;::S>:-:!!;
2:S>:- ;.!!>.!;!.;.;!.>..
;'*;
'.."
s
1PsS:ZSS5s
:: :fS:S. St.Sff-:fS::::WS 44.R::S .':
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::::fi' 371:
8 S.,hp...44,-
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ularity of screening among women of this
age group, probably due to a decrease in
regular gynecologic examinations. The
low levels of recent Pap smear screening
at older ages may also be partiaLly related
to the high prevalence of hysterectomies
in older women.36
These results are based on data col-
lected in 1987. For mammography screen-
ing, recent studies indicate that usage has
increased greatly in the past several
years.37 (For Pap smear screening, no dra-
matic changes in recent years have been
reported.) However, we do not know if
these welcome increases are uniform
across demographic profiles, are more
prevalent in high-risk groups (where
change is most needed), or are concen-
trated among women who are already re-
ceiving the greatest proportion of avail-
able services. The 1987 data provide a
good baseline of demographic disparities
in screening againstwhich to measure cur-
rent and future gains. E]
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60 American Journal of Public Health Januaiy 1993, Vol. 83, No. 1