Regular articleRacial, ethnic, socioeconomic, and access disparities in the use of preventive services among women☆
Introduction
Utilization of preventive medical care and cancer screening procedures is associated with reduction in mortality among women [1], [2]. Yet, recent research suggests that between 1993 and 1998 there was no substantial improvement in overall receipt of preventive care [3]. Not surprisingly, Healthy People 2010 includes increasing rates of preventive services [4]. For example, Healthy People 2010 aims to increase the proportion of women aged 18 years and older who have received a Papanicolaou smear (Pap) test within the preceding 3 years to 90% and increase the proportion of women aged 40 years and older who have received a mammogram within the preceding 2 years to 70% [4]. For all adults, Healthy People 2010 includes increases the proportion who have had a blood cholesterol check in the past 5 years to 80% and those who have had a blood pressure test (and know whether it is normal or high) in the past 2 years to 95% [4].
At the same time, Healthy People 2010 has as a central goal the reduction of health disparities. Substantial disparities by racial and socioeconomic characteristics have been documented in rates of use of preventive services. For example, research indicates that racial minorities, such as Latinos, are less likely than white non-Latinos to receive preventive care services including blood pressure checks, Pap smears, and cholesterol screening [5]. Native American women, Asian women, and women of other races are less likely to have mammography than Caucasian, African-American, or Latino women [6]. Mammography and Pap smears are more likely to be used by more affluent, younger, college-educated women [7], [8], [9]. Recent findings from the Community Tracking Study Household Survey show that between 1997 and 1999 while there was an increase in the percentages of white and African-American women receiving preventive care no such increases were noted for Latinas [10]. Socioeconomic inequities in preventive care have been documented not only in the United States but also in other Western countries [11] such as Spain [12], [13], Belgium [14], and Canada [15].
Access to health care may increase rates of use of preventive services. Within the U.S. context, access is closely related to insurance coverage, but also includes type of insurance and having a regular source of care, all of which have may partially explain disparities in preventive services. It has been documented that having health insurance and a regular source of care is strongly associated with receipt of preventive care services including blood pressure screening, clinical breast examinations, mammograms, and Pap smears [16], [17], [18], [19], [20], [21]. With the expansion of managed care, it is suggested HMO enrollees are more likely than enrollees in indemnity plans to receive preventive services [22], [23], [24], [25]. A study on health outcomes of women aged 55 to 64 years shows evidence that HMO penetration positively affects the probability of recent mammography receipt [26]. Among women with health insurance, managed care is also shown to be associated with higher rates of mammography, breast exam, and Pap tests only for specific ethnic groups [27]. However, the effect of managed care on use of prevention services is unclear. An updated literature review of 18 studies published between 1990 and 1998 provides little support to the common assertion that the managed care plan enrollees are more likely than other enrollees to obtain preventive services [28].
While previous studies have shed some light on use of preventive services among women, many of these studies have been restricted to specific subpopulations, regions, sites, or clinics, thus limiting the generalizability of preventive care estimates from these studies. The 1996 Medical Expenditure Panel Survey (MEPS) data have been used to examine use of preventive services; however the studies were restricted to older women who were on Medicare [29] or women who had insurance [27]. Even recent nationally representative studies rely primarily on descriptive data [3], [30], [31]. Exploring beyond descriptive data and understanding the relative influence of socioeconomic status, race, and ethnicity, and access to care inform us about where public health strategies should be targeted.
In this article, we estimate the proportions of women who have received mammograms, Pap smears, blood pressure reading, and cholesterol screening according to the recommendations of the 1996 U.S. Preventive Services Task Force (USPSTF), using a nationally representative sample of women. Using USPSTF guidelines allows us to focus on rates of appropriate level of services use, in contrast to focusing on any use, which may also reflect overutilization by some groups [32]. Rates and disparities in the use of preventive services vary by type of service [33], and one cannot assume that the predictors are identical for all types of services. Examining variation in predictors by type of service can inform policy makers whether strategies that may work in one area would be equally effective in increasing rates of other types of preventive services.
We focus on the importance of race/ethnicity, socioeconomic status, and access to health care (health insurance and usual source of care) in explaining variation in the utilization of preventive services. We hypothesize that the traditionally disadvantaged groups such as racial minorities and women with less education and income will be less likely to receive preventive services. Such disparities in care may occur because of inequity in access to care. For example, compared with white non-Latinos, Latinos are less likely to have insurance or a usual source of care [5], [34]. This article seeks to assess whether such differences in access to care (usual source of care and insurance) and socioeconomic status explain race or ethnic differences within a multivariate framework.
Section snippets
Study population
Our study is based on 6,218 women between 21 and 64 years of age from the household component (HC) of the 1996 Medical Expenditure Panel Survey (MEPS), which provides comprehensive information about health care use and costs in the United States. The HC collects data on approximately 10,000 families and 24,000 individuals across the nation, drawn from a nationally representative subsample of households that participated in the prior year's National Health Interview Survey (NHIS). The MEPS is
Findings
Table 1 describes the characteristics of women included in the analyses of each preventive service and the percentages receiving age-appropriate services. The analyses of utilization of Pap tests and blood pressure screening include all women aged 21 to 64 (columns 1–4). Analyses of mammogram services are limited to women aged 50 through 64 (columns 5–7), while analyses of cholesterol checks are limited to women aged 45 through 64 (columns 8–10). Columns 1 and 2 in Table 1 describe the
Discussion
This article set out to explore the disparities in receipt of preventive services by race/ethnicity, socioeconomic status, and access to health care (health insurance and usual source of care) and whether racial/ethnic disparities can be explained by differences in socioeconomic status or access to care within a multivariate framework. Our results suggest that differences in the utilization of preventive services by racial/ethnic groups differ by type of service. For example, we did not find
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The findings and opinions reported here are those of the authors and do not necessarily represent the views of any other individuals or organizations.