In 2018, Mexico's government estimated that 44.4 percent of Mexico's population lives in moderate poverty and 7.4 percent lives in extreme poverty . It is hard to estimate the correctness of these figures, but it can be assumed that the figures are not vastly different at the present date i.e. a large proportion of the population lives in poverty in Mexico. This fact is most important and may explain several of the findings in the present investigation. The MMa area is not representative of all Mexico in socioeconomic and cultural terms since Mexico is extremely diverse. Consequently, no single area reflects all Mexico. However, the principal factors can be extrapolated to the whole of Mexico.
A systematic review of barriers and facilitators to mammography attendance in Hispanic women showed that financial barriers and social characteristic were significant predictors of mammography attendance. This finding was similar to those found in other populations with LI women i.e. it is not unique to Latinas . In terms of mammography screening, there are a very few Mexican studies on LI women [23,24].and only a few studies on middle or upper-income Latinas living in the United States .
Barriers to attend mammography screening for Latinas living in the United States include lack of health insurance, the cost, lack of information, and limited access to treatment . These barriers seem to be very similar in Mexico and are in fact related to financial issues. Further complicating are the cultural factors associated with Latino women adding barriers to screening attendance.
The MMa mammography screening services are deficient  and appear to remain deficient (2019). This despite that MMa has the highest average income in Mexico and the most developed healthcare in the country.
Regarding the public conditions for national mammography screening and BCa treatment recommendation programs, Mexico does not have a national cancer register, precluding data sharing between public screening facilities or sharing from public to private healthcare institutions. There are no central monitoring and evaluation, nor documentation of BCa treatment outcomes. In case any monitoring exists, it is not systematic.
The BCa prevention programs in Mexico are fragmented, continue to be only limited to geographic areas and for short duration [17,25]. There are no comprehensive public reports that could provide information on the number, type, and scope of Mexican/Latin American BCa prevention programs .
Missing answers of the participants. The vast majority of the women irrespective of their socioeconomic status positively received the questionnaire. However, there were some questions that the subjects could not or did not want to answer. Most missing answers were about the mammography attendance, first mammogram, and age at first attendance. About one third in the LI group and one fifth in MI group did not answer. Other questions with missing answers were; whether lack or faith in God could cause the BCa (40%, in both groups), question on fatalism (51% LI, 16% MI), questions on the insurance status (41% LI and 63% MI) and, who paid for the health care (49% LI and 35% MI). The interpretation could be that they simply did not remember about mammography attendance and the financial questions were either in some way embarrassing or they did not remember. Questions regarding faith in God and relation to the BCa and fatalism appeared to be sensitive issues with missing answers especially among LI women.
Women secrecy. The participants paid great importance to the confidentiality of their answers. That was even the reason for the few women that refused to participate claiming that “My health it’s a very confidential matter”. Women with Mexican ancestry in USA responded actually with the same phrase in another screening barrier study .
Breast Cancer. The LI women were diagnosed at middle age (average 52 years) while MI women were diagnosed at upper middle age (average of 59 years). Maffuz et al. studied Mexican BCa patients from the center and south of Mexico and found that the average age of BCa diagnosis was 53 years while in Europe and US, the mean diagnosis age was 63 years .
Breast Cancer screening. In the USA in 2015, 65.3 percent of women aged 40 and over had a mammogram in the previous 2 years . In MMa, ~61 percent of the MI and LI women had a mammography during the last 2 years and a ~27 percent of women (both groups) never did a mammography. Its most probably among the highest attendance in Mexico. It can be anticipated that corresponding figure in rural areas would approach zero. WHO states that for a screening program to be effective, it must cover at least 70 percent of the intended population .
Knowledge about mammography. Seventy-three percent of the women considered themselves to be well informed about BCa and mammography. However, there were frequent misconceptions about the causes of BCa, e.g., ~ 47 percent believed that physical trauma could cause BCa and ~53 percent believed that mammography itself could cause BCa. Some of the official mammography recommendations in MMa were not up to date (frequency of examinations). Our search on the web information from MMa hospitals (public and private) showed that info was not up to date and sometimes even inaccurate. This results in "opportunistic" mammographic screenings that fail to comply with up to date international guidelines .
A Mexican study found that the dissemination of BCa information, both to the general population and to health providers, was deficient . Consequently, there is a large general knowledge deficiency regarding BCa among the population, but also among the health care providers.
Women´s socioeconomic situation. Only 24 percent of the women paid themselves their health care costs. Thirty-five percent of the women raised their children alone. Their financial dependence from spouse/partner, family or friends can be an obstacle for seeking early medical care. Women in financial dependence do not have decisional power of their lives and they have to stay under submission of the family or partner. The women assume family obligations, working at early age contributing to household economy. As a consequence, they leave school early resulting in low education level. Women living MMa area have the best working income and medical accessibility (private/public) with more hospitals and clinics per capita that the rest of the country. However, they continue struggling with mammography payments even when having the Popular Security (SP) insurance. The SP was established 2007 has increased the access and adherence to medical treatment . However, it covers only a fraction of the population with the lowest income, approximately 60 percent of the Mexican population . There are additional costs not covered by SP like “Out of the pocket payments” and needs from private health services, despite the SP . In January 2020, the SP was replaced officially by the Institute of Health for Well-being insurance (Insabi). In August 2020, Insabi was still not completely implemented in MMa/ Mexico. Noteworthy is that Insabi only covers between 40-60% of the costs for major conditions as cancer and subsequent treatments.This limitation of Insabi might appear discouraging to attend cancer screening “since you anyway cannot afford treatment” if diagnosed with cancer.
This study shows that a 71 percent LI and 34 percent the MI group of MMa women were covered by the SP. Even the MI group of women uses the SP because of the high costs for medical care. For mammography, 38 percent of the women complain high costs. In general, the women cannot afford to pay for diagnoses and subsequent treatment. Instead they give priority to their children and their health care expenses. The minimum wage in Mexico is among the lowest in all Latino-America with 5.1 $USD/Day from 1960 to 2019  (increase to 6.36 $USD in 2020). Mexican MI spend approximately 50 $USD by month in medical services .
The mammography cost in MMa was 21 to 140 $USD (May 2020). That means that the cost for one mammogram corresponds to 4 to 27.5 days woman income. Only two state hospitals in the MMa area offers mammography without cost until December 2019.
The result of the MMa women economic shortages is that approximately 70 percent of the women neglect their own health and seek medical care only when they are sick i.e. have disease symptoms. For the women that live in poverty/extreme poverty in the south of Mexico (10 times lower income) where access to health care is very limited, the situation is of course much more serious.
The mammography organization in Mexico is inefficient benefitting only a socioeconomic fraction of the population. As a consequence, available statistics show that a high percentage (68%) of the BCa patients come late for medical attention resulting in high treatment costs and low overall survival. To improve this, radical changes are needed, e.g. free mammography and free treatment when needed, a central cancer prevention institution with single data register and broad information programs regarding the importance of early detection of BCa.
Fear as mammography barrier. On average, 56 percent of women (both groups) hesitated to tell their spouse about “breast related problems”. BCa diagnosis induces life changes for the women, their families and their spouses/partners. BCa Interventions should also involve spouse and family .
Fear of pain during mammography was an important issue for ~67 percent of the women. Mammography staff could resolve this fear through appropriate training to properly address the women fears/concerns. Fear of cancer induced by the mammography itself (radiation) is another misconception to resolve through proper information .
This study shows that some women did mammography before the age of 40, which constitute a risk for incorrect diagnosis and subsequent overtreatment .
Religious faith influence on health behavior. The majority of the Mexican population belongs to the Roman Catholic Church. The religion is a prominent part of the socio-cultural life and can impact the attendance to health care programs (e.g. faith-based prevention programs) [37,38]. Women high degree of faith-related fatalism cause passive behavior and is a barrier for seeking help for health-related issues. We did not expect a so important association from the religious believes to health behavior. Typical remark of 70 percent of MMa women was, “We die when our time comes”. Another faith related answer from 25-50 percent of the MMa women was that “Lack of faith cause cancer”. Both are examples of a passive relationship with God, transferring to God the responsibility of their own health. In general, the first reaction to health problems was to pray, and wait for divine healing, thus delaying diagnosis and treatment. This was reflected in ~80 percent of the women answering, “Our future is in God hands”.
Previous studies indicate that a delay of ≥ 3 months is associated with more advance BCa which results in increased BCa mortality [39,40]. One study done in the USA on Latina women, also identified cultural beliefs as “Faith in God can protect me you from breast cancer” (48%) precluding BCa screening attendance .
One limitation of this study is the diversity of Mexico, making it very difficult to extrapolate results from one part of the country to another. However, the two principal findings appear to be general for all Mexico.