The Impact of Race, and Insurance Status on Breast Cancer Screening: Results from the Behavioral Risk Factor Surveillance System Data

Breast cancer is the second major cause of cancer-related death of women in the United States 1 , yet current gaps exist in breast cancer screening for minority women 2 . The purpose of this study is to address these gaps by assessing the relationships among race, health insurance coverage, and breast cancer screening in a nationally representative sample of women. A cross-sectional descriptive analysis of the 2018 BRFSS survey data was used to meet the study purpose. BRFSS participants who declared themselves to be of female sex and who were adults with the age ≥ of 40 years were selected for inclusion. Data were analyzed using SPSS version 26. Exploratory and descriptive analyses were performed, followed by comparative analyses based on the variable type. Relationships between race, insurance status, and mammogram screening were examined. Chi-square, logistic, and multinomial logistic regression were used. the


Introduction
Breast cancer is currently the second major cause of cancer-related death for women in the United States 1 . Notwithstanding its limitations, mammography remains the only screening test for breast cancer advocated by the United States Preventive Services Task Force and the American Cancer Society, thus, currently, the most effective screening exam to decrease breast cancer mortality 3 . The American College of Radiology (ACR) has advised yearly mammography screening commencing at age 40 for females with a normal risk of developing breast cancer 2 . Mammogram screening has reliably decreased breast cancer mortality by approximately 40% since 1990 and most of this improvement is ascribed to early detection 2 . Although the national efforts by the Center for Disease Control and Prevention and the Breast and Cervical Cancer Early Detection Program were effective in increasing breast cancer screening rates, there are still substantial disparities in breast cancer screening utilization and breast cancer mortality among racial and ethnic minority women 4 .
Factors such as paucity of socioeconomic resources and limited access to healthcare have led to inequalities in the care of underprivileged populations 5 . Compared with their White counterparts, racial and ethnic minorities women experience more underinsurance or lack health insurance coverage completely 5 . The disparity in insurance status and the resulting decrease in access to care stems from social determinants of health and results in a lower adherence to breast cancer screening recommendations 4 . Lower rates of screening mammography result in diagnosis of cancer at a later stage disease and impacts survival rates 4 . Recognizing social determinants of health that cause delays in care accessibility may lead to individualized interventions mainly targeted to increase adherence to mammogram screening; hence, improving health outcomes for women who experience health inequality.
The purpose of this study is to examine the relationship of race and health insurance coverage on screening for breast cancer by using the data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, in a nationally representative sample of adult women.

Data Source, Ethical Conduct of Research
The BRFSS is a recurrent cross-sectional survey carried out with technical and methodological aid from the Centers for Disease Control and Prevention (CDC) 6 .The BRFSS data was initially devised to assist the nation in its data gathering efforts in order to obtain a comprehensive view of state and local data for health program development. Since 1984, the CDC began to conduct yearly health-related telephone survey in the United States and its territories to collect data on health behaviors, chronic diseases, health care accessibility, and the use of health services. State health organizations jointly work together to develop the survey and conduct the interviews themselves or through the assistance of contractors.
Participants' samplings are performed through the random digit dialing from commercially accessible phone catalogs. Once consented, participants take part in the survey using Computer-Assisted Telephone Interviews (CATI) system 6 . Cellular surveys use the Telecordia database of telephone exchanges and 1000 banks to arbitrary choose telephone numbers. Once gathered, 2018 data was processed, aggregated, weighted by the CDC and made openly accessible for analysis on the CDC website. The 2018 BRFSS data was retrieved and an analysis of the relationships between race, insurance status, and screening for breast cancer was performed. Due to the de-identi ed freely available national data used in this analysis, Institutional Review Board review was not sought or required.

Study Population and Sample
For the present analysis, the populations of interest were noninstitutionalized adult females ≥ 40 years since the recommended mammograms screening starts at age 40. Exclusion criteria included men, women younger than 40 years of age, transgender individuals, institutionalized female population, and women of unknown race.

Descriptive Variables
The current study consisted of female survey participants ≥ 40 years who responded to questions in the Breast and Cervical Cancer-Screening module of the BRFSS (Sect. 14 of the 2018 survey) 6 .

Race
Race was collected as a categorical variable and provided in the dataset via the following categories: (White, Black, Hispanic, Other (Asian, American Indian or Alaskan Native, Native Hawaiian or others Paci c Islander, others race, multiracial).

Marital status
Marital status was collected as a categorical variable and provided in the dataset via the following categories: Marital status (Married, Divorced, Widowed, Separated, Never married, A member of an unmarried couple).

Employment
Employment was collected as a categorical variable and provided in the dataset via the following categories: (Employed for wages, Self-employed, Out of work for 1 year or more, Out of work for 1less than 1 year, A homemaker, A student, Retired, Unable to work).

Education
Education was collected as a categorical variable and provided in the dataset via the following categories: (Never attended school or only kindergarten, Elementary, Some high school, High school graduate, Some college or technical school, College graduate).

Independent variables
Primary Health Insurance Coverage Primary Health Insurance Coverage was collected as a categorical variable and provided in the dataset via the following categories: (A plan purchased through an employer or union, A plan that you or another family member buys on your own, Medicare, Medicaid or other state program, Tricare formerly champus VA or Military, Alaska native, Indian health service, tribal health services, Some other source, None No coverage).

Race
Race was collected as a categorical variable and provided in the dataset via the following categories: (White, Black, Hispanic, Other (Asian, American Indian or Alaskan Native, Native Hawaiian or others Paci c Islander, others race, multiracial).

Dependent variables
Mammogram screening was collected as a categorical variable and provided in the dataset via the following categories: (Have You Ever Had a Mammogram: Yes and No).

Results
After cleaning and screening the data, the nal sample for this analysis included 16,147 female participants aged between 40 and 74 years. Most of the participants were married (58.2%), had less than a 4 year college degree (61.1%) were employed for wages (40.5%) or retired (30.0%), had an income of less than $75,000 (58.4), had a mammogram in the past two years (76.1%), were White, non-Hispanic

Race and Mammogram
A signi cant relationship between race and having a mammogram in the past two years was found (χ2(6) = 92.06, p < 0.01). The detailed results of the chi square analysis are found in Table 2 below.

Healthcare Coverage and Mammogram
A signi cant relationship between healthcare coverage and whether participants had a mammogram in the past two years was found (χ2(5) = 84.00, p < 0.01). The detailed results of the chi square analysis are found in Table 3 below.  (7) = 92.29, p < 0.01). The model as a whole explained 1.0% (Nagelkerke R 2) of the variance in mammograms performed in the past two years and correctly classi ed 76.1% of cases. As shown in Table 4, only three races made a unique statistically signi cant contribution to the model. However, the odds ratio indicated that Black only -non-Hispanic and American Indian or Alaskan native only non-Hispanics were less likely to have a mammogram in the past two years when compared to White only, non-Hispanics. (Nagelkerke R 2) of the variance in mammograms performed in the past two years and correctly classi ed 76.1% of cases. As indicated in Table 5, only two health coverage plans made a unique statistically signi cant contribution to the model. However, the odds ratio indicated that participants with a plan that they or another family member bought on their own and participants with Medicaid or other state program were less likely to have a mammogram in the past two years when compared to participants who had a plan purchased through an employer or union.

Discussion
The current study revealed a relationship between obtaining mammography screening and multiple factors including race and lack of adequate health insurance coverage. Regular screening for breast cancer, including annual mammograms and breast exams by a quali ed medical expert is crucial for early detection of breast cancer 2 . However, the social determinants of health such as age, race, income, and insurance status are impediments that could constitute barriers to carrying out the recommended guidelines for screening. Social determinants of health are in uential factors of healthcare utilization and this association has been demonstrated in the literature previously 7; 8 . Since the ndings of the present investigation were obtained by using a large national sample exploiting data from a national survey (BRFSS) with known higher response rates, there is a smaller margin of error in examining relationships for hard to reach populations such as minorities. In addition, the random sampling of the participants via random digit dialing from commercially available phone lists increases the generalization of the results.
Hence, the sample is representative of the larger national populations and is less likely to be subject to bias.

Race and Mammogram
This analysis found a signi cant relationship between race and having a mammogram. Black women were less like to have a mammogram in the past two years when compared to other races. Existing evidence indicates that racial and ethnic minority women are prone to experience delays in treatment, as well as lower than recommended rates of mammogram screening 9 . This delay in diagnosis and treatment for black women leads to an increased rate of diagnosis at a later-stage breast cancer and subsequently leads to an increased morbidity and mortality rates 8 .

Insurance status and Mammogram
The role of adequate insurance coverage was identi ed in this study as important in access to Mammogram screening. Women having employer or union purchased health insurance coverage were more likely to have a mammogram in the past two years when compared to women who were underinsured through state or state subsidized insurance programs. This nding supports currently available literature linking social determinants of health with preventative screening 9 . The ndings of this analysis are consistent with the ndings of a retrospective chart review of 157 women ages 40-75 years 10 . Of the patients who were able to get their screening mammograms performed in Khali and colleagues 'study, 84.5% utilized BRIDGE healthcare clinic's program (student-run free clinics). Therefore, this study substantiated the evidence that volunteer providers such as student-run free clinics play an essential part in expanding uninsured patients' access to mammograms. Consequently, facilitating access to care and increasing access to payment for breast cancer screening through innovative programs may be linked with screening mammography compliance and subsequently earlier diagnosis of breast cancer 11 . Thus, healthcare coverage and accessibility are essential tools required for successful health prevention campaigns 10 .

Race, Insurance Status, and Mammogram
The combined impact of race and adequate insurance coverage was found to be signi cant with having a mammogram. While a secured source of health coverage increased the prospect of having a mammogram, race was also important. White women and their Black counterparts were more likely to have a mammogram when compared to other races. Similarly, in a previously published systematic review, White women were more likely to have adequate health insurance coverage when compared to other ethnic minority women 11 . This investigation has provided evidence that obtaining a screening mammography exam is related to both race and insurance coverage. Hence, a major role in healthcare accessibility such as paying for recommended healthcare services can be nancially draining for individuals with income scarcity and lack of adequate health insurance coverage. Thus, having access to care and having an adequate insurance coverage may be linked with the likelihood of getting a screening mammography and consequently earlier diagnosis of breast cancer 11 .

Social Determinants of Health
These ndings support that the social determinants of health such as marital status, education, employment, and having adequate health insurance may be important related to having screening mammography. As it was established in prior research, these social determinant aspects were found to be prominent factors of healthcare utilization 12; 13 . Comparably to the ndings of the existing study, being married, having a university education were among positive predictors for mammography uptake (66.8 %) 14 . Likewise, another study revealed participants with a higher education were signi cantly more likely to adhere to the recommendations of breast cancer screenings 15 . Similarly, published evidence that employment was also a determining factor for participating in mammogram 16 . Moreover, having a usual source of healthcare and a woman's geographical location were associated with timely screening mammography 9 . Having a consistent source of care increased the likelihood of acquiring preventive health education and an annual breast cancer screening as recommended 17 . Furthermore, women of color differ from their White counterparts in the degree to which increasing socioeconomic resources is correlated with increasing cancer screening utilization 18 .

Future Clinical and Research Implications
Breast health awareness is a fundamental part of health promotion and a key factor in early stage breast cancer detection. However, the importance of a yearly screening mammogram remains limited and not adequately practiced among minority women who lack consistent health insurance. Factors such as ethnicity, socio-economic status, and geographical location are in uential assessment ndings to be considered. For clinicians, assessing for these social determinants of health may contribute to mammography adherence. Assisting women to overcome these barriers may increase breast cancer screening and early detection. In addition, providing education about an individual risks and barriers to obtaining screening and subsequent treatment could also increase the mammography adherence rates and early intervention if needed.
As per the Association of Women's Health, Obstetric and Neonatal Nurses' (AWHONN) advocacy and recommendations, it is necessary to provide resources and education to women's health nurses so they can be better equipped to assist female patients with their breast health 19 . Subsequently, taking into consideration the particularities presented by each participant, and proactively encouraging individuals on the health advantages of cancer preventive services could raise awareness and consequently improve mammogram screening rates 9 . Future policy work should focus on nding means to expand healthcare accessibility and involvement in disadvantaged populations. Breast cancer awareness can be improved and eventually breast cancer disparity reduced by developing a community-based participatory approach and a culturally responsive breast cancer screening program 20; 21 . Through their contribution, practicing nurses empower women by encouraging them to take active roles in monitoring their own breast health.
Therefore, practicing nurses assist in improving outcomes of care, and simultaneously contribute in shrinking the gap and apparent disparity in cancer diagnosing and treatment 19 . Healthcare providers' counseling and suggestions about mammogram screening and recommended national guidelines 9 serve as a preliminary point for exploring some of the socio-demographic, health-related, and circumstantial characteristics that obstruct timely screening mammography 22 . Future research should continue to focus on the impact of social determinants of health on access and outcomes of care.

Limitations
Although the BRFSS dataset is a sizeable nationwide representative sample, this study does have shortcomings. Using the BRFSS dataset, to conduct a secondary analysis constrained the investigator to the sampling measures and the data at hand. The cross-sectional design limits establishing any causal relationships between Race, Health Insurance Coverage, and Breast Cancer Screening. Since the BRFSS is a telephone survey, potential participants who live in households without telephone coverage, may be excluded. Furthermore, The BRFSS relies on self-reported data obtained from the participants which may be sources of possible error that could result in some misclassi cation of the variables: age, race, education, income, employment, primary health insurance coverage, and mammogram screening.

Conclusion
This study discovers that race and insurance status have an impact on breast cancer screening. The results of this study provide further evidence that having health insurance coverage facilitates access to preventive care for women. Since mammography screening rates continue to be lower than recommended in patients with low socioeconomic status, these results will be foundational to a developing a program of research focused on increasing access to care and eliminating healthcare disparity in ethnic minority women with breast cancer. Identifying and understanding these in uences will be key to the development of interventions aimed at increasing healthcare availability in this population.
Through individualized patients 'care plans, education, and awareness, practicing nurses can empower racial and ethnic minority women to adhere to their recommended yearly mammography screening guidelines.