For many women in the United States, the Healthy People 2010 mammography goal (70%) was achieved between 1996 and 2007. Beginning in year 2000, the overall past-two year mammography target was met and remained relatively stable thereafter. Puerto Rican and White women, respectively, reported the highest mammography use which exceeded the screening criterion, and Black and Cuban women had rates that approached the Healthy People 2010 goal.(7
) From 1996 to 2007, Mexican Latinas reported mammography rates that were markedly below (about 10% lower) the Healthy People 2010 goal and the other ethnic/racial groups examined, and remained for the duration. Similar to previous findings, the inequalities for Mexican Latinas we found were largely explained by factors that enable access to healthcare, such as healthcare insurance,(11
) and would not meet our use of the IOM criteria for a healthcare disparity. For Mexican Latinas, lack of insurance coverage lessens the likelihood of having a usual source of healthcare that could decrease opportunities for informed counseling and orders for cancer screening, including mammography.(10
) Lack of healthcare insurance, particularly for foreign-born Mexicans, may further widen the screening divide with other ethnic/racial groups of women. With Mexican Latinas being the largest and most rapidly growing group of Latinos in the U.S., our findings suggest public health efforts clearly specify appropriate targets for reducing ethnic/racial “disparities” in healthcare quality within this vulnerable population. Furthermore, our findings point to potential solutions for decreasing inequalities in cancer screening.
Our findings for Mexican Latinas suggest some reasons for the sustained mammography inequalities. First, the Mexican Latino population has the lowest household income and healthcare insurance rate of all major ethnic/racial groups in the U.S.(29
)As our findings indicate, eliminating insurance inequalities has the potential for reducing the striking and unmoving differences in mammography that we observed between 1996 and 2007. Secondly, it may be that the inequalities in mammography use that we found have been simply overlooked. This could be due to the common practice of “lumping” ethnic/racial minorities.(11
) Specifically, ethnic/racial minorities are not disaggregated in the National Healthcare Disparities Reports, Healthy People goals and most other state and private healthcare quality surveillance systems.(4
) When Latinos are disaggregated as recommended by the IOM report on Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement
) the pattern of ethnic/racial inequality we found herein become apparent.(14
) Current population estimates indicate that Latinos will comprise about one-third of the U.S. population in year 2050 and Mexican Latinos will remain the vast majority of them in the coming decades. Ignoring the changing ethnic/racial composition of the nation in setting healthcare quality and equity goals may ensure that the inequalities we found will persist. As new healthcare quality and equity goals are established, it becomes essential that the sights are properly trained on targeted populations and identification of needs to improve health services. Furthermore, once breast abnormalities are found some evidence suggests that diagnostic delays persist for non Hispanic Black and Hispanic/Latino populations despite health insurance coverage.(34
Furthermore, breast cancer remains a leading cause of cancer death among Latinas, which suggests the need for better cancer screening methods and innovative strategies to encourage appropriate cancer screening. Mexican Latinas have the lowest mammography consistent with established screening practice guidelines, and the lowest prevalence of ever
having had a lifetime mammogram.(26
) Considering previous findings that Mexican Latinas may have above-average rates of pre-menopausal breast cancer,(35
) and in the context of the USPSTF recommendations for women of average risk to begin breast cancer screening at age 50, mounting evidence suggests an interventionist role for public health practioners who serve this vulnerable population to discuss the risk of breast cancer. Early mammography screenings may assist in lowering rates among Mexican Latinas.
Readers should consider several caveats in evaluating our study. First, we imposed most of the IOM criteria for a healthcare disparity, but were unable to ascertain the preferences
criterion. It is possible that the inequalities in mammography we observed relate to preferences founded in cultural differences. While we were unable to test this alternative explanation for the inequalities we found, our evidence indicates that the differences in mammography by ethnicity/race were related to the availability of health insurance. Nevertheless, examining ethnic/racial subgroup preferences for mammography may provide insights useful in meeting screening goals. Secondly, mammography use was ascertained by self-report, which is subject to recall and social-desirability biases.(36
) Previous studies of overestimation of mammography use have found differences based on age and ethnic/racial group, with African American women having the highest rates of over-reporting (24.4%), followed by Whites (19.3%) and then Latinas (17.9%).(2
) As such, our estimates of mammography use may be inflated, and the potential bias is likely to have affected all groups. Additionally, it is unclear if overestimates of mammography reporting are similar between Latina ethnic subgroups.
Healthy People 2010 goals for ethnic/racial minority parity in mammography have been accomplished for most, but not all ethnic/racial minorities in the U.S., specifically not Mexican Latinas. Our findings indicate that mammography goals should reflect important characteristics of the ethnic/racial composition of the nation to ensure proper targets are set and met. Adequate epidemiologic evidence is essential to ensure ethnic/racial groups are not overlooked in establishing national and local healthcare goals. With the Healthy People 2020 national mammography objectives largely unchanged, it is essential that national healthcare priorities be modified to follow the changing demography and needs of all Americans. Further healthcare providers need to recognize the potential for increased risk of breast cancer in important, but underserved populations.