Year of Publication

2014

College

Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Katherine Eddens, MPH, PhD

Committee Member

Linda Alexander, Ed.D.

Committee Member

Mark Swanson, PhD

Abstract

Breast cancer is the second leading cause of death (14%) among all cancers in women in Kentucky.1 In 2010 the United States incident rates of breast cancer in white women were 122.6 per 100,000, and 118 per 100,000 in black women.2 Although breast cancer is diagnosed more in white women, black women are more likely to die from breast cancer and usually have more advanced stages of breast cancer upon diagnosis.2 In Kentucky from 2003-2007 the age-adjusted breast cancer mortality rate was 23.6 per 100,00 in white women and 32.8 per 100,000 black women. Black women die from breast cancer at a higher rate than any other group in Kentucky.1 Healthy People 2020 named “Access to Health Services” and “Social Determinants of Health” on their “Leading Health Indicators” list as high priority health issues. Health insurance and health care access are two integral parts of social determinants of health.3 Racial and ethnic minorities, comprising one-third of the US population, are less likely to have insurance than the rest of the population.4 The Department of Health and Human Services reported that this disparity, more than any other barrier, negatively affects the quality of care received by minority populations.4 In 2010, according to a study by the Centers for Disease Control and Prevention, 25% of women over 40 in the US were not compliant with mammography screening recommendations, with mammography use lower in women without health insurance or a primary source of health care.2 Research using data from the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) program registries revealed that black women with breast cancer had lower five-year survival rates, regardless of stage and age, and were more likely to be 3 diagnosed with tumors with worse prognosis.5 A recent study using SEER Medicare data found that black women with breast cancer had less evidence of at least one primary care visit, lower rates of breast cancer screenings, and longer delays in treatment.6 There were differences in survival and were primarily related to presentation at diagnosis more than treatment differences between white and black women.6 Multiple studies have examined the correlation between health insurance and breast cancer, including evidence of association between individuals without insurance or with Medicaid and more advanced stages of breast cancer at diagnosis and poorer outcomes.6-11 A cohort study among black women revealed that regular use and adherence to mammography screening were most associated with having health insurance, more than any other socioeconomic factor.12 Little research has been performed specific to the Kentucky population in relationship to health insurance status and breast cancer. One study focused on cancer survival and health insurance by examining the Kentucky Cancer Registry. Women with breast cancer who had private insurance, Medicare, or other federally funded healthcare had better survival rates then women with Medicaid.13 After controlling for length of follow-up, age, stage, health insurance, and treatment, black women with breast cancer still had a higher risk of death than white women (39%).13 The increased detrimental effect of breast cancer on black populations, and especially low-income individuals, has also been attributed to other factors including individual’s diet, differences in the biology of tumors in black women, cultural and psychosocial factors, breast feeding practices, multiple parity at younger ages and other socioeconomic factors.14-17,5,11 Certain health care system factors like access to care and quality of care have been associated with breast cancer disparities.18 Social factors like racism, low socioeconomic 4 status, lack of transportation and not having a primary care physician have also been documented as contributing to this disparity in survival rates, stage at diagnosis, and difference in treatment and mortality rates in black women.18-27 Understanding disparities experienced by this population will help improve outcomes through targeting the identified roots of this issue.18 There are still many complex questions as to why black women are disproportionately affected by breast cancer.28 The primary purpose of this study is to assess how race, health insurance coverage, income and education correlate with access to health care in women diagnosed with breast cancer in Kentucky. Is access to health care different among black women and women without private insurance with breast cancer? We anticipate that among these women, those who are black and those without private health insurance will report more barriers to services and differences in access to care than non-black women and privately insured women in Kentucky with breast cancer. Secondly, we will assess the relationship among these variables in women 40 or older that report not receiving guidelinerecommended yearly mammogram screenings. We anticipate that black women and women without private health insurance outside mammography guidelines will report more barriers to service and difference in access to care than non-black women and privately insured women in Kentucky outside mammography guidelines. Lastly, we anticipate women that report lower yearly income and education level will have differences in access to health care.

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