Social Determinants of Breast Cancer Screening: A Multilevel Analysis of Proximal and Distal Factors Related to the Practice of Mammography

Abstract

Background: Mammography is crucial for early breast cancer detection. In Latin America, Argentina faces a significant breast cancer burden, with varying mammography rates. The social factors influencing mammography practices remain unclear. This study aimed to identify the proximal and distal social determinants of this practice among Argentinean women using a multilevel approach. Methods: This nationwide cross-sectional study included 4,924 women, ages 50 to 70, participating in the 2018 National Risk Factor Survey of Argentina. Two-level logistic models were used to estimate measures of association (ORs) between timely mammography practice (within the last 2 years) and selected covariates (sociodemographics, proximal environment, and distal-level variables). The intraclass correlation coefficient and proportional change in variance were calculated. Results: Of the total participants, 62.8% of women underwent timely mammography. Age [OR ¼ 0.96; 95% confidence interval (CI), 0.94–0.97], health insurance (OR ¼ 2.22; 95% CI, 1.87–2.63), education (OR ¼ 2.1; 95% CI, 1.74–2.64), and income (OR ¼ 1.56; 95% CI, 1.23–1.97) were associated with mammography practice. Women in nonmarital (OR ¼ 0.61; 95% CI, 0.52–0.72) or larger households (OR ¼ 0.61; 95% CI, 0.51–0.63) were less likely to have timely mammography; living in a larger city was positively associated with timely mammography (OR ¼ 1.28; 95% CI, 1.12–1.46). Women in provinces with higher physician density (OR ¼ 1.06; 95% CI, 1.01–1.11) and lower maternal mortality ratio (OR ¼ 0.9; 95% CI, 0.87–0.96) had higher chances of timely mammography. The intraclass correlation coefficient and proportional change in variance suggested that the explored healthcare indicators largely explained the macro-contextual effect. Conclusions: Multilevel factors influenced mammography practices in Argentina. The results highlight disparities linked to sociodemographic characteristics and healthcare resources. Impact: Efforts to address social inequalities in breast cancer screening must consider multilevel determinants, including in healthcare settings.