mammography use is now similar nationally for all ethnic groups— 68 percent for white women; 66 percent for African-American women; and 60 percent for Hispanic women. Increased use of mammography from 1987 to 1998 is also evident for different age groups, with the most striking changes noted among women over 60, whose rates have nearly tripled. However, some important disparities remain. For example, Wu, Black, and Markides (2001) recently reported that older Hispanic women were less likely than other women to have had recent mammograms and Pap tests.

However, there are still cultural groups for whom mammography use is lower. For example, in some areas of the United States, Hispanic women are less likely to have mammograms than women of other racial/ethnic groups (Breen et al., 2001). Recent immigrants also have lower use. In some areas of the country, such as eastern North Carolina, African-American women have lower rates of screening (e.g., O’Malley et al., 2001). A recent analysis of Behavioral Risk Factor Surveillance System (BRFSS) data with a focus on Appalachian women found that rates of mammography use were slightly below the U.S. population. Women over age 60, those with less than a high school education, and women who had not seen a doctor in the past year were also less likely to have had mammograms (Hall et al., 2002). Coughlin and Uhler (2002) reported BRFSS data from the United States and Puerto Rico for Hispanic women. The findings were similar in terms both of proportion screened and the variables that predicted underutilization. These data highlight the importance of educational and economic characteristics as determinants of screening. As Coughlin and Uhler stressed, more efforts are needed to provide access to services for the medically underserved.

The lowest mammography rates currently are found among women who have low incomes (rates are between 43 and 54 percent, depending on age) and who do not have high school diplomas (between 47 and 58 percent, depending on age). For example, women age 50 and older who live below the poverty line are 21 percent less likely than women living above the poverty line to have had a mammogram in the previous 2 years. Also, women in

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