Background: Cancer is the second leading cause of death in the United States, accounting for 22% of all deaths among women. Despite the importance of the Pap test in preventing and detecting cervical cancer, screening rates among poor women remain low. The pathways linking poverty with lower Pap test use remain unclear. The screening disparity for this low-cost test suggests that poor women may face other transaction costs, opportunity costs and barriers in accessing Pap tests that are not faced by women living above poverty.
Data/Methods: The data set merged the 2005 California Health Interview Survey, 2000 Census, and safety net clinic data. I examine elements of the patient-provider interaction (racial/ethnic discrimination) and healthcare system (distance to the nearest safety net clinic) as possible mediators between individual-level poverty and Pap tests. I then examine the role of individual-level poverty in moderating the association between discrimination and Pap test use and safety net distance and Pap test use. I also examine whether the neighborhood-level poverty moderates the association between individual-level poverty and Pap tests, discrimination and Pap tests, and distance and Pap tests. The sample included women, 18-64, with a physician visit in the previous 5 years and no history of cervical cancer. Mediation was tested using Generalized Estimating Equations (GEE) and a weighted product-of-coefficients test. Moderation was tested using GEE and including interaction terms.
Results: Poor women were significantly less likely to report a timely Pap test, had significantly higher odds of reporting discrimination, and were more likely to reside closer to a safety net clinic. Discrimination did not predict Pap tests and was not a mediator between individual-level poverty and Pap tests. Safety net distance predicted Pap tests and was a mediator between individual-level poverty and Pap tests. Neither individual-level poverty nor neighborhood-level poverty modified the proposed relationships with Pap test use.
Conclusion: Racial/ethnic discrimination did not explain disparities in Pap tests. Proximity to a safety net clinic was shown to be protective against disparities and may play a role in addressing disparities in screening. Individual-level poverty and neighborhood-level poverty did not influence the role of proposed mediators in predicting Pap tests.