The socioeconomic position of women in Chile influences the use of early breast cancer screening tools. This is the central conclusion of the study "Socioeconomic position and breast cancer screening use in Chile: A population-based study", published in Preventive Medicine Reports (Volume 50, 2025). The research, with corresponding authorship by Dr. Maria Luisa Garmendia, an academic at the Institute of Nutrition and Food Technology (INTA) of the Universidad de Chile, analyzes how various social indicators affect the frequency of mammography screening.
The study aimed to evaluate how socioeconomic position (SEP), measured multidimentionsionally, influences breast cancer screening use among women aged 50 to 69 — the age group defined by clinical guidelines as the priority population for systematic screening.
Methodology and study design
The research team conducted a population-based epidemiological analysis using data from the 2022 National Socioeconomic Characterization Survey (CASEN), carried out by the Chilean Ministry of Social Development and Family. The final analytical sample included 26,337 women belonging to the national target screening group, drawn from 760 municipality -area units.
Unlike studies that rely on isolated indicators, this research adopted a multidimensional approach to define socioeconomic position, considering three key indicators: educational level, per capita household income (by quintile), and type of occupation. Multilevel logit-binomial regression models were used to estimate prevalence ratios for the association between these factors and mammography use in the past three years, adjusting for sociodemographic variables and health status.
As with any observational study, the authors acknowledge limitations: the CASEN 2022 survey had a response rate of 68.7%, which may introduce selection bias — particularly among women with greater difficulty accessing health services. The study also did not include variables such as awareness of mammography programs, frequency of primary care visits, or intersectionality dimensions. These aspects should be addressed in future research.
Educational gaps, income, and employment in mammography use
The study results show that the overall mammography coverage in the evaluated group was 66.9%. While this figure aproches international standards, detailed analysis reveals marked disparities by socioeconomic profile.
Three socioeconomic position (SEP) indicators were significantly associated with non-use of mammography. Women with primary education or lower had a 20% higher probability of not having a mammogram compared to women with tertiary education. The effect of income was even more pronounced: women in the lowest income quintile (under USD 158/month) showed a 49% higher prevalence of non-use compared to those in the highest quintile (over USD 778/month), with a statistically significant gradient across all quintiles.
Regarding ocupation type, unemployed women showed a 34% higher prevalence of non-use compared to managers and professionals, while service and trade workers showed a 21% higher gap. The authors note that these disparities are concentrated among women with precarious or unpaid employment, who tend to face structural barriers to accessing healthcare, including long working hours and limited social security coverage.
Notably, the income effect persisted despite mammography screening being free of charge at primary care level in Chile. The authors suggest that a significant proportion of women may be unaware that the exam is publicly funded, and that higher-income women are more likely to pay for screening at private facilities.
Implications for public health and early diagnosis
The publication highlights that educational level acts as a facilitator for understanding the importance of screening and managing healthcare appointments. Meanwhile, the precarious employment conditions of the most affected groups — long working hours, lack of time for health care, limited awareness of available services — represent structural barriers that the current passive screening model does not adequately address.
Chile’s breast cancer screening program operates under a passive approach: mammograms are offered during routine visits to health centers, rather than through proactive outreach to the target populatoin via letters or calls. The authors argue that this model places a greater burden on women with fewer socioeconomic resources, who are less likely to seek care spontaneously.
The findings suggest the need to move from universal, uniform health policies toward strategies focused on lower socioeconomic groups. Strengthening outreach in primary care, reducing administrative barriers for women with lower education levels, and incorporating equity and territorial considerations into early detection detection programs are identified as necessary actions to improve timely diagnosis.
The identification of these inequities adds to the evidence on how social stratification in Chile shapes access to critical health services, reinforcing the idea that the success of public health programs depends on their ability to effectively reach the most vulnerable populations—particularly given that this pattern is not limited to breast cancer. A study by the same research team, published in 2025 in Scientific Reports, found similar socioeconomic inequities in the stage at diagnosis across multiple cancer types in Chile, suggesting that these gaps extend across different points in the cancer control continuum.
- The study shows that lower-income women use mammography significantly less, even when the exam is free. What concrete barriers explain that cost is not the only obstacle, and what should the public system change to overcome them?
There are many barriers that could explain why cost is not the only obstacle to mammography access in the public health system. First, preventive health actions are difficult to carry out among highly precarious women, who simultaneously manage paid work and unpaid caregiving responsibilities at home, drastically reducing the time available to attend health checkups. Second, there is a widespread perception that the public health system is low quality, which may lead part of the population to delay care rather than seek out services they perceive as poor. Added to this are geographical barriers, transportation difficulties, and the lack of support networks for childcare or dependent care, all of which may affect whether women complete this exam.
In response, we believe the public health system should advance in several directions. On one hand, it needs to deepen its understanding of the specific reasons behind non-use of mammography, since our study sheds some light on socioeconomic factors but other research is needed to capture the perspectives of the women themselves. On the other hand, the system should develop territorially grounded strategies, since the reality in Santiago differs substantially from that in the north or south of the country. Understanding local constraints and complexities is an essential prerequisite for designing interventions that can increase mammography use among socioeconomically disadvantaged populations. Finally, the system should move—as is already happening in several municipalities—toward more flexible care models, including extended hours, mobile mammography units, and the elimination of administrative barriers that may currently discourage mammography use at the primary care level.
- How does precarious employment combine with low educational attainment or low income to ultimately displace prevention among the most vulnerable women?
Precarious employment is a significant phenomenon in Chile and affects the lives of the most vulnerable populations. Various reports indicate that women are concentrated in informal, part-time jobs in the service and trade sectors, characterized by low wages and job instability. This situation combines with low educational levels, which can make it harder to understand the importance of screening and to navigate the administrative processes the health system requires.
These conditions interact and lead women to channel all their resources—time, energy, and money—toward meeting basic needs such as food and housing. In that context, preventive actions like mammography tend to be displaced from immediate priorities, especially when their benefits may be perceived as uncertain. Women who work long hours, with little control over their schedules and no access to paid leave for health appointments, face a real opportunity cost when attending a checkup that addresses no current urgency. In our view, the intersection of precarious employment, low income, and low educational attainment creates a form of cumulative vulnerability that the health system has yet to effectively address.
- Chile's program expects women to come to checkups on their own. Since that is not working, what active outreach strategies should primary care implement to reach those currently excluded from screening?
We do believe that Chile's current model—where women seek care spontaneously—is proving insufficient for the most vulnerable groups. We would not venture to propose a formal active screening program along the lines of those in European countries without first developing a solid understanding of the reasons behind non-use of mammography in different parts of Chile. However, we think that primary care, with greater resources, could become significantly more involved in active outreach through concrete strategies tailored to the realities of each territory and designed to enable the earliest possible breast cancer diagnosis.
In that regard, we believe it is important for primary care to continue identifying women in the relevant age range who have not had a mammogram in the recommended period, using available records such as electronic health files and FONASA databases—an approach that could also incorporate socioeconomic dimensions into active outreach efforts, in light of our study's findings.
We also believe that deploying mobile mammography units to neighborhoods, local markets, or workplaces—alongside evening and weekend appointment slots—would lower the time barrier to screening. Finally, outreach strategies should engage community organizations, neighborhood associations, and women's networks in local territories, recognizing that community trust is often more effective than institutional communication in motivating preventive health behaviors.
DOI: 10.1016/j.pmedr.2025.102973
Link: https://doi.org/10.1016/j.pmedr.2025.102973
