The Effect of Social Associations on Mammography Screening Disparities in Rural Communities: A County‐Level Secondary Analysis

INTRODUCTION: Mammography screening rates in rural counties are lower compared to urban counties. We hypothesized that social associations may help ameliorate this rural-urban disparity. Thus, the purpose of this ecological study was to explore the relationships among rurality, social associations, and mammography screening. METHODS: We conducted a secondary, county-level analysis of the 2022 County Health Rankings and Roadmaps data. We classified counties as rural or urban (rural-urban continuum code of 4+ vs. others), and we gathered the number of social organizations per 10,000 residents (i.e., "social associations"). We used a structural equation model to examine the direct and indirect effects of rurality and social associations on the mammography screening. RESULTS: Of 3143 U.S. counties, 1976 (62.9%) were rural. Rural counties have greater social associations compared to urban counties (β = 0.20, SE = 0.02, p < 0.0001). Counties with greater social associations had higher mammography screening rates (β = 0.34, SE = 0.02, p < 0.0001) while rural counties had lower screening rates (β = -0.24, SE = 0.02, p < 0.0001). There was a significant indirect effect of rurality through social associations on mammography screening (β = 0.07, SE = 0.01, p < 0.0001). Living in a rural area in the presence of increased social associations led to increased mammography screening. CONCLUSIONS: Rural counties have more social associations but a lower rate of mammography screening. These analyzes revealed, however, that social associations buffer the negative relationship between rurality and mammography, leading to increased mammography screening rates. Clinical-community partnerships leveraging social associations could minimize rural mammography screening disparities.