Graduation Year


Document Type




Degree Granting Department


Major Professor

Gabriel Picone, Ph.D

Committee Member

Andrei Barbos, Ph.D.

Committee Member

Murat Munkin, Ph.D.

Committee Member

Joshua K.Wilde, Ph.D.

Committee Member

Arthur R. Williams, Ph.D.


mammography, peer effects, social multiplier


This dissertation contributes to the field of health economics, which, in the past couple of decades, has substantially increased our understanding of the determinants of human health, health-related behavior, and health care choices.

A large body of literature has documented the influence of peer group behavior on individual choices. The purpose of my research is to examine the extent of such a phenomenon in breast cancer preventive behavior. Using Behavioral Risk Factors Surveillance System (BRFSS) surveys from 1993-2008, I measured the effect of other female screening behavior on an individual's decision to have a routine breast cancer screening by calculating the size of a so called social multiplier in mammography.

I estimated a vector of social multipliers in the use of annual mammograms by taking the ratio of group-level effects of exogenous explanatory variables to individual-level effects of the same variables. Peer groups are defined as same-aged women living in the same geographical area: county or state. Several econometric methods were used to analyze the effect of social interactions on decision to undergo mammography, including ordinary least squares, fixed effects, the split sample instrumental variable approach, and a falsification test.

My results supported the hypothesis that social interactions have an impact on the decision to have a mammogram. For all women over age 40, I found strong evidence of social interactions being associated with individual's education and ethnicity. In addition, the decision for women ages 40-49 to have a screening was subject to peer influence through their place of employment and ownership of health insurance. Finally, for women age 75 and older, being married and aging were the most important channels through which peer group influenced the decision to have a mammogram.

This research has important policy implications in the presence of current health care reform that reimburses breast cancer screening at 100%, while rates of mammography receipt remain below the policy goal.

Furthermore, I examined the effect of the 2009 United States Preventive Services Task Force change in screening recommendations on screening behavior. I demonstrated an immediate reduction in the receipt of mammography among women of all age groups following the revision of screening guidelines. I found that in 2010, the twelve month mammography receipt decreased by 1.97 (women ages 40-49), 2.20 (ages 50-74), and 3.61 (age 75 and older) percentage points, and the twenty-four months mammography receipt decreased by 1.47 (women ages 40-49), 1.05 (ages 50-74), and 1.92 (age 75 and older) percentage points. Analysis using a two-year follow up period after the revision of screening recommendations provided further support to this conclusion.

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Economics Commons