Civic engagement and breast cancer screening participation among US citizens

ABSTRACT

Background

Civic engagement may influence health behavior, but little is known about its relation to the use of preventive care services like cancer screening. This study examined relationships between civic engagement and breast cancer screening, overall and stratified by age, education, income, and race/ethnicity.

Methods

Data were from the 2023 National Health Interview Survey. Measures of civic engagement included binary (yes/no) indicators of participation in the most recent local election, past‐year public meeting attendance, and past‐year volunteering. The dependent variable was past‐year mammogram use. Associations were evaluated using survey‐weighted logistic regression models with adjustment for multiple sociodemographic characteristics, health insurance status, and self‐rated health.

Results

Analyses included 5733 respondents eligible for breast cancer screening. In adjusted models, the prevalence of past‐year screening was higher among those who voted (adjusted prevalence ratio [aPR], 1.18; 95% confidence interval [CI], 1.12–1.24), attended a public meeting (aPR, 1.08; 95% CI, 1.01–1.16), or volunteered (aPR, 1.11; 95% CI, 1.06–1.16) relative to those who did not. Associations were strongest for those who participated in two or more measures of civic engagement relative to none (aPR, 1.26; 95% CI, 1.18–1.35). In stratified models, associations were generally positive across subgroups and were consistently stronger in magnitude for those with a high school education or less than those with higher educational attainment.

Conclusions

Breast cancer screening is higher in civically engaged adults. More research is needed to understand the social mechanisms that underlie this relationship, but the findings support efforts to advance cancer control through paired public health and civic health programming.

Short abstract

Civically engaged adults are more likely to participate in routine breast cancer screening, a pattern that is consistent across sociodemographic groups. The findings support efforts to advance cancer control through paired public health and civic health programming.

INTRODUCTION

Breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer death among women in the United States. ¹ Screening mammography is a critical component of breast cancer control that promotes early disease detection, when treatment prognosis is typically most favorable, and reduces mortality. ² Despite the benefits of screening mammography, participation is relatively low in groups that experience socioeconomic disadvantages, with disparities by income and education being among the most pronounced. For example, the proportion of up‐to‐date breast cancer screening is 70% for those with less than a high school diploma, compared with 85% for those with a college degree or higher. ³

Disparities in cancer screening participation are shaped by various social determinants of health, from educational factors like health literacy to economic and built‐environment factors, including financial and logistical concerns around transportation, lost wages, diagnostic follow‐up, and overall lack of cost transparency for medical services. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ Social context also correlates strongly to screening participation, especially for breast cancer. For example, prior studies demonstrate that adherence to breast cancer screening guidelines is lower for women who lack social‐emotional support, feel isolated, experience high levels of mental distress, and report low levels of life satisfaction compared with those who do not. ¹⁰ , ¹¹ Other studies have linked breast cancer screening adherence to social characteristics of residential environments, including neighborhood social cohesion and measures of collective efficacy, like the willingness of neighbors to work together on neighborhood improvement projects. ¹² , ¹³

An understudied social determinant of health in research on preventive care use is civic engagement, which encompasses a wide array of activities that support the public good, including voting, volunteering, social organizing, and participating in public meetings and community groups. ¹⁴ There is growing recognition among public health advocates that civic engagement supports health; in fact, improving voting participation was recently adopted as a core objective of 2030. ¹⁵ Prior studies on civic engagement have demonstrated favorable associations with a range of mental and physical health outcomes, including better self‐rated health and well‐being, and lower risk of depression, chronic disease, and mortality. ¹⁴ , ¹⁶ , ¹⁷ , ¹⁸ However, few studies have examined civic engagement in relation to cancer screening.

Civic engagement is closely related to measures of social context, including social capital and social support, that may be mechanistically linked to screening participation (see conceptual model presented in Figure 1). Social capital refers to both tangible and intangible resources, derived from membership in a social network, that benefit individual and collective well‐being. ¹⁹ Among these resources are diverse types of social support that can facilitate screening behavior, including instrumental or material support, informational support, and emotional support. ¹⁹ , ²⁰ , ²¹ Civic engagement may influence screening through pathways involving supportive mechanisms like these. Consistent with the added value hypothesis, these supports may be especially beneficial to adults with low socioeconomic status (SES), for whom material hardship and low health literacy are key barriers to screening. ²² Existing evidence on differences in the relation between social support mechanisms and breast cancer screening across SES groups is limited and mixed. ²³ , ²⁴

FIGURE 1.

Conceptual model linking civic engagement to personal health practices like cancer screening and health.

Civic engagement may also be linked to screening participation through psychosocial pathways. For example, civic engagement is associated with having a stronger sense of life purpose, which may enhance motivation to participate in behaviors that promote health and disease prevention, as demonstrated in prior studies of physical activity and preventive care use, including mammograms. ²⁵ , ²⁶ , ²⁷ , ²⁸

Structural inequities that undermine civic engagement, such as disinvestment in civic infrastructure (e.g., parks, libraries, and other public spaces), felony disenfranchisement, and voter suppression laws, disproportionately affect marginalized groups with historically low cancer screening participation rates. However, little is known about civic engagement in the context of cancer control, particularly in relation to screening and early detection. Understanding this relationship may inform efforts to engage under‐screened adults in cancer control. Therefore, we conducted a study to examine associations between three forms of civic engagement and the use of routine breast cancer screening among eligible US citizens, overall and for groups defined by age, educational attainment, income, and race/ethnicity.

MATERIALS AND METHODS

Data sources and study sample

Data were obtained from the 2023 National Health Interview Survey (NHIS), ²⁹ which collects cross‐sectional data from a nationally representative sample of civilian, noninstitutionalized adults in US households through in‐person and phone‐based interviews. The response rate was 47.0% in 2023. Respondents were eligible for inclusion in this study if they were US citizens and met criteria for routine breast cancer screening according to US Preventive Services Task Force (USPSTF) recommendations during the survey year, namely, women aged 50–74 years with no prior breast cancer diagnosis. ² Citizenship was included as an inclusion criterion because voting, one of the primary indicators of civic engagement, is generally disallowed among noncitizens. Eligible respondents with missing data (2%) were excluded (see Figure S1).

Dependent variables

The dependent variable was receipt of mammogram within the past 1 year, derived from items in which respondents were asked whether they had ever received a mammogram and, if so, when their most recent mammogram was completed. We selected past‐year mammogram as the primary outcome in lieu of adherence to the biennial screening recommendation from the USPSTF to reduce the threat of reverse causality, because several indicators of civic engagement (the main exposure of interest) were measured for the past 1 year only. ² Up‐to‐date screening, defined as receipt of mammogram in the past 2 years according to USPSTF guidelines, was modeled as the dependent variable in sensitivity analyses.

Independent variables

Indicators of civic engagement included three binary (yes/no) measures of voting participation (Did you vote in the last local election, such as for mayor, councilmembers, or school board?), attendance at public meetings (During the past 12 months, did you attend a public meeting, such as a zoning or school board meeting, that discussed a local issue?), and volunteering (an affirmative response on either of the following items: During the past 12 months, did you spend any time volunteering for any organization or association? or Some people don't think of activities they do infrequently or for children's schools or youth organizations as volunteer activities. During the past 12 months, have you done any of these types of activities?). These items comprised the civic engagement and volunteering subsections of the NHIS, which were included as an emerging content area in 2023. A fourth measure of civic engagement was derived from the number of yes responses on the three aforementioned indicators and categorized as participation in zero, one, and two or more civic activities.

Covariates included demographic and socioeconomic characteristics, including age (50–64 or 65–74 years), race/ethnicity (Hispanic, non‐Hispanic [NH] White, NH Black, NH Asian, or other [NH American Indian/Alaska Native alone or in combination with any other groups, and other single and multiple race groups]), educational attainment (high school graduate or less, some college, or a 4‐year college graduate or higher), poverty level (income at 0%–199%, 200%–399%, or ≥400% of the federal poverty level) and urbanicity (metropolitan or nonmetropolitan county of residence). Additonal controls for confounding health and social factors included measures of self‐rated health (excellent/very good, good, or fair/poor), health insurance status (insured or uninsured), and marital status (married or not married). To test multicollinearity between independent variables, we examined variance inflation factors derived from unweighted linear regression models on the overall sample. All variance inflation factors were <2.2, indicating minimal multicollinearity.

Statistical analysis

We calculated descriptive statistics for the analytic sample and tested differences in crude distributions by screening status using χ² tests. For each civic engagement measure, we ran a series of logistic regression models: a crude model, an adjusted model that included all covariates, and adjusted models stratified by age group, educational attainment, poverty level, and race/ethnicity. From these models, we estimated predicted marginal probabilities of screening and calculated prevalence ratios to quantify associations with civic engagement. Stratified models for the NH Asian and other racial/ethnic categories were not estimated because of small sample sizes. All analyses were performed in SAS‐callable SUDAAN using procedures (SAS Institute Inc.) that account for survey weights and the complex sampling design of the NHIS.

In the primary analyses, poverty level was categorized using income data that were imputed for approximately 25% of survey respondents. Several sensitivity analyses were conducted to assess whether the analysis of imputed values biased statistical inferences in adjusted models for the overall sample. These analyses involved the following approaches: (1) including a binary indicator of whether income was imputed as a model covariate, (2) excluding poverty level as a covariate in adjusted models, and (3) excluding respondents with imputed income.

RESULTS

In total, 5733 respondents were included in the analytic sample. The mean age was 61.8 years, and most respondents were NH White (70.5%), married (60.7%), and residents of metropolitan counties (83.7%; Table 1). Approximately one third of respondents had a high school education or less (33.0%), and 26.2% reported a household income below 200% of the federal poverty level. Overall, 65.1% reported having a mammogram in the past year. Of the three civic engagement activities, voting was the most endorsed (68.1%), followed by volunteering (30.9%), and attending a public meeting (11.5%) in the past year. Around one quarter (25.8%) of respondents did not engage in any of the three civic activities, whereas 29.2% engaged in two or more.

TABLE 1.

Descriptive statistics of US citizens eligible for female breast cancer screening: 2023 National Health Interview Survey, n = 5773.

	Overall, no. (%w)	Past‐year mammogram, no. (%w)
		No	Yes	p
Total	5773 (100)	2057 (34.9)	3716 (65.1)	NA
Age, years
50–64	3202 (62.6)	1207 (36.7)	1995 (63.3)	.001
65–74	2571 (37.4)	850 (31.9)	1721 (68.1)
Race/ethnicity
Hispanic	516 (10.2)	199 (36.8)	317 (63.2)	.041
NH White	4195 (70.5)	1518 (35.4)	2677 (64.6)
NH Black	720 (12.5)	214 (29.9)	506 (70.1)
NH Asian	204 (4.7)	64 (32.8)	140 (67.2)
NH Other	138 (2.2)	62 (43.8)	76 (56.2)
Educational attainment
High school or less	1784 (33.0)	757 (41.8)	1027 (58.2)	< .001
Some college	1810 (32.3)	688 (36.6)	1122 (63.4)
Four‐year college degree	2179 (34.7)	612 (26.8)	1567 (73.2)
Income
<200% FPL	1647 (26.2)	783 (45.5)	864 (54.5)	< .001
200%–399% FPL	1673 (28.4)	564 (34.8)	1109 (65.2)
≥400% FPL	2453 (45.4)	710 (28.9)	1743 (71.1)
Insurance status
Insured	5588 (96.6)	1921 (33.7)	3667 (66.3)	< .001
Uninsured	185 (3.4)	136 (71.1)	49 (28.9)
Self‐rated health
Fair/poor	1085 (18.7)	505 (45.2)	580 (54.8)	< .001
Good	1763 (30.6)	637 (35.4)	1126 (64.6)
Excellent/very good	2925 (50.6)	915 (30.8)	2010 (69.2)
County urbanicity
Nonmetropolitan	1020 (16.3)	424 (39.8)	596 (60.2)	.005
Metropolitan	4753 (83.7)	1633 (34.0)	3120 (66.0)
Marital status
Married	2767 (60.7)	859 (31.3)	1908 (68.7)	< .001
Not married	3006 (39.3)	1198 (40.6)	1808 (59.4)
Voted in last local election
Yes	3951 (68.1)	1200 (29.7)	2751 (70.3)	< .001
No	1822 (31.9)	857 (46.0)	965 (54.0)
Attended public meeting, past year
Yes	698 (11.5)	179 (25.8)	510 (74.2)	< .001
No	5084 (88.5)	1878 (36.1)	3206 (63.9)
Volunteered, past year
Yes	1828 (30.9)	502 (26.8)	1326 (73.2)	< .001
No	3945 (69.1)	1555 (38.6)	2390 (61.4)
No. of civic activities endorsed
Zero	1476 (25.8)	712 (47.0)	764 (53.0)	< .001
One	2543 (45.0)	903 (34.9)	1640 (65.1)
Two or more	1754 (29.2)	442 (24.3)	1312 (75.7)

Note: Overall percentages are for column totals. All other percentages are for row totals.

Abbreviations: %w, weighted percentage; FPL, federal poverty level; NA, not applicable; NH, non‐Hispanic.

For each civic activity, the crude prevalence of past‐year breast cancer screening was significantly higher for those who did versus did not engage (p < .001 for all). These patterns persisted in adjusted models. After adjustment, the estimated relative prevalence of past‐year screening was 18% higher (68.4% vs. 58.2%; adjusted prevalence ratio [aPR], 1.18, 95% confidence interval [CI], 1.12–1.24) for those who voted; 8% higher (70.0% vs. 64.5%; aPR, 1.08; 95% CI, 1.01–1.16) for those who attended a public meeting; and 11% higher (70.0% vs. 63.0%; aPR, 1.11; 95% CI, 1.06–1.16) for those who volunteered in the past year compared with those who did not (Table 2, Figure 2). Engaging in more civic activities was also associated with higher past‐year screening; compared with those who did not report engaging in any of three civic activities, past‐year screening was 26% higher for those who engaged in two or more civic activities (72.6% vs. 57.5% [aPR, 1.26]; 95% CI, 1.18–1.35), and 13% higher for those who engaged in any one civic activity (64.9% [aPR, 1.13]; 95% CI, 1.06–1.20; Figure 3).

TABLE 2.

Predicted marginal probabilities of past‐year mammogram use with 95% confidence intervals, by civic engagement indicator: 2023 National Health Interview Survey, n = 5773.

Indicator	Estimate (95% CI)
Voted in last local election
Yes	68.4 (66.7–70.1)
No	58.2 (55.5–60.9)
Attended public meeting in past year
Yes	70.0 (65.6–74.0)
No	64.5 (62.9–66.1)
Volunteered in past year
Yes	70.0 (67.4–72.6)
No	63.0 (61.2–64.8)
No. of civic activities
Zero	57.5 (54.4–60.5)
One	64.9 (62.7–67.0)
Two or more	72.6 (70.0–75.1)

Note: Estimates derived from logistic regression models adjusted for age, educational attainment, poverty level, race/ethnicity, self‐rated health, insurance status, county urbanicity, and marital status.

Abbreviation: CI, confidence interval.

FIGURE 2.

Overall and stratified relative prevalence of past‐year breast cancer screening by civic engagement indicator, 2023 National Health Interview Survey (n = 5773). Models were adjusted for age (50–64 or 65–74 years), educational attainment (high school or less, some college, or college graduate), poverty level (0%–199%, 200%–399%, or ≥400% FPL), race/ethnicity (Hispanic, NH White, NH Black, NH Asian or NH other), insurance status (insured or uninsured), self‐rated health (fair/poor, good, or excellent/very good), county urbanicity (metropolitan or nonmetropolitan), and marital status (married or not married). CI indicates confidence interval; FPL, federal poverty level; NH, non‐Hispanic; PR, prevalence ratio.

FIGURE 3.

Overall and stratified relative prevalence of past‐year breast cancer screening by number of civic engagement activities endorsed, 2023 National Health Interview Survey (n = 5773). Models were adjusted for age (50–64 or 65–74 years), educational attainment (high school or less, some college, or college graduate), poverty level (0%–199%, 200%–399%, or ≥400% FPL), race/ethnicity (Hispanic, NH White, NH Black, NH Asian or NH other), insurance status (insured or uninsured), self‐rated health (fair/poor, good, or excellent/very good), county urbanicity (metropolitan or nonmetropolitan), and marital status (married or not married). CI indicates confidence interval; FPL, federal poverty level; NH, non‐Hispanic; PR, prevalence ratio.

In models stratified by sociodemographic characteristics, point estimates for civic engagement indicators were generally positive for all subgroups and were consistently larger in magnitude for those with a high school education or less compared to those with higher educational attainment (Figures 2 and 3). For example, engaging in any one civic activity was associated with 26% higher past‐year screening for those with a high school education or less (aPR, 1.26; 95% CI, 1.13–1.41; Figure 3) but was not significantly associated with past‐year screening among those with some college or a college degree. For those engaged in two or more civic activities, past‐year screening was 47% higher for those with a high school education or less (aPR, 1.47; 95% CI, 1.29–1.67), 14% higher for those with some college (aPR, 1.14; 95% CI, 1.01–1.28), and 18% higher for those with a college degree (aPR, 1.18; 95% CI, 1.07–1.30). Associations between voting and past‐year screening were significant for all subgroups except those with household incomes 200%–399% of the federal poverty level, in which confidence limits narrowly crossed the null (aPR, 1.09; 95% CI, 1.00–1.19). Subgroup‐specific associations for public meeting attendance were strongest for Hispanic respondents (aPR, 1.24; 95% CI, 1.02–1.50) but were nonsignificant for most other subgroups.

In sensitivity models of up‐to‐date screening, overall associations with all indicators of civic engagement were statistically significant but attenuated in magnitude compared with those for past‐year screening, and patterns by educational attainment were consistent (see Figures S2 and S3). Statistical inferences were consistent in sensitivity analyses addressing the use of imputed income, and point estimates were the same or similar in magnitude (data not shown).

DISCUSSION

The results of this study indicate that civic engagement is associated with greater participation in routine breast cancer screening. Voting, public meeting attendance, and volunteering were each positively associated with both past‐year and up‐to‐date mammogram use, and associations were strongest for those who engaged in two or more civic activities. Although few prior studies have examined civic engagement in relation to cancer screening, the results are consistent with several that have looked at similar exposures. For example, an analysis of data from the Health and Retirement Study found that the odds of receiving a mammogram were 53% higher for individuals who engaged in volunteer work compared with nonvolunteers. ²⁵ A recent ecologic analysis indicated that mammogram participation rates for Medicare enrollees were elevated in counties with higher scores on a community health index constructed partially from data on the share of adults who engage in volunteerism and public meetings. ³⁰ The findings are also consistent with some prior studies that have demonstrated positive associations between cancer screening and social network characteristics like membership in community and religious organizations, which often provide opportunity structures for civic engagement through organized meetings and volunteer efforts. ³¹ , ³² To our knowledge, this study is among the first to demonstrate an association between voting and mammogram use at the individual level.

In analyses stratified by age, education, income, and race/ethnicity, associations between all civic engagement indicators and breast cancer screening were consistently in the positive direction (except the association for public meeting attendance among NH Black adults). However, not all subgroup‐specific associations were statistically significant, and several CIs only narrowly crossed the null. Since the NHIS was redesigned in 2019, only the 2023 iteration has included items on both civic engagement and breast cancer screening; with only a single year of data, the stratified analyses may have been underpowered to detect modest subgroup‐specific associations, particularly for subgroups with smaller sample sizes and for less common civic activities (e.g., public meeting attendance) with limited response variability, resulting in type II error. For subgroups like NH Black women, marginally significant or nonsignificant associations could also be caused by a ceiling effect given their high participation in mammogram. Still, the consistency of positive point estimates is notable and suggests that civic engagement may benefit screening participation across diverse demographic and socioeconomic groups.

The positive associations between civic engagement and breast cancer screening were strongest in magnitude for those with limited educational attainment. This finding generates hypotheses about the social mechanisms that might link civic engagement to breast cancer screening. For example, civic engagement may provide added value to those with limited educational attainment by increasing informational support (e.g., exposure to lay messaging from peers and community groups on preventive care guidelines and local resources) and awareness of favorable social norms around screening participation. The salience of these mechanisms has been emphasized in several studies. For example, higher levels of civic engagement were linked to greater recall of messaging from a community‐wide, health‐education intervention for adults in Minnesota. ³³ In their qualitative work on health volunteerism, Molina et al. underscore the role of repeated exposure to health information, cues to action, and influential social norms on screening participation both among volunteers and within their social networks through beneficial spillover effects. ³⁴ Few studies have compared associations between distinct types of social support and mammogram use, and the evidence is mixed. ²⁴ , ³⁵ , ³⁶ However, one study indicated that emotional/informational social support, but not tangible social support, was associated with repeated use of mammograms. ²⁴ If informational support is a primary mechanism linking civic engagement to breast cancer screening, this might explain why associations were more pronounced at lower levels of educational attainment (in which informational support needs are presumably the greatest) than at lower levels of income (in which tangible support needs are presumably the greatest). Ultimately, more research is needed to understand the specific social mechanisms that underlie associations between civic engagement and mammogram participation and whether they vary by measures of SES.

The statistically significant, albeit modest, overall associations between civic engagement and breast cancer screening have important implications for cancer health equity and underscore the potential value of paired public health and civic health programming to advance cancer control. In recent years, growing numbers of organizations have formally acknowledged civic engagement (specifically voting) as a social determinant of health that is within the scope of public health advocacy and have endorsed efforts to promote accessible and inclusive voting policies. ³⁷ , ³⁸ Health care–based voter mobilization initiatives have recently gained traction as a strategy for improving civic engagement, particularly among marginalized groups, from within the health sector. ³⁹ These strategies may miss some women who are under‐screened for breast cancer because of lack of health care access; however, post‐hoc analyses indicated that the majority (70%) of those not up‐to‐date with USPSTF recommendations did have a routine wellness visit in the past year. Receiving a clinician recommendation for screening is among the strongest determinants of screening participation, and efforts to improve patient–clinician communication about screening are needed. Still, civic health programming delivered in the clinical setting could arguably reach a substantial proportion of under‐screened adults and additionally bolster screening participation. As others have noted, many health care providers and public health practitioners (e.g., at Federally Qualified Health Centers and other safety‐net institutions) routinely work with patients from marginalized communities that disproportionately experience voter suppression and other barriers to civic engagement and thus are uniquely positioned to promote civic health in these groups in a safe and nonpartisan setting. ⁴⁰ If the relation between civic engagement and breast cancer screening is causal, then directing civic health programming (e.g., voter registration campaigns) to low‐SES groups, in which screening disparities are most pronounced, will likely generate the greatest benefit for health equity.

Health systems could also leverage the favorable associations between civic engagement and breast cancer screening in nonclinical settings to enhance preventive care. For example, community health centers and hospital systems might support civic engagement in their catchment areas by partnering with community groups and organizations (e.g., churches, nonprofit organizations, neighborhood associations, etc.) that provide opportunities for civic participation through volunteering, membership on committees, and other community improvement efforts. Cancer control messaging might be especially effective when delivered in the community‐based settings where civic participation occurs, and such partnerships could also yield opportunities for shared programming. Finally, better understanding the specific mechanisms that link civic engagement to screening may allow health advocates to design programming that amplifies the most supportive social resources in community settings.

Strengths of this study include the use of a nationally representative sample and the inclusion of multiple indicators of civic engagement that have not previously been examined in relation to cancer screening. Several limitations must also be acknowledged. First, because the data are collected through self‐report, misclassification due to recall and social desirability biases is possible. Prior studies indicate that agreement between self‐reported and medical records–verified breast cancer screening is generally moderate to high, although under‐screened adults (especially those from minoritized racial/ethnic and low‐SES groups) tend to over‐report their screening. ⁴¹ , ⁴² , ⁴³ Responder bias may also be a factor because individuals who participate in surveys tend to be more civically engaged than nonresponders. ⁴⁴ Overestimation of screening and civic engagement may have driven effect estimates upward; therefore, associations should be interpreted with caution. Second, although we modeled past‐year mammogram as the primary outcome to reduce the threat of reverse causality, we were not able to evaluate whether civic engagement affects screening prospectively. In addition, our ability to make definitive recommendations for health programming based on this analysis is limited because the study did not evaluate causality or the social mechanisms that link civic engagement to breast cancer screening. Third, because the NHIS does not provide geographic data for respondents beyond census region, it was not possible to evaluate the role of contextual factors that shape civic engagement and often vary at state, county, and local levels, e.g., voting rights, policies around redistricting and gerrymandering, and resource allocation for strengthening civic infrastructure. More research is needed to understand how contextual factors like these and others affect screening. We were also unable to account for mechanisms at the community level, such as collective efficacy and community empowerment, e.g., successful lobbying to bring more health resources into a medically underserved area. More research is needed to understand whether these and other contextual factors affect the relationship between civic engagement and breast cancer screening.

CONCLUSIONS

Civically engaged citizens are more likely to participate in routine breast cancer screening. Actively participating in community improvement through behaviors like voting, volunteering, and joining public meetings may enhance an individual's sense of purpose and motivation to pursue health maintenance and facilitate exposure to health‐promoting social resources. Longitudinal research is needed to understand the temporality of associations between civic engagement and preventive care use and the social mechanisms that link them. Overall, the current findings support growing efforts to advance cancer control, and health equity more broadly, through paired public health and civic health programming.

AUTHOR CONTRIBUTIONS

Jordan Baeker Bispo: Conceptualization; formal analysis; writing—original draft; writing—review and editing. Hyunjung Lee: Writing—review and editing. Jingyi Tian: Formal analysis; writing—review and editing. Ahmedin Jemal: Writing—review and editing. Farhad Islami: Writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors disclosed no conflicts of interest.

Supporting information

Supplementary Material

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available from the Centers for Disease Control and Prevention and the National Center for Health Statistics at https://www.cdc.gov/nchs/nhis/index.htm.