Community Based Strategies for Cancer Control and Prevention

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Community Based Strategies for Cancer Control and
Prevention

• Elaine Puleo, Ph.D.
• Associate Dean of Research
• School of Public Health and Health Sciences
• University of Massachusetts
• Amherst, MA

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Leading Causes of Death in US for 2007 (number of
deaths reported)

• Heart disease (616,067)
• Cancer (562,875)
• Stroke (cerebrovascular diseases) (135,952)
• Chronic lower respiratory diseases (127,924)
• Accidents (unintentional injuries) (123,706)
• Alzheimer's disease (74,632)
• Diabetes (71,382)
• Influenza and Pneumonia (52,717)

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Estimated numbers of new cases and deaths for 5
leading cancer types
Cancer Type Estimated New Cases Estimated Deaths
Lung 222,520 157,300
Colon and Rectal (Combined) 142,570 51,370
Breast (Female- Male) 207,090 1,970 39,840 390
Pancreatic 43,140 36,800
Prostate 217,730 32,050
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Risk Factor Analysis

• Current scientific evidence suggests that the
  risk associated with a majority of health
  conditions are attributable to lifestyles and
  health behaviors that are modifiable given the
  right opportunity structure, access to health
  care, and information.
• Behavioral Risk Factors
• Physical/environmental risk factors
• Social-structural factors

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• Behavioral Risk Factors
• There is solid epidemiological evidence for red
  meat, folate, physical activity, and smoking as
  part of cancer prevention efforts.

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• Smoking accounts for 30 percent of all cancer
  deaths and is the leading preventable cause of
  cancer in the United States.
• Specifically, smoking has been linked to cancers
  of the lung, oral cavity, digestive tract, and
  colon.

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• An additional 30 percent of cancer deaths can be
  attributed to adult diet.
• Higher intake of red meat is a risk factor for
  colon cancer, and recent evidence links red meat
  to risk for prostate cancer.

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• The relationship between physical activity and
  cancer risk has been widely studied.
• A strong and consistent relationship is found
  with risk for colon cancer.
• Some studies have also shown a protective
  effect of physical activity on breast cancer,
  although results are less consistent than for
  colon cancer.

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• Folate is protective against colon cancer.
• Long-term multi-vitamin use, in particular has
  been found to reduce risk for colon cancer,
  likely because of its folate content.

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Physical/Environmental Risk Factors specific to
Low Income populations

• Internet Access
• While approximately 76 of Americans age
  18 have access to the internet, there exists a
  digital divide, with people from higher income
  and education demonstrating greater access and
  usage compared to those who are from lower SES
  groups.
• Even if access is improved, fewer websites
  in health information seeking are designed to
  cater to the needs of those in the lower SES
  groups, who are more likely to have lower
  literacy skills.
• Online use for health is influenced by
  broadband access and experience in usage and
  those with less education, income and who are
  older are less likely to have Broadband
  connections at home.

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2. Barriers to successful dissemination of
evidence-based interventions

• Often these are costly and time consuming
  intensive interventions that could limit
  generalizability
• Limited resources, staff time, and expertise in
  the community to capitalize on the availability
  of evidence-based interventions
• Competing demands for limited resources,
  especially among those groups serving underserved
  populations
• Failure to address outcomes that are of
  relevance, interest and importance to community
  leaders, policy makers and practitioners
• Inadequate training of practitioners
• Complexity and difficulty in use of the
  interventions
• Lack of an effective engagement of the community
  in promoting the adoption of interventions

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Social-structural Factors

• Across multiple health behaviors, patterns of
  risk by socioeconomic position (SEP) and
  race/ethnicity remain constant
• Persons of higher SEP engage in fewer high risk
  behaviors than persons of lower SEP, and there
  have been greater improvements over time in the
  health behaviors of higher income groups vs.
  lower income groups. Risk patterns also differ by
  ethnicity.
• 2. Meat consumption in the US has declined over
  the last 10 years, but greater declines have been
  seen in high-income households than in low income
  households. Similar patterns have been observed
  by race/ethnicity.
• 3. Although sedentary behavior is pervasive in
  the US population at large, minority populations
  are consistently found to be less active than
  whites. Lower income populations less active
  than higher income groups.
• 4. Whites are more likely to use vitamin
  supplements than minorities, a positive
  relationship has been found between SEP and
  supplement use.
• 5. Disparities in smoking rates by SEP and
  race/ethnicity are well-documented.

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Three Current NIH Funded Research Projects

• Open Doors to Health
• A randomized control trial designed to address
  colorectal cancer prevention through low income
  housing sites.
• Conducted in 12 diverse low income housing sites
  eligible residents were enrolled. The housing
  site was the unit of randomization.

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Open Doors to Health (cont. 1)

• The delivered Intervention a social contextual,
  housing site based intervention that included
• Increased access to screening
• Increased development of social norms and social
  support
• Addressed social and environmental barriers to
  participation
• Brought sustainable resources for prevention to
  the housing site through involvement of peer
  leaders.

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Open Doors to Health (cont. 2)

• Successes
• Enrolled and retained 1554 subjects across 12 low
  income housing sites.
• Increased social networks and social capital
  among intervention group.
• Established walking maps for all sites
• Sustained peer leaders in all sites

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Open Doors to Health (cont. 3)

• Barriers
• High rate of colon cancer screening (over 66) at
  baseline was a barrier to seeing any but modest
  effects of the intervention
• Low participation rate in on-site intervention
  activities decreased their effectiveness

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2. Click to Connect

• A randomized controlled trial focused on
  underserved peoples capacity to obtain and
  process health information by developing their
  capacity to seek and use health information by
  providing them access to and training in the use
  of the Internet.
• Recruitment based in adult literacy classes
  across the metro-Boston area.

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Click to Connect (cont. 1)

• Intervention
• Free computers and high-speed Internet access for
  one year
• A web-portal with links to health information
  websites at appropriate literacy levels
• Training classes in computer and Internet use
• Free technical support for one year

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Click to Connect (cont. 2)

• Primary outcomes include several factors that
  contribute to health literacy operationalized
  as media use and exposure to health
• Internet use,
• health information seeking
• information efficacy.
• Participants complete a telephone survey at
  baseline and one month after intervention ends
• Currently approximately 350 participants have
  enrolled

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Project PLANET

• To facilitate the dissemination of
  evidence-based cancer prevention interventions,
  the National Cancer Institute (NCI) and partners
  have developed the Cancer Control P.L.A.N.E.T., a
  state-of-the-art web-based resource for community
  groups, program planners and researchers,
  intended to help them design, implement and adopt
  evidence-based cancer control interventions
  (http//cancercontrolplanet.cancer.gov/), .
• The website is maintained by NCI and is a
  product of a government-private sector
  partnership including NCI, the Centers for
  Disease Control and Prevention (CDC) and the
  American Cancer Society (ACS) among others. While
  much effort has been devoted to envisioning and
  creating PLANET, to date, there is virtually no
  literature or information on the adoption of it
  and the efficacy of its dissemination approaches.

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Project PLANET (cont. 1)

• The goal of our project is to develop and
  test a community participatory model for
  dissemination of evidence-based cancer prevention
  interventions, building off of the resources
  provided through PLANET.
• Community-based participatory research (CBPR)
  methods are an appropriate vehicle for working
  with communities that are considering adoption of
  evidence-based interventions and may enhance the
  probability of successful adoption of the
  interventions.
• Drawing on principles of CBPR, we promote the
  adoption of PLANET in three underserved
  Massachusetts communities Boston, Lawrence
  Worcester.

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Project PLANET (cont. 2)

• Components of the intervention
• Use mixed methods to conduct formative research
  to understand the barriers and facilitators to
  successful adoption of evidence-based cancer
  control interventions.
• Create a web portal, that will (a) provide the
  necessary community-specific information on
  cancer control topics, access to Cancer Control
  PLANET and other web links, and (b) improve
  collective efficacy and social capital among
  local partners by providing a forum for
  exchanging information on health program issues
  and for communicating with each other. Training
  on the portals use will be provided.
• Test if the new PLANET MassCONECT web portal, and
  training of community members will lead to
  increases in a) collective efficacy for adopting
  evidence-based interventions b) use of the
  PLANET (c) PLANET Reach, and (d) Program
  planning and program adoption.

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Implications

• Reaching an underserved population has great
  benefit in reducing cancer burden.
• Positive aspects of involving community members
  in development of such interventions
• The intervention is culturally sensitive
• More participation by the community
• Longer lasting effects and continued programs

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