Community Based Strategies for Cancer Control and Prevention

1. 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

2. 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)

3. Estimated numbers of new cases and deaths for 5 leading cancer types:

4. 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

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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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.

14. 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.

15. 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

16. 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

17. 2. Click to Connect • A randomized controlled trial focused on underserved people’s 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.

18. 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

19. 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

20. 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.

21. 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.

22. 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 portal’s 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.

23. 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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