Addressing Disparities in Cancer Risk: Opportunities for Cancer - - PowerPoint PPT Presentation

Social Disparities & Tobacco Control 1

Addressing Disparities in Cancer Risk: Opportunities for Cancer Prevention

Glorian Sorensen, PhD, MPH

Harvard School of Public Health Dana-Farber Cancer Institute March 2, 2006

Social Disparities & Tobacco Control 2

Overview

• Disparities in cancer risks

– Tobacco use as an example risk behavior

• Factors associated with these disparities
• Intervention implications
• Research opportunities and priorities

Social Disparities & Tobacco Control 5

Tobacco use prevalence by education: Persons > 18 years

NHIS, US, 2000

10 20 30 40 50 60

9-11 GED diploma 12 (diploma) Associate degree Some college Undergraduate degree Graduate degree

Men Women

Percentage

Social Disparities & Tobacco Control 6

Source: National Health Interview Survey; n=20,043. United States 1997

5 10 15 20 25 30 35 40 Males Females White Collar Blue Collar Farm Service

Percentage

Tobacco use prevalence by

• ccupation

Social Disparities & Tobacco Control 7

Overview

• Disparities in cancer risk
• Factors associated with these disparities
• Intervention implications
• Research opportunities and priorities

Quitting Smoking Quitting Smoking Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Individual factors Mediating Mechanisms: Individual factors Intervention Intervention

The health behavior change process

Sorensen et al (in review)

Population Characteristics

gender, age, ethnicity/race, education, income, social class, disability, geographic location, sexual orientation, religion, occupation, mental illness and institutionalization

Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Individual factors Mediating Mechanisms: Individual factors Intervention Intervention

The health behavior change process

Quitting Smoking Quitting Smoking Population Characteristics Population Characteristics

Sorensen et al (in review)

Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Individual factors Mediating Mechanisms: Individual factors Intervention Intervention

The health behavior change process

Modifying Conditions: Social Context

Individual factors

• Daily hassles

Interpersonal factors

• Family roles/responsibilities

Organizational factors

• Job strain

Neighborhood/community

• Advertising

Societal factors

• Discrimination

Modifying Conditions: Social Context

Individual factors

• Daily hassles

Interpersonal factors

• Family roles/responsibilities

Organizational factors

• Job strain

Neighborhood/community

• Advertising

Societal factors

• Discrimination

Quitting Smoking Quitting Smoking Population Characteristics Population Characteristics

Sorensen et al (in review)

Social Disparities & Tobacco Control 11

Factors associated with low income among adults, from the Almeda County study, 1988-1990

• Current smoking
• Sedentary
• Obesity
• Unmet needs for

medical care

• Functional problems
• Unemployment
• No decision making
• Unsafe neighborhood
• No instrumental support
• No social support
• No preventive care
• Unmet need for food

Adapted from: Kaplan, 1995

Social Disparities & Tobacco Control 12

Influences on smoking among low income women

• Everyday responsibilities
• Material circumstances
• Social support and social networks
• Personal and health resources

Source: Graham 1993

Social Disparities & Tobacco Control 13

Marketing influences by the tobacco industry

“Previous analyses have shown that our market is much less highly educated than consumers in general, with the younger adult smokers becoming much less educated… in the future, marketing to a “working class/present oriented” mindset will be even more important in appealing to younger adult smokers.”

– RJR, 10/30/86, anonymous

Social Disparities & Tobacco Control 14

Tobacco Tobacco use use patterns patterns

Class

Intersecting effects of multiple sources of inequalities

Gender Occupation Age Race/ Ethnicity

Social Disparities & Tobacco Control 15

Overview

• Disparities in cancer risk
• Factors associated with these disparities
• Intervention implications
• Research opportunities and priorities

Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Organizational and policy factors Mediating Mechanisms: Individual factors Mediating Mechanisms: Individual factors Intervention Intervention

The health behavior change process

Quitting Smoking Quitting Smoking Population Characteristics Population Characteristics Modifying Conditions: Social Context

Individual factors

• Daily hassles

Interpersonal factors

• Family roles/responsibilities

Organizational factors

• Job strain

Neighborhood/community

• Safety

Societal factors

• Discrimination

Modifying Conditions: Social Context

Individual factors

• Daily hassles

Interpersonal factors

• Family roles/responsibilities

Organizational factors

• Job strain

Neighborhood/community

• Safety

Societal factors

• Discrimination

Sorensen et al (in review

Social Disparities & Tobacco Control 17

Case Example: WellWorks-2

Social Disparities & Tobacco Control 18

Challenges in worksite health promotion for blue-collar workers

• Less access to health promotion programs
• Lower participation rates
• Structural barriers to participation in programs
• Less supportive work environment
• Other health priorities and job concerns

Social Disparities & Tobacco Control 19

Upstream Midstream Downstream

Reducing youth access Nonsmoking policies Warning labels Mass media counter advertising School and smoking education programs Quit smoking classes Patient education

Adapted from McKinlay, 1995

Continuum of intervention approaches to promote tobacco control

Reduced exposures to job hazards Raising cigarette taxes

Social Disparities & Tobacco Control 20

WellWorks-2: Study hypothesis

The integration of health protection with health promotion will enhance the intervention impact on behavior change over and above health promotion alone.

Social Disparities & Tobacco Control 21

Health Promotion Health Promotion Health Promotion plus Health Protection Health Promotion plus Health Protection Baseline Assessments in 15 worksites (n=9,019) Baseline Assessments in 15 worksites (n=9,019) Randomization Randomization Final Assessments Final Assessments

WellWorks-2: Study hypothesis

Social Disparities & Tobacco Control 22

Comparison of worksite intervention models

Traditional health WellWorks integrated promotion programs model Intervention target Individual behaviors Individual behaviors and the work environment Assumptions about responsibility for worker Individual worker Shared between worker health and management Audience Workers Workers, union, management Program planning Outside expert Collaboration with worksite committees

Social Disparities & Tobacco Control 23

Adjusted six-month quit rates at final by intervention and job type (cohort of smokers at baseline: n=880)

11.8 5.9 9.9 12.7 2 4 6 8 10 12 14 Hourly workers Salaried workers HP/OSH final HP final

Sorensen et al, Cancer Causes and Control, 2002

Quit rates

Social Disparities & Tobacco Control 24

Implications for impact

Expected implications for reducing the burden

• f cancer:

– 700,000 blue-collar workers in Massachusetts with 80% participation 200,000 smokers – 2,880 lung cancer cases avoided

Colditz, Cancer Causes and Control, 2003

Social Disparities & Tobacco Control 25

Cancer prevention for unionized blue-collar workers: Tools for Health

Aims

– Assess job and behavioral risks among construction laborers – Design intervention appropriate for the audience – Test efficacy of telephone-delivered intervention targeting tobacco use cessation and increased fruit and vegetable consumption

Reach

Individual Counseling Group Program Brief Counseling Self-help Guides Pamphlets High Low

Intervention Efficacy

High Mass Media

Social Disparities & Tobacco Control 27

Tools For Health

• Union collaboration
• Formative research informed intervention design
• Individual workers randomized to intervention

condition

• Tailored telephone-delivered intervention
• Messages link tobacco use, occupational hazards

and diet

Social Disparities & Tobacco Control 29

Tools for Health: Final results

0% 5% 10% 15% 20% Intervention Control % Baseline Smokers Quitting

19% 8% Smoking cessation rates (p=0.03)

Social Disparities & Tobacco Control 30

Tools for Health: Final results

0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Intervention Control

Change in servings, baseline to final

Fruit and vegetable consumption (servings/day; p=0.0001) 1.5 servings 0 servings

Social Disparities & Tobacco Control 31

Overview

• Disparities in cancer risk
• Factors associated with these disparities
• Intervention implications
• Research opportunities and priorities

Social Disparities & Tobacco Control 32

Questions to guide future research

• Who is at elevated risk?
• What contextual factors are related to their risk
• utcomes?
• What resources and assets does the worksite/union
• r other community partner bring?
• What factors influence intervention success across

multiple levels?

• How can we plan for the dissemination of effective

interventions?

Social Disparities & Tobacco Control 33

Research recommendations for the near term

• Analyze existing data sources

– assess intersecting roles of multiple sources of disparities – understand the role of social contextual factors

• Extend partnerships

– with diverse community groups – for transdisciplinary collaborations

Social Disparities & Tobacco Control 34

Research recommended for the long term: Priority directions

• Explore the “black box” of social contextual

factors influencing tobacco use patterns

• Identify community resources and assets
• Understand complex intersections across

multiple sources of disparity

• Understand determinants of successful

interventions across multiple levels

• Assess factors contributing to effective

dissemination