Community Based Strategies Community Based Strategies for Cancer Control and for Cancer Control and

PreventionPreventionElaine Puleo, Ph.D.Elaine Puleo, Ph.D.

Associate Dean of ResearchAssociate Dean of ResearchSchool of Public Health and Health SciencesSchool of Public Health and Health Sciences

University of MassachusettsUniversity of MassachusettsAmherst, MAAmherst, MA

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

reported)reported)

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

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

Cancer TypeCancer Type Estimated New Estimated New CasesCases

Estimated DeathsEstimated Deaths

Lung Lung 222,520222,520 157,300157,300

Colon and Rectal Colon and Rectal (Combined)(Combined)

142,570142,570 51,37051,370

Breast (Female- Breast (Female- Male)Male)

207,090 – 1,970207,090 – 1,970 39,840 – 39039,840 – 390

PancreaticPancreatic 43,14043,140 36,80036,800

ProstateProstate 217,730217,730 32,05032,050

Risk Factor AnalysisRisk Factor AnalysisCurrent scientific evidence suggests Current scientific evidence suggests

that the risk associated with a that the risk associated with a majority of health conditions are majority of health conditions are attributable to lifestyles and health attributable to lifestyles and health behaviors that are modifiable given behaviors that are modifiable given the right opportunity structure, the right opportunity structure, access to health care, and access to health care, and information.information.

Behavioral Risk FactorsBehavioral Risk FactorsPhysical/environmental risk factorsPhysical/environmental risk factorsSocial-structural factorsSocial-structural factors

Behavioral Risk Factors:Behavioral Risk Factors:

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

SmokingSmoking accounts for 30 percent of accounts for 30 percent of all cancer deaths and is the leading all cancer deaths and is the leading preventable cause of cancer in the preventable cause of cancer in the United States. United States.

Specifically, smoking has been linked to Specifically, smoking has been linked to cancers of the lung, oral cavity, cancers of the lung, oral cavity, digestive tract, and colon.digestive tract, and colon.

An additional 30 percent of cancer An additional 30 percent of cancer deaths can be attributed to deaths can be attributed to adult adult dietdiet..

Higher intake of Higher intake of red meatred meat is a risk factor is a risk factor for colon cancer, and recent evidence for colon cancer, and recent evidence links red meat to risk for prostate links red meat to risk for prostate cancer. cancer.

The relationship between The relationship between physical physical activityactivity and cancer risk has been and cancer risk has been widely studied.widely studied.

A strong and consistent relationship is found A strong and consistent relationship is found with risk for colon cancer.with risk for colon cancer.

Some studies have also shown a protective Some studies have also shown a protective effect of physical activity on breast cancer, effect of physical activity on breast cancer, although results are less consistent than for although results are less consistent than for colon cancer.colon cancer.

Folate is protective against colon Folate is protective against colon cancer.cancer.

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

Physical/Environmental Risk Factors specific Physical/Environmental Risk Factors specific to Low Income populationsto Low Income populations

1.1. Internet Access:Internet Access:

While approximatelyWhile approximately 76% of Americans age 18+ have access to 76% of Americans age 18+ have access to the internet, there exists a “digital divide,” with people from the internet, there exists a “digital divide,” with people from higher income and education demonstrating greater access higher income and education demonstrating greater access and usage compared to those who are from lower SES groups. and usage compared to those who are from lower SES groups.

Even if access is improved, fewer websites in health Even if access is improved, fewer websites in health information seeking are designed to cater to the needs of information seeking are designed to cater to the needs of those in the lower SES groups, who are more likely to have those in the lower SES groups, who are more likely to have lower literacy skills. lower literacy skills.

Online use for health is influenced by broadband access and Online use for health is influenced by broadband access and experience in usage and those with less education, income experience in usage and those with less education, income and who are older are less likely to have Broadband and who are older are less likely to have Broadband connections at home. connections at home.

2. 2. Barriers to successful dissemination of Barriers to successful dissemination of evidence-based interventionsevidence-based interventions

Often these are costly and time consuming intensive interventions Often these are costly and time consuming intensive interventions that could limit generalizabilitythat could limit generalizability

Limited resources, staff time, and expertise in the community to Limited resources, staff time, and expertise in the community to

capitalize on the availability of evidence-based interventions capitalize on the availability of evidence-based interventions

Competing demands for limited resources, especially among those Competing demands for limited resources, especially among those groups serving underserved populations groups serving underserved populations

Failure to address outcomes that are of relevance, interest and Failure to address outcomes that are of relevance, interest and importance to community leaders, policy makers and practitioners importance to community leaders, policy makers and practitioners

Inadequate training of practitioners Inadequate training of practitioners

Complexity and difficulty in use of the interventions Complexity and difficulty in use of the interventions

Lack of an effective engagement of the community in promoting Lack of an effective engagement of the community in promoting the adoption of interventions the adoption of interventions

Social-structural FactorsSocial-structural FactorsAcross multiple health behaviors, patterns of risk by Across multiple health behaviors, patterns of risk by

socioeconomic position (SEP) and race/ethnicity socioeconomic position (SEP) and race/ethnicity remain constant: remain constant:

1.1. Persons of higher SEP engage in fewer high risk behaviors than persons Persons of higher SEP engage in fewer high risk behaviors than persons of lower SEP, and there have been greater improvements over time in of lower SEP, and there have been greater improvements over time in the health behaviors of higher income groups vs. lower income groups. the health behaviors of higher income groups vs. lower income groups. Risk patterns also differ by ethnicity.Risk patterns also differ by ethnicity.

2. Meat consumption in the US has declined over the last 10 years, but 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 greater declines have been seen in high-income households than in low income households. Similar patterns have been observed by income households. Similar patterns have been observed by race/ethnicity. race/ethnicity.

3. Although sedentary behavior is pervasive in the US population at large,3. Although sedentary behavior is pervasive in the US population at large, minority populations are consistently found to be less active than whites. minority populations are consistently found to be less active than whites. Lower income populations less active than higher income groups. Lower income populations less active than higher income groups.

4. Whites are more likely to use vitamin supplements than minorities, a 4. Whites are more likely to use vitamin supplements than minorities, a positive relationship has been found between SEP and supplement use. positive relationship has been found between SEP and supplement use.

5. Disparities in smoking rates by SEP and race/ethnicity are well-5. Disparities in smoking rates by SEP and race/ethnicity are well-documented.documented.

Three Current NIH Funded Three Current NIH Funded Research ProjectsResearch Projects

1.1. Open Doors to HealthOpen Doors to Health• A randomized control trial designed to A randomized control trial designed to

address colorectal cancer prevention address colorectal cancer prevention through low income housing sites.through low income housing sites.

• Conducted in 12 diverse low income Conducted in 12 diverse low income housing sites; eligible residents were housing sites; eligible residents were enrolled. The housing site was the unit enrolled. The housing site was the unit of randomization.of randomization.

Open Doors to Health (cont. 1)Open Doors to Health (cont. 1)

• The delivered InterventionThe delivered Intervention – a social – a social contextual, housing site based contextual, housing site based intervention that included intervention that included • Increased access to screeningIncreased access to screening• Increased development of social norms Increased development of social norms

and social supportand social support• Addressed social and environmental Addressed social and environmental

barriers to participationbarriers to participation• Brought sustainable resources for Brought sustainable resources for

prevention to the housing site through prevention to the housing site through involvement of peer leaders.involvement of peer leaders.

Open Doors to Health (cont. 2)Open Doors to Health (cont. 2)

Successes:Successes:

• Enrolled and retained 1554 subjects across 12 Enrolled and retained 1554 subjects across 12 low income housing sites.low income housing sites.

• Increased social networks and social capital Increased social networks and social capital among intervention group.among intervention group.

• Established walking maps for all sitesEstablished walking maps for all sites• Sustained peer leaders in all sitesSustained peer leaders in all sites

Open Doors to Health (cont. 3)Open Doors to Health (cont. 3)

Barriers Barriers

• High rate of colon cancer screening (over High rate of colon cancer screening (over 66%) at baseline was a barrier to seeing 66%) at baseline was a barrier to seeing any but modest effects of the interventionany but modest effects of the intervention

• Low participation rate in on-site Low participation rate in on-site intervention activities decreased their intervention activities decreased their effectivenesseffectiveness

2. Click to Connect2. Click to Connect

• A randomized controlled trial focused on A randomized controlled trial focused on underserved people’s capacity to obtain underserved people’s capacity to obtain and process health information by and process health information by developing their capacity to seek and developing their capacity to seek and use health information by providing use health information by providing them access to and training in the use of them access to and training in the use of the Internet. the Internet.

• Recruitment based in adult literacy Recruitment based in adult literacy classes across the metro-Boston area. classes across the metro-Boston area.

Click to Connect (cont. 1)Click to Connect (cont. 1)

Intervention:Intervention:• Free computers and high-speed Internet Free computers and high-speed Internet

access for one year access for one year

• A web-portal with links to health information A web-portal with links to health information websites at appropriate literacy levelswebsites at appropriate literacy levels

• Training classes in computer and Internet Training classes in computer and Internet useuse

• Free technical support for one year Free technical support for one year

Click to Connect (cont. 2)Click to Connect (cont. 2) Primary outcomes include several factors Primary outcomes include several factors

that contribute to health literacy – that contribute to health literacy – operationalized as media use and exposure to operationalized as media use and exposure to health:health: Internet use, Internet use, health information seekinghealth information seeking information efficacy. information efficacy.

Participants complete a telephone survey at Participants complete a telephone survey at baseline and one month after intervention ends baseline and one month after intervention ends

Currently approximately 350 participants have Currently approximately 350 participants have enrolledenrolled

3.3. Project PLANETProject PLANET To facilitate the dissemination of evidence-based cancer To facilitate the dissemination of evidence-based cancer

prevention interventions, the National Cancer Institute (NCI) prevention interventions, the National Cancer Institute (NCI) and partners have developed the Cancer Control P.L.A.N.E.T., a and partners have developed the Cancer Control P.L.A.N.E.T., a state-of-the-art web-based resource for community groups, state-of-the-art web-based resource for community groups, program planners and researchers, intended to help them program planners and researchers, intended to help them design, implement and adopt evidence-based cancer control design, implement and adopt evidence-based cancer control interventions (interventions (http://http://cancercontrolplanet.cancer.govcancercontrolplanet.cancer.gov//), . ), .

The website is maintained by NCI and is a product of a The website is maintained by NCI and is a product of a government-private sector partnership including NCI, the government-private sector partnership including NCI, the Centers for Disease Control and Prevention (CDC) and the Centers for Disease Control and Prevention (CDC) and the American Cancer Society (ACS) among others. While much American Cancer Society (ACS) among others. While much effort has been devoted to envisioning and creating PLANET, to effort has been devoted to envisioning and creating PLANET, to date, date, there is virtually no literature or information on there is virtually no literature or information on the adoption of it and the efficacy of its dissemination the adoption of it and the efficacy of its dissemination approaches.approaches.

Project PLANET (cont. 1)Project PLANET (cont. 1) The goal of our project is to develop and test a The goal of our project is to develop and test a

community participatory modelcommunity participatory model for dissemination of for dissemination of evidence-based cancer prevention interventions, evidence-based cancer prevention interventions, building off of the resources provided through building off of the resources provided through PLANET. PLANET.

CCommunity-based participatory research ommunity-based participatory research (CBPR) (CBPR) methods are an appropriate vehicle for working with methods are an appropriate vehicle for working with communities that are considering adoption of communities that are considering adoption of evidence-based interventions and may enhance the evidence-based interventions and may enhance the probability of successful adoption of the interventions. probability of successful adoption of the interventions.

Drawing on principles of CBPR, we promote the Drawing on principles of CBPR, we promote the adoption of PLANET in three underserved adoption of PLANET in three underserved Massachusetts communities: Massachusetts communities: Boston, Lawrence & Boston, Lawrence & WorcesterWorcester. .

Project PLANET (cont. 2)Project PLANET (cont. 2)Components of the intervention:Components of the intervention:

Use mixed methods to conduct formative research to Use mixed methods to conduct formative research to understand the barriers and facilitators to successful understand the barriers and facilitators to successful adoption of evidence-based cancer control interventions.adoption of evidence-based cancer control interventions.

Create a web portal, that will: (a) provide the necessary Create a web portal, that will: (a) provide the necessary community-specific information on cancer control topics, community-specific information on cancer control topics, access to Cancer Control PLANET and other web links, and access to Cancer Control PLANET and other web links, and (b) improve collective efficacy and social capital among (b) improve collective efficacy and social capital among local partners by providing a forum for exchanging local partners by providing a forum for exchanging information on health program issues and for information on health program issues and for communicating with each other. Training on the portal’s communicating with each other. Training on the portal’s use will be provided.use will be provided.

Test if the new PLANET MassCONECT web portal, and Test if the new PLANET MassCONECT web portal, and training of community members will lead to increases in: a) training of community members will lead to increases in: a) collective efficacy for adopting evidence-based collective efficacy for adopting evidence-based interventions; b) use of the PLANET; (c) PLANET Reach, and interventions; b) use of the PLANET; (c) PLANET Reach, and (d) Program planning and program adoption.(d) Program planning and program adoption.

ImplicationsImplications Reaching an underserved population Reaching an underserved population

has great benefit in reducing cancer has great benefit in reducing cancer burden.burden.

Positive aspects of involving Positive aspects of involving community members in development community members in development of such interventions:of such interventions: The intervention is culturally sensitiveThe intervention is culturally sensitive More participation by the communityMore participation by the community Longer lasting effects and continued Longer lasting effects and continued

programs programs

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