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 1
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 2
Tobacco use prevalence by education: Persons > 18 years Men Women 60 50 40 Percentage 30 20 10 0 9-11 GED diploma 12 (diploma) Associate Some college Undergraduate Graduate degree degree degree NHIS, US, 2000 Social Disparities & Tobacco Control 5
Tobacco use prevalence by occupation 40 35 30 Percentage 25 20 15 10 5 0 Males Females White Collar Blue Collar Farm Service Source: National Health Interview Survey; n=20,043. United States 1997 Social Disparities & Tobacco Control 6
Overview • Disparities in cancer risk • Factors associated with these disparities • Intervention implications • Research opportunities and priorities Social Disparities & Tobacco Control 7
The health behavior change process Intervention Intervention Population Characteristics gender, age, Mediating Mechanisms: Mediating Mechanisms: ethnicity/race, Organizational Organizational education, income, social class, and policy factors and policy factors disability, geographic location, Quitting sexual orientation, Quitting religion, occupation, Smoking Smoking mental illness and institutionalization Mediating Mechanisms: Mediating Mechanisms: Individual factors Individual factors Sorensen et al (in review)
The health behavior change process Intervention Intervention Mediating Mechanisms: Mediating Mechanisms: Organizational Organizational Population and policy factors Population and policy factors Characteristics Characteristics Quitting Quitting Smoking Smoking Mediating Mechanisms: Mediating Mechanisms: Individual factors Individual factors Sorensen et al (in review)
The health behavior change process Intervention Intervention Modifying Conditions: Modifying Conditions: Mediating Mechanisms: Mediating Mechanisms: Social Context Social Context Organizational Organizational Population and policy factors Population and policy factors Individual factors Individual factors Characteristics • Daily hassles Characteristics • Daily hassles Quitting Quitting Interpersonal factors Interpersonal factors Smoking Smoking • Family roles/responsibilities • Family roles/responsibilities Organizational factors Organizational factors Mediating Mechanisms: Mediating Mechanisms: • Job strain • Job strain Individual factors Individual factors Neighborhood/community Neighborhood/community • Advertising • Advertising Societal factors Societal factors • Discrimination • Discrimination Sorensen et al (in review)
Factors associated with low income among adults, from the Almeda County study, 1988-1990 • Current smoking • No decision making • Sedentary • Unsafe neighborhood • Obesity • No instrumental support • Unmet needs for • No social support medical care • No preventive care • Functional problems • Unmet need for food • Unemployment Adapted from: Kaplan, 1995 Social Disparities & Tobacco Control 11
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 12
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 13
Intersecting effects of multiple sources of inequalities Class Race/ Age Ethnicity Tobacco Tobacco Gender Occupation use use patterns patterns Social Disparities & Tobacco Control 14
Overview • Disparities in cancer risk • Factors associated with these disparities • Intervention implications • Research opportunities and priorities Social Disparities & Tobacco Control 15
The health behavior change process Intervention Intervention Modifying Conditions: Modifying Conditions: Mediating Mechanisms: Mediating Mechanisms: Social Context Social Context Organizational Organizational Population and policy factors Population and policy factors Individual factors Individual factors Characteristics • Daily hassles Characteristics • Daily hassles Quitting Quitting Interpersonal factors Interpersonal factors Smoking Smoking • Family roles/responsibilities • Family roles/responsibilities Organizational factors Organizational factors Mediating Mechanisms: Mediating Mechanisms: • Job strain • Job strain Individual factors Individual factors Neighborhood/community Neighborhood/community • Safety • Safety Societal factors Societal factors • Discrimination • Discrimination Sorensen et al (in review
Case Example: WellWorks-2 Social Disparities & Tobacco Control 17
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 18
Continuum of intervention approaches to promote tobacco control Reduced exposures to job hazards School and Raising smoking cigarette Patient education taxes education Reducing Warning programs youth labels Quit smoking access classes Nonsmoking Mass media policies counter advertising Upstream Midstream Downstream Adapted from McKinlay, 1995 Social Disparities & Tobacco Control 19
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 20
WellWorks-2: Study hypothesis Baseline Assessments in 15 worksites Baseline Assessments in 15 worksites (n=9,019) (n=9,019) Randomization Randomization Health Promotion Health Promotion Health Health plus plus Promotion Promotion Health Protection Health Protection Final Final Assessments Assessments Social Disparities & Tobacco Control 21
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 22
Adjusted six-month quit rates at final by intervention and job type (cohort of smokers at baseline: n=880) 12.7 14 11.8 HP/OSH final 12 9.9 HP final 10 Quit rates 8 5.9 6 4 2 0 Hourly workers Salaried workers Sorensen et al , Cancer Causes and Control, 2002 Social Disparities & Tobacco Control 23
Implications for impact Expected implications for reducing the burden of cancer: – 700,000 blue-collar workers in Massachusetts with 80% participation � 200,000 smokers – 2,880 lung cancer cases avoided Social Disparities & Tobacco Control 24 Colditz, Cancer Causes and Control, 2003
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 Social Disparities & Tobacco Control 25
High Mass Media Pamphlets Self-help Guides Reach Brief Counseling Group Program Individual Counseling Low High Intervention Efficacy
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 27
Tools for Health: Final results Smoking cessation rates (p=0.03) 20% % Baseline Smokers Quitting 15% 10% 5% 0% Intervention Control 8% 19% Social Disparities & Tobacco Control 29
Tools for Health: Final results Fruit and vegetable consumption (servings/day; p=0.0001) Change in servings, baseline to final 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Intervention Control 0 servings 1.5 servings Social Disparities & Tobacco Control 30
Overview • Disparities in cancer risk • Factors associated with these disparities • Intervention implications • Research opportunities and priorities Social Disparities & Tobacco Control 31
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