It Takes a Village: Community Factors and Cancer Prevention

Issue 27 Summer/Fall 2016

A wealth of data, from a variety of sources, points to an unequal burden of cancer across racial/ethnic groups and socioeconomic status.1

It's also clear that multiple, complex factors - related to both the prevention and treatment of cancer - combine to drive these disparities.

Why do these inequities exist? There's growing evidence that they are at least partly the result of unequal distribution of resources, so that certain vulnerable groups lack access to opportunities to improve their health.2

Seeking to better target research to understand these persistent - and sometimes increasing - cancer health disparities, experts have devised a framework known as the "social determinants of health," or SDOH - an important means of identifying the upstream factors behind these inequalities.

SDOH is defined by the World Health Organization as, "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life." 3

There are some obvious examples - social support and access to health care services (including high-quality services) come to mind.

But beyond those are institutional forces - factors such as residential segregation, as well as neighborhood factors, such as built environments and community resources.

Of course the individual does have the power to change his or her health. In fact, it's been estimated that more than half of cancers can be avoided through modifiable health behaviors, including cigarette smoking, being overweight or obese, poor diet, lack of exercise, etc.4

However, the rate at which people adopt behaviors like these varies widely across communities. Why? SDOH highlights the notion that for individuals to improve their health by adopting healthy behaviors, we must also consider influences outside the individual's control.

This is because people's health is determined, in part, by access to what's available in their surroundings. In this way, where people live can be a powerful determinant of health - including their homes, neighborhoods, communities, and even workplaces and schools.

This is a crucial concept when it comes to cancer health disparities, because often people from poor and underserved communities do not have choices for adopting such behaviors.

All of this means that we are moving away from putting the responsibility solely on the individual, and instead asking communities and stakeholders to also help provide solutions.

Evidence of this new paradigm comes from the U.S. government's Healthy People 2020 (HP2020) initiative, where one of the four overarching goals is to "Create social and physical environments that promote good health for all." 5

In doing so, HP2020 calls for identifying ways to create social and physical environments that promote good health for all. Their framework identifies five key areas of SDOH: economic stability; education; social and community context; health and health care; and, neighborhood and built environment (see figure).5

HP2020 also posits that sustainable changes will come by establishing policies that positively influence social and economic conditions, along with supporting changes in individual behavior.

In that sense, the saying "It Takes a Village" is truly applicable in the SDOH framework. Building healthy communities requires that we provide equal opportunities to achieve health, regardless of race, ethnicity, gender, social class, sexual orientation, language, etc.

Take the obesity epidemic as an example, which contributes to 20 percent of cancers.4 Also, obesity prevalence is high in blacks and Hispanics and in lowincome communities.6

How do we address this epidemic? It is not enough to tell people that obesity is "bad for their health." Real solutions require the engagement of stakeholders and communities to make changes so that neighborhoods where low-income individuals reside have access to stores that provide affordable, healthy food choices; that residents are taught how to prepare healthy meals; that local government organizations build safe neighborhood parks and recreation facilities; that sidewalks and bicycle lanes are available; that children have access to healthy food in schools, including those who receive free or reduced-cost school meals.

Another important consideration for addressing cancer disparities and inequities is that because the causes are evident at different levels (i.e., individual, neighborhood, health care system, etc.), then the solutions must consider these different levels and how they interact.2

This multi-level framework for understanding the causes of disparities and inequities is essential for addressing those causes, and is the driving force of much of the current research agenda. It is through these integrated efforts that we have the potential to improve health in all communities - and in doing so, reduce cancer disparities related to prevention.

María Elena Martínez

María Elena Martínez
Professor, Family Medicine and Public Health
UC San Diego Moores Cancer Center
San Diego, CA

Scarlett Lin Gomez

Scarlett Lin Gomez
Research Scientist
Cancer Prevention Institute of California
Member, Stanford Cancer Institute
Stanford, CA

References

  1. Kish JK, et al. Racial and ethnic disparities in cancer survival by neighborhood socioeconomic status in Surveillance, Epidemiology, and End Results (SEER) Registries. J Natl Cancer Inst Monogr. 2014 Nov;2014(49):236-43.
  2. Warnecke et al., Approaching Health Disparities From a Population Perspective: The National Institutes of Health Centers for Population Health and Health Disparities. Am J Public Health. 2008 September; 98(9): 1608–1615.
  3. World Health Organization. Social Determinants of Health. http://www.who.int/social_determinants/en/. Accessed March 15, 2016.
  4. Colditz GA, Wolin KY, Gehlert S. Applying what we know to accelerate cancer prevention. Sci Transl Med. 2012 Mar 28;4(127):127rv4. doi: 10.1126/scitranslmed.3003218.
  5. Office of Disease Prevention and Health Promotion. Social Determinants of Health. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed March 13, 2016.
  6. Ogden CL, et al. Prevalence of obesity in the United States. JAMA. 2014 Jul;312(2):189-90.