by Lyn B Robertson DrPH, RN, MSN & Beth Simon DrPH, RN, MSN

Nobody can explain why the chance of getting some types of cancer is greater for blacks than for whites. Through programs at the University of Pittsburgh Cancer Institute, we are working directly with those who are affected to understand this problem and to do something about it. One example of this effort is the UPCI/UPMC Cancer Control with Healthcare for the Homeless. This collaboration, initiated in January 2008, reaches out to men and women in eight shelters throughout the city of Pittsburgh and is growing. In addition to educating people about the importance of regular screening (for breast, prostate, and colorectal cancers) to find the diseases early enough to intervene, we also provide clear, concise information on ways to reduce the risk of the disease by improving nutritional and other lifestyle factors and reducing other environmental risk factors.

The men and women we serve are often individuals in transition who may have neglected their health care needs for a period of time. Some have physical or mental disabilities that make it difficult for them to navigate the health care system. When appropriate, we use navigation services to help these individuals maneuver through the health care system, particularly in the areas of diagnostic testing and follow-up.

Our mission to help the disadvantaged is only partially realized if we focus solely on individuals and fail to address the environments in which people live and work. The reasons why people of color experience some diseases and injuries more frequently and more severely than the general population are not well understood. While it is well known that socioeconomic factors contribute to health disparities, not enough attention is given to the environmental factors such as air pollution and workplace hazards that more often plague communities in disadvantaged neighborhoods, many of which can also contribute to disparities in health outcomes.(1)

The “natural” environment such as air, water and soil has a direct influence on health. (2) Individuals of color or individuals with a low socio-economic status (SES) are five times more likely to live in areas where the environment is of poorer quality. The social environment affects health directly and indirectly, influencing behavior and limiting options. People who live in poorer neighborhoods tend to experience more personal and environmental stress which can contribute to poorer mental and physical health. (3) For instance, fruit and vegetable intake —known to lower the risk of some cancers, was 32% higher in African American neighborhoods that were close to supermarkets. We are working with our colleagues at UPCI and the Center for Minority Health of the Graduate School of Public Health to promote healthier individual and family behaviors and to encourage broad community efforts to create healthier social environments.(4) We recognize that it is important to address both those conditions that individuals can control directly, such as tobacco use, inactivity, and high fat diets, and the availability of healthier options.

Consistent with prior research, the most recent National Health Care Disparities Report (NHDR) confirmed that disparities related to race, ethnicity, and socioeconomic status still pervade the American health care system.(5) according to the EPA, blacks and Hispanics are much more likely to live near hazardous waste facilities or in more degraded neighborhoods. This means that the chances of incurring workplace and other hazards is much greater for minorities.

For more than twenty years, the Department of Health and Human Services (DHHS) has lead many initiatives aimed at reducing health care disparities and improving quality of care. There are also numerous private organizations that have taken key roles in this endeavor. In 2005, the NHDR undertook efforts to track changes in core measures related to health care disparities. These studies have demonstrated that although some disparities are diminishing, others are increasing. For Blacks, Asians and Hispanics, disparities involved all domains of quality that could be tracked, including: access to preventative services, treatment of acute illness, chronic illness and disability management, timelines, and patient centeredness. There remain many opportunities for improvement and our cancer control efforts are making a difference here in western PA.

By including well-documented individual behavioral risk factors with those in the environment, our evolving program will provide a unique combination of efforts aimed at reducing the burden of the personal and general environment for cancer. There remain many opportunities for improvement.

When developing approaches to improve the community environment, it is important to focus on both risk and resilience. (6) Resilience can be characterized as protective factors and can be integrated into community planning efforts. Threats to health and safety may be minimized by limiting risk factors, but this will not necessarily provide conditions that support good health. Resilience can counteract the negative impact of exposure to risk factors.(7&8) So what can be done to increase resilience? A few examples of efforts that may be effective include: engaging local politicians and community leaders so that community voices can be heard and responded to; organizing community beautification projects through planting of community flower, fruit and vegetable gardens; creative use of paintings such as murals on buildings; and educating the community about ways to decrease their exposure to environmental toxins to which it is in their control to reduce their exposure. If these efforts are successful, then resilience within the community increases, which can then be harnessed to counteract some of the negative impact of other environmental risk factors.

References:

1. Smedley BD, Syme SL, A social environmental approach to health and health interventions. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Behavioral Research. Washington DC: National Academy Press; 2000: 81-124.
2. Lee C. Environmental justice: building a unified vision of health and the environment. (2002), Environmental Health Perspect.110 (suppl 2):141-144.
3. Husain A. Psychosocial stressors of asthma in inner-city school children.  APHA poster presentation at: Putting the Public Back into public Health: 130th APHA Annual Meeting; November 9-13, 2002; Philadelphia PA.
4. Adler NE, Newman K Socioeconomic disparities in health: pathways and policies. Health Affairs. 2002:21(2):69.
5. National Healthcare Disparities Report, 2007; Summary from Agency for Healthcare Research and Quality
6. Davis R, Cook D, Cohen L, Community resilience approach to reducing ethnic and racial disparities in health. American Journal of Public Health. 2005; 95(12), 2168-2173.
7. Bradley RH, Whileside L, Mundfrom DJ, Casey PH, Kelleher KJ, Pope SK. Early indications of resilience and their relation to experiences in the home environments of low birth weight, premature children living in poverty.  Child Development. 1994; 65:346-360
8. Smith C, Lizotte AJ, Thornberry TP, Krohn MD. Resilient youth: identifying factors that prevent high-risk youth from engaging in delinquency and drug use.  In Hagan J ed. Delinquency in the life Course: Contextual and Dynamic Analysis. Greenwich, CT: JAI Press; 1995:217-247.