# Presentation: 096727

## Does Unequal Income Translate intoUnequal Knowledge?

- The Knowledge Gap and Cancer Health Disparities

## Does Unequal Income Translate into Unequal Knowledge?

- Collaborators
- Nancy Breen, PhD, NCI
- Whitney Randolph, PhD, NCI
- Vish Viswanath, PhD, Harvard U.
- Richard P. Moser, PhD, NCI
- Helen Meissner, PhD, NCI
- Bill Rakowski, PhD, Brown University
- Brad Hesse, PhD, NCI

## The burden of cancer is borne unequally

- SES is strongly associated with prevalence and mortality of cancer
- Risk factors --such as tobacco use, obesity and infections-- are more prevalent in lower SES groups
- Protective behaviors –such as regular screening and sun protection– are more prevalent in higher SES groups

## WHY?Knowledge gap is one hypothesis

## The Knowledge Gap Hypothesis

- Differences in knowledge results from socio-economic-based inequalities.
-  Persons with higher SES groups tend to acquire information at a faster rate than lower SES groups.
- Thus the gap between information rich and information poor grows.

## How do income & education affect the knowledge gap? 

- We hypothesize that people from high SES groups know more than those from lower SES groups
- We expect that respondents with low income and high education will do better than persons with high income and low education

**Notes:**
After first hypo, say:  we were also interested in investigating whether education confers more of an advantage than high income.  To look at that, we hypothesize the following:

## Analysis Plan

- Analyze household income and individual educational attainment
- Focus on indicators for which scientific evidence for cancer cause is strong
- smoking and sun exposure

## Defining SES

- Educational attainment and income
- High = GE$50K & GT HS grad
- Medium 1 = LT$50K & GT HS grad
- Medium 2 = GE$50K & LT HS grad
- Low = LT$50K & LT HS grad

**Notes:**
To test our hypo, we combined education and income as follows:

## Knowledge Outcomes

- Q: Which causes the most deaths each year in the US?
- 		R: Cigarettes vs other response
- Q: Smoking increases your chance of getting cancer?
- 		R: A lot vs other response
- Q: Sun exposure increases your chance of getting cancer?
- 		R: A lot vs other response

## Logistic Regression Model

- Age (18-44, 45-64, 65+)
- Race/ethnicity (Hispanic, NH White, NH Black, Other)
- Health insurance (yes, no)

- Confident you’d find info you need  (very vs. somewhat or less)
- Saw a doc in past 12 mos  (yes, no)
- Doesn’t pay attention to medical info (6 different media sources)
- Income and education

**Notes:**
Other:  NAAN, Asian, NHOPI or NH Multiple races

## Table 1:  Likelihood of response that cigarettes are the primary cause of death

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| --- | --- | --- |
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**                                                                   ****Unweighted****	****Predicted margins**
**	****   ****n****	****          ****(95% CI)**
**Age****  ****    ****                              ****	****	****	**
**  ****18-44                      ****	****2656****	****44.1 (41.9 - 46.4)**
**    ****45-64                           ****	****1861****	****39.0 (35.8 - 42.1)**
**    ****65+                            ****	****  995****	****32.9 (29.1 - 36.6)**
**Number of "not at all" responses to pay attention to information about health topics****	**
**  ****0                               ****	****1531****	****42.8 (39.7 - 45.9)**
**    ****1                               ****	****1788****	****42.6 (39.3 - 45.8)**
**    ****2                               ****	****1092****	****39.4 (36.1 - 42.7)**
**    ****3                               ****	****  633****	****35.7 (30.6 - 40.8)**
**    ****4                            ****	****  314****	****41.6 (34.1 - 49.0)**
**    ****5                              ****	****  154****	****29.8 (22.5 - 37.2)**
**Household income and educational attainment**** ****	****	****	**
**  ****>= $50,000 and  > HS grad       ****	****1711****	****44.4 (41.9 - 47.0)**
**     ****< $50,000 and  > HS grad****	****1538****	****40.3 (37.3 - 43.4)**
**    ****>= $50,000 and <= HS grad****	****  424****	****43.3 (36.8 - 49.9)**
**     ****< $50,000 and <= HS grad****	****1839****	****37.2 (33.5 - 41.0)**

**Table 1:  Likelihood of response that cigarettes are the primary cause of death**

- Source 2003 Health Information National Trends Survey

**Predicted margins for significant results only**

**Notes:**
Predicted margins are OR transformed into percentages and they can be understood as percentages.
Only discuss SES variable.  We are starting to see a pattern here....

## Table 2: Likelihood of response that smoking increases chances of getting cancer “a lot” 

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**                                                                   ****Unweighted**
**	****n****	****Predicted margins****	****	****	****                   N****	****	****         (95% CI)**
**Do you have any kind of health coverage?****	****	**
**  ****Yes                                  ****	****2395****	****	****  86.1 (83.9 - 88.3) **
**  ****No                                   ****	****  368****	****	****  79.6 (73.7 - 85.5) **
**Number of "not at all" responses to pay attention to information about health topics ****	**
**  ****0                                    ****	****  771****	****	****  90.8 (88.2 - 93.5) **
**  ****1                                    ****	****  875****	****	****  86.3 (83.5 - 89.1) **
**  ****2                                    ****	****  552****	****	****  83.3 (79.0 - 87.5) **
**  ****3                                    ****	****  305****	****	****  80.2 (73.4 - 87.0) **
**  ****4                                    ****	****  168****	****	****  76.8 (69.0 - 84.7) **
**  ****5                                    ****	****    92****	****	****  81.6 (71.7 - 91.4) **
**Household income and educational attainment****	****	**
**  ****>= $50,000 and  > HS grad            ****	****  860****	****	****  88.3 (85.2 - 91.5) **
**   ****< $50,000 and  > HS grad****	****  757****	****	****  87.2 (84.4 - 90.0) **
**  ****>= $50,000 and <= HS grad****	****  214****	****	****  86.5 (81.5 - 91.4) **
**   ****< $50,000 and <= HS grad****	****  932****	****	****  81.6 (78.0 - 85.3) **

**Table 2: Likelihood of response that smoking increases chances of getting cancer “a lot” **

- Source 2003 Health Information National Trends Survey

**Predicted margins for significant results only**

## Table 3:  Likelihood of response that sun exposure increases chances of getting cancer “a lot”

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**                                                                   ****Unweighted**
**	****n****	****Predicted margins****	****	****	****                   N****	****	****         (95% CI)**
**Race/ethnicity   ****                      ****	****	**
**  ****Hispanic                             ****	****  338****	**** 67.6 (62.3 - 72.8)**
**  ****Non-Hispanic white                   ****	****1892****	****  68.8 (65.7 - 71.9)**
**  ****Non-Hispanic black or African American****	****  330****	****  44.8 (38.3 - 51.4)**
**  ****Non-Hispanic (other or multiple)****	****  148****	****  46.7 (35.4 - 58.0)**
**  ****Ref/NA/DK/Missing                    ****	****    29****	****  53.7 (24.8 - 82.6)**
**Saw a doctor or other health care professional in the past 12 months****     ****	****	**
**  ****Yes                                  ****	****2342****	****  66.2 (63.7 - 68.8)**
**  ****No                                   ****	****  395****	****  56.4 (50.3 - 62.5)**
**Household income and educational attainment **** ****	****	**
**  ****>= $50,000 and  > HS grad            ****	****  850****	****  71.1 (67.3 - 74.8)**
**   ****< $50,000 and  > HS grad****	****  779****	****  67.1 (62.9 - 71.4)**
**  ****>= $50,000 and <= HS grad****	****  210****	****  59.5 (51.7 - 67.4)**
**   ****< $50,000 and <= HS grad****	****  898****	****  59.4 (54.2 - 64.7)**

**Table 3:  Likelihood of response that sun exposure increases chances of getting cancer “a lot”**

- Source 2003 Health Information National Trends Survey

**Predicted margins for significant results only**

## Summary of Findings

- Household income and educational attainment were consistent strong predictors of a knowledge gap for the outcomes studied
- Results were in the expected directions for the 2 extremes
- However, education didn’t compensate more than income, as we anticipated....
- having high income (and low education) was similar to having high education (and low income)
- High income and low education seems more difficult to achieve.  Fewer people had high income and low education (n=424)  than low income and high education (n=1538)