Community-Driven Approaches for Reducing Health Disparities in Cancer
Authors: Edward Partridge
Journal: JAMA (2010)

SINCE 1990, OVERALL CANCER MORTALITY RATES HAVE declined at a rate of approximately 1% per year, with mortality from breast, colorectal, prostate, and lung cancer declining at about 2% per year. These declines have largely been attributed to favorable trends in some risk factors for cancer, increased use of methods to detect cancer earlier, and more effective means to treat the disease. However, cancer-related mortality rates for African Americans continue to be considerably higher than those for non-Hispanic whites in the United States. Although the mortality gap has decreased somewhat, mostly secondary to tobacco-related cancers and reflecting declining tobacco use by African Americans, the mortality gap has not diminished for cancers with rates affected by early detection or effective treatment. Differences in mortality and prevalence of risk factors are related to social class as defined by level of educational achievement. The decline in cancer mortality is greater for college graduates than for high school graduates, and no decline has occurred among those with less than a high school education. Other causes of cancer health disparities involve limited access to care, including prevention and early detection; unequal treatment when cancer is diagnosed; differences in behaviors that increase cancer risk, such as tobacco use, unhealthful diet, and lack of physical activity; differences in behaviors that decrease cancer risk, such as screening for breast, colorectal, and cervical cancer; and diverse cultural beliefs that influence the care-seeking behavior of patients. Advances in medical knowledge and technology also widen the disparity gap because technological innovations are differentially delivered to various groups and populations. Elimination of the screening gap between African American and white patients for breast, cervical, and colorectal cancer is perhaps the easiest way to influence cancer health disparity. Screening is at most an annual event, and at least for breast cancer and cervical cancer, most of the population has access to screening either through insurance, Medicare, or the Breast and Cervical Cancer Early Detection Program (colorectal screening is being added to the latter program incrementally). One approach to increase screening involves engaging low-income, low-education, mostly minority communities in a community-based participatory process that leads to “community efficacy,” a willingness on the part of community residents to help for the common good. This approach resulted in elimination of disparities in Medicare mammography screening rates between African American and white women in targeted counties in Alabama and Mississippi. Screening is in many ways the low-hanging fruit that allows programs to demonstrate success, and it also is an effective way to engage the community because the task is clear, achievable, and measurable in the short term. Other interventions, such as those aimed at tobacco cessation, healthful eating, and increased physical activity, require efforts that go beyond the individual behavioral change to a socioecological approach that engages all facets of the community—the individual, family, neighborhood, organizations, and policy makers. Because it is more complex, this approach is more difficult to implement. The first step is to engage the community. However, academic institutions, nongovernmental organizations, cancer volunteer organizations, and public health departments too often attempt health promotion from afar, working through the media, creating culturally relevant literature, and meeting with community members in conference rooms, without establishing an onsite presence in the community. Cancer control from a distance does not work in the geographic areas and demographic populations most at risk for disparities. Organizations and agencies must leave the comfort zone of the home base and begin engaging community members in the community, building mutual trust, offering guidance, sharing expertise, and empowering community volunteers to address the problem locally. Access to care will remain a major impediment to closing the disparity gap in cancer as long as substantial