Social-ecological model and cancer

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Introduction

The prevalence of certain types of cancer seems to vary among various subgroups concerning race, ethnicity, and age among others. Breast cancer particularly is the most common form of cancer among women in the U.S with new diagnoses estimated at 232,340 in 2013 alone (CDC, 2014; Coughlin, 2015). A further examination reveals other key statistics. Particularly, studies have revealed race/ethnicity-based disparities in intervention approaches seeking to address breast cancer among women. This explains findings of higher mortality rates from breast cancer among African-American women than white women (Coughlin, 2015). Indeed, the disparities referred to are attributable to social factors, including (among others): socioeconomic factors; biological factors; and access to relevant services (including screening mammography) (Mitchell, 2010; Coughlin, 2014). Based on these elements, this paper suggests an intervention plan whose main objective is to enhance and support early screening among the target population. This will accordingly be based on a social-ecological model (SEM), which focuses on social and structural factors associated with the spread and prevention/treatment of breast cancer.

Population Description: African-American Women

As already noted above, African-American women experience higher mortality rates from breast cancer than the white women. These disparities persist even after stage of disease and characteristics of tumor have been accounted for. For example, although since 1975 breast cancer’s relative survival rate has improved by five years among both African-American and white women, there remain substantial racial disparities. Among African-American women, the 5-year relative survival rate is 92 percent for white women as compared to only 79 percent among African-American women (Coughlin, 2014). There are many reasons for these disparities, as already noted above: socioeconomic factors; biological factors; and access to relevant services (including screening mammography).

African-American women are the most affected by later-stage diagnoses as well as poorer survival at stage-specific. Studies have also shown that African-American women are less likely – compared to white women – to receive timely follow-up after an inconclusive or abnormal screening mammogram. These are likely the result of socioeconomic factors, with most African-American women having low income and low educational attainment, and lacking insurance, among others (Mitchell, 2010; Coughlin, 2014). Remarkably, though, African-American women tend to have even more aggressive breast cancer.

The Plan

Levels of SEM and Stakeholders

The understanding here is that a big part of the problem is the lack of knowledge and awareness on appropriate health behaviors among African-American women. Intervention, therefore, should focus on this – that is, increasing African-American women’s knowledge and awareness on the right health behaviors that can significantly reduce the prevalence of breast cancer among them as well as boost the survivorship of those already diagnosed with the disease Coughlin, 2014). The primary objective in this regard is to improve early screening among the target population.

The SEM model of intervention focuses on four key levels: individual, interpersonal, organizational/institutional, community, and policy. The premise is that the effectiveness of an intervention depends on the social context and the factors therein that either support or adversely affect the efforts made (CDC, 2014; Moore et al., 2015). In this respect, the understanding is that, while individual efforts on the part of African-American women is important, they all require all the support they can get from the various stakeholders involved.

There are many stakeholders to cooperate with and involve toward the success of this intervention plan. These vary from one level to another. Naturally, the first key stakeholders are the individual African-American women (that is, at the individual level). This expands to the interpersonal level, to include members of family, friends, neighbors, and coworkers. At the organizational or institutional level, stakeholders include specific healthcare institutions. The focus, in this respect, is on the organizational and/or institutional traits (such as operational rules and regulations) that would advance intervention goals and objectives (Moore et al., 2015). At the community level, stakeholders include a formal and informal network of institutions. Finally, the policy levels will involve government offices (at the local, state and federal levels) with the mandate to enact policies.

Actual Intervention

Individual Level

At this level, the main goal is to improve individual knowledge and health literacy, attitudes, and behavior. Ultimately, the objective is to encourage the individuals to take the early screening. The following efforts are expected to prove valuable: effective awareness campaign; using client reminders, etc.

The primary targets here are individuals, and there are some ways to ensure that they take efforts to go for early screening. Effective awareness campaigns can go a long way in ensuring health literacy among the target population. This includes utilizing mass media; cell phone text messaging as well as Smartphone apps, and black radio and TV. These platforms can be used to disseminate health messages on screening for breast cancer among black communities. These tools are effective in some ways. For example, black radio is a largely trusted source of information on various topics that African-Americans like to hear about. According to Coughlin (2014), over 94 percent of African-Americans above the age of 55 listen to the radio every week. Mobile phones have also become important tools, with more than 85 percent of adults in the US owning a mobile phone or Smartphones. This makes text-messaging and/or Smartphones effective campaign tools.

Client reminders can also be valuable in this regard. These may be written notes or telephone messages that remind women when they are due or even overdue for screening. This strategy has proved successful elsewhere (CDC, 2014). Particularly, it was used by a National Cancer Institute project in Seattle, where women members of Health Maintenance Organization (HMO) were reminded of their screening dates by postcards and telephone calls.

Interpersonal Level

Here, the goal is to provide social networks and support systems (including families, friends, neighbors, and coworkers, among others) that would facilitate positive attitudes towards screening among African. Specific efforts here would include: effective awareness campaigns; establish programs for patient navigation.

Other than awareness campaigns, such as the ones discussed above, establishing a patient navigation program is another important strategy. This involves creating individualized help for patients, families and/or caregivers, which can help them to overcome barriers to the healthcare system and thereby facilitate timely access to screening. This includes reducing out-of-pocket costs when going for screening.

Organizational/Institutional Level

At this level, the primary goal is to help specific organizations/institutions create an environment that encourages and ensures early screening among the target population. Specific strategies in this regard include: using provider reminder systems; and reducing structural barriers to screening.

Individual healthcare organizations and/or institutions also need to take steps to help African-American women to go for screening more often. On the other side of client reminders, for instance, there are provider reminder systems. These are either manually or electronically generated messages that inform providers when a patient is due or overdue for screening. It is an important follow-up tool (CDC, 2014). These organizations/institutions should also reduce structural barriers to screening. These are noneconomic obstacles and/or burdens to screening. Among other things, they can expand clinical hours and offer services in nonclinical (that is alternative) settings.

Community Level

Here, the idea is to develop appropriate formal and informal relationships that would provide much-needed support for the goal of this intervention plan. Specific strategies include church-based interventions; and creating support strategies for patients to establish medical homes.

The church can be a valuable platform for offering health promotion activities. Such projects have been successful before. In North Carolina, there was the Forsyth County Cancer Screening Project, which helped to improve screening rates among African-American women from low-income households. The project recorded a 31-56 percent increase in the proportion of women in the area having regular mammography (Coughlin, 2014). Creating a support system for patients looking to establish medical homes is also important. This involves a system-based approach to a patient-centered care that is comprehensive, coordinated and accessible.

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Policy Level

In this respect, the objective is to advocate for African-American women, with the aim of having government institutions create policies that would facilitate the target population’s access to screening services. Many policies can be enacted toward this goal. Particularly, such policy should focus on the barriers that prevent African-American women from having access to breast cancer screening services (CDC, 2014; Moore et al., 2015). These include: funding for patient navigation (for patient follow-up); community screening projects; reducing costs (that is, out-of-pocket costs); mandatory awareness campaigns, among others.

Conclusion

The basic premise of this intervention paper is that African-American women are largely marginalized in the fight against breast cancer. More of them die from it, compared to the white women, and this is to a large extent attributable to social factors. The purpose of this SEM-based intervention, therefore, was to propose solutions to the social factors that are being barriers to the existing intervention efforts. Ultimately, this paper suggests solutions are the individual, interpersonal, organizational/institutional, community and policy levels. Particularly, these include: awareness campaigns, follow-up strategies and tools, family/caregiver support, church-based intervention (as a community-based strategy), and cost-reduction, among others. There is certainly more to breast-cancer intervention, but these suggestions are a good way to begin.

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  1. Centers for Disease Control and Prevention (CDC) (2014).Increasing population-based breast and cervical cancer screenings: An action guide to facilitate evidence-based strategies.Atlanta: US Dept. of Health and Human Services.
  2. Coughlin, S. S. (2015). Intervention approaches for addressing breast cancer disparities among African-American women. Ann Transl Med Epidemiol, 1(1): pp. 1-12.
  3. Mitchell, J. A. (2010). Social ecological factors influencing cancer-related preventive health behaviors in African American men.Dissertation for the Degree of Philosophy in the Graduate School of The Ohio State University.
  4. Moore, A. R., Buchanan, N. D., Fairley, T. L., Smith, J. L. (2015). Public health action model for cancer survivorship.American Journal of Medicine, 49(6): pp. 470-476.
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