Paper Session 22: Social and Environmental Context and Health

Background: Participatory modeling conceptualizes and models a problem by centering and incorporating community member knowledge. In the African American Resilience in Surviving Cancer (ARISE) Study, this strategy was applied through collaboration with Black community stakeholders to refine a social-ecological model of quality of life (QOL) among Black cancer survivors that focused on community, interpersonal, and individual factors. The current study describes this process, including identification of an understudied construct, church-based social support (CBSS), and its association with racist experiences and QOL among Black survivors.

Methods: The study team convened the ARISE Action Council (AAC): 15 Black cancer survivors and caregivers who engaged in concept mapping and consensus building exercises to ensure that the ARISE model represented the survivors’ lived experiences. The final model directly informed assessment of 535 African American breast and prostate cancer survivors recruited from a population-based cohort. Structural equation modeling (SEM) using maximum likelihood estimation was used to examine this model, including the contribution CBSS. A measure of CBSS was not found in the literature so the study team and AAC adapted a 7-item measure. Other key constructs included an index of race-related stress based on six separate racism measures as well as general social support, measured by the PROMIS Instrumental Support - Short Form.

Results: The AAC identified new constructs for inclusion in the ARISE model, including urban policies, spirituality (vs. religiosity), and CBSS. A subset of 186 participants reporting church involvement were included in analyses of CBSS. SEM showed that race-related stressors had a direct effect on QOL (p<.01) when CBSS was not in the model. General social support was not associated with QOL. After including CBSS in the model as well as its interaction with racial stressors, the association between racial stressors and QOL was nearly twice as strong for those with CBSS (B=-7.3, p<.01) compared to high CBSS (B=-4.5, p<0.001), suggesting that CBSS weakened its effect.

Discussion: Participatory modeling enabled investigation of a novel construct, CBSS, that may represent a pathway for addressing racism among Black cancer survivors that may undermine QOL. Findings broadly suggest that participatory modeling can be transformative in efforts to confront the social determinants of cancer health inequities.

Co-Author - Charles S.H. Robinson, Ph.D.,
Karmanos Cancer Institute - Wayne State University

Co-Author - Jasminder Phalore, MPH,
Karmanos Cancer Institute - Wayne State University

Co-Author - Maida Herrera, MPH,
Karmanos Cancer Institute - Wayne State University

Co-Author - Voncile Brown-Miller,
Karmanos Cancer Institute - Wayne State University

Co-Author - Mikayla Harrison,
Karmanos Cancer Institute - Wayne State University

Co-Author - Malcolm Cutchin, Ph.D.,
Pacific Northwest University of Health Sciences

Co-Author - David Chae, Sc.D.,
Tulane University

Co-Author - Janaka Liyanage, Ph.D.,
Karmanos Cancer Institute - Wayne State University

Co-Author - Tricia Miranda-Hartsuff, Ph.D.,
Wayne State University

Co-Author - Louis A. Penner, BA MA PHD, BA MA PHD,
Wayne State University

Co-Author - Ann G. Schwartz, Ph.D.,
Karmanos Cancer Institute - Wayne State University

Co-Author - Felicity W. K. Harper, PhD, FSBM, PhD, FSBM,
Karmanos Cancer Institute/Wayne State School of Medicine

Background: People with disabilities are significantly more likely to experience chronic conditions and are at risk of dying up to 20 years earlier due largely to systemic inequities and preexisting conditions. Contributing to these inequities, stigma, prejudice, and discrimination undermine optimal healthcare, particularly among people with lower socioeconomic status living in resource limited environments. Appalachian Kentucky, an underserved rural area, has twice the rate of disability (22.7% versus 12.6% nationally) and almost three times the rate of disability benefits (14.3% versus 5.1% nationally). Using the socioecological model, this ethnographic study investigates the relationship between stigma and disability benefits in Appalachian Kentucky.

Methods: I conducted participant observation and semi-structured key informant interviews in Kentucky from July-November 2022 and January-August 2024. Participant observation at primary and specialty healthcare clinics investigated care encounters. Selected based on personal or professional experiences with disability, participants were interviewed on topics across the socioecological model, including state and public policy, environment, institutions, interpersonal relationships, and individual health challenges. Interviews were transcribed and coded using thematic content analysis.

Results: 19 key informants completed interviews, including people with disabilities, family caregivers, and health and human service providers. Participants described a complex relationship between disability as a cultural category and disability benefits as a state program. Interviews revealed five themes, including: (1) disability-seeking as culture, (2) stigma associated with disability and disability benefits, (3) valorization of work, (4) notions of deservingness and legitimacy and, (5) empathy due to systemic barriers that lead to unmet needs.

Conclusion: While stigma against both people with disabilities and people on disability benefits persists, it is critical to understand the context in which disability is lived. In the context of rural Appalachia, a region long under resourced, health is intertwined with broader cultural and structural factors across the socioecological model. Widespread stigma forecloses disability as a potential basis of intervention and activism to alleviate health inequities. Only by examining disability-related stigma in context can we challenge these beliefs and work towards health equity.

Co-Author - Michelle K. Roberts, MS,
University of Kentucky

Co-Author - Ann E. Kingsolver, PhD,
University of Kentucky

Co-Author - Nancy E. Schoenberg, PhD,
Univerity of Kentucky

Co-Author - Anastasia Todd, PhD,
University of Kentucky

Co-Author - Erin Koch, PhD,
University of Kentucky

Background: Historical mortgage lending risk largely based on race (i.e., “redlining”) has been associated with poor health outcomes, such as high body mass index (BMI), decades later. It is unclear whether the association between living in historically redlined neighborhoods and BMI is mediated by health behaviors (diet quality and physical activity [PA]) and neighborhood factors, and, if so, whether this mediation differs by race and gender.
Methods: We linked participants’ residential locations to the 1930’s Home Owners’ Loan Corporation (HOLC) maps that assessed neighborhoods’ creditworthiness. We used CARDIA data from 1985-86 (N=3964) (participant ages 18-30 years) to test whether cross-sectional associations between historically redlined neighborhoods and BMI were mediated by individual-level a priori diet quality score (‘diet quality’ hereafter) and PA behaviors, and neighborhood-level social and economic factors, food outlet availability, and PA resources. Models were clustered on Census tract, controlled for study center, individual demographics, and self-reported discrimination. We used multi-group modeling to identify interactions by self-reported race and gender, separately.
Results: Both neighborhood socioeconomic deprivation and participants’ diet quality in the 1980’s mediated associations between historical redlining and BMI across race and gender. While diet quality was negatively associated with BMI consistently by gender, this association differed by race. Historical redlining was indirectly associated with White adults’ higher BMI by 0.03 kg/m2 (β=0.03,95% CI[0.007,0.06]) through paths from higher neighborhood socioeconomic deprivation to lower diet quality. The associations for men and women were similar to those for White participants. In contrast, historical redlining was indirectly associated with Black adults’ lower BMI by 0.03 kg/m2 (β=-0.03,95% CI[-0.08,-0.007]) through paths from higher neighborhood socioeconomic deprivation to lower diet quality. Neighborhood restaurant, food store, and neighborhood PA resource associations were inconsistent and PA associations were null.
Conclusions: Historically redlined neighborhoods were socioeconomically deprived 50 years later, which may have contributed to lower diet quality and in turn residents’ higher BMI as seen in men, women, and in White but not Black adults.

Presenter - Andrea Richardson, PhD, MPH,
RAND

Co-Author - Tamara Dubowitz, ScD, SM, MSc,
university of Pittsburgh

Co-Author - Kirsten Beyer, PhD,
Medical College of Wisconsin

Co-Author - Yuhong Zhou, PhD, MS, ME,
Medical College of Wisconsin

Co-Author - Kiarri Kershaw, PhD, PhD,
Northwestern University Feinberg School of Medicine

Co-Author - Waverly Duck, PhD, MSc,
University of California Santa Barbara

Co-Author - Feifei Ye, PhD,
RAND

Co-Author - Robin Beckman, MPH,
RAND

Co-Author - Penny Gordon-Larsen, PhD,
University of North Carolina Chapel Hill

Co-Author - James Shikany, DrPh,
University of Alabama Birmingham

Co-Author - Catarina Kiefe, MD, PhD,
UMass Chan Medical School

Background: Structural racism is how interconnected societal systems perpetuate racial inequity. Recent research suggests the role of structural racism in cancer health outcomes, but the role of structural racism in cancer screening behaviors is unclear. This study assessed the association between state-level structural racism and prostate cancer screening among men in the U.S. and Black-White racial differences in this association.
Methods: Data from 22,165 men in the 2023 Behavioral Risk Factor Surveillance System survey were merged with an existing index composed of five dimensions (e.g., segregation, economic, incarceration) measuring structural racism at the state level. Hierarchical binary logistic regression modeling, accounting for participant clustering at the state level, assessed associations between state-level structural racism and individuals’ lifetime receipt of prostate specific antigen (PSA) screening for prostate cancer, controlling for individual characteristics (e.g., age, income, and health insurance status). Models stratified by Black and White race were conducted and the moderating effect of race on the association between structural racism and PSA screening was tested using slope estimate comparisons.
Results: An inverse association was detected between the state-level structural racism index and PSA screening behavior, such that individuals residing in states with higher structural racism scores (i.e., more structural racism) were less likely to have ever received a PSA screening for prostate cancer. Stratified analyses trended toward a greater adverse influence of structural racism on PSA screening behavior among Black men as compared to White men, however, moderation analyses revealed no statistically significant differences in the association by race.
Conclusions: Structural racism is predictive of prostate cancer screening behavior among men in the U.S., even when measured as distally as at the state level. Moreover, the deleterious influence of structural racism on prostate cancer screening behaviors is not limited to Black or minoritized populations but affects White majority populations as well.
Impact: It is critical to address the persistent crisis of structural racism to support positive cancer health behaviors and improve cancer health outcomes. Multi-level policies designed to address structural racism and instituted at various levels, including that of the state, are crucial to advancing public health.

Presenter - Nathaniel Woodard, PhD, MPH, PhD, MPH,
University at Buffalo