Abstract ED04-03: Conceptual framework for community interventions to reduce cancer health disparities

This presentation will discuss the value of incorporating a conceptual/theoretical perspective into all aspects of conducting community based trials to reduce cancer disparities including the planning, implementation and data interpretation stages of research. In addition, the applicability and utility of existing theories and constructs for various ethnic minority, cultural and socioeconomic groups will be explored. The heuristic framework of the multi-dimensional Health Behavior Framework will be used to illustrate these points.

It is widely recognized that an important approach to mitigating the unequal burden of cancer in certain segments of our population involves the conduct of community-based trials to develop effective intervention strategies. Many such trials focus on enhancing health behaviors that are linked to positive cancer outcomes. However, achieving health behavior change is a complex process. Research indicates that people do not initiate or continue screening behavior, stop smoking, change diet, increase physical activity or whatever else is recommended unless: barriers both perceived and real are overcome; self-reinforcement of behavior occurs; and the behavior is supported and encouraged by peers, friends, family or providers. A health recommendation is unlikely to be followed if it goes against strong normative pressures and people are unlikely to follow a preventive regimen that they do not believe is valuable. They will shun a regimen which is purported to prevent a disease they do not fear, or a disease they do not believe that they will acquire. They may not hear the recommendation of a professional they dislike, and if they do not understand recommendations clearly, they certainly will fail to adhere to them. Finally, even if all the above factors are positively aligned, circumstances in the health care system, the workplace, and the broader geographic, social and political environment may impede the receipt of the health service or engagement in the health behavior.

A sound conceptual framework can be a critical asset for achieving order in this complex environment, and can provide a roadmap for systematically addressing the multiple determinants of the health behavior in which change is desired. The Health Behavior Framework, developed at the University of California Los Angeles, is based on the premise that we can only influence complex multi-faceted behaviors by using a multi-dimensional model derived from varying theoretical orientations. Thus, the Health Behavior Framework represents a synthesis of some of the major theoretical formulations in the area of health behavior, including the Health Belief Model, Social Cognitive Theory, the Theory of Reasoned Action/Planned Behavior, the Transtheoretical Model of Change, and Social Influence Theory. In addition, the model considers the context within which the desired behavior and behavior change are enacted, including the health care system and larger community and societal influences. This Framework has guided numerous cancer control studies targeting patients, the lay public, physicians, and other caregivers; the design and development of intervention strategies and approaches; and the creation of data collection instruments. The Health Behavior Framework has been successfully used to examine antecedents of health behaviors, and to design interventions for, diverse ethnic, cultural and linguistic populations, including various Asian ethnic groups.

This presentation will use the example of our Program Project on Liver Cancer Control Interventions for Asian-Americans to illustrate how the Health Behavior Framework is being utilized to shape the data collection instruments and interventions in three separate controlled trials among Vietnamese, Hmong, and Korean target populations that all share a common outcome measure: receipt of hepatitis B serologic testing. Although the Asian subgroups and the intervention strategies vary among projects, we expect the drivers of health behavior to be similar across projects. Since all of the projects target individual subjects as agents of change, greatest emphasis will be placed on individual level constructs from the Framework such as knowledge, beliefs, and cultural factors. These are the mutable factors in our Framework that we will attempt to influence via our interventions. Our Framework fully recognizes physician and health care system factors as being important, but these factors are not directly assessed in this project, but rather reported by subjects as perceived. The scope of this project also does not allow for measurement of the broader contextual factors that can influence study outcomes.

The following describes some of the mutable factors of the Health Behavior Framework that we are attempting to influence in the Program Project. Most theories are in agreement that knowledge is a necessary, though not sufficient, condition for behavior to occur. Thus, an important component of the intervention will consist of supplying subjects with the appropriate information regarding hepatitis B transmission routes, the availability of hepatitis B tests and vaccines, and the potential health consequences for individuals who do not know their hepatitis B status. In addition, effective communication of these messages becomes critical: behavioral prescriptions needs to be clear, explicit, unambiguous and easily interpreted. At least four health beliefs are thought to be central to health behaviors such as hepatitis B serological testing and are included in the Framework: the person's perception of his/her own susceptibility to hepatitis B, belief in the severity of hepatitis B, belief in the benefits and costs of completing hepatitis B testing and belief in the efficacy of hepatitis B testing in preventing or controlling infection and/or liver cancer. We also attempt to enhance perceived control over developing the disease and self-efficacy, which is the conviction that one can successfully undertake the behavior that is required to produce the desired outcome.

Normative beliefs involve an individual's perception of whether or not a referent group would approve of hepatitis B serological testing. Our research will make a special attempt to address these factors by trying to involve peers in encouraging subjects to obtain hepatitis B serological testing. The component projects will attempt to convey positive peer norms through mass media (Vietnamese project), lay health workers (Hmong project) and by inviting individuals who have undergone testing to share their experience in church-based small group sessions (Korean project). Past health behaviors are often a strong predictor of future health behaviors. For example, individuals who have undergone breast or colorectal cancer screening may be more likely to obtain hepatitis B testing than their peers who have never obtained any type of screening test in the past. Cultural factors such as low value placed on preventive health care utilization or the belief that blood tests can deplete the body of energy can also function as barriers. On the other hand, cultural values such as the need to maintain health to fulfill family obligations will be emphasized during the study and used as arguments for undergoing hepatitis B testing when appropriate.

In the Health Behavior Framework, a person's health behavior is immediately preceded by his/her intention. However, even a stated commitment on the part of the individual does not ensure behavioral change. For a variety of reasons that involve internal and external forces, the person may be unable to carry out the desired behavior. Many obstructing factors or barriers (such as negative beliefs, cost considerations, social disapproval) and facilitating factors or supports (such as social support or a hepatitis B testing program offered by a local community clinic) are likely to influence whether behavioral intentions will actually be carried out. Therefore, our interventions will target barriers to hepatitis B testing, either proactively in media stories or advertising (Vietnamese project), or in response to barriers stated by individuals (Hmong project) or at small group sessions (Korean project).

The Health Behavior Framework is a general heuristic framework which is dynamic rather than static. The constellation of predictive factors and their interrelationships is expected to vary depending upon the particular subject populations and health behaviors in question. For example, model factors are expected to behave somewhat differently for discrete behaviors such as cancer screening compared to ongoing behaviors such as healthy eating. Despite some differences, extensive experience with the Framework has shown that the main drivers of behavior tend to be similar across populations. The discussion will focus on ways to incorporate theory into various types of intervention approaches and on the similarities and differences among ethnic and other disadvantaged groups with respect to theoretical components.