Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations

Abstract

Background

This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations.

Methods

The Harvard Cancer Prevention Program Project includes three studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design.

Results

Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities.

Conclusions

By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

Introduction

Recent public health efforts place a high priority on reducing disparities in health by socioeconomic position and race/ethnicity [1], [2], [3], [4]. While individual health behaviors do not fully explain differentials in mortality by socioeconomic position [5], they are significant determinants of societal patterns of risk. Recent epidemiologic studies document dramatic reductions in chronic disease risk with adherence to public health guidelines for weight status, diet and physical activity, and smoking [6], [7]. Across multiple health behaviors, patterns of risk by socioeconomic position remain relatively constant: persons with higher levels of income or education or in higher status jobs engage in fewer risk behaviors than persons with lower income or education or in lower status jobs [1], [2], [3], [8], [9], [10]. Patterns of health behaviors also differ by race/ethnicity [1], [2], [3], [4]. Race/ethnicity and social class are part of the fabric of life experiences for all groups [11]. These variables, along with other sources of disparities such as gender and age, create interlocking systems of privilege and disadvantage [12], [13], [14], [15]. Those at increased vulnerability, reflected by lower levels of power and resources and fewer life chances, are at increased risk for health problems, including increased cancer risk [1], [8], [16], [17], [18], [19], [20], [21], [22].

Borrowing from the sociological literature, social class may be defined as a social relationship premised on people’s structural location within the economy [17]. Thus, social class determines one’s prospects in life; access to social, educational, and economic resources; and exposures to life stressors [21], [23]. These patterns reflect larger structural forces that shape the texture of people’s day-to-day realities, which we refer to in this article as social context, including an array of social and material resources that ultimately have profound effects on health [15], [24], [25], [26]. For example, results of the Alameda County Study demonstrated a clustering of factors associated with low income, including not only behavioral risks (e.g., sedentary lifestyle, smoking, obesity), but also unemployment, lack of instrumental support, living in an unsafe neighborhood, and having unmet needs for food and for medical care [15]. Graham [26], [27] similarly found that such social contextual factors associated with low income were also particularly relevant for smoking patterns, as one example of risk-related behaviors. She concluded that different dynamics drive the smoking habits of low-income women, compared to those in middle and upper classes: low-income women used smoking as a means of coping with their economic pressures and the resulting demands placed on them to care for others. She categorized these influences as including everyday responsibilities, such as child care and patterns of paid work; material circumstances, including housing circumstances, debt and budgeting, and access to a car; social support and social networks; and personal and health resources, including patterns of health-related behavior and alternative coping strategies. Even among low-income women, Graham found smoking rates highest among women with fewer resources and higher role responsibilities.

Similarly, race/ethnicity shapes a range of social contextual factors that may be related to health behaviors, from cultural norms and patterns of interactions with family and the broader community, to potential exposure to discrimination. Within the United States, disparities in health by race and ethnicity are growing as the population becomes increasingly diverse [28]. The causes of these disparities are complex, as race and ethnicity often interact with socioeconomic position, with a disproportional representation of racial/ethnic minorities living in poverty. Health behaviors and health status may be further influenced by cultural norms and patterns of interactions with family, the broader community, and health care systems; increased potential for exposure to discrimination; and patterns of resource utilization and expectations for individual behaviors stemming from both culture and lived experience [28], [29], [30], [31]. Race and ethnicity may also influence the availability of social resources, culturally based facilitators, and assets that may enhance health outcomes [31].

Health disparities by socioeconomic position and race/ethnicity are inextricably related, but are also distinctive [22]. Race and ethnicity are major determinants of socioeconomic position; in addition, race and ethnicity have important implications for health outcomes that are independent of their influence on socioeconomic position [32]. Current evidence indicates that the traditional racial categories are more alike than different in terms of biological characteristics or genetics [33], [34], [35]. Race is thus more of a social than a biological category [36]. Nonetheless, these social categories capture important parts of social inequalities in our society, and reflect important power and status differentials. Socioeconomic differences between racial or ethnic groups account for much but not all of the racial differences in health [11], [14], [37].

Little work has been done to date to identify methods for redressing social disparities in risk reduction interventions. This article proposes a conceptual framework that draws on a range of social and behavioral theories to explicate the social contextual pathways by which race/ethnicity and social class may influence health behaviors. By illuminating these pathways, it will be possible to design risk reduction interventions that are meaningful and relevant to the intended audiences because they attend to social contextual factors in these pathways, thereby potentially enhancing the effectiveness of interventions aimed at reducing social inequalities in risk behaviors. The purpose of this article is to describe this conceptual framework and to illustrate how we are operationalizing it within the Harvard Cancer Prevention Program Project. The aim of this program project is to develop and evaluate cancer prevention interventions for working class, multiethnic populations. Two intervention studies incorporate elements of the social context in which people live in the design and delivery of the intervention. Behavioral outcomes will be linked to their health and economic consequences in a third study, which provides policy recommendations based on assessment of the population-level benefits of the behavioral interventions in terms of decreased cancer rates, increased quality-adjusted years of life, and the associated economic impact.