Be Well™ Acres Homes: a community-driven, evidence-based approach to reduce health inequities through sustained cross-sector partnership.

PURPOSE: Be Well Communities™ is MD Anderson's signature place-based approach for cancer prevention and control, working with communities to promote wellness and address modifiable risk factors for cancer. The purpose of this paper is to describe implementation of the planning phase of the Be Well Communities model in Acres Homes which began in 2019. METHODS: A community advisory group (Steering Committee) including residents, non-profit organizations, health care partners, city and county agencies, plus other stakeholders, was convened and aligned through a structured process to develop shared goals, foster multisector collaboration, as measured by a stakeholder survey administered twice, and enhance community capacity to improve health outcomes through development of a Community Action Plan. RESULTS: Clear, achievable goals were developed, multisector collaboration was enhanced, and more than 400 h of capacity building support led to a Community Action Plan initially focused on healthy eating and active living, including 15 evidence-based interventions led by 18 organizations. The majority (93%) of the Steering Committee reports that this plan reflects community priorities and will reach the residents most in need. CONCLUSION: By listening and developing trust, the Be Well Communities team successfully worked with Acres Homes residents and organizations to enhance community capacity to address health inequities in one of Houston's most diverse and historic communities.

Reducing risk for chronic disease: evaluation of a collective community approach to sustainable evidence-based health programming.

BACKGROUND: Community initiatives can shape health behaviors, such as physical activity and dietary habits, across a population and help reduce the risk of developing chronic disease. To achieve this goal and impact health outcomes, Pasadena Vibrant Community aimed to engage communities in an ongoing dialogue about the importance of healthy behaviors, implement and advance community-based strategies to promote health, and improve diet and physical activity behaviors. The initiative was centered around a collaboration between a backbone organization, steering committee, and 7 collaborating organizations funded to implement multicomponent, evidence-based programs.. The common agenda was detailed in a community action plan, which included 19 interventions targeting healthy eating and active living among adults and youth in Pasadena, Texas. METHODS: A mixed methods evaluation of the initiative was conducted over 4 years. Data sources included document reviews of quarterly progress reports (n = 86) and supplemental data reports (n = 16) provided by collaborating organizations, annual Steering Committee surveys (n = 4), and interviews conducted with staff from a subset of Collaborating Organizations (n = 4). RESULTS: The initiative reached over 50,000 community members per year through 19 evidence-based interventions and impacted health outcomes, including knowledge and adoption of healthy eating practices and increased physical activity. Thirty-one systems-level changes were implemented during the initiative, including 16 environmental changes. Steering Committee meetings and shared goals enabled connections, communication, and cooperation, which allowed Collaborating Organizations to address challenges and combine resources to deliver their programs. CONCLUSIONS: Community initiatives can effectively permeate the community by reaching individuals, improving physical activity and dietary habits, and ensuring sustainability. Based on the experience reported here, the success of a community initiative can be facilitated if collaborating organizations come together to implement evidence-based interventions and tailor them to the community, and if they are empowered by significant leadership and supportive collaboration and aligned by a common agenda.

Enhancing the utilization of healthy living interventions among cancer survivors in historically underserved populations and communities.

PURPOSE: This study aimed to describe the clinical characteristics and wellness programming preferences of cancer survivors from Acres Homes, a historically Black neighborhood in Houston, Texas, with areas of persistent poverty. The goal of this study was to identify opportunities to increase cancer survivor utilization of healthy eating and active living interventions aligned to cancer center community outreach and engagement efforts. METHODS: This multiple methods study included a retrospective review of electronic health record data (n = 413) and qualitative interviews with cancer survivors (n = 31) immediately preceding initiation of healthy eating, active living programming in Acres Homes. RESULTS: This study found Acres Homes survivors have high rates of co-occurrent cardiometabolic disease including obesity (45.0%), diabetes (30.8%), and other related risk factors as well as treatment-related symptoms. Four major concepts emerged from interviews: (1) Factors that influence survivors' ability to eat well and exercise, (2) Current usage of community resources, (3) Interest in relevant programming, and (4) Specific programming preferences. Opportunities for current and future health promotion programming for cancer survivors were explored. CONCLUSION: Strategically tailoring community resources for cancer survivors can provide a more robust network of support to promote healthy eating and active living in this population. This work informed community implementation of evidence-based health interventions in Acres Homes and may support future projects aiming to enhance community-led cancer prevention efforts in historically underserved communities.

Patterns of home cooking practices among participants in a behavioral weight loss program: A latent class analysis.

Cooking education is a popular approach to health promotion; however, the relationship between specific cooking practices, diet and weight loss is not well understood. The goal of this study was to 1) evaluate the relationship between cooking practices, dietary behaviors, and weight loss after a weight loss intervention and 2) identify patterns of cooking practices and their implications on weight loss. Using a quasi-experimental, single-arm cohort study design, we analyzed data from 249 adults with overweight/obesity who were participating in a weight loss program. Participants self-reported demographics, height and weight, and diet and physical activity behaviors. The Health Cooking Questionnaire 2 (HCQ2) was used to collect information on cooking practices post intervention. The HCQ2 responses were used to generate Healthy Cooking Index (HCI) scores, a summative measure of cooking practices with the potential to influence health. Latent Class Analysis (LCA) was utilized to define distinct patterns of cooking behaviors. Cooking patterns and HCI scores were examined relative to participant demographics, dietary behaviors, and weight loss. HCI scores post-intervention were positively associated with age, weight loss, and favorable dietary behaviors in this study. The LCA revealed three distinct patterns of cooking behavior (Red Meat Simple, Vegetarian Simple, Health & Taste Enhancing). The Red Meat Simple cooking pattern was associated with less weight loss compared to other patterns. The findings of this study set the foundation for more research on cooking education as a method for improving weight loss outcomes in the context of behavioral interventions.

Implementation and outcome evaluations of a multi-site improvement program in cancer genetics.

Program evaluation can identify the successes and challenges of implementing clinical programs, which can inform future dissemination efforts. A cancer genetics improvement program, disseminated from the Lead Team's institution to five health systems (Participating Sites), was genetic counselor led, using virtual implementation facilitation to support Participating Sites' performance of quality improvement (QI) activities over several years. Program implementation and outcome evaluations were performed and included evaluation of program delivery and initial effects of the program on Participating Sites. A logic model guided evaluation of program implementation (inputs, activities, outputs, delivery/fidelity, and coverage/reach) and initial outcomes (short-term and intermediate outcomes). Data were collected from program documents and an Evaluation Survey of Participating Site team members (21 respondents), compared against the Lead Team's expectations of participation, and analyzed using descriptive statistics. All program inputs, outputs, and activities were available and delivered as expected across the five Participating Sites. The most frequently used activities and inputs were facilitation-associated meetings and meeting resources, which were rated as useful/helpful by the majority of respondents. Nearly all respondents noted improvement in short-term outcomes following participation: 82.4% reported increased awareness of clinical processes, 94.1% increased knowledge of QI methods, 100% reported increased perceived importance of QI, 94.1% increased perceived feasibility of QI, and 76.5% reported increased problem-solving skills and self-efficacy to use QI at their site. Intermediate outcomes (identifying barriers, developing interventions, improved teamwork, and capacity) were achieved following program participation as indicated by the results of the program document review and Evaluation Survey responses. Implementation challenges at Participating Sites included staffing constraints, difficulties obtaining buy-in and participation, and developing interventions over time. The multi-site improvement program was delivered and implemented with high levels of fidelity and resulted in improved short and intermediate outcomes. Future research will evaluate long-term, patient-level outcomes associated with site-specific QI interventions.

Educational interventions to promote sun-protection behaviors in adolescents in the United States: A systematic review.

The most prevalent modifiable risk factor for skin cancer is cumulative lifetime exposure to ultraviolet (UV) radiation, supporting the development of interventions promoting the early adoption of sun-protection behaviors. This systematic review summarizes behavioral interventions designed to promote sun-protection behaviors and reduce harmful UV exposure among U.S. adolescents. Ten studies describing 15 intervention arms were ultimately included in this review and comprised seven cross-sectional studies, a cohort study, a quasi-experimental study, and a randomized controlled trial. Most interventions included in this review were effective in increasing awareness of skin cancer and knowledge of the risk factors for skin cancer, but knowledge did not correlate with self-reported frequency of sun-protection behaviors in this population.

Be Well Communities™: mobilizing communities to promote wellness and stop cancer before it starts.

PURPOSE: Increasingly, cancer centers are delivering population-based approaches to narrow the gap between known cancer prevention strategies and their effective implementation. Leveraging successful healthy community initiatives, MD Anderson developed Be Well Communities™, a model that implements evidence-based actions to directly impact people's lives. METHODS: In partnership with local organizations, MD Anderson's Be Well Communities team executed and evaluated 16 evidence-based interventions to address community priorities in healthy diets, physical activity, and sun safety. Evaluation included assessing the effectiveness of evidence-based interventions, stakeholders' perceptions of collaboration, and the population-level impact on dietary and physical activity behaviors among students using the School Physical Activity and Nutrition Survey and the System for Observing Fitness Instruction Time. Two-tailed t-tests were used to compare tested parameters at baseline and follow-up. p values less than .05 were considered significant. RESULTS: This model achieved its early outcomes, including effectively implementing evidence-based interventions, building strong partnerships, increasing access to healthy foods, improving the built environment, and increasing healthy food and water consumption and moderate to vigorous physical activity among students (p < .001). CONCLUSIONS: Be Well Communities is an effective model for positively impacting community health which could be leveraged by others to deliver evidence-based actions to improve population health.

Identifying and addressing the needs of adolescents and young adults with cancer: summary of an Institute of Medicine workshop.

Cancer is the leading disease-related cause of death in adolescents and young adults (AYAs). This population faces many short- and long-term health and psychosocial consequences of cancer diagnosis and treatment, but many programs for cancer treatment, survivorship care, and psychosocial support do not focus on the specific needs of AYA cancer patients. Recognizing this health care disparity, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop to examine the needs of AYA patients with cancer. Workshop participants identified many gaps and challenges in the care of AYA cancer patients and discussed potential strategies to address these needs. Suggestions included ways to improve access to care for AYAs, to deliver cancer care that better meets the medical and psychosocial needs of AYAs, to develop educational programs for providers who care for AYA cancer survivors, and to enhance the evidence base for AYAs with cancer by facilitating participation in research.

Medical costs and productivity losses of cancer survivors--United States, 2008-2011.

The number of persons in the United States with a history of cancer has increased from 3 million in 1971 to approximately 13.4 million in 2012, representing 4.6% of the population. Given the advances in early detection and treatment of cancer and the aging of the U.S. population, the number of cancer survivors is projected to increase by >30% during the next decade, to approximately 18 million. Cancer survivors face many challenges with medical care follow-up, managing the long-term and late effects of treatments, monitoring for recurrence, and an increased risk for additional cancers. These survivors also face economic challenges, including limitations in work and daily activities, obtaining health insurance coverage and accessing health care, and increasing medical care costs. To estimate annual medical costs and productivity losses among male and female cancer survivors and persons without a cancer history, CDC, along with other organizations, analyzed data from the 2008-2011 Medical Expenditure Panel Survey (MEPS), sponsored by the Agency for Healthcare Research and Quality. The results indicate that the economic burden of cancer survivorship is substantial among all survivors. For male cancer survivors, during 2008-2011, average annual medical costs and productivity losses resulting from health problems per person and adjusted to 2011 dollars were significantly higher among cancer survivors than among persons without a cancer history, by $4,187 and $1,459, respectively; for females, the estimated annual costs per person were $3,293 and $1,330 higher among cancer survivors than among persons without a cancer history, respectively. These findings suggest the need to develop and evaluate health and employment intervention programs aimed at improving outcomes for cancer survivors and their families.

Population-level trends in posttreatment cancer survivors' concerns and associated receipt of care: results from the 2006 and 2010 LIVESTRONG surveys.

UNLABELLED: There is a need to better understand the posttreatment concerns of the nearly 14 million survivors of cancer alive in the United States today and their receipt of care. Using data from 2,910 posttreatment survivors of cancer from the 2006 or 2010 LIVESTRONG Surveys, the authors examined physical, emotional, and practical concerns, receipt of care, and trends in these outcomes at the population level. RESULTS: 89% of respondents reported at least one physical concern (67% received associated posttreatment care), 90% reported at least one emotional concern (47% received care), and 45% reported at least one practical concern (36% received care). Female survivors, younger survivors, those who received more intensive treatment, and survivors without health insurance often reported a higher burden of posttreatment concerns though were less likely to have received posttreatment care. These results reinforce the importance of posttreatment survivorship and underscore the need for continued progress in meeting the needs of this population. Efforts to increase the availability of survivorship care are extremely important to improve the chances of people affected by cancer living as well as possible in the posttreatment period.

Correlates of positive health behaviors in cancer survivors: results from the 2010 LIVESTRONG survey.

Positive health-promoting behaviors, including lifestyle factors (e.g., physical activity) and appropriate health service utilization (e.g., screening for secondary cancers), can minimize the health risks and challenges facing cancer survivors. The goal of this article is to examine factors associated with positive health behaviors in 2,615 posttreatment cancer survivors who completed the 2010 LIVESTRONG survey. Multivariate logistic regression was used to model odds of reporting each of six positive health behaviors "as a result of your experience with cancer": three "healthy lifestyle" behaviors and three "health care utilization" behaviors. In fully adjusted models, factors associated with greater likelihood of engaging in positive lifestyle behaviors (e.g., physical activity, changing diet) included sociodemographic factors, greater knowledge about how to reduce cancer risk; and reporting more psychological benefits due to cancer (ps <.01). Factors associated with greater likelihood of attending medical appointments and obtaining recommended cancer screenings included older age, better patient-provider communication, greater knowledge about how to reduce cancer risk, and more psychological benefits of cancer (ps <.01). Results suggest that knowledge about how to prevent cancer and benefit finding after cancer are related to positive health behaviors broadly, whereas better patient-provider communication is associated with positive cancer screening and health care utilization but not healthy lifestyle behaviors. Clinical interventions targeting these modifiable factors could maximize positive health behavior changes among cancer survivors, affecting risk for cancer recurrence as well as overall health and well-being.

Creating and Activating an Implementation Community to Drive HPV Vaccine Uptake in Texas: The Role of an NCI-Designated Cancer Center.

The University of Texas MD Anderson Cancer Center, a comprehensive cancer center designated by the National Cancer Institute (NCI), defines its service population area as the State of Texas (29.1 M), the second most populous state in the country and the state with the greatest number of uninsured residents in the United States. Consistent with a novel and formal commitment to prevention as part of its core mission, alongside clear opportunities in Texas to drive vaccine uptake, MD Anderson assembled a transdisciplinary team to develop an institutional Framework to increase adolescent HPV vaccination and reduce HPV-related cancer burden. The Framework was developed and activated through a four-phase approach aligned with the NCI Cancer Center Support Grant Community Outreach and Engagement component. MD Anderson identified collaborators through data-driven outreach and constructed a portfolio of collaborative multi-sector initiatives through review processes designed to assess readiness, impact and sustainability. The result is an implementation community of 78 institutions collaboratively implementing 12 initiatives within a shared measurement framework impacting 18 counties. This paper describes a structured and rigorous process to set up the implementation of a multi-year investment in evidence-based strategies to increase HPV vaccination that solves challenges preventing implementation of recommended strategies and to encourage similar initiative replication.

Using new media to reach Hispanic/Latino cancer survivors.

In the USA, cancer is a leading cause of morbidity and premature death among the Hispanic/Latino population. It is estimated that one in two Hispanic men and one in three Hispanic women will be diagnosed with cancer during their lifetime (American Cancer Society 2010). Despite this significant cancer burden, few innovative strategies for communication and outreach to this population currently exist. In 2009, LIVESTRONG launched a national outreach campaign, which utilized social marketing, specifically targeting Hispanics with the goal of increasing awareness and usage of LIVESTRONG's Spanish-language cancer navigation resources. This campaign, one of the first undertaken by a national cancer-related organization, led to increased awareness and utilization of resources, including a 238% increase in traffic over traditional marketing campaigns which focused on radio alone. The success of this campaign highlights the use of social media as a cost-effective method to raise awareness of cancer resources among Hispanics.

Capturing the emotional geographies of school professionals working with children with cancer.

Students diagnosed with cancer who return to school as quickly as possible are less likely to fall as far behind academically and are more likely to be reintegrated readily into the school social environment. For students to return to school successfully, a team of support may be required and should include school professionals. Traditionally, school professionals have received very little training on how to help students with cancer return to the school environment and working with such students can be an intense emotional experience. The present study explored the cognition, motivation, and emotion of school professionals working with students with cancer during the school re-entry process. Case studies were conducted to explore the participants' emotional experience as it related to helping students to return and reintegrate into the classroom environment.

Feasibility and Effectiveness of a Worksite-Weight-Loss Program for Cancer Prevention among School-District Employees with Overweight and Obesity.

The effects of Vibrant Lives, a 6-month worksite-weight-loss program, were examined in a cohort of school-district employees with overweight or obesity. The VL Basic (VLB) participants received materials and tailored text messages, the VL Plus (VLP) participants additionally received WIFI-enabled activity monitors and scales and participated in health challenges throughout the school year, and the VL Plus with Support (VLP + S) participants additionally received coaching support. The levels of program satisfaction and retention and changes in weight, physical activity (PA), and diet were compared across groups using Pearson chi-square tests, repeated-measure mixed models, and logistic regression. After the program, the VLB (n = 131), VLP (n = 87), and VLP + S (n = 88) groups had average weight losses of 2.5, 2.5, and 3.4 kg, respectively, and average increases in weekly PA of 40.4, 35.8, and 65.7 min, respectively. The VLP + S participants were more likely than the other participants to have clinically significant weight loss (≥3%; p = 0.026). Compared with the VLB participants, the VLP participants were less likely to meet the recommendations for consuming fast food (p = 0.022) and sugar-sweetened beverages (p = 0.010). The VLP and VLP + S participants reported higher program satisfaction than the VLB participants. The VL program facilitates weight loss among school-district employees with overweight and obesity by increasing their PA and healthy diet.

The post-treatment experience of cancer survivors with pre-existing cardiopulmonary disease.

PURPOSE: The purpose of this study was to explore the cancer experience of survivors with pre-existing diagnoses of heart and/or lung disease following active treatment. METHOD: The Lance Armstrong Foundation recruited cancer survivors throughout the United States to complete a web-based survey to provide insight into post-treatment supportive care needs. Experts in survey methodology and oncology, as well as cancer survivors, provided input into the survey. RESULTS: Among the 2,307 respondents, 137 individuals had been told by their physicians that they had heart or lung problems. They were 50 years old on average, and most were more than 5 years past active treatment. Two thirds of these respondents reported pain for long periods, and 20% of them agreed that they now need help with everyday tasks that they did not need help with before their cancer. Among those who were tired, had no energy, or had trouble sleeping and/or resting, less than half (47%) agreed that they had received help with this problem. One third of these respondents indicated that they had decreased their physical activity since their cancer diagnosis because of fatigue, and 26% decreased their activities because of pain. More respondents indicated that their needs were met during their cancer treatment than afterwards. CONCLUSIONS: Researchers and healthcare providers are urged to consider the unmet supportive care needs of cancer survivors with co-morbid conditions following active treatment, particularly the necessity for careful monitoring of their complex health conditions.

Building and Advancing Coalition Capacity to Promote Health Equity: Insights from the Health Equity Collective's Approach to Addressing Social Determinants of Health.

This article presents the structure and function of the Health Equity Collective in developing a systemic approach to promoting health equity across the Greater Houston area. Grounded in Kania and Kramer's five phases of collective impact for coalition building, The Collective operationalizes its mission through its backbone team, steering committees, and eight workgroups; each has goals that mutually reinforce and advance its vision. To date, Phase I (generating ideas), Phase II (initiating action), and Phase III (organizing for impact) have been completed. Phases IV (implementation) and Phase V (sustainability) are currently underway.

Cancer-Related Risk Perceptions and Beliefs in Texas: Findings from a 2018 Population-Level Survey.

BACKGROUND: Cancer beliefs and perceptions of cancer risk affect the cancer continuum. Identifying underlying factors associated with these beliefs and perceptions in Texas can help inform and target prevention efforts. METHODS: We developed a cancer-focused questionnaire and administered it online to a nonprobability sample of the Texas population. Weighted multivariable logistic regression analysis identified key factors associated with perceptions and beliefs about cancer. RESULTS: The study population comprised 2,034 respondents (median age, 44.4 years) of diverse ethnicity: 45.5% were non-Hispanic white, 10.6% non-Hispanic black, and 35.7% Hispanic. Self-reported depression was significantly associated with cancer risk perceptions and cancer beliefs. Those indicating frequent and infrequent depression versus no depression were more likely to believe that: (i) compared to other people their age, they were more likely to get cancer in their lifetime [OR, 2.92; 95% confidence interval (CI), 1.95-4.39 and OR, 1.79; 95% CI, 1.17-2.74, respectively]; and (ii) when they think about cancer, they automatically think about death (OR, 2.05; 95% CI, 1.56-2.69 and OR, 1.46; 95% CI, 1.11-1.92, respectively). Frequent depression versus no depression was also associated with agreement that (i) it seems like everything causes cancer (OR, 1.67; 95% CI, 1.26-2.22) and (ii) there is not much one can do to lower one's chance of getting cancer (OR, 1.44; 95% CI, 1.09-1.89). Other predictors for perceived cancer risk and/or cancer beliefs were sex, age, ethnicity/race, being born in the United States, marital status, income, body mass index, and smoking. CONCLUSIONS: Depression and other predictors are associated with cancer risk perceptions and beliefs in Texas. IMPACT: Increased attention to reducing depression may improve cancer risk perceptions and beliefs.

Social problem solving and strategy use in young children.

In the present study, the authors investigated what prosocial-assertive, passive, and coercive strategies 6-year-olds (N=257) would propose in response to stories about 2 socially challenging situations: displacing another child in a game and obtaining a toy from another child. The scenarios also varied the gender composition of the characters. Participants' verbalizations while acting out their responses using toy props fell into 13 categories of strategies. Teachers reported antisocial behavior and social competence of the participants. Girls and boys responded similarly in their general suggestions of prosocial or assertive strategies, but girls were more likely to offer prosocial strategies with other girls than with boys. Teacher-rated competence and antisocial behavior interacted in predicting coercive responses by girls but not by boys. The results demonstrate that prosocial and antisocial behaviors need to be considered in interaction to fully understand the nature of social competence.

Lifestyle Modifications and Policy Implications for Primary and Secondary Cancer Prevention: Diet, Exercise, Sun Safety, and Alcohol Reduction.

Improved cancer treatments and cancer detection methods are not likely to completely eradicate the burden of cancer. Primary prevention of cancer is a logical strategy to use to control cancer while also seeking novel treatments and earlier detection. Lifestyle modification strategies to improve primary prevention and risk reduction for the development of cancer include choosing a healthy diet with an emphasis on plant sources, maintaining a healthy weight throughout life, being physically active, regularly using sunscreen and wearing protective clothing, limiting sun exposure during the hours of 10 AM to 2 PM, avoiding indoor tanning, and reducing or eliminating alcohol use. In addition to continued use of ongoing education of the public, health care providers, and cancer support communities, other policy and public health efforts should be pursued as well. Examples of supported and successful policy approaches are included in this article, including efforts to limit indoor tanning and improve community-wide interventions to reduce ultraviolet radiation exposure as well as to formally support various alcohol policy strategies including increasing alcohol taxes, reducing alcohol outlet density, improving clinical screening for alcohol use disorders, and limiting youth exposure to alcohol marketing and advertising. These prevention strategies are expected to have the largest impact on the development of melanoma as well as breast, colorectal, head and neck, liver, and esophageal cancers. The impact of these strategies as secondary prevention is less well understood. Areas of additional needed research and implementation are also highlighted. Future areas of needed research are the effects of these modifications after the diagnosis of cancer (as secondary prevention).