Addressing Latino Cancer Health Equity by Exploring Non-Medical Drivers of Health

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This content is from the “Advancing the Science of Cancer in Latinos: 2024 Conference Proceedings.”

Designing Food Pantries to Improve Food Security Among Cancer Survivors

Dr. Sandi Pruitt is Associate Professor and Associate Director of Community Outreach, Engagement, and Equity in the Harold C. Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center. She also serves as Vice Chair of the Board of Directors for Crossroads Community Services.

Food security and cancer

Dr. Sandi Pruitt’s presentation discussed food security and cancer, best practices and solutions, and a Dallas pantry redesign. The gold standard for measuring food security is the validated US Food and Drug Administration (FDA) survey, which is offered in 6, 10, and 18 question options. In the survey, “high food security” describes households having no problems, or anxiety about, consistently accessing adequate food. “Marginal food security” describes households having problems at times, or anxiety about, accessing adequate food, but the quality, variety, and quantity of their food intake are not substantially reduced. “Low food security” describes households with reduced quality, variety, and desirability of their diets, but the quantity of food intake and normal eating patterns are not substantially disrupted. “Very low food security” means that at times during the year, eating patterns of one or more household members are disrupted and food intake is reduced because the household lacks money and other resources for food. In clinical practice, since a lengthy survey is not practical, a 2 question screening tool called Hunger Vital Sign may be used.

In 2021, 10% of US individuals were food insecure, a rate which is much higher when considering children alone. In Texas, 13.7% of individuals were food insecure in 2021. Across the cancer continuum, food insecurity reduces adherence to therapy, compromises cognitive capacity, lowers access to resources, and is linked to worse overall physical health and mental health, including stress, anxiety, and depression. Malnutrition is common among cancer patients, ranging from 40-80%, and tumors and their associated pain, depression, and stress can impact appetite. Malnutrition can also increase the side effects and adverse reactions of cancer treatment and can lead to extended hospital stays.

In the US, from April 2020 through August 2021, Latino adults had 17.3% food insecurity, second only to non-Hispanic Black adults at 18.9%. Between 1999 and 2018, US born Latino individuals had 21% food insecurity, while foreign-born Latino individuals had 32% food insecurity. Latinos speaking predominantly English had 19% food insecurity, a number that rose to 26% among those who spoke English and Spanish equally, and 34% among those speaking predominantly Spanish.

Best practices and solutions

Federal food programs for mixed age groups include grocery programs such as food bank-operated pantry programs, ad hoc food pantries, home-delivered groceries, mobile markets and pantries, school or other pantries, and community gardens. Meal programs are also important, such as food bank-operated meal programs, community kitchens, group homes and transitional housing programs, rehab and residential programs, and soup kitchens. Finally, food-related benefits programs such as Supplemental Nutrition Assistance (SNAP) (in which 40 million Americans are enrolled) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are also helpful.

Food banks collect surplus food from government commodities, restaurants, farms, markets, consumers, and grocery retailers. They then typically deliver the food to community service organizations, who in turn distribute the food to those in need. Through the COVID-19 pandemic, food banks and other services increased activity drastically, resulting in no increase in food insecurity from 2019 to 2020. However, when this increase in services was rolled back in 2023, food insecurity increased; in Texas, those without enough to eat over a 1-week period increased by 60% between 2021 and 2023. This shows the utility of food banks and other services in minimizing food insecurity.

Building food security in cancer care involves 5 A’s: awareness through empathetic, non-stigmatizing screenings; adjustment of clinical workflows to accommodate assessment and mitigation; assistance of cancer patients through useful guidance and resources; alignment by investing in partnerships with local organizations; and advocacy for policies to prevent food insecurity.

Dallas pantry redesign

Through partnerships with organizations such as Crossroads Community Services, Dr. Pruitt and colleagues have designed an innovative food pantry that emphasizes food equity, meaning client choice is prioritized and a nutrition-based food selection system is utilized. An algorithm is used to match the amount of food to the need, and there are no restrictions on food types. At each visit, this food pantry provides enough food for 21 meals per household member; enough for everyone to have enough food for one full week of food. On average, this pantry provides 100 pounds of groceries per family of four and families can attend the pantry once per month. The redesigned food pantry has also moved away from a hub model to a partnership model within the community, resulting in increased pantry visit frequency and therefore food security.

Changing pantry operations can save time, resources, and increase impact, overcoming the obstacles and stigma associated with food insecurity. This has enormous potential to improve food security and nutrition of cancer survivors and caregivers to transform health. When combined with best practices and common-sense policy, these interventions can greatly improve the food insecurity experienced by many Latino individuals. However, community engagement and true partnership is needed to achieve these goals.

How to Help Latina Mothers Who are Diagnosed with Cancer

Dr. Rebecca Palacios is Professor in the College of Health Education and Social Transformation in the Department of Public Health Sciences at New Mexico State University.

Cancer in Latina mothers

Dr. Palacios’ presentation focused on discovering and addressing social determinants of health experienced by diagnosed Latina mothers in the Paso del Norte border region, which includes bordering areas of Texas, New Mexico, and Mexico. Every year, approximately 144,154 Latino individuals are diagnosed with cancer, 18.3% of which are parents of minor children. Of these recently diagnosed parents, 78.9% are female, meaning that over 20,000 Latina mothers are diagnosed with cancer each year.

All cancer site incidence is rising in Latina women under the age of 50, both in the border states and nationwide. US incidence is 110.3 per 100,000, with Texas slightly higher at 111.5 per 100,000, and New Mexico even higher at 115.2 per 100,000. Cancer incidence in young Latinas is even higher in the Paso del Norte border region, with El Paso County, TX incidence at 126.6 per 100,000, and Doña Ana County, NM incidence at 122.3 per 100,000.^,

Although Latina women have much lower incidence of breast cancer than non-Hispanic White (NHW) women nationwide, this trend is non-existent in El Paso County, or in New Mexico at large. In Doña Ana County, NM specifically, the trend is reversed, with Latina women showing significantly higher incidence of breast cancer. Furthermore, Latina women tend to be diagnosed at a younger age (median 55 years vs 59 years for NHW women), with 35% of Latina women diagnosed before the age of 50 compared to 24% of NHW women.

Although cancer screening guidelines have been adjusted so that women over 40 are now eligible for breast cancer screening, 12% of cancer cases in Latina women present before age 40. Latina women also have a higher incidence of triple-negative breast cancers which have fewer treatment options and a poorer prognosis compared to other subtypes. Latina underrepresentation in clinical trials means that most health-related research and practice is based on NHW, urban, middle-class, American “norms”.

Solutions for young Latina mothers diagnosed with cancer must begin with an increase in clinical research, including intentional recruitment in Latino-dense regions and public health and clinical collaboration leading to Spanish consent forms and culturally adapted recruitment and study materials. Emphasis must also be placed on increasing young Latinas’ awareness of their risk for earlier cancer presentation and training them on breast self-exam guidelines. Clinician awareness of early cancer presentation in young Latinas, including training on screening for risk factors, is also vital. Finally, young Latinas need training to communicate with their doctors so they can successfully advocate for their health.

Social determinants of health along the border

Dr. Palacios and colleagues studied the social determinants of health that impact the Paso del Norte border region, including Las Cruces, NM, El Paso, TX, and Juárez, Mexico. This is a medically underserved region with no comprehensive cancer centers, limited cancer prevention and support groups, and limited cancer survivor education and behavioral interventions. Socio-economic determinants of health for young Latina women in this area were stark. Compared with other young Latina women nationwide, those in the border counties had higher poverty rates, higher chances of leading a household as a single provider, higher rates of uninsured, and lower high school graduation rates.

Low socio-economic status is associated with less access to insurance and time off from work, greater cancer-related financial toxicity, lower access to high-quality care, and higher risk factors for developing or dying from cancer.^, Limited English proficiency and undocumented status are also associated with significant barriers to care.^, Comprehensive centers are needed in underserved areas to combat these barriers. Incentives for cancer specialists/researchers to serve in these areas, expanding the number of Latino or Spanish speaking clinicians, and increasing education/support/services for Latina mothers diagnosed with cancer may help mitigate these barriers. Policy changes are also key to helping young Latina mothers.

Qualitative research and interventions

Qualitative research performed by Dr. Palacios and colleagues has led to a deeper understanding of personal struggles experienced by Latina mothers with cancer. Feelings of loneliness, guilt, difficulty at home, difficulty communicating with their children, needing support during treatment, and feeling like the treatment was worse than the disease were common themes.^, The Conexiones program is a culturally-tailored, evidence-based cancer parenting intervention designed for child-rearing Latina mothers diagnosed with cancer. Program interventions include 5 cancer education sessions designed to reduce maternal depressed mood and anxiety, improve parenting quality, skills, and self-efficacy, and to improve children’s behavioral/emotional adjustment to their mother’s cancer.  The cultural adaptation was geared toward improved comprehension and cultural relevance, and added protocols for domestic violence, self-harm and suicide, and socio-economic status burdens.

Lessons learned through the Conexiones program and other research indicate the need for a multifaceted approach to helping young Latina mothers diagnosed with cancer. Medical assistance is needed for symptom management, including preparing Latinas on what to expect and strategies for managing extreme side effects; there is also a need for training and recruiting pain management and behavioral health specialists to underserved regions. Culturally adapted cancer education programs can help address disparities in social determinants of health. Finally, health equity-focused research strategies such as community-based participatory research, clinical trials exclusive to young Latinas, and new research strategies and instrumentation may help progress the research efforts with young Latina mothers diagnosed with cancer.