**3. A balanced perspective: understanding the social determinants of health**

To elucidate the global perspective of lower-resourced communities, the Social-Ecological Model of Health provides an applicable theoretical framework. The model proposes that individual health is influenced by biological and genetic functioning, social and familial relationships, the built environment, and broader psychosocial and economic factors (Figure 1). Health is influenced by multiple facets in the physical and social environment; the environment itself is multidimensional, incorporating social, physical, actual or perceived elements as discrete attributes or constructs. An individual's environment is influenced by the interaction with people who share that environment. Person-environment interactions occur in cycles in which people influence their settings; these changes in turn influence health behaviors.(Stokols 1996)

Global health disparities is a critical area of concern and intensifies the issue of cancer in developed and developing countries.(Jones, Chilton et al. 2006; Kawahara, Masui et al. 2010) Cancer is the leading cause of death worldwide with mortality rates spiking in low- and middle- income countries.(Linkov, Padilla et al. 2010) Medical care alone cannot adequately improve health related quality of life or reduce cancer disparities without also addressing where and how people live.(Subban, Terwoord et al. 2008) As countries become more culturally diverse, taking action to train the future cancer workforce to better serve their changing communities is a top priority. (Dogra, Reitmanova et al. 2010) Public & private health systems need to move beyond identifying problems to development of novel interventions and their implementation. Additionally, genuine efforts need to be made to offer culturally & linguistically appropriate services to the world's most vulnerable

Addressing global cancer health disparities requires a holistic solution to a complex and interdependent set of patient, provider, and health system factors. Through educational interventions, projects can aim to position the health care system to effectively serve patients and communities of color. The state of the cancer workforce displays a grim picture, with several shortages including oncologists, pharmacists and nurses. These shortages can be characterized as supply and demand determinants; the demand for oncologists – the lifetime probability of developing cancer is 1 in every 2 men and 1 in every 3 women - is expected to exceed supply by 25%-30% by 2020. Against this backdrop, bolstering the basic cancer care competency knowledge and skills of medical, nursing and pharmacy students is essential as an evidence-based prevention priority and sustainable capacity for cancer

Cancer health disparities in low- and middle- income countries provides a uniquely rich platform for educational interventions as reflected by the large number of physicians, nurses and pharmacists serving resource-challenged and underserved populations. By "mainstreaming" cultural competence-embedded cancer care education into health professions curricula, a competent cadre of health care providers produced as a result of revised competencies and cancer education curricula has a "ready practice setting" to

**3. A balanced perspective: understanding the social determinants of health**  To elucidate the global perspective of lower-resourced communities, the Social-Ecological Model of Health provides an applicable theoretical framework. The model proposes that individual health is influenced by biological and genetic functioning, social and familial relationships, the built environment, and broader psychosocial and economic factors (Figure 1). Health is influenced by multiple facets in the physical and social environment; the environment itself is multidimensional, incorporating social, physical, actual or perceived elements as discrete attributes or constructs. An individual's environment is influenced by the interaction with people who share that environment. Person-environment interactions occur in cycles in which people influence their settings; these changes in turn influence

**2. Racial, cultural and ethnic disparities in cancer care** 

populations.

care.(C-Change 2008; Smith, Tyus et al. 2009)

health behaviors.(Stokols 1996)

implement those skills in a fashion that is measurable.

Influencing Proximal, Intermediate, & Distal Factors

Fig. 1. Social-ecological model: reversing the social determinants that widen the healthy divide.

Social determinants are inextricably linked with socioeconomic disparities that impact every phase of the cancer care spectrum from screening to palliative care. (Smedley, Stith et al. 2003) Despite the United States nationally acclaimed decreases in breast and cervical cancer mortality due in large part to early screening and better therapeutics, African American Hispanic and American Indian/Alaska Native (AI/AN) populations have not enjoyed these same benefits. African American and Hispanic women have higher breast and cervical cancer mortality respectively despite similar screening rates to White women. Colorectal cancer screening rates are also lower while advanced stage at diagnosis higher within African American and Hispanic people. Treatment disparities are particularly concerning. The absolute proportion of African American and Hispanic women receiving radiation therapy less than 1 year after breast conserving therapy is 12% lower in African American and 19% lower in Hispanic women. There is no stable data for AI/AN women. (Natale Pereira, Enard et al. 2011) African American women with breast cancer were less likely to receive full course chemotherapy (Griggs, Sorbero et al. 2003)and more likely to receive nonstandard chemotherapy regimens (OR 1.93 [1.11 – 3.36]). (Griggs, Culakova et al. 2007; Griggs, Culakova et al. 2007)This correlated with stage of disease i.e. Stage II and III OR 2.82 (2.01 – 3.95) and 7.95 (4.06-15.98) respectively, and lower education levels i.e. less than high school OR 3.24 (1.17 – 9.0), high school graduate OR 1.8 (1.08-3.0). These data in part,

Creating a Sustainable Cancer Workforce: Focus on Disparities and Cultural Competence 407

Treatment outcome starts with the patient's first encounter with the health care system. The quality of that encounter, distinct from customer service, significantly impacts the subsequent patient-provider relationship, ultimate partnership, adherence to treatment recommendations, quality of life during treatment and the survivorship continuum. Qualitative factors have an equal if not greater role than quantitative information in patient decision making. Therefore, the qualitative approach that the provider chooses to communicate the quantitative information is paramount. The provider must understand the culture through which the patient relates and understands information about medical and

Cultural nuances differ ethnically as well as geographically a factor which becomes especially important when dealing with populations in various phases of acculturation in a country or community. For example, in the United States, all phases of the patient-provider interaction center on the implicit understanding that the patient will make the ultimate treatment decision. In certain Hispanic cultures, the husband might make the ultimate decision while in Asian culture, the eldest son will be the decision maker. In African American culture, the children and spouse collectively drive the treatment decisions of the patient. Failure to address these decision makers through all phases of the patient encounter and decision making process will negatively impact on the overall quality of the providerpatient relationship and ultimately treatment compliance by creating an environment of

Understanding how people from different cultures actually make treatment decisions is critical. In western culture, the process is linear- treatment discussion, research treatment options via internet/publications, analyze the data and reach a decision within a defined, usually short, timeframe. If the provider does not realize that the doctor's opinion rather than the research process may be the deciding factor for Hispanic patients, that the American Indian patient may want to discuss their condition with the tribal elders or healer, that African American patients may want to discuss their options with the family matriarch/patriarch and obtain *their* treatment decisions before informing the provider of the patient's treatment decision then the delay in treatment decision will not 'make sense'. Furthermore, the questions posed to the provider through the patient may in fact emanate from these other individuals. This can result in mismatched patient-provider expectations leading to miscommunication and narrow, biased interpretations of how 'capable' a given

Subtle aspects of the patient encounter engagement process are important. African American patients expect direct eye contact as lack thereof conveys the message that the provider cannot be trusted. Conversely, Asian patients will avoid eye contact as direct eye contact is a sign of disrespect to the provider who is perceived, in that setting to have higher status. Conversely, listening to the provider's treatment discussion with closed eyes does not signify disinterest or information/emotional overload for the Japanese patient but indicates that the provider has the patient's full attention. Failing to directly address the husband of a Hispanic woman when making treatment recommendations is an insult to her husband. The importance of cultural competence in the provider patient partnership cannot

be overstressed and is critical to effectively address health disparities.

social aspects of the disease process and treatment.

mistrust and devaluing the patient and their support system.

patient may be to 'understand' their treatment.

may explain the lower survival rates in African American and Hispanic women although data in Hispanic women is lacking. System factors pose significant problems with lower proportions of Hispanic women reporting timely receipt of appointments (35 vs. 49%) and higher proportion reporting difficulty in getting care when needed compared to White women (66 vs. 55.8%). Higher poverty rates, lower insurance rates and higher discontinuously insured rates, decreased English proficiency when compared to White populations characterize African American and/or Hispanic populations. (Smith Bindman, Miglioretti et al. 2006; Elkin, Ishill et al. 2010; Miranda, Wilkinson et al. 2011) Effective cancer care cannot be delivered without a multi-tiered approach that effectively links and integrates the patient with all components of the cancer care delivery system. Patient navigation is a promising strategy that can affect this.
