Addressing Health Disparity: The Role of Social Network Support

1. Social determinants of health disparity: The ameliorating effects of social network’s support and activation Nihal Mohamed, PhD and Ash Tewari, MD Department of Urology The Icahn School of Medicine Mount Sinai Health System, New York, USA

2. Social Determinants of Health Disparity • Prostate cancer (PCa) incidence and outcomes vary substantially by race and ethnicity with African American (AA) men experiencing higher incidence and worst outcomes in the US. • However, mainly focusing on racial differences in PCa outcomes may bolster pseudoscientific agreements about the causal roles biological differences between AA and European-American (EA) patients play. • This may lead to missed opportunities to efficiently address the observed racial disparities via targeting potentially modifiable factors (e.g., reducing the impact of low SES by providing needed resources). DeSantis C, Naishadham D, Jemal A. Cancer statistics for African Americans, 2013. CA: A Cancer Journal for Clinicians. 2013;63(3):151-166. Borysova EM, Sultan HD, Chornokur G, Dalton JK, Troutman A. Prostate Cancer Disparities throughout the Cancer Control Continuum. Social Sciences. 2013;2(4).

3. Social determinants of health disparity: The impact of low socioeconomic status (SES) • SES explains approximately 50% of the racial differences in PCa survival. • PCascreening is suboptimal in high risk AA men specially in men with low SES. • The presence of comorbidities (e.g., diabetes, cardiovascular diseases), more common in AA patients with low SES, affects treatment selectionand contributes to relative inequalities in PCa survival. • Low SES could further contribute to cancer progression in AA patients by decreasing patient adherence to follow-up care. • Racial disparities in job retention and work accommodation in AA survivors with low SES (e.g., low skills and low wage jobs) have been documented and are significantly associated with increased financial toxicity and worse quality of life. Xiao H et al. Impact of Comorbidities on Prostate Cancer Stage at Diagnosis in Florida. American Journal of Men's Health. 2016;10(4):285-295. Halbert CH et al. Ever and Annual Use of Prostate Cancer Screening in African American Men. American Journal of Men's Health. 2017;11(1):99-107. Schwartz R et al. Interplay of Race, Socioeconomic Status, and Treatment on Survival of Patients With Prostate Cancer. Urology. 2009;74(6):1296-1302. Tewari AK et al. Effect of socioeconomic factors on long-term mortality in men with clinically localized prostate cancer. Urology. 2009;73(3):624-630.

4. How to buffer the impact of low SES on PCa disparities?

5. Mitigating the impact of low SES: The potential benefits of social support • Social support pertains to the resources and interactions provided by a patient’s social network that may help the patient manage the disease and treatment outcomes. • A patient’s social network could include his significant others (i.e., spouses/partners, family members), his medical team, his work network (e.g., employers, co-workers), and his community network (e.g., church). • Both the structural (e.g., number and strength of social ties) and the functional (e.g., informational and financial support) aspects of social networks have been related to cancer morbidity and mortality. • A meta-analysis study of over 300,000 participants found that supportive relationships were related to a 46% increased survival rate (Holt-Lunstad et al., 2010). • The link between supportive relationships and lower mortality was found comparable to traditional biomedical risk factors such as diet, smoking, and physical exercise (Holt-Lunstad et al., 2010). Willis TA, Filer FM. Social networks and social support. In: Baum A, Revenson TA, Singer JE, eds. Handbook of health psychology. Mahwah, NJ: Erlbaum; 2001. Jan M, Bonn SE, Sjölander A, et al. The roles of stress and social support in prostate cancer mortality. Scandinavian Journal of Urology. 2016;50(1):47-55 Holt-Lunstad, J. L., Smith, T. B., & Layton, B. (2010). Social relationships and mortality: A meta-analysis. PLoS Medicine, 7, 1–20. .

6. Social determinants of health disparity: The impact of low socioeconomic status (SES) Although there is a compelling evidence that social relations and networks are linked to better health and wellbeing across the lifespan and in different patient populations, however negative impact of social network and support provided is also documented. Negative Impact: Social relations and networks : • can provoke conflicts and increase stress levels • undermine individuals’ health goals • increase risk behavior Thoits PA. Mechanisms Linking Social Ties and Support to Physical and Mental Health. Journal of Health and Social Behavior 52(2) 145 –161 Kroenke CH et al. Social Networks, Social Support, and Survival After Breast Cancer Diagnosis. Journal of Clinical Oncology. 2006;24(7):1105-1111. Sigrunn D et al. Coping with a possible breast cancer diagnosis: demographic factors and social support. Journal of Advanced Nursing. 2005;51(3):217-226.

7. Socio-behavioral mechanism linking social network’s support to health Social Support can improve coping and emotional adjustment to PCa by: Strengthening beliefs about: • belonging (e.g., acceptance by network’s members provides security that one’s needs will be fulfilled). • self-esteem (e.g., beliefs about how worthy we are). • sense of control (e.g., confidence in one’s ability to cope with stress). • social influences (e.g., norms about appropriateness of using tobacco, alcohol, or drugs, attending to diet, exercise, seeking care). Social Support can improve health outcomes by encouraging health monitoring behavior and reducing risk behavior: • Received social support (e.g., social network’s provision of needed health-related informational and instrumental resources). • Behavioral control (e.g., attempts from network’s members to monitor health and discourage risk behavior). Thoits PA. Mechanisms Linking Social Ties and Support to Physical and Mental Health. Journal of Health and Social Behavior 52(2) 145 –161 .

8. Biological mechanism linking social network’s support to Health • There is evidence that the effects of social support may be biologically mediated, particularly through neuroendocrine or neuro-immune pathways possibly associated with tumor progression. • Significant associations between support and higher natural killer cell activity in breast cancer patients, as well as lower cortisol levels in metastatic breast cancer patients were reported. • Examining such biological approaches can provide an important step toward a more integrative understanding of the complex biological and socio-behavioral pathways between social support and patients’ outcomes and may have implications for future interventions. • However, the field still lacks a complete understanding of the integrative pathways underlying the association between close relationships, social support, and disease risk about outcomes. Uchino BN, Baldwin MW. Integrative Pathways Linking Close Family Ties to Health: A Neurochemical Perspective. Psychological Association 2017, 72(6), 590–600 Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377–387. Kroenke CH, et al. Social Networks, Social Support, and Survival After Breast Cancer Diagnosis. Journal of Clinical Oncology. 2006;24(7):1105-1111.

9. Patient and network’s factors affecting the quality of social support Quality and type of support received from the network may be influenced by: • Patients’ demographics (e.g., older age, marital status, sexual orientation), and clinical characteristics (e.g., comorbidities). • Characteristics of the social network itself (e.g., having a social network with similar SES, race, and health behavior). Prior research has shown that: • Older patients may be at greater risk for having insufficient social support due to diminished network size because of age-related limitations. • Single and GBT patients tend to have different networks and unique social support needs, particularly as they pertain to health care access and treatment side effects. • For GBT patients of African descent with low SES, PCa disparities could be multiplied based on these characteristics. • Thus, further understanding of the relationships among support and patients’ characteristics may yield important insights into causes of disparities in PCa outcomes. Allen L et al. Socioeconomic status and non-communicable disease behavioral risk factors in low-income and lower-middle-income countries: a systematic review. The Lancet Global health. 2017;5(3):e277-e289. Cornwell EY, Waite LJ. Social disconnectedness, perceived isolation, and health among older adults. Journal of health and social behavior. 2009;50(1):31-48. Umberson D et al. Physical Illness in Gay, Lesbian, and Heterosexual Marriages: Gendered Dyadic Experiences. Journal of health and social behavior. 2016;57(4):517-531

10. Measures of structural support and network characteristics Structural Support: Assessment of social network can generate three categories of network metrics; • a) structure (e.g., the number, degree of closeness, the frequency of contact, proximity to patient, and length of time of these relationship in years). • b) composition (e.g., the percent of individuals in the network who are family members, diversity of sex and race, and family history of PCa). • c) behavior (e.g., negative health habits, including smoking, sedentary lifestyle). Functional Support: Assessment of received support can generate three categories of received or perceived support including emotional, informational, and instrumental support (e.g., The Berlin Social Support Scales). Dhand A, White CC, Johnson C, Xia Z, De Jager PL. A scalable online tool for quantitative social network assessment reveals potentially modifiable social environmental risks. Nature communications. 2018;9(1):3930-3930. Schulz U, Schwarzer R. SozialeUnterstützungbei der Krankheitsbewältigung: Die Berliner Social Support Skalen (BSSS). [Social Support in Coping with Illness: The Berlin Social Support Scales (BSSS).]. Diagnostica. 2003;49(2):73-82.

11. Social support in the health education and health promotion programs Ways in which health interventions can be geared toward enhancing social networks and social support: 1. Enhancing existing social network linkages (e.g., helping patients to identify supportive network members and to mobilize and maintain those relationships). 2. Developing new social network linkages (e.g., when existing social networks are small or overburdened interventions can focus on providing individuals with a mentor or »buddy«, or providing opportunities to participate in a self-help or support group). 3. Enhancing networks through the use of indigenous natural helpers (e.g., identifying volunteers in the community and training them in relevant health topics). 4. Enhancing networks through community capacity building and problem solving (e.g., involving community members to identify and resolve community problems may indirectly strengthen the social networks that exist in the community). Doncho D et al. Social Networks and Social Support in Health Promotion Programs. Health Promotion And Disease Prevention

12. Summary • PCa continues to disproportionately burden the health and wellbeing of AA patients. • Patients’ low SES can significantly affect their PCa treatment outcomes and survival. • Focusing mainly on biological differences may limit our abilities to identify efficacious targets for interventions that could reduce PCa disparities. • Structural/functional social support has the potential to reduce PCa disparities. • Understanding the relationships among social support, low SES, and patient’s’ characteristics may yield important insights into potential interventions to reduce disparities in PCa. • Social support field still lacks a complete understanding of the mechanisms underlying the associations between social ties, social support, and disease risk and outcomes.

13. THANK YOU Questions? • nihal.mohamed@mountsinai.org Grant Support: • DoD-PC140612 Care Planning for Prostate Cancer Patients on Active Surveillance (PI. Mohamed, Co-I. Tewari) • DoD- PC160194 Racial, Cultural, and Dyadic Relationship Factors Influencing Treatment Decisions About Active Surveillance for Localized Prostate Cancer (PI. Mohamed; Co-PI Tewari)