Assessing Physical Activity Behavior of Cancer Survivors by Race and Social Determinants of Health

Abstract

Introduction:

Black cancer survivors remain at a higher risk for secondary cancers, cancer recurrence, and comorbid conditions than non-Hispanic White survivors. Physical activity may help improve health outcomes and overall quality of life. We assessed cancer survivors’ physical activity by race/ethnicity and the effect of social determinants of health (SDH) constructs (i.e., economic stability, education, and access to health care) on physical activity.

Methods:

This was a cross-sectional analysis of data from the 2016 Behavioral Risk Factor Surveillance System. The outcome variable was physical activity after cancer diagnosis and the predictor variables were SDH and race. Multivariable logistic regressions were used to examine associations between race and physical activity and the effect of SDH on physical activity.

Results:

Among 3,787 cancer survivors, 91.6% self-identified as White and 8.4% as Black. Blacks were more likely than Whites to report low economic stability, low access to health care, and low health literacy (all ps < .01). Blacks were less likely than Whites to engage in physical activity after controlling for demographic and clinical factors (adjusted odds ratio [ORAdj] = 0.71; 95% confidence interval [CI] = 0.56–0.91; p = .01) and after additional adjustment of SDH (ORAdj = 0.77; 95% CI = 0.60–0.99; p = .04).

Conclusions:

The findings suggest that though Black cancer survivors are less than White to engage in physical activity, and SDH partially explained the racial difference in physical activity behaviors. These findings highlight the need to address barriers to health-care access, economic stability, and educational attainment.

Introduction

Approximately 15.5 million cancer survivors were living in the United States in 2016.¹ It is projected that by the year 2026 there will be 20.3 million cancer survivors living in the United States.¹ The increase in survivorship rates is seen across all racial and ethnic groups, with the Black population experiencing a higher 5-year survival rate increase than the White population.² In fact, the 5-year relative survival rate for all cancers combined has increased by 20% among non-Hispanic Whites and by 24% among Blacks in the past three decades.¹ Nevertheless, even with recent increases in survival, racial and ethnic minorities experience disproportionately higher cancer mortality rates than non-Hispanic Whites.³ Cancer survivors, regardless of race, experience a high incidence of comorbid conditions,⁴ and racial and ethnic minority cancer survivors remain at higher risk than White cancer survivors for secondary cancers, cancer recurrences,^5–7 and comorbid conditions.^8,9 Minority cancer survivors remain at higher risk due to the interplay of socioeconomic factor, culture, diet, stress, the environment, and biology.¹⁰ These observations demonstrate the need for cancer survivors to be aware of risk factors that contribute to the development of secondary cancers and recurrence, but also of the need to engage in healthy lifestyles that can help improve their overall health.^5,11 Engaging in at least 150 minutes of moderate intensity physical activity per week^12–14; following a diet high in vegetables, fruits, and whole grains; and quitting smoking may improve cancer survivors’ health and quality of life.¹⁴

Physical Activity Behavior

Empirical evidence and prospective longitudinal studies have suggested that engaging in physical activity is beneficial to people with chronic diseases from different age groups and ethnic backgrounds.² Physical activity is associated with a reduction of cancer recurrence and can help mitigate the negative impact of cancer and its treatments.^15–19 Physical activity has also been found to reduce cancer-related fatigue, cognitive impairment, sleep problems, depression, pain, anxiety, neuropathy,²⁰ and physical dysfunction including impaired muscular function, cardiopulmonary function, and loss of bone density during and after cancer treatment.²¹

Notwithstanding the documented benefits of physical activity, racial and ethnic minorities including Black cancer patients and survivors are underrepresented in physical activity research studies.²² A study has found that, in the non-cancer population, about 59.1% of Blacks/African Americans compared to 46.4% of non-Hispanic Whites are not meeting the 150 minutes of moderate physical activity per week recommendation.²³ Saffer, Dave, Grossman, and Leung estimated from the 2007 National Health Interview Survey that in the general population 33.8% of Whites, 23.8% of Hispanics, and 23.2% of Blacks engaged in regular physical activity.²⁴

Most current research either focuses on cancer patients or survivors, with evidence suggesting that low participation of minority cancer patients in physical activity is attributable to both structural and personal barriers.²⁵ Structural barriers include neighborhood and community safety concerns,^26–28 lack of sidewalks and physical activity facilities,^26,29,30 and lack of physically active role models.^27,31 Embedded in the structural barriers is a low-socioeconomic status (SES) that not only affects health outcomes and quality of life of minority cancer patients but also perpetuates participation disparities in physical activity. Previous studies suggest that personal barriers to physical activity among minority cancer patients include lack of time,^26,32 lack of motivation,^26,29,33 tiredness/fatigue,^26,34 lack of knowledge,^34,35 health conditions,^26,29 physical appearance concerns,^27,31,34 cost of facilities,^{26,29,34,36,37} and lack of social support.^26,31,35

A few studies have examined physical activity behavior among racial minority populations including Blacks.^38–40 For example, Paxton et al.³⁹ reported that Black cancer survivors (32%) were less likely to be physically active than non-Hispanic White (52%), Asian American (48%), and Hispanic (39%) cancer survivors. However, the possible influence of socioeconomic factors, health literacy, and access to health care on cancer survivors’ health behaviors was not evaluated in their study. Also, Irwin et al.³⁸ demonstrated that among Black, White, and Hispanic breast cancer survivors, Black breast cancer survivors spent significantly less time engaged in physical activity than non-Hispanic White and Hispanic White breast cancer survivors. Blanchard et al.⁴⁰ examined cancer survivors’ adherence to lifestyle behaviors including physical activity and fruit and vegetable consumption and showed that the majority of the participants did not meet American Cancer Society recommendations of at least 150 minutes of moderate-intensity physical activity per week.⁴⁰ In addition, Kish et al.⁴¹ identified a significant association between Black cancer patients and low-SES. Although these previous research studies have contributed to our understanding of Black/African American cancer patients’ physical activity behavior, the direct relationships and effects of social determinants of health (SDH) on minority cancer patients’ physical activity behavior were not the focus of these studies. Thus, a study examining the associations among race, SDH, and physical activity engagement among cancer survivors is warranted.

Theoretical Framework

The constructs of SDH can serve to identify factors associated with these cancer-related disparities.⁴² The SDH framework⁴² is predicated on the premise that behavior is influenced by economic stability, education, social and community context, health, and access to health care, and neighborhood and environment.^42,43 These determinants are the underlying factors for health disparities and disease outcomes^1,44 and are widespread phenomena among racial and ethnic minority populations.^45,46 In the general population without cancer, SDH factors are known to influence individual health behaviors.⁴⁷ SDH constructs are directly associated with health behaviors and health outcomes,⁴⁸ and therefore SDH can be a useful framework for understanding cancer-related health disparities. To our knowledge, the interaction between SDH constructs and physical activity among cancer patients and survivors has been understudied.

The primary purpose of this study was to assess cancer patients’ and survivors’ physical activity behaviors by race/ethnicity. The secondary purpose was to identify SDH constructs (i.e., economic stability, education, and access to health care) associated with physical activity behaviors and determine whether these factors explain existing differences in physical activity behaviors among White and Black cancer survivors.

Methods

Study Design

The study was a cross-sectional, secondary analysis based on de-identified data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a nationwide telephone survey conducted by public health departments. The data set was obtained from the Centers for Disease Control and Prevention database.

Study Population

The sampling frame consisted of noninstitutionalized adults who were 18 years and older. Participants selected for this study were those who self-reported a diagnosis of cancer by their doctors (hereafter will be referred to as survivors). Inclusion criteria were patients who were going through cancer treatment, did not go through treatment, those who had completed treatments, self-identified as non-Hispanic White or Black, and provided information about their physical activity behaviors.

Measures

1. The demographic variables from the BRFSS included marital status, gender, and age of the participants. Multiple choice items were used to assess marital status. Participants were asked to identify their gender and report their age.

2. Clinical conditions such as cancer-related health status (treatment or not treatment status, cancer type, and multiple cancer) and body mass index (BMI) were controlled as covariate variables.

3. In this study, three constructs of SDH were operationalized as independent variables, economic stability, education, and access to health care. (a) Economic stability items were dichotomized: employment status (employed or unemployed), annual household income (low income <$50,000 or high income >$50,000) [This dichotomy is consistent with the literature],⁴⁹ and medical bills (yes or no medical bills). A respondent was operationalized as economically stable if he or she was employed, had a high income, and had no medical bills; all others were considered economically unstable. (b) The education variable was dichotomized into having higher education⁴² (that is earned a college degree and associate degree) or having lower education (i.e., less than an associate degree). This dichotomy is consistent with SDH definition.⁴² A respondent was operationalized as higher education if he or she had earned a college degree or associate degree; all others were considered to have lower education.⁴² (c) Access to health-care variables were insurance (yes or no) and ability to see physician or provider (yes or no). Respondents who had insurance and could see a provider were operationalized as having high access to health care; all others were considered to have low access to health care.

4. The outcome variable was physical activity behavior and a single item used was “During the past month, other than your regular job, did you participate in any physical activity or exercise or walking for exercise?” (yes or no).

We submitted the study protocol to the University of Rochester Medical Center Institutional Review Board for approval, and they exempted this study from review because it was based on deidentified public data.

Data Analyses

The demographic characteristics of the participants were stratified by racial group, and descriptive statistics were used to evaluate possible differences in demographic variables. Multivariable logistic regressions were used to examine the associations among race, physical activity, and SDH factors; all the analyses were weighted. The modeling was executed in two hierarchical steps: the first model evaluated the association between race and physical activity after controlling for variables such as age, gender, marital status, and body mass index (BMI). The SDH factors were added in the second step to evaluate the effects of SDH on differences in physical activity between racial/ethnic groups. All analyses applied two-sided tests using a cutoff of p ≤ .05 for significance. Statistical analyses were performed using SAS software version 9.4 and SPSS software version 24.

Results

Demographic Characteristics

During the study period, January to December 2016, a total of 43,471 self-reported cancer diagnosis by their doctors, but 3,787 cancer survivors (all cancer types combined) met the inclusion criteria, thus were included in the analysis. There were 91.6% survivors who self-identified as White (n = 3,469) and 8.4% who self-identified as Black (n = 318) (see Table 1).

Table 1.

Demographic Characteristics, Health Behaviors, and Social Determinants of Health of Respondents by Race and Ethnicity (Total n = 3,787).

	Whites		Blacks
	n	%	n	%
Demographics
Gender
Male	1,292	37.2	119	37.4
Female	2,177	62.8	199	62.6
Marital status
Unmarried	1,619	46.7	210	66.0
Married	1,850	53.3	108	34.0
Age
≥65 years	174	5.0	17	5.3
45–64 years	1,001	28.9	102	32.1
18–44 years	2,294	66.1	199	62.6
Clinical conditions
Cancer type
Breast	838	24.2	90	28.3
Gynecologic	440	12.7	30	9.4
Head and neck	149	4.3	7	2.2
Gastrointestinal	310	8.9	35	11.0
Hematologic	205	5.9	18	5.7
Genitourinary	716	20.6	80	25.2
Lung	135	3.9	16	5.0
Other	676	19.5	42	13.2
Multiple cancer
One cancer type	2,468	71.1	258	81.1
Two or more cancer types	1,001	28.9	60	18.9
Treatment
No treatment	439	12.7	46	14.5
In treatment	435	12.5	54	17.0
Complete treatment	2,595	74.8	218	68.6
Body mass index (BMI; kg/m2)
BMI ≤ 25	1,089	31.4	92	28.9
BMI ≥ 25	2,380	68.6	226	71.1
Economic stability items
Employment
Not working	2,528	72.9	247	77.7
Employed	941	27.1	71	22.3
Annual household income
≤$50,000	2,121	61.1	231	72.6
≥$50,000	1,348	38.9	87	27.4
Medical bills
No	3,416	98.5	295	92.8
Yes	53	1.5	23	7.2
Literacy item
Education
No college degree	1,272	36.7	151	47.5
College degree	2,197	63.3	167	52.5
Health-care access items
Insurance
No	112	3.2	9	2.8
Yes	3,357	96.8	309	97.2
Medical cost
Not able to see physician	296	8.5	42	13.2
Able to see physician	3,173	91.5	276	86.8

SDH and Race

Black cancer survivors were more likely to report low economic stability; specifically, Blacks trended more toward not working (Blacks 77.7% vs. Whites 72.9%; p = .06) and a low annual income (Blacks 72.6% vs. Whites 61.1%; p < .01). Black cancer survivors reported low access to health care; specifically, Blacks were more likely to report that they could not see their physicians because of medical cost (Blacks 13.2% vs. Whites 8.5%; p < .01), but there was no significant difference in health insurance coverage between Black and White cancer survivors (Blacks 97.2% vs. Whites 96.8%; p = .70). In addition, Blacks reported lower educational attainment compared to Whites, meaning they were more likely to report not having a college degree (Blacks 47.5% vs. Whites 36.7%; p < .01). After adjusting for age, sex, marital status, cancer types, treatment status, multiple cancer types, and BMI, multivariable logistic regression models showed Black cancer survivors still reported lower educational attainment (adjusted odds ratio [ORAdj] = 0.89; 95% confidence interval [CI] = 0.81–0.98; p < .01), lower access to health care (ORAdj = 0.71; 95% CI = 0.62–0.81; p < .01), and lower economic stability (ORAdj = 0.52; 95% CI = 0.45–0.61; p = .01) compared (see Figure 1).

Figure 1.

The adjusted odds ratios and 95% confidence interval comparing Black versus White cancer survivors SDH variables.

Physical Activity

Survivors with BMI ≥25 (OR = 0.62; 95% CI = 0.52–0.72; p < .01) and those who completed cancer treatment (OR = 0.66; 95% CI = 0.53–0.81; p < .01) were significantly less likely to report physical activity behavior compared to those with BMI ≤25 and those who had no cancer treatment, respectively (see Table 2). Overall, Black cancer survivors were less likely than White cancer survivors to engage in physical activity (Blacks 30.7% vs. White 40.6%; OR = 0.65; 95% CI = 0.51–0.82; p < .01). When adjusted for age, sex, marital status, cancer types, treatment status, multiple cancer types, and BMI in the multivariable logistic regression, Black cancer survivors were less likely to engage in physical activity (ORAdj = 0.71; 95% CI = 0.56–0.91; p = .01). After additional controlling for SDH constructs in the final model (Table 2), Black cancer survivors remained less likely to engage in physical activity (ORAdj = 0.77; 95% CI = 0.60–0.99; p = .04). Figure 2 shows the trend in change of the odds ratios comparing Black versus White cancer survivors for engagement in physical activity. As potential confounders were added to the model, the odds ratios trended closer to 1 (the null value; see Figure 2). The SDH constructs were significantly related to the participants’ physical activity behaviors; thus participants with high health-care access (ORAdj = 1.40; 95% CI = 1.11–1.77; p = .01), high economic stability (ORAdj = 1.86; 95% CI 1.64–2.21; p < .01), and greater educational attainment (ORAdj = 1.91; 95% CI = 1.64–2.21; p < .01) reported participating in more physical activity than those with health-care access, economic stability, and lower educational attainment, respectively (see Table 2). There was no significant interaction effect between race and economic stability (p = .40), race and access to health care (p = .10), and race and educational attainment (p = .42) for participants’ physical activity behavior.

Table 2.

Association of Race/Ethnicity, Demographic, Clinical, and SDH Factors With Engagement in Physical Activity (Multivariate Logistic Regression Analysis, n = 3,787).

	Physical activity
	Adjusted odds ratio	95% CI
		Lower	Upper	p
Race
White	1.00	-	-	-
Black	.77	.60	.99	.04
Gender
Male	1.00	-	-	-
Female	.74	.60	.90	<.01
Marital status
Unmarried	1.00	-	-	-
Married	1.40	1.20	1.62	<.01
Age				<.01
≥65 years	1.00
45–64 years	2.23	1.49	3.32	<.01
18–4 years	1.01	.85	1.21	.90
Cancer type	-	-	-	<.01
Breast	1.17	.91	1.49	.21
Gynecologic	.85	.64	1.13	.27
Head and neck	.95	.64	1.43	.82
Gastrointestinal	.78	.59	1.04	.09
Hematologic	1.10	.78	1.56	.59
Genitourinary	1.06	.82	1.37	.67
Lung	.54	.37	.79	<.01
Treatment				<.01
No treatment	1.00	-	-	-
In treatment	0.84	.68	1.04	.11
Completed treatment	.66	.53	.81	<.01
Multiple cancer types				.35
≥ Three cancer types	1.00	-	-	-
One cancer type	1.25	.90	1.75	.18
Two cancer types	1.16	.82	1.65	.40
Body mass index (BMI; kg/m2)
BMI ≤25	1.00
BMI ≥25	.62	.52	.72	<.01
Health-care access
Low	1.00	-	-	-
High	1.40	1.11	1.77	<.01
Economic stability
Low	1.00	-	-	-
High	1.86	1.45	2.38	<.01
Education
Low	1.00	-	-	-
High	1.91	1.64	2.21	<.01

Abbreviations: CI, confidence interval; (–), reference; SDH, social determinants of health.

Figure 2.

The adjusted odds ratios and 95% confidence interval comparing Black versus White cancer survivors for engagement in physical activity.

Note. Model 1 controls for covariates such as age, gender, marital status, cancer types, treatment status, multiple cancer types, and body mass index. Model 2 consists of Model 1 and also controls for SDH constructs.

Discussion

This study examined relationships between race/ethnic differences and SDH constructs in cancer survivors and their current physical activity engagement. The first finding of the study was that physical activity differed by race, with Black cancer survivors reporting less physical activity behaviors even after adjusting for confounders and SDH constructs. This result is consistent with other studies that report racial differences in health behaviors.^5,50 Physical inactivity among cancer survivors, especially Black cancer survivors, should galvanize public health professionals to intensify health education and promotion interventions to increase physical activity across diverse racial backgrounds, especially among Black cancer survivors.

Another important finding of this study is that SDH was positively correlated with physical activity behavior; respondents with higher economic status, educational attainment, and access to health care were more likely to engage in physical activity than those respondents at the lower end of SDH. After adjusting for the covariates, although race remained a factor in determining physical activity behavior, the SDH constructs significantly explain physical inactivity behaviors among Black cancer survivors. This was evident as the odds ratios trended closer to 1 when the SDH constructs were added in the physical activity final model (see Figure 2). Thus, our results suggest that the differences in physical activity behaviors between non-Hispanic White and Black survivors were partially mediated by SDH. These findings support several studies in the general population that SES directly influences physical activity.^48,50–55 The findings are also consistent with Park et al.’s⁵⁶ conclusions that low-SES in cancer survivors is associated with unhealthy behaviors.

Participants’ BMI had a very strong association with lack of physical activity. Those participants with BMI ≥25 were less likely to engage in physical activity, and Lee et al.⁵⁷ came to the similar conclusion that physical activity is associated with a lower prevalence of obesity using both waist-to-height ratio and BMI.

We found racial differences between White and Black cancer survivors with regard to SDH constructs. Our findings showed that Black cancer survivors were more likely to report lower values for all SDH constructs. These findings support several other studies in the general population about the prevalence of poor socioeconomic conditions, barriers to health care, low educational background, and unemployment among the minority population.^48,50–55 Moreover, there is literature to support our findings that less educated, unemployed, and poor Blacks are more likely to be physically inactive.^52,58 Another way to frame our findings is that this study confirms that the SDH constructs are barriers to some cancer survivors’, especially Black cancer survivors’, ability to engage in healthy behaviors, and this has the potential to worsen their health outcomes and quality of life. Because low-SES and poor educational attainment have strong associations with poor health outcomes and quality of life,⁵⁹ it is of great importance to address these disparities in SDH by changing policies at the local, community, state, and federal government levels. Specifically, increasing public and providers’ awareness of disparities in SDH, expanding health insurance coverage to all,⁶⁰ improving the capacity and number of providers in underserved communities, increasing the minimum wage, and increasing the knowledge base on disparities in SDH and interventions may help reduce those disparities.⁶⁰ Admittedly, addressing the inequalities in economic, education, housing, and health-care policies and their effects on improving the underserved and minority communities, their health outcomes, and quality of life is a daunting proposition, but any incremental efforts targeted at SDH factors should be encouraged.

Another finding worth noting is the proportion of cancer survivors who were not working. In this study, 77.7% of Black cancer survivors and 72.9%, White cancer survivors reported not working. This finding is inconsistent with the study by Clarke et al.⁶¹ who found that the majority of Black and White cancer survivors in their study were working. Similarly, the proportion of cancer survivors who reported having health insurance in this study is high (Whites 96.8% vs. 97.2%) and that might account for the reason why the majority of the participants (Whites 91.5% vs. 86.8%) had no problem seeing their physicians. These results suggested that the majority of the respondents had health-care access; however, there was still a significant difference between Black cancer survivors and White cancer survivors with regard to their access to health care.

Limitations

First, the study relied on phone interviews; as a result, findings may be subject to recall, undercoverage, and nonresponse biases. These biases may reduce the external validity of the findings. However, White et al.⁵ observed that studies have generally found that most BRFSS measures related to health behavior and physical activity are sufficiently reliable and valid. Second, the physical activity behavior was measured using a single item and that physical activity frequency, intensity, and types were not measured. However, the use of a single item to measure physical activity behavior is consistent with another study.⁵ Third, the use of existing data is a significant limitation because other important variables may not be included in the data. For example, SDH variables such as neighborhood and environment and social and community context were not in BRFSS data set and therefore could not be included in this study. These variables may have a significant influence on Black cancer survivors’ physical activity behaviors. Future research should look at neighborhood and community context variables and their effect on cancer survivors’ physical activity behavior. Again, classifying education into having a college degree or an associate degree and not having a college degree or an associate degree is also a limitation, as this could result in classification bias. However, Chuang et al.⁴² classified education in SDH as higher education and lower education⁴² and using education as a proxy for health literacy is a common practice in the literature.⁶² Future study should use variables such as participants’ ability to read and understand health instruction to assess their health literacy level. Nonetheless, using the cutoff point of income >$50,000 could be problematic as classification may either understate or overstate the participants’ economic stability variables. Nonetheless, using a cutoff point of income >$50,000 is a common practice in the literature.⁴⁹ Future studies should use categorical variables to measure income which may show greater sensitivity in illustrating the degree of difference between those who have a higher income. The final limitation of the study is that the Black cancer survivor sample size was small, which makes it difficult to conduct further subgroup analysis among Black survivors. With that said, Black cancer survivors are hard to reach for any study,⁴³ and therefore this study does contribute to the existing body of knowledge.

Significance

Notwithstanding these limitations, this study has several strengths. First, health behaviors and health status among cancer survivors have been documented previously.⁵ However, to our knowledge, this is the first population-based study to examine racial/ethnic differences in physical activity and the influence of SDH constructs among cancer survivors. Second, our study not only validates existing body of literature, but it also expands the conversation in the literature about SES, race, and physical activity to include Black cancer survivors. In the general population, it is a well-known phenomenon that structural barriers like SDH contribute to physical inactivity among racial minority and underserved population,⁶³ but studies that examine the interaction between SDH and race among cancer patients are relatively rare. This study helps close this gap in the literature. The use of the SDH constructs helped us explain cancer survivors’ physical activity behaviors, and these results can be used to design an intervention program to promote physical activity among racial and ethnic minority cancer survivors. The use of this theoretical framework enhances the ability to replicate and validate this study and associated findings. Finally, this study is an incremental effort toward addressing the Healthy People 2020’s overarching goal of eliminating health disparities in the United States.

Implications

The study has two main implications for practice and policy makers. A comprehensive approach that addresses structural barriers including SDH factors and individual behavioral factor may help improve physical activity behavior among Black cancer survivors. First, low educational attainment, low access to health care, and low economic stability were found to be the underlying mechanisms that moderate Black cancer survivors’ physical activity behaviors. Racial disparities and SDH are structural barriers that require policy-makers, the community, and society to address. Until these structural barriers are addressed, any interventions to address individual physical activity behavior may be futile. Second, racial/ethnic differences were noted in cancer survivors’ physical activity participation. Intervention efforts may be needed to help Black cancer survivors’ engage in physical activity.

In conclusion, this study reveals that there are significant racial disparities in SDH constructs. Black cancer survivors are more likely than Whites to have lower economic stability, educational attainment, and access to health care. These disparities are strongly associated with less physical activity behavior among Black cancer survivors. Although it may be important to implement health promotion and education interventions to enhance Black cancer survivors, physical activity engagement, it is imperative to change policies regarding SDH, including access to health care, economic stability, and educational attainment.

Author Biographies

Matthew Asare holds a PhD Health Education from the University of Cincinnati. He is currently an assistant professor in the Public Health Department at Baylor University. His research interest is in health disparities relating to cancer control and prevention, patient-provider relationship, cultural humility and responsiveness, and sexual education. His scholarship is grounded in theories to facilitate pro-health behavior changes at the individual and community levels, especially among racial and ethnic minorities and underserved populations. Dr. Asare’s global research is in the prevention of HPV-related cancers in sub-Saharan Africa.

Scott McIntosh holds a PhD in Counseling Psychology from the University of Miami. He is an associate professor in the Department of Public Health Sciences at the University of Rochester Medical Center. As associate director of the Smoking Research Program and director of the Center for a Tobacco-Free Finger Lakes, Dr. McIntosh is currently involved with the study of nicotine dependence interventions with various populations and the training of physicians and other medical professionals in guideline-based nicotine dependence interventions. He has completed an NCI-funded randomized controlled trial studying WATI with community college students. He is co-investigator on several global health projects concerning distance training platforms, maternal health improvement, and diabetes prevention. He was recently co-investigator for a randomized controlled trial for smoking cessation in the Dominican Republic, investigator on an obesity prevention project in large worksites, and Site Principal Investigator for a study of smoking cessation education in Medical Schools.

Eva Culakova holds a PhD in Mathematics from the University of Rochester, where she also completed her postdoctoral training in Biostatistics. She has more than 15 years of statistical experience in analyzing studies on the side effects of anticancer treatments and the symptom burden related to disease and treatment. Dr. Culakova currently serves as the lead biostatistician at the University of Rochester Medical Center Cancer Control Program, where she holds a research assistant professor position. To date, Dr. Culakova has co-authored more than 40 manuscripts.

Amina Alio holds a PhD in Applied Anthropology from the University of South Florida. She is currently an associate professor in the Department of Public Health Sciences at the University of Rochester Medical Center. She has extensive experience in community-based research, evaluation design, and qualitative and quantitative research methodologies. Dr. Alio’s research focuses primarily on health disparities and the impact of behavioral, psychosocial, and environmental factors on pregnancy outcomes, particularly among African Americans. Her international research is in women’s reproductive health, HIV/AIDS, and pregnancy outcomes in sub-Saharan Africa.

M. Renee Umstattd Meyer holds a PhD in Health Promotion, Education, and Behavior from the University of South Carolina, Arnold School of Public Health. She is currently an associate professor in the Public Health Department at Baylor University. Her work focuses on promoting health and health equity through an active living lens. She works with communities using mixed methods to understand cultural context and advance approaches and policies to foster healthy and active opportunities and lifestyles for all people. She focuses much of her work partnering with underserved rural communities and families, which has been supported by the Robert Wood Johnson Foundation through Active Living Research and the Physical Activity Research Center (PARC), the Physical Activity Policy and Research Network Plus (PAPRN+) through the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, and the U.S. Department of Education. As part of her expertise, she co-leads the PAPRN + Rural Workgroup and has been invited to serve on advisory panels and/or lead webinars for Voices for Healthy Kids, America Walks, the Physical Activity Research Center, and the diversity committee for the 2016 National Physical Activity Plan, to name a few. In addition to serving in these capacities, she is currently co-chair of the 2019 Active Living Conference and the Immediate Past-President for the American Academy of Health Behavior, a multidisciplinary society of health behavior scholars and researchers.

Amber S. Kleckner holds a PhD in Nutrition from The Ohio State University and she is a Registered Dietician. She is currently a staff scientist in the Cancer Control Unit at the University of Rochester Medical Center.

Georges Adunlin holds a PhD in Pharmacoeconomics and Health Outcome Research from Florida A&M University. He is currently an assistant professor in the Department of Pharmaceutical, Social and Administrative Sciences at the Samford University McWhorter School of Pharmacy. His research interests are focused in the areas of pharmacoeconomics, outcomes research, and health disparities. His current work includes the economic evaluations of new and existing cancer screening and treatment technologies. His personal mission to inspire others to discover their purpose and potential has led him to a passion for teaching. Dr. Adunlin has taught courses in social/behavioral pharmacy, health-care economics, research methods, and financial management.

Ian R. Kleckner holds a PhD in Biophysics from The Ohio State University. He is currently an assistant professor in the Department of Surgery at the University of Rochester Medical Center. His work aims to ameliorate the symptoms of cancer and its treatment by leveraging an understanding how the brain processes the state of the body. He uses methods from psychophysiology (measuring heartbeats, skin conductance), brain imaging (fMRI), and exercise science with computational approaches honed from his background from physics and biophysics.

Kelly R. Ylitalo holds a PhD in Epidemiological Science from the University of Michigan School of Public Health, Ann Arbor, MI. She is currently an assistant professor in Public Health Department at Baylor University. Her research interests include physical functioning, obesity, and physical activity. Specifically, she is interested in physical functioning trajectories during the mid-life and older adult years, and how behaviors like physical activity throughout the life course can facilitate healthy aging trajectories. Dr. Ylitalo applies quantitative statistical methods to longitudinal cohort studies and complex survey samples. As an epidemiologist, she works with national and local partners to evaluate and understand the health of individuals and their communities.

Charles S. Kamen holds a PhD in Clinical Psychology from the University of Georgia. He is currently an assistant professor in the Department of Surgery at the University of Rochester Medical Center. He has a strong background and training in behavioral medicine, health disparities, and interventions for diverse couples and dyads. He leads the Health Disparities research effort in the University of Rochester NCI Community Oncology Research Program Research Base. His research has focused on factors that lead to health disparities among sexual and gender minority populations, specifically disparities in cancer-related health outcomes and psychological distress.