Cancer: Financial Strain and Modifiable Risk Factors in African Americans

Dr. Lorraine R. Reitzel Ph.D Associate Professor in the Health Program of the Department of Educational Psychology College of Education, University of Houston in Houston, Interview with:
Dr. Lorraine R. Reitzel Ph.D
Associate Professor in the Health Program of the Department of Educational Psychology
College of Education, University of Houston in Houston, Texas. Please tell us about your study.

Dr. Reitzel: The current study represented a secondary analysis of data that were collected by Dr. Lorna McNeill and colleagues at The University of Texas MD Anderson Cancer Center. The parent study was focused on better understanding factors associated with cancer risk among African American adults, and several faculty members including myself contributed ideas about the variables we thought might play a role. The current study represents one of several studies emerging from these data. The current study was led by Ms. Pragati S. Advani, a graduate student on my research team, who was interested in better understanding the associations between financial strain and modifiable behavioral risk factors for cancer among African American adults. Financial strain represents an unfavorable income to needs ratio and was assessed using a questionnaire that tapped into current difficulty affording things that represent pretty basic components of life, including suitable food, clothing, and housing for the respondent and their family. The modifiable behavioral risk factors for cancer examined included smoking cigarettes, at-risk alcohol use, being overweight/obese, getting insufficient physical activity, and having inadequate fruit and vegetable intake. We also included a tally of the total number of these factors (0 to 5) as an outcome variable of interest. Tell us about your recruitment setting and sampling method.

Dr. Reitzel: We know from previous research that study recruitment through churches represents a good way to reach African American adults, who represent an understudied population group at increased risk of morbidity and mortality relative to their white counterparts, as studies suggest that more than 50% of African American adults attend church weekly. In addition, churches represent feasible and acceptable forums for the conduct and dissemination of health-related interventions to African American adults. Therefore, Dr. McNeill and her colleagues formed relationships with local churches in order to pursue their goal of better understanding and ultimately affecting health disparities among African American adults. For more information about the parent study that was the source of our data, please see: The parent study used a convenience sampling method, which meant that we enrolled those who were interested and were eligible for study participation, without regard for trying to achieve a balance between the sexes. Therefore, there were more women than men in the current study (77% vs 23%). The higher proportion of females in the parent study probably reflects their higher representation within church congregations and their potentially greater interest in participating in research studies relative to African American  men.  In addition, our sample was relatively well-to-do from an income perspective, with 38% of the sample reporting an annual household income of $80,000 or more. Of course, even individuals earning a good living can experience financial strain if their expenditures (including payment of debts) outweigh those earnings. Overall, our analyzable sample included 1278 church-going African American adults. What are the main findings of the study?

Dr. Reitzel: The main finding from the current study was that a relationship exists between the experience of financial strain and modifiable behavioral risk factors for cancer – specifically, greater financial strain was associated with greater odds of insufficient physical activity and current cigarette smoking, as well as with the total number of modifiable behavioral risk factors for cancer. Importantly, these associations were significant in analyses adjusted for age, sex, partner status, income, educational level, employment status, and multiple statistical comparisons. Because the study was cross-sectional, we cannot say that financial strain caused these behaviors, but we know that they are associated. Furthermore, some of these associations may be influenced by both stress and depressive symptoms. Specifically, we found that financial strain was linked to greater stress and more depressive symptoms, which in turn were linked with physical inactivity and a greater number of modifiable cancer risk factors. Again, definitive causal pathways in this area await future longitudinal studies. However, relations between financial strain and modifiable risk behaviors through psychosocial mediators such as stress and depressive symptoms are consistent with conceptual models in the literature. However, please keep in mind that results may not generalize to other samples that differ from ours in substantial ways (e.g., samples with a greater proportion of men, those with a greater proportion of low income individuals). Additional studies are needed with other, more diverse samples. What should clinicians and patients take away from your report?

Dr. Reitzel: African Americans suffer disproportionately from the adverse consequences of behavioral risk factors for cancer relative to other ethnic groups, and they are more likely to be physically inactive and experience more difficulty quitting smoking relative to whites. Results suggest that interventions to promote physical activity and quitting smoking might be especially important to target toward individuals experiencing financial strain.

Previous studies have suggested that financial literacy and economic management programs may be helpful to address financial strain among at-risk groups. Our results also suggest that attention to the psychological correlates of financial strain (stress, depressive symptoms) may also be important considerations for interventions. In addition, attention to policy changes focused on facilitating the availability of state or federal resources for individuals experiencing financial strain may also be important.

Overall, this study hopefully raises awareness about how socioeconomic factors can potentially play an important role in health and even health disparities among African American adults. Although typical indices of socioeconomic status like income and education have been linked to health for decades among individuals of diverse race/ethnicities, the current study adds to an emerging literature on how financial strain in particular might contribute to behavioral risk factors for cancer. Other recent studies in this area include Siahpush et al. “Prolonged financial stress predicts subsequent obesity: results from a prospective study of an Australian national sample.” Obesity, 2014, vol 22, 616-621 and Kendzor et al. “Financial strain and smoking cessation among racially/ethnically diverse smokers.” American Journal of Public Health, 2010, vol 100, 702-706. These studies suggest that financial strain is a distinct construct from the usual socioeconomic indicators, and that its incremental relations with health risk behaviors and outcomes is worthy of additional study. What recommendations do you have for future research as a result of this study?

Dr. Reitzel: We want to make sure to point out that this study was cross-sectional, which means that we cannot say that financial strain causes cancer-related risk behaviors – we only showed that these factors were associated with one another in a “snapshot of time.” Future studies in this area should use longitudinal methods to assess causation. In addition, future research should address how interventions – individual, church-based, and policy-level – can be implemented to affect these associations and ultimately, reduce the health-related disparities experienced by African American adults.

Also, we would like to point out that we do not necessarily assume that relations between financial strain and modifiable behavioral risk factors for cancer would be different for adults of other racial/ethnic groups; however, our focus on African American adults in this study was important because of their under-representation in research studies and because they tend to suffer poorer health outcomes relative to at least some other racial/ethnic groups (i.e., whites). Future research should assess these relations among other racial/ethnic groups at risk for health disparities to determine if these associations are consistent with what we found in this study. Anything else you’d like to add?

Dr. Reitzel: We are grateful for the opportunity to work with these data and to contribute to the understanding of how financial strain might play a role in the health of African American adults. We are especially appreciative of the study participants who provided these data, and the church leadership who facilitated the conduct of this study.


Financial Strain and Cancer Risk Behaviors among African Americans

Pragati S. Advani, Lorraine R. Reitzel, Nga T. Nguyen, Felicia D. Fisher, Elaine J. Savoy, Adolfo G. Cuevas, David W. Wetter, and Lorna H. McNeill

Cancer Epidemiol Biomarkers Prev cebp.0016.2014; Published OnlineFirst April 16, 2014; doi:10.1158/1055-9965.EPI-14-0016