ABSTRACT- PROJECT 1. Disparities in cancer prevention and outcomes by poverty status are rooted in structural and intermediate social determinants of health (SDH), including neighborhood built and social environments. Features of the built environment (e.g., walkability, safety, healthcare facilities) and the social environment (e.g., collective efficacy) have major implications for cancer risk through behaviors such as physical activity and access to preventive care. Adverse neighborhood conditions also exacerbate the stress response, in the form of high allostatic load, which is a risk factor for many cancers. This is a problem in persistent poverty (PP) areas where adverse neighborhood conditions are highly prevalent. However, despite compelling evidence that the living (built and social) environment impacts health-related behaviors and outcomes, including cancer, there are virtually no interventions that determine to what extent modifications of the neighborhood built and social environments reduce cancer risk. The proposed study aims to fill this knowledge gap. We propose a 5-year research project to implement Cancer Prevention through Enhanced EnvironMent (Cancer PREEMpT), to test whether a comprehensive community intervention that improves the neighborhood built and social environments can reduce cancer risk in PP areas. The specific aims of Cancer PREEMpT include: 1) Implementing Cancer PREEMpT and assessing whether the enhancement of living (built and social) environments leads to increased public safety, use of parks and community spaces, community events, and prevention services; 2) Determining the effect of improved living environments on community-level perceptions and behaviors related to cancer risk, such as walkability and safety, self-reported physical activity, social cohesion and collective efficacy, and use of preventive care and cancer screening; and 3) Evaluating the impact of improved living environments on self-reported and objective chronic stress (including allostatic load} and healthcare utilization (including cancer screening). Using a multisectoral approach to bring together citizens, organizations, businesses, and local governments to improve their living environment, the theorybased Cancer PREEMpT intervention will engage community members in five adjacent, urban PP census tracts in Bessemer, Alabama. After a community-engaged needs assessment, modifications will be made in the built and social environments, followed by an evaluation in Year 5. We will apply sequential explanatory mixed methods assessments using a two-group design with independent samples of 300 residents at pre( Year 1) and post-intervention (Year 5), and focus groups with residents. Finally, to ascertain impact on health care utilization, we will compare Electronic Health Records of all residents of the target area receiving care through the UAB Health System with residents of control urban PP communities similar in racial make-up. Cancer PREEMpT ...