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Rana T, Chan DN, So WK. A young adult community health advisor-led intervention to increase colorectal cancer screening uptake among South Asians: A feasibility study. Asia Pac J Oncol Nurs 2023; 10:100287. [PMID: 37886721 PMCID: PMC10597810 DOI: 10.1016/j.apjon.2023.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/01/2023] [Indexed: 10/28/2023] Open
Abstract
Objective The present study explored the feasibility and acceptability of a young adult community health advisor (YACHA)-led intervention among South Asians aged between 50 and 75 years in Hong Kong. Methods A pilot randomized controlled trial was conducted from July to November 2022. Thirty-six eligible participants were randomized to either the YACHA-led intervention (n = 19) or the control group (n = 17). The study outcomes were measured at baseline and 4 weeks after baseline. Results A total of 36 eligible South Asian participants with a mean age of 56.00 years (SD = 5.53) participated in the study. The consent rate was 100.0%, and the overall dropout rate among the participants was 11.1%. The proposed YACHA-led intervention components were implemented as planned with the intended modality and frequency. More than 90% of the participants showed the acceptance of and satisfaction with a YACHA-led intervention that they received during the month-long process of undergoing colorectal cancer screening. Conclusions The present study revealed that it was feasible to conduct a YACHA-led intervention to increase the utlization of colorectal cancer screening by eligible South Asians in Hong Kong. A full-scale study should be conducted to reveal its effects and to explore whether the participants would continue their participation in the colorectal cancer screening program and be screened for colorectal cancer annually or biannually, as recommended by the Hong Kong government. Trial registration This study was registered with the Chinese Clinical Trial Registry (ChiCTR2200058241).
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Affiliation(s)
- Tika Rana
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dorothy N.S. Chan
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Winnie K.W. So
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
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Haynes D, Hughes K, Haas M, Richards GL, Robinson B. Breast Cancer Champions: a peer-to-peer education and mobile mammography program improving breast cancer screening rates for women of African heritage. Cancer Causes Control 2023; 34:625-633. [PMID: 37133574 PMCID: PMC10154761 DOI: 10.1007/s10552-023-01704-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Nationally, women of African heritage die at higher rates from breast cancer than women of other races or ethnicities. We developed Breast Cancer Champions (BCC) a peer-to-peer education program, which recruited 12 women and deployed them into the community in August 2020 during the height of the COVID pandemic. BCC aims to improve breast cancer screening rates for women of African heritage through peer-to-peer education, which has proven successful for addressing cancer-related health disparities. METHODS BCC community experts, or "Champions," are peer-to-peer educators that conduct awareness and screening events in their communities. Champion's education activities were tracked by bi-weekly check-in calls, which recorded the activity type, location, and the number of participants for each event. We used spatial and statistical analyses to determine the efficacy of the program at increasing screening rates for women within the area of Champion activity versus women outside of their activity area. RESULTS Over 15 months, Champions conducted 245 in-person or online events to engage women in their community for screening. More women of African heritage were screened in areas Champions were active during the intervention compared to historical data comparing areas outside of the Champion activity in the prior 15 months (X 2 = 3.0845, p = 0.079). CONCLUSION BCC successes could be attributed to pivoting to online community building when in-person events were restricted and enabling Champions to design and conduct their own events, which increased outreach possibilities. We demonstrate improved screening outcomes associated with an updated peer-to-peer education program.
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Affiliation(s)
- David Haynes
- Institute for Health Informatics, University of Minnesota, 516 Delaware Street SE, Suite 8-110, Minneapolis, MN, 55455, USA.
| | - Kelly Hughes
- Sage Programs, Minnesota Department of Health, St. Paul, MN, 55164, USA
| | - McKenna Haas
- School of Public Health, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Gay Lynn Richards
- Sage Programs, Minnesota Department of Health, St. Paul, MN, 55164, USA
| | - Benita Robinson
- Sage Programs, Minnesota Department of Health, St. Paul, MN, 55164, USA
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Champion VL, Paskett ED, Stump TE, Biederman EB, Vachon E, Katz ML, Rawl SM, Baltic RD, Kettler CD, Seiber EE, Xu WY, Monahan PO. Comparative Effectiveness of 2 Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Among Women in the Rural US: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2311004. [PMID: 37115541 PMCID: PMC10148202 DOI: 10.1001/jamanetworkopen.2023.11004] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/19/2023] [Indexed: 04/29/2023] Open
Abstract
Importance Women living in rural areas have lower rates of breast, cervical, and colorectal cancer screening compared with women living in urban settings. Objective To assess the comparative effectiveness of (1) a mailed, tailored digital video disc (DVD) intervention; (2) a DVD intervention plus telephonic patient navigation (DVD/PN); and (3) usual care with simultaneously increased adherence to any breast, cervical, and colorectal cancer screening that was not up to date at baseline and to assess cost-effectiveness. Design, Setting, and Participants This randomized clinical trial recruited and followed up women from rural Indiana and Ohio (community based) who were not up to date on any or all recommended cancer screenings. Participants were randomly assigned between November 28, 2016, and July 1, 2019, to 1 of 3 study groups (DVD, DVD/PN, or usual care). Statistical analyses were completed between August and December 2021 and between March and September 2022. Intervention The DVD interactively assessed and provided messages for health beliefs, including risk of developing the targeted cancers and barriers, benefits, and self-efficacy for obtaining the needed screenings. Patient navigators counseled women on barriers to obtaining screenings. The intervention simultaneously supported obtaining screening for all or any tests outside of guidelines at baseline. Main Outcomes and Measures Receipt of any or all needed cancer screenings from baseline through 12 months, including breast, cervical, and colorectal cancer, and cost-effectiveness of the intervention. Binary logistic regression was used to compare the randomized groups on being up to date for all and any screenings at 12 months. Results The sample included 963 women aged 50 to 74 years (mean [SD] age, 58.6 [6.3] years). The DVD group had nearly twice the odds of those in the usual care group of obtaining all needed screenings (odds ratio [OR], 1.84; 95% CI, 1.02-3.43; P = .048), and the odds were nearly 6 times greater for DVD/PN vs usual care (OR, 5.69; 95% CI, 3.24-10.5; P < .001). The DVD/PN intervention (but not DVD alone) was significantly more effective than usual care (OR, 4.01; 95% CI, 2.60-6.28; P < .001) for promoting at least 1 (ie, any) of the needed screenings at 12 months. Cost-effectiveness per woman who was up to date was $14 462 in the DVD group and $10 638 in the DVD/PN group. Conclusions and Relevance In this randomized clinical trial of rural women who were not up to date with at least 1 of the recommended cancer screenings (breast, cervical, or colorectal), an intervention designed to simultaneously increase adherence to any or all of the 3 cancer screening tests was more effective than usual care, available at relatively modest costs, and able to be remotely delivered, demonstrating great potential for implementing an evidence-based intervention in remote areas of the midwestern US. Trial Registration ClinicalTrials.gov Identifier: NCT02795104.
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Affiliation(s)
- Victoria L. Champion
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
| | - Electra D. Paskett
- Comprehensive Cancer Center, The Ohio State University, Columbus
- Division of Cancer Prevention and Control, Department of Medicine, College of Medicine, The Ohio State University, Columbus
| | - Timothy E. Stump
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | | | - Eric Vachon
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Center for Health Services Research, Regenstrief Institute, Indianapolis, Indiana
| | - Mira L. Katz
- Comprehensive Cancer Center, The Ohio State University, Columbus
- Division of Health Behavior and Health Promotion, College of Public Health, The Ohio State University, Columbus
| | - Susan M. Rawl
- School of Nursing, Indiana University, Indianapolis
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
| | - Ryan D. Baltic
- Comprehensive Cancer Center, The Ohio State University, Columbus
| | - Carla D. Kettler
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
| | - Eric E. Seiber
- Division of Health Services Management and Policy, The Ohio State University, Columbus
| | - Wendy Y. Xu
- Division of Health Services Management and Policy, The Ohio State University, Columbus
| | - Patrick O. Monahan
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis
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Effectiveness of Community Health Worker-Led Interventions in Enhancing Colorectal Cancer Screening Uptake in Racial and Ethnic Minority Populations: A Systematic Review and Meta-analysis. Cancer Nurs 2023:00002820-990000000-00126. [PMID: 36927698 DOI: 10.1097/ncc.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND The colorectal cancer (CRC) screening uptake rate is substantially lower in ethnic minority populations than in the general population. Racial and ethnic minority individuals experience more barriers in obtaining a screening test for CRC when compared with the non-Hispanic White population. OBJECTIVE To examine the effectiveness of community health worker-led interventions in improving the CRC screening uptake rate in racial and ethnic minority populations. METHODS Five databases, EMBASE, CINAHL, MEDLINE, Scopus, and PubMed, were systematically searched, and reference lists of the identified articles were manually searched for relevant articles in May 2022. Only randomized controlled trials were included. RESULTS A total of 10 randomized controlled trials conducted in the United States were included in this review. The findings of the meta-analysis showed that CRC screening uptake was enhanced in participants receiving community health worker-led interventions compared with those receiving no intervention (odds ratio, 2.25; 95% confidence interval, 1.48-3.44; P < .001). The subgroup analysis by diverse racial and ethnic groups and number of components (single vs multiple) of the community health worker-led interventions showed that multicomponent interventions were more effective in increasing the CRC uptake rate among all racial and ethnic groups regardless of their background. CONCLUSIONS Multicomponent community health worker-led interventions can improve CRC screening uptake in racial and ethnic minority populations. IMPLICATIONS FOR PRACTICE The findings of the present review show that multicomponent community health worker-led interventions are shown to be effective to improve the CRC screening uptake targeting other racial and ethnic minority groups in other countries.
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Lapidos A, Kieffer EC, Guzmán R, Hess K, Flanders T, Heisler M. Barriers and Facilitators to Community Health Worker Outreach and Engagement in Detroit, Michigan: A Qualitative Study. Health Promot Pract 2022; 23:1094-1104. [PMID: 34549635 DOI: 10.1177/15248399211031818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
An effective approach to engaging populations who face health care access barriers is support from community health workers (CHWs). There is little research, however, on specific barriers and facilitators related to two key areas of CHW practice: outreach, defined as the ability to make any initial contact with the priority population, and engagement, defined as the ability to continue to work with the priority population after initial contact is made. The current qualitative study is ancillary to a randomized evaluation of a CHW-led program for Medicaid Health Plan enrollees. Implementation experiences with outreach and engagement led the evaluators to develop the current study in which health plan and nonhealth plan CHWs (n = 12) serving low-income, predominantly Black populations in Detroit participated in qualitative semistructured interviews to elucidate barriers and facilitators to outreach and engagement. All audio recordings were transcribed verbatim. The study team used inductive qualitative data analysis techniques. Barriers to outreach included inaccurate contact information and mistrust. Barriers to engagement included lack of ability to provide needed resources, leading to hopelessness and diminished trust, and discontinuity of services due to eligibility changes and terminated programs. Facilitators included adapting outreach schedules and strategies to community needs, availability of resources, and relational strategies that leveraged CHW social proximity. Further research should systematically investigate the relative success of different CHW-led outreach and engagement strategies for specific populations so as to better design and implement CHW programs.
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Affiliation(s)
| | | | | | | | | | - Michele Heisler
- University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Center for Clinical Management Research, Washington, DC, USA
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Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis 2022; 19:E26. [PMID: 35588522 PMCID: PMC9165474 DOI: 10.5888/pcd19.210258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES Colorectal cancer screening rates remain suboptimal in the US. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) seeks to increase screening in health system clinics through implementation of evidence-based interventions (EBIs) and supporting activities (SAs). This program provided an opportunity to assess the uptake of EBIs and SAs in 355 clinics that participated from 2015 to 2018. INTERVENTION APPROACH The 30 funded awardees of CRCCP partnered with clinics to implement at least 2 of 4 EBIs that CDC prioritized (patient reminders, provider reminders, reducing structural barriers, provider assessment and feedback) and 4 optional strategies that CDC identified as SAs (small media, professional development and provider education, patient navigation, and community health workers). EVALUATION METHODS Clinics completed 3 annual surveys to report uptake, implementation, and integration and perceived sustainability of the priority EBIs and SAs. RESULTS In our sample of 355 clinics, uptake of 4 EBIs and 2 SAs significantly increased over time. By year 3, 82% of clinics implemented patient reminder systems, 88% implemented provider reminder systems, 82% implemented provider assessment and feedback, 76% implemented activities to reduce structural barriers, 51% implemented provider education, and 84% used small media. Most clinics that implemented these strategies (>90%) considered them fully integrated into the health system or clinic operations and sustainable by year 3. Fewer clinics used patient navigation (30%) and community health workers (19%), with no increase over the years of the study. IMPLICATIONS FOR PUBLIC HEALTH Clinics participating in the CRCCP reported high uptake and perceived sustainability of EBIs that can be integrated into electronic medical record systems but limited uptake of patient navigation and community health workers, which are uniquely suited to reduce cancer disparities. Future research should determine how to promote uptake and assess cost-effectiveness of CRCCP interventions.
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Affiliation(s)
- Annette E Maxwell
- University of California Los Angeles, Los Angeles, California.,Department of Health Policy and Management, University of California, Los Angeles, 650 Charles Young Dr South, A2-125 CHS, Box 956900, Los Angeles, CA 90095-6900. E-mail:
| | - Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Juzhong Sun
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Leng J, Li R, Lui F, Gany F. Healthcare Professionals' Perspectives on Adapting a Community Health Worker Model to Facilitate Lung Cancer Screening for Chinese For-Hire Vehicle Drivers. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:311-318. [PMID: 32583351 PMCID: PMC7759596 DOI: 10.1007/s13187-020-01813-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chinese immigrant for-hire vehicle (FHV) drivers who smoke or smoked are at high risk for lung cancer due to the combined impact of tobacco use and air pollution exposure yet underutilize lung cancer screening (LCS). Community Health Worker (CHW) programs have been effective at improving cancer screening rates. This study describes a community needs assessment to inform the adaptation of an existing CHW intervention to facilitate LCS among Chinese FHV drivers. Interviews were conducted until saturation with 13 Chinese-serving health professionals to determine the community's needs, priorities, and preferences. Transcripts were qualitatively analyzed using Atlas.ti. Seven frequently occurring themes were identified: knowledge of guidelines/access to LCS, acceptability of CHW program, CHW role in screening process, qualities of an ideal CHW, barriers to LCS, challenges to implementing a CHW program, and adaptations to CHW program. The adapted CHW intervention should include culturally tailored health education to increase LCS knowledge for patients and providers.
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Affiliation(s)
- Jennifer Leng
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., 2nd Floor, New York, NY, 10017, USA.
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10017, USA.
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, 10017, USA.
| | - Randall Li
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Florence Lui
- City College & The Graduate Center, City University of New York, New York, NY, USA
| | - Francesca Gany
- Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave., 2nd Floor, New York, NY, 10017, USA
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10017, USA
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, 10017, USA
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8
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Rogers CC, Pope S, Whitfield F, Cohn WF, Valdez RS. The lived experience during the peri-diagnostic period of breast cancer: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:547-585. [PMID: 34210570 DOI: 10.1016/j.pec.2021.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The aim of this scoping review is to provide an overview of the existing research that investigates the lived experience during the peri-diagnostic period of breast cancer. METHODS Nine databases were searched for relevant literature between January 2007 and April 2019. Data were extracted and categorized using deductive and inductive approaches. RESULTS A majority of the 66 studies included used qualitative methods to retrospectively explore the treatment decision making process of female breast cancer patients. Patients experienced uncertainty, emotional distress, and a need for more information from providers and relied on social support and family guidance during this period. CONCLUSIONS The results of this review show that the burdens experienced during the peri-diagnostic period parallel those in later periods of cancer care. However, these burdens are prompted by different circumstances. More research is needed to explore the lived experience during this period through the use of mixed-methods and by recruiting a diverse sample with regards to role in the breast cancer experience, age, gender, race, and ethnicity. PRACTICE IMPLICATIONS Interventions positioned at earlier points in the breast cancer experience should provide informational support, which could be delivered through shared decision making models. Additional support could be facilitated by patient navigation programs and health information technology.
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Affiliation(s)
- Courtney C Rogers
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA, United States; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Shannon Pope
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Francesca Whitfield
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Wendy F Cohn
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Rupa S Valdez
- Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA, United States; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States.
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Huberty J, Bhuiyan N, Neher T, Joeman L, Mesa R, Larkey L. Leveraging a Consumer-Based Product to Develop a Cancer-Specific Mobile Meditation App: Prototype Development Study. JMIR Form Res 2022; 6:e32458. [PMID: 35029528 PMCID: PMC8800087 DOI: 10.2196/32458] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/30/2021] [Accepted: 11/27/2021] [Indexed: 01/20/2023] Open
Abstract
Background Mobile meditation apps may offer a long-term, accessible, and effective solution for ongoing symptom management in cancer patients/survivors. However, there are currently no commercial cancer-specific meditation apps that reflect cancer specialist expertise, input from cancer patients/survivors, and features and content specific to cancer patients’/survivors’ needs. Objective The aim of this study was to gain insight (via surveys, daily journals, and focus groups) from cancer patients/survivors, health care providers, and current subscribers of Calm (a consumer-based mobile meditation app) who were patients/survivors to develop a prototype of a mobile meditation app specifically designed for cancer patients/survivors. Methods Participants were recruited via prior partnerships, word-of-mouth referrals, and recruitment posts on Facebook and Instagram. Cancer patients/survivors and health care providers were instructed to download and use the Calm app for at least 10 minutes a day for 7 days, complete an online daily journal for 7 days, and participate in a virtual focus group (one for cancer patients/survivors and one for providers). Current Calm subscribers who were cancer patients/survivors completed an online survey about different aspects of the Calm app and participated in a third virtual focus group. Data were qualitatively analyzed using a combination of deductive and inductive coding. Results A total of 27 participants (11 cancer patients/survivors, 10 health care providers, 6 current Calm subscribers) completed the study. Similar themes and subthemes were found across surveys, daily journals, and focus groups, and fell into two major categories, content and functionality, with cancer-specific and noncancer-specific themes identified within each category. The majority of content preferences and suggestions that arose were cancer-specific, such as content related to negative emotions or feelings (eg, anxiety, grief, trauma/posttraumatic stress disorder, fear of recurrence, isolation), positive feelings and finding meaning (eg, gratitude, storytelling, acceptance), scenarios and experiences (eg, waiting, treatment-specific mediations), type and stage of cancer journey, and movement modifications. Some of the noncancer-specific themes under app content included sleep, music, and visualizations. In terms of app functionality, the majority of participants expressed interest in having a section/tab/area of the app that was specifically geared toward cancer patients/survivors. Preferences and suggestions for cancer-specific functionality features included options based on symptoms or journey, being able to communicate with other patients or survivors to share suggestions for specific meditations, and having an emergency toolkit for patients/survivors. Conclusions Findings from cancer patients/survivors, health care providers, and current Calm subscribers who were patients/survivors to be incorporated into the development of the prototype fell into two major categories: (1) content of the app and (2) functionality of the app. The prototype’s form and function will be pilot-tested among 30 cancer patients/survivors in a 4-week study, and the resulting feasibility data will be used to inform the final app design and an efficacy study.
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Affiliation(s)
| | - Nishat Bhuiyan
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Taylor Neher
- Research Consultancy, Little Rock, AR, United States
| | - Lynda Joeman
- Lynda Joeman Research Consultancy, Tonbridge, United Kingdom
| | - Ruben Mesa
- Mays Cancer Center, University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, TX, United States
| | - Linda Larkey
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, United States
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Malone S, Prewitt K, Hackett R, Lin JC, McKay V, Walsh-Bailey C, Luke DA. The Clinical Sustainability Assessment Tool: measuring organizational capacity to promote sustainability in healthcare. Implement Sci Commun 2021; 2:77. [PMID: 34274004 PMCID: PMC8285819 DOI: 10.1186/s43058-021-00181-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/29/2021] [Indexed: 12/14/2022] Open
Abstract
Background Few validated assessment tools are available to increase understanding and measure factors associated with sustainment of clinical practices, an increasingly recognized need among clinicians. We describe the development of the Clinical Sustainability Assessment Tool (CSAT), designed to assess factors that contribute to sustainable practices in clinical settings. Methods Sixty-four participants from clinical and research fields participated in concept mapping and were recruited to brainstorm factors that lead to sustained clinical practices. Once repeated factors were removed, participants sorted items based on similarity and rated them by importance and feasibility. Using concept mapping analyses, items were grouped into meaningful domains to develop an initial tool. We then recruited pilot sites and early adopters, for a total of 286 practicing clinicians, to pilot and evaluate the tool. Individuals were recruited from clinical settings across pediatric and adult medical and surgical subspecialties. The data were analyzed using confirmatory factor analysis (CFA) to test hypothesized subscale structure in the instrument. We used root mean square error of approximation (RMSEA) and the standardized root mean square residual (SRMR) to assess fit and thus the ability of CSAT to measure the identified domains. Results The concept mapping produced sorted statements that were edited into items that could be responded to, resulting in the creation of a tool with seven determinant domains and 47 items. The pilot and CFA testing resulted in a final CSAT instrument made up 35 items, five per domain. CFA results demonstrated very good fit of the seven domain structure of the CSAT (RMSEA = 0.049; SRMR = 0.049). Usability testing indicated the CSAT is brief, easy to use, easy to learn, and does not require extensive training. Additionally, the measure scored highly (18/20) on the Psychometric and Pragmatic Evidence Rating Scale (PAPERS). The seven final CSAT domains were engaged staff and leadership, engaged stakeholders, organizational readiness, workflow integration, implementation and training, monitoring and evaluation, and outcomes and effectiveness. Conclusions The CSAT is a new reliable assessment tool which allows for greater practical and scientific understanding of contextual factors that enable sustainable clinical practices over time. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00181-2.
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Affiliation(s)
- Sara Malone
- Washington University in St. Louis, Brown School, St. Louis, MO, USA. .,Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, St. Louis, USA.
| | - Kim Prewitt
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
| | - Rachel Hackett
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
| | - John C Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, USA
| | - Virginia McKay
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
| | | | - Douglas A Luke
- Washington University in St. Louis, Brown School, St. Louis, MO, USA
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11
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Duggleby W, Pesut B, Warner G, Ruiz KJ, Nekolaichuk C, Ghosh S, Hallström L, Fassbender K, Swindle J, Holroyd-Leduc J, Jackman D, Woytkiw T. A Feasibility Study of a Volunteer Navigation Program in the Palliative Context. Am J Hosp Palliat Care 2020; 38:963-971. [PMID: 33030044 PMCID: PMC8212391 DOI: 10.1177/1049909120965945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIMS This mixed methods longitudinal study evaluated Nav-CARE for feasibility, acceptability, ease of use, and satisfaction by older persons and volunteers. METHODS Nine volunteer navigators visited 23 older persons with serious illness every 3 to 4 weeks for 1 year. Data were collected from volunteer navigators, and older person participants at baseline, during the year- long implementation and post implementation. RESULTS Volunteer navigators and older persons reported Nav-CARE was easy to use, feasible and acceptable. The majority of older persons agreed or strongly agreed that they were satisfied with the navigation services (100%; 8/8), that navigation services were important to them (87%; 7/8), that they would recommend the program to someone else (87%; 7/8), and would participate in the program again (75%; 6/8). Similarly, volunteer navigators reported 100% (9/9) satisfaction with the program, 100% (9/9) would recommend it to others, and 67% (6/8) would participate again. CONCLUSIONS Nav-CARE appears to be a feasible, acceptable, and satisfactory program for older persons with serious illness and volunteer navigators.
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Affiliation(s)
- Wendy Duggleby
- Faculty of Nursing, Edmonton Clinic Health Academy, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Barbara Pesut
- 8166University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Grace Warner
- School of Occupational Therapy, 70338Dalhousie University, Forrest Building, Halifax, Nova Scotia, Canada
| | - Kathya Jovel Ruiz
- Faculty of Nursing, Edmonton Clinic Health Academy, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, c/o Palliative Institute, Health Services Centre, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Alberta Health Services-Cancer Control Alberta, 3158University of Alberta, Edmonton, Alberta, Canada.,Department of Medical Oncology, 3158University of Alberta, Edmonton, Alberta, Canada.,Department of Mathematical and Statistical Sciences, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Lars Hallström
- Political Studies (Augustana Faculty) and REES (ALES) University of Alberta, Camrose, Alberta, Canada
| | - Konrad Fassbender
- Division of Palliative Care Medicine, Department of Oncology, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Jenny Swindle
- Faculty of Nursing, Edmonton Clinic Health Academy, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Jayna Holroyd-Leduc
- Division/Section of Geriatric Medicine, Brenda Strafford Chair in Geriatric Medicine, 70401University of Calgary, Calgary, Alberta, Canada
| | - Deirdre Jackman
- Faculty of Nursing, Edmonton Clinic Health Academy, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Terri Woytkiw
- Special Programs, Seniors Health North Zone, Onoway, Alberta, Canada
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12
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Huberty J, Puzia M, Eckert R, Larkey L. Cancer Patients' and Survivors' Perceptions of the Calm App: Cross-Sectional Descriptive Study. JMIR Cancer 2020; 6:e16926. [PMID: 32039812 PMCID: PMC7055788 DOI: 10.2196/16926] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 01/05/2023] Open
Abstract
Background There is a need for tools to decrease cancer patients’ and survivors’ long-term symptom burden. Complementary strategies, such as meditation, can accompany pharmacologic therapy to improve symptoms. Although support programs with targeted content have wider reach, higher adherence, and greater impact, there are no consumer-based meditation apps designed specifically for cancer. Objective This study aimed to gather information to advise the development of a cancer-specific meditation app in a small convenience sample of cancer patients and survivors who currently use the Calm app. Methods Adult cancer patients and survivors who are Calm users (N=82) were recruited through the Daily Calm Facebook page. Participants completed a Web-based survey related to Calm app use and satisfaction, interest in and ideas for a cancer-specific Calm app, and demographic characteristics. Open-ended responses were inductively coded. Results Participants were aged between 18 and 72 years (mean 48.60 years, SD 15.20), mostly female (77/82, 94%), white (65/79, 82%), and non-Hispanic (70/75, 93%), and reported using Calm at least 5 times per week (49/82, 60%). Although rates of satisfaction with current Calm components were high (between 65/82, 79% and 51/81, 63%), only 49% (40/82) of participants used guided meditations that they felt specifically helped with their cancer-related symptoms and survivorship, and 40% (33/82) would prefer more cancer-related content, with guided meditations for cancer-specific anxieties (eg, fear of recurrence; n=15) and coping with strong emotions (n=12) being the most common suggestions. A majority of participants (51/82, 62%) reported that they would be interested in becoming a member of a Calm cancer community (eg, in-app discussion boards: 41/46, 89%; and social media communities: 35/42, 83%). Almost half of the participants (37/82, 45%) reported that they would benefit from features that tracked symptoms in concurrence with app usage, but respondents were divided on whether this information should be shared with health care providers through the app (49/82, 60% would share). Conclusions Responses suggest ways in which the current Calm app could be adapted to better fit cancer patients’ and survivors’ needs and preferences, including adding cancer-specific content, increasing the amount of content focusing on coping with strong emotions, developing communities for Calm users who are cancer patients and survivors, and including features that track cancer-related symptoms. Given differences in opinions about which features were desirable or would be useful, there is a clear need for future cancer-specific apps to be customizable (eg, ability to turn different features on or off). Although future research should address these topics in larger, more diverse samples, these data will serve as a starting point for the development of cancer-specific meditation apps and provide a framework for evaluating their effects.
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Affiliation(s)
- Jennifer Huberty
- College of Health Solutions, Arizona State University, Phoenix, AZ, United States
| | - Megan Puzia
- Behavioral Research and Analytics, LLC, Salt Lake City, UT, United States
| | - Ryan Eckert
- 3Mays Cancer Center, University of Texas Health MD Anderson, San Antonio, TX, United States
| | - Linda Larkey
- College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, United States
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13
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Turner BJ, Rochat A, Lill S, Bobadilla R, Hernandez L, Choi A, Guerrero JA. Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations. Ann Intern Med 2019; 171:865-874. [PMID: 31791065 DOI: 10.7326/m18-3573] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) disproportionately affects disadvantaged communities. OBJECTIVE To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices. DESIGN Mixed-methods retrospective analysis. SETTING 5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations. PATIENTS Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018. INTERVENTION The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients. MEASUREMENTS All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively. RESULTS Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing. LIMITATION No control practices were included, and data were missing for some variables. CONCLUSION Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control. PRIMARY FUNDING SOURCE Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.
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Affiliation(s)
- Barbara J Turner
- Joe R. and Teresa Lozano Long School of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas, and Keck Medical Center and Gehr Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California (B.J.T.)
| | - Andrea Rochat
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Sarah Lill
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Raudel Bobadilla
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Ludivina Hernandez
- Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.R., S.L., R.B., L.H.)
| | - Aro Choi
- Joe R. and Teresa Lozano Long School of Medicine and Center for Research to Advance Community Health, University of Texas Health Science Center at San Antonio, San Antonio, Texas (A.C.)
| | - Juan A Guerrero
- Joe R. and Teresa Lozano Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas (J.A.G.)
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Goss CW, Richardson WJ, Shore JH. Outcomes and Lessons Learned from the Tribal Veterans Representative Program: A Model for System Engagement. J Community Health 2019; 44:1076-1085. [PMID: 31227961 DOI: 10.1007/s10900-019-00683-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
American Indian and Alaska Native Veterans are more rural than Veterans of any other race or ethnicity and face significant barriers to accessing care. Since 2001, the Tribal Veterans Representative (TVR) Program, a partnership between the U.S. Department of Veterans Affairs (VA) and tribal nations, has trained liaisons from tribal communities to facilitate access to VA benefits and services. We delineate the TVR program model alongside supporting data. We reviewed TVR training materials and program evaluations to identify components of the program essential for increasing access to VA services and benefits. We then report a quantitative assessment of benefits attained in one tribal community. The TVR model is characterized by the exchange of two sets of knowledge and resources-'institutional' and 'community'-during a co-sponsored educational program aiming to train community liaisons about the institution. The institution leads the program's content; the community's traditions inform its process. Following the program, liaisons use support networks comprising trainers, trainees and local organizations to teach other community members to access health care and benefits. In the evaluation community, one liaison has facilitated access for hundreds of Veterans, with financial compensation exceeding $400,000 annually. The TVR program has begun to demonstrate its utility for other rural populations, though further formal evaluation is recommended. Compared with similar models to increase rural populations' access to health care and benefits, the long-term support networks from the TVR model may be most useful when the institution must build trust and engage with the target population.
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Affiliation(s)
- Cynthia W Goss
- U.S. Department of Veterans Affairs (VA) Office of Rural Health's (ORH), Veterans Rural Health Resource Center in Salt Lake City, Salt Lake City, Utah, USA.
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Nighthorse Campbell Native Health Building, 13055 E. 17th Avenue, Mail Stop F800, Aurora, Colorado, 80045, USA.
| | - W J Richardson
- U.S. Department of Veterans Affairs (VA), Veterans Affairs Rocky Mountain Healthcare Network (VISN 19), Fort Harrison, Montana, USA
| | - Jay H Shore
- U.S. Department of Veterans Affairs (VA) Office of Rural Health's (ORH), Veterans Rural Health Resource Center in Salt Lake City, Salt Lake City, Utah, USA
- Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, Nighthorse Campbell Native Health Building, 13055 E. 17th Avenue, Mail Stop F800, Aurora, Colorado, 80045, USA
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15
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Leeman J, Glanz K, Hannon P, Shannon J. The Cancer Prevention and Control Research Network: Accelerating the implementation of evidence-based cancer prevention and control interventions. Prev Med 2019; 129S:105857. [PMID: 31718801 PMCID: PMC7110411 DOI: 10.1016/j.ypmed.2019.105857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 11/19/2022]
Abstract
This editorial provides a high level overview of the articles included in this supplement.
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Affiliation(s)
- Jennifer Leeman
- University of North Carolina, School of Nursing, 120 N. Medical Drive, Chapel Hill, NC 27599-7460, USA.
| | - Karen Glanz
- University of Pennsylvania, Perelman School of Medicine and School of Nursing, 801 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA
| | - Peggy Hannon
- University of Washington, Department of Health Services, 1959 NE Pacific Street, Magnuson Health Sciences Bldg, Box 357660, Seattle, WA 98195, USA
| | - Jackilen Shannon
- Oregon Health and Science University, School of Public Health, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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16
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Barrington WE, DeGroff A, Melillo S, Vu T, Cole A, Escoffery C, Askelson N, Seegmiller L, Gonzalez SK, Hannon P. Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Prev Med 2019; 129S:105858. [PMID: 31647956 PMCID: PMC7055651 DOI: 10.1016/j.ypmed.2019.105858] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 11/17/2022]
Abstract
Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.
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Affiliation(s)
| | - Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Stephanie Melillo
- Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Thuy Vu
- University of Washington, Seattle, WA, United States of America
| | - Allison Cole
- University of Washington, Seattle, WA, United States of America
| | - Cam Escoffery
- Emory University, Atlanta, GA, United States of America
| | | | | | | | - Peggy Hannon
- University of Washington, Seattle, WA, United States of America
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17
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Heisler M, Lapidos A, Henderson J, Guzman RM, Wolfe J, Meyer P, Law D, Kieffer EC, Ernst C, Djelaj V, Khaldun J, Ayanian JZ. Study protocol for a Community Health Worker (CHW)-led comprehensive neighborhood-focused program for medicaid enrollees in detroit. Contemp Clin Trials Commun 2019; 16:100456. [PMID: 31646214 PMCID: PMC6804462 DOI: 10.1016/j.conctc.2019.100456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/12/2019] [Accepted: 09/21/2019] [Indexed: 01/16/2023] Open
Abstract
Residents of low income neighborhoods disproportionately experience poor health, and many have unmet social needs. Clinical trials have shown the efficacy of Community Health Worker (CHW) programs in improving outcomes for a variety of health conditions. An important next step is developing and evaluating financially sustainable CHW program models in real-life settings. This program evaluation examines health care utilization among participants in a geographically targeted program led by salaried CHWs from three Medicaid health plans. Beneficiaries who reside in the Cody Rouge neighborhood of Detroit and had more than 3 Emergency Department (ED) visits or at least 1 ambulatory care-sensitive hospitalization in the prior 12 months are eligible for the program. Health plan CHWs assigned to the program reach out to eligible beneficiaries to provide an assessment; link them to resources; and provide follow-up. At 12-month follow up, claims data on ED visits, ambulatory care-sensitive hospitalizations, primary care visits, and related costs will be compared between beneficiaries who participated and eligible beneficiaries randomized to receive usual outreach. We hypothesize that patients enrolled in the CHW intervention will experience a reduction in acute care usage resulting in cost savings compared to those receiving usual health plan outreach. This study is among the first to evaluate the impact on health care utilization of augmented services delivered by health plan CHWs for high-utilizing health plan members as part of a health plan-community-academic partnership. This study will provide important information on CHW program sustainability and provide insights into effective implementation of such programs. Trial registration NCT03924713.
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Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan Medical School, 1600 Plymouth Road, Ann Arbor, MI, 48109, USA.,Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, 1700 SPH I, Ann Arbor, MI, 48109, USA
| | - Adrienne Lapidos
- Department of Psychiatry, University of Michigan Medical School, 1600 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - James Henderson
- Consulting for Statistics Computing & Analytics Research, University of Michigan, 3550 Rackham, 915 E. Washington St, Ann Arbor, MI, 48109, USA
| | - Rebeca M Guzman
- Detroit Health Department, 3245 E. Jefferson, Suite 100, Detroit, MI, 48203, USA
| | - Jason Wolfe
- University of Michigan Institute for Healthcare Policy & Innovation, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI, 48109, USA
| | - Patricia Meyer
- University of Michigan Institute for Healthcare Policy & Innovation, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI, 48109, USA
| | - David Law
- Joy-Southfield Community Development Corp, 18917 Joy Road, Detroit, MI, 48228, USA
| | - Edith C Kieffer
- University of Michigan School of Social Work, 1080 South University, Ann Arbor, MI, 48109, USA
| | - Caleb Ernst
- University of Michigan Institute for Healthcare Policy & Innovation, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI, 48109, USA
| | - Valentina Djelaj
- Detroit Health Department, 3245 E. Jefferson, Suite 100, Detroit, MI, 48203, USA
| | - Joneigh Khaldun
- Detroit Health Department, 3245 E. Jefferson, Suite 100, Detroit, MI, 48203, USA.,State of Michigan Department of Health and Human Services, USA
| | - John Z Ayanian
- Department of Internal Medicine, University of Michigan Medical School, 1600 Plymouth Road, Ann Arbor, MI, 48109, USA.,University of Michigan Institute for Healthcare Policy & Innovation, 2800 Plymouth Road, North Campus Research Complex, Building 16, Ann Arbor, MI, 48109, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, 1415 Washington Heights, 1700 SPH I, Ann Arbor, MI, 48109, USA.,Gerald R. Ford School of Public Policy, University of Michigan, 735 S. State St, Ann Arbor, MI, 48109, USA
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18
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Gu J, Maxwell AE, Ma GX, Qian X, Tan Y, Hsieh HC, Tu SP, Wang JHY. Evaluating the Training of Chinese-Speaking Community Health Workers to Implement a Small-Group Intervention Promoting Mammography. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:705-711. [PMID: 29654506 PMCID: PMC6186510 DOI: 10.1007/s13187-018-1361-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This study evaluated the training of Chinese American Community Health Workers (CHWs) to implement a small-group mammography video and discussion program as part of a randomized controlled trial that had the goal to increase adherence to mammography screening guidelines among Chinese American women. A total of 26 Chinese American CHWs in the metropolitan Washington DC area, Southern California, and New York City participated in a 4-h training workshop and completed surveys before and after the workshop to assess their knowledge regarding mammography screening guidelines and human subjects protection rules. The results showed significantly increased knowledge of mammography screening guidelines and human subjects protection rules (both p < 0.01) after the training. CHWs were also trained to lead a discussion of the video, including screening benefits and misconceptions. Forty-three audio recordings of discussions led by 13 active CHWs were transcribed and qualitatively analyzed to assess implementation fidelity. Ten out of 13 active CHWs fully addressed about 3 of the 5 benefit items, and 11 out of 13 CHWs fully addressed more than 5 of the 9 misconception items. Chinese CHWs can be trained to implement research-based intervention programs. However, a one-time training resulted in moderate adherence to the discussion protocol. Ongoing or repeat trainings throughout the intervention period may be needed to enhance implementation fidelity.
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Affiliation(s)
- Jiayan Gu
- Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington D.C., USA
| | - Annette E Maxwell
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Grace X Ma
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Xiaokun Qian
- Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington D.C., USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Hsing-Chuan Hsieh
- Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington D.C., USA
| | - Shin-Ping Tu
- Division of General Internal Medicine, Geriatrics, and Bioethics, University of California Davis, Sacramento, CA, USA
| | - Judy Huei-Yu Wang
- Department of Oncology, Cancer Prevention and Control Program, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington D.C., USA.
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Ganann R, Sword W, Newbold K, Thabane L, Armour L, Kint B. Provider Perspectives on Facilitators and Barriers to Accessible Service Provision for Immigrant Women With Postpartum Depression: A Qualitative Study. Can J Nurs Res 2019; 51:191-201. [DOI: 10.1177/0844562119852868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background Immigrant women are at greater risk for postpartum depression than native-born women and face multiple barriers to accessing services. Service providers themselves face challenges in delivering accessible care for immigrant women with postpartum depression. Purpose This research explored provider perspectives on facilitators and barriers providers faced in terms of providing accessible services. Methods The study used an interpretive descriptive design, shaped by an integrated knowledge user–researcher partnership. Fourteen health and social service providers participated in individual in-depth interviews. Using a socioecological framework as an organizing structure, an inductive thematic content analysis was conducted. Results Providers identified attributes that foster relationship building, including building trust, addressing power dynamics, understanding women’s experiences, enacting cultural competence, involving family members, providing adequate time, and facilitating system navigation. Organizational features shaping accessibility included assessment and treatment approaches, wait times, gate keeping, and the ability to address social health determinants. Different organizational approaches could facilitate or discourage service coordination across organizations. Finally, providers believed that health and immigration system mechanisms could work more effectively for optimal postpartum depression support. Conclusion Health service providers are critical in supporting immigrant women with postpartum depression and facilitating service accessibility. Organizational and system gaps restrict optimal postpartum depression service provision and integration.
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Affiliation(s)
- R. Ganann
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - W. Sword
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - K.B. Newbold
- School of Geography & Earth Sciences, McMaster University, Hamilton, ON, Canada
| | - L. Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
| | - L. Armour
- Aisling Discoveries Child and Family Centre, Toronto, ON, Canada
| | - B. Kint
- Toronto Public Health, Toronto, ON, Canada
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20
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Hilder J, Gray B, Stubbe M. Health navigation and interpreting services for patients with limited English proficiency: a narrative literature review. J Prim Health Care 2019; 11:217-226. [DOI: 10.1071/hc18067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 08/12/2019] [Indexed: 11/23/2022] Open
Abstract
ABSTRACT
INTRODUCTIONCulturally and linguistically diverse populations (CALD) have significant health outcome disparities compared to dominant groups in high-income countries. The use of both navigators and interpreters are strategies used to address these disparities, but the intersections between these two roles can be poorly understood.
AIMTo gain an overview of the literature on health navigation and similar roles, with particular reference to the New Zealand context, and to explore the interface between these roles and that of interpreters for CALD populations with limited English proficiency.
METHODSA narrative review of the literature was conducted using a range of search strategies and a thematic analysis was conducted.
RESULTSThere are several barriers to health-care access relating to health systems and CALD populations. For over 50 years, health workers who are members of these communities have been used to address these barriers, but there are many terms describing workers with wide-ranging roles. There is some evidence of efficacy in economic, psychosocial and functional terms. For health navigation services to work, they need to have staff who are well selected, trained and supported; are integrated into health-care teams; and have clearly defined roles. There may be a place for integrating interpreting more formally into the navigator role for members of communities who have limited English proficiency.
CONCLUSIONTo achieve better access to health care for CALD populations, there is an argument for adding another member to the health team who combines clearly defined aspects of the roles of interpreter, community health worker and navigator. Organisations considering setting up such a position should have a clear target population, carefully consider the barriers they are trying to address and define a role, scope of practice and training requirements best suited to addressing those barriers.
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21
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Scott K, Beckham SW, Gross M, Pariyo G, Rao KD, Cometto G, Perry HB. What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers. HUMAN RESOURCES FOR HEALTH 2018; 16:39. [PMID: 30115074 PMCID: PMC6097220 DOI: 10.1186/s12960-018-0304-x] [Citation(s) in RCA: 310] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 07/30/2018] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems. METHODS We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards. FINDINGS We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance. CONCLUSION Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.
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Affiliation(s)
- Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - S. W. Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, 21205 United States of America
| | - Margaret Gross
- Welch Medical Library, Johns Hopkins Medical Institutions, 1900 E Monument Street, Baltimore, 21205 United States of America
| | - George Pariyo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Krishna D Rao
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
| | - Giorgio Cometto
- Health Workforce Department, World Health Organization, Avenue Appia 20, 1202 Geneva, Switzerland
| | - Henry B. Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, 21205 United States of America
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Parker SM, Stocks N, Nutbeam D, Thomas L, Denney-Wilson E, Zwar N, Karnon J, Lloyd J, Noakes M, Liaw ST, Lau A, Osborne R, Harris MF. Preventing chronic disease in patients with low health literacy using eHealth and teamwork in primary healthcare: protocol for a cluster randomised controlled trial. BMJ Open 2018; 8:e023239. [PMID: 29866737 PMCID: PMC5988137 DOI: 10.1136/bmjopen-2018-023239] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/20/2018] [Accepted: 05/11/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Adults with lower levels of health literacy are less likely to engage in health-promoting behaviours. Our trial evaluates the impacts and outcomes of a mobile health-enhanced preventive intervention in primary care for people who are overweight or obese. METHODS AND ANALYSIS A two-arm pragmatic practice-level cluster randomised trial will be conducted in 40 practices in low socioeconomic areas in Sydney and Adelaide, Australia. Forty patients aged 40-70 years with a body mass index ≥28 kg/m2 will be enrolled per practice. The HeLP-general practitioner (GP) intervention includes a practice-level quality improvement intervention (medical record audit and feedback, staff training and practice facilitation visits) to support practices to implement the clinical intervention for patients. The clinical intervention involves a health check visit with a practice nurse based on the 5As framework (assess, advise, agree, assist and arrange), the use of a purpose-built patient-facing app, my snapp, and referral for telephone coaching. The primary outcomes are change in health literacy, lifestyle behaviours, weight, waist circumference and blood pressure. The study will also evaluate changes in quality of life and health service use to determine the cost-effectiveness of the intervention and examine the experiences of practices in implementing the programme. ETHICS AND DISSEMINATION The study has been approved by the University of New South Wales (UNSW) Human Research Ethics Committee (HC17474) and ratified by the University of Adelaide Human Research Ethics committee. There are no restrictions on publication, and findings of the study will be made available to the public via the Centre for Primary Health Care and Equity website and through conference presentations and research publications. Deidentified data and meta-data will be stored in a repository at UNSW and made available subject to ethics committee approval. TRIAL REGISTRATIONREGISTRATION NUMBER ACTRN12617001508369; Pre-results.
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Affiliation(s)
- Sharon M Parker
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Nigel Stocks
- Discipline of General Practice, University of Adelaide, Adelaide, South Australia, Australia
| | - Don Nutbeam
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Louise Thomas
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Nicholas Zwar
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Jon Karnon
- School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Lloyd
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - Manny Noakes
- Nutrition and Health Program, CSIRO Health and Biosecurity, Adelaide, South Australia, Australia
| | - Siaw-Teng Liaw
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Annie Lau
- Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Richard Osborne
- School of Health and Social Development, Centre for Population Health Research, Faculty of Health, Deakin University, Melbourne, Victoria, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
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Molina Y, San Miguel LG, Tamayo L, Robledo C, Díaz CS, Lucio A, Coronado N, Ferrans CE. The "Empowering Latinas to Obtain Breast Cancer Screenings" study: Rationale and design. Contemp Clin Trials 2018; 71:1-8. [PMID: 29803815 DOI: 10.1016/j.cct.2018.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/08/2018] [Accepted: 05/22/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Latinas suffer disproportionately from breast cancer (BC) in part due to lower guideline-concordant screening. Multiple intervention approaches have been developed to promote screening through direct patient education and empowerment approaches (i.e., training community members to share BC information). This study compares the relative effects of these approaches on: 1) women's BC screening; and, 2) women's dissemination of BC information within their social networks. DESIGN/METHODS Our quasi-experimental trial is being implemented in community venues in two predominantly Latino neighborhoods in South and West Chicago. Eligible participants: 1) are female; 2) are 52-74 years old; 3) have not obtained a mammogram in the past 2 years; and, 4) have not previously participated in health-related volunteerism. Based on their geographic location, participants are assigned to one of two group-based interventions. Both interventions consist of three two-hour sessions, which includes BC early detection education. The education intervention sessions also covers BC prevention (diet, physical activity), whereas the empowerment intervention covers sharing information with family/friends, and health volunteerism. Navigation is provided for all women who wish to obtain mammograms. Primary outcomes include: 1) receipt of BC screening; and, 2) participants' dissemination of BC information. Secondary outcomes include positive changes in 1) participants' self-reported psychosocial facilitators; and, 2) social network members' BC behaviors. DISCUSSION The design of our program allows for a preliminary comparison of the effectiveness of these two approaches. This work will inform larger comparativeness trials and offers a new approach to intervention evaluation via social network analysis.
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Falk D. A Mixed Methods Review of Education and Patient Navigation Interventions to Increase Breast and Cervical Cancer Screening for Rural Women. SOCIAL WORK IN PUBLIC HEALTH 2018; 33:173-186. [PMID: 29412063 DOI: 10.1080/19371918.2018.1434583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Reviews have assessed studies of breast and cervical cancer screening access and utilization for rural women, but none analyze interventions to increase screening rates. A mixed methods literature search identified studies of breast and/or cervical cancer prevention education and patient navigation interventions for rural women. Rural areas need greater implementation and evaluation of screening interventions as these services address the challenges of delivering patient-centered cancer care to un-/underserved communities. The lack of intervention studies on breast and cervical cancer education and patient navigation programs compared to urban studies highlights the need for validation of these programs among diverse, rural populations.
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Affiliation(s)
- Derek Falk
- a School of Social Work , The University of Texas at Austin , Austin , Texas USA
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25
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Bellhouse S, McWilliams L, Firth J, Yorke J, French DP. Are community-based health worker interventions an effective approach for early diagnosis of cancer? A systematic review and meta-analysis. Psychooncology 2017; 27:1089-1099. [DOI: 10.1002/pon.4575] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Sarah Bellhouse
- Christie Patient Centred Research Group, School of Oncology; The Christie NHS Foundation Trust; UK
| | - Lorna McWilliams
- Christie Patient Centred Research Group, School of Oncology; The Christie NHS Foundation Trust; UK
| | - Joseph Firth
- Division of Psychology and Mental Health, School of Health Sciences; University of Manchester; UK
- NICM, School of Science and Health; University of Western Sydney; Australia
| | - Janelle Yorke
- Christie Patient Centred Research Group, School of Oncology; The Christie NHS Foundation Trust; UK
- Division of Nursing, Midwifery and Social Work, School of Health Sciences; University of Manchester; UK
| | - David P. French
- Manchester Centre for Health Psychology, School of Health Sciences; University of Manchester; UK
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26
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Naylor KB. Addressing Colorectal Cancer Disparities Among African American Men Beyond Traditional Practice-Based Settings. Am J Public Health 2017; 107:1356-1358. [PMID: 28787203 PMCID: PMC5551620 DOI: 10.2105/ajph.2017.303974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2017] [Indexed: 07/22/2023]
Affiliation(s)
- Keith B Naylor
- Keith B. Naylor is with the Section of Gastroenterology, Hepatology & Nutrition, University of Chicago Medicine, Chicago, IL
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27
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Hill LM, Maman S, Holness D, Moodley D. Legal knowledge, needs, and assistance seeking among HIV positive and negative women in Umlazi, South Africa. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2016; 16:3. [PMID: 26800890 PMCID: PMC4722747 DOI: 10.1186/s12914-016-0077-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 01/18/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The rights of women and people living with HIV (PLHIV) are protected under South African law, yet there is a gap in the application of these laws. While there are numerous systemic and social barriers to women's and PLHIV's exercise of their legal rights and rights to access social services, there has been little effort to document these barriers as well as legal needs and knowledge in this context. METHODS 1480 HIV-positive and HIV-negative women recruited from an antenatal clinic in Umlazi Township completed a questionnaire on legal knowledge, experience of legal issues, assistance seeking for legal issues, and barriers to seeking assistance. We compared the legal knowledge and experience of legal issues of HIV-positive and HIV-negative women, and described assistance seeking and barriers to assistance seeking among all women. RESULTS Both HIV-positive and HIV-negative women had high levels of knowledge of their legal rights. There were few important differences in legal knowledge and experience of legal issues by HIV status. The most common legal issues women experienced were difficulty obtaining employment (11 %) and identification documents (7 %). A minority of women who had ever experienced a legal issue had sought assistance for this issue (38 %), and half (50 %) of assistance sought was from informal sources such as family and friends. Women cited lack of time and government bureaucracy as the major barriers to seeking assistance. CONCLUSIONS These results indicate few differences in legal knowledge and needs between HIV-positive and HIV-negative women in this context, but rather legal needs common among women of reproductive age. Legal knowledge may be a less important barrier to seeking assistance for legal issues than time, convenience, and cost. Expanding the power of customary courts to address routine legal issues, encouragement of pro bono legal assistance, and introduction of legal navigators could help to address these barriers.
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Affiliation(s)
- Lauren M. Hill
- />Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 331 Rosenau Hall, CB #7440, Chapel Hill, 27599 NC USA
| | - Suzanne Maman
- />Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 331 Rosenau Hall, CB #7440, Chapel Hill, 27599 NC USA
| | - David Holness
- />University of KwaZulu-Natal Law Clinic, Durban, South Africa
| | - Dhayendre Moodley
- />Department of Obstetrics and Gynaecology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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