An Evaluation of a Rural Community-Based Breast Education and Navigation Program: Highlights and Lessons Learned

Oncology Nurse Navigation in Underserved Communities: Opportunities and Future Directions

OBJECTIVES

Provide an overview of navigation in three disparate populations: rural, Native American/Alaska Native, and low- to middle-income countries. Discuss gaps in care and opportunities to improve cancer care.

METHODS

A literature search was conducted in PubMed and on Google Scholar using search terms, nurse navigation, cancer, disparit*, low- to middle-income countries, Native American, American Indian, and rural. Peer-reviewed research studies, review articles, databases and websites of professional organizations, and historical books were reviewed to provide an overview of oncology nurse navigation in underserved communities. Experiences in working with these populations over the past 30 years were also provided to support current literature.

RESULTS

Forty references were included in this overview of nurse navigation in underserved communities. Nurse navigation in these disparate areas is in its infancy. While some programs exist and outcomes have been positive, their dissemination is sparse. A need exists to expand nurse navigation into these areas to provide care for these underserved communities.

CONCLUSION

Oncology nursing navigation for each of these underserved communities requires a culturally sensitive approach. Many of these approaches are universal to cultural competency and can be applied to most disparate populations.

IMPLICATIONS FOR NURSING PRACTICE

Nurses comprise the largest workforce around the globe and are well-equipped to develop navigation programs in some of the most disparate communities around the world. To do so, it is important to use a foundation of building trust, embracing individual differences, providing culturally sensitive education and resources for growth, and good communication.

The Effect of Two Interventions to Increase Breast Cancer Screening in Rural Women

Guideline-based mammography screening is essential to lowering breast cancer mortality, yet women residing in rural areas have lower rates of up to date (UTD) breast cancer screening compared to women in urban areas. We tested the comparative effectiveness of a tailored DVD, and the DVD plus patient navigation (PN) intervention vs. Usual Care (UC) for increasing the percentage of rural women (aged 50 to 74) UTD for breast cancer screening, as part of a larger study. Four hundred and two women who were not UTD for breast cancer screening, eligible, and between the ages of 50 to 74 were recruited from rural counties in Indiana and Ohio. Consented women were randomly assigned to one of three groups after baseline assessment of sociodemographic variables, health status, beliefs related to cancer screening tests, and history of receipt of guideline-based screening. The mean age of participants was 58.2 years with 97% reporting White race. After adjusting for covariates, 54% of women in the combined intervention (DVD + PN) had a mammogram within the 12-month window, over 5 times the rate of becoming UTD compared to UC (OR = 5.11; 95% CI = 2.57, 10.860; p < 0.001). Interactions of the intervention with other variables were not significant. Significant predictors of being UTD included: being in contemplation stage (intending to have a mammogram in the next 6 months), being UTD with other cancer screenings, having more disposable income and receiving a reminder for breast screening. Women who lived in areas with greater Area Deprivation Index scores (a measure of poverty) were less likely to become UTD with breast cancer screening. For rural women who were not UTD with mammography screening, the addition of PN to a tailored DVD significantly improved the uptake of mammography. Attention should be paid to certain groups of women most at risk for not receiving UTD breast screening to improve breast cancer outcomes in rural women.

How cancer programs identify and address the financial burdens of rural cancer patients

PURPOSE

Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients.

METHODS

Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis.

RESULTS

We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns.

CONCLUSIONS

Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Evaluating a Community-Based Breast Cancer Prevention Program for Rural Underserved Latina and Black Women

Persistent racial and ethnic disparities and rural-urban disparities in breast cancer mortality in North Carolina require attention. The Pitt County Breast Wellness Initiative-Education (PCBWI-E) provided culturally tailored breast cancer education and navigation to age-appropriate screening services (mammography and clinical breast exams) for uninsured and underinsured Black and Latina women age 25 and older in two rural counties in North Carolina (Pitt and Edgecombe Counties). Using a lay health model, the PCBWI-E trained 23 community members and public health undergraduate students as lay breast health educators. Breast health educators educated 735 women across the 2-year program. Baseline knowledge about breast health was low at year 1 and 2 (mean knowledge score = 59%, SD = 0.21 and 57%, SD = 0.22, respectively) and was higher at follow-up post-intervention for both years 1 and 2 (mean knowledge score = 78%, SD = 0.18 and 75%, SD = 0.19, respectively) (p < 0.001). In terms of navigation, almost three-quarters (72%) of those recommended to receive a mammogram, received one. Of the population served by the PCBWI-E who were aged 40 and above, 34% had never received a mammogram. Of those women who had never received a mammogram, 68% received one through the PCBWI-E program. The PCBWI-E was successful in increasing both breast health knowledge and access to age-appropriate breast cancer screening among uninsured and underserved Latina and Black women in rural eastern North Carolina. Future efforts should support the large-scale implementation of successful evidence-based culturally appropriate models like this one in the reduction of racial, ethnic, and rural breast cancer disparities.

Community Breast Health Education for Immigrants and Refugees: Lessons Learned in Outreach Efforts to Reduce Cancer Disparities

Community-academic partnerships are vital to address cancer disparities in geographic areas with diverse socioeconomic, language, and cultural barriers. Regarding breast health, immigrant and refugee women are a particularly vulnerable population, with considerably lower mammography rates than most communities, including racial and ethnic minorities. To promote health care equity in this high-risk population, we developed a community-academic partnership (CAP) model to promote breast health education at community faith-based centers in the city of Milwaukee, WI. In this paper, we describe the success of our partnerships, our lessons learned, and future directions.

An Evaluation of Follow-Up Activities of Participants From an Urban Prostate Cancer Screening Event

This study aims to evaluate follow-up activities completed by participants attending community prostate cancer (PCa) screening events. On-site surveys were collected from participants of 17 free PCa screening events from 2007 to 2011 in the St. Louis, MO metropolitan area. Follow-up action surveys were mailed to all on-site participants to assess medical (i.e., made an appointment with a doctor, got additional testing for PCa, made an appointment to be screened) and nonmedical activities (i.e., sought social support, health information-seeking, health behavior modifications) completed after the PCa screening event. Further, t tests and chi-square tests characterized participant information from the on-site survey and within each follow-up activity category for the mailed surveys. Among 1,088 on-site community PCa screening participants, the mean age was 50 years old, 94% were Black, and 30% responded to the mailed follow-up action survey. For the recorded follow-up activities, 65% of participants reported medically reported activities, of which “made an appointment to get a yearly physical” was the most common action (29%). Health behavior modifications were the most common nonmedically related activities (44%). Health information-seeking behaviors were the least reported follow-up action (22%). Men with higher incomes, married, with health insurance, and a primary care physician, most often participated in post-PSA screening activities, namely medically-related and social support activities. Understanding the most common activities completed by participants of a community PCa screening suggests the effectiveness of community events to re-engage underserved populations in the health-care system and provides insight on acceptable health promotion opportunities.