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Bergeron E, Valdez R, Moreland CJ, Wang R, Knight T, Kushalnagar P. Community Health Navigators for Cancer Screening Among Deaf, Deafblind, and Hard of Hearing Adults Who Use American Sign Language. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2024; 39:353-359. [PMID: 38411867 PMCID: PMC11219252 DOI: 10.1007/s13187-024-02416-x] [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] [Accepted: 02/13/2024] [Indexed: 02/28/2024]
Abstract
Deaf, deafblind, and hard of hearing (DDBHH) individuals experience barriers to accessing cancer screening, including ineffective patient-physician communication when discussing screening recommendations. For other underserved communities, culturally and linguistically aligned community health navigators (CHNs) have been shown to improve cancer screening and care. A needs assessment study was conducted to identify barriers and gather recommendations for CHN training resources. A community-based participatory needs assessment was conducted from May 2022 to June 2022 using three focus groups. Eight were cancer survivors, six advocates/navigators, and three clinicians. All questions were semi-structured and covered screening barriers, observations or personal experiences, perceived usefulness of having a CHN to promote cancer screening adherence, and training resources that may be useful to American Sign Language (ASL)-proficient CHNs, who are also culturally and linguistically aligned. Out of 20 focus group participants, seven self-identified as persons of color. Data highlighted systemic, attitudinal, communication, and personal-level barriers as recurrent themes. The most frequently cited barrier was access to training that supports the role and competencies of CHNs, followed by cultural considerations, access to cancer guidelines in ASL, dialect diversity in sign language, and the health system itself. Unaddressed barriers can contribute to health disparities, such as lower preventive cancer screening rates amongst DDBHH individuals. The next step is to translate recommendations into actionable tasks for DDBHH CHN training programs. As a result, CHNs will be well-equipped to help DDBHH individuals navigate and overcome their unique barriers to cancer screening and healthcare access.
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Affiliation(s)
- E Bergeron
- Center for Deaf Health Equity, Gallaudet University, Washington, DC, USA
| | - R Valdez
- Department of Public Health Sciences and Department of Engineering Systems and Environment, University of Virginia, Charlottesville, VA, USA
| | - C J Moreland
- Department of Internal Medicine, Dell Medical School at the, University of Texas, Austin, TX, USA
| | - R Wang
- Department of Family Medicine, University of California at San Diego, San Diego, CA, USA
| | - T Knight
- Department of World Languages and Cultures, Sam Houston State University, Huntsville, TX, USA
| | - P Kushalnagar
- Center for Deaf Health Equity, Gallaudet University, Washington, DC, USA.
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Baggett TP, Sporn N, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Critchley N, Kennedy E, Hart K, Joyce A, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:892-902. [PMID: 38856994 PMCID: PMC11165412 DOI: 10.1001/jamainternmed.2024.1662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Importance People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation. Objective To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program. Design, Setting, and Participants This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023. Intervention Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers. Main Outcomes and Measures The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention. Results In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator. Conclusions and Relevance In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT04308226.
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Affiliation(s)
- Travis P. Baggett
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Nora Sporn
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | | | | | - Natalia Critchley
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Evangeline Kennedy
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Katherine Hart
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Andrea Joyce
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Yuchiao Chang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Elyse R. Park
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Nancy A. Rigotti
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Meier J, Murimwa G, Nehrubabu M, Yopp A, DiMartino L, Singal AG, Zeh HJ, Polanco P. Defining the Role of Social Vulnerability in Treatment and Survival in Localized Colon Cancer: A Retrospective Cohort Study. Ann Surg 2024:00000658-990000000-00829. [PMID: 38545790 PMCID: PMC11436472 DOI: 10.1097/sla.0000000000006282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
OBJECTIVE To determine whether variations in Social Vulnerability Index (SVI) are associated with disparities in colon cancer surgery and mortality. SUMMARY BACKGROUND DATA Colon cancer mortality is influenced by health care access, which is affected by individual and community-level factors. Prior studies have not used the SVI to compare surgical access and survival in localized colon cancer patients. Further, it is unclear if those above 65 years are more vulnerable to variations in SVI. METHODS We queried the Texas and California Cancer Registries from 2004-2017 to identify patients with localized colonic adenocarcinoma and categorized patients into <65 and ≥65 years. Our outcomes were survival and access to surgical intervention. The independent variable was census tract social vulnerability index, with higher scores indicating more social vulnerability. We used multivariable logistic regression and Cox proportional hazards for analysis. RESULTS We included 73,923 patients with a mean age of 68.6 years (SD 13.0), mean SVI of 47.2 (SD 27.6), and 51.1% male. After adjustment, increasing SVI was associated with reduced odds of undergoing surgery (OR 0.996; 95% CI 0.995-0.997; P < 0.0001 and increased mortality (HR 1.002; 95% CI 1.001-1.002; P < 0.0001). Patients < 65 years were more sensitive to variation in SVI. CONCLUSIONS Increased social vulnerability was associated with reduced odds of receiving surgery for early-stage colon cancer as well as increased mortality. These findings amplify the need for policy changes at the local, state, and federal level to address community-level vulnerability to improve access to surgical care and reduce mortality.
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Affiliation(s)
- Jennie Meier
- University of Texas Southwestern, Department of Surgery, Dallas, TX
| | - Gilbert Murimwa
- University of Texas Southwestern, Department of Surgery, Dallas, TX
| | - Mithin Nehrubabu
- University of Texas at Dallas, Department of Mathematics, Dallas, TX
| | - Adam Yopp
- University of Texas Southwestern, Department of Surgery, Dallas, TX
| | - Lisa DiMartino
- University of Texas Southwestern, Peter O'Donnell Jr. School of Public Health, Dallas, TX
| | - Amit G Singal
- University of Texas Southwestern, Division of Digestive & Liver Diseases, Dallas, TX
| | - Herbert J Zeh
- University of Texas Southwestern, Department of Surgery, Dallas, TX
| | - Patricio Polanco
- University of Texas Southwestern, Department of Surgery, Dallas, TX
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Varon ML, Geng Y, Fellman BM, Troisi C, Fernandez ME, Li R, Reininger B, Schmeler KM, Allanson E. Interventions to increase follow-up of abnormal cervical cancer screening results: A systematic literature review and meta-analysis. PLoS One 2024; 19:e0291931. [PMID: 38381754 PMCID: PMC10880967 DOI: 10.1371/journal.pone.0291931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 09/10/2023] [Indexed: 02/23/2024] Open
Abstract
INTRODUCTION Ensuring timely follow-up of abnormal screening results is essential for eliminating cervical cancer. OBJECTIVE The purpose of the study was to review single and multicomponent interventions designed to improve follow-up of women with abnormal cervical cancer screening results. We report on effectiveness across studies, and describe what aspects of these interventions might be more impactful. METHODS Publications were searched between January 2000 and December 2022. The search included observational, quasi-experimental (pre-post studies) and randomized controlled studies describing at least one intervention to increase follow-up of women with abnormal cervical cancer screening results. Outcomes of studies included completion of any follow-up (i.e., attending a follow-up appointment), timely diagnosis (i.e., colposcopy results within 90 days of screening) and time to diagnostic resolution (i.e., days between screening and final diagnosis). We assessed risk of bias for observational and quasi-experimental studies using the Newcastle-Ottawa Scale (NOS) tool and the Cochrane collaboration tool for randomized studies. We conducted a meta-analysis using studies where data were provided to estimate a summary average effect of the interventions on follow-up of patients and to identify characteristics of studies associated with an increased effectiveness of interventions. We extracted the comparison and intervention proportions of women with follow-up before and after the intervention (control and intervention) and plotted the odds ratios (ORs) of completing follow-up along with the 95% confidence intervals (CIs) using forest plots for the interventions vs. controls when data were available. FINDINGS From 7,457 identified studies, 28 met the inclusion criteria. Eleven (39%) of the included studies had used a randomized design. Most studies (63%) assessed completion of any follow-up visit as the primary outcome, whereas others measured time to definite diagnosis (15%) or diagnostic resolution (22%). Navigation was used as a type of intervention in 63% of the included studies. Most interventions utilized behavioral approaches to improve outcomes. The overall estimate of the OR for completion of follow-up for all interventions was 1.81 (1.36-2.42). The highest impact was for programs using more than one approach (multicomponent interventions) to improve outcomes with OR = 3.01 (2.03-4.46), compared with studies with single intervention approaches with OR = 1.56 (1.14-2.14). No statistical risks were noted from publication bias or small-study effects in the studies reviewed. CONCLUSION Our findings revealed large heterogeneity in how follow-up of abnormal cervical cancer screening results was defined. Our results suggest that multicomponent interventions were more effective than single component interventions and should be used to improve follow-up after abnormal cervical cancer screening results. Navigation appears to be an important tool for improving follow-up. We also provide recommendations for future studies and implications for policy in terms of better defining outcomes for these interventions.
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Affiliation(s)
- Melissa Lopez Varon
- Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Bryan M. Fellman
- Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Catherine Troisi
- Management, Policy & Community Health, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Maria E. Fernandez
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Ruosha Li
- Biostatistics, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, United States of America
| | - Belinda Reininger
- Health Promotion & Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, Texas, United States of America
| | - Kathleen M. Schmeler
- Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - Emma Allanson
- The Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, Australia
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Mosquera I, Todd A, Balaj M, Zhang L, Benitez Majano S, Mensah K, Eikemo TA, Basu P, Carvalho AL. Components and effectiveness of patient navigation programmes to increase participation to breast, cervical and colorectal cancer screening: A systematic review. Cancer Med 2023; 12:14584-14611. [PMID: 37245225 PMCID: PMC10358261 DOI: 10.1002/cam4.6050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/03/2023] [Accepted: 04/26/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Inequalities in cancer incidence and mortality can be partly explained by unequal access to high-quality health services, including cancer screening. Several interventions have been described to increase access to cancer screening, among them patient navigation (PN), a barrier-focused intervention. This systematic review aimed to identify the reported components of PN and to assess the effectiveness of PN to promote breast, cervical and colorectal cancer screening. METHODS We searched Embase, PubMed and Web of Science Core Collection databases. The components of PN programmes were identified, including the types of barriers addressed by navigators. The percentage change in screening participation was calculated. RESULTS The 44 studies included were mainly on colorectal cancer and were conducted in the USA. All described their goals and community characteristics, and the majority reported the setting (97.7%), monitoring and evaluation (97.7%), navigator background and qualifications (81.4%) and training (79.1%). Supervision was only referred to in 16 studies (36.4%). Programmes addressed mainly barriers at the educational (63.6%) and health system level (61.4%), while only 25.0% reported providing social and emotional support. PN increased cancer screening participation when compared with usual care (0.4% to 250.6% higher) and educational interventions (3.3% to 3558.0% higher). CONCLUSION Patient navigation programmes are effective at increasing participation to breast, cervical and colorectal cancer screening. A standardized reporting of the components of PN programmes would allow their replication and a better measure of their impact. Understanding the local context and needs is essential to design a successful PN programme.
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Affiliation(s)
- Isabel Mosquera
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Adam Todd
- School of PharmacyNewcastle University, Newcastle upon TyneUK
| | - Mirza Balaj
- Centre for Global Health Inequalities Research (CHAIN), Department of Sociology and Political ScienceNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Li Zhang
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Sara Benitez Majano
- Noncommunicable Diseases, Violence and Injuries Prevention Unit, Pan American Health OrganizationWashingtonDCUSA
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical MedicineLondonUK
| | - Keitly Mensah
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Terje Andreas Eikemo
- Centre for Global Health Inequalities Research (CHAIN), Department of Sociology and Political ScienceNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Partha Basu
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
| | - Andre L. Carvalho
- Early Detection, Prevention & Infections Branch, International Agency for Research on CancerLyonFrance
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Preston MA, Cadet D, Hunley R, Retnam R, Arezo S, Sheppard VB. Health Equity and Colorectal Cancer Awareness: a Community Health Educator Initiative. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2023; 38:225-230. [PMID: 34677801 PMCID: PMC8532449 DOI: 10.1007/s13187-021-02102-2] [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] [Accepted: 10/09/2021] [Indexed: 06/13/2023]
Abstract
Disparities in colorectal cancer (CRC) incidence and mortality persist in rural and underserved communities. Our Community Outreach and Engagement (COE) activities are grounded in a bi-directional Community-to-Bench model in which the National Outreach Network Community Health Educator (NON CHE) Screen to Save (S2S) initiative was implemented. In this study, we assessed the impact of the NON CHE S2S in rural and underserved communities. Descriptive and comparative analyses were used to examine the role of the NON CHE S2S on CRC knowledge and CRC screening intent. Data included demographics, current CRC knowledge, awareness, and future CRC health plans. A multivariate linear regression was fit to survey scores for CRC knowledge. The NON CHE S2S engaged 441 participants with 170 surveys completed. The difference in participants' CRC knowledge before and after the NON CHE S2S intervention had an overall mean of 0.92 with a standard deviation of 2.56. At baseline, White participants had significantly higher CRC knowledge scores, correctly answering 1.94 (p = 0.007) more questions on average than Black participants. After the NON CHE S2S intervention, this difference was not statistically significant. Greater than 95% of participants agreed that the NON CHE S2S sessions impacted their intent to get screened for CRC. Equity of access to health information and the health care system can be achieved with precision public health strategies. The COE bi-directional Community-to-Bench model facilitated community connections through the NON CHE and increased awareness of CRC risk reduction, screening, treatment, and research. The NON CHE combined with S2S is a powerful tool to engage communities with the greatest health care needs and positively impact an individual's intent to "get screened" for CRC.
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Affiliation(s)
- Michael A Preston
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA.
| | - Debbie Cadet
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA
| | - Rachel Hunley
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA
| | - Reuben Retnam
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA
| | - Sarah Arezo
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA
| | - Vanessa B Sheppard
- Department of Health Behavior and Policy, Office of Health Equity & Disparities Research-Community Outreach & Engagement, Virginia Commonwealth University, PO Box 980149, 830 East Main Street, Richmond, VA, 23298-0149, USA
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Nurse's Roles in Colorectal Cancer Prevention: A Narrative Review. JOURNAL OF PREVENTION (2022) 2022; 43:759-782. [PMID: 36001253 DOI: 10.1007/s10935-022-00694-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 02/07/2023]
Abstract
The objective of this paper is to investigate the different roles of nurses as members of healthcare teams at the primary, secondary, and tertiary levels of colorectal cancer prevention. The research team conducted a narrative review of studies involving the role of nurses at different levels of colorectal cancer prevention, which included a variety of quantitative, qualitative, and mixed-method studies. We searched PubMed, Scopus, Web of Science, Cochrane Reviews, Magiran, the Scientific Information Database (SID), Noormags, and the Islamic Science Citation (ISC) databases from ab initio until 2021. A total of 117 studies were reviewed. Nurses' roles were classified into three levels of prevention. At the primary level, the most important role related to educating people to prevent cancer and reduce risk factors. At the secondary level, the roles consisted of genetic counseling, stool testing, sigmoidoscopy and colonoscopy, biopsy and screening test follow-ups, and chemotherapy intervention, while at the tertiary level, their roles were made up of pre-and post-operative care to prevent further complications, rehabilitation, and palliative care. Nurses at various levels of prevention care also act as educators, coordinators, performers of screening tests, follow-up, and provision of palliative and end-of-life care. If these roles are not fulfilled at some levels of colorectal cancer, it is generally due to the lack of knowledge and competence of nurses or the lack of instruction and legal support for them. Nurses need sufficient clinical knowledge and experience to perform these roles at all levels.
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Baggett TP, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Sporn N, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2022; 113:106666. [PMID: 34971796 DOI: 10.1016/j.cct.2021.106666] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers. METHODS The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results. DISCUSSION This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, United States of America.
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Elijah C Rodriguez
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; New York University Grossman School of Medicine, New York, NY, United States of America
| | - Nillani Anandakugan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nora Sporn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elyse R Park
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Cusumano VT, Myint A, Corona E, Yang L, Bocek J, Lopez AG, Huang MZ, Raja N, Dermenchyan A, Roh L, Han M, Croymans D, May FP. Patient Navigation After Positive Fecal Immunochemical Test Results Increases Diagnostic Colonoscopy and Highlights Multilevel Barriers to Follow-Up. Dig Dis Sci 2021; 66:3760-3768. [PMID: 33609211 DOI: 10.1007/s10620-021-06866-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The fecal immunochemical test (FIT) is a common colorectal cancer screening modality in the USA but often is not followed by diagnostic colonoscopy. AIMS We investigated the efficacy of patient navigation to increase diagnostic colonoscopy after positive FIT results and determined persistent barriers to follow-up despite navigation in a large, academic healthcare system. METHODS The study cohort included all health system outpatients with an assigned primary care provider, a positive FIT result between 12/01/2016 and 06/01/2019, and no documentation of colonoscopy after positive FIT. Two non-clinical patient navigators engaged patients and providers to encourage follow-up, offer solutions to barriers, and assist with colonoscopy scheduling. The primary intervention endpoint was completion of colonoscopy within 6 months of navigation. We documented reasons for persistent barriers to colonoscopy despite navigation and determined predictors of successful follow-up after navigation. RESULTS There were 119 patients who received intervention. Of these, 37 (31.1%) patients completed colonoscopy at 6 months. In 41/119 (34.5%) cases, the PCP did not recommend colonoscopy, most commonly due to a normal colonoscopy prior to the positive FIT (19, 46.3%). There were 41/119 patients (34.5%) that declined colonoscopy despite the patient navigator and the PCP order. Male sex and younger age were significant predictors of follow-up (aOR = 2.91, 95%CI, 1.18-7.13; aOR = 0.92, 95%CI, 0.87-0.99). CONCLUSIONS After implementation of patient navigation, diagnostic colonoscopy was completed for 31.1% of patients with a positive FIT result. However, navigation also highlighted persistent multilevel barriers to follow-up. Future work will develop targeted solutions for these barriers to further increase FIT follow-up rates in our health system.
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Affiliation(s)
- Vivy T Cusumano
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Anthony Myint
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edgar Corona
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Liu Yang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer Bocek
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Antonio G Lopez
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Marcela Zhou Huang
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA
| | - Naveen Raja
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Anna Dermenchyan
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lily Roh
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Faculty Practice Group and Office of Population Health and Accountable Care, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria Han
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel Croymans
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA.,Quality Program, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Folasade P May
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, 650 Charles Young Drive South, Room A2-125 CHS, Los Angeles, CA, 90095-6900, USA. .,Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. .,Cancer Prevention Control Research, UCLA Kaiser Permanente Center for Health Equity, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, CA, USA. .,Department of Medicine, Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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10
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Mistry SK, Harris E, Harris M. Community Health Workers as Healthcare Navigators in Primary Care Chronic Disease Management: a Systematic Review. J Gen Intern Med 2021; 36:2755-2771. [PMID: 33674916 PMCID: PMC8390732 DOI: 10.1007/s11606-021-06667-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND This review was carried out to synthesize the evidence of the effectiveness of community health worker (CHW) navigation in primary care chronic disease management. METHODS We searched the English language literature between January 1990 and March 2020 in Medline, Embase, Emcare, PubMed, Psych Info, CINAHL, Scopus, and Medline Epub ahead of print. Data extraction, quality rating, and assessment of the reporting of interventions were performed by two reviewers independently and the findings were synthesized narratively. RESULTS Twenty-nine articles met the inclusion criteria. All but two were carried out in the USA and half were randomized controlled trials. Six of the 29 studies were of strong methodological quality while 12 were moderate and 11 weak. Overall, CHW navigation interventions were effective in increasing adherence to cancer screening and improving use of primary care for chronic disease management. There was insufficient evidence that they improved clinical outcomes or risk factors and reduced use of secondary or tertiary care or that they were cost-effective. However, criteria for recruitment, duration, and mode of training and supervision arrangements varied greatly between studies. DISCUSSION CHW navigation interventions improved aspects of chronic disease management. However, there is insufficient evidence of the impact on patient experience, clinical outcomes, or cost-effectiveness of the interventions. Future research should focus on standardizing organizational components of the CHW navigation interventions and evaluating their cost-effectiveness. PROTOCOL REGISTRATION The review protocol was published in PROSPERO (CRD42020153921).
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Affiliation(s)
- Sabuj Kanti Mistry
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia.
| | - Elizabeth Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
| | - Mark Harris
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
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11
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Mendelsohn RB, DeLeon SF, Calo D, Villegas S, Carlesimo M, Wang JJ, Winawer SJ. Feasibility of Patient Navigation and Impact on Adherence to Screening Colonoscopy in a Large Diverse Urban Population. J Racial Ethn Health Disparities 2021; 8:559-565. [PMID: 32643126 PMCID: PMC9338426 DOI: 10.1007/s40615-020-00812-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/28/2020] [Accepted: 06/30/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Disparities observed in colorectal cancer (CRC) incidence and mortality among blacks and Hispanics compared with whites may be in part due to lower screening rates. The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) has implemented a patient navigator (PN) program at NYC hospitals serving lower-income patients to promote high adherence by patients referred for screening colonoscopy. A prior study showed this PN program increased adherence at 3 public hospitals. The aim of this study was to determine the feasibility of expanding the PN program to 10 hospital sites by assessing the impact of the PN program on adherence to screening colonoscopy in a large, urban, lower-income population. METHODS Data were collected from 2007 through the first quarter of 2012 from PN sites. One site also contributed data from the pilot phase of the project, from 2005 to 2006. Adherence to scheduled screening colonoscopy among those ≥ 50 years was assessed among 10 hospital sites in NYC participating in the colonoscopy PN program. RESULTS Among the 37,077 asymptomatic adults ≥ 50 years who were scheduled for a screening colonoscopy from 2005 to the first quarter of 2012, 84.2% (83.2% of black, 84.9% of Hispanic, and 87.5% of white adults) were adherent to scheduled colonoscopy. CONCLUSIONS Expansion of PN programs to navigate all patients referred for a colonoscopy was feasible in a large, urban setting. This can be implemented resulting in high overall adherence rates to screening colonoscopies. The program likely did not result in large ethnic disparities.
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Affiliation(s)
- Robin B Mendelsohn
- Memorial Sloan Kettering Cancer Center, Department of Medicine, 1275 York Avenue, New York, NY, 10065, USA.
| | | | - Delia Calo
- Memorial Sloan Kettering Cancer Center, Department of Medicine, 1275 York Avenue, New York, NY, 10065, USA
| | - Sonia Villegas
- NYC Department of Health and Mental Hygiene, New York, NY, USA
| | - Mari Carlesimo
- NYC Department of Health and Mental Hygiene, New York, NY, USA
| | - Jason J Wang
- Hofstra Northwell School of Medicine, Department of Medicine, Hempstead, NY, USA
| | - Sidney J Winawer
- Memorial Sloan Kettering Cancer Center, Department of Medicine, 1275 York Avenue, New York, NY, 10065, USA
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12
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Lam H, Quinn M, Cipriano-Steffens T, Jayaprakash M, Koebnick E, Randal F, Liebovitz D, Polite B, Kim K. Identifying actionable strategies: using Consolidated Framework for Implementation Research (CFIR)-informed interviews to evaluate the implementation of a multilevel intervention to improve colorectal cancer screening. Implement Sci Commun 2021; 2:57. [PMID: 34059156 PMCID: PMC8167995 DOI: 10.1186/s43058-021-00150-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/28/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts. METHODS We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders' implementation experience. The interviews were conducted in the participant's clinic, audio-taped, and professionally transcribed for analysis. RESULTS We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR (Electronic Health Record) provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality. CONCLUSIONS The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice.
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Affiliation(s)
- Helen Lam
- Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA.
| | - Michael Quinn
- Department of Internal Medicine Section of General Internal Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Toni Cipriano-Steffens
- University of Chicago Medicine, 5841 S. Maryland Ave, MC 2115, Suite G109, Chicago, IL, 60637, USA
| | - Manasi Jayaprakash
- Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA
| | - Emily Koebnick
- Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA
| | - Fornessa Randal
- Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA
| | - David Liebovitz
- Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Dr., 10th Floor, Chicago, IL, 60611, USA
| | - Blasé Polite
- University of Chicago Medicine Hematology and Oncology, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Karen Kim
- Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA
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13
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Ma GX, Zhu L, Lin TR, Tan Y, Do P. Multilevel Pathways of Colorectal Cancer Screening Among Low-Income Vietnamese Americans: A Structural Equation Modeling Analysis. Cancer Control 2021; 28:10732748211011077. [PMID: 33896230 PMCID: PMC8204627 DOI: 10.1177/10732748211011077] [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] [Indexed: 11/16/2022] Open
Abstract
Background: Colorectal cancer (CRC) disproportionately affects Vietnamese Americans, especially those with low income and were born outside of the United States. CRC screening tests are crucial for prevention and early detection. Despite the availability of noninvasive, simple-to-conduct tests, CRC screening rates in Asian Americans, particularly Vietnamese Americans, remain suboptimal. The purpose of this study was to evaluate the interplay of multilevel factors – individual, interpersonal, and community – on CRC screening behaviors among low-income Vietnamese Americans with limited English proficiency. Methods: This study is based on the Sociocultural Health Behavior Model, a research-based model that incorporates 6 factors associated with decision-making and health-seeking behaviors that result in health care utilization. Using a community-based participatory research approach, we recruited 801 Vietnamese Americans from community-based organizations. We administered a survey to collect information on sociodemographic characteristics, health-related factors, and CRC screening-related factors. We used structural equation modeling (SEM) to identify direct and indirect predictors of lifetime CRC screening. Results: Bivariate analysis revealed that a greater number of respondents who never screened for CRC reported limited English proficiency, fewer years of US residency, and lower self-efficacy related to CRC screening. The SEM model identified self-efficacy (coefficient = 0.092, P < .01) as the only direct predictor of lifetime CRC screening. Educational attainment (coefficient = 0.13, P < .01) and health beliefs (coefficient = 0.040, P < .001) had a modest significant positive relationship with self-efficacy. Health beliefs (coefficient = 0.13, P < .001) and educational attainment (coefficient = 0.16, P < .01) had significant positive relationships with CRC knowledge. Conclusions: To increase CRC screening uptake in medically underserved Vietnamese American populations, public health interventions should aim to increase community members’ confidence in their abilities to screen for CRC and to navigate associated processes, including screening preparation, discussions with doctors, and emotional complications.
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Affiliation(s)
- Grace X Ma
- Center for Asian Health, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA.,Department of Clinical Sciences, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Lin Zhu
- Center for Asian Health, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Timmy R Lin
- Center for Asian Health, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Yin Tan
- Center for Asian Health, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Phuong Do
- Center for Asian Health, 12314Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
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14
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Gastroenterology visitation and reminders predict surveillance uptake for patients with adenomas with high-risk features. Sci Rep 2021; 11:8764. [PMID: 33888839 PMCID: PMC8062682 DOI: 10.1038/s41598-021-88376-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/05/2021] [Indexed: 01/19/2023] Open
Abstract
Individuals diagnosed with colorectal adenomas with high-risk features during screening colonoscopy have increased risk for the development of subsequent adenomas and colorectal cancer. While US guidelines recommend surveillance colonoscopy at 3 years in this high-risk population, surveillance uptake is suboptimal. To inform future interventions to improve surveillance uptake, we sought to assess surveillance rates and identify facilitators of uptake in a large integrated health system. We utilized a cohort of patients with a diagnosis of ≥ 1 tubular adenoma (TA) with high-risk features (TA ≥ 1 cm, TA with villous features, TA with high-grade dysplasia, or ≥ 3 TA of any size) on colonoscopy between 2013 and 2016. Surveillance colonoscopy completion within 3.5 years of diagnosis of an adenoma with high-risk features was our primary outcome. We evaluated surveillance uptake over time and utilized logistic regression to detect factors associated with completion of surveillance colonoscopy. The final cohort was comprised of 405 patients. 172 (42.5%) patients successfully completed surveillance colonoscopy by 3.5 years. Use of a patient reminder (telephone, electronic message, or letter) for due surveillance (adjusted odds = 1.9; 95%CI = 1.2-2.8) and having ≥ 1 gastroenterology (GI) visit after diagnosis of an adenoma with high-risk features (adjusted odds = 2.6; 95%CI = 1.6-4.2) significantly predicted surveillance colonoscopy completion at 3.5 years. For patients diagnosed with adenomas with high-risk features, surveillance colonoscopy uptake is suboptimal and frequently occurs after the 3-year surveillance recommendation. Patient reminders and visitation with GI after index colonoscopy are associated with timely surveillance completion. Our findings highlight potential health system interventions to increase timely surveillance uptake for patients diagnosed with adenomas with high-risk features.
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15
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Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol. Implement Sci 2020; 15:96. [PMID: 33121536 PMCID: PMC7599111 DOI: 10.1186/s13012-020-01045-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation. Methods This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase. Discussion There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study. Trial registration This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.
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16
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Haverkamp D, English K, Jacobs-Wingo J, Tjemsland A, Espey D. Effectiveness of Interventions to Increase Colorectal Cancer Screening Among American Indians and Alaska Natives. Prev Chronic Dis 2020; 17:E62. [PMID: 32678062 PMCID: PMC7380299 DOI: 10.5888/pcd17.200049] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Screening rates for colorectal cancer are low in many American Indian and Alaska Native (AI/AN) communities. Direct mailing of a fecal immunochemical test (FIT) kit can address patient and structural barriers to screening. Our objective was to determine if such an evidence-based intervention could increase colorectal cancer screening among AI/AN populations. METHODS We recruited study participants from 3 tribally operated health care facilities and randomly assigned them to 1 of 3 study groups: 1) usual care, 2) mailing of FIT kits, and 3) mailing of FIT kits plus follow-up outreach by telephone and/or home visit from an American Indian Community Health Representative (CHR). RESULTS Among participants who received usual care, 6.4% returned completed FIT kits. Among participants who were mailed FIT kits without outreach, 16.9% returned the kits - a significant increase over usual care (P < .01). Among participants who received mailed FIT kits plus CHR outreach, 18.8% returned kits, which was also a significant increase over usual care (P < .01) but not a significant increase compared with the mailed FIT kit-only group (P = .44). Of 165 participants who returned FIT kits during the study, 39 (23.6%) had a positive result and were referred for colonoscopy of which 23 (59.0%) completed the colonoscopy. Twelve participants who completed a colonoscopy had polyps, and 1 was diagnosed with colorectal cancer. CONCLUSION Direct mailing of FIT kits to eligible community members may be a useful, population-based strategy to increase colorectal cancer screening among AI/AN people.
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Affiliation(s)
- Donald Haverkamp
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Albuquerque, New Mexico
- 1720 Louisiana Blvd, NE, No. 208, Albuquerque, NM 87110.
| | - Kevin English
- Albuquerque Area Indian Health Board, Albuquerque, New Mexico
| | - Jasmine Jacobs-Wingo
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Albuquerque, New Mexico
| | - Amanda Tjemsland
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Albuquerque, New Mexico
| | - David Espey
- Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Albuquerque, New Mexico
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17
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Butterly LF. Proven Strategies for Increasing Adherence to Colorectal Cancer Screening. Gastrointest Endosc Clin N Am 2020; 30:377-392. [PMID: 32439077 DOI: 10.1016/j.giec.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.
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Affiliation(s)
- Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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18
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Temucin E, Nahcivan NO. The Effects of the Nurse Navigation Program in Promoting Colorectal Cancer Screening Behaviors: a Randomized Controlled Trial. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:112-124. [PMID: 30470978 DOI: 10.1007/s13187-018-1448-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although screening programs are known and recommended for the early detection of colorectal cancer (CRC), the screening rates for the fecal occult blood test (FOBT) and colonoscopy are very low among adult individuals. Navigation programs, also known as individualized counseling, have recently begun to be used for increasing screening rates. The purpose of this study was to compare the efficacy of the Nurse Navigation Program versus usual care on CRC screening participation and movement in stage of adoption for CRC screening and to examine perceived benefits of and barriers to CRC screening. This study was designed in line with a pre- and posttest two-group methodology. A total of 110 participants (55 nurse-navigated and 55 non-navigated patients) were studied. Data were collected using the following three tools: a sociodemographic information form, the Harvard Colorectal Cancer Risk Assessment Tool, and Instruments to Measure Colorectal Cancer Screening Benefits and Barriers. Following the Nurse Navigation Program, the FOBT (82 and 84%, respectively) and colonoscopy completion rates (15 and 22%, respectively) were significantly higher in the nurse-navigated group than in the non-navigated group at 3 and 6 months follow-up. Following the program, the benefit perceptions of the nurse-navigated group about CRC screening were improved, and their barrier perceptions were reduced. The results showed that the Nurse Navigation Program had significant effects on CRC screening behavior and health-related beliefs concerning CRC screening. Further assessment of the Nurse Navigation Program in different groups should be performed to observe its effects.
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Affiliation(s)
- Elif Temucin
- Nursing Faculty, Oncology Nursing Department, University of Health Sciences, Istanbul, Turkey.
| | - Nursen O Nahcivan
- Florence Nightingale Nursing Faculty, Public Health Nursing Department, Istanbul University, Istanbul, Turkey
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19
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Schein YL, Winje BA, Myhre SL, Nordstoga I, Straiton ML. A qualitative study of health experiences of Ethiopian asylum seekers in Norway. BMC Health Serv Res 2019; 19:958. [PMID: 31829251 PMCID: PMC6907115 DOI: 10.1186/s12913-019-4813-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Norway, like other European countries, has a growing refugee population. Upon arrival to Norway, refugees and asylum seekers need to learn about Norwegian society and social services such as healthcare. Despite various programs and assistance, they face numerous challenges using the healthcare system. Understanding the healthcare experiences of Ethiopian refugees and asylum seekers may improve how services such as informational sessions and delivery of medical care are provided. This qualitative study seeks to describe the health-related experiences of Ethiopians who have sought asylum in Norway and shed light on potential barriers to care. METHODS Individual interviews were conducted with ten Ethiopian refugees and asylum seekers in Norway. Thematic analysis was used to understand the broader context of refugee resettlement and how this experience influences participants' health experiences and health seeking behaviors. RESULTS We identified three main themes that played a role in participants' health and healthcare experiences. Participants described how 'living in limbo' during their application for residency took a mental toll, the difficulties they had 'using the healthcare system', and the role 'interpersonal factors' had on their experiences. While applying for asylum, participants felt consumed by the process and were affected by the lack of structure in their lives, the conditions in the reception center, and perceived inadequate healthcare. Participants perceived a change in access to services before and after they had been granted residency. Participants learned about the healthcare system both through official information sessions and social networks. Doctor-patient communication and interpersonal factors such as a sense of feeling valued, language, and discrimination had a large impact on perceived quality of care. CONCLUSIONS Ethiopian refugees and asylum seekers face numerous challenges accessing, using, and interacting with Norway's healthcare system. Contextualizing these challenges within the asylum seeking process may help policy makers better understand, and therefore address, these challenges. Interventions offered at reception centers and in health worker trainings may improve healthcare experiences for this and similar populations.
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Affiliation(s)
- Yvette Louise Schein
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Brita Askeland Winje
- Department of Vaccine Preventable Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Sonja Lynn Myhre
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
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20
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DeGroff A, Gressard L, Glover-Kudon R, Rice K, Tharpe FS, Escoffery C, Gersten J, Butterly L. Assessing the implementation of a patient navigation intervention for colonoscopy screening. BMC Health Serv Res 2019; 19:803. [PMID: 31694642 PMCID: PMC6833190 DOI: 10.1186/s12913-019-4601-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/04/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A recent study demonstrated the effectiveness of the New Hampshire Colorectal Cancer Screening Program's (NHCRCSP) patient navigation (PN) program. The PN intervention was delivered by telephone with navigators following a rigorous, six-topic protocol to support low-income patients to complete colonoscopy screening. We applied the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to examine implementation processes and consider potential scalability of this intervention. METHODS A mixed-methods evaluation study was conducted including 1) a quasi-experimental, retrospective, comparison group study examining program effectiveness, 2) secondary analysis of NHCRCSP program data, and 3) a case study. Data for all navigated patients scheduled and notified of their colonoscopy test date between July 1, 2012 and September 30, 2013 (N = 443) were analyzed. Researchers were provided in-depth call details for 50 patients randomly selected from the group of 443. The case study included review of program documents, observations of navigators, and interviews with 27 individuals including staff, patients, and other stakeholders. RESULTS Program reach was state-wide, with navigators serving patients from across the state. The program successfully recruited patients from the intended priority population who met the established age, income, and insurance eligibility guidelines. Analysis of the 443 NHCRCSP patients navigated during the study period demonstrated effectiveness with 97.3% completing colonoscopy, zero missed appointments (no-shows), and 0.7% late cancellations. Trained and supervised nurse navigators spent an average of 124.3 min delivering the six-topic PN protocol to patients. Navigators benefited from a real-time data system that allowed for patient tracking, communication across team members, and documentation of service delivery. Evaluators identified several factors supporting program maintenance including consistent funding support from CDC, a strong program infrastructure, and partnerships. CONCLUSIONS Factors supporting implementation included funding for colonoscopies, use of registered nurses, a clinical champion, strong partnerships with primary care and endoscopy sites, fidelity to the PN protocol, significant intervention dose, and a real-time data system. Further study is needed to assess scalability to other locations.
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Affiliation(s)
- Amy DeGroff
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | | | - Rebecca Glover-Kudon
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Ketra Rice
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Felicia Solomon Tharpe
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Cam Escoffery
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
- Department of Behavioral Sciences and Health Education Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, 5th Floor, Atlanta, GA 30322 USA
| | - Joanne Gersten
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, NH USA
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 USA
| | - Lynn Butterly
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, NH USA
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
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21
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Arnold CL, Rademaker AW, Morris JD, Ferguson LA, Wiltz G, Davis TC. Follow-up approaches to a health literacy intervention to increase colorectal cancer screening in rural community clinics: A randomized controlled trial. Cancer 2019; 125:3615-3622. [PMID: 31355924 DOI: 10.1002/cncr.32398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/28/2019] [Accepted: 04/05/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Significant disparities exist in colorectal cancer (CRC) screening rates among those of low socioeconomic status, with fewer years of education, lacking health insurance, or living in rural areas. METHODS A randomized controlled trial was conducted to compare the effectiveness of 2 follow-up approaches to a health literacy intervention to improve CRC screening: automated telephone call or personal call. Patients aged 50 to 75 years residing in 4 rural community clinics in Louisiana were given a structured interview that assessed demographic, health literacy and CRC screening barriers, knowledge, and attitudes. All were given health literacy-informed CRC education, a patient-friendly CRC screening pamphlet, simplified fecal immunochemical test (FIT) instructions, and a FIT kit, and a "teach-back" method was used to confirm understanding. Patients were randomized to 1 of 2 telephone follow-up arms. If they did not mail their FIT kit within 4 weeks, they received a reminder call and were called again at 8 weeks if the test still was not received. RESULTS A total of 620 patients were enrolled. Approximately 55% were female, 66% were African American, and 40% had limited literacy. The overall FIT completion rate was 68%: 69.2% in the automated telephone call arm and 67% in the personal call arm. Greater than one-half of the patients (range, 58%-60%) returned the FIT kit without receiving a telephone call. There was no difference noted with regard to the effectiveness of the follow-up calls; each increased the return rate by 9%. CONCLUSIONS Providing FIT kits and literacy-appropriate education at regularly scheduled clinic visits with a follow-up telephone call when needed was found to increase CRC screening among low-income, rural patients. The lower cost automated call was just as effective as the personal call.
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Affiliation(s)
- Connie L Arnold
- Department of Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana
| | - Alfred W Rademaker
- Department of Preventive Medicine, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - James D Morris
- Department of Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana
| | - Laurie Anne Ferguson
- College of Nursing and Health, Loyola University New Orleans, New Orleans, Louisiana
| | - Gary Wiltz
- Teche Action Clinic, Franklin, Louisiana
| | - Terry C Davis
- Department of Medicine, Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana
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22
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Davis TC, Rademaker A, Morris J, Ferguson LA, Wiltz G, Arnold CL. Repeat Annual Colorectal Cancer Screening in Rural Community Clinics: A Randomized Clinical Trial to Evaluate Outreach Strategies to Sustain Screening. J Rural Health 2019; 36:307-315. [PMID: 31523848 DOI: 10.1111/jrh.12399] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/17/2019] [Accepted: 08/19/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The majority of colorectal cancer (CRC) research using the fecal immunochemical test (FIT) has studied short-term screening results in predominantly urban areas. The purpose of this study was to evaluate the effectiveness of 2 outreach strategies embedded in a health literacy intervention on repeat CRC screening in rural community clinics. METHODS A 2-arm randomized controlled trial was conducted in 4 rural clinics in Louisiana. During a regularly scheduled clinic visit, participants ages 50-75 received a FIT kit and brief educational intervention. Participants were randomized to receive an automated call or a personal call by a prevention counselor after 4 weeks and 8 weeks if FIT kits were not returned. In year 2, materials were mailed, and follow-up calls were conducted as in year 1. The primary outcome was repeat FIT-the return of the FIT kit in both years. PARTICIPANTS Of 568 eligible participants, 55% were female, 67% were African American, and 39% had low health literacy. FINDINGS Repeat FIT rates were 36.5% for those receiving the automated call and 33.6% for those receiving a personal call (P = .30). No annual FITs were returned in 30% of participants, while only 1 FIT was returned by 35% of participants (31% only year 1 and 4% only year 2). CONCLUSION Sustaining CRC screening with FIT is challenging in rural clinics. A lower cost automated call was just as effective as the personal call in promoting repeat annual screening. However, more intensive strategies are needed to improve long-term FIT screening among rural participants.
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Affiliation(s)
- Terry C Davis
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Alfred Rademaker
- Department of Preventive Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - James Morris
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Gary Wiltz
- Teche Action Clinic, Franklin, Louisiana
| | - Connie L Arnold
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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23
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Myers RE, Stello B, Daskalakis C, Sifri R, González ET, DiCarlo M, Johnson MB, Hegarty SE, Shaak K, Rivera A, Gordils-Molina L, Petrich A, Careyva B, de-Ortiz R, Diaz L. Decision Support and Navigation to Increase Colorectal Cancer Screening Among Hispanic Patients. Cancer Epidemiol Biomarkers Prev 2018; 28:384-391. [PMID: 30333221 DOI: 10.1158/1055-9965.epi-18-0260] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/22/2018] [Accepted: 10/09/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Effective strategies are needed to raise colorectal cancer screening rates among Hispanics. METHODS We surveyed and randomized 400 Hispanic primary care patients either to a Decision Support and Navigation Intervention (DSNI) Group (n = 197) or a Standard Intervention (SI) Group (n = 203). Both groups received a colorectal cancer screening kit [bilingual informational booklet, fecal immunochemical stool blood test (SBT), and colonoscopy screening instructions]. The DSNI Group received a telephone contact from a patient navigator. The navigator clarified screening test preference and likelihood of test performance, helped to develop a screening plan, and provided guidance through test performance. An endpoint telephone survey and medical chart review were completed. Multivariable analyses were conducted to assess 12-month screening adherence, change in decision stage, and knowledge and perceptions. RESULTS Screening adherence was significantly higher in the DSNI Group than the SI Group [OR, 4.8; 95% confidence interval (CI), 3.1-7.6]. The DSNI Group, compared with the SI Group, also displayed higher SBT screening [OR, 4.2; 95% CI, 2.6-6.7), higher colonoscopy screening (OR, 8.8; 95% CI, 4.1-18.7), and greater forward change in screening decision stage (OR, 4.9; 95% CI, 2.6-9.5). At endpoint, study groups did not differ in screening knowledge or perceptions. CONCLUSIONS The DSNI had a greater positive impact on colorectal cancer screening outcomes than the SI. IMPACT Health system implementation of DSNI strategies may help to reduce Hispanic colorectal cancer screening disparities in primary care.
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Affiliation(s)
- Ronald E Myers
- Division of Population Science, Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Brian Stello
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Constantine Daskalakis
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Randa Sifri
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Melissa DiCarlo
- Division of Population Science, Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Sarah E Hegarty
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kyle Shaak
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Alicia Rivera
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | - Anett Petrich
- Division of Population Science, Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Beth Careyva
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | | | - Liselly Diaz
- Lehigh Valley Health Network, Allentown, Pennsylvania
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Wolf AMD, Fontham ETH, Church TR, Flowers CR, Guerra CE, LaMonte SJ, Etzioni R, McKenna MT, Oeffinger KC, Shih YCT, Walter LC, Andrews KS, Brawley OW, Brooks D, Fedewa SA, Manassaram-Baptiste D, Siegel RL, Wender RC, Smith RA. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018; 68:250-281. [PMID: 29846947 DOI: 10.3322/caac.21457] [Citation(s) in RCA: 1166] [Impact Index Per Article: 194.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022] Open
Abstract
In the United States, colorectal cancer (CRC) is the fourth most common cancer diagnosed among adults and the second leading cause of death from cancer. For this guideline update, the American Cancer Society (ACS) used an existing systematic evidence review of the CRC screening literature and microsimulation modeling analyses, including a new evaluation of the age to begin screening by race and sex and additional modeling that incorporates changes in US CRC incidence. Screening with any one of multiple options is associated with a significant reduction in CRC incidence through the detection and removal of adenomatous polyps and other precancerous lesions and with a reduction in mortality through incidence reduction and early detection of CRC. Results from modeling analyses identified efficient and model-recommendable strategies that started screening at age 45 years. The ACS Guideline Development Group applied the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in developing and rating the recommendations. The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) examination, depending on patient preference and test availability. As a part of the screening process, all positive results on noncolonoscopy screening tests should be followed up with timely colonoscopy. The recommendation to begin screening at age 45 years is a qualified recommendation. The recommendation for regular screening in adults aged 50 years and older is a strong recommendation. The ACS recommends (qualified recommendations) that: 1) average-risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. The options for CRC screening are: fecal immunochemical test annually; high-sensitivity, guaiac-based fecal occult blood test annually; multitarget stool DNA test every 3 years; colonoscopy every 10 years; computed tomography colonography every 5 years; and flexible sigmoidoscopy every 5 years. CA Cancer J Clin 2018;68:250-281. © 2018 American Cancer Society.
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Affiliation(s)
- Andrew M D Wolf
- Associate Professor and Attending Physician, University of Virginia School of Medicine, Charlottesville, VA
| | - Elizabeth T H Fontham
- Emeritus Professor, Louisiana State University School of Public Health, New Orleans, LA
| | - Timothy R Church
- Professor, University of Minnesota and Masonic Cancer Center, Minneapolis, MN
| | - Christopher R Flowers
- Professor and Attending Physician, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA
| | - Carmen E Guerra
- Associate Professor of Medicine of the Perelman School of Medicine and Attending Physician, University of Pennsylvania Medical Center, Philadelphia, PA
| | - Samuel J LaMonte
- Independent retired physician and patient advocate, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ruth Etzioni
- Biostatistician, University of Washington and the Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matthew T McKenna
- Professor and Director, Division of Preventive Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kevin C Oeffinger
- Professor and Director of the Duke Center for Onco-Primary Care, Durham, NC
| | - Ya-Chen Tina Shih
- Professor, Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Louise C Walter
- Professor and Attending Physician, University of California, San Francisco and San Francisco VA Medical Center, San Francisco, CA
| | - Kimberly S Andrews
- Director, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Otis W Brawley
- Chief Medical and Scientific Officer and Executive Vice President-Research, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Strategic Director for Risk Factor Screening and Surveillance, American Cancer Society, Atlanta, GA
| | | | - Rebecca L Siegel
- Strategic Director, Surveillance Information Services, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
| | - Robert A Smith
- Vice President, Cancer Screening, Cancer Control Department, American Cancer Society, Atlanta, GA
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25
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Salimzadeh H, Khabiri R, Khazaee-Pool M, Salimzadeh S, Delavari A. Motivational interviewing and screening colonoscopy in high-risk individuals. A randomized controlled trial. PATIENT EDUCATION AND COUNSELING 2018; 101:1082-1087. [PMID: 29402572 DOI: 10.1016/j.pec.2018.01.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/12/2017] [Accepted: 01/22/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To measure the impact of motivational interviewing (MI) on cancer knowledge and screening practice among first degree relatives (FDRs) of patients with colon cancer. METHODS This randomized controlled trial targeted patients with colon cancer first to recruit their possible FDRs. Digit randomization of the eligible index patients into intervention or control groups resulted in allocating their belonging FDRs to the same study arm. FDRs (n = 120) in intervention arm received MI counseling on phone by a trained oncology nurse and FDRs (n = 120) in control group received standard generic information by a physician on phone. Primary outcome was the rate of documented colonoscopy in FDRs within six months after the baseline. RESULTS A total of 227 FDRs were followed up, 115 in the intervention and 112 in the control group. At follow-up, the uptake of screening colonoscopy in the intervention group was 83.5% versus 48.2% in controls (crude odds ratio, 5.4; 95% confidence interval, 2.9-10.0, P < .001). CONCLUSION This was the first randomized controlled trial in Iran that confirmed the efficaciousness of a phone-based MI counseling in improving colonoscopy uptake among family members of patients with colon cancer. PRACTICE IMPLICATIONS Phone-based motivational counseling that involves trained nurses or health providers seems to be feasible approach in Iran health system and enhances screening for colon cancer.
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Affiliation(s)
- Hamideh Salimzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Roghaye Khabiri
- Tabriz Health Service Management Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Maryam Khazaee-Pool
- Department of Health Education and Promotion, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Somayeh Salimzadeh
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Delavari
- Digestive Oncology Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Ajeesh S, Luis R. A Comprehensive Electronic Health Record Based Patient Navigation Module Including Technology Driven Colorectal Cancer Outreach and Education. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2018; 33:627-633. [PMID: 28188568 DOI: 10.1007/s13187-017-1184-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this concept paper is to propose an innovative multifaceted patient navigation module embedded in the Electronic Health Record (EHR) to address barriers to efficient and effective colorectal cancer (CRC) care. The EHR-based CRC patient navigation module will include several patient navigation features: (1) CRC screening registry; (2) patient navigation data, including CRC screening data, outcomes of patient navigation including navigation status (CRC screening referrals, fecal occult blood test (FOBT) completed, colonoscopy scheduled and completed, cancelations, reschedules, and no-shows); (3) CRC counseling aid; and 4) Web-based CRC education application including interactive features such as a standardized colonoscopy preparation guide, modifiable CRC risk factors, and links to existing resources. An essential component of health informatics is the use of EHR systems to not only provide a system for storing and retrieval of patient health data but can also be used to enhance patient decision-making both from a provider and patient perspective.
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Affiliation(s)
- Sunny Ajeesh
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Rustveld Luis
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
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27
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Zolfaghari Z, Rezaee N, Shakiba M, Navidian A. Motivational interviewing-based training vs traditional training on the uptake of cervical screening: a quasi-experimental study. Public Health 2018; 160:94-99. [PMID: 29800792 DOI: 10.1016/j.puhe.2018.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/16/2018] [Accepted: 04/13/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVES Cervical cancer, a major health issue affecting women, is preventable and can be successfully treated. It is essential that measures are taken to improve the uptake of screening for this cancer. The aim of this study was to compare the effects of motivational interviewing (MI)-based training and traditional training on the frequency of cervical cancer screening tests in a group of working female teachers. STUDY DESIGN This is a quasi-experimental study. METHODS This research was conducted in 2017 among 134 teachers (aged 30-60 years) working in southeastern Iran. The participants were selected from among the eligible individuals and subsequently divided into MI-based training and traditional training groups (n = 67 for each group). Each group received a three-session training program, and 20 weeks after the end of the last training session, the information obtained from cervical cancer screening tests was documented. To analyze the data, independent t-test and Chi-squared test were run in SPSS, version 21. RESULTS There was no significant difference between the two groups in terms of demographic characteristics such as age, age at the first pregnancy, age of marriage, the number of parities, and educational level. Twenty weeks after intervention, 20.9% of the MI-based training group underwent Pap smear screening test, while 9% of the women in the traditional training group took the test, indicating a statistically significant difference between the two groups (P < 0.0.5). CONCLUSION MI-based training has a significant positive effect on women's compliance with cervical cancer screening tests. Therefore, it is recommended that this technique be adopted in women's health centers. TRIAL REGISTRATION NUMBER IRCT2017100729954N4.
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Affiliation(s)
- Z Zolfaghari
- Department of Nursing, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - N Rezaee
- Department of Nursing, Community Nursing Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - M Shakiba
- Department of Psychiatry, Zahedan University of Medical Sciences, Zahedan, Iran.
| | - A Navidian
- Pregnancy Health Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
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Calanzani N, Cavers D, Vojt G, Orbell S, Steele RJC, Brownlee L, Smith S, Patnick J, Weller D, Campbell C. Is an opportunistic primary care-based intervention for non-responders to bowel screening feasible and acceptable? A mixed-methods feasibility study in Scotland. BMJ Open 2017; 7:e016307. [PMID: 29025829 PMCID: PMC5652541 DOI: 10.1136/bmjopen-2017-016307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES We aimed to test whether a brief, opportunistic intervention in general practice was a feasible and acceptable way to engage with bowel screening non-responders. DESIGN This was a feasibility study testing an intervention which comprised a brief conversation during routine consultation, provision of a patient leaflet and instructions to request a replacement faecal occult blood test kit. A mixed-methods approach to evaluation was adopted. Data were collected from proformas completed after each intervention, from the Bowel Screening Centre database and from questionnaires. Semi-structured interviews were carried out. We used descriptive statistics, content and framework analysis to determine intervention feasibility and acceptability. PARTICIPANTS Bowel screening non-responders (as defined by the Scottish Bowel Screening Centre) and primary care professionals working in five general practices in Lothian, Scotland. PRIMARY AND SECONDARY OUTCOME MEASURES Several predefined feasibility parameters were assessed, including numbers of patients engaging in conversation, requesting a replacement kit and returning it, and willingness of primary care professionals to deliver the intervention. RESULTS The intervention was offered to 258 patients in five general practices: 220 (87.0%) engaged with the intervention, 60 (23.3%) requested a new kit, 22 (8.5%) kits were completed and returned. Interviews and questionnaires suggest that the intervention was feasible, acceptable and consistent with an existing health prevention agenda. Reported challenges referred to work-related pressures, time constraints and practice priorities. CONCLUSIONS This intervention was acceptable and resulted in a modest increase in non-responders participating in bowel screening, although outlined challenges may affect sustained implementation. The strategy is also aligned with the increasing role of primary care in promoting bowel screening.
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Affiliation(s)
- Natalia Calanzani
- The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, UK
| | - Debbie Cavers
- The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, UK
| | - Gabriele Vojt
- Department of Psychology, Glasgow Caledonian University, Glasgow, UK
| | - Sheina Orbell
- Department of Psychology, University of Essex, Colchester, Essex, UK
| | - Robert J C Steele
- Department of Surgery and Molecular Oncology, Ninewells Hospital, University of Dundee, Dundee, UK
| | | | - Steve Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Midlands and NW Bowel Cancer Screening Hub, Rugby, UK
| | | | - David Weller
- The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, UK
| | - Christine Campbell
- The Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, Medical School, University of Edinburgh, Edinburgh, UK
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29
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DeGroff A, Schroy PC, Morrissey KG, Slotman B, Rohan EA, Bethel J, Murillo J, Ren W, Niwa S, Leadbetter S, Joseph D. Patient Navigation for Colonoscopy Completion: Results of an RCT. Am J Prev Med 2017; 53:363-372. [PMID: 28676254 PMCID: PMC8855664 DOI: 10.1016/j.amepre.2017.05.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 04/11/2017] [Accepted: 05/11/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Colorectal cancer is a leading cause of cancer-related death in the U.S. Although screening reduces colorectal cancer incidence and mortality, screening rates among U.S. adults remain less than optimal, especially among disadvantaged populations. This study examined the efficacy of patient navigation to increase colonoscopy screening. STUDY DESIGN RCT. SETTING/PARTICIPANTS A total of 843 low-income adults, primarily Hispanic and non-Hispanic blacks, aged 50-75 years referred for colonoscopy at Boston Medical Center were randomized into the intervention (n=429) or control (n=427) groups. Participants were enrolled between September 2012 and December 2014, with analysis following through 2015. INTERVENTION Two bilingual lay navigators provided individualized education and support to reduce patient barriers and facilitate colonoscopy completion. The intervention was delivered largely by telephone. MAIN OUTCOME MEASURE Colonoscopy completion within 6 months of study enrollment. RESULTS Colonoscopy completion was significantly higher for navigated patients (61.1%) than control group patients receiving usual care (53.2%, p=0.021). Based on regression analysis, the odds of completing a colonoscopy for navigated patients was one and a half times greater than for controls (95% CI=1.12, 2.03, p=0.007). There were no differences between navigated and control groups in regard to adequacy of bowel preparation (95.3% vs 97.3%, respectively). CONCLUSIONS Navigation significantly improved colonoscopy screening completion among a racially diverse, low-income population. Results contribute to mounting evidence demonstrating the efficacy of patient navigation in increasing colorectal cancer screening. Screening can be further enhanced when navigation is combined with other evidence-based practices implemented in healthcare systems and the community.
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Affiliation(s)
- Amy DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Paul C Schroy
- Boston Medical Center, Gastroenterology, Boston, Massachusetts
| | | | | | - Elizabeth A Rohan
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | | | - Steven Leadbetter
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Djenaba Joseph
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Gerber DE, Hamann HA, Santini NO, Abbara S, Chiu H, McGuire M, Quirk L, Zhu H, Lee SJC. Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial. Contemp Clin Trials 2017; 60:78-85. [PMID: 28689056 PMCID: PMC7066861 DOI: 10.1016/j.cct.2017.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/26/2017] [Accepted: 07/03/2017] [Indexed: 01/22/2023]
Abstract
The National Lung Screening Trial demonstrated improved lung cancer mortality with annual low-dose computed tomography (CT) screening, leading to lung cancer screening endorsement by the United States Preventive Services Task Force and coverage by the Centers for Medicare and Medicaid. Adherence to annual CT screens in that trial was 95%, which may not be representative of real-world, particularly medically underserved populations. This pragmatic trial will determine the effect of patient-focused, telephone-based patient navigation on adherence to CT-based lung cancer screening in an urban safety-net population. 340 adults who meet standard eligibility for lung cancer screening (age 55-77years, smoking history≥30 pack-years, quit within 15years if former smoker) are referred through an electronic medical record-based order by physicians in community- and hospital-based primary care settings within the Parkland Health and Hospital System in Dallas County, Texas. Eligible patients are randomized to usual care or patient navigation, which addresses adherence, patient-reported barriers, smoking cessation, and psycho-social concerns related to screening completion. Patients complete surveys and semi-structured interviews at baseline, 6-month, and 18-month follow-ups to assess attitudes toward screening. The primary endpoint of this pragmatic trial is adherence to three sequential, prospectively defined steps in the screening protocol. Secondary endpoints include self-reported tobacco use and other patient-reported outcomes. Results will provide real-world insight into the impact of patient navigation on adherence to CT-based lung cancer screening in a medically underserved population. This study was registered with the NIH ClinicalTrials.gov database (NCT02758054) on April 26, 2016.
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Affiliation(s)
- David E Gerber
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Medical Oncology Clinic, Parkland Health and Hospital System, Dallas, TX, USA; Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Heidi A Hamann
- Departments of Psychology and Family and Community Medicine, University of Arizona, Tucson, AZ, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Noel O Santini
- Ambulatory Services, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Suhny Abbara
- Departments of Radiology, UT Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Hsienchang Chiu
- Division of Pulmonary Medicine, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA; Lung Diagnostics Clinic, Parkland Health and Hospital System, Dallas, TX, USA.
| | - Molly McGuire
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Lisa Quirk
- Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Hong Zhu
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Simon J Craddock Lee
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA; Department of Clinical Sciences, UT Southwestern Medical Center, Dallas, TX, USA.
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Reuland DS, Brenner AT, Hoffman R, McWilliams A, Rhyne RL, Getrich C, Tapp H, Weaver MA, Callan D, Cubillos L, Urquieta de Hernandez B, Pignone MP. Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population: A Randomized Clinical Trial. JAMA Intern Med 2017; 177:967-974. [PMID: 28505217 PMCID: PMC5710456 DOI: 10.1001/jamainternmed.2017.1294] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Colorectal cancer (CRC) screening is underused, especially among vulnerable populations. Decision aids and patient navigation are potentially complementary interventions for improving CRC screening rates, but their combined effect on screening completion is unknown. OBJECTIVE To determine the combined effect of a CRC screening decision aid and patient navigation compared with usual care on CRC screening completion. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial, data were collected from January 2014 to March 2016 at 2 community health center practices, 1 in North Carolina and 1 in New Mexico, serving vulnerable populations. Patients ages 50 to 75 years who had average CRC risk, spoke English or Spanish, were not current with recommended CRC screening, and were attending primary care visits were recruited and randomized 1:1 to intervention or control arms. INTERVENTIONS Intervention participants viewed a CRC screening decision aid in English or Spanish immediately before their clinician encounter. The decision aid promoted screening and presented colonoscopy and fecal occult blood testing as screening options. After the clinician encounter, intervention patients received support for screening completion from a bilingual patient navigator. Control participants viewed a food safety video before the encounter and otherwise received usual care. MAIN OUTCOMES AND MEASURES The primary outcome was CRC screening completion within 6 months of the index study visit assessed by blinded medical record review. RESULTS Characteristics of the 265 participants were as follows: their mean age was 58 years; 173 (65%) were female, 164 (62%) were Latino; 40 (15%) were white non-Latino; 61 (23%) were black or of mixed race; 191 (78%) had a household income of less than $20 000; 101 (38%) had low literacy; 75 (28%) were on Medicaid; and 91 (34%) were uninsured. Intervention participants were more likely to complete CRC screening within 6 months (68% vs 27%); adjusted-difference, 40 percentage points (95% CI, 29-51 percentage points). The intervention was more effective in women than in men (50 vs 21 percentage point increase, interaction P = .02). No effect modification was observed across other subgroups. CONCLUSIONS AND RELEVANCE A patient decision aid plus patient navigation increased the rate of CRC screening completion in compared with usual care invulnerable primary care patients. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02054598.
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Affiliation(s)
- Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Alison T Brenner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Richard Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City5University of Iowa Holden Comprehensive Cancer Center, University of Iowa, Iowa City6Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Andrew McWilliams
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, North Carolina
| | - Robert L Rhyne
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque8University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Christina Getrich
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque9Department of Anthropology, University of Maryland, College Park
| | - Hazel Tapp
- Department of Family Medicine, Carolinas HealthCare System, Charlotte, North Carolina
| | - Mark A Weaver
- Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill10Department of Biostatistics, University of North Carolina, Chapel Hill
| | - Danelle Callan
- University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Laura Cubillos
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill
| | | | - Michael P Pignone
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill2Division of General Medicine & Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill3Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill11Department of Internal Medicine, University of Texas Dell Medical School, Austin
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Abstract
Colorectal cancer (CRC) contributes a major burden of cancer mortality in the United States. There are multiple effective screening approaches that can reduce CRC mortality. These approaches are supported by different levels of evidence, and each has its own advantages and disadvantages. Implementing a systematic approach to screening that addresses the multiple steps involved in the screening process is essential to improving population-level CRC screening. Offering patients stool-based screening is important for increasing screening uptake. However, programs that offer stool testing must support the population health infrastructure needed to promote adherence to repeat testing and follow-up of abnormal tests.
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Affiliation(s)
- Alison T Brenner
- Cecil G Sheps Center for Health Services Research, University of North Carolina, 725 Martin Luther King Jr Boulevard, CB# 7590, Chapel Hill, NC 27599-7590, USA.
| | - Michael Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, 4182 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27599-6134, USA
| | - Daniel S Reuland
- Division of General Internal Medicine, Department of Medicine, University of North Carolina, 725 Martin Luther King Jr Boulevard, CB# 7590, Chapel Hill, NC 27599-7590, USA
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Rice K, Gressard L, DeGroff A, Gersten J, Robie J, Leadbetter S, Glover-Kudon R, Butterly L. Increasing colonoscopy screening in disparate populations: Results from an evaluation of patient navigation in the New Hampshire Colorectal Cancer Screening Program. Cancer 2017; 123:3356-3366. [PMID: 28464213 DOI: 10.1002/cncr.30761] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 04/05/2017] [Accepted: 04/12/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND To investigate uniformly successful results from a statewide program of patient navigation (PN) for colonoscopy, this comparison study evaluated the effectiveness of the PN intervention by comparing outcomes for navigated versus non-navigated patients in one of the community health clinics included in the statewide program. Outcomes measured included screening completion, adequacy of bowel preparation, missed appointments and cancellations, communication of test results, and consistency of follow-up recommendations with clinical guidelines. METHODS The authors compared a subset of 131 patients who were navigated to a screening or surveillance colonoscopy with a similar subset of 75 non-navigated patients at one endoscopy clinic. The prevalence and prevalence odds ratios were computed to measure the association between PN and each study outcome measure. RESULTS Patients in the PN intervention group were 11.2 times more likely to complete colonoscopy than control patients (96.2% vs 69.3%; P<.001), and were 5.9 times more likely to have adequate bowel preparation (P =.010). In addition, intervention patients had no missed appointments compared with 15.6% of control patients, and were 24.8 times more likely to not have a cancellation <24 hours before their appointment (P<.001). All navigated patients and their primary care providers received test results, and all follow-up recommendations were consistent with clinical guidelines compared with 82.4% of patients in the control group (P<.001). CONCLUSIONS PN appears to be effective for improving colonoscopy screening completion and quality in the disparate populations most in need of intervention. To the best of our knowledge, the results of the current study demonstrate some of the strongest evidence for the effectiveness of PN to date, and highlight its value for public health. Cancer 2017;123:3356-66. © 2017 American Cancer Society.
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Affiliation(s)
- Ketra Rice
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lindsay Gressard
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joanne Gersten
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire
| | - Janene Robie
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire
| | - Steven Leadbetter
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rebecca Glover-Kudon
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lynn Butterly
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire.,Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Roland KB, Milliken EL, Rohan EA, DeGroff A, White S, Melillo S, Rorie WE, Signes CAC, Young PA. Use of Community Health Workers and Patient Navigators to Improve Cancer Outcomes Among Patients Served by Federally Qualified Health Centers: A Systematic Literature Review. Health Equity 2017; 1:61-76. [PMID: 28905047 PMCID: PMC5586005 DOI: 10.1089/heq.2017.0001] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation. Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013. Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members. Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.
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Affiliation(s)
- Katherine B Roland
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Elizabeth A Rohan
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan White
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stephanie Melillo
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Weyl H, Yackzan S, Ross K, Henson A, Moe K, Lewis CP. Understanding colorectal screening behaviors and factors associated with screening in a community hospital setting. Clin J Oncol Nurs 2016; 19:89-93. [PMID: 25689654 DOI: 10.1188/15.cjon.89-93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death in the United States. More than 2,000 Kentuckians are diagnosed with CRC annually, and more than 800 die from the disease. Little research has been conducted in Kentucky to better understand why individuals are not screened for CRC and what strategies might encourage them to do so. OBJECTIVES The purpose of this study was to evaluate the efficacy of educational materials mailed to participants supporting the need for CRC screening on the decision to complete screening post-hospital discharge. An additional focus was to identify the characteristics of individuals screened and not screened. METHODS A quasi-experimental study was conducted on 167 adult patients discharged from a 383-bed Magnet-designated hospital. An investigator-designed, semistructured telephone interview was conducted to collect data on research-based factors identified to influence CRC screening rates. FINDINGS Although not statistically significant, slightly more patients who remembered receiving educational materials in the mail completed screening. Future educational efforts should focus on the importance of screening and financial resource availability.
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Patient Navigation in a Colorectal Cancer Screening Program. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2016; 21:433-40. [PMID: 25140407 DOI: 10.1097/phh.0000000000000132] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT Colorectal cancer (CRC) is the second leading cause of cancer death among cancers affecting both men and women in the United States. The Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) supports both direct clinical screening services (screening provision) and activities to promote screening at the population level (screening promotion). OBJECTIVE The purpose of this study was to characterize patient navigation (PN) programs for screening provision and promotion for the first 1 to 2 years of program funding. PARTICIPANTS We conducted a cross-sectional survey of the 29 CRCCP grantees (25 states and 4 tribal organizations) and 14 in-depth interviews to assess program implementation. MAIN OUTCOME MEASURES The survey and interview guide collected information on CRC screening provision and promotion activities and PN, including the structure of the PN program, characteristics of the navigators, funding mechanism, and navigators' activities. RESULTS Twenty-four of 28 CRCCP grantees of the survey used PN for screening provision whereas 18 grantees used navigation for screening promotion. Navigators were often trained in nursing or public health. Navigation activities were similar for both screening provision and promotion, and common tasks included assessing and responding to patient barriers to screening, providing patient education, and scheduling appointments. For screening provision, activities centered on making reminder calls, educating patients on bowel preparation for colonoscopies, and tracking patients for completion of the tests. Navigation may influence screening quality by improving patients' bowel preparation for colonoscopies. CONCLUSIONS Our study provides insights into PN across a federally funded CRC program. Results suggest that PN activities may be instrumental in recruiting people into cancer screening and ensuring completed screening and follow-up.
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Buscemi J, Miguel YS, Tussing-Humphreys L, Watts EA, Fitzgibbon ML, Watson K, Winn RA, Matthews KL, Molina Y. Rationale and design of Mi-CARE: The mile square colorectal cancer screening, awareness and referral and education project. Contemp Clin Trials 2016; 52:75-79. [PMID: 27888090 DOI: 10.1016/j.cct.2016.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 12/14/2022]
Abstract
Although colorectal cancer (CRC) is largely preventable through identification of pre-cancerous polyps through various screening modalities, morbidity and mortality rates remain a challenge, especially in African-American, Latino, low-income and uninsured/underinsured patients. Barriers to screening include cost, access to health care facilities, lack of recommendation to screen, and psychosocial factors such as embarrassment, fear of the test, anxiety about testing preparation and fear of a cancer diagnosis. Various intervention approaches to improve CRC screening rates have been developed. However, comparative effectiveness research (CER) to investigate the relative performance of different approaches has been understudied, especially across different real-life practice settings. Assessment of differential efficacy across diverse vulnerable populations is also lacking. The current paper describes the rationale and design for the Mile Square Colorectal Cancer Screening, Awareness and Referral and Education Project (Mi-CARE), which aims to increase CRC screening rates in 3 clinics of a large Federally Qualified Health Center (FQHC) by reducing prominent barriers to screening for low-income, minority and underserved patients. Patients attending these clinics will receive one of three interventions to increase screening uptake: lay patient navigator (LPN)-based navigation, provider level navigation, or mailed birthday CRC screening reminders. The design of our program allows for comparison of the effectiveness of the tailored interventions across sites and patient populations. Data from Mi-CARE may help to inform the dissemination of tailored interventions across FQHCs to reduce health disparities in CRC.
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Affiliation(s)
| | - Yazmin San Miguel
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
| | | | - Elizabeth A Watts
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
| | - Marian L Fitzgibbon
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
| | - Karriem Watson
- University of Illinois Cancer Center, University of Illinois at Chicago, United States.
| | - Robert A Winn
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
| | - Kameron L Matthews
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
| | - Yamile Molina
- University of Illinois Cancer Center, University of Illinois at Chicago, United States
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Rohan EA, Slotman B, DeGroff A, Morrissey KG, Murillo J, Schroy P. Refining the Patient Navigation Role in a Colorectal Cancer Screening Program: Results From an Intervention Study. J Natl Compr Canc Netw 2016; 14:1371-1378. [PMID: 27799508 DOI: 10.6004/jnccn.2016.0147] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/13/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Oncology patient navigators help individuals overcome barriers to increase access to cancer screening, diagnosis, and timely treatment. This study, part of a randomized intervention trial investigating the efficacy of patient navigation in increasing colonoscopy completion, examined navigators' activities to ameliorate barriers to colonoscopy screening in a medically disadvantaged population. METHODS This study was conducted from 2012 through 2014 at Boston Medical Center. We analyzed navigator service delivery and survey data collected on 420 participants who were navigated for colonoscopy screening after randomization to this intervention. Key variables under investigation included barriers to colonoscopy, activities navigators undertook to reduce barriers, time navigators spent on each activity and per contact, and patient satisfaction with navigation services. Descriptive analysis assessed how navigators spent their time and examined what aspects of patient navigation were most valued by patients. RESULTS Navigators spent the most time assessing patient barriers/needs; facilitating appointment scheduling; reminding patients of appointments; educating patients about colorectal cancer, the importance of screening, and the colonoscopy preparation and procedures; and arranging transportation. Navigators spent an average of 44 minutes per patient. Patients valued the navigators, especially for providing emotional/peer support and explaining screening procedures and bowel preparation clearly. CONCLUSIONS Our findings help clarify the role of the navigator in colonoscopy screening within a medically disadvantaged community. These findings may help further refine the navigator role in cancer screening and treatment programs as facilities strive to effectively and efficiently integrate navigation into their services.
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Affiliation(s)
- Elizabeth A Rohan
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Beth Slotman
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Amy DeGroff
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Kerry Grace Morrissey
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Jennifer Murillo
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
| | - Paul Schroy
- From Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Westat, Rockville, Maryland; and Boston Medical Center, Department of Gastroenterology, Boston, Massachusetts
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Peitzmeier SM, Khullar K, Potter J. Effectiveness of four outreach modalities to patients overdue for cervical cancer screening in the primary care setting: a randomized trial. Cancer Causes Control 2016; 27:1081-91. [DOI: 10.1007/s10552-016-0786-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/11/2016] [Indexed: 11/29/2022]
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Maxwell AE, Danao LL, Cayetano RT, Crespi CM, Bastani R. Implementation of an evidence-based intervention to promote colorectal cancer screening in community organizations: a cluster randomized trial. Transl Behav Med 2016; 6:295-305. [PMID: 27282431 PMCID: PMC4927441 DOI: 10.1007/s13142-015-0349-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
UNLABELLED The implementation of evidence-based strategies to promote colorectal cancer (CRC) screening remains challenging. The aim of this study is to evaluate two strategies to implement an evidence-based intervention to promote CRC screening in Filipino American community organizations. Twenty-two community organizations were randomized to either a basic or enhanced implementation strategy. In both arms, community health advisors recruited participants non-adherent to CRC screening guidelines, conducted educational sessions, distributed print materials and free fecal occult blood test kits, reminded participants to get screened, and mailed letters to participants' providers. In the enhanced arm, leaders of the organizations participated in implementation efforts. While the effectiveness was similar in both arms of the study (screening rate at 6-month follow-up was 53 % in the enhanced arm, 49 % in the basic arm), 223 participants were screened in the enhanced arm versus 122 in the basic arm. The enhanced implementation strategy reached 83 % more participants and achieved a higher public health impact. TRIAL REGISTRATION NCT01351220 (ClinicalTrials.gov).
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Affiliation(s)
- Annette E Maxwell
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, CA, USA.
- , 650 Charles Young Dr. South, A2-125 CHS, Box 956900, Los Angeles, CA, 90095-6900, USA.
| | - Leda L Danao
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, CA, USA
| | - Reggie T Cayetano
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, CA, USA
| | - Catherine M Crespi
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, CA, USA
| | - Roshan Bastani
- Fielding School of Public Health and Jonsson Comprehensive Cancer Center, UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, CA, USA
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López-Torres Hidalgo J, Rabanales Sotos J, Simarro Herráez MJ, López-Torres López J, Campos Rosa M, López Verdejo MÁ. Effectiveness of three interventions to improve participation in colorectal cancer screening. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:315-22. [PMID: 27055722 DOI: 10.17235/reed.2016.4048/2015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Participation in colorectal cancer (CRC) screening varies widely among different countries and different socio-demographic groups. Our objective was to assess the effectiveness of three primary-care interventions to increase CRC screening participation among persons over the age of 50 years and to identify the health and socio-demographic-related factors that determine greater participation. METHODS We conducted a randomized experimental study with only one post-test control group. A total of 1,690 subjects were randomly distributed into four groups: written briefing; telephone briefing; an invitation to attend a group meeting; and no briefing. Subjects were evaluated 2 years post-intervention, with the outcome variable being participation in CRC screening. RESULTS A total of 1,129 subjects were interviewed. Within the groups, homogeneity was tested in terms of socio-demographic characteristics and health-related variables. The proportion of subjects who participated in screening was: 15.4% in the written information group (95% confidence interval [CI]: 11.2-19.7); 28.8% in the telephone information group (95% CI: 23.6-33.9); 8.1% in the face-to-face information group (95% CI: 4.5-11.7); and 5.9% in the control group (95% CI: 2.9-9.0), with this difference proving statistically significant (p < 0.001). Logistic regression showed that only interventions based on written or telephone briefing were effective. Apart from type of intervention, number of reported health problems and place of residence remained in the regression model. CONCLUSIONS Both written and telephone information can serve to improve participation in CRC screening. This preventive activity could be optimized by means of simple interventions coming within the scope of primary health-care professionals.
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Ustjanauskas AE, Bredice M, Nuhaily S, Kath L, Wells KJ. Training in Patient Navigation: A Review of the Research Literature. Health Promot Pract 2015; 17:373-81. [PMID: 26656600 DOI: 10.1177/1524839915616362] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the proliferation of patient navigation programs designed to increase timely receipt of health care, little is known about the content and delivery of patient navigation training, or best practices in this arena. The current study begins to address these gaps in understanding, as it is the first study to comprehensively review descriptions of patient navigation training in the peer-reviewed research literature. Seventy-five patient navigation efficacy studies published since 1995, identified through PubMed and by the authors, were included in this narrative review. Fifty-nine of the included studies (79%) mentioned patient navigation training, and 55 of these studies additionally provided a description of training. Most studies did not thoroughly document patient navigation training practices. Additionally, several topics integral to the role of patient navigators, as well as components of training central to successful adult learning, were not commonly described in the research literature. Descriptions of training also varied widely across studies in terms of duration, location, format, learning strategies employed, occupation of trainer, and content. These findings demonstrate the need for established standards of navigator training as well as for future research on the optimal delivery and content of patient navigation training.
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Affiliation(s)
- Amy E Ustjanauskas
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | | | | | - Lisa Kath
- San Diego State University, San Diego, CA, USA
| | - Kristen J Wells
- University of California, San Diego Moores Cancer Center, San Diego, CA, USA San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA San Diego State University, San Diego, CA, USA
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43
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Muliira JK, D'Souza MS. Effectiveness of patient navigator interventions on uptake of colorectal cancer screening in primary care settings. Jpn J Nurs Sci 2015; 13:205-19. [DOI: 10.1111/jjns.12102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 08/17/2015] [Indexed: 02/06/2023]
Affiliation(s)
- Joshua Kanaabi Muliira
- College of Nursing, Department of Adult Health and Critical Care; Sultan Qaboos University; Muscat Oman
| | - Melba Sheila D'Souza
- College of Nursing, Department of Adult Health and Critical Care; Sultan Qaboos University; Muscat Oman
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Canary H, Bullis C, Cummings J, Kinney AY. Structuring Health in Colorectal Cancer Screening Conversations: An Analysis of Intersecting Activity Systems. SOUTHERN COMMUNICATION JOURNAL 2015; 80:416-432. [PMID: 27182185 PMCID: PMC4865265 DOI: 10.1080/1041794x.2015.1081974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
This study used structurating activity theory to analyze 21 conversations between genetic counselors and individuals at increased risk for familial colorectal cancer (CRC). The qualitative analysis revealed ways elements of family, primary healthcare, cancer prevention and treatment, and other systems emerged in intervention conversations as shaping CRC screening attitudes and behaviors. Results indicate that family stories, norms, and roles are resources for enacting health practices in families and that the authority of healthcare providers is a resource for making screening decisions. Conclusions include practical implications for using findings in clinical applications as well as future research directions to build on this exploratory study.
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Affiliation(s)
| | | | | | - Anita Y Kinney
- Department of Internal Medicine, School of Medicine, University of New Mexico, and University of New Mexico Cancer Center
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Quintiliani LM, Russinova ZL, Bloch PP, Truong V, Xuan Z, Pbert L, Lasser KE. Patient navigation and financial incentives to promote smoking cessation in an underserved primary care population: A randomized controlled trial protocol. Contemp Clin Trials 2015; 45:449-457. [PMID: 26362691 DOI: 10.1016/j.cct.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 10/23/2022]
Abstract
Despite the high risk of tobacco-related morbidity and mortality among low-income persons, few studies have connected low-income smokers to evidence-based treatments. We will examine a smoking cessation intervention integrated into primary care. To begin, we completed qualitative formative research to refine an intervention utilizing the services of a patient navigator trained to promote smoking cessation. Next, we will conduct a randomized controlled trial combining two interventions: patient navigation and financial incentives. The goal of the intervention is to promote smoking cessation among patients who receive primary care in a large urban safety-net hospital. Our intervention will encourage patients to utilize existing smoking cessation resources (e.g., quit lines, smoking cessation groups, discussing smoking cessation with their primary care providers). To test our intervention, we will conduct a randomized controlled trial, randomizing 352 patients to the intervention condition (patient navigation and financial incentives) or an enhanced traditional care control condition. We will perform follow-up at 6, 12, and 18 months following the start of the intervention. Evaluation of the intervention will target several implementation variables: reach (participation rate and representativeness), effectiveness (smoking cessation at 12 months [primary outcome]), unintended consequences (e.g., purchase of illicit substances with incentive money), adoption (use of intervention across primary care suites), implementation (delivery of intervention), and maintenance (smoking cessation after conclusion of intervention). Improving the implementation of smoking cessation interventions in primary care settings serving large underserved populations could have substantial public health impact, reducing cancer-related morbidity/mortality and associated health disparities.
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Affiliation(s)
- Lisa M Quintiliani
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA; Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
| | - Zlatka L Russinova
- Boston University, Center for Psychiatric Rehabilitation, 940 Commonwealth Ave., West, Boston, MA 02215, USA.
| | - Philippe P Bloch
- Boston University, Center for Psychiatric Rehabilitation, 940 Commonwealth Ave., West, Boston, MA 02215, USA.
| | - Ve Truong
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA.
| | - Ziming Xuan
- Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
| | - Lori Pbert
- University of Massachusetts Medical School, Department of Medicine, Division of Preventive and Behavioral Medicine, 55 Lake Ave. North, Worcester, MA 01655, USA.
| | - Karen E Lasser
- Boston University, School of Medicine, Section of General Internal Medicine, 801 Massachusetts Ave., Crosstown Center, 2nd Floor, Boston, MA 02118, USA; Boston University, School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave. Crosstown Center, 4th Floor, Boston, MA 02118, USA.
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Kerner J, Liu J, Wang K, Fung S, Landry C, Lockwood G, Zitzelsberger L, Mai V. Canadian cancer screening disparities: a recent historical perspective. ACTA ACUST UNITED AC 2015; 22:156-63. [PMID: 25908914 DOI: 10.3747/co.22.2539] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Across Canada, introduction of the Pap test for cervical cancer screening, followed by mammography for breast cancer screening and, more recently, the fecal occult blood test for colorectal cancer screening, has contributed to a reduction in cancer mortality. However, another contribution of screening has been disparities in cancer mortality between certain populations. Here, we explore the disparities associated with breast and cervical cancer screening and preliminary data concerning disparities in colorectal cancer screening. Although some disparities in screening utilization have been successfully reduced over time (for example, mammography and Pap test screening in rural and remote populations), screening utilization data for other populations (for example, low-income groups) clearly indicate that disparities have existed and continue to exist across Canada. Organized screening programs in Canada have been able to successfully engage 80% of women for regular cervical cancer screening and 70% of women for regular mammography screening, but of the women who remain to be reached or engaged in regular screening, those with the least resources, those who are the most isolated, and those who are least culturally integrated into Canadian society as a whole are over-represented. Population differences are also observed for utilization of colorectal cancer screening services. The research literature on interventions to promote screening utilization provides some evidence about what can be done to increase participation in organized screening by vulnerable populations. Adaption and adoption of evidence-based screening promotion interventions can increase the utilization of available screening services by populations that have experienced the greatest burden of disease with the least access to screening services.
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Affiliation(s)
- J Kerner
- Canadian Partnership Against Cancer, Toronto, ON
| | - J Liu
- Canadian Partnership Against Cancer, Toronto, ON
| | - K Wang
- Canadian Partnership Against Cancer, Toronto, ON
| | - S Fung
- Canadian Partnership Against Cancer, Toronto, ON
| | - C Landry
- Canadian Partnership Against Cancer, Toronto, ON
| | - G Lockwood
- Canadian Partnership Against Cancer, Toronto, ON
| | | | - V Mai
- Canadian Partnership Against Cancer, Toronto, ON
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Strauss SM, Jensen AE, Bennett K, Skursky N, Sherman SE, Schwartz MD. Clinicians' panel management self-efficacy to support their patients' smoking cessation and hypertension control needs. Transl Behav Med 2015; 5:68-76. [PMID: 25729455 DOI: 10.1007/s13142-014-0287-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Panel management, a set of tools and processes for proactively caring for patient populations, has potential to reduce morbidity and improve outcomes between office visits. We examined primary care staff's self-efficacy in implementing panel management, its correlates, and an intervention's impact on this self-efficacy. Primary care teams at two Veterans Health Administration (VA) hospitals were assigned to control or intervention conditions. Staff were surveyed at baseline and post-intervention, with a random subset interviewed post-intervention. Panel management self-efficacy was higher among staff participating in the panel management intervention. Self-efficacy was significantly correlated with sufficient training, aspects of team member interaction, and frequency of panel management use. Panel management self-efficacy was modest among primary care staff at two VA hospitals. Team level interventions may improve primary care staff's confidence in practicing panel management, with this greater confidence related to greater team involvement with, and use of panel management.
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Affiliation(s)
- Shiela M Strauss
- New York University College of Nursing, 726 Broadway, 10th floor, New York, NY 10003 USA
| | - Ashley E Jensen
- VA New York Harbor Healthcare System, New York, USA ; Department of Medicine, New York University School of Medicine, New York, USA
| | - Katelyn Bennett
- VA New York Harbor Healthcare System, New York, USA ; Department of Medicine, New York University School of Medicine, New York, USA
| | - Nicole Skursky
- VA New York Harbor Healthcare System, New York, USA ; Department of Medicine, New York University School of Medicine, New York, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, USA ; Department of Population Health, New York University School of Medicine, New York, USA
| | - Mark D Schwartz
- VA New York Harbor Healthcare System, New York, USA ; Department of Population Health, New York University School of Medicine, New York, USA
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Hou SI, Roberson K. A systematic review on US-based community health navigator (CHN) interventions for cancer screening promotion--comparing community- versus clinic-based navigator models. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2015; 30:173-86. [PMID: 25219543 DOI: 10.1007/s13187-014-0723-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This study synthesized lessons learned from US-based community and clinic health navigator (CHN) interventions on cancer screening promotion to identify characteristics of models and approaches for addressing cancer disparities. The combination terms "cancer screening" and "community health workers or navigators" or "patient navigators" were used in searching Medline, CINAHL, and PsycInfo. A total of 27 articles published during January 2005∼April 2014 were included. Two CHN models were identified: community-based (15 studies) and clinic/hospital-based (12 studies). While both models used the term "navigators," most community-based programs referred them as community health workers/navigators/advisors, whereas clinic-based programs often called them patient navigators. Most community-based CHN interventions targeted specific racial/ethnic minority or rural groups, while clinic-based programs mostly targeted urban low income or mixed ethnic groups. Most community-based CHN programs outreached members from community networks, while clinic-based programs commonly worked with pre-identified in-service clients. Overall, regardless model type, CHNs had similar roles and responsibilities, and interventions demonstrated effective outcomes. Our review identified characteristics of CHN interventions with attention to different settings. Lessons learned have implication on the dissemination and implementation of CHN interventions for cancer screening promotion across setting and target groups.
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Affiliation(s)
- Su-I Hou
- Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, 309 Ramsey Center, Athens, GA, 30602, USA,
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Horne HN, Phelan-Emrick DF, Pollack CE, Markakis D, Wenzel J, Ahmed S, Garza MA, Shapiro GR, Bone LR, Johnson LB, Ford JG. Effect of patient navigation on colorectal cancer screening in a community-based randomized controlled trial of urban African American adults. Cancer Causes Control 2014; 26:239-246. [PMID: 25516073 DOI: 10.1007/s10552-014-0505-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 11/27/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE In recent years, colorectal cancer (CRC) screening rates have increased steadily in the USA, though racial and ethnic disparities persist. In a community-based randomized controlled trial, we investigated the effect of patient navigation on increasing CRC screening adherence among older African Americans. METHODS Participants in the Cancer Prevention and Treatment Demonstration were randomized to either the control group, receiving only printed educational materials (PEM), or the intervention arm where they were assigned a patient navigator in addition to PEM. Navigators assisted participants with identifying and overcoming screening barriers. Logistic regression analyses were used to assess the effect of patient navigation on CRC screening adherence. Up-to-date with screening was defined as self-reported receipt of colonoscopy/sigmoidoscopy in the previous 10 years or fecal occult blood testing (FOBT) in the year prior to the exit interview. RESULTS Compared with controls, the intervention group was more likely to report being up-to-date with CRC screening at the exit interview (OR 1.55, 95 % CI 1.07-2.23), after adjusting for select demographics. When examining the screening modalities separately, the patient navigator increased screening for colonoscopy/sigmoidoscopy (OR 1.53, 95 % CI 1.07-2.19), but not FOBT screening. Analyses of moderation revealed stronger effects of navigation among participants 65-69 years and those with an adequate health literacy level. CONCLUSIONS In a population of older African Americans adults, patient navigation was effective in increasing the likelihood of CRC screening. However, more intensive navigation may be necessary for adults over 70 years and individuals with low literacy levels.
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Affiliation(s)
- Hisani N Horne
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.
- National Institutes of Health/NCI/DCEG/HREB, 9609 Medical Center Drive, Rm 7E234, MSC 7234, Bethesda, MD, 20892-7234, USA.
| | - Darcy F Phelan-Emrick
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Craig E Pollack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Diane Markakis
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Wenzel
- Department of Oncology, Department of Acute and Chronic Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health and Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mary A Garza
- Department of Behavioral and Community Health, School of Public Health, University of Maryland College Park, College Park, MD, USA
| | - Gary R Shapiro
- Health Partners Cancer Program and Institute for Education and Research, Minneapolis, MN, USA
| | - Lee R Bone
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jean G Ford
- The Brooklyn Hospital Center, Brooklyn, NY, USA
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50
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Myers RE, Sifri R, Daskalakis C, DiCarlo M, Geethakumari PR, Cocroft J, Minnick C, Brisbon N, Vernon SW. Increasing colon cancer screening in primary care among African Americans. J Natl Cancer Inst 2014; 106:dju344. [PMID: 25481829 DOI: 10.1093/jnci/dju344] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The study aimed to determine the effect of preference-based tailored navigation on colorectal cancer (CRC) screening adherence and related outcomes among African Americans (AAs). METHODS We conducted a randomized controlled trial that included 764 AA patients who were age 50 to 75 years, were eligible for CRC screening, and had received care through primary care practices in Philadelphia. Consented patients completed a baseline telephone survey and were randomized to either a Standard Intervention (SI) group (n = 380) or a Tailored Navigation Intervention (TNI) group (n = 384). The SI group received a mailed stool blood test kit plus colonoscopy instructions, and a reminder. The TNI group received tailored navigation (a mailed stool blood test kit or colonoscopy instructions based on preference, plus telephone navigation) and a reminder. A six-month survey and a 12-month medical records review were completed to assess screening adherence, change in overall screening preference, and perceptions about screening. Multivariable analyses were performed to assess intervention impact on outcomes. RESULTS At six months, adherence in the TNI group was statistically significantly higher than in the SI group (OR = 2.1, 95% CI = 1.5 to 2.9). Positive change in overall screening preference was also statistically significantly greater in the TNI group compared with the SI group (OR = 1.5, 95% CI = 1.0 to 2.3). There were no statistically significant differences in perceptions about screening between the study groups. CONCLUSIONS Tailored navigation in primary care is a promising approach for increasing CRC screening among AAs. Research is needed to determine how to maximize intervention effects and to test intervention impact on race-related disparities in mortality and survival.
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Affiliation(s)
- Ronald E Myers
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV).
| | - Randa Sifri
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Constantine Daskalakis
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Melissa DiCarlo
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Praveen Ramakrishnan Geethakumari
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - James Cocroft
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Christopher Minnick
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Nancy Brisbon
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
| | - Sally W Vernon
- : Division of Population Science, Medical Oncology (REM, MD, JC), Department of Family and Community Medicine (RS, NB), and Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics (CD), Thomas Jefferson University, Philadelphia, PA; Department of Internal Medicine, Albert Einstein Healthcare Network (PRG); Cancer Center, Albert Einstein Healthcare Network, Philadelphia, PA (CM); Division of Health Promotion and Behavioral Sciences, Center for Health Promotion and Prevention Research, University of Texas School of Public Health, Houston, TX (SWV)
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