A practical method for integrating community priorities in planning and implementing cancer control programs.

PURPOSE: Community engagement is essential in effective public health programs. This paper illustrates the methods used to engage community in the development of a multi-level implementation intervention to address cancer disparities related to hereditary cancer syndromes. METHODS: Implementation Mapping (IM), was used to guide the co-creation of an intervention. Key partners were recruited to a 13-member statewide community advisory board (CAB) representing healthcare and community-based organizations. As part of a needs assessment, a 3-round modified Delphi method with the CAB was used to identify implementation outcomes to use in later steps of IM. An anonymous online survey of a validated community engagement measure assessed CAB members' satisfaction with the process. RESULTS: Using a modified Delphi method as part of the needs assessment of IM, the CAB identified three broad categories of strategies: Changing infrastructure using patient navigation; training and educating patients, navigators and providers; and supporting clinicians in case identification and management. Self-reported satisfaction with the IM and Delphi process was high. CONCLUSIONS: Implementation Mapping facilitated the use of available evidence, new data, and community engagement to identify strategies to improve the delivery of programs to reduce hereditary cancer disparities. The modified Delphi method was easy to administer in a virtual environment and may be a useful for others in community-engaged research.

Reducing Youth Vaping: A Pilot Test of the Peer-Led "Youth Engaged Strategies for Changing Adolescent Norms!" (YES-CAN!) Program.

Effective prevention interventions are needed to stem the rising tide of nicotine vaping among adolescents. We conducted a quasi-experimental, non-equivalent comparison group pilot study of the effectiveness of the "Youth Engaged Strategies for Changing Adolescent Norms" (YES-CAN!) program for reducing risks for youth nicotine vaping. YES-CAN! is an innovative peer-led program that supports older adolescents in developing and delivering short narrative prevention videos and related prevention education to younger adolescents. High-school and middle-school program participants and non-program comparison group students completed pre and post surveys assessing vaping susceptibility, behavioral intentions, resistance, knowledge, attitudes, perceived harm, and normative beliefs. Vaping knowledge and the perceived number of friends and classmates who vape showed significantly greater pre- to post-program increases among high-school participants compared to non-participants, and positive vaping attitudes demonstrated significantly greater decreases. Among middle-school students, vaping knowledge increased significantly more among program participants compared to non-participants. The findings from this study indicate that the YES-CAN! program holds promise for reducing risks of nicotine vaping among adolescents. This contributes to a growing body of evidence regarding the utility of peer-led approaches to adolescent health promotion. Further evaluation of the YES-CAN! program in a large-scale randomized control trial is warranted to determine its effectiveness in curbing the escalation of youth nicotine vaping that has characterized the past decade. Future studies should monitor program effect on perceptions of vaping prevalence to ensure participation and/or exposure does not inadvertently promote vaping by increasing perceptions that others vape.

Flexibility, adaptation, and roles of patient navigators in oncology during COVID-19.

BACKGROUND: The impact of COVID-19 on cancer care during the first 6 months of the pandemic has been significant. The National Navigation Roundtable Workforce Development Task Group conducted a national survey to highlight the role of patient navigators (PNs). METHODS: An anonymous online survey captured how cancer care navigation changed during 2 phases: 1) March 13 to May 31, 2020; and 2) June 1 to September 4, 2020. Differences between the 2 time periods for categorical variables were assessed using χ2 tests, and 1-way analyses of variance were used for ordinal variables. RESULTS: Almost one-half of PNs expected changes in duties (49%) during phase 1. By phase 2, PNs showed greater confidence in retaining PN work (P < .001) and reduced changes to duties (P < .01). PNs reported new training on COVID-19 and telehealth during phase 1 (64% and 27%, respectively) and phase 2 (54% and 19%, respectively). Significant decreases in service delays were identified by phase 2 for cancer screening (P < .001), preventive care (P < .001), medical treatment (P < .01), cancer treatment (P < .001), and cancer survivorship services (P < .01). PNs reported that the top patient issues were COVID-19 concerns, medical care disruptions, and finances, and there were decreases in medical care disruptions (P < .01) during phase 2. PNs addressed myths related to mask use, COVID-19 spread, disbelief, risk, clinical changes, transmission prevention, and finances/politics. CONCLUSIONS: The PN role demonstrated resiliency and adaptability. Both clinical and nonclinical oncology PNs identified key patient needs and can provide connections with patient populations that have been economically and socially marginalized, which is necessary to build trust throughout the pandemic.

Exploring classes of cancer patient navigators and determinants of navigator role retention.

BACKGROUND: In the current nationwide study, the authors used latent class analysis (LCA) to identify classes of cancer patient navigators (CPNs) and examined whether class membership and 12 indicators were related to navigator role retention. METHODS: By using data from 460 CPNs in the United States, LCA identified classes (ie, homogenous subgroups) of CPNs with the following indicators: type of CPN (clinical vs nonclinical), education level, area(s) of the cancer care continuum in which the CPN provided patient navigation, region and urbanity where the CPN provided services, organizational work setting, and patient navigation program funding source. The associations of navigator retention with class membership and each indicator were examined using χ2 tests. RESULTS: LCA identified 3 classes of CPNs. Classes 1 and 3 were conceptualized as distinct, homogeneous subgroups of clinical CPNs that appeared to differ mainly on their likelihood of engagement in outreach, survivorship, palliative care, and end-of-life patient navigation. Class 2 was conceptualized as a nonclinical CPN subgroup that was distinct primarily based on their high endorsement of employment in programs, which are at least partially funded by grants and engagement in earlier stages of patient navigation (eg, early detection). The provision of survivorship and treatment patient navigation was related to navigator role retention, with senior CPNs providing these patient navigation services more than novice CPNs. CONCLUSIONS: The current study highlights 3 distinct classes of CPNs, provides initial information regarding determinants of navigator retention, and makes several recommendations for future patient navigation research.

Comparing clinical and nonclinical cancer patient navigators: A national study in the United States.

BACKGROUND: A nationwide survey was conducted to examine differences between clinical and nonclinical oncology navigators in their service provision, engagement in the cancer care continuum, personal characteristics, and program characteristics. METHODS: Using convenience sampling, 527 oncology navigators participated and completed an online survey. Descriptive statistics, χ2 statistics, and t tests were used to compare nonclinical (eg, community health worker) and clinical (eg, nurse navigators) navigators on the provision of various navigation services, personal characteristics, engagement in the cancer care continuum, and program characteristics. RESULTS: Most participants were clinical navigators (76.1%). Compared to nonclinical navigators, clinical navigators were more likely to have a bachelor's degree or higher (88.6% vs 69.6%, P < .001), be funded by operational budgets (84.4% vs 35.7%, P < .001), and less likely to work at a community-based organization or nonprofit (2.0% vs 36.5%, P < .001). Clinical navigators were more likely to perform basic navigation (P < .001), care coordination (P < .001), treatment support (P < .001), and clinical trial/peer support (P = .005). Clinical navigators were more likely to engage in treatment (P < .001), end-of-life (P < .001), and palliative care (P = .001) navigation. CONCLUSIONS: There is growing indication that clinical and nonclinical oncology navigators perform different functions and work in different settings. Nonclinical navigators may be more likely to face job insecurity because they work in nonprofit organizations and are primarily funded by grants.

Preventing intimate partner violence among foreign-born Latinx mothers through relationship education during nurse home visiting.

AIMS: This study aimed to examine the effectiveness of an augmented home visiting programme in preventing intimate partner violence among Latinx mothers by nativity. BACKGROUND: Intimate partner violence diminishes home visit programmes' effectiveness. Immigrant Latinx mothers are especially vulnerable and need culturally tailored prevention. METHODS: We performed secondary analyses of 33 US-born and 86 foreign-born Latinx mothers at baseline and 1- and 2-year follow-up in a longitudinal randomized controlled trial of the Nurse-Family Partnership programme augmented with nurse-delivered Within My Reach relationship education curriculum and violence screening and referrals in Oregon. We estimated proportional odds models via generalized estimating equations on total physical and sexual victimization and/or perpetration forms (an ordinal variable), adjusting for intervention, wave, age and education. RESULTS: The intervention-nativity interaction was not significant (p = .953). Foreign-born status was associated with lower reported violence at baseline (adjusted odds ratio: 0.29, 95% confidence interval: 0.13-0.67, p = .004). This association was marginally significant at 1-year follow-up (0.43, 0.17-1.08, p = .072) and not significant at 2-year follow-up (0.75, 0.33-1.67, p = .475). CONCLUSIONS: This augmented programme was not effective for Latinx mothers by nativity. Their nativity gap diminished over time. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leaders should support culturally tailored home visiting programmes to detect and prevent intimate partner violence affecting Latinx immigrants. CLINICAL TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT01811719. The full trial protocol can be accessed at https://clinicaltrials.gov/ct2/show/NCT01811719.

Gaps in Hospital and Skilled Nursing Facility Responsibilities During Transitions of Care: a Comparison of Hospital and SNF Clinicians' Perspectives.

BACKGROUND: Adverse outcomes are common in transitions from hospital to skilled nursing facilities (SNFs). Gaps in transitional care processes contribute to these outcomes, but it is unclear whether hospital and SNF clinicians have the same perception about who is responsible for filling these gaps in care transitions. OBJECTIVE: We sought to understand the perspectives of hospital and SNF clinicians on their roles and responsibilities in transitional care processes, to identify areas of congruence and gaps that could be addressed to improve transitions. DESIGN: Semi-structured interviews with interdisciplinary hospital and SNF providers. PARTICIPANTS: Forty-one clinicians across 3 hospitals and 3 SNFs including nurses (8), social workers (7), physicians (8), physical and occupational therapists (12), and other staff (6). APPROACH: Using team-based approach to deductive analysis, we mapped responses to the 10 domains of the Ideal Transitions of Care Framework (ITCF) to identify areas of agreement and gaps between hospitals and SNFs. KEY RESULTS: Although both clinician groups had similar conceptions of an ideal transitions of care, their perspectives included significant gaps in responsibilities in 8 of the 10 domains of ITCF, including Discharge Planning; Complete Communication of Information; Availability, Timeliness, Clarity and Organization of Information; Medication Safety; Educating Patients to Promote Self-Management; Enlisting Help of Social and Community Supports; Coordinating Care Among Team Members; and Managing Symptoms After Discharge. CONCLUSIONS: As hospitals and SNFs increasingly are held jointly responsible for the outcomes of patients transitioning between them, clarity in roles and responsibilities between hospital and SNF staff are needed. Improving transitions of care may require site-level efforts, joint hospital-SNF initiatives, and national financial, regulatory, and technological fixes. In the meantime, building effective hospital-SNF partnerships is increasingly important to delivering high-quality care to a vulnerable older adult population.

Community health workers and non-clinical patient navigators: A critical COVID-19 pandemic workforce.

The COVID-19 pandemic has resulted in substantial morbidity and mortality and challenged public health agencies and healthcare systems worldwide. In the U.S., physical distancing orders and other restrictions have had severe economic and societal consequences. Populations already vulnerable in the United States have experienced worse COVID-19 health outcomes. The World Health Organization has made recommendations to engage at risk populations and communicate accurate information about risk and prevention; to conduct contract tracing; and to support those affected by COVID-19. This Commentary highlights the ways in which an existing and cost-effective, but underutilized workforce, community health workers and non-clinical patient navigators, should be deployed to address the COVID-19 pandemic. Community health workers and non-clinical patient navigators have skills in community engagement and health communication and are able to gain the trust of vulnerable communities. Furthermore, many community health workers and non-clinical patient navigators have skills in assisting community members with meeting basic needs and with navigating public health and healthcare systems. Members of this workforce are more than prepared to conduct contact tracing. State, local, tribal, and territorial public health agencies and healthcare systems should be collaborating with national, state, and local organizations that represent and employ CHWs/non-clinical patient navigators to determine how to better mobilize this workforce to address the COVID-19 pandemic. Furthermore, Congress, the Centers for Medicare & Medicaid Services (CMS), and individual states need to adopt policies to sustainably fund their critically needed services in the long term.

Satisfaction with cancer care among underserved racial-ethnic minorities and lower-income patients receiving patient navigation.

BACKGROUND: Patient navigation is a barrier-focused program of care coordination designed to achieve timely and high-quality cancer-related care for medically underserved racial-ethnic minorities and the poor. However, to the authors' knowledge, few studies to date have examined the relationship between satisfaction with navigators and cancer-related care. METHODS: The authors included data from 1345 patients with abnormal cancer screening tests or a definitive cancer diagnosis who participated in the Patient Navigation Research Program to test the efficacy of patient navigation. Participants completed demographic questionnaires and measures of patient satisfaction with cancer-related care (PSCC) and patient satisfaction with interpersonal relationship with navigator (PSN-I). The authors obtained descriptive statistics to characterize the sample and conducted regression analyses to assess the degree of association between PSN-I and PSCC, controlling for demographic and clinical factors. Analyses of variance were conducted to examine group differences controlling for statistically significant covariates. RESULTS: Statistically significant relationships were found between the PSCC and PSN-I for patients with abnormal cancer screening tests (1040 patients; correlation coefficient (r), 0.4 [P<.001]) and those with a definitive cancer diagnosis (305 patients; correlation coefficient, 0.4 [P<.001]). The regression analysis indicated that having an abnormal colorectal cancer screening test in the abnormal screening test group and increased age and minority race-ethnicity status in the cancer diagnosis group were associated with a higher satisfaction with cancer care (P<.01). CONCLUSIONS: Satisfaction with navigators appears to be significantly associated with satisfaction with cancer-related care. Information regarding the patient-navigator relationship should be integrated into patient navigation programs to maximize the likelihood of reducing caner disparities and mortality for medically underserved racial-ethnic minorities and the poor.

Barriers to health care contribute to delays in follow-up among women with abnormal cancer screening: Data from the Patient Navigation Research Program.

BACKGROUND: There is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. METHODS: Secondary analyses of data from the intervention arms of the Patient Navigation Research Program were performed, which included navigated participants with abnormal breast and cervical cancer screening tests from 2007 to 2010. Independent variables were: 1) the number of unique barriers to care (0, 1, 2, or ≥3) documented during patient navigation encounters; and 2) the presence of socio-legal barriers originating from social policy (yes/no). The median time to diagnostic resolution of index screening abnormalities was estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression examined the impact of barriers on time to resolution, controlling for sociodemographics and stratifying by study center. RESULTS: Among 2600 breast screening participants, approximately 75% had barriers to care documented (25% had 1 barrier, 16% had 2 barriers, and 34% had ≥3 barriers). Among 1387 cervical screening participants, greater than one-half had barriers documented (31% had 1 barrier, 11% had 2 barriers, and 13% had ≥3 barriers). Among breast screening participants, the presence of barriers was associated with less timely resolution for any number of barriers compared with no barriers. Among cervical screening participants, only the presence of ≥2 barriers was found to be associated with less timely resolution. Both types of barriers, socio-legal and other barriers, were found to be associated with delay among breast and cervical screening participants. CONCLUSIONS: Navigated women with barriers resolved cancer screening abnormalities at a slower rate compared with navigated women with no barriers. Further innovations in navigation care are necessary to maximize the impact of patient navigation programs nationwide.

Dissemination of patient navigation programs across the United States.

OBJECTIVE: To use diffusion and dissemination frameworks to describe how indicators of economic and health care disparity affect the location and type of patient navigation programs. METHODS: A cross-sectional national Web-based survey conducted during 2009-2010 with support from 65 separate national and regional stakeholder organizations. PARTICIPANTS: A total of 1116 self-identified patient navigators across the United States. MAIN OUTCOME MEASURE: The location and characteristics of patient navigation programs according to economic and health care disparity indicators. RESULTS: Patient navigation programs appear to be geographically dispersed across the United States. Program differences were observed in navigator type, population served, and setting by poverty level. Programs in high-poverty versus low-poverty areas were more likely to use lay navigators (P < .001) and to be located in community health centers and agencies with religious affiliations (50.6 vs 36.4%, and 21.5% vs 16.7%. respectively; P ≤ 0.01). CONCLUSION(S): Results suggest that navigation programs have spread beyond initial target inception areas and also serve as a potentially important resource in communities with higher levels of poverty and/or relatively low access to care. In addition, while nurse navigators have emerged as a significant component of the patient navigation workforce, lay health navigators serve a vital role in underserved communities. Other factors from dissemination frameworks may influence the spread of navigation and provide useful insights to support the dissemination of programs to areas of high need.

A national patient navigator training program.

Patient Navigation is an intervention aimed at addressing cancer health disparities by eliminating barriers to diagnosis, treatment, and services. Three major patient navigation (PN) programs (The National Cancer Institute, The American Cancer Society &The Center for Medicare and Medicaid Services) are underway to address the needs of medically underserved cancer patients. There has not been national training with a defined curriculum for patient navigators (PNs). Curriculum for training the PNs was created by experts from the three programs. The efficacy of training was evaluated using a pre- and posttest. The data show that overall the posttest scores improved from the pretest. In addition, having a high school education or greater or having more years of work experience were significantly related to improvements on the posttest. The first successful standardized national training program was attended by 116 PNs representing 85 cities with the goal to reduce health disparities for medically underserved.

The early dissemination of patient navigation interventions: results of a respondent-driven sample survey.

Patient navigators (PNs) coordinate medical services and connect patients with resources to improve outcomes, satisfaction, and reduce costs. Little national information is available to inform workforce development. We analyzed 819 responses from an online PN survey conducted in 2009-2010. Study variables were mapped to the five Consolidated Framework for Implementation Research (CFIR) constructs to explore program variations by type of PN. Five logistic regression models compared each PN type to all others while adjusting for covariates. Thirty-five percent of respondents were nurse navigators, 28% lay navigators, 20% social work (SW)/counselor navigators, 7% allied health navigators, and 10% were "other" types of PNs. Most were non-Hispanic White (71%), female (94%), and at least college educated (70%). The primary differences were observed among: the core intervention tasks; position structure; work setting; health conditions navigated; navigator race/ethnicity; personal cancer experiences; navigation training; and patient populations served. Lay PNs had fewer odds of identifying as Hispanic, work in rural settings and assist underserved populations compared to others. Nurse navigators showed greater odds of clinical responsibilities, work in hospital or government settings and fewer odds of navigating minority populations compared to others. SW/counselor navigators also had additional duties, provided greater assistance to Medicare patient populations, and less odds of navigating underserved populations than others. In summary, our survey indicates that the type of PN utilized is an indicator of other substantial differences in program implementation. CFIR provides a robust method to compare differences and should incorporate care coordination outcomes in future PN research.

Promoting guideline-based cancer genetic risk assessment for hereditary breast and ovarian cancer in ethnically and geographically diverse cancer survivors: Rationale and design of a 3-arm randomized controlled trial.

BACKGROUND: Although national guidelines for cancer genetic risk assessment (CGRA) for hereditary breast and ovarian cancer (HBOC) have been available for over two decades, less than half of high-risk women have accessed these services, especially underserved minority and rural populations. Identification of high-risk individuals is crucial for cancer survivors and their families to benefit from biomedical advances in cancer prevention, early detection, and treatment. METHODS: This paper describes community-engaged formative research and the protocol of the ongoing randomized 3-arm controlled Genetic Risk Assessment for Cancer Education and Empowerment (GRACE) trial. Ethnically and geographically diverse breast and ovarian cancer survivors at increased risk for hereditary cancer predisposition who have not had a CGRA are recruited through the three statewide cancer registries. The specific aims are to: 1) compare the effectiveness of a targeted intervention (TP) vs. a tailored counseling and navigation(TCN) intervention vs. usual care (UC) on CGRA utilization at 6 months post-diagnosis (primary outcome); compare the effectiveness of the interventions on genetic counseling uptake at 12 months after removal of cost barriers (secondary outcome); 2) examine potential underlying theoretical mediating and moderating mechanisms; and 3) conduct a cost evaluation to guide dissemination strategies. DISCUSSION: The ongoing GRACE trial addresses an important translational gap by developing and implementing evidence-based strategies to promote guideline-based care and reduce disparities in CGRA utilization among ethnically and geographically diverse women. If effective, these interventions have the potential to reach a large number of high-risk families and reduce disparities through broad dissemination. TRIAL REGISTRATION NUMBER: NCT03326713; clinicaltrials.gov.