Schools and Wastewater Surveillance: Practical Implications for an Emerging Technology to Impact Child Health.

Since the start of the COVID-19 pandemic, wastewater surveillance has emerged as a public health tool that supplements traditional surveillance methods used to detect the prevalence of the SARS-CoV-2 virus in communities. In May 2020, the Houston Health Department (HHD) partnered with a coalition of municipal and academic partners to develop a wastewater monitoring and reporting system for the city of Houston, Texas. The HHD subsequently launched a program to conduct targeted wastewater sampling at 52 school sites located in a large, urban school district in Houston. Data generated by this program are shared with school district officials and nurses from participating schools. Although initial feedback from these stakeholders indicated that they considered the wastewater data valuable, the emergency nature of the pandemic prevented a systematic evaluation of the program. To address this gap in knowledge, the HHD and Rice University conducted a study to determine how wastewater data are used to make decisions about COVID-19 prevention and mitigation practices in schools. Our findings indicate that maximizing the utility of wastewater data in the school context will require the development of communication strategies and education efforts tailored to the needs of specific audiences and improving collaboration between local health departments, school districts, and school nurses.

Effect of a Patient Decision Aid on Lung Cancer Screening Decision-Making by Persons Who Smoke: A Randomized Clinical Trial.

Importance: Lung cancer screening with low-dose computed tomography lowers lung cancer mortality but has potential harms. Current guidelines support patients receiving information about the benefits and harms of lung cancer screening during decision-making. Objective: To examine the effect of a patient decision aid (PDA) about lung cancer screening compared with a standard educational material (EDU) on decision-making outcomes among smokers. Design, Setting, and Participants: This randomized clinical trial was conducted using 13 state tobacco quitlines. Current and recent tobacco quitline clients who met age and smoking history eligibility for lung cancer screening were enrolled from March 30, 2015, to September 12, 2016, and followed up for 6 months until May 5, 2017. Data analysis was conducted between May 5, 2017, and September 30, 2018. Interventions: Participants were randomized to the PDA video Lung Cancer Screening: Is It Right for Me? (n = 259) or to EDU (n = 257). Main Outcomes and Measures: The primary outcomes were preparation for decision-making and decisional conflict measured at 1 week. Secondary outcomes included knowledge, intentions, and completion of screening within 6 months of receiving the intervention measured by patient report. Results: Of 516 quit line clients enrolled, 370 (71.7%) were younger than 65 years, 320 (62.0%) were female, 138 (26.7%) identified as black, 47 (9.1%) did not have health insurance, and 226 (43.8%) had a high school or lower educational level. Of participants using the PDA, 153 of 227 (67.4%) were well prepared to make a screening decision compared with 108 of 224 participants (48.2%) using EDU (odds ratio [OR], 2.31; 95% CI, 1.56-3.44; P < .001). Feeling informed about their screening choice was reported by 117 of 234 participants (50.0%) using a PDA compared with 66 of 233 participants (28.3%) using EDU (OR, 2.56; 95% CI, 1.72-3.79; P < .001); 159 of 234 participants (68.0%) using a PDA compared with 110 of 232 (47.4%) participants using EDU reported being clear about their values related to the harms and benefits of screening (OR, 2.37; 95% CI, 1.60-3.51; P < .001). Participants using a PDA were more knowledgeable about lung cancer screening than participants using EDU at each follow-up assessment. Intentions to be screened and screening behaviors did not differ between groups. Conclusions and Relevance: In this study, a PDA delivered to clients of tobacco quit lines improved informed decision-making about lung cancer screening. Many smokers eligible for lung cancer screening can be reached through tobacco quit lines. Trial Registration: ClinicalTrials.gov identifier: NCT02286713.

Randomized trial of a patient-centered decision aid for promoting informed decisions about lung cancer screening: Implementation of a PCORI study protocol and lessons learned.

PURPOSE: We describe the methods, stakeholder engagement, and lessons learned from a study comparing a video decision aid to standard educational materials on lung cancer screening decisions. METHODS: The study followed rigorous methodology standards from the Patient-Centered Outcomes Research Institute. The importance of patient-centeredness and patient/stakeholder engagement are reflected across the study's conceptualization, execution, interpretation, and dissemination efforts. Advisory groups of current and former smokers, quitline service providers, clinicians, and patient advocates were formed for the project. The study used both retrospective and prospective recruitment strategies. Randomization of patients occurred within state-based quitlines, with aggressive tracking of participants. We collected data at baseline and 1-week, 3-month and 6-months after receiving the intervention. The patient-centered outcomes included whether patients' receiving the decision aid a) felt better prepared to make a decision, b) felt more informed about the screening decision, c) had more clarity on their values regarding the benefits and harms of lung cancer screening, and d) were more knowledgeable about lung cancer screening than patients receiving the standard education materials. Exploratory outcomes included making an appointment with a health care provider to discuss screening, scheduling and completing lung cancer screening. RESULTS: We have enrolled and randomized 516 quitline patients and learned many lessons about executing the trial based on significant patient and stakeholder engagement. CONCLUSIONS: Conducting patient-centered outcomes research requires new ways of thinking and continuously checking-in with patients/stakeholders. The engagement of quitline service providers and patient advisors has been key to successful recruitment and dissemination planning. PCORI- CER-1306-03385 ClinicalTrials.gov NCT ID: NCT02286713.

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.

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.

Patient navigation and the American Cancer Society.

OBJECTIVES: To review the evolution, implementation, and development of the American Cancer Society's Navigator program. DATA SOURCES: American Cancer Society reports and published articles CONCLUSION: The American Cancer Society has a long history of supporting the growth and development of navigation, from provision of funding for Dr Freeman's pilot program, to developing a program that includes training, policy development, and research. The Society continues to play a key role in providing leadership to advance patient navigation as a means to improve patients' access to care, movement through the health care system while furthering patient centered care, patients' quality of life and eliminating health outcome disparities. IMPLICATIONS FOR NURSING PRACTICE: With the American Cancer Society navigation model, navigators are trained to meet with patients, identify barriers to care, and work with institutional health care teams to support patients and assist staff with aspects of care that can be managed by non-medical personnel.

Measuring the impact and potential of patient navigation: proposed common metrics and beyond.

In March 2010, the American Cancer Society hosted the National Patient Navigation Leadership Summit. The Summit organizers invited cancer clinicians, researchers, practicing public health and measurement experts, funders, and patient navigators to develop a national consensus on common outcomes to solidify the scientific evidence and efficacy of patient navigation. The goal of the Summit was to develop and propose core metrics to measure outcomes of navigation on individuals as well as populations across the continuum. It is the sincere hope of the editors, funders, authors, and workgroup members that this supplement and the proposed measures provide a roadmap for the development, implementation,and evaluation of patient navigation programs.

Evolving information priorities of hematologic cancer survivors, caregivers, and other relatives.

Little is known about information priorities of people touched by hematologic cancers. We interviewed and surveyed 29 survivors/patients, 13 caregivers, and 19 non-caregiver relatives. Qualitative interviews indicated limited information describing topics other than specific cancer subtypes and treatment options. The survey exercise revealed the following priorities: at diagnosis, cancer types and treatment options; during initial treatment, treatment options and coping with side effects; after treatment, follow-up tests and long-term side effects; at remission/during maintenance treatment at relapse, treatment options and follow-up tests; for patients, cancer types and treatment options; for caregivers, future outlook and support; for non-caregivers, finances. Information priorities vary by role and over time.

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.

Development of a health risk factors questionnaire for Chinese and Vietnamese residents of the Houston, Texas area.

The purpose of the Asian American Health Needs Assessment (AsANA) project was to collect information on the health risks, behaviors, and beliefs among Chinese and Vietnamese residents in the Houston area, two of the largest Asian American subgroups in Texas. The first phase of the project was to develop the AsANA survey instrument, which was adapted from the Texas Community Health Survey, a condensed version of the Behavioral Risk Factors Surveillance System. This report describes the steps used in adapting, modifying and developing the survey instrument, and provides insights, which may assist other investigators conducting similar research.