Patient Navigation Improves Subsequent Breast Cancer Screening After a Noncancerous Result: Evidence from the Patient Navigation in Medically Underserved Areas Study.

BACKGROUND: Past efforts to assess patient navigation on cancer screening utilization have focused on one-time uptake, which may not be sufficient in the long term. This is partially due to limited resources for in-person, longitudinal patient navigation. We examine the effectiveness of a low-intensity phone- and mail-based navigation on multiple screening episodes with a focus on screening uptake after receiving noncancerous results during a previous screening episode. METHODS: The is a secondary analysis of patients who participated in a randomized controlled patient navigation trial in Chicago. Participants include women referred for a screening mammogram, aged 50-74 years, and with a history of benign/normal screening results. Navigation services focused on identification of barriers and intervention via shared decision-making processes. A multivariable logistic regression intent-to-treat model was used to examine differences in odds of obtaining a screening mammogram within 2 years of the initial mammogram (yes/no) between navigated and non-navigated women. Sensitivity analyses were conducted to explore patterns across subsets of participants (e.g., navigated women successfully contacted before the initial appointment; women receiving care at Hospital C). RESULTS: The final sample included 2,536 women (741 navigated, 1,795 non-navigated). Navigated women exhibited greater odds of obtaining subsequent screenings relative to women in the standard care group in adjusted models and analyses including women who received navigation before the initial appointment. CONCLUSIONS: Our findings suggest that low-intensity navigation services can improve follow-up screening among women who receive a noncancerous result. Further investigation is needed to confirm navigation's impacts on longitudinal screening.

Health Volunteerism and Improved Cancer Health for Latina and African American Women and Their Social Networks: Potential Mechanisms.

Health volunteerism has been associated with positive health outcomes for volunteers and the communities they serve. This work suggests that there may be an added value to providing underserved populations with information and skills to be agents of change. The current study is a first step toward testing this hypothesis. The purpose is to identify how volunteerism may result in improved cancer health among Latina and African American women volunteers. A purposive sample of 40 Latina and African American female adults who had participated in cancer volunteerism in the past 5 years was recruited by community advocates and flyers distributed throughout community venues in San Diego, CA. This qualitative study included semi-structured focus groups. Participants indicated that volunteerism not only improved their health but also the health of their family and friends. Such perceptions aligned with the high rates of self-report lifetime cancer screening rates among age-eligible patients (e.g., 83-93 % breast; 90-93 % cervical; 79-92 % colorectal). Identified mechanisms included exposure to evidence-based information, health-protective social norms and support, and pressure to be a healthy role model. Our findings suggest that train-the-trainer and volunteer-driven interventions may have unintended health-protective effects for participating staff, especially Latina and African American women.

Patient Navigation in Medically Underserved Areas study design: A trial with implications for efficacy, effect modification, and full continuum assessment.

BACKGROUND: The Patient Navigation in Medically Underserved Areas study objectives are to assess if navigation improves: 1) care uptake and time to diagnosis; and 2) outcomes depending on patients' residential medically underserved area (MUA) status. Secondary objectives include the efficacy of navigation across 1) different points of the care continuum among patients diagnosed with breast cancer; and 2) multiple regular screening episodes among patients who did not obtain breast cancer diagnoses. DESIGN/METHODS: Our randomized controlled trial was implemented in three community hospitals in South Chicago. Eligible participants were: 1) female, 2) 18+years old, 3) not pregnant, 4) referred from a primary care provider for a screening or diagnostic mammogram based on an abnormal clinical breast exam. Participants were randomized to 1) control care or 2) receive longitudinal navigation, through treatment if diagnosed with cancer or across multiple years if asymptomatic, by a lay health worker. Participants' residential areas were identified as: 1) established MUA (before 1998), 2) new MUA (after 1998), 3) eligible/but not designated as MUA, and 4) affluent/ineligible for MUA. Primary outcomes include days to initially recommended care after randomization and days to diagnosis for women with abnormal results. Secondary outcomes concern days to treatment initiation following a diagnosis and receipt of subsequent screening following normal/benign results. DISCUSSION: This intervention aims to assess the efficacy of patient navigation on breast cancer care uptake across the continuum. If effective, the program may improve rates of early cancer detection and breast cancer morbidity.

The effects of navigation and types of neighborhoods on timely follow-up of abnormal mammogram among black women.

BACKGROUND: Despite the availability of relatively simple and inexpensive screening tools, minority women are more often diagnosed at a late stage of breast cancer, in part due to delays in follow-up of abnormal screening result. One of the key factors for timely follow-up of abnormal mammogram may be neighborhood characteristics. Patient Navigation (PN) programs aim to diminish barriers, but its differential effects by neighborhood have not been fully examined. The current study examines the effect of types of neighborhoods on time to follow-up of abnormal mammogram, and the differential effects of PN by neighborhood characteristics. METHODS: We examined data from a total of 1,696 randomized patients from a randomized controlled trial, "the Patient Navigation in Medically Underserved Areas" study that explored the effect of navigation on breast health outcomes. We categorized participants' neighborhoods into three categories and compared the effect of navigation between these neighborhood types. RESULTS: Navigated women in mixed race neighborhoods had a shorter time to follow-up compared with non-navigated women in the neighborhoods. Black women living in mixed neighborhoods had a significant longer time to follow-up of abnormal mammogram, compared with black women living in middle class black neighborhoods. CONCLUSION: Patient navigation interventions improve timely follow-up of abnormal mammogram. Patient navigation may be particularly beneficial for minority women who reside in racially heterogeneous neighborhoods which may be less likely to have access to affordable health clinics and social services. Health policies concerning breast cancer early detection for minority women need to pay further attention to those who might potentially be excluded from health services due to the characteristics of neighborhoods. Socioeconomic conditions of neighborhood may affect individual health through multiple interlinked mechanisms. Neighborhood characteristics, such as poverty, segregation, access to resources, and social cohesion, cannot be fully understood with simplistic measures of neighborhood disadvantage.

Medical mistrust and patient satisfaction with mammography: the mediating effects of perceived self-efficacy among navigated African American women.

BACKGROUND: Medical mistrust is salient among African American women, given historic and contemporary racism within medical settings. Mistrust may influence satisfaction among navigated women by affecting women's perceptions of their health-care self-efficacy and their providers' roles in follow-up of abnormal test results. OBJECTIVES: To (i) examine whether general medical mistrust and health-care self-efficacy predict satisfaction with mammography services and (ii) test the mediating effects of health-related self-efficacy. DESIGN: The current study is a part of a randomized controlled patient navigation trial for medically underserved women who had received a physician referral to obtain a mammogram in three community hospitals in Chicago, IL. After consent, 671 African American women with no history of cancer completed questionnaires concerning medical mistrust and received navigation services. After their mammography appointment, women completed health-care self-efficacy and patient satisfaction questionnaires. RESULTS: Women with lower medical mistrust and greater perceived self-efficacy reported greater satisfaction with care. Medical mistrust was directly and indirectly related to patient satisfaction through self-efficacy. CONCLUSIONS: Preliminary findings suggest future programmes designed to increase health-care self-efficacy may improve patient satisfaction among African American women with high levels of medical mistrust. Our findings add to a growing body of literature indicating the importance of self-efficacy and active participation in health care, especially among the underserved.

A qualitative evaluation of a faith-based breast and cervical cancer screening intervention for African American women.

This article presents a formative evaluation of a CDC Racial and Ethnic Approaches to Community Health (REACH) 2010 faith-based breast and cervical cancer early detection and prevention intervention for African American women living in urban communities. Focus groups were conducted with a sample of women (N=94) recruited from each church participating in the intervention. One focus group was conducted in each of the nine participating churches following completion of the 6-month REACH 2010 intervention. Transcribed data were coded to identify relevant themes. Key findings included (a) the acceptability of receiving cancer education within the context of a faith community, (b) the importance of pastoral input, (c) the effectiveness of personal testimonies and lay health advocates, (d) the saliency of biblical scripture in reinforcing health messages, (e) the effectiveness of multimodal learning aids, and (f) the relationship between cervical cancer and social stigma. Study findings have implications for enhancing faith-based breast and cervical cancer prevention efforts in African American communities.

Using multilevel, multisource needs assessment data for planning community interventions.

African Americans and Latinos share higher rates of cardiovascular disease (CVD) and diabetes compared with Whites. These diseases have common risk factors that are amenable to primary and secondary prevention. The goal of the Chicago REACH 2010-Lawndale Health Promotion Project is to eliminate disparities related to CVD and diabetes experienced by African Americans and Latinos in two contiguous Chicago neighborhoods using a community-based prevention approach. This article shares findings from the Phase 1 participatory planning process and discusses the implications these findings and lessons learned may have for programs aiming to reduce health disparities in multiethnic communities. The triangulation of data sources from the planning phase enriched interpretation and led to more creative and feasible suggestions for programmatic interventions across the four levels of the ecological framework. Multisource data yielded useful information for program planning and a better understanding of the cultural differences and similarities between African Americans and Latinos.