Culturally Tailored Navigator Intervention Program for Colorectal Cancer Screening

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death in the United States. While morbidity and mortality from CRC can be reduced through early detection and treatment, rates of CRC screening are lower than for other preventable cancers. CRC screening rates are especially low among ethnic minorities, non-English speakers, and low-income individuals.

Strategies such as mailed reminders with educational information have been shown to increase cancer screening rates in low-income populations and those with limited English proficiency. More recently, evaluations have been conducted of "navigator programs", which are specifically designed to overcome patients' perceived barriers to screening. These programs use flexible problem-solving rather than providing a predetermined set of services. They often employ individuals who are bilingual and familiar with the social and cultural nuances of the patients they serve. Navigators help guide patients through the complexities of the health care system, coordinating appointments with work schedules and stressing the importance of consistent treatment and follow-up.

While two randomized controlled trials have been conducted to evaluate navigator programs, to date, there have been no evaluations of large-scale studies designed to increase overall rates of CRC screening among low-income communities using a multilingual navigator program. There is a need for a navigator program designed to increase CRC screening rates for patients regardless of their race, ethnicity, language, or insurance status.

The Culturally Tailored Navigator Intervention Program for CRC Screening is a multilingual navigator program that aims to increase screening rates, particularly colonoscopy, for low-income patients regardless of their race, ethnicity, language, or insurance status. College-educated outreach workers and interpreters are recruited to serve as full-time patient navigators. They speak English and at least one of the other languages spoken by the patients served by the center hosting the program. 

All navigators participate in a 6-hour training course run by the program developer and the center's community health director. Training addresses several topics related to patient navigation and CRC screening, including performing an initial interview with patients to identify and explore barriers, working with patients to overcome barriers, educating patients about CRC screening, motivating and coaching patients, and scheduling and accompanying patients to colonoscopy testing. Each navigator is supervised by the program developer and community health director. 

During the initial meeting, the navigator educates the patient about CRC screening and explores the patient's barriers to screening (e.g., lack of transportation, language barriers, scheduling difficulties). Subsequent meetings are tailored to each patient with the intention of overcoming personal, cultural, and systemic barriers to successfully complete screening. During these meetings, the navigator continues to educate about CRC screening, helps schedule screening appointments, reminds about appointments, reviews and translates information regarding the required bowel preparation, arranges for transportation, and accompanies those who do not have family members available. Navigators encourage patients to undergo colonoscopy, which is a preferred method and is covered by most insurance. If a patient prefers another CRC screening method, the navigator also assists in getting the screening through the alternative method. 

This program uses an intervention approach recommended by the Community Preventive Services Task Force: patient navigation services to increase cancer screening and advance health equity (Colorectal Cancer Screening - Colonoscopy Alone). This program also uses the following intervention approach for which the Community Preventive Services Task Force finds insufficient evidence: interventions to reduce structural barriers for clients (Colorectal Cancer Screening - Colonoscopy Alone). Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective.

To administer the Culturally Tailored Navigator Intervention Program for CRC, the following time is required:

- Training for each health center outreach worker and interpreter as a patient navigator takes 6 hours. 

- Navigators need an average of 1-2 hours per week per patient to administer services and up to 20 hours if the navigator accompanies the patient to the procedure or conducts home supervision.

- Navigators need 4-6 hours per week to conduct home visit supervision in the first month and afterwards 2 hours. 

The primary audience for the program is adults aged 52-79 with low income and low proficiency in English. 

The program is designed to be administered to participants in urban community health centers and gastroenterology departments. 

The Culturally Tailored Navigator Intervention Program for CRC toolkit includes the following materials:

- Implementation Guide
- Take Control Brochure (English and Spanish)
- Colorectal Cancer Screening Basic Fact Sheet (English and Spanish)
- Navigator Training DVD,  "Colon Cancer Screening: Deciding What's Right for You" (Available at http://blog.healthdialog.com/order-health-dialog-decision-aids/)
- Patient Contact Form

For costs associated with this program, click on Contact Program Developer on the Program Materials page.

The participants in this study were patients aged 52-79 at the Massachusetts General Hospital (MGH) Chelsea HealthCare Center, the largest provider of care for the residents of Chelsea, Massachusetts. This city of 35,080 people has been a gateway for refugees and immigrants for more than a century. Recent immigrants have come from Bosnia, Somalia, Afghanistan, Northern and Western Africa, and Central America. Poverty levels in this area are more than twice the statewide average. 

To be eligible, participants could not have undergone a colonoscopy in the past 10 years, a sigmoidoscopy/barium enema in the past 5 years, or home fecal occult blood testing in the past year. Patients were also not eligible if they were acutely ill or had dementia, metastatic cancer, schizophrenia, or any terminal illness. Participants were identified for the study using an algorithm that assigned all patients seen in the MGH primary care network to either a specific primary care physician or to the primary care practice. They were then randomized into intervention and usual care control groups in a 1:2 ratio, with 409 participants assigned to early intervention and 814 to the usual care control group. Patients in the usual care control group received navigator services after completion of the 9-month intervention.

A list of the participants was entered into a navigator database to track their visits to the health center and gastroenterology unit. The navigator sent all intervention patients an introductory letter in their native language explaining the project, along with a packet of educational materials related to CRC screening. Subsequently, the navigator recruited patients during their visits to the health center or via telephone. 

After the patient completed the CRC screening, the navigator updated the patient's medical record with the screening results. The primary outcome was the percentage of eligible patients in the intervention versus the control group who received CRC screening, which was defined as colonoscopy, sigmoidoscopy, barium enema, or home fecal occult blood testing during the study period. 

• During the 9-month study period, the rate of CRC screening was significantly higher in the intervention group than in the usual care control group, with rates of 27.4% and 11.9%, respectively (p<.001).
   

• During the 9-month study period, the rate of patients receiving colonoscopy was significantly higher in the intervention group than in the usual care control group, with rates of 20.8% and 9.6%, respectively (p<.001). 
   

• During the 9-month study period, the number of polyps detected per 100 patients was significantly higher in the intervention group than in the usual care control group, with rates of 10.5 and 6.8 polyps detected, respectively (p=.04).