Peer-Navigator Breast Cancer Screening Program for Korean-American Women

Until recently, the U.S. Preventive Services Task Force recommended screening mammography, with or without clinical breast examination, every 1-2 years for women aged 40 and older. As many as 15-20 percent of women who receive a screening mammogram and/or a clinical breast exam have abnormal, suboptimal, or incomplete findings that require follow-up diagnostic tests. However, many of these women never return to complete the recommended test. Patient factors associated with incomplete and delayed follow-up after abnormal or suboptimal cancer screening tests include older age, low income and education level, non-White race, lack of social support, patients' lack of remembering the follow-up recommendation, concerns about cost, lost wages and transportation, and patients' fears. A few prospective studies have shown that patient navigation, where a peer provides one-on-one guidance and assistance to individuals to eliminate barriers as the patient moves through the health care system, is an effective strategy to increase adherence to diagnostic follow-up tests among Latino, African American, and White women. However, this strategy has not been tested among Asian American women. 

The Peer Navigator Breast Cancer Screening Program for Korean-American Women was designed to increase knowledge and self-efficacy among women to complete a diagnostic follow-up exam after an abnormal breast cancer screening test, thus assisting them in overcoming barriers to completing the exam. The program, based on the Health Behavior Framework, uses a bicultural Korean-American peer navigator who is bilingual in English and Korean to provide individually tailored assistance.  Their role also includes reminding women before an appointment, explaining the need for and the nature of the exam, providing transportation or meeting women at the referral clinic or hospital, helping them to complete forms, and providing information and emotional support. Training of the peer navigator takes place over the course of 3 half-days and covers the following topics: breast health and cancer, focusing on prevention and early detection methods, screening abnormalities and follow-up diagnostics; pertinent key medical terms and concepts; protocols and procedures; information about the medical facilities involved, including information about the typical referral centers; types of assistance to be offered to the women; and general etiquette and safety precautions in working with strangers. The peer navigator training also utilizes written materials and other resources from the American Cancer Society, the Komen Foundation, and the National Cancer Institute (i.e., videotapes, Web sites). 

The training of a peer navigator requires approximately 12 hours over 3 half-day sessions.

The intended audience for this intervention is low-income Korean-American women aged 40 and older who are uninsured or underinsured and who need help navigating the health care system. 

Suitable settings for this intervention include medical clinics, hospitals, and doctors' offices.

Required resources to implement the program include the following:
 
-A trained English-Korean bilingual Korean-American peer navigator

-Training materials

    -A Woman's Guide to Breast Cancer Treatment (English and Korean versions)

    -Cancer Facts for Women (Korean version): No longer available on-line.

    -Breast Cancer: Your Guide to Breast Self-Awareness video

-Initial Assessment and Intervention Form (English and Korean version)

There were a total of 116 eligible women who participated in the study. Thirty nine percent were aged 40-49, 41 percent were aged 50-59, and 21 percent were aged 60 or older.  The study was conducted in Koreatown, Los Angeles at two clinics that provided free screenings to women aged 40 and older with no or insufficient health insurance and income less than 200 percent of the poverty level. Korean-American women were identified by case managers based on their Korean first or last name. Women who missed their follow-up diagnostic appointments were eligible to participate in the study. The study used a post-randomization consent design in which women were allocated to the intervention group or a control group prior to obtaining informed consent. Women in the usual care condition received up to two telephone calls by a case manager and a registered letter, urging them to make an appointment for a follow-up exam. Women in the intervention condition received the peer navigator intervention in addition to usual care. A bi-cultural Korean-American peer navigator who was bi-lingual in English and Korean was used in the study.  Their role included reminding women before an appointment, explaining the need for and the nature of the exam, providing transportation or meeting women at the referral clinic or hospital, helping them to complete forms, and providing information and emotional support.  The peer navigator had an average of 3.8 contacts per woman, and 91 percent of the women who consented to be in the intervention arm of the study received at least one service. Almost all services were provided via telephone or when the peer navigator met the patient at the hospital. The peer navigator made only one home visit for one woman and provided transportation to the hospital for two women.

Six months after the women were identified, they completed a 20-minute telephone survey conducted by study staff that assessed self-reported completion of the recommended follow-up exam.  Women in both arms of the study were also asked for permission to conduct a chart review to confirm self-reported completion of follow-up exams.  Forty women in the intervention group and 10 in the control group gave permission to verify completion of follow-up appointments.

• Among women who completed the survey at 6-month follow-up (73.4 percent), self-reported completion of follow-up procedures was 97 percent for the intervention group and 67 percent for the control group (p<.001). Based on an intent-to-treat analysis of all women who were randomized and an assumption that at least 5 percent of women in both arms of the study who did not complete the survey did complete diagnostic follow-up procedures, the difference in completion of follow-up procedures is statistically significant at p<.05.