How Navigators Help Patients Overcome Healthcare Inequality
This article was originally published in the Northwestern University Feinberg School of Medicine News Center. It has been edited for the Breakthroughs in Care audience.
The healthcare system can be daunting for almost anyone. Add in the many obstacles that low-income uninsured populations face, and it becomes tremendously more difficult. But guidance from trained navigators can help patients overcome healthcare inequities.
A Northwestern Medicine study looked at community navigators who worked with uninsured Spanish-speaking women in DuPage County to obtain timely follow-up care after an abnormal breast or cervical cancer screening result. Postponed diagnosis after an abnormal test can lead to less effective treatment and lower chances of survival.
Ninety-seven percent of the Spanish-speaking patients in the study were recent immigrants and two-thirds did not finish high school. They had significantly lower income, lower health literacy, less confidence self-managing health and more distrust of the healthcare system than English-speaking patients in DuPage. Though these barriers put Spanish-speaking women at a higher risk for stalled follow-up care, patients in the navigation study did not have longer follow-up times than their English-speaking counterparts.
How the Study Worked
During the five-year study, led by Melissa Simon, MD, ’06 GME, the George H. Gardner, MD, Professor of Clinical Gynecology at Northwestern University Feinberg School of Medicine, six navigators worked with 477 uninsured women in DuPage County who had received abnormal breast or cervical screens. The navigators helped make appointments, provided interpreter services, referred patients to community services and gave emotional support.
The study’s investigators calculated each patient’s follow-up time, which is defined as the number of days between the abnormal breast or cervical screen and the diagnostic test that resolves the abnormal screening test into a cancer or non-cancer diagnosis, such as a colposcopy, diagnostic mammogram or breast biopsy. Obtaining a diagnosis more than 60 days after an abnormal screen was considered delayed follow-up.
Median follow-up time for women in the study was 29 days for breast screening abnormalities and 56.5 days for cervical screening abnormalities. The study found no differences in likelihood of delayed follow-up between Spanish-speaking patients working with navigators and English-speaking patients, despite barriers faced by the former group. DuPage patients who worked with navigators also had shorter follow-up times than patients living in similar suburban counties outside Chicago who did not receive help from navigators.
Community Partnerships to Combat Language Barriers and Poverty
Getting healthcare is more difficult for patients like the ones in the DuPage study for a number of reasons.
“Language barriers can make follow-up appointment scheduling challenging, stifle choices in care providers, hinder doctor-patient interactions and reduce adherence to treatment,” said Dr. Simon, who is an associate professor of Obstetrics and Gynecology, Preventive Medicine and Medical Social Sciences, and a member of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.
The “suburbanization of poverty,” which refers to the national shift of poor populations from urban centers to suburbs that often lack developed public health safety nets, can make the problem worse, explained study co-investigator Joe Feinglass, PhD, research professor of Medicine in the Division of General Internal Medicine and Geriatrics and Preventive Medicine.
Suburban DuPage, the second-largest county in Illinois, doesn’t have resources such as a public hospital or expansive public transportation infrastructure. But it does have Access DuPage, a coalition of community organizations, local hospitals and the health department that provides primary care to uninsured residents.
Dr. Simon and her collaborators teamed up with Access DuPage to adapt a navigation model previously implemented by the National Cancer Institute’s Patient Navigation Research Program. Notably, they scaled the model across a community rather than limiting navigators to a specific hospital or clinic as previous studies had done.
“The old studies were very controlled and not performed in realistic settings,” Dr. Simon said. “Our navigators moved fluidly around a community going from one clinic to another, one hospital to the next.”
To make this possible, the program partnered with community organizations tied to health and social services.
“First we built strong relationships with organizations – we heard their needs so we could create a navigator intervention that’s flexible and realistic within that particular community setting,” Dr. Simon said.
Project coordinator and patient navigator Nadia Hajjar points out that community organizations can benefit from the navigator programs, not just the patients.
“Believe it or not, organizations – from the health department to the county building – don’t always know about each other’s resources,” Hajjar said. “Our program empowered women, but also helped bridge the gap between the medical team and neighboring organizations. People don’t realize what a team effort it takes to get a patient through something as simple as a mammogram.”
With the bonds that navigators build, the community resources can work together to provide help beyond healthcare, said Dr. Simon.
“It wasn’t just about getting a patient follow-up for an abnormal mammogram, it became about helping her find a job, get her electricity turned back on and figure out childcare,” she said. “Navigators have a multimodal impact – that’s an important part of this story.”
An Ongoing and Expansive Effort
The project is part of an ongoing series of studies focusing on patient navigation and barriers to care across a variety of populations in the Chicagoland area led by Dr. Simon.
“Healthcare reform in the United States has opened the doors for many, but millions remain uninsured. Community navigator programs may have a key role to play in improving the health of the nation’s most vulnerable populations,” said Dr. Simon.
According to Dr. Simon, programs with a similar navigation model to the one in the study wouldn’t be difficult for other communities to implement, as long as they had funding. Navigators don’t need to be medical experts – they receive extensive training on the job. Rather, they need to understand the social conditions in the community and build relationships with community resources. Most importantly, they should feel comfortable advocating for patients and confident speaking to healthcare providers.
“A common thread among these studies is the promise of community navigators as connectors and advocates for healthcare services delivery for culturally and linguistically isolated populations in communities with limited healthcare safety net systems,” she said.
In addition to the DuPage County study, Dr. Simon also directs ongoing navigator projects in Chicago’s Chinatown and South Side neighborhoods, and downstate in rural Illinois.
“Women come here from other countries, sometimes as refugees with no family or resources, and they need treatment,” Hajjar said. “As a navigator, you become their everything. I’m so proud to be part of this team and I hope we can do more projects – not just for cancer, but for diabetes, heart disease and all the other issues people are facing.”
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