“This Call Is Being Recorded for Quality and Training Purposes”: A Qualitative Analysis of Patient Navigation for Colorectal Cancer Screening In An Urban Setting

Theoretical Background and research questions/hypothesis:  Patient navigation has been associated with good outcomes in cancer screening and treatment. The process of helping patients through the healthcare maze will never be uniform, as navigation must be tailored to the needs of individual patients. How then can we determine the quality of a patient navigation intervention?  We addressed this question by conducting a process evaluation of patient navigation during the first six months of a large randomized controlled trial of interventions designed to increase colorectal cancer (CRC) screening (CA116576).  

Methods:  Following a baseline survey, patients in the study arm of interest were sent a targeted brochure about CRC screening and a personalized message page tailored to their preferred CRC screening test. The patient navigator called 2 weeks later, sought additional consent, and recorded the call. Twenty-four calls (of approximately 300 made during the time period), lasting 9-40 minutes each, were recorded, transcribed and entered into MaxQDA software for qualitative data analysis. We coded the transcripts based on the best practice literature for patient navigation, the theoretical framework of the parent study, or where the dialogue suggested changes in patient knowledge, attitude or intention. All transcripts were coded before patient screening outcomes were known.  

Results:  In over 1900 coded dialogue segments, we identified 50 unique forms as relevant to patient intention to screen: 7 forms of patient behavior and 12 for the navigator seemed to facilitate screening. We also identified 9 forms of patient behavior that presented obstacles to screening, as well as 9 kinds of missed opportunities or misdirection by the navigator.  The remaining dialogue segments were coded as basic navigation (10 forms) or pertaining to the patient’s health status (3 forms). When the study is complete, we will be able to analyze these specific forms of patient navigation against completion of screening. This will provide a more precise view of the role played by tailored navigation in a multi-intervention study. 

Conclusions: This process evaluation suggests that patient navigation can be assessed for factors that are positively or negatively associated with patient acquisition of knowledge, attitudes or intentions to complete CRC screening. 

Implications for research and/or practice: These findings provide the basis for fine tuning our navigator’s script, and provide specific examples of where a change in technique might prompt a more effective response (e.g. using teach-back). Similarly, we can demonstrate specific patient call behaviors (e.g. disengagement, distraction) that the navigator should address. The pilot also suggests a way to treat patient navigation more precisely in future studies where it is used as an intervention.