Abstract
BackgroundThere is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts. We (1) systematically reviewed the literature to generate a preliminary program theory to describe how patient navigator interventions are designed and delivered; and (2) describe how the resulting program theory was applied in context to inform a prototype for a patient navigator program.MethodsThe current study includes a secondary review of a larger systematic review. We reviewed studies included in the primary review to identify those that designed and evaluated programs to assist patients in accessing and/or adhering to care. We conducted a content analysis of included publications to describe the barriers targeted by PN interventions and the navigator activities addressing those barriers. A program theory was constructed by mapping patient navigator activities to corresponding constructs within the capability-opportunity-motivation model of behavior change (COM-B) model of behavior change. The program theory was then presented to individuals with chronic disease, healthcare providers, and system stakeholders, and refined iteratively based on feedback.ResultsTwenty one publications describing 19 patient navigator interventions were included. A total of 17 unique patient navigator activities were reported. The most common included providing education, facilitating referrals, providing social and emotional support, and supporting self-management. The majority of navigator activities targeted barriers to physical opportunity, including facilitating insurance claims, assistance with scheduling, and providing transportation. Across all interventions, navigator activities were designed to target a total of 20 patient barriers. Among interventions reporting positive effects, over two thirds targeted knowledge barriers, problems with scheduling, proactive re-scheduling following a missed appointment, and insurance. The final program design included a total of 13 navigator activities—10 informed by the original program theory and 3 unique activities informed by stakeholders.ConclusionsThere is considerable heterogeneity in intervention content across patient navigator interventions. Our results provide a schema from which to develop PN interventions and illustrate how an evidence-based model was used to develop a real-world PN intervention. Our findings also highlight a critical need to improve the reporting of intervention components to facilitate translation.Systematic review registrationPROSPERO CRD42013005857
Highlights
There is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts
The heterogeneity in intervention design and diversity of implementation strategies can reflect the adaptability of patient navigator interventions, this variation presents a challenge for those seeking templates to guide the design and implementation of navigator programs
Studies from the primary review were included in the secondary review if (1) the program aim involved actively working with the patient to determine barriers to accessing and/or adhering to recommended treatment; (2) the PN facilitated the patient’s ability to overcome barriers; (3) the study population was specific to individuals with diabetes OR the study population involved another chronic condition but included adherence to treatment and/or healthcare utilization as outcomes
Summary
There is a great deal of variation in the design and delivery of patient navigator (PN) programs, making it difficult to design or adopt these interventions in new contexts. We (1) systematically reviewed the literature to generate a preliminary program theory to describe how patient navigator interventions are designed and delivered; and (2) describe how the resulting program theory was applied in context to inform a prototype for a patient navigator program. Patient navigation programs emerged as a promising strategy to improve access to and reduce disparities in clinical cancer care, and have since been applied across a variety of chronic conditions [1]. We recently conducted a systematic review that identified wide variation in navigator program design across a range of chronic conditions, including the specific barriers targeted, qualifications required for the navigator role, and the measured outcome [4]. The value of program theory in the evaluation of complex interventions is well recognized, as the quality and clarity of the underlying theory largely determine the ability to effectively scale up an intervention in new contexts [6,7,8,9]
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