Patient Navigator Training in the Republic of the Marshall Islands

Abstract

Dear Editors: Cancer is the second leading cause of death in the Republic of the Marshall Islands (RMI) and is, in part, a consequence of 12 years of U.S. nuclear testing.1 There are numerous barriers to cancer prevention and treatment which include limited resources, poverty, low health literacy, cultural orientation on fatalism regarding cancer, lack of transportation, and challenges in seeking off-island referrals. The RMI Ministry of Health (MOH), National Comprehensive Cancer Control Program, in partnership with the John A. Burns School of Medicine (JABSOM), Department of Geriatric Medicine, Division of Palliative Medicine, University of Hawaii, organized a patient navigation training, with the following objectives: 1. To create a culturally appropriate navigation curriculum for RMI. 2. To train lay volunteers from nongovernmental organizations and faith-based organizations as navigators. We trained a total of 35 volunteers; direct outreach and fliers led to high participation. Palliative medicine specialists at JABSOM designed questionnaires to measure attitudes and knowledge on navigation. The planning team from MOH organized group discussions with the cancer support group to learn about their cancer experience. Barriers to care, desired supports, and learning topics were identified. A five-day patient navigation workshop was conducted in March 2012 in Majuro. This 40-hour curriculum consisted of the following: • Day 1 – Cancer 101 (cancer prevention, screening, treatment) • Day 2 – Palliative Care 101 (symptom management, spiritual care) • Day 3 – Caregiving 101 (caregiver stress, activities of daily living) • Day 4 – Navigation 101 (Ebeye navigation program, off-island referrals, asset mapping) • Day 5 – Setting up a navigation program Local experts were involved in the training. Materials were translated into Marshallese and interpreters were provided. Role-play exercises on delivering bad news and storytelling by Ebeye zone navigators were well received. Participants enjoyed walking tours of the hospital. Small group discussions revolved around vision, goals, activities, and care plans. The majority (97%) of Marshallese participants were female, ranging in age from 20 to over 60 years. Ninety-two percent had completed elementary school or earned a high school diploma. There was high satisfaction with the training; the overall rating was 4.88 based on a Likert scale of 1 to 5. Attitudes on the role of a navigator were assessed pre- and post- training. Knowledge on medical interpretation, cancer prevention, grief, communication, and off-island referrals was assessed using a multiple choice questionnaire. Changes were evaluated using paired t-tests. The knowledge on cancer prevention improved significantly (p=0.01), while the remainder did not change. Table 1 describes the composite mean scores, which show a trend in improvement (p=0.06). Table 1. Attitudes and Knowledge of Participants (N=24) Patient navigation has been developed for cancer programs, resulting in higher rates of screening, follow-up, and treatment.2 Navigation is a tool that reduces disparities in key areas of prevention, early detection, coordination, and cultural competency.3 The participants formed a vision statement, “Drijo im ukoj,” which is a call to work together in advancing mutual affairs and is an essential Marshallese principle. MOH will hire a navigation coordinator. Volunteers prefer to be matched to patients via zones based on age and gender, and carry a caseload of one to two patients. Collaboration with MOH is key to implementation and sustainability.