Patient Navigation Strategies Among Low-Income Women in Need of Mammography and Pap Smears

Background/Purpose:  Mammography and Pap tests are evidence-based opportunities to reduce cancer disparities among low-income and underserved women. Although screening and test rates have improved since the early 1990s, significant differences still persist among these women, due to a range of stressors that create multiple barriers to screening. Patient navigation, a feature of the Patient Protection and Affordable Care Act (2010), can help reduce some of these psychosocial barriers, however traditional navigation alone is not sufficient for many of these women’s stressors and barriers. This study advances and expands patient navigation by providing detailed examples of real-time stressors and clinical telephone skills that facilitated adherence to mammogram screening and Pap testing. The primary objective of this study was to examine how core navigation skills can be systematically applied to promote mammography and Pap testing among a cohort of low-income women.

Methods: A qualitative substudy was used to analyze audio-recorded telephone interactions between patient navigators and United Way 2-1-1 callers who were low-income, minority, and in need of mammography screening and/or Pap testing. For the mammography need group, women had to be 40 + years old and  unscreened in the last year; and for the Pap smear group, women 18+ could not have had a Pap smear within the past 3 years. Two African American females who were similar in age to the average 2-1-1 caller were hired as navigators. A template analysis approach was used by multiple team members to: 1) Identify the general issues related to stressors, based on a priori sensitizing concepts from Turner and Avison's (2003) stress exposure list; and 2) Iteratively examine and code core navigation skills, in order to produce a conceptual cluster matrix to compare codes across women in need of mammography or Pap testing.

Results: Of the 198 women eligible for mammography or Pap, 153 eligible were provided referral for mammography and 108 were provided referral for Pap testing. Among women receiving referrals, mammography was identified as a need by 56% (N=111) and Pap by 35.9% (N=71).. Upon 3-month follow-up, 98.7% (N=151) indicated that they had received the mammography referral and 95.4% (n=103) indicated that they had received the referral for Pap testing. Four core navigation intervention skills are used to promote women’s mammogram and Pap screenings: 1) motivational strategies; 2) information and education; 3) empowerment; and 4) case management.

Conclusions/Implications: In cases where women have access and are well informed about screening and testing, there is still a need to emphasize motivational strategies. Consistent communication is a critical factor influencing adherence and is shown to be a common thread that ties together the identified core elements of navigation identified. Due to overwhelming layers of sensitive psychosocial issues, we need to ensure navigators are formally trained to identify mental health or behavioral health risk issues. Future research will have to meet the challenge of trying to develop innovative interventions which convince and motivate low-income women to consider their social/behavioral longevity, while simultaneously addressing numerous everyday life stressors and chronic barriers, both personal and structural.