Women in rural areas experience higher risk of breast cancer death than women in urban areas. The urban/rural breast cancer disparity is primarily due to a combination of health system factors that decrease access to care and patient factors that lower patients' capacity to advocate for their needs. These barriers to timely care contribute to advanced stage breast cancer at diagnosis and subsequent lower survival. Patient navigation can improve breast cancer survival by helping women reduce barriers to timely care. However, there is limited evidence to inform health service organizations how to successfully implement this intervention. Factors such as perceptions that an intervention is not effective, an unsupportive culture, or inadequate resources can result in failed implementation. To identify promising practices for successful implementation more information is needed to understand how this intervention is being used in rural areas. To fill this gap in knowledge, we have partnered with key stakeholders in rural southeast Missouri to address these specific aims: 1) assess the extent to which patient navigation is implemented in rural areas to assist women complete follow-up care after an abnormal mammogram; 2) identify theoretically informed organizational characteristics (context, facilitation processes, perceptions of the evidence) that are associated with implementation of patient navigation; 3) identify promising strategies for implementation success. To fulfill these aims we will survey 72 Federally Qualified Health Centers and Rural Health Clinics in 10 counties in southeast Missouri and then use descriptive statistics to report on variability in the level of patient navigation use and implementation success (Aim #1); build multivariable linear regression models to examine associations between organizational factors, level of patient navigation use and implementation success (Aim #2). We will use data from Aim #2 to purposefully sample four organizations for maximum variability of implementation success (two high-level and two low-level) then conduct in-depth interviews with a minimum 20 organizational representatives and 20 patients who recently had an abnormal mammogram. After triangulating interview data with descriptive statistics (Aim #1), we will conduct a latent content analysis that will enable us to discover how and why patient navigation is successful in some organizations. The American Cancer Society has funded us to conduct Aims #1, #2 and the organizational interviews (Aim #3). This proposal request funds for the patient surveys and case study analysis (Aim#3) so we increase the richness of our study results for a low marginal cost. The results from our study will provide decision-makers with useful information and inform plans for a pragmatic trial to examine the effect of promising strategies for successful implementation of patient navigation to reduce delays in breast cancer diagnosis and treatment for women in rural areas.
The proposed project has the potential to generate information that will reduce the excess burden of breast cancer deaths experienced by women in rural areas compared to urban areas. We will accomplish this goal by surveying and interviewing representatives from organizations and interviewing patients to identify promising strategies used by rural clinics and health centers to successfully implement patient navigation after an abnormal mammogram. The results from our study will provide decision-makers with useful information and inform plans for a pragmatic trial to examine the effect of promising strategies for successful implementation of patient navigation to reduce delays in breast cancer diagnosis and treatment for women in rural areas.
