Patient Navigation, Community
Based Participatory Research and
Asian Health Disparities
Karen Freund MD MPH
Professor and Vice Chair of Medicine
Tufts Medical Center
Tufts University School of Medicine
Goal of today’s talk
• Patient Navigation to address health
disparities
• Why community participation in patient
navigation research was critical to its
success
• What are the important health issues for
Asian American women today?
Theoretical Model of Factors that Influence
Disparities
BIOLOGIC
PATIENT
PROVIDER
SYSTEM
Prevention
Screening
Diagnosis
Morbidity and Mortality
Treatment
Patient Navigation as a Systems Intervention to
Address Diagnostic Delays
BIOLOGIC
PATIENT
PROVIDER
SYSTEM
Prevention
Screening
Diagnosis
Morbidity and Mortality
Treatment
General Framework of Patient Navigation
• Abnormal finding/diagnosis
to resolution
• Eliminate critical delivery gap
for populations experiencing
disparities
Abnormal results/
Diagnosis
Diagnosis
Treatment
Conclude Navigation Resolution
Initial Contact
OUTREACH
Abnormal Finding
PATIENT NAVIGATION
REHABILITATION
Survivorship
Patient Navigators Address Individual
Patient Barriers
Translate medical next steps and
what to expect into lay language
Promote understanding of
healthcare system pathways
Understand the patient’s
health belief system
Coaching and cultural, emotional and
psychosocial support
Assistance with physical needs and
other barriers to care
Facilitate referrals to community
resources and social services
Impact of Patient Navigation Intervention on
those with Diagnostic Resolution in 1 Year
% Resolved
Percent of Subjects Who Reach Diagnostic Resolution
100
95
90
85
80
75
70
Pre Post
Intervention
Pre Post
Control
Breast Screening Abnormalities
Pre Post
Intervention
Pre Post
Control
Cervical Screening Abnormalities
Does everyone need navigation?
Percent Resolved
Cervical Abnormality Site A
100
90
80
70
60
50
40
30
20
10
0
0
50
100
150
200
250
Days
Control
Navigated
300
350
400
• Is there a subset of
patients who
benefit?
• Can we determine
who benefits a priori
• Reduce resources for
the same benefit
Who benefits the most from navigation?
• Navigation eliminated the gap for these
vulnerable populations
▫ Low income
▫ Unmarried
▫ Unstable housing
▫ Unemployed
• Navigation also benefited those with:
▫ Multiple health care problems
▫ Social and legal barriers to care
Why was patient navigation
successful?
• Partnership between the research team
and community stakeholders
What is Community Based
Participatory Research (CBPR)?
• A true community-academic partnership
• Goal of improving health in the
community
Community Based Participatory Research
• Asks the right questions
• Advises on methods
that will work
• Interprets the findings
based on knowledge of
community
• Uses the findings to
benefit the community
Researchers
Change
Community
members
How was CBPR critical to success of
patient navigation?
• Helped understand barriers to care
• Aligned important stakeholders to help
• Helped design a study that could be
completed in multiple community health
centers
• Once the results were in, we worked
together to find resources for ongoing
support
What do investigators need to do?
• Ask questions
• Support the community efforts in the
research
▫ Provide resources once the research is
funded
• Ask for help to interpret the findings
• Use the stakeholder group to
disseminate results
Asian Health Disparities in Women today
• What are the important health
questions?
Boston’s Chinatown
Cancer leading cause of
death among Asian
American women
Breast Cancer most
common cancer in
Chinese American
women
Fifth largest Chinese
population
Most densely settled
neighborhood
56% foreign born
62% linguistically
isolated
High rates of liver and
stomach cancer
Asian Cancer Disparities
• Foreign born Asian
populations have the
greatest unmet needs
during cancer care
• Foreign born Asian
populations have
greater
miscommunication
about goals of cancer
treatment
Asian Diabetes Disparities
• More diabetes,
metabolic diseases
at lower weight
▫ Overweight and
obesity redefined
for Asian
populations
Asian Mental Health Disparities
• Least likely to be screened for depression
• Present with physical symptoms
• Although patients understand their
symptoms to have emotional cause, less
likely to receive treatment
Asian Health Disparities
• Challenge of heterogeneity
• One size does not fit all
• Different challenges for different sub
populations
• Barriers to care often greater in foreign born
Asian American women
• Disease risks may or with place of birth
What we hope to gain today
• Community perspective
▫ Important health needs among Asian
American women
▫ Challenges
▫ Solutions
• Academic perspective
▫ Interventions to test solutions
▫ Methods to evaluate the interventions