Nurse navigation can improve quality of cancer care and reduce racial disparities in care outcomes. Addressing persistent structurally-rooted disparities requires research on strategies that support patients by prompting structural changes to systems of care. We applied a novel conceptualization of social support to an analysis of racial equity-focused navigation and patient-reported outcomes.
Method
We applied an antiracism lens to create a theory-informed definition of system-facing social support: intervening in a care system on a patient’s behalf. Participants were adults with early-stage breast or lung cancer, who racially identified as Black or White, and received specialized nurse navigation (n = 155). We coded navigators’ clinical notes (n = 3,251) to identify instances of system-facing support. We then estimated models to examine system-facing support in relation to race, perceived racism in health care settings, and mental health.
Results
Twelve percent of navigators’ clinical notes documented system-facing support. Black participants received more system-facing support than White participants, on average (b = 0.78, 95% confidence interval [CI]: [0.25, 1.31]). The interaction of race*system-facing support was significant in a model predicting perceived racism in health care settings at the end of the study controlling for baseline scores (b = 0.05, 95% CI [0.01, 0.09]). Trends in simple slopes indicated that among Black participants, more system-facing support was associated with slightly more perceived racism; no association among White participants.
Discussion
The term system-facing support highlights navigators’ role in advocating for patients within the care system. More research is needed to validate the construct system-facing support and examine its utility in interventions to advance health care equity.
AlcaláH. E. (2014). Differential mental health impact of cancer across racial/ethnic groups: Findings from a population-based study in California. BMC Public Health, 14(1), Article 930. https://doi.org/10.1186/1471-2458-14-930
2.
AlcarazK. I.WiedtT. L.DanielsE. C.YabroffK. R.GuerraC. E.WenderR. C. (2020). Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA: A Cancer Journal for Clinicians, 70(1), 31–46. https://doi.org/10.3322/caac.21586
3.
BaikS. H.GalloL. C.WellsK. J. (2016). Patient navigation in breast cancer treatment and survivorship: A systematic review. Journal of Clinical Oncology, 34(30), 3686–3696. https://doi.org/10.1200/JCO.2016.67.5454
4.
BarringtonW. E.DeGroffA.MelilloS.VuT.ColeA.EscofferyC.AskelsonN.SeegmillerL.GonzalezS. K.HannonP. (2019). Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs. Preventive Medicine, 129, 105858. https://doi.org/10.1016/j.ypmed.2019.105858
5.
BassettM. T.GravesJ. D. (2018). Uprooting institutionalized racism as public health practice. American Journal of Public Health, 108(4), 457. https://doi.org/10.2105/AJPH.2018.304314
6.
BazarganM.CobbS.AssariS. (2021). Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. The Annals of Family Medicine, 19(1), 4–15. https://doi.org/10.1370/afm.2632
7.
BickellN. A.NeumanJ.FeiK.FrancoR.JosephK.-A. (2012). Quality of breast cancer care: Perception versus practice. Journal of Clinical Oncology, 30(15), 1791–1795. https://doi.org/10.1200/JCO.2011.38.7605
8.
BlackK. Z.LightfootA. F.SchaalJ. C.MouwM. S.YongueC.SamuelC. A.FaustinY. F.AckertK. L.AkinsB.BakerS. L.FoleyK.HiltonA. R.Mann-JacksonL.RobertsonL. B.ShinJ. Y.YonasM. A.EngE. (2021). It’s like you don’t have a roadmap really: Using an antiracism framework to analyze patients’ encounters in the cancer system. Ethnicity & Health, 26(5), 676–696. https://doi.org/10.1080/13557858.2018.1557114
9.
ChanR. J.MilchV. E.Crawford-WilliamsF.AgbejuleO. A.JosephR.JohalJ.DickN.WallenM. P.RatcliffeJ.AgarwalA.NekhlyudovL.TieuM.Al-MomaniM.TurnbullS.SathiarajR.KeefeD.HartN. H. (2023). Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature. CA: A Cancer Journal for Clinicians, 73(6), 565–589. https://doi.org/10.3322/caac.21788
10.
CharlsonM.SzatrowskiT. P.PetersonJ.GoldJ. (1994). Validation of a combined comorbidity index. Journal of Clinical Epidemiology, 47(11), 1245–1251. https://doi.org/10.1016/0895-4356(94)90129-5
11.
CykertS.EngE.ManningM. A.RobertsonL. B.HeronD. E.JonesN. S.SchaalJ. C.LightfootA.ZhouH.YongueC. (2020). A multi-faceted intervention aimed at Black-White disparities in the treatment of early stage cancers: The ACCURE Pragmatic Quality Improvement trial. Journal of the National Medical Association, 112(5), 468–477. https://doi.org/10.1016/j.jnma.2019.03.001
12.
DuX. L.LinC. C.JohnsonN. J.AltekruseS. (2011). Effects of individual-level socioeconomic factors on racial disparities in cancer treatment and survival: Findings from the National Longitudinal Mortality Study, 1979-2003. Cancer, 117(14), 3242–3251. https://doi.org/10.1002/cncr.25854
13.
EngE.SchaalJ.BakerS.BlackK.CykertS.JonesN.LightfootA.RobertsonL.SamuelC.SmithB. (2017). Partnership, transparency, and accountability. In WallersteinN.MinklerM.OetzelJ. G.DuranB. (Eds.), Community-based participatory research for health: Advancing social and health equity (pp. 107–122). John Wiley.
GriesemerI.BirkenS. A.RiniC.MamanS.JohnR.ThatcherK.DixonC.YongueC.BakerS.BosireC.GarikipatiA.RyalsC. A.LightfootA. F. (2023). Mechanisms to enhance racial equity in health care: Developing a model to facilitate translation of the ACCURE intervention. SSM—Qualitative Research in Health, 3, 100204. https://doi.org/10.1016/j.ssmqr.2022.100204
18.
GriesemerI.LightfootA. F.EngE.BosireC.GuerrabF.KoteyA.AlexanderK. M.BakerS.BlackK. Z.DixonC.EllisK. R.FoleyK.GoettschC.MooreA.RyalsC. A.SmithB.YongueC.CykertS.RobertsonL. B. (2023). Examining ACCURE’s nurse navigation through an antiracist lens: Transparency and accountability in cancer care. Health Promotion Practice, 24(3), 415–425. https://doi.org/10.1177/15248399221136534
19.
GrubbsS. S.PoliteB. N.CarneyJ.Jr.BowserW.RogersJ.KaturakesN.HessP.PaskettE. D. (2013). Eliminating racial disparities in colorectal cancer in the real world: It took a village. Journal of Clinical Oncology, 31(16), 1928–1930. https://10.1200/JCO.2012.47.8412
HashemiS.-M.RafiemaneshH.AghamohammadiT.BadakhshM.AmirshahiM.SariM.BehnamfarN.RoudiniK. (2020). Prevalence of anxiety among breast cancer patients: A systematic review and meta-analysis. Breast Cancer, 27(2), 166–178. https://doi.org/10.1007/s12282-019-01031-9
22.
HaysR. D.BjornerJ. B.RevickiD. A.SpritzerK. L.CellaD. (2009). Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of Life Research, 18(7), 873–880. https://doi.org/10.1007/s11136-009-9496-9
23.
HeaneyC. A.IsraelB. A. (2008). Social networks and social support. In GlanzK. R. B. K.ViswanathK. (Eds.), Health behavior and health education: Theory, research, and practice (Vol. 4, pp. 189–210). Jossey-Bass.
24.
HershmanD. L.KushiL. H.HillyerG. C.CoromilasE.BuonoD.LameratoL.BovbjergD. H.MandelblattJ. S.TsaiW.-Y.ZhongX.JacobsonJ. S.WrightJ. D.NeugutA. I. (2016). Psychosocial factors related to non-persistence with adjuvant endocrine therapy among women with breast cancer: The Breast Cancer Quality of Care Study (BQUAL). Breast Cancer Research and Treatment, 157(1), 133–143. https://doi.org/10.1007/s10549-016-3788-x
25.
JojolaC.ChengH.WongL.PaskettE.FreundK.JohnstonF. (2017). Efficacy of patient navigation in cancer treatment: A systematic review. Journal of Oncology Navigation & Survivorship, 8(3), 106–115.
26.
KennardB. D.StewartS. M.OlveraR.BawdonR. E.LewisC. P.WinickN. J. (2004). Nonadherence in adolescent oncology patients: Preliminary data on psychological risk factors and relationships to outcome. Journal of Clinical Psychology in Medical Settings, 11(1), 31–39. https://doi.org/10.1023/B:JOCS.0000016267.21912.74
27.
KrebberA.BuffartL.KleijnG.RiepmaI.De BreeR.LeemansC.BeckerA.BrugJ.Van StratenA.CuijpersP. (2014). Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psycho-Oncology, 23(2), 121–130. https://doi.org/10.1002/pon.3409
28.
LaVeistT. A.NickersonK. J.BowieJ. V. (2000). Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. Medical Care Research and Review, 57(Suppl. 1), 146–161. https://doi.org/10.1177/1077558700057001S07
29.
MadisonA. A.PengJ.ShroutM. R.RennaM. E.AlfanoC. M.PovoskiS. P.LipariA. M.AgneseD. M.CarsonW. E.MalarkeyW. B.Kiecolt-GlaserJ. K. (2021). Distress trajectories in Black and White breast cancer survivors: From diagnosis to survivorship. Psychoneuroendocrinology, 131, 105288. https://doi.org/10.1016/j.psyneuen.2021.105288
30.
MarshallJ. K.MbahO. M.FordJ. G.Phelan-EmrickD.AhmedS.BoneL.WenzelJ.ShapiroG. R.HowertonM.JohnsonL.BrownQ.EwingA.PollackC. E. (2016). Effect of patient navigation on breast cancer screening among African American Medicare beneficiaries: A randomized controlled trial. Journal of General Internal Medicine, 31(1), 68–76. https://doi.org/10.1007/s11606-015-3484-2
MitchellA. J.ChanM.BhattiH.HaltonM.GrassiL.JohansenC.MeaderN. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. The Lancet Oncology, 12(2), 160–174. https://doi.org/10.1016/S1470-2045(11)70002-X
33.
NelsonH. D.CantorA.WagnerJ.JungbauerR.FuR.KondoK.StillmanL.QuiñonesA. (2020). Effectiveness of patient navigation to increase cancer screening in populations adversely affected by health disparities: A meta-analysis. Journal of General Internal Medicine, 35(10), 3026–3035. https://doi.org/10.1007/s11606-020-06020-9
34.
PilevarzadehM.AmirshahiM.AfsargharehbaghR.RafiemaneshH.HashemiS.-M.BalouchiA. (2019). Global prevalence of depression among breast cancer patients: A systematic review and meta-analysis. Breast Cancer Research and Treatment, 176(3), 519–533. https://doi.org/10.1007/s10549-019-05271-3
SastryS.ZollerH. M.WalkerT.SunderlandS. (2017). From patient navigation to cancer justice: Toward a culture-centered, community-owned intervention addressing disparities in cancer prevention. Frontiers in Communication, 2, Article 19. https://doi.org/10.3389/fcomm.2017.00019
37.
ShaversV. L.FaganP.JonesD.KleinW. M.BoyingtonJ.MotenC.RorieE. (2012). The state of research on racial/ethnic discrimination in the receipt of health care. American Journal of Public Health, 102(5), 953–966. https://doi.org/10.2105/AJPH.2012.300773
38.
WallersteinN. B.DuranB. (2006). Using community-based participatory research to address health disparities. Health Promotion Practice, 7(3), 312–323. https://doi.org/10.1177/1524839906289376
39.
WangY.-H.LiJ.-Q.ShiJ.-F.QueJ.-Y.LiuJ.-J.LappinJ. M.LeungJ.RavindranA. V.ChenW.-Q.QiaoY.-L.ShiJ.LuL.BaoY.-P. (2020). Depression and anxiety in relation to cancer incidence and mortality: A systematic review and meta-analysis of cohort studies. Molecular Psychiatry, 25(7), 1487–1499. https://doi.org/10.1038/s41380-019-0595-x
40.
WellsK. J.CampbellK.KumarA.ClarkT.Jean-PierreP. (2018). Effects of patient navigation on satisfaction with cancer care: A systematic review and meta-analysis. Supportive Care in Cancer, 26(5), 1369–1382. https://doi.org/10.1007/s00520-018-4108-2
41.
WheelerS. B.Reeder-HayesK. E.CareyL. A. (2013). Disparities in breast cancer treatment and outcomes: Biological, social, and health system determinants and opportunities for research. Oncologist, 18(9), 986–993. https://doi.org/10.1634/theoncologist.2013-0243
42.
WolfA.AlpertN.TranB. V.LiuB.FloresR.TaioliE. (2019). Persistence of racial disparities in early-stage lung cancer treatment. The Journal of Thoracic and Cardiovascular Surgery, 157(4), 1670–1679.e1674. https://doi.org/10.1016/j.jtcvs.2018.11.108
43.
YonasM. A.JonesN.EngE.VinesA. I.AronsonR.GriffithD. M.WhiteB.DuBoseM. (2006). The art and science of integrating undoing racism with CBPR: Challenges of pursuing NIH funding to investigate cancer care and racial equity. Journal of Urban Health, 83(6), 1004–1012. https://doi.org/10.1007/s11524-006-9114-x
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