Since the first health navigation program was established for low-income women with breast cancer in 1990,4 navigation programs for other cancers, diabetes, mental illness and HIV have proliferated. Navigators have become so widespread in North America because they may play a pivotal role in improved healthcare coordination.
Most of the evidence to support health navigation's impact on care coordination and health outcomes comes from research in cancer care; however, some evidence also exists in other fields, including HIV. Health navigation is so promising that several new initiatives are taking place. The National Cancer Institute in the United States has funded large randomized control trials that will help us better understand the efficacy of these programs.5 In HIV care, the Centers for Disease Control and Prevention in the United States have designated navigation an effective intervention.
This evidence review will define health navigation and describe navigators, their role and the clients they serve. This review will describe the available evidence from cancer care, diabetes care and HIV care to support navigation's impact on screening, testing and diagnosis outcomes, care outcomes, and treatment outcomes. Finally, it will also review client-reported outcomes such as satisfaction, self-reported mental health, and self-management skills.
We know that people living with HIV need support to link to and remain engaged in HIV care and treatment. The concept of the HIV treatment cascade (also known as the continuum of care) is one way to determine how well the system is doing to engage and keep people in care. The cascade is based on the successive steps that are needed for a person living with HIV to achieve an undetectable viral load, which is an optimal clinical endpoint. We know that treatment for HIV not only improves health but also quality of life.
We also know that an undetectable viral load plays a key role in the prevention of HIV transmission, meaning that keeping people in care and on treatment helps both the person living with HIV and their partners.
Health navigators have the potential to play a crucial role engaging people in HIV care across the treatment cascade. They can do this by helping people get HIV tests and diagnoses, linking clients to appropriate medical care (and other services), supporting clients while in care, helping clients access HIV treatment if and when they are ready, and supporting clients who are on treatment.
We know that many people living with HIV are not optimally engaged in care. Research tells us that individuals are lost at each step along the continuum of care. In the United States, it is estimated that between 19% and 28% of people living with HIV have an undetectable viral load.6,7 That means that up to 80% of people living with HIV in the U.S. may not be receiving optimal care because they were unable to take the necessary steps or receive the help they needed to do so. Although national data on the Canadian HIV treatment cascade is not available, we know from the numbers in Alberta (54%) and British Columbia (65%) that most people living with HIV in Canada are not receiving optimal care as measured by undetectable viral loads.8,9
There are two kinds of barriers clients may experience when accessing health care: systems-level barriers and individual barriers. Systems-level barriers are barriers that are caused as a result of the structure of the healthcare system. Barriers such as the appointment scheduling process,10 fragmented service delivery,11,12 and lack of specialized local healthcare services are all systems-level barriers.13 Navigators can advocate for reducing these barriers over time, but for individual clients, navigators tend to find ways to reduce the immediate impact these barriers have on client care by working with clients and other service providers.
Individual-level barriers are specific to each client. A lack of access to transportation,14 lack of access to adequate food and lodging,1 insufficient finances4,14 and lack of social support13,14 are all individual-level barriers. In the case of HIV care, active substance use and mental illness may also be significant individual-level barriers to care.
Navigators work with each client to identify the potential barriers they might face, find and implement solutions to those barriers, and over time, build the capacity of the client to manage these barriers themselves. By building relationships with each client, navigators may reduce the impact of all barriers on client access to care. This may improve client engagement in care, even in the face of barriers that may make accessing care a challenge.
Health navigation is an approach to improving healthcare delivery that helps individuals access the care they need.1-3 Health navigation is also known as peer navigation and patient navigation, and can share similar approaches to some care coordination and case management interventions. There is no standard definition of navigation because each navigation program targets the specific needs of clients in the local context. In this review, we use the term health navigation, or navigation, to encompass all these roles in addition to the roles of some peer educators and community health workers who may provide navigation services.
Health navigation services can be divided into two distinct categories:15
Most health navigation programs provide the following services:
Who is a navigator?
The first cancer navigation programs used lay community health workers, often survivors themselves, to improve access to care for other clients. The use of lay community health workers (often called peers in the HIV field) as navigators has since changed in many navigation programs.12 Professionals -- typically nurses or social workers -- are now taking on navigator roles in some programs.15
Whether professionals or lay workers are used, navigators must have the appropriate cultural knowledge and language skills to work with clients,15,19 and be able to build trust with clients.15 Navigators should also be able to improve the capacity of clients to make health-related decisions,12 educate clients,12 and address the psychosocial issues that may arise for clients as a result of care.12
Who is targeted by navigation programs?
Although most navigation programs in cancer care are targeted toward populations at higher risk for receiving inadequate care (for example, inner-city residents, Aboriginal peoples, low-income populations, minority populations and rural residents),15,16 there has been a trend toward providing navigation to all clients regardless of their need.12 More research is needed to determine the best populations to target for navigation.
In Canada, specific populations may be more likely than others to experience difficulty getting good care. We know that Aboriginal peoples,20 gay men and other men who have sex with men,21 people of African and Caribbean descent,22 and people who use injection drugs23 are all at higher risk of acquiring HIV and may also be less likely to receive the best care once diagnosed. These populations may benefit the most from HIV navigation services.
There is no standard model for health navigation that fits the needs of all populations, settings or systems because navigation programs are built to address the needs of the local context.15 Even when the approaches used vary, the goal of navigation -- to increase access to care -- remains the same. Navigation may be delivered in different settings (community versus hospital); to different populations; and by different workers (nurses versus peers).
Although most navigators receive some training, there is no standard approach or content.16 In 2012, the International Association of Providers of AIDS Care and the National Minority AIDS Council in the United States responded to the need for training materials and developed a training manual.
The available scientific literature was reviewed to determine if health navigation works. Details on the methodology we used can be found at the end of this article.
The available scientific evidence to support each outcome was assessed and assigned an evidence rating. Although the evidence rating is somewhat flexible, ratings were based on the following criteria:
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