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Health Navigation: A Review of the Evidence

Fall 2014

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Client-Reported Outcomes

Client-reported outcomes are a key measure of the success of navigator programs. Client dissatisfaction with navigation may suggest that programs are not meeting client needs. Client reported outcomes include satisfaction with care, mental health scores, and self-management skills.

There is moderate evidence that clients are satisfied with navigation programs. There is moderate evidence that navigation programs have a positive impact on client mental health outcomes. There is moderate evidence that navigation programs impact client self-management skills.


Satisfaction

Satisfaction with navigation is a key component of any successful program. Clients who do not like working with a navigator may not reap the potential benefits, including improved testing and diagnosis rates, improved retention in care and improved treatment outcomes.

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There is moderate evidence from cancer care, including a randomized control trial and observational research that clients who have a navigator are more likely to report higher satisfaction with their overall care when compared to the satisfaction scores of clients who did not receive navigation services.42-46 There is no evidence from HIV care or diabetes care on client satisfaction with navigator services.

A randomized control trial determined that patient satisfaction with care was higher among patients who received navigation (mean satisfaction score: 4.3/5), compared to those who did not (2.9/5).42

A cohort study among Aboriginal clients found that the proportion of clients who said that they received good overall care increased from 83% (before working with a navigator) to 96% (after receiving navigation).43

Two studies measured satisfaction with their programs, with no comparison group. Satisfaction rates were high in both studies, ranging from 93% to 96%.44,45

There is limited evidence from cancer care on primary care provider satisfaction with navigation programs. A study that measured the satisfaction of healthcare providers with navigation found that 75% of primary care providers gave their navigation program an overall rating of very satisfied or satisfied.27


Mental Health Outcomes

Reducing stress, anxiety and depression associated with illness and using the healthcare system may improve the likelihood that clients will stay in care.

There is moderate evidence from cancer care that navigation has a positive impact on mental health outcomes.42,47-49 There is no evidence from HIV care or diabetes care that navigation impacts mental health outcomes.

Among cancer patients, research from a randomized control trial and observational research shows that navigation can reduce anxiety,42 improve emotional well-being,47 and reduce distress.48 One study showed that the presence of a navigator was associated with a better emotional quality of life.49


Self-Management

Self-management, the ability to make informed choices about care and treatment options independently, is an important skill for many clients seeking health care. Good self-management skills may increase client retention and improve treatment outcomes as clients feel more engaged in their care.

There is moderate evidence from cancer care, including a randomized control trial and observational research, that navigation programs improve a client's ability to self-manage, as measured by improved decision-making skills.3,14,50 There is no evidence from HIV care or diabetes care that navigation improves self-management.

Clients in cancer care report being able to make informed choices about their options after working with a navigator.3,14,50 One randomized study found that 82% of women in navigation reported having a real say in their treatment options compared to 70% of women who did not have a navigator.50

In research based on 18 case studies of cancer clients working with navigators in Hawaii, 17 reported that working with a navigator improved their control over and confidence in making healthcare choices.14


Summary Table: Evidence to Support Navigation's Impact on Outcomes Across the Continuum of Care
 

Strong

Moderate

Limited

None

Ineffective

Screening/Testing

X

   

Confirmatory Testing

X

   

Diagnosis

  

X

 

Access to Care

  

X

 

Retention in Care

  

X

 

Treatment

  

X

 

Satisfaction with Care

 

X

  

Physician Satisfaction with Navigation

  

X

 

Mental Health Outcomes

 

X

  

Disease self-Management

 

X

  


What does this mean for organizations considering a health navigation program in HIV care?

There is evidence to suggest that health navigation may be beneficial for clients seeking testing, care, and treatment for some health conditions, including HIV. Critically, there is also evidence that navigation is acceptable to clients and that they are more satisfied with their health care than clients who do not have navigators. Although there is limited evidence on the efficacy of HIV navigation from randomized control trials, there is a fair amount of evidence from observational studies. Although randomized control trials are typically seen as the best type of study, they may not be the best way to measure the success of this type of intervention. Navigation programs are diverse and it may be more appropriate at times to conduct observational studies to measure their impact on the health of people living with HIV.

There is no standard model of health navigation, as each program is tailored to the needs of the local context. Organizations considering the implementation of a health navigation program for HIV should perform a needs assessment. Such an assessment would help identify an approach to navigation that meets the needs of the community, the needs of the healthcare setting, and the type of medical system in place.

Assessments should also identify local barriers to care; the types of interventions that may help overcome these barriers; whether lay workers or professionals would be best suited to provide navigation; and identify potential community and/or clinical partners for the program.

Organizations considering a navigation program for HIV care may want to learn from a jurisdiction that has already implemented one. Currently, there are three navigation programs in Canada for people living with HIV: Peer Navigation Services in Vancouver, B.C.; the Chronic Health Navigation Program in Kamloops, B.C.; and the Peer-to-Peer Program in Regina, SK.


Methodology

This review is based on a search that included the use of PubMed, CINAHL, and The Cochrane Library. MeSH search terms included patient navigation, delivery of health care, continuity of patient care, health services accessibility, patient acceptance of health care, case management, community health workers, peer group, medication adherence, patient compliance, HIV infections, hepatitis C, diabetes mellitus, and neoplasms.

Keyword search terms included health navigation, linkage, linking, engagement, and retention. The reference lists of relevant articles were also reviewed for additional citations. The search for diabetes literature was limited to systematic reviews. The search for cancer literature focused on systematic reviews and also included other recent literature from 2010 to the present. All searches focused on North American settings.

Logan Broeckaert holds a master's degree in history and is currently a researcher/writer at CATIE. Before joining CATIE, Logan worked on provincial and national research and knowledge exchange projects for the Canadian AIDS Society and the Ontario Public Health Association. Laurel Challacombe holds a master's degree in epidemiology and is currently manager of research and evaluation at CATIE. Laurel has worked in the field of HIV for more than 10 years and has held various positions in both provincial and regional organizations, working in research and knowledge transfer and exchange.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 

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