Naveguemos con Salud: Providing Comprehensive Breast Health Support for Philadelphia Latinas

Breast Cancer as a Public Health Issue

According to the Centers for Disease Control and Prevention (CDC), in 2007, 202,964 women in the U.S. were newly diagnosed with breast cancer and another 40,598 died from the disease (CDC 2010). Breast cancer has been the most prevalent type of cancer among women from 1999 to 2007 (NPCR n.d.). Rates of late-stage breast cancer are prominent among African American and Hispanics (Halpern et al. 2007).

In Philadelphia, nearly 8 percent (264) of all cancer deaths were from breast cancer in 2005 (Schwarz 2009). According to the 2008 Public Health Management Corporation Pennsylvania Household Health Survey, 38.4 percent of Latinas ages 18 and older did not receive a clinical breast exam in the previous year. Further, nearly a quarter (22.8 percent) of Latinas in Philadelphia ages 40 and older had not received a mammogram in the previous two years, and 13 percent had never had one. Underutilization of breast cancer screenings contributes to the prevalence of late-stage cancers.

The Patient Navigation Model: Providing Support throughout the Cancer Care Continuum

The patient navigation model is a National Cancer Institute evidence-based model designed to support an individual throughout the cancer care continuum with help from a staff patient navigator. The navigator addresses care barriers and advocates for the individual during diagnosis, treatment, survivorship and end-of-life (Harold P. Freeman Institute 2011). Navigation services vary but barriers may result from:

• Finances (insurance problems)
• Communication (language)
• System issues (inconvenient appointments)
• Psychological concerns (fear/distrust)
• Other (such as mammography as low priority, transportation, child care) (Parkington et al. 2009; George 2000; Ahmed et al. 2010; Dohan & Schrag 2005; Adams et al. 2009)

Each navigation program reflects the needs of the patient. Stronger programs incorporate partnerships with healthcare systems and other community-based organizations (C-Change n.d.).

Naveguemos Con Salud: Bringing Patient Navigation to Philadelphia Latinas

In an effort to address barriers to care, improve breast cancer screening utilization rates, and assist with navigation services for Philadelphia Latinas, the Health Promotion Council created Naveguemos Con Salud (NCS) in 2010 with funding from the Department of Health and Human Services' Office of Minority Health. NCS has 4 objectives:

1. Increase awareness of breast cancer risk factors and prevention methods;
2. Increase knowledge of breast cancer;
3. Provide navigation services; and
4. Develop network of support the navigator.

HPC is well-positioned to lead NCS given its longstanding presence in Philadelphia, including demonstrated experience leading multi-partner initiatives reaching Latinos, and 7 years of experience in the breast cancer field.

NCS employs a project director, Tinesha Banks, and a navigator, Marla Vega. Ms. Banks provides oversight over the program while Ms. Vega provides navigation services to approximately 87 women. NCS also partners with a Philadelphia nonprofit, Esperanza, to train peer volunteers, or promotoras. Currently, approximately 13 promotoras and Ms. Vega provide breast health education workshops. Workshops also provide opportunities for NCS to recruit participants.

Ms. Banks defines a successful navigation program as one where the patient receives education and emotional support, and obtains screening and needed follow-up services. Ms. Banks says that “a patient navigator should be like a good friend who lives in the city you are traveling to for the first time…. [Y]ou can rely on her knowledge and expertise to get you from place to place safely so that you do not have to worry about getting lost.” For Ms. Vega to provide support, HPC convenes a Breast Health Navigation Network (BHNN) of approximately 16 partners including PHMC, Aspira, Inc., Esperanza, Living Beyond Breast Cancer and other organizations. Meeting 6 times per year, BHNN assists Ms. Vega with overcoming unanticipated challenges and provides linkages.

Innovation: Creating Support Structures for the Participant and Patient Navigator in the Community

NCS stands apart from hospital navigator programs by connecting participants with culturally specific resources in their own communities. Using the combination of the BHNN, navigator and community supporters, NCS identifies many in-community resources. Marla Vega says, “What makes NCS unique is the combination of patient education, the network resources and personal service provided in a culturally competent way.” Hospital navigator programs may do outreach within their system but usually are not a fixture in a targeted community. NCS specializes in meeting women in their home communities. Through workshops at neighborhood agencies (e.g., Esperanza), health centers (Health Center 6 in North Philadelphia) and other venues, NCS demonstrates its willingness to serve wherever it is needed. The map in Figure 1 depicts how NCS provides workshops and navigation services in areas with a high density of Latinas.
In addition to providing NCS participants with culturally appropriate supports, NCS also strives to ensure that Ms. Vega is armed with resources to be an effective advocate. As illustrated in the case study below, patient navigation is labor-intensive. 

Ms. Latina (name has been changed) is a 42-year old woman that has never had a clinical breast exam or mammogram. For the last 5 years, Ms. Latina has been experiencing discharge from her nipples but has been unable to afford the doctor’s visit and is too consumed with life to get checked out. She has 3 children. Two of her children are autistic and one is bipolar. She devotes most of her time, energy and limited funds to caring for her children. She speaks minimal English and has few family supports. Before she can even think about caring for herself, she has to get help caring for her children. Through NCS, Ms. Vega has: helped Ms. Latina line up child care, obtained insurance and financial assistance, scheduled and accompanied her to breast health appointments, provided translation services, and helped her to enroll in an ESL class. Ms. Latina was not diagnosed with cancer but is still undergoing tests. She still uses NCS navigation services for follow-up appointments.

Although many participants have similarly intense needs as Ms. Latina, studies that measured the efficacy of navigator programs have failed to report on the intensive work and other challenges confronting the navigator. In fact, at NCS, the navigator has on average 2 personal contacts per week (telephone or in person) with every woman on her caseload. To help her avoid burnout, BHNN ensures continuity and integration of expertise, access and support, and NCS provides her with comprehensive information about local resources.

Outcomes and Next Steps

Since its inception in 2010, NCS has made substantial progress in serving Philadelphia’s Latinas. Outcomes as of November 2011 include:

• Over 2,300 people have been reached through awareness mechanisms including face-to-face and/or telephonic outreach activities (e.g., health fairs, riding SEPTA, visiting waiting rooms at health centers). Twenty-seven educational sessions presented, at which surveys have shown increased knowledge among attendees.
• Ms. Vega has worked one-on-one with 87 women, helping them to obtain breast health and other services; among these almost 30 have received breast care, including 22 mammograms.
• Appointments are scheduled through early 2012.

Having experienced success in serving the Latino community, HPC looks to expand its navigation services to include African Americans. In 2011, the Chief Medical Officer of the American Cancer Society said that making progress against breast cancer will involve ensuring that “all women have access to high-quality prevention, detection, and treatment services.” NCS is committed to this perspective by providing community-specific labor intensive navigation services.

Naveguemos con Salud (NCS) Staff Bios

Tinesha Banks, MPH is the Deputy Executive Director, Strategic Development of HPC where she assists the Executive Director in agency management, strategic planning and development activities. Ms. Banks has over 15 years of experience in public health including expertise in health disparities, social marketing, cancer research, behavioral health and health information technology. Ms. Banks has her Bachelor’s in Sociology from State University of New York (SUNY) at Albany, NY and her Master’s in Public Health from Temple University.  

Marla Vega, M.Ed. is the Patient Navigator for HPC’s Naveguemos Con Salud program where she provides breast cancer navigation services to Philadelphia Latinas. Ms. Vega has over 9 years of direct health education experience as care coordinator for NCS and HPC’s asthma project. Ms. Vega has served the Philadelphia community since 1996. Ms. Vega earned a Master’s in Education and Bachelor’s in Social Work from Central Bayamon University in Puerto Rico.

References

Adams, E.K., L. Chien, C.S. Florence, and C. Raskind-Hood. (2009). The breast and cervical cancer prevention and treatment act in Georgia: Effects on time to Medicaid enrollment. Cancer. 115:1300-1309.

Ahmed, N.U., G. Haber, K.A. Semenaya, and M.K. Hargreaves. (2010). Randomized controlled trial of mammography intervention in insured very low-income women. Cancer, Epidemiology, Biomarkers and Prevention. 19(7): 1790-1798.

Breast Cancer Resource Directory of North Carolina, Fourth Edition. (2011). Hispanic American/latina Women. Available at http://bcresourcedirectory.org/directory/05-hispanic_american.htm.

C-Change. (n.d.) Cancer Patient Navigation Overview. Available at http://www.cancerpatientnavigation.org/.

Centers for Disease Control and Prevention. (2010). Breast cancer statistics. Available at http://www.cdc.gov/cancer/breast/statistics/index.htm.

Dohan, D. and D. Schrag. (2005). Using navigators to improve care of underserved patients: Current practices and approaches. American Cancer Society. 104: 848-855.

George, S.A. (2000). Barriers to breast cancer screening: An integrative review. Health Care for Women International. 21(1):53-65.

Halpern, M.T., J. Bian, E.M. Ward, N.M. Schrag, and A.Y. Chen. (2007). Insurance status and stage of cancer at diagnosis among women with breast cancer. Cancer. 110:403-411.

Harold P. Freeman Patient Navigation Institute. (2011). Our Model. Available at http://www.hpfreemanpni.org/our-model/.

National Program of Cancer Registries (NPCR). (n.d.) United States Cancer Statistics: 1999-2007 Cancer Incidence and Mortality Data. Atlanta, (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2010. Available at http://apps.nccd.cdc.gov/uscs/: http://www.cdc.gov/uscs.

Parkington, S.R., N. Faine, M.C. Nguyen, M.T. Lowry, and P.A. Virginkar. (2009). Barriers to breast cancer screening in a managed care population. Managed Care. 18(4): 34-45.

Schwarz, D.F. (2009, January 14). Philadelphia Department of Public Health, Cancer in Philadelphia: Surveillance, prevention and control. Available at http://www.phila.gov/health/pdfs/CancerinPhiladelphia_1.09.pdf.