Japan Journal of Nursing Science (2016)

(2015) 13, 205–219 doi:10.1111/jjns.12102

doi:10.1111/jjns.12102

REVIEW ARTICLE

Effectiveness of patient navigator interventions on uptake of

colorectal cancer screening in primary care settings
Joshua Kanaabi MULIIRA and Melba Sheila D’SOUZA
College of Nursing, Department of Adult Health and Critical Care, Sultan Qaboos University, Muscat, Oman

Abstract
Aim: Colorectal cancer is the fourth most common type of cancer in the world and every year it is
responsible for 610,000 deaths worldwide. The aim of this review was to examine the effectiveness of patient
navigator interventions towards enhancing uptake of colorectal cancer screening in primary care settings.
Methods: Electronic databases such as PubMed, CINHAL, Google Scholar and SCOPUS were searched to
retrieve articles reporting on primary studies applying any patient navigator intervention to promote uptake
of colorectal cancer screening in eligible patients. The search yielded 292 articles and 15 met the inclusion
criteria.
Results: All 15 studies were conducted in urban settings located in the USA. The findings of the review show
that patient navigator interventions can increase colorectal cancer screening rates in diverse primary care
settings. Patient navigator interventions were most effective in patients who belong to minority groups and
enhanced uptake of colorectal cancer screening with rates ranging 11–91%.
Conclusion: There is a need for further studies to examine the effectiveness of patient navigator interven-
tions in rural populations and other countries. Such studies will help us to clearly characterize the effec-
tiveness of patient navigator interventions.
Key words: cancer prevention, colorectal cancer screening, colorectal cancer, navigation, primary care.

INTRODUCTION 2009; Musaiger, 2004). Some specific diseases such as

Colorectal cancer (CRC) is the fourth most common
type of cancer in the world and every year it is respon-
sible for 610,000 deaths worldwide (World Health
Organization, 2013). The most common risk factors for
CRC are those related to genetic predisposition and
dietary practices such as consumption of a high-fat diet,
high amounts of red meat, and lack of fiber and veg-
etable in the diet (Huxley et al., 2009; Umar &
Greenwald, 2009). The other risk factors for CRC
include obesity, smoking, age older than 50 years, lack
of exercise, and chronic use of alcohol (Huxley et al.,
Correspondence: Joshua K. Muliira, College of Nursing,
Department of Adult Health and Critical Care, Sultan
Qaboos University, PO Box 66 Al Khod, Muscat, PC 123,
Oman. Email: jmuliira@squ.edu.om; jkmuliira@gmail.com
Received 22 November 2014; accepted 17 August 2015.
ulcerative colitis, Crohn’s disease, and diabetes are also
associated with increased risk for CRC (Huxley et al.,
2009).
One of the crucial responses and strategies used to
reduce the mortality and morbidity associated with
CRC is early detection through screening (Edwards
et al., 2010; Siegel, DeSantis, & Jemal, 2014). Screening
is a systematic application of medical tests in asymptom-
atic populations to identify individuals with abnormali-
ties suggestive of precancer or cancer states and referring
them to get prompt diagnosis and treatment. The cancer
screening services are mostly provided or initiated in the
primary care settings. However, unlike other cancer
screening tests and procedures (e.g. Papanicolaou smear
and mammograms), the majority of tests or procedures
used to screen for CRC are more complex and invasive.
As a result, many patients face several barriers that
reduce their propensity to get screened for CRC. The

© 2015 Japan Academy of Nursing

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J. K.
J. K. Muliira
Muliira and M. S. D’Souza
barriers to CRC screening include patient factors, pro-
vider factors, and healthcare system factors (Hendren
et al., 2010).
The patient factors that are commonly reported
include lack of trust in the healthcare provider, low
health literacy, lack of healthcare insurance, fear of news
about ones cancer status, fatalistic views about cancer
(Lasser, Ayanian, Fletcher, & Good, 2008), and fear of
embarrassment or invasion of privacy during the proce-
dure (Filippi et al., 2012). The common provider and
healthcare system barriers include lack of systems to
identify patient eligible for screening, lack of clear pro-
tocols on how to provide results to patients (Levy, Daly,
Schmidt, & Xu, 2012), lack of cultural competency,
difficulty in scheduling appointments for screening or
waiting for long periods to get a screening appointment,
and lack of systems to remind patients about scheduled
appointments (Hendren et al., 2010; Medina,
McQueen, Greisinger, Bartholomew, & Vernon, 2012).
One of the interventions used to overcome the barri-
ers and to enhance CRC screening uptake is patient
navigation or patient navigators (PN). Published work
about the origin and evolution of patient navigation
shows that the concept was initiated as a response to the
hearings conducted by the American Cancer Society in
1989 focusing on strategies to eliminate barriers to
timely diagnosis of cancer and other chronic diseases
(Freeman, 2012). Subsequently, the first patient naviga-
tion program was initiated in 1990 in Harlem (New
York, NY, USA) to save lives of cancer patients by
eliminating barriers (financial, communication, infor-
mation, medical system, fear, distrust, and emotional
barriers) to timely care between the point of suspicious
cancer findings to the time of diagnosis and treatment
(Freeman, 2012). In some settings in the USA, providing
patient navigation services has since developed into an
auxiliary health profession where PN with various edu-
cational backgrounds receive tailored training to assist
cancer patients in navigating the barriers to the different
types of needed cancer care services.
Patient navigators are persons who assist individuals
in the community or primary care settings to maneuver
and navigate through the personal, healthcare provider,
and healthcare system barriers in order to attain better
access to healthcare services (Ramsey et al., 2009). PN
provide support and guidance which enables the patient
to overcome the personal and healthcare system per-
ceived and actual barriers to receiving timely cancer care
such as screening, diagnostic resolution, and treatment
(Freund et al., 2008). PN interventions are commonly
used in communities with limited access to health care
2206
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of Nursing
JournalScience (2016)Science
of Nursing 13, 205–219
(2015)
(Robinson-White, Conroy, Slavish, & Rosenzweig,
2010; Wells et al., 2008).
Patient navigator interventions are founded on the
tenets of the social support and social networks theory
which illustrate that the influence of a person or
members in one’s social network can affect their health
behavior and related decision-making (Charles &
DeMaio, 1993; Israel & McLeroy, 1985). The individu-
al’s social network provides him or her with: emotional
support (empathy, moral support, trust, concern, and
caring); instrumental support (tangible help such as
resources, time, transport and others); informational
support (advice, suggestions, directions, and other infor-
mation); and appraisal support (affirmation, construc-
tive feedback, and stimulating self-appraisal) (House,
1981). The support provided influences the person’s
behaviors (House, 1981).
Patient navigator interventions provide patients with
different forms of support and assistance to overcome a
variety of barriers that may be preventing them from
accessing the needed care, thus reducing delays in attain-
ing health services (Paskett, Harrop, & Wells, 2011).
The support provided to patients through PN interven-
tions may include scheduling of medical appointments,
transportation, teaching about the disease condition or
screening procedures, counseling, encouragement,
reminding of scheduled appointment, and others
(Nguyen, Tanjasiri, Kagawa-Singer, Tran, & Foo, 2008;
Robinson-White et al., 2010).
AIM
The aim of this review was to assess the effectiveness of
PN interventions towards enhancing uptake of CRC
screening in primary care settings.
METHODS
The review focused on published studies about the effec-
tiveness of PN interventions towards enhancing uptake
of CRC screening which were implemented in primary
care settings. The authors individually searched pub-
lished work from databases known to have publications
about studies focusing on the PN intervention and CRC
screening. The articles published during the period of
January 2003 to May 2014 were searched and retrieved
from databases including SCOPUS, CINAHL, Google
Scholar, and PubMed. This period was selected because
the PN intervention and its application in cancer pre-
vention first appeared in scientific published work
© 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2016)
(2015) 13, 205–219
around 2003. The articles were retrieved from the data-
bases in the period between November 2013 to May
2014.
The MeSh terms used to retrieve the articles were:
[Patient Navigator] and 1-[Colorectal Cancer],
2-[Cancer Screening], 3-[Cancer Early Detection],
4-[Cancer Screening Tests], 5-[Early Diagnosis of
Cancer], 6-[Cancer Early Diagnosis], and 7-[Screening
Tests]. The reference lists of the identified articles were
also reviewed during the primary search to find addi-
tional articles which might have been missed during
database searches.
The two search strategies (searching using the elec-
tronic databases and reviewing the reference lists of
identified articles) were limited to articles which were
written in English language, reporting on primary quan-
titative studies using any type of PN intervention, and
studies where CRC screening was measured as one of
the outcomes of the intervention. A total of 15 articles
were selected from the electronic databases as illustrated
in Figure 1 and no additional articles were found by
reviewing their respective reference lists. The 15 articles
were studied by the authors and used to develop the
results presented in Tables 1 and 2.
In this review, uptake of CRC screening was defined
as a patient undergoing any type test (fecal occult blood
test, flexible sigmoidoscopy, or colonoscopy) for the
purpose of screening for CRC. The PN intervention was
Data Sources: SCOPUS, CINAHL, Google Scholar, PUBMED
292 titles identified in the first step of literature search
272 articles were excluded (CRC
screening was not one of the outcomes
measured; studies involved treatment for
CRC; studies were about diagnostic
resolution after initial screening; articles
were not reporting about qualitative
studies; literature review articles; and
articles reporting about complications or
side effects of CRC screening).
20 articles were selected
5 articles were excluded (qualitative
studies, focusing on only diagnostic
resolution as the main outcome, and
focusing on only cost analysis of a
patient navigator program).
15 articles finally selected
Figure 1 Pathway to search strategy. CRC, colorectal cancer.
Nursing Science
© 2015 Japan Academy of Nursing Science
Patient
Patient navigation
navigation and
and CRC
CRC screening
screening
defined as having an individual (peer, layperson, or pro-
fessional) specifically prepared and assigned to assist
patients to navigate or move through the healthcare
system to get screened for CRC (Sly, Edwards, Shelton,
& Jandorf, 2012). The above definition of the PN inter-
vention is in line with the social support and social
networks theory which posits that social support net-
works entrench linkages among persons who are sup-
portive of each other on a regular basis or in times of
need or crisis (Grant & Ramcharan, 2001). According
to the social support and social networks theory, indi-
viduals in one’s social network such PN provide differ-
ent types of support and do things for the patient by
working with him or her and others in the social
network, social organizations, or the community in
which the patient resides (Parker et al., 2010). The
support provided by the PN in turn influences the
patient’s health behaviors and helps them to meet spe-
cific needs (House, 1981).
REVIEW PROCESS
The two investigators performed an initial review of all
article titles for relevance to the focus of the study (PN
intervention and CRC screening uptake). If at least one
of the two investigators determined that the title of the
article was relevant, the abstract was retrieved and
reviewed. Each abstract was screened by the two inves-
tigators working independently using the following
inclusion criteria: published in the year 2003 or later;
reporting on a primary quantitative study; involved par-
ticipants of age 50 years and above; participants
received or had access to a PN intervention; and partici-
pants underwent or were expected to undergo CRC
screening. The complete papers for each of the abstracts
that met the above criteria were retrieved and included
in the review. Articles with the following characteristics
were excluded from the review: CRC screening was not
one of the outcomes measured; focusing on treatment
for CRC or diagnostic resolution after initial screening;
focusing on complications associated with CRC screen-
ing tests and procedures; and qualitative studies or pub-
lished work review articles. The process of handling the
retrieved articles is illustrated in Figure 1.
RESULTS
The 15 articles included in the review (see Tables 1 and
2) were analyzed to get information about the authors,
year of publication, study setting, sample size, design,
participants characteristics, type of PN intervention,
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Table 1 Randomized controlled trials focusing on the effect of patient navigator intervention on uptake of CRC screening
First author Information Design, type of PN intervention and
(year) Study setting Sample characteristics about PN outcome measures Outcomes of the PN intervention and conclusion Limits
K. Muliira

Myers et al. 10 primary care n = 742: patients not The PN was a Design: randomized controlled trial Primary outcomes: • Conducted in a
(2013) practices compliant with the nurse. Interventions: • Patients were not up to date with ACS screening state with high
affiliated with ACS screening • Tailored PN group: PN provided guidelines (baseline rate for setting was not penetration of
the Christiana guidelines (78% mailing of CRC screening reported). programs to
Care Health white, 62% female, information booklets and screening • After 6 months, CRC screening adherence was enhance CRC
System in 57% had greater test materials as per participant’s higher in PN (38%) and SI (33%) group compared screening.
Delaware. than high school preferences, telephone calls to verify with that of the control group (12%; P = 0.001 for • Sample was
education). and update screening test preference, both comparisons). obtained from a
• Tailored PN discussing concerns and barriers to
Muliira and M. S. D’Souza

• After 12 months, screening rates of PN (43%) and population with

intervention group screening with the participants, SI (36%) group were still significantly higher than high social
(n = 312). giving encouragement and reminders that of the control group (18%; P = 0.001 for both status.
• Standard at 30 and 90 days for those who comparisons). • Health
intervention (SI) preferred stool blood test and insurance status
colonoscopy, respectively.
• CRC screening adherence in the PN and SI group
group (n = 316). was similar (P = 0.86). of participants
• Control group • SI group: received mailed Secondary outcomes was not
(n = 317). information booklets on CRC • CRC screening by colonoscopy and FOBT was reported.
screening (the booklet also included higher in the PN group than in the control group.
a nurse contact telephone number if
needed to schedule colonoscopy,
• At baseline, 75% of the PN group, 78% of the SI
group, and 73% of the control group had decided
stool blood test kit) and a reminder
to do CRC screening.
letter was sent 30 days post
randomization. • At 6 months, more of the PN group (91%) and SI
• Control group: received usual care group (87%) participants had decided to do or
(screening in the absence of received screened compared with those in the
intervention). control group (81%; P = 0.001 for both
Outcome measure comparisons).
• CRC screening: adherence at 6 and Conclusion:
12 months (getting any CRC • Tailored PN increased adherence to CRC screening,
screening test recommended by the and was more effective than the mailed intervention
guidelines). in moving forward in terms of CRC screening
decision stage.
Jandorf et al. Mount Sinai’s n = 503: participants • Culturally Design: randomized clinical trials. Primary outcomes: • No control
(2012) Primary Care were above the age targeted peer Interventions: • Patients had not received a colonoscopy for at least group.
Clinic (East of 50 years, without or lay PN • Community-based culturally the past 5 years and were not up to date with other • Data from the
Harlem, NY, gastrointestinal (African targeted peer PN for African forms of CRC screening (baseline rate for setting four different
USA). symptoms, American). American participants. was not reported). PN groups was
comorbidity, history • Culturally • Culturally targeted professional PN • In 2 years, 78.5% of PN patients completed analyzed
Japan JournalJapan

of inflammatory targeted for African American participants. colonoscopy (level of significance not reported). together.
bowel disease, and professional • Non-targeted professional PN • Total cost of navigation (supplies, training and PN
colonoscopy for at PN (trained
of Nursing

(language concordance maintained). salaries) for each completer was $US 28.83
least the past 5 health compared with $US 21.40 for non-completers.
years. Participants
• Non-targeted professional PN
educator and (language concordance maintained). Conclusion
were not up to date African • PN among minority patients with public insurance,
Navigation using scripted telephone
JournalScience

with other forms of American) increased colonoscopy screening rates and generated
calls. Services provided include
CRC screening • Non-targeted additional income.
scheduling, bowel preparation
(68% female, professional
of Nursing

instructions, reminder postcards,

46.3% African PN (trained assessment of transportation needs,
Americans, 45.7% health patient education, and support.
Latino, 52.7% educator, but Outcome measures:
Medicaid, 26.8%
(2016)Science

maintaining • Colonoscopy completion rate and

Medicare, and language PN costs.
20.5% had private concordance).
insurance).

© 2015 Japan Academy of Nursing Science

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13, 205–219
 Lasser et al. Four community n = 465: low-income Three PN who Design: randomized clinical trail. Primary outcomes: • Excluded some
(2011) health centers patients aged 52–74 were trained, Intervention: • Patients were not up to date with CRC screening eligible patients
and two public years who had not bilingual • Maximum of 6 h of PN in 6 according to the USPSTF guidelines (baseline rate (with substance
hospital-based completed CRC (speaking months. The PN provided services for the facility was not reported). abuse or mental
clinics in MA, screening according English and a such as education about CRC, • After 1 year, 33.6% of the PN patients had illness).
USA. to USPSTF second mailing screening brochures with received CRC screening compared with 20% in the • Study was
guidelines (48% language such information about screening tests control group (P < 0.001). conducted in
white, 27% black, as Spanish, and bowel preparation, motivating • After 1 year, 26.4% of the PN patients had community with
33% private Portuguese, patients, assisting patients to get received screening colonoscopy compared with a high rate of

© 2015 Japan Academy of Nursing

insurance, 21% and/or insurance coverage, scheduling 13% in the control group (P < 0.001). CRC screening
Medicare, and 20% Haitian appointments and escorting patients (61%).
• After 1 year, 40% of black PN patients had
Japan Journal of Nursing Science (2016)

had Medicaid). Creole) and to their homes after the screening

received CRC screening compared with 17% of
• Intervention group experienced in tests or procedure.

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non-black patients in the same group (P = 0.004).
(n = 235). community • Control group: received usual care
• Control group outreach Outcome measures:
• After 1 year, more patients whose primary language
work was not English in the PN group (40%) had
(n = 230). • Completion of CRC screening
(certified received CRC screening compared with 18.6% of
(FOBT, barium enema,
nurse the same category in the control group (P < 0.001).
(2015) 13, 205–219

sigmoidoscopy, and colonoscopy) in

assistant, Conclusion:
1 year.
bachelors in • PN increased completion of CRC screening in
clinical ethnically diverse patients.
psychology).
Christie et al. Primary care n = 21: age greater The PN was a Design: prospective randomized Primary outcomes: • Small sample
(2008) practice settings than 50 years, health controlled trial. • Patients were not up to date with CRC screening size.
in New York asymptomatic for educator Intervention: (baseline rate for setting was not reported).
City (NY, USA). gastrointestinal trained in • PN provided services such as • After 6 months, 54% of PN patients had completed
symptoms, had a navigation following up colonoscopy referrals, colonoscopy compared with 13% of control group
primary care services. patient education, answering patient (P = 0.058).
physician, and a questions about colonoscopy, • 23% of PN patients refused colonoscopy compared
referral for sending reminders of colonoscopy with 63% of the control group (level of significance
screening appointments, explaining the not reported).
colonoscopy (71% screening procedure and Secondary outcomes:
Hispanics, 21% expectations in English and Spanish, • 100% of PN patients were very satisfied with PN
African American, assisting patient with transportation services.
75% male, 81% and rescheduling appointments.
had annual income
• 86% of PN patients had excellent or very good
• Control group: received usual care bowel preparation.
<$20,000, 52% (colonoscopy referral form inserted Conclusion:
Patient

were uninsured, and in the patient’s chart). • PN improved compliance with screening
71% had less than Outcome measures: colonoscopy in low-income minorities.
high school • Compliance with screening
education). colonoscopy.
• Intervention group
(n = 13).
Patient navigation

• Control group
navigation and

(n = 8).
and CRC
CRC screening

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screening
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Table 1 Continued
J. K.

6210
First author Information Design, type of PN intervention and
(year) Study setting Sample characteristics about PN outcome measures Outcomes of the PN intervention and conclusion Limits

Percac-Lima Massachusetts Age range of 52–79 PN were college Design: randomized controlled trial. Primary outcomes: • Data was
K. Muliira

et al. General years, eligible for educated. One Intervention: • Patients were not up to date with CRC screening collected from a
(2008) Hospital’s CRC screening of the PN was • The PN provided services such as according to the USPSTF guidelines (CRC screening single, urban
Chelsea according to the bilingual patient education, scheduling rate for the setting was reported to be 53.7%). community
Healthcare USPSTF guidelines (English and screening appointments, assistance • After 9 months, 27.4% of PN patients received health center.
Center (Chelsea, (60% female, 40% Spanish) and with transportation, sending CRC screening compared with 11.9% in the • Some patients in
MA, USA). Latino, 47% white, the other four reminders of screening control group (P < 0.001). the control
5% black, 40% spoke appointments, interpreting bowel • After 9 months, colonoscopy was performed in group might
non-English different preparation instructions in native 20.8% of PN patients compared with 9.6% of the have received
speakers, 53% had combinations language of patient, encouraging control group (P < 0.001). CRC screening
Muliira and M. S. D’Souza

private insurance, of six other patients to do screening and elsewhere.

• Patients contacted by the PN in person were more
27% Medicare and languages. accompanying them to and from the • No blinding of
likely to complete CRC screening (42.7%)
13% were receiving procedure. intervention
compared to those contacted by other methods
free health care). • Control group: received usual care. status.
(33%; P = 0.09).
• Intervention group Outcome measures:
(n = 409). • 35% of patients contacted in person by PN • There is a
• CRC screening rate (colonoscopy, chance that the
• Control group received colonoscopy compared with 23.2% of
sigmoidoscopy, barium enema, Latino
patients contacted by other methods (P = 0.03).
(n = 814). FOBT) established through chart population was
Secondary outcomes:
review. contaminated.
• Non-English speaking and Latino PN patients had
higher screening rates than control group
(P < 0.001).
• 10.5% polyps were detected per 100 PN patients
compared with 6.8% in control group (P = 0.04).
Conclusion:
• The culturally tailored, language-concordant PN
improved colonoscopy rates in low-income and
ethnically diverse population.
Jandorf et al. One primary care n = 78: above 50 years PN had a similar Design: Prospective clinical trial Primary outcomes: • Small sample
(2005) health center in of age, ethnic Intervention: • Patients were not up to date with CRC screening size.
New York City asymptomatic, with background • The participants had a physician (baseline rate not reported). • No
(East Harlem, no FOBT in past 1 and lived in recommendation for FOBT, • After 3 months, FOBT completion was higher in documentation
NY, USA). year, no the same endoscopic screening and received PN patients (42.1%) than in the control group of physician
sigmoidoscopy or community as the PN services. The PN provided (25%), but not statistically significant. recommendation.
barium enema in the services such as written reminders, • After 3 months, 18.4% of the PN patients had • Qualifications of
past 3–5 years, or participants. scheduling of screening scheduled endoscopy appointments compared with the PN are not
colonoscopy in past appointments, telephone support 0% in the control group (P = 0.005). described.
10 years (74.4% and encouragement to participate in
• Within 6 months, completion of endoscopic CRC
Japan JournalJapan

female, 82.1% CRC screening, and patient

screening was higher in the PN patients (23.7%)
Hispanic, 95% had education about CRC.
than in control group patients (5%; P = 0.019).
a primary provider, • Control group: received only
• Within 6 months, 15.8% of PN patients had
of Nursing

69% had Medicare physician recommendation for

and/or Medicaid, complied with endoscopic screening compared with
FOBT and endoscopic screening.
91% were 5% in the control group (P = 0.019).
Outcome measures:
unemployed, and Conclusion:
• Completion of CRC screening (chart
JournalScience

66% had annual • In 6 months, the PN intervention increased CRC

review) in 6 months.
income screening by endoscopy in a predominantly poor
urban minority population.
of Nursing

<$US 10,000).
• Intervention group
(n = 38).
• Control group
(2016)Science

(n = 40).
ACS, American Cancer Society; CRC, colorectal cancer; FOBT, fecal occult blood testing; PN, patient navigator; USPSTF, US Preventive Services Task Force.

© 2015 Japan Academy of Nursing Science

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 Table 2 Studies using other designs and showing effect of patient navigator intervention on uptake of CRC screening
First author Information Outcomes of the PN
(year) Study setting Sample characteristics about PN intervention and conclusion Results and conclusion Limits

Honeycutt Thirteen clinics in n = 809: low-income, Trained Design: quasi experimental Primary outcomes: • No
et al. federally underinsured or professional Intervention: • At baseline, the rate of CRC screening referral, randomization of
(2013) qualified uninsured, non-high-risk navigator • PN provided services such as colonoscopy completion, and compliance with CRC patients and
community adults in age group of employed by coordination, follow up of screening guidelines in eligible patients at both clinics.
health centers in 50–64 years and eligible the health screening, sending intervention and comparison clinics was 35.3%, • No clear
South West for colonoscopy as per center. appointment reminders, 16%, and 22.1%, respectively. distinction
Georgia (USA). USPSTF guidelines assisting with transportation • After 18 months, 58% of PN patients received between
• Four (67% female, 63% and one-on-one patient referrals for screening compared with 24% in screening or
intervention black, 37% white). education. comparison group (OR = 4.8, P < 0.001). diagnostic
clinics. • Intervention group: Other services provided with • After 18 months, 35% of PN patients received colonoscopy.
• Nine n = 289. the intervention: reduced colonoscopy compared with 7% in comparison • Qualifications of

© 2015 Japan Academy of Nursing

comparison • Comparison group: cost for colonoscopy. group (OR = 7.9, P < 0.001). PN were not
clinics. n = 520. • Comparison group: received reported.
usual care.
• After 18 months, 42.6% of PN group were
Japan Journal of Nursing Science (2016)

guideline compliant compared with 10.6% in

Outcome measures:

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Science
comparison group (OR = 5.9, P < 0.001).
• Rate of CRC screening
Conclusion:
referral and colonoscopy
• PN can be effective at ensuring preventive screening
completion.
in low-income adults in rural settings.
Cavanagh Suffolk County n = 886: uninsured or Trained bilingual Design: interventional project. Primary outcomes: • No
(2015) 13, 205–219

et al. Department of underinsured, above the PN (English Intervention: • The participants were due for CRC screening randomization.
(2013) Health Services age of 50 years, and Spanish) • The PN provided services (baseline colonoscopy completion rates not • No control
Community asymptomatic and due with a such as initial contact with reported). group.
Health Centers for colorectal cancer bachelor’s patients by telephone to • In a period of 40 months 90% of the participants
and Stony screening (65% female, degree in a explain the colonoscopy completed colonoscopy (level of significance not
Brook 45.3% Hispanic, 26.6% health-related procedure, scheduling reported).
University white, 16.9% black). field and prior appointments, sending Secondary outcomes:
Medical working appointment reminders, • 2 months after the colonoscopy, 99% of the
Center’s experience sending written bowel patients indicated positive satisfaction with the
Department of with preparation instructions, program (level of significance not reported).
Preventive disadvantaged telephone-based patient Conclusion:
Medicine (New populations. education, emotional • Coordination of care, directing the recruitment,
York, NY, USA). support, and physical escort scheduling, prescreening education, evaluation and
to the medical center. preparation of target population had an overall
Outcome measures positive effect on CRC screening with colonoscopy.
• Colonoscopy completion
Leone et al. Community care of n = 413: Medicaid patients Trained staff Design: quasi-experimental Primary outcomes: • No
(2013) Lower Cape above 50 years who (Medicaid Intervention: • The baseline CRC screening rates at intervention randomization.
Fear (NC, USA). were not up to date patient • Mailed screening reminder practices was 35.6% and 46% at the control • Data for control
• Six intervention with USPSTF outreach and tested decision aid practices. group was based
Patient

primary care recommendations coordinator) (DVD) and telephone-based • After 6 months, 9.2% of PN patients had a CRC on claim
practices. (57.2% female, 53.1% provided PN. PN provided services screening test compared with 7.5% in the control information and
• Six matched black, 40.1% white). telephone-based such as scheduling group (not statistically significant). not on chart
control primary • Intervention group: patient appointments, • After 1 year, 16.3% of PN patients had been review.
care practices. n = 240. navigation. transportation, sending screened compared with 10.3% in the control • Qualifications of
Patient navigation

• Matched control group: appointment reminders, and group (not statistically significant). the PN were not
n = 174. preparing patients for the Conclusion: reported.
navigation and

testing. • The PN intervention had limited reach and little

• Matched control practices: effect after 6 months on the number of participants
participants received usual screened.
and CRC

care.
Outcome measures
• Completion of any CRC
screening test in the 6
CRC screening

months intervention period.

2117
screening

8212
Table 2 Continued
First author
(year) Study setting Sample characteristics
Lebwohl Columbia Intervention group Professional PN
et al. University (n = 749): eligible urban
(2011) Medical Center, minorities identified by
Manhattan, the primary care
New York (NY. providers at the general
USA). medical clinic,
gynecological clinic and
Human
Immunodeficiency Virus
Clinic (87% Medicaid;
41% Male).
Comparison group
(n = 1856): urban
minorities,
non-navigated patients
who received
colonoscopy before the
program (63% female).
Private patients (n = 7365):
56% female.
Ma et al. Six Korean n = 167: Korean American Culturally
(2009) American above the age of 50
Churches in Los years, without CRC
Angeles County polyps or CRC, family
(CA, USA). history of CRC
(first-degree relatives)
and never had any CRC
screening or overdue for
screening (eligible for
CRC screening
according to ACS
guidelines).
• Intervention group at
three churches (n = 84):
61% female, 38%
university degree; 95%
did not speak English at
all or not well, 39% had
health insurance, and
50% had a physician.
• Control group at three
churches (n = 83): 57%
female, 63% university
degree, 84% did not
speak English at all or
not well, 62% had
health insurance and
57% had a physician.
© 2015 Japan Academy of Nursing Science
Information Outcomes of the PN
about PN intervention and conclusion
Design: cohort study.
(qualifications Intervention:
of the PN • Referral by primary care
were not provider and services of a
reported). trained PN at the referring
clinic. The PN provided
services such scheduling of
screening appointments,
providing written bowel
preparation instructions,
appointment reminders,
addressing concerns on the
day of the procedure, follow
up on recommendations and
results after screening.
• Comparison group: not
navigated but received
colonoscopy.
Outcome measures:
• Volume of colonoscopies
and increase in screening
rates.
Design: two group
tailored PN quasi-experimental (pre/post
(bilingual design)
health Intervention:
educator • Intervention group had a PN
speaking providing services such as
Korean and one-on-one or small group
English) education in Korean,
scheduling appointments,
appointment reminders,
assistance with completion
of paperwork or translation,
and assistance with
transportation.
• Control group: received
small group patient
education sessions delivered
by trained Korean
community health
educators. Patient education
focused on routine health
examination, screening for
various diseases,
hypertension, diabetes,
exercise, nutrition, and
smoking cessation.
Outcome measures:
• CRC screening use.
• Knowledge about CRC and
related screening.
J.
J. K.
Results and conclusion Limits
K. Muliira
Primary outcomes: • No
• Number of screening colonoscopies at baseline was randomization.
5081 and this increased to 5637 after 1 year (11% • Qualifications of
change in period of the PN program). the PN were not
• After 1 year, 78% of PN patients received screening reported.
colonoscopy compared with 49% of non-PN • No clear
comparison (P < 0.0001). description of
• Colonoscopy performed for screening purposes the sample’s
Muliira and M. S. D’Souza
increased by 54% in outpatient Medicaid patients characteristics.
compared with 5% in private patients (level of
significance not reported).
Secondary outcomes:
• Cecum was reached in 97% of PN colonoscopies
compared with 94% in non-navigated Medicaid
patients (P < 0.0001).
• PN patients had lower proportion of poor
colonoscopy bowel preparations (7%) compared
with non-PN patients (15%; P < 0.0001).
Conclusion:
• The PN intervention increased colonoscopy volume
and maintained a high quality of bowel preparation.
Primary outcomes: • No
• At baseline only 13.1% of PN group and 9.6% of randomization.
control group participants had ever received CRC • Small
screening (P = 0.482). mono-ethnic
• 12 months after the intervention, the screening rate sample.
was higher in the PN group (77.4%) compared • There were
with 10.8% in control (P = 0.001). differences in
• 78.6% of PN patients completed CRC screening. access to regular
Secondary outcomes: health
• There was a significant improvement in PN patient’s insurance, level
perceived susceptibility (P < 0.05), perceived benefit of education
of screening (P < 0.001), and perceived barriers to between
screening (P < 0.001). intervention and
control group.
• Knowledge about CRC and CRC screening
Japan JournalJapan
increased in both patients in the PN and control • The
group, but more increase was seen in the PN group qualifications of
(P < 0.001). the PN were not
of Nursing
Conclusion: clearly reported.
• A culturally appropriate church-based intervention
can reduce barriers and increase knowledge and
access to CRC screening.
JournalScience
of Nursing
(2016)Science
(2015)
13, 205–219
 Lasser et al. Fifteen primary n = 183: patients living in Bilingual PN
(2009) care community low-income areas, aged
health centers in 52–80 years who were
low-income unscreened for CRC
areas of according to USPSTF
Massachusetts guidelines (67% white,
(USA). 75% had insurance
coverage, 25% had no
© 2015 Japan Academy of Nursing
insurance coverage,
48% were non-English
speakers, 66% of
intervention group had
Nursing Science
Science
Medicare health
insurance, and 51% of
control had Medicare
health insurance).
• Intervention group
(n = 93).
• Control group (n = 90).
Myers et al. Primary care n = 154: patients in the age The PN is
(2008) practice settings range of 50–79 years,
in Philadelphia without CRC
(PA, USA). symptoms, had not
recently had a CRC test,
and were not too
mentally or physically
debilitated (81% white,
and 51% had high
school or less
education).
2139
Design: multilevel
(speaking interventional study:
English and Intervention:
Spanish, or • Intervention group:
Portuguese or notification of need for CRC
French). PN screening, PN services, and
were certified CRC screening brochures
nurse (English, Portuguese,
assistant, Spanish, or French) offering
medical orientation about reason for
assistant, or screening, types of screening
community tests, and required lifestyle
health worker changes to lower risk of
(with a CRC. PN provided
masters in explanation of CRC
clinical screening options, telephone
psychology). reminders and support to
address barriers to CRC
screening.
• Control group: usual care.
Outcome measures:
• Completion of any CRC
screening test in 6 months.
Design: pre/post.
reported as a Intervention:
trained • Mailing tailored navigation
navigator materials containing FOBT
(qualifications kit or colonoscopy
or level of instruction depending on
education was patient preference and PN
not reported). services. The PN provided
services such as telephone
calls to guide and encourage
participants towards
screening.
• No control group.
Outcome measures:
• Screening use (FOBT,
flexible sigmoidoscopy,
colonoscopy, or barium
enema X-ray).
• Screening preference.
Primary outcomes: • Small sample
• Participants were those who were not current with size.
CRC screening (CRC screening rate at the study • No
sites was 47%). randomization.
• After 6 months, 31% of PN patients had completed • Exclusion
CRC screening compared with 9% in the control criteria may
(P = 0.002). have left out
• After 6 months, 17% of PN patients had received some eligible
screening using FOBT compared with 8% of participants.
control group (level of significance not reported).
Japan Journal of Nursing Science (2016)
• After 6 months, 14% of PN patients had completed
screening by colonoscopy compared to 1% of
control group (level of significance not reported).
Conclusion:
• PN are effective at increasing CRC screening in
diverse urban poor populations.
(2015) 13, 205–219
Primary outcomes: • No
• Estimated baseline CRC screening rate was 30%. randomization.
• After 6 months, 41% of participants had • No control
undergone CRC screening (level of significance not group.
reported). • Did not
• At baseline, 23% of participants had never heard ascertain
of or were undecided about screening, but after 6 insurance status
months only 8% reported that they had never of participants.
heard of or were undecided about screening (level
• Guidelines used
of significance not reported). to determine
• Overall, the screening preference from baseline to eligibility were
end-point (6 months) increased by 63% (level of not clearly
significance not reported). stated.
Patient
Secondary outcomes:
• Age (P = 0.02) and perceiving screening as
important (P = 0.05) were significant predictors of
use of CRC screening.
Conclusion:
Patient navigation
• The PN intervention increases use of CRC screening
and CRC screening preference.
navigation and
and CRC
CRC screening
screening
 J.

10
J. K.

214
Table 2 Continued
K. Muliira

First author Information Outcomes of the PN

(year) Study setting Sample characteristics about PN intervention and conclusion Results and conclusion Limits

Chen et al. Teaching hospital n = 532: patients with PN was a Design: cohort study. Primary outcomes: • No
(2008) in New York average risk for colonic female, Intervention: • The reference baseline colonoscopy screening rate randomization.
City (NY, USA). neoplasia, bilingual • Referral for screening was 47%. • Sample was
asymptomatic, age of 50 health colonoscopy and PN • 66% of PN patients completed colonoscopy (the predominantly
years and above, with educator provided by a bilingual time from baseline and level significance were not female.
no history of CRC or trained in Hispanic PN. PN provided
Muliira and M. S. D’Souza

reported). • Time from

inflammatory bowel
disease (31% African
Americans, 55%
Hispanics, 79% female).
Nash et al. Lincoln Medical Patients referred for
(2006) Center, Bronx, screening colonoscopy.
New York City Pre-intervention (n = 470):
(NY, USA). 59% female, 79%
Hispanic, 73%
Medicaid or Medicare
or both, and 10%
uninsured.
Post intervention
(n = 1297): 61% female,
69% Hispanic, 61%
Medicaid or Medicare
or both, and 17%
uninsured.
issues related patient education,
to CRC scheduling appointments,
screening and counseling and support,
navigation assistance with
process. transportation and escorting
patient to health facility.
Other services provided with
the intervention: free
screening colonoscopy for
uninsured.
Outcome measures:
• Colonoscopy screening rates
and patient satisfaction with
the services.
PN Design: retrospective pre/post
characteristics analysis
were not intervention:
described. • Direct endoscopy referrals
and PN services. PN
provided assistance to
complete the paper work,
scheduling screening
appointments, sending
appointment reminders, and
facilitated endoscopic
referrals.
Outcome measures:
• Number of screening and
• Women were 1.3 times more likely than men to baseline to
complete colonoscopy (P = 0.014). measurement of
outcome
• Hispanics were 1.67 times more likely to complete
colonoscopy (P = 0.013) compared with African variable was not
reported.
Americans.
• 98% overall patient satisfaction with the services.
• 66% of participants stated that they would not
have completed screening colonoscopy without the
service of the PN.
Conclusion:
• The PN intervention increased completed
colonoscopies among majority urban minorities and
enhanced patient satisfaction.
• At baseline, the mean number of persons screened • Retrospective
per month was 75.7 and after 6 months of PN study using
intervention the average increased to 119 (level of before and after
significance not reported). comparison.
• PN intervention was associated with 45% of all • No data about
screening colonoscopies during the period of the referred patients
intervention (level of significance not reported). who did not
• Colonoscopies associated with PN increased from receive
11% to 42% (P < 0.001). colonoscopy.
• Qualifications
• Uninsured persons receiving screening or diagnostic
colonoscopy increased from 10% at baseline to and other
characteristics of
17% after 6 months of PN intervention
the PN were not
(P < 0.001).
Japan JournalJapan

Secondary outcomes: reported.

diagnostic colonoscopies
• Broken colonoscopy appointments reduced from
done.
67.2% before the intervention to 5.3% after the
of Nursing

intervention (level of significance not reported).

• Chance of keeping an appointment after the PN
intervention increased by 2.6 times (OR = 2.6, 95%
JournalScience

CI = 2.2–3).
Conclusion:
• The PN intervention increased the number of
of Nursing

screening colonoscopy.
ACS, American Cancer Society; CI, confidence interval; CRC, colorectal cancer; FOBT, fecal occult blood testing; OR, odds ratio; PCP, primary care provider; PN, patient navigator; USPSTF, US Preventive Services Task Force.
(2016)Science

© 2015 Japan Academy of Nursing Science

(2015)
13, 205–219
Japan Journal of Nursing Science (2016)
(2015) 13, 205–219
CRC screening outcome measures, conclusions, and
limitations. All 15 articles were reporting on studies
conducted in the USA and most of them were reporting
on studies conducted in the state of New York (Jandorf
et al., 2012; Christie et al., 2008; Jandorf, Gutierrez,
Lopez, Christie, & Itzkowitz, 2005; Cavanagh, Lane,
Messina, & Anderson, 2013; Lebwohl et al., 2011;
Chen et al., 2008; Nash, Azeez, Vlahov, & Schori,
2006). The other articles were reporting on studies con-
ducted in the USA states of Massachusetts, Delaware,
Georgia, North Carolina, Pennsylvania, and California.
The primary care settings used include community
health centers, local county government health centers,
primary care practice clinics, and community churches.
Therefore, the PN intervention has been mainly tested in
urban primary care settings located in one geographical
region of the USA. There were no studies that had
implemented the PN intervention in rural settings or
other countries.
Participants
The majority of the studies had samples mainly com-
prised of participants from urban minority populations
(African American and Latino or Hispanic) with low
incomes (indicated by socioeconomic and/or healthcare
insurance status) (Cavanagh et al., 2013; Chen et al.,
2008; Christie et al., 2008; Honeycutt et al., 2013;
Jandorf et al., 2005, 2012; Lebwohl et al., 2011; Leone
et al., 2013; Nash et al., 2006; Percac-Lima et al.,
2008). Only three studies had a sample comprised of a
majority of white participants (Lasser et al., 2009;
Myers et al., 2008, 2013). The information about par-
ticipants shows that PN interventions have been pre-
dominantly used in urban, low-income, minority
populations. However, the results of the studies show
that the PN intervention was able to generally improve
uptake of CRC screening in samples comprised of the
majority of white (Lasser et al., 2009; Myers et al.,
2008, 2013) or ethnic minority participants (Cavanagh
et al., 2013; Chen et al., 2008; Christie et al., 2008;
Honeycutt et al., 2013; Jandorf et al., 2005, 2012;
Lebwohl et al., 2011; Leone et al., 2013; Ma et al.,
2009; Nash et al., 2006; Percac-Lima et al., 2008).
Study design
Until now, few studies using randomized controlled trial
(RCT) design have tested the effectiveness of the PN
intervention towards enhancing uptake of CRC screen-
ing. Only six of the 15 studies reviewed used an RCT
design (Christie et al., 2008; Jandorf et al., 2005, 2012;
Lasser et al., 2011; Myers et al., 2013; Percac-Lima
Nursing Science
© 2015 Japan Academy of Nursing Science
Patient
Patient navigation
navigation and
and CRC
CRC screening
screening
et al., 2008). The other studies used pre/post design with
a professional PN, quasi-experimental designs with pro-
fessional PN, or cohort study designs. The majority of
the studies (RCT and non-RCT) had very large samples
(>400 participants). There were several differences in the
PN interventions used by the studies. The differences in
the intervention were related to the services provided by
the PN, method of delivering the services (telephone or
person-to-person contact), and number of times the par-
ticipants were contacted by the PN. None of the 15
studies reported about the power analysis.
Type of PN
Three different categories of PN intervention were used
by the studies included in the review and these were:
professional PN (nurse, health educators, and other
trained staff) (Christie et al., 2008; Honeycutt et al.,
2013; Lebwohl et al., 2011; Leone et al., 2013; Myers
et al., 2008, 2013), language-concordant and/or ethnic-
concordant professional PN (trained staff who were
bilingual or spoke the language and/or belonged to the
same ethnicity as the participants they were working
with) (Cavanagh et al., 2013; Chen et al., 2008; Jandorf
et al., 2005; Lasser et al., 2009, 2011; Ma et al., 2009;
Percac-Lima et al., 2008), and language-concordant
and/or ethnic-concordant lay or peer PN (Jandorf et al.,
2012). In one study, the details and characteristics of the
PN used were not provided (Nash et al., 2006) and in
another study three different types PN were utilized but
for different samples (Jandorf et al., 2012).
The support and services provided through the differ-
ent categories of PN interventions included scheduling
of screening appointments, sending appointment
reminders, assisting with transportation, patient educa-
tion about screening and preparation for screening tests,
and providing encouragement to participants. In some
studies, the PN escorted the patient to undergo the
screening procedure (Cavanagh et al., 2013; Chen et al.,
2008; Lasser et al., 2011; Percac-Lima et al., 2008) and
in others it was clearly stated that part or all of the
intervention was provided through telephone calls
(Jandorf et al., 2012; Lasser et al., 2009; Leone et al.,
2013; Myers et al., 2008, 2013). None of the studies
provided a comprehensive report about the number of
contacts the PN had with the participants, stage at
which encouragement and support was provided, and
how the date or time for the screening test was selected.
Uptake of CRC screening
All of the six studies that used an RCT design had results
showing that the PN intervention increased CRC
11
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J. K.
J. K. Muliira
Muliira and M. S. D’Souza
screening rates. Three out of the six studies reported a
statistically significant increase in the rate of CRC
screening in the intervention group (Lasser et al., 2011;
Myers et al., 2013; Percac-Lima et al., 2008). The other
three RCT reported improvements in the intervention
group’s rates of CRC screening which were not statisti-
cally significant or without stating the level of signifi-
cance (Christie et al., 2008; Jandorf et al., 2005, 2012).
The findings from three RCT which had statistically
significant results show that PN interventions were able
to increase the rate CRC screening by at least 14% in the
intervention group compared with the control group in
a period of 3–12 months (Lasser et al., 2011; Myers
et al., 2013; Percac-Lima et al., 2008). The results from
the RCT studies also show that the intervention
improved CRC screening rates in samples comprised of
the majority of white (Lasser et al., 2011; Myers et al.,
2013) or ethnic minority participants (Percac-Lima
et al., 2008). Other findings from the RCT studies show
that the PN intervention was associated with increased
adenoma detection (Lasser et al., 2011; Percac-Lima
et al., 2008), patient satisfaction, and high quality of
bowel preparation prior to colonoscopy (Christie et al.,
2008).
The nine studies that were not RCT also had results
showing that the PN intervention increased CRC screen-
ing rates, but only five had statistically significant results
(Honeycutt et al., 2013; Lasser et al., 2009; Lebwohl
et al., 2011; Ma et al., 2009; Nash et al., 2006). The
other four studies reported changes in rates of screening
which were not statistically significant or did not report
the level of significance (Cavanagh et al., 2013; Chen
et al., 2008; Leone et al., 2013; Myers et al., 2008).
Findings from studies which are not RCT, but with
statistically significant results, show that PN interven-
tions were able to increase CRC screening rates by at
least 22% in the intervention group compared with the
control group in a period of 6–18 months (Honeycutt
et al., 2013; Lasser et al., 2009; Lebwohl et al., 2011;
Ma et al., 2009; Nash et al., 2006).
The studies which used language-concordant and/or
ethnic-concordant professional PN reported higher
rates of CRC screening (14–66%) (Lasser et al., 2009,
2011; Ma et al., 2009) compared with those that used
professional PN (17–34%) (Honeycutt et al., 2013;
Lebwohl et al., 2011; Myers et al., 2013; Nash et al.,
2006; Percac-Lima et al., 2008). Therefore, all types of
PN interventions enhanced uptake of CRC screening,
but the language-concordant and/or ethnic-concordant
professional PN interventions seem to be more
effective.
12
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Japan JournalJapan
of Nursing
JournalScience (2016)Science
of Nursing 13, 205–219
(2015)
The time from the baseline to the point when effec-
tiveness of PN intervention was measured might also
have had an effect on the CRC screening rates reported
by the studies. Studies which measured the CRC screen-
ing outcomes in a period of less than 1 year after
initiating the intervention (6–9 months), reported
improvements in screening rates ranging 17–31%
(Lasser et al., 2009; Myers et al., 2013; Nash et al.,
2006; Percac-Lima et al., 2008). The studies which mea-
sured the CRC screening outcomes in a period of 1–2
years, reported screening rates ranging 14–66%
(Honeycutt et al., 2013; Lasser et al., 2011; Lebwohl
et al., 2011; Ma et al., 2009).
DISCUSSION
The findings of this review show that when PN inter-
ventions are utilized in primary care settings located in
urban areas, they can increase the rates of uptake of
CRC screening. All of the 15 studies included in the
review show that the participants who received a PN
intervention attained higher rates of CRC screening. The
reported improvements in CRC screening rates were
statistically significant in eight studies and this is a tes-
tament to the potential of this intervention in terms of
promoting uptake of CRC screening. The findings of
this review are consistent with reports of other system-
atic reviews about effectiveness of PN interventions
towards enhancing uptake of care and screening for
other types of cancer. For instance, PN interventions
have been reported to improve uptake of cancer screen-
ing, diagnostic resolution, and treatment initiation in
patients with breast, prostate, and cervical cancer
(Freund et al., 2014; Robinson-White et al., 2010).
The findings of this review also show that the PN
intervention can lead to other quality outcomes which
are relevant to CRC screening. For instance, in some
studies, the PN interventions were associated with
increased patient knowledge about CRC screening (Ma
et al., 2009), quality of bowel preparation before colo-
noscopy (Honeycutt et al., 2013; Lebwohl et al., 2011),
and patient satisfaction (Cavanagh et al., 2013; Chen
et al., 2008; Christie et al., 2008). The type of PN inter-
vention used and period of implementation are key
factors which seem to influence the magnitude of screen-
ing rates. The findings of this review show that there are
differences in the reported rates of CRC screening
among studies which measured the screening outcomes
at 6 months and at 1 year and above, and those which
used language-concordant and/or ethnic-concordant
professional PN intervention and a professional PN
© 2015 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2016)
(2015) 13, 205–219
intervention. It is possible that using a language-
concordant and/or ethnic-concordant professional PN
intervention reduces the time required by the patient to
start trusting and assimilating the PN services, thus
easing the process of accepting the support, advice, and
services that lead to uptake of CRC screening. It also
seems the outcomes of the PN intervention are better
after a period of 6 months. This seems to suggest that
the PN intervention becomes more effective as the PN
and patients become more trustful and integrated in the
patient’s social support network.
The findings which show that language-concordant
and/or ethnic-concordant professional PN interventions
are associated with a higher propensity to comply with
CRC screening also highlight the importance of having a
good understanding of the patient’s culture. Available
published work shows that the approach of tailoring
specific interventions to ensure language concordance
and/or ethnic concordance is increasingly being used to
address CRC screening disparities because it positively
influences uptake of screening (Jerant et al., 2014). It
has been reported elsewhere that using language-
concordant approaches helps in overcoming healthcare
provider and patient-related barriers to CRC screening
(Hendren et al., 2010; Medina et al., 2012).
Despite the reported effectiveness, there is still need
for further experimental studies to examine the PN
intervention as a strategy for enhancing CRC screening,
because all the available studies were predominantly
conducted in urban areas located in one region of a
developed country with a unique healthcare system.
Additional studies to standardize and identify the essen-
tial services that should be part of a PN intervention and
best methods of delivering this intervention (telephone-
based navigation, person-to-person contact navigation
or a combination of telephone based and person-to-
person navigation) are also needed. Such studies can
help to streamline the intervention for easy adoption in
other countries.
The findings of this review have specific implications
for CRC screening services, cancer prevention pro-
grams, and nursing practice. Based upon the findings of
this review, the following aspects need to be considered
by nurses involved in CRC screening service: PN inter-
ventions enhance uptake of CRC screening in urban,
low-income, and minority populations, and can be
modified to address specific patient characteristics; PN
interventions provide a good opportunity for promoting
CRC screening through collaboration between primary
care providers and community agencies (churches, lay
people, and others); PN interventions improve the
Nursing Science
© 2015 Japan Academy of Nursing Science
Patient
Patient navigation
navigation and
and CRC
CRC screening
screening
quality of primary care services because they have addi-
tional quality outcomes such as higher patient satisfac-
tion and bowel preparation; and primary care service
that use approaches that address the patient’s culture
and/or ethnic background are likely to enhance the
patient’s propensity to comply with CRC screening.
CONCLUSION
The PN intervention seems to be an effective strategy for
enhancing uptake of CRC screening in urban popula-
tions with limited access to health care, but its effective-
ness in rural populations and other countries needs to be
studied further. The findings of the review also suggest
that the effectiveness of the PN intervention can be
enhanced by using approaches such as utilizing
language-concordant and/or ethnic-concordant profes-
sional PN. Further studies to clearly delineate the essen-
tial services that need to be provided through PN
interventions are needed. The current review and its
conclusions need to be interpreted in light of the follow-
ing limitations. Although efforts were made to include
all relevant published articles, there is a possibility that
some articles were missed. The articles included in the
review were only those written in English. Therefore,
relevant publications in other languages or from non-
English speaking countries are not represented. The
review excluded non-scientific reports about community
projects, public health campaigns, and targeted adver-
tising which are sometimes used to promote CRC
screening and can augment the impact of the PN
interventions.
CONFLICT OF INTEREST
The authors have no funding or conflicts of interest to
disclose.
AUTHOR CONTRIBUTIONS
J. K. M. conceived the study idea and design. J. K. M.
and M. S. D. both contributed towards the published
work review, analysis, and writing and critical revision
of the manuscript.
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