A Culturally Tailored Navigator Program for Colorectal Cancer
Screening in a Community Health Center: A Randomized,
Sanja Percac-Lima, MD PhD
, Richard W. Grant, MD MPH
Alexander R. Green, MD MPH
, Jeffrey M. Ashburner, MPH
, Gloria Gamba
, Sarah Oo, MSW
James M. Richter, MD
, and Steven J. Atlas, MD MPH
Chelsea HealthCare Center, Massachusetts General Hospital, Chelsea, MA, USA;
General Medicine Division, Massachusetts General
Hospital, Boston, MA, USA;
Disparities Solutions Center, Massachusetts General Hospital, Boston, MA, USA;
Massachusetts General Hospital, Boston, MA, USA;
Harvard Medical School, Boston, MA, USA.
BACKGROUND: Minority racial/ethnic groups have low
colorectal cancer (CRC) screening rates.
OBJECTIVE: To evaluate a culturally tailored intervention
to increase CRC screening, primarily using colonoscopy,
among low income and non-English speaking patients.
DESIGN: Randomized controlled trial conducted from
January to October of 2007.
SETTING: Single, urban community health center
serving a low-income, ethnically diverse population.
PATIENTS: A total of 1,223 patients 52-79 years of age
overdue for CRC screening, randomized to intervention
(n=409) vs. usual care control (n=814) groups.
INTERVENTION: Intervention patients received an in-
troductory letter with educational material followed by
phone or in-person contact by a language-concordant
“navigator.” Navigators (n=5) were community health
workers trained to identify and address patient-
reported barriers to CRC screening. Individually tailored
interventions included patient education, procedure
scheduling, translation and explanation of bowel prepa-
ration, and help with transportation and insurance
coverage. Rates of colorectal cancer screening were
assessed for intervention and usual care control patients.
RESULTS: Over a 9-month period, intervention patients
were more likely to undergo CRC screening than control
patients (27% vs. 12% for any CRC screening, p<0.001;
21% vs. 10% for colonoscopy completion, p<0.001). The
higher screening rate resulted in the identification of
10.5 polyps per 100 patients in the intervention group
vs. 6.8 in the control group (p=0.04).
LIMITATIONS: Patients were from one health center.
Some patients may have obtained CRC screening
outside our system.
CONCLUSIONS: A culturally tailored, language-
concordant navigator program designed to identify and
overcome barriers to colorectal cancer screening can
significantly improve colonoscopy rates for low income,
ethnically and linguistically diverse patients.
ClinicalTrials.gov registration number: NCT00476970
KEY WORDS: colon cancer; screening; colonoscopy; patient navigation;
randomized control trial.
J Gen Intern Med 24(2):211–7
© Society of General Internal Medicine 2008
Colorectal cancer (CRC) is the third most commonly diagnosed
cancer and the second leading cause of cancer death in the
Although CRC-related morbidity and mortality can be
reduced through early detection and treatment, almost two-
thirds of patients are diagnosed with advanced stage disease.
Rates of CRC screening are lower than for other preventable
and are particularly low in ethnic minorities, non-
English speakers, and low income individuals.
nosed with CRC, these individuals present with cancer in later
stages and have higher mortality rates than white, English-
speaking, and higher income patients.
Barriers to CRC screening include lack of patient knowledge
regarding the importance of screening and procedure-related
patient concerns (e.g., regarding modesty, fear of pain, per-
Factors particularly relevant for low income
and limited English proficiency patients may include: insuffi-
cient time to effectively discuss CRC screening during clinic
visits, difficulty contacting patients, financial strains associat-
ed with taking time off from work, lack of health insurance,
difficulty obtaining transportation, and/or lack of interpreters
at procedure sites.
These unique barriers may contribute
to observed disparities in care.
Strategies shown to modestly increase preventive cancer
screening rates in low income and limited English proficiency
populations have included both mailed reminders with educa-
tional information for patients and physician-directed efforts
to increase recommendation rates.
programs” specifically designed to overcome patients’ per-
ceived barriers to screening have been evaluated.
programs are oriented towards flexible problem solving rather
than providing a predefined set of services and often employ
bilingual individuals familiar with social and cultural nuances
Published online December 6, 2008