Racial and ethnic minorities, rural communities, and those with low socioeconomic status, including those who are un- or under-insured, bear a disproportionately high burden of cancer in the United States.^1–4 These disparities persist across the cancer continuum, from prevention to screening, treatment, and long-term survivorship.^4–6 Barriers to cancer prevention, screening, and care often include fear or distrust of the medical community, lack of or inadequate health insurance coverage, financial hardship, low levels of health literacy and education, and logistical barriers, such as lack of transportation.^7,8 The social determinants of health, that is, the social, economic, cultural, and physical contexts within which people live, are considered important when addressing health disparities.^9–11

Patient navigation (PN) and community health worker (CHW) interventions have been demonstrated to reduce health disparities by addressing the social determinants of health.^9,12–18 Cancer PN is a process that provides “individualized assistance to cancer patients, families, and caregivers to help overcome healthcare system barriers and facilitate timely access to quality health and psychosocial care from pre-diagnosis through all phases of the cancer experience.”¹⁹ PNs assist patients in overcoming barriers to cancer screening and treatment, offer peer counseling, provide linkages to financial and community resources, and provide culturally competent patient education, particularly among (but not limited to) the underserved.²⁰ Studies have shown the effectiveness of PN in increasing patient completion of cancer screening and reducing disparities among the medically underserved.^12,13,21,22 A recent systematic review of both PN and CHW interventions at Federally Qualified Health Centers, which provide primary care to medically underserved communities, found that PN/CHW interventions were effective in increasing cancer screening rates.⁹ Similarly, a systematic review of CHW interventions and mammography found that such interventions improve mammography rates.¹⁷

Dr. Harold Freeman pioneered PN in 1990 to address the challenges low-income, medically underserved populations experience with access to timely cancer screenings, treatment, and care.¹³ PNs often come from the community they serve, but they typically function in clinical settings to reduce barriers to cancer screening and timely treatment, act as liaison to the medical team, and help cancer patients and families manage the logistics of cancer treatment, which often includes various specialists and time-intensive treatment. Depending on the needs of the health care setting, PNs may be lay members of the community they serve or health care professionals (usually nurses or social workers).²³ Their scopes of practice are reflective of their backgrounds.²⁴

CHW programs gained popularity in the United States in the 1960s, but their international origins date back to the 19th century.¹⁵ CHWs are frontline public health workers who are trusted members of the community they serve and provide the cultural expertise to help link the community to health and social services.^9,15,25–27 Depending on community or context, CHWs are also known as community health advisors, outreach workers, community health representatives (CHRs), promotoras(es), peer counselors, lay health advocates, and peer health educators, among other titles.^28,29 Historically, CHWs have worked through community-based organizations focusing on health education, prevention, and screening, while PNs have functioned in clinical settings to navigate cancer patients through the health care system,²³ although recent trends using CHWs within health care teams and navigators for outreach have blurred those boundaries.^30–32

PNs and CHWs have become increasingly valued members of the U.S. health care workforce in addressing health disparities and other public health priorities, particularly following changes in health care payment structures and grant funding under the Patient Protection and Affordable Care Act,^33,34 in addition to recommendations and guidance contained in the U.S. Department of Health and Human Services' National Prevention Strategy.³⁵ Since 2015, the American College of Surgeon's Commission on Cancer has required PN services as a component of accreditation.¹³

The Centers for Disease Control and Prevention (CDC) funds the National Comprehensive Cancer Control Program (NCCCP) in all 50 states, the District of Columbia, and several tribes, tribal organizations, U.S. territories, and Pacific Island Jurisdictions to broadly promote cancer prevention and control activities and interventions.³⁶ NCCCP awardees focus their activities on the following priority areas: emphasizing primary prevention of cancer; assisting with coordination of early detection and treatment activities; addressing public health needs of cancer survivors; helping with using policy, systems, and environmental changes (PSEs) to guide sustainable cancer control; and promoting health equity and reducing disparities.³⁷ Each NCCCP awardee works with a coalition and other stakeholders to develop and implement comprehensive cancer plans, which are blueprints for addressing their population's particular cancer burden, and they document progress in yearly action plans.³⁸ Since PNs and CHWs could be used to address most of the NCCCP priority areas, we sought to examine the extent to which awardees are engaging in activities related to and supportive of PN and/or CHW interventions. The objective of this content analysis was to examine NCCCP action plans for incorporation of PN and/or CHW interventions in cancer control.

We abstracted content from NCCCP action plans (n=65) in December 2015 from CDC's Chronic Disease Management Information System (CDMIS; www.cdc.gov/cdmis/index.html) using these keywords: navigate, navigator(s), navigation, peer educator, community navigator, community health aid, lay health worker, Promotora(s), peer counselor, peer leader, lay health educator, CHWs, PNs, CHRs, lay health advisor, peer health advisor, peer health educator, community health advisor, and outreach worker. The NCCCP action plans spanned a 3-year time period, beginning in 2012 at the onset of a new 5-year funding cycle (2012–2017). As part of funding expectations, NCCCP awardees submit via CDMIS annual action plans that outline specific objectives and activities to be accomplished in the upcoming year, and report on progress they made during the current project year for each action plan objective. CDMIS meets all federal requirements and approvals for public data collection (OMB No. 0920-0841).

After abstraction, we deleted duplicate text entries and reviewed action plan text for inclusion, based on where in the action plan the term appeared. Only plans that used the keyword in text as part of an objective, strategy, or goal were included. For example, we excluded content describing webinars attended by NCCCP awardees on PN/CHW topics or descriptions of coalition members who were PNs or CHWs, without reference to a planned activity or intervention engaging PNs or CHWs or involving workforce development.

Beginning with a summative approach to content analysis³⁹ and later using an inductive approach we (E.A.R. and R.M.) open-coded text, according to specific areas of PN and/or CHW intervention (e.g., screening, survivorship, and cancer type). We (E.A.R., R.M., and J.T.) developed a detailed codebook that defined codes and specified how to apply them to text. One researcher (R.M.) had the primary responsibility of coding content according to codebook rules, using NVivo10^® (Victoria, Australia) to manage the data, but had frequent meetings with other investigators (E.A.R. and J.T.) to review analysis. Analysis first assessed whether action plans included PN and/or CHW language. For those action plans that did contain PN and/or CHW language, we coded to reflect the context in which the PN and/or CHW language was used. We used descriptive statistics to characterize overall results and calculated chi-squares to determine differences in PN and/or CHW activities and settings among programs.

Figure 1 depicts whether action plans from each NCCCP awardee contained PN content only, CHW content only, both, or neither. Twenty-three (35%) of plans contained PN language only, 9 (14%) contained CHW language only, 20 (31%) contained PN and CHW content, and 13 plans (20%) had no language related to PN or CHW. A total of 82% (n=53) of 65 NCCCP action plans had content related to PN and/or CHW activities. Of those 53 with PN and/or CHW language, more action plans contained PN (83%; n=44) than CHW (58%; n=31) language. Among plans that contained either PN or CHW language, this pattern held true in that 22 mentioned only PN (42%) and 9 mentioned only CHW (17%) language.

This is the first assessment of PN/CHW content in NCCCP action plans. The vast majority of NCCCP awardees reported engaging in PN and/or CHW activities, indicating a prioritization of this intervention in cancer prevention and control consistent with cancer PN literature.⁴⁰ Since PN originated within cancer,²⁰ it is not surprising that our review showed that this term was more prevalent than CHW in NCCCP action plans.

Our findings that NCCCP action plans often described engaging PNs/CHWs in screening and in relation to breast, cervical, or colorectal cancer are also supported by the literature. A systematic review found that most PN efficacy studies have been conducted in relation to screening for breast, cervical, or colorectal cancers.⁴⁰ Action plans described PNs and CHWs most often in relation to addressing barriers and providing patient education, which is also consistent with the literature.⁸ Additional evidence is needed for assessing the efficacy of engaging PNs and CHWs in screening for lung cancer or increasing uptake of HPV vaccination. Since lung cancer screening is complex^41,42 and HPV vaccination rates remain low in the United States,^43,44 there may be a role for PNs and or CHWs in one or both of these arenas as well.

Workforce development is an important aspect in advancing the work of PNs and CHWs.^45–48 NCCCP action plans reflected the many ways programs are working to develop and build capacity within PN and CHW workforces by providing trainings and networking opportunities, working to secure solid sources of financing, working to standardize roles and competencies, and working toward credentialing. Not every NCCCP awardee reported being involved in each of these workforce development activities, but it is clear that many awardees have prioritized taking part in PN and/or CHW workforce development to increase the capacity of PNs and CHWs to serve populations within their jurisdictions.

Finally, our findings showed that action plans used CHW language more often related to outreach, patient education, cultural competence, community settings, and primary prevention while action plans used PN language more often related to cancer survivorship. This is consistent with the established perception that CHWs are trusted members of the communities they serve.^29,45,46,49 PN was pioneered in the field of oncology²⁰; the association of PNs with individuals post-diagnosis (cancer survivors) seems consistent with this history.

Understanding how NCCCP awardees engage PNs and CHWs, including awardees' needs for workforce development in this area, can help CDC provide more focused technical assistance to NCCCP awardees as they work to support cancer prevention and screening, improve the quality of life among cancer survivors, and help reduce disparities in cancer prevention and control. This review can serve as a baseline assessment of PN/CHW activities in CCC plans and give some indication as to the integration of these approaches into comprehensive cancer control efforts. Future PN/CHW efforts among NCCCP awardees can include the specific population addressed, which may allow for easier assessment of the effects of PNs/CHWs in reducing health disparities. Reporting on the specific population served may additionally provide best practices for other NCCCP awardees working within similar populations. Overall, our findings highlight similarities and distinguishing characteristics among how the NCCCP awardees engage PNs and CHWs and can help inform the implementation and evaluation of cancer prevention and control efforts within both public health and oncology health care programs that engage PNs and CHWs. Ongoing support of the implementation of PN and CHW interventions and continued assessment of their added value in cancer control offers public health programs, including the NCCCP, a means to further improve chronic disease health equity.⁹