Periodic Reporting for period 2 - CANCERLESS (Cancer prevention and early detection among the homeless population in Europe: Co-adapting and implementing the Health Navigator Model)
Berichtszeitraum: 2022-12-01 bis 2024-05-31
Cancer-related mortality is twice and morbidity five times as high in people experiencing homelessness (PEH) compared to the housed population due to structural barriers in accessing health services and higher prevalence of individual cancer risk factors. Disparities in cancer outcomes continue to grow due to social stigmatization, discrimination, and general lack of information on highly fragmentized health and social systems. Providing timely and evidence-based prevention strategies, including optimization of healthcare delivery, are possible solutions to reducing the cancer burden and associated costs across Europe. In this vein, CANCERLESS project developed a theoretical basis for and co-designed the Health Navigator Model (HNM): an evidence-based, patient-centered intervention to 1) empower PEH through health education and social support, and 2) enable access to primary and secondary cancer prevention services with the help of Health Navigators (HNs). The overarching objective of CANCERLESS was to use the HNM for timely access to cancer prevention for PEH. The HNM was co-designed and then piloted as an intervention in 4 European countries (Austria, Greece, Spain, UK) while also being evaluated for its feasibility and overall effectiveness using mixed-methods. Across all pilot sites 1981 PEH were reached. From those, 652 PEH were included in the study. Reasons for non-participation included unwillingness to participate in a scientific study, mistrusting the health and social system. The HNM was proven successful: Data showed an increase in overall quality of life and empowerment and had more frequent contact with health and social services and increased participation in cancer screening programs. The cost-utility analysis showed cost-effectiveness of the HNM, suggesting that the HNM might reduce costs associated with frequent late diagnoses in PEH. Finally, data gathered was used to create Integrated Cancer Care Pathways for the 4 European countries and a set of policy recommendations using results of a Delphi study with 34 European experts. Results were presented to political stakeholders, including at the European Parliament, and to international stakeholders during a final Symposium. The HNM proved to be an effective and low-threshold solution to tackling cancer inequity in Europe, fulfilling the goals of Europe’s Beating Cancer Plan and the UN SDG 3.4. Hopefully, member states and the Commission will take note of the results of CANCERLESS, and will use the outlined policy recommendations to adopt principles of the HNM to truly leave no one behind.
Work package (WP) 1 coordinated activities as per Description of Action administratively and financially. During the project 66 bi-monthly and 7 full consortium meetings were held. All milestones were achieved and deliverables submitted on time. WP2 co-designed the HNM, meeting the needs of organizations, healthcare professionals and PEH through a systematic scoping review. Following, 69 interviews with PEH and healthcare professionals were done to explore healthcare needs and barriers for PEH accessing cancer prevention services across all 4 countries (Austria, Greece, Spain, UK), and co-adaptation focus group discussions with 56 participants were done to define HNM parameters. WP3 implemented the HNM in partner countries, preceded by capacity building. Based on pilot implementation plans, the implementation started in 06/2022 and finished in 12/2023. Overall, 20 HNs received training and provided participants with a range of services. By the end, 169 individual cancer screenings had been done. As part of feasibility analysis, WP3 reported major barriers to be systemic: inability to include PEH with no active health insurance, system fragmentation and discrimination. Individual barriers included competing needs (immediate help during acute homelessness vs. future cancer prevention). WP4 used a mixed-methods approach to conduct a formative and summative evaluation of the HNM. Questionnaires were used at 3 time points: baseline, 6 weeks, and study exit. Questionnaires and qualitative interviews were also done with the HNs and focus groups with 86 healthcare professionals involved in the implementation. Results showed improvement in quality of life, empowerment, interpersonal communication, and an increase in use of cancer preventive services. Results of the cost-utility analysis demonstrated a positive impact on quality-adjusted life years across pilot sites. Using CFIR and RE-AIM frameworks, we demonstrated the HNM to be effective form PEH’s and professionals’ perspective and multi-adaptable. WP5 used systematic reviews and Delphi methodology to define standards for the Integrated Cancer Care Pathways for PEH. The pathways were internally and externally validated and created a set of policy recommendations for national and EU adoption of the HNM. Communication in WP6 promoted societal knowledge on health inequalities to illustrate the barriers PEH face in accessing cancer prevention by creating online information outlets, scientific symposia, and events at the European Parliament. Overall, consortium members participated at 45 conferences and led 14 dedicated workshops/webinars, 6 articles and 4 research abstracts were published in peer-reviewed journals. One of the abstracts was voted best at the 2022 European Cancer Summit. WP7 and WP8 ensured all activities complied with national and international ethics and data protection regulations, with no issues being reported.
The HNM developed in the course of CANCERLESS presents a novel intervention to foster cancer prevention and early diagnosis among PEH in the European context. The outcomes of this innovative intervention address a gap in evidence, especially an overall lack of studies performed with PEH, and provide further understanding of feasibility and suitability of navigation models regarding the needs of a highly vulnerable population. PEH are known to experience poor health-related outcomes and a disproportionate risk of cancer-related mortality. Data evaluation generated statistical insights about demographics, health status, Patient Reported Experience Measurements, and Patient Reported Outcomes Measures - creating one of the largest datasets on PEH health in Europe besides providing evidence on the clinical utility and effectiveness of HN interventions for the first time in Europe. As part of the evaluation, the project also identified factors facilitating or hampering effective and successful HNM implementation, pivotal for the replicability, feasibility, and sustainability of like interventions. Microsimulations based on the collected data created synthetic populations and predictive modeling allowing for the aggregation of health predictors – an entirely unexplored field not yet applied to PEH, promising exciting scientific results. The microsimulation is also a tangible prototype to be developed to further for evidence-based policy making in future PEH cancer preventive programs. As the first EU-project focused on health of PEH, CANCERLESS shed light on a population usually invisible and empowered PEH through the use of co-design. Consortium partners continue to develop national and local initiatives, further ensuring sustainability.