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JMIR Med Inform
JMIR Med Inform
JMI
JMIR Medical Informatics
2291-9694
JMIR Publications Toronto, Canada

v12i1e50307
10.2196/50307
Review
Review
Characteristics of Existing Online Patient Navigation Interventions: Scoping Review
Lovis Christian
van Harten Wim
Crocker Bradley
Marsh Meghan MScOT 1https://orcid.org/0000-0001-9879-3958

Shah Syeda Rafia MScOT 1https://orcid.org/0000-0002-7964-2262

Munce Sarah E P PhD 123https://orcid.org/0000-0002-0595-8395

Perrier Laure PhD 4https://orcid.org/0000-0001-9941-7129

Lee Tin-Suet Joan BSc 2https://orcid.org/0000-0002-6962-2700

Colella Tracey J F APN, RN, PhD 2https://orcid.org/0000-0001-6228-9012

Kokorelias Kristina Marie PhD https://orcid.org/0000-0002-1277-472X
15Section of Geriatrics Sinai Health and University Health Network 600 University Avenue Geriatrics Department Toronto, ON, M5G1X5 Canada 1 4165864800 ext 4573 kristina.kokorelias@sinaihealth.ca

1 Department of Occupational Science and Occupational Therapy University of Toronto Toronto, ON Canada
2 KITE Toronto Rehabiliation Institute Toronto, ON Canada
3 Institute of Health Policy, Management and Evaluation University of Toronto Toronto, ON Canada
4 Toronto Western Hospital University Health Network Toronto, ON Canada
5 Section of Geriatrics Sinai Health and University Health Network Toronto, ON Canada
Corresponding Author: Kristina Marie Kokorelias kristina.kokorelias@sinaihealth.ca
2024
19 8 2024
12 e5030726 6 2023
25 10 2023
19 12 2023
30 6 2024
©Meghan Marsh, Syeda Rafia Shah, Sarah E P Munce, Laure Perrier, Tin-Suet Joan Lee, Tracey J F Colella, Kristina Marie Kokorelias. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 19.08.2024.
2024
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information, a link to the original publication on https://medinform.jmir.org/, as well as this copyright and license information must be included.

Background

Patient navigation interventions (PNIs) can provide personalized support and promote appropriate coordination or continuation of health and social care services. Online PNIs have demonstrated excellent potential for improving patient knowledge, transition readiness, self-efficacy, and use of services. However, the characteristics (ie, intervention type, mode of delivery, duration, frequency, outcomes and outcome measures, underlying theories or mechanisms of change of the intervention, and impact) of existing online PNIs to support the health and social needs of individuals with illness remain unclear.

Objective

This scoping review of the existing literature aims to identify the characteristics of existing online PNIs reported in the literature.

Methods

A scoping review based on the guidelines outlined in the Joanna Briggs Institute framework was conducted. A search for peer-reviewed literature published between 1989 and 2022 on online PNIs was conducted using MEDLINE, CINAHL, Embase, PsycInfo, and Cochrane Library databases. Two independent reviewers conducted 2 levels of screening. Data abstraction was conducted to outline key study characteristics (eg, study design, population, and intervention characteristics). The data were analyzed using descriptive statistics and qualitative content analysis.

Results

A total of 100 studies met the inclusion criteria. Our findings indicate that a variety of study designs are used to describe and evaluate online PNIs, with literature being published between 2003 and 2022 in Western countries. Of these studies, 39 (39%) studies were randomized controlled trials. In addition, we noticed an increase in reported online PNIs since 2019. The majority of studies involved White females with a diagnosis of cancer and a lack of participants aged 70 years or older was observed. Most online PNIs provide support through navigation, self-management and lifestyle changes, counseling, coaching, education, or a combination of support. Variation was noted in terms of mode of delivery, duration, and frequency. Only a small number of studies described theoretical frameworks or change mechanisms to guide intervention.

Conclusions

To our knowledge, this is the first review to comprehensively synthesize the existing literature on online PNIs, by focusing on the characteristics of interventions and studies in this area. Inconsistency in reporting the country of publication, population characteristics, duration and frequency of interventions, and a lack of the use of underlying theories and working mechanisms to inform intervention development, provide guidance for the reporting of future online PNIs.

online
patient navigation
peer navigation
patient navigation interventions
online patient navigation interventions
scoping review
patient portals
social care services
online medical tools
eHealth
telehealth
personal support
social care
patient navigation intervention
==== Body
pmcIntroduction

Background

Individuals living with chronic illness or illnesses or disability have reported increased reliance on the health care system, as well as social supports for relevant resources or services (ie, medication, equipment, therapy, and counseling), particularly emphasizing the past decade [1-4]. This poses a problem, as they also face a number of challenges when navigating the health care system. These challenges can be attributed to various factors, such as a lack of proper care coordination and continuity of health care services [5-8]. Other concerns include patients’ inadequate knowledge related to their conditions or disabilities and the lack of adherence to treatment plans [2,9]. It is also specifically challenging for patients with complex health needs to find appropriate health care services as there is a lack of training in specialized care provision [10-12]. Altogether, these challenges pose a threat to the use, coordination, and continuation of health care services for patients with chronic health conditions or disabilities.

In particular, individuals struggle with coordination difficulties [13]. Literature supports this finding, with a relationship between self-reported care coordination difficulties and the level of patient engagement and chronic illness complexity being observed [13,14]. It is critical to address this gap by providing navigation services for these patients with multiple and complex chronic conditions as a lack of proper coordination and continuation of services can lead to negative outcomes related to one’s health and well-being, including one’s ability to integrate and participate within the community [5-8,13,15].

Patient navigation commonly involves the use of one-to-one interactions between navigators and patients or their family members and caregivers to promote recommended health care use behaviors from patients’ screening, to diagnosis, to resolution [10,16-19]. Patient navigation can be provided in the form of a professional, lay, or peer (with training) navigator [20].

Current literature has identified patient navigation interventions (PNIs) as an effective care approach for populations with chronic illness or disabilities in relation to managing their care through assistance with navigating the health care system [1,10,13,16,21-27]. In a systematic review, McBrien et al [27] assessed the impact of patient navigation on patients living with chronic diseases such as cancer, diabetes, HIV or AIDS, cardiovascular disease, chronic kidney disease, and dementia. The authors found that of the included 67 randomized controlled trials (RCTs), 44 trials indicated that patient navigation improved primary outcomes, specifically those related to the patients’ care or health care navigation process [27]. A meta-analysis of RCTs involving various patient populations revealed that compared to usual care, patient navigation more than doubled the likelihood of patients’ health screening rates and attendance at care events [25]. Similar findings were reported in a scoping review by Kokorelias et al [10] that summarized the literature on patient navigation for adults with chronic conditions, whereby patient navigation increased a patient’s overall satisfaction with their care and improved access to care, education, and adherence to medication and treatment completion. Likewise, in the context of cancer care, reviews of patient navigation have concluded that PNI programs were found to be cost-effective approaches to care when considering factors such as life expectancy, incremental cost-effectiveness ratios, and quality-adjusted life-years [28,29], thus further supporting the benefit and need for patient navigation. While informative, these reviews focused on PNIs in general and were not specific to online PNIs.

One example of patient navigation is peer navigation, which involves trained peer navigators who have lived experiences of health conditions or disabilities that they can use to provide personalized support to patients with different needs [19,23,30-33]. Personalized support in patient or peer navigation may involve the following types of support: educational or informational (sharing of advice, personal experiences, first-hand knowledge, resources, and factual information), psychosocial (provision of emotional and social support using empathy, validation, mentorship, motivation, feedback, and reflection), and instrumental (assistance with administrative activities, accessing and navigating services or resources, advocacy) [19,23,30-33].

Consistent with the theoretical underpinnings of the Social Cognitive Theory [34], the provision of such personalized support in patient navigation can promote patients’ perceived self-efficacy, appropriate health care use behaviors, and related outcomes (ie, community integration, quality of life, and well-being). For instance, Cabassa et al [35] systematic review identified peer-based navigation interventions to be among the most promising interventions for improving the health outcomes of individuals with serious mental illnesses. Peer navigators with lived experience improved health outcomes by facilitating linkages between individuals seeking care and health care services [10,36-39].

One area of development that warrants further exploration is online PNIs for a breadth of chronic conditions in the adult population. Research has shown that online-based PNIs have a great potential for improved health outcomes (eg, increased patient knowledge, transition readiness, self-efficacy, and appropriate use of health care services) in various patient populations. Casillas et al [40] conducted a three-arm RCT to test the efficacy of both a peer navigation intervention and an intervention involving the use of mobile technology (ie, SMS text messaging) in promoting cancer survivorship care in adolescents and young adults. Compared to standard care, these online interventions demonstrated the following statistically significant benefits: online peer navigation improved participants’ self-efficacy in survivorship care, SMS text messaging improved survivorship-focused knowledge, and both interventions improved participants’ attitudes in seeking survivorship care [40]. Specifically, the SMS text messaging group exhibited higher levels of survivorship care knowledge compared to the control group (P<.05), while the peer navigation group showed increased survivorship care self-efficacy compared to the control group (P<.05). Both intervention groups demonstrated more positive attitudes toward seeking survivor-focused care compared to the control group (SMS text messaging group: P<.05; peer navigation group: P<.05) [40]. Considering the initial efficacy observed in both interventions, each has the potential to be used in the future to educate and empower adolescent and young adult cancer survivors in accessing necessary survivorship care [40]. Online support has also been deemed a more flexible and sustainable care model when offered to individuals with intellectual disabilities, especially during the COVID-19 pandemic [41]. Moreover, online patient navigation can better reach rural, remote, and other underserved communities.

Objective

Despite the demonstrated benefits of online patient navigation for various patient populations, the extent of the literature specifically focused on online PNIs across a range of chronic conditions or disabilities is uncharted. Therefore, the purpose of this scoping review is to comprehensively search databases and summarize data from peer-reviewed publications to address the following research question: What is known from the existing literature about the key characteristics (ie, intervention type, mode of delivery, duration, frequency, outcomes and outcome measures, underlying theories or mechanisms of change of the intervention, and impact) of online PNIs used across a range of chronic conditions or disabilities?

Methods

Research Design and Methodological Framework

A scoping review methodology was used given the broad nature of the research objective and question, and the lack of previous comprehensive reviews conducted in this area. A scoping review, also known as a scoping study, serves as a form of knowledge synthesis designed to explore research questions and map key concepts, types of evidence, and research gaps related to a defined area or field. This approach involves systematic searching, selection, and synthesis of existing knowledge [42] (page 28). Thus, a scoping review was deemed suitable to help identify key concepts and evidence related to online PNIs for adults with chronic conditions or disabilities. This scoping review was guided by the framework proposed by the Joanna Briggs Institute (JBI) Manual for Evidence [43-45]. The JBI framework was selected as it was developed based on previously reported methodological frameworks by Arksey and O’Malley [46] and Levac et al [47]. This refined framework provides additional guidance and clarity on the steps involved in the collection, analysis, and dissemination of research findings [43-45]. Specifically, the JBI framework focuses on aspects of the research process that have not been addressed as extensively in previous frameworks. The methods and the findings are reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews; Multimedia Appendix 1) to further enhance the reporting of findings, as consistent with the JBI methodology [43-45,48]. A protocol was not published prior to the completion of this scoping review.

Inclusion and Exclusion Criteria

All empirical study designs (eg, experimental, quasi-experimental, observational, qualitative studies, not review methodologies) reported in peer-reviewed, full text (eg, no conference abstracts) were included to increase the scope of the literature found. To address the identified gaps in the current literature on online PNIs, only peer-reviewed studies involving trained navigators and PNIs delivered using an online format, and software or application-based PNIs both with or without allocated trained navigator support were included. Our review encompasses a broad spectrum of online PNIs including those featuring hybrid formats. These interventions incorporate both online elements and face-to-face or other non–internet-related components, ensuring a comprehensive assessment of diverse intervention modalities and their characteristics. Participants in these studies had to be adults (aged 18 years and older) with chronic conditions or disabilities as recognized by the Public Health Agency of Canada (PHAC) [49], the Canadian Chronic Disease Surveillance System, and the World Health Organization. These conditions based on their PHAC categorization could include exclusively physical or mental health–based conditions, or both. Examples of common chronic diseases and conditions, as defined by the PHAC, the Canadian Chronic Disease Surveillance System, and the World Health Organization, include cardiovascular disease (eg, heart failure, hypertension, and stroke), chronic respiratory disease (eg, asthma and chronic obstructive pulmonary disease), diabetes mellitus (types combined, but not gestational diabetes), mental illnesses (alcohol or drug-induced disorders, mood and anxiety disorders, and schizophrenia), musculoskeletal disorders (eg, arthritis and osteoporosis), and neurological conditions (eg, dementia, epilepsy, multiple sclerosis, and Parkinson) [49-51]. Additionally, studies with participants living with HIV and AIDS were also included [52]. Only studies published between 1989 and 2022 and available in full text in English were included due to feasibility considerations (ie, members of the research team could only read in English) and resource constraints. The Report to the Nation on Cancer in the Poor that began work in the area of patient navigation began in 1989 [21]. Exclusion criteria included PNIs that were delivered in alternate formats (eg, face-to-face, telephone, and mail).

Data Collection and Management

Comprehensive literature search strategies based on the inclusion and exclusion criteria of this scoping review were developed in collaboration with an experienced librarian (LP). The search strategies were further informed by the Participants/Concept/Context framework as recommended in the JBI methodology. The search strategy included medical subject headings and text words related to adults with chronic conditions or disabilities and online PNIs (Multimedia Appendix 2). The search strategy was first developed, tested, and refined in MEDLINE (OVID interface) prior to being used in other databases. The following databases were searched using the finalized MEDLINE strategy: CINAHL (EBSCO interface), Embase (OVID interface), PsycInfo (OVID interface), and Cochrane Central Register Controlled Trials (Cochrane Library). The use of multiple health care–related databases helped broaden the scope of the comprehensive literature search. Data yielded from the comprehensive literature search strategies were stored and screened using the online Covidence software program (SaaS Enterprise) [53,54]. These data were screened at 2 levels (ie, level 1 and level 2 screening). Study titles and abstracts were screened first, followed by the screening of full-text studies. Screening at both levels was conducted by 2 independent reviewers (MM and SRS) to ensure accuracy in the included results. Discrepancies were addressed through consensus between the reviewers and the senior author (KMK). Reference lists of all included studies were reviewed to determine any studies that may have been missed from the database search. Gray literature was not included.

Data Extraction and Analysis

Data extraction was carried out by extracting key information or data from the included studies. A data extraction form, developed by the authors, was used to chart and record this information to ensure easy referencing and tracking of each study to ensure clarity. The form was first piloted on the first 5 included studies by all members of the research team. The extraction template was further informed by the Template for Intervention Description and Replication (TIDieR) checklist and guide, which is a framework that aims to promote replicability and implementation of interventions through the consistent reporting of key intervention characteristics [55]. The following data were extracted from the full-text studies: study characteristics (ie, title, author or authors, publication year, publication country, study purpose or objective or objectives, and study design), participant population characteristics (ie, sample size, race or ethnicity, condition or disability, age, and sex), and key characteristics of the intervention (ie, name, type, description, setting, duration, frequency, mode of delivery, underlying theories, behavior change techniques or working mechanisms, context, outcome measures used, and quantitative and qualitative outcomes). In line with scoping review methodologies, we did not evaluate the quality of included studies [56]. Data were extracted by 2 independent reviewers (MM and SRS) and any disagreements were resolved through consensus. Following data extraction, the following information was specifically summarized using descriptive statistics [57] and directed content analysis [58] to provide an accurate overview of the published literature on the key characteristics of online PNIs in adults with chronic conditions or disabilities. The research team reviewed the coded data to create a set of categories that capture the key themes, concepts, and variables relevant to the research question. This involved both inductive categories (emerging from the data) and deductive categories (informed by the TIDieR framework). The authors then began coding the selected studies according to this scheme, using Excel (Microsoft Corp) to facilitate this process. The Excel document was then reviewed by all members of the research team to identify patterns and trends. The team met over a series of meetings to determine key interpretations of the results.

Results

Overview

The PRISMA-ScR flowchart displayed in Figure 1 shows an overview of our comprehensive literature search, which yielded 11,925 studies.

Figure 1 PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) flowchart.

Study Characteristics

The publication dates ranged from 2003 to 2022, with some years yielding no publications. The greatest number (n=20, 20%) were published in 2019 with 19 (19%) studies published in 2020. As for the publication country, all studies were published in Western countries. A total of 48 (48%) studies were conducted and published in the United States, followed by 23 (23%) studies from Canada, and 19 (19%) studies from the United Kingdom. There was a variation of study designs observed in the review. The most common study design included RCTs (n=39, 39%). The included studies focused on the development, implementation, and testing of online PNIs. Of the studies included, 82 (82%) studies specified their sample size. There was a significant range in the overall participant sample size (including intervention and control arm or arms), observed from 9 to 14,584 participants, with the median being 97 (IQR 342) participants. When comparing the sample sizes of the intervention and control arms, 24 studies had an approximately equal division, while 21 studies did not. In addition, 55 studies did not specify the sample size of the intervention or control groups. Multimedia Appendix 3 outlines the study characteristics.

Population Characteristics

Among the included full-text studies, the majority (n=79, 79%) of the studies’ participants had conditions or disabilities that would be classified exclusively as physical health-based conditions according to the PHAC (including cancer, heart disease, diabetes, and stroke), while only 11% (n=11) of the studies represented participants with solely mental health-based conditions (eg, mood disorders, substance use and addictions, and eating disorders). A total of 10% (n=10) of the studies represented participants who had both physical and mental health–based conditions. One study represented participants who had post–COVID-19 condition. In terms of the participants’ age, 55% (n=55) of the studies provided this information. Across the studies that reported age (regardless of study design), the mean age range (with SD) of the participants included in the studies’ intervention arms (ie, those who participated in online PNI) was between 19.84 (SD 1.61) and 69.6 (SD 9.1) years. When comparing the age of the participants in the intervention and control arms, 37% (n=37) of the studies had similarly aged participants (ie, 20-70 years of age). With regards to the sex of participants, 20 (20%) studies included only female participants while only 4 (4%) studies included only male participants. A total of 19 (19%) studies had an approximately equal distribution of females and males, and 14 (14%) studies did not specify the sex of the participants or inconsistently reported this information. In terms of the racial or ethnic representation of participants in studies, more than half (n=54, 54%) of the studies did not specify this information. Among those that did, in 20 (20%) studies, the majority of the participants were White, followed by the following racial groups: Black, African, or African-American (16 studies), Hispanic or Latinx (5 studies), and Asian or Asian American (4 studies; terminology as used by the original authors of the included studies). Only one study focused on the Indigenous population (in Australia).

Intervention Characteristics

Types of Intervention

Among the 100 included studies, the most common intervention type was a combination (n=61, 61%), which included a mix of peer, patient, and other navigation types including coaching, digital navigation (including mobile, eHealth, or telehealth-based interventions, or software application-based interventions), and self-management. Within the “other” category, intervention types included a mixture or combination of peer, patient, and other navigation intervention types, as well as the exclusive implementation of interventions such as coaching, counseling, health promotion, digital navigation, self-monitoring, or self-management. A total of 32 (32%) studies were exclusively patient navigation-based, and 7 (7%) studies were exclusively peer navigation-based. Other studies did not clearly specify the intervention type (ie, who the intervention was led by or what it involved).

Several studies explored diverse online PNIs for cancer-related support and care. While the interventions varied across studies, commonalities and differences emerged. One study introduced a virtual navigation tool providing comprehensive cancer information accessible 24/7, emphasizing its value in validating information and controlling exposure, while another used nurse navigators sending scripted messages, resulting in improved quality of life and symptom burden among participants [59]. A similar modality was used by other studies that used peer navigation and SMS text messaging interventions for educating cancer survivors on late effects and survivorship care, leading to improved survivorship knowledge, attitudes, and self-efficacy [40]. On the contrary, some scholars focused on self-monitoring and physical activity, noting enthusiasm and continued use among participants [60,61].

In the context of multimorbidity, the studies featured various adaptations and design elements tailored for both physical and mental health conditions and examined technology use for patients with multiple chronic conditions, focusing on communication tools, tracking medical information, and decision-making support, intending to address self-management challenges and health care navigation issues [62]. Allen et al [63] developed an internet-based health coaching intervention targeting chronic pain, depression, and mobility difficulties, emphasizing patient-clinician communication improvement and patient empowerment through goal-setting and constructive communication tools. On the other hand, some interventions focused on peer visitation, support groups, and educational materials, enhancing recovery expectations and satisfaction [64,65]. Thus, both chronic conditions, like cancer and multiple chronic conditions, used strategies such as technology integration for communication, support, and information dissemination, tailored interventions addressing specific conditions and associated challenges, peer support networks fostering engagement and optimism, and empowerment strategies encouraging collaborative patient-clinician communication, goal-setting, and self-efficacy. Multimedia Appendix 4 outlines the intervention characteristics.

Duration and Frequency

Of the included studies, the duration and frequency of interventions were varied. Of the 100 included studies, 55 (55%) studies specified a duration and only 17 (17%) studies specified a frequency of the intervention. Other studies included a variable duration or frequency that was tailored to the needs of individual patients. Of the 55 (55%) studies that specified duration, 7 (7%) studies were offered for a year. A total of 41 (41%) studies were offered for 1 month up to 11 months, 3 studies were offered weekly (eg, one time per week), and 4 (4%) studies were held on a daily basis. In addition, of the total studies included, 14 studies had a variable duration, 24 (24%) studies did not specify, and there were 7 (7%) studies where the duration was not applicable (eg, proof of concept, usability, and beta-testing). In terms of frequency, of the 17 (17%) studies that specified frequency for interventions, 3 (3%) studies were month-based, 10 (10%) studies were week-based, and 4 studies required day-to-day engagement from participants. Of the total studies included, 46 (46%) online PNIs had variable frequency, 30 (30%) did not specify frequency, and there were 7 (7%) studies that reported interventions where the frequency was not applicable as the interventions only occurred once.

Mode of Delivery

Of the included studies, 56 (56%) of the 100 studies reported using an online mode of asynchronous or synchronous delivery for interventions, without any other components. A total of 13 (13%) studies used a format that was hybrid, with both online and offline intervention formats. In total, 22 (22%) studies included SMS text messaging as the main component of intervention delivery, of which 14 (14%) studies had SMS text messaging mixed with other intervention formats such as the use of telephone calls, educational videos, websites, and online support groups. Finally, 9 (9%) of the 100 studies used a mixed format including intervention components such as software programs and applications, telephone calls, in-person interactions, email, automated phone lines, and other online-based intervention formats.

Underlying Theories

In total, 78 (78%) studies did not specify the use of any underlying theories, models, and frameworks, that were used to guide the PNIs. Of the 22 (22%) studies that did specify an existing theory, a total of 21 different theories were identified. Four studies indicated that the intervention was based on more than one theory. Social cognitive theory followed by the self-determination theory, self-efficacy theory, behavior change theory, and community empowerment were the most common theories used. The most common working mechanism among these was a combination (n=20, 20%) of various mechanisms, which included coaching, education, peer support, navigation, self-management, and cognitive behavioral therapy among others. Self-management (n=19, 19%) and navigation (n=19, 19%) followed as other commonly identified mechanisms.

Outcome Measures

Multiple outcome measures were used in these studies; however, the most commonly used outcome measures included: the Short Form-36 survey questionnaire to measure participants’ health-related quality of life, the Patient Health Questionnaire-9 to measure participants’ psychological outcomes, and the Health Education Impact Questionnaire to measure participants’ knowledge and self-management related outcomes. Additional standardized and nonstandardized outcome measures were used to report on common intervention outcomes such as the interventions’ feasibility, acceptability, efficacy, effectiveness, uptake, use, and retention, and participants’ clinical symptoms or outcomes (physical, mental, emotional or psychosocial), lifestyle or behavioral changes, quality of life, user experience or satisfaction, adherence, knowledge, attitudes, and self-efficacy.

Outcomes and Impact of Online PNIs

Out of the 76 (76%) studies that reported quantitative findings (including RCTs and non-RCTs), 46 (60.5%) studies demonstrated significant improvements. Improvements were commonly demonstrated in the following outcomes: appointment adherence, intervention retention, knowledge, self-monitoring of symptoms, and physical and mental health symptoms. Of the 23 (23%) studies that reported qualitative findings, 8 (35%) studies identified specific themes and subthemes [62,66-72]. The included qualitative studies spoke of themes that described usability or user experience, as well as participants’ experience with the PNI as it related to self-management, education, knowledge, navigation, engagement, encouragement or support, and feedback.

Discussion

Principal Findings

This scoping review aimed to investigate the key characteristics of reported online PNIs to inform future intervention development and research evaluation. A total of 100 peer-reviewed studies were included. Overall, online PNIs are highly variable with various modalities for delivery, durations, frequencies, and contexts of support provided. Few studies reported participants’ sex, diagnoses, age, and race or ethnicity. Moreover, most of the literature was published in Western countries, resulting in a lack of data from non-Western countries, as well as PNIs that reflect the needs of individuals from non-Western countries. Despite this, we were able to ascertain through the results of 20 RCTs (the highest level of evidence) [73] that in general, online PNIs improve outcomes of patients’ self-management, knowledge, clinical symptoms (physical or mental health–based), and use and navigation of health care services.

The majority of the online PNIs were designed for physical health-based conditions (including cancer, heart disease, diabetes, and stroke), while few studies focused solely on mental health–based conditions. Our investigation revealed a notable scarcity of online PNIs specifically targeting multimorbidity of physical and mental health conditions (n=10), signifying a considerable gap in available interventions addressing the complex needs of individuals with multiple chronic conditions. This paucity carries significant implications, indicating an unmet need within the digital health landscape, that is needed to ensure comprehensive care for those navigating multifaceted health challenges. Participants in the RCTs ranged from 20 to 70 years of age. As with other reviews of digital health interventions to support the coordination of care [74,75], our review noted a lack of inclusion of particular groups of older adults (ie, 70 years and older), despite this group representing a large proportion of individuals living with chronic conditions [76] who could benefit from online health interventions [75,77]. Moreover, our review found a lack of literature exploring the impact of online PNIs on Indigenous populations and non-White populations such as Black, Asian, and Hispanic individuals, making it difficult to ascertain their unique needs to inform further online PNIs. As such, future research on online PNIs is encouraged to explore the interaction of racial and cultural factors of different groups to improve service delivery [78].

Our review highlights how future online PNIs can better support various patient populations. Only one study cited in our review noted the racial preferences of participants in which Black patients preferred the services of a Black (virtual) provider [79]. Ethnic minorities and other underserved populations often face unique barriers to accessing health services that patient navigation is able to assist with overcoming [10,80,81]. Social and environmental factors, such as finances, health literacy, and availability of health services, influence health access [82-84]. To overcome these barriers, it is necessary to create efficient processes for referring communities affected by social and environmental factors to suitable resources, ensuring that their needs are adequately met [85,86]. Culturally appropriate patient navigation can assist with learning about the unique information needs and barriers that face particular communities and facilitate an appropriate referral and support process to services [10,87]. While online PNIs can help overcome traditional barriers to seeking support, such as transportation [88], it is important to consider that shifting to online PNIs may also increase risks to access and equity as a result of digital inequity (ie, gaps in use and participation in the use of technology) [89]. Future research efforts on online PNIs should also consider the individual needs of target populations (eg, access and geographical location, income, and digital literacy), as well as the significance of an individual-based versus group-based mode of delivery of online PNIs.

We also noted the lack of consistent reporting of intervention characteristics. For example, the duration and frequency of interventions were not reported consistently or were variable among the included studies in our review. Moreover, multiple studies did not specify the exact frequency of their intervention. Similar trends were observed in a previous review on web-based peer support interventions where the authors reported “a lack of consistency” and variation regarding the reporting of intervention characteristics such as duration and frequency [75]. The reporting of intervention doses associated with improved outcomes is important to guide other jurisdictions looking to implement or build upon existing interventions [90]. Frameworks, such as the TIDieR, have been posited as helpful for guiding researchers in reporting a full description of complex interventions [55] such as PNIs. The TIDieR can help guide the reporting of future online PNIs to ensure transparency and improve the quality of patient navigation research. Relying solely on reported intervention characteristics, however, can imply a limitation of the personalization of interventions (ie, inflexibility in the duration and frequency tailored to participant needs). While this can be a great guide for replicating the interventions, and further testing and implementation, patients with chronic illness may require individualized approaches to care [91]. Further research is needed to understand how the duration, frequency, and support provided within existing online PNIs may evolve across the illness and care trajectory of patients. Moreover, the TIDieR is only beneficial for reproducibility in the setting specified by the original individual study and therefore cannot guide researchers to implement the intervention in different contexts or settings [90]. Researchers should then reply on implementation frameworks, such as the PRACTical planning for Implementation and Scale-up guide to provide practical direction on implementing online PNIs into new sessions [92].

Despite a substantial portion (78%) of the studies not explicitly delineating underlying theories or frameworks, the 22% of studies that did highlight a diverse array of theoretical foundations (ie, Social Cognitive Theory emerged prominently, followed by self-determination theory, self-efficacy theory, behavior change theory, and community empowerment among others). This diversity underscores the need for a more comprehensive and structured integration of theoretical frameworks within the design and implementation of online PNIs. Integration of frameworks within online PNIs can help researchers understand the underlying mechanisms driving these interventions and will help to establish standardized evaluation metrics. Moving forward, comprehensive research could delve into exploring the efficacy and synergies of combining multiple theories to inform the design and implementation of online PNIs effectively. Furthermore, investigating how specific mechanisms within these theories (eg, coaching, education, and peer support) contribute to PNI outcomes can enrich our understanding and potentially optimize intervention strategies. This calls for a systematic and comparative analysis to discern the differential impact of diverse theoretical orientations on the effectiveness, sustainability, and scalability of PNIs across various health contexts and participant demographics.

Digital health interventions often incorporate elements akin to navigation programs including patient education, remote monitoring, and personalized feedback. These features aim to empower patients in self-management and facilitate communication with health care providers. In contrast, navigation programs traditionally focus on guiding patients through complex health care systems, providing support in appointment scheduling, access to resources, and continuity of care. However, as digital health evolves, distinctions between these approaches can blur. Many digital health solutions now integrate navigation functionalities such as decision support tools and care coordination platforms. This integration raises questions about the delineation between virtual care and navigation programs, particularly regarding their roles in improving health outcomes and patient experience across different chronic diseases. Moving forward, future research should explore synergies between digital health interventions and navigation programs to optimize their combined impact on chronic disease management. This includes examining the effectiveness of integrated approaches in enhancing patient adherence, reducing health care disparities, and improving the overall quality of care.

Finally, we found that online PNIs are an accessible and user-friendly option for navigational support to patients. Similar trends were observed in other studies involving peer and professional navigators [10,19,20,36,93-101]. Similarly, positive and statistically significant outcomes were also reported in another scoping review on web-based peer support, where the authors found that interventions in 4 of their 6 included RCTs improved the health navigation, emotional self-management, self-efficacy, social participation, and attitudes of adults with chronic conditions [75]. Overall, these findings demonstrate how online PNIs could play a crucial role in improving health use and navigation among adults with chronic conditions and disabilities. Additionally, a common theme that was reported by patients, specifically among the qualitative findings of studies from our review was that online PNIs provided more accessibility, engagement, and encouragement to participants navigating their health. Gaining insight on what would construe the ideal patient navigator and ideal patient navigator program for patients with chronic health conditions is still in its infancy [102,103], and as such conducting more qualitative research with diverse patient populations would be valuable in refining and co-designing novel online PNIs and navigator roles.

Limitations

Although a systematic, comprehensive review was conducted to identify key characteristics of online PNIs, the authors acknowledge that this scoping review has some limitations. First, search results were limited to publications in English studies published after 1989, and while the broad search strategy made it unlikely that potentially eligible publications were missed as a result, we may have created a bias toward studies from English-speaking countries, which might have contributed to the majority of data coming from Western countries. We also excluded gray literature. The majority of the data extraction was not completed in duplicate, which may have affected the reliability of the extracted data. Incomplete reporting on study characteristics by original study authors also made it challenging to comment on additional participant characteristics (eg, socioeconomic status, education level, and digital literacy) that would have provided valuable information.

Conclusions

This review has mapped the existing literature on online PNIs, and in doing so, has identified several gaps that should be addressed in future research and intervention development efforts. Although many positive outcomes were reported for online PNIs, a lack of variation in included study samples, as well as a lack of consistency in reporting, was observed in the reporting of TIDieR intervention characteristics including the following: the publication country of studies, population characteristics such participants’ age, sex, and racial or ethnic background, duration and frequency of interventions, and the use of underlying theories and working mechanisms to inform intervention development. Future research and development efforts should consider using theories and models, expanding inclusion criteria, and reporting key intervention characteristics more consistently.

Multimedia Appendix 1 PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

Multimedia Appendix 2 Search Strategy.

Multimedia Appendix 3 Overview of study characteristics.

Multimedia Appendix 4 Intervention characteristics.

Abbreviations

JBI Joanna Briggs Institute

PHAC Public Health Agency of Canada

PNI patient navigation intervention

PRISMA-ScR Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

RCT randomized controlled trial

TIDieR Template for Intervention Description and Replication

Conflicts of Interest: None declared.
==== Refs
1 Dixit N Rugo H Burke NJ Navigating a path to equity in cancer care: the role of patient navigation Am Soc Clin Oncol Educ Book 2021 41 3 10 10.1200/EDBK_100026 33830828
2 A guideline for transition from paediatric to adult health care for youth with special needs: a national approach CAPHC 2016 2024-08-03 https://www.childhealthbc.ca/sites/default/files/caphc_transition_to_adult_health_care_guideline_may_2017.pdf
3 Entwistle VA Cribb A Owens J Why health and social care support for people with long-term conditions should be oriented towards enabling them to live well Health Care Anal 2018 26 1 48 65 10.1007/s10728-016-0335-1 27896539 10.1007/s10728-016-0335-1 27896539
4 Webkamigad S Rowe R Peltier S Chow AF McGilton KS Walker JD Identifying and understanding the health and social care needs of indigenous older adults with multiple chronic conditions and their caregivers: a scoping review BMC Geriatr 2020 20 1 145 10.1186/s12877-020-01552-5 32306912 10.1186/s12877-020-01552-5 32306912
5 Blum RW Garell D Hodgman CH Jorissen TW Okinow NA Orr DP Slap GB Transition from child-centered to adult health-care systems for adolescents with chronic conditions. A position paper of the society for adolescent medicine J Adolesc Health 1993 11 14 7 570 576 10.1016/1054-139x(93)90143-d 8312295 1054-139X(93)90143-D 8312295
6 Stevens SE Steele CA Jutai JW Kalnins IV Bortolussi JA Biggar WD Adolescents with physical disabilities: some psychosocial aspects of health J Adolesc Health 1996 19 2 157 164 10.1016/1054-139X(96)00027-4 8863089 1054-139X(96)00027-4 8863089
7 Steinbeck KS Brodie L Towns SJ Transition in chronic illness: who is going where? J Paediatr Child Health 2008 44 9 478 482 10.1111/j.1440-1754.2008.01321.x 18928466 JPC1321 18928466
8 Brown MM Transitions of care Chronic Illness Care 2018 New York City Springer 369 373
9 Mitchell SE Laurens V Weigel GM Hirschman KB Scott AM Nguyen HQ Howard JM Laird L Levine C Davis TC Gass B Shaid E Li J Williams MV Jack BW Care transitions from patient and caregiver perspectives Ann Fam Med 2018 16 3 225 231 10.1370/afm.2222 29760026 29760026
10 Kokorelias KM Shiers-Hanley JE Rios J Knoepfli A Hitzig SL Factors influencing the implementation of patient navigation programs for adults with complex needs: a scoping review of the literature Health Serv Insights 2021 14 11786329211033267 10.1177/11786329211033267 34349519 10.1177_11786329211033267 34349519
11 Coleman EA Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs J Am Geriatr Soc 2003 51 4 549 555 10.1046/j.1532-5415.2003.51185.x 12657078 jgs51185 12657078
12 Hudon C Aubrey-Bassler K Chouinard M Doucet S Dubois M Karam M Luke A Moullec G Pluye P Tzenov A Ouadfel S Lambert M Angrignon-Girouard E Schwarz C Howse D MacLeod KK Gaudreau A Sabourin V Better understanding care transitions of adults with complex health and social care needs: a study protocol BMC Health Serv Res 2022 22 1 206 10.1186/s12913-022-07588-0 35168628 10.1186/s12913-022-07588-0 35168628
13 Maeng DD Martsolf GR Scanlon DP Christianson JB Care coordination for the chronically ill: understanding the patient's perspective Health Serv Res 2012 47 5 1960 1979 10.1111/j.1475-6773.2012.01405.x 22985032 22985032
14 Berntsen G Høyem A Lettrem I Ruland C Rumpsfeld M Gammon D A person-centered integrated care quality framework, based on a qualitative study of patients' evaluation of care in light of chronic care ideals BMC Health Serv Res 2018 18 1 479 10.1186/s12913-018-3246-z 29925357 10.1186/s12913-018-3246-z 29925357
15 Chen L Xiao LD Chamberlain D An integrative review: challenges and opportunities for stroke survivors and caregivers in hospital to home transition care J Adv Nurs 2020 76 9 2253 2265 10.1111/jan.14446 32511778 32511778
16 Aboumatar H Pitts S Sharma R Das A Smith BM Day J Holzhauer K Yang S Bass EB Bennett WL Patient engagement strategies for adults with chronic conditions: an evidence map Syst Rev 2022 11 1 39 10.1186/s13643-021-01873-5 35248149 10.1186/s13643-021-01873-5 35248149
17 Reid AE Doucet S Luke A Azar R Horsman A The impact of patient navigation: a scoping review protocol JBI Database System Rev Implement Rep 2019 17 6 1079 1085 10.11124/JBISRIR-2017-003958 31021974
18 Valaitis RK Carter N Lam A Nicholl J Feather J Cleghorn L Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review BMC Health Serv Res 2017 17 1 116 10.1186/s12913-017-2046-1 28166776 10.1186/s12913-017-2046-1 28166776
19 Kelly K Doucet S Luke A Exploring the roles, functions, and background of patient navigators and case managers: a scoping review Int J Nurs Stud 2019 98 27 47 10.1016/j.ijnurstu.2019.05.016 31271977 S0020-7489(19)30148-8 31271977
20 Reid AE Doucet S Luke A Exploring the role of lay and professional patient navigators in Canada J Health Serv Res Policy 2020 25 4 229 237 10.1177/1355819620911679 32188293 32188293
21 Freeman HP Rodriguez RL History and principles of patient navigation Cancer 2011 117 S15 3539 3542 10.1002/cncr.26262 21780088 21780088
22 Freeman HP The history, principles, and future of patient navigation: commentary Semin Oncol Nurs 2013 29 2 72 75 10.1016/j.soncn.2013.02.002 23651676 S0749-2081(13)00012-0 23651676
23 Lorhan S Cleghorn L Fitch M Pang K McAndrew A Applin-Poole J Ledwell E Mitchell R Wright M Moving the agenda forward for cancer patient navigation: understanding volunteer and peer navigation approaches J Cancer Educ 2013 28 1 84 91 10.1007/s13187-012-0424-2 23104142 23104142
24 Kelly E Fulginiti A Pahwa R Tallen L Duan L Brekke JS A pilot test of a peer navigator intervention for improving the health of individuals with serious mental illness Community Ment Health J 2014 50 4 435 446 10.1007/s10597-013-9616-4 23744292 23744292
25 Ali-Faisal SF Colella TJ Medina-Jaudes N Benz Scott L The effectiveness of patient navigation to improve healthcare utilization outcomes: a meta-analysis of randomized controlled trials Patient Educ Couns 2017 100 3 436 448 10.1016/j.pec.2016.10.014 27771161 S0738-3991(16)30483-9 27771161
26 Munce SEP Shepherd J Perrier L Allin S Sweet SN Tomasone JR Nelson MLA Guilcher SJT Hossain S Jaglal S Online peer support interventions for chronic conditions: a scoping review protocol BMJ Open 2017 7 9 e017999 10.1136/bmjopen-2017-017999 28947464 bmjopen-2017-017999
27 McBrien KA Ivers N Barnieh L Bailey JJ Lorenzetti DL Nicholas D Tonelli M Hemmelgarn B Lewanczuk R Edwards A Braun T Manns B Patient navigators for people with chronic disease: a systematic review PLoS One 2018 13 2 e0191980 10.1371/journal.pone.0191980 29462179 PONE-D-17-23683 29462179
28 Bernardo BM Zhang X Hery CMB Meadows RJ Paskett ED The efficacy and cost‐effectiveness of patient navigation programs across the cancer continuum: a systematic review Cancer 2019 125 16 2747 2761 10.1002/cncr.32147 31034604 31034604
29 Tan CHH Wilson S McConigley R Experiences of cancer patients in a patient navigation program: a qualitative systematic review JBI Database System Rev Implement Rep 2015 13 2 136 168 10.11124/jbisrir-2015-1588 26447039
30 Raut A Thapa P Citrin D Schwarz R Gauchan B Bista D Tamrakar B Halliday S Maru D Schwarz D Design and implementation of a patient navigation system in rural Nepal: improving patient experience in resource-constrained settings Healthc (Amst) 2015 3 4 251 257 10.1016/j.hjdsi.2015.09.009 26699353 S2213-0764(15)00093-7 26699353
31 Jean-Pierre P Hendren S Fiscella K Loader S Rousseau S Schwartzbauer B Sanders M Carroll J Epstein R Understanding the processes of patient navigation to reduce disparities in cancer care: perspectives of trained navigators from the field J Cancer Educ 2011 26 1 111 120 10.1007/s13187-010-0122-x 20407860 20407860
32 Krulic T Brown G Bourne A A scoping review of peer navigation programs for people living with HIV: form, function and effects AIDS Behav 2022 26 12 4034 4054 10.1007/s10461-022-03729-y 35672548 10.1007/s10461-022-03729-y 35672548
33 Bender JL Flora PK Soheilipour S Dirlea M Maharaj N Parvin L Matthew A Catton C Jamnicky L Pollock P Kwan W Finelli A Kazanjian A Web-based peer navigation for men with prostate cancer and their family caregivers: a pilot feasibility study Curr Oncol 2022 29 6 4285 4299 10.3390/curroncol29060343 35735452 curroncol29060343 35735452
34 Bandura A Social cognitive theory: an agentic perspective Annu Rev Psychol 2001 52 1 26 10.1146/annurev.psych.52.1.1 11148297 52/1/1 11148297
35 Cabassa LJ Camacho D Vélez-Grau CM Stefancic A Peer-based health interventions for people with serious mental illness: a systematic literature review J Psychiatr Res 2017 84 80 89 10.1016/j.jpsychires.2016.09.021 27701013 S0022-3956(16)30411-3 27701013
36 Reid AE Exploring the Role of Lay and Professional Patient Navigators in Canada 2019 New Brunswick Graduate Academic Unit of Interdisciplinary studies, University of New Brunswick
37 Rocque G Dionne-Odom J Williams C Jackson BE Taylor R Pisu M Partridge E Kvale E Huang CHS Niranjan SJ Halilova KI Kenzik KM Briggs LA Implementation and impact of lay navigator-led advance care planning for cancer patients (FR440C) J Pain Symptom Manage 2017 53 2 368 10.1016/j.jpainsymman.2016.12.132
38 Steinberg ML Fremont A Khan DC Huang D Knapp H Karaman D Forge N Andre K Chaiken LM Streeter OE Lay patient navigator program implementation for equal access to cancer care and clinical trials: essential steps and initial challenges Cancer 2006 107 11 2669 2677 10.1002/cncr.22319 17078056 17078056
39 Freund KM Haas JS Lemon SC White KB Casanova N Dominici LS Erban JK Freedman RA James TA Ko NY LeClair AM Moy B Parsons SK Battaglia TA Standardized activities for lay patient navigators in breast cancer care: recommendations from a citywide implementation study Cancer 2019 125 24 4532 4540 10.1002/cncr.32432 31449680 31449680
40 Casillas JN Schwartz LF Crespi CM Ganz PA Kahn KL Stuber ML Bastani R Alquaddomi F Estrin DL The use of mobile technology and peer navigation to promote adolescent and young adult (AYA) cancer survivorship care: results of a randomized controlled trial J Cancer Surviv 2019 13 4 580 592 10.1007/s11764-019-00777-7 31350681 10.1007/s11764-019-00777-7 31350681
41 Zaagsma M Volkers K Swart E Schippers A Van Hove G The use of online support by people with intellectual disabilities living independently during COVID-19 J Intellect Disabil Res 2020 64 10 750 756 10.1111/jir.12770 32830390 32830390
42 Colquhoun HL Levac D O'Brien KK Straus S Tricco AC Perrier L Kastner M Moher D Scoping reviews: time for clarity in definition, methods, and reporting J Clin Epidemiol 2014 67 12 1291 1294 10.1016/j.jclinepi.2014.03.013 25034198 S0895-4356(14)00210-8 25034198
43 Peters M Godfrey C Khalil H McInerney P Parker D Soares C Guidance for conducting systematic scoping reviews Int J Evid Based Healthc 2015 13 3 141 146 10.1097/XEB.0000000000000050 26134548 26134548
44 Peters MD Godfrey CM McInerney P Soares CB Khalil H Parker D The Joanna Briggs Institute reviewers' manual 2015: methodology for JBI scoping reviews TJBI 2015 1 24 10.46658/jbimes-24-09
45 Peters MD Marnie C Tricco AC Pollock D Munn Z Alexander L McInerney P Godfrey CM Khalil H Updated methodological guidance for the conduct of scoping reviews JBI Evid Synth 2020 18 10 2119 2126 10.11124/JBIES-20-00167 33038124 02174543-202010000-00004 33038124
46 Arksey H O'Malley L Scoping studies: towards a methodological framework Int J Social Res Methodol 2005 8 1 19 32 10.1080/1364557032000119616
47 Levac D Colquhoun H O'Brien KK Scoping studies: advancing the methodology Implement Sci 2010 5 1 69 10.1186/1748-5908-5-69 20854677 1748-5908-5-69 20854677
48 Tricco AC Lillie E Zarin W O'Brien KK Colquhoun H Levac D Moher D Peters MD Horsley T Weeks L Hempel S Akl EA Chang C McGowan J Stewart L Hartling L Aldcroft A Wilson MG Garritty C Lewin S Godfrey CM Macdonald MT Langlois EV Soares-Weiser K Moriarty J Clifford T Tunçalp Ö Straus SE PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation Ann Intern Med 2018 169 7 467 473 10.7326/M18-0850 30178033 2700389 30178033
49 Diseases and conditions Canada PHAo 2024-08-03 https://www.canada.ca/en/public-health/services/diseases.html
50 Betancourt M Roberts K Bennett T Driscoll E Jayaraman G Pelletier L Monitoring chronic diseases in Canada: the chronic disease indicator framework Chronic Dis Inj Can 2014 34 1 1 30 10.24095/hpcdp.34.s1.01f
51 Preventing Chronic Diseases: A Vital Investment 2005 Geneva, Switzerland World Health Organization
52 Liddy C Shoemaker ES Crowe L Boucher LM Rourke SB Rosenes R Bibeau C Kendall CE How the delivery of HIV care in Canada aligns with the chronic care model: a qualitative study PLoS One 2019 14 7 e0220516 10.1371/journal.pone.0220516 31348801 PONE-D-19-10009 31348801
53 Macdonald M Misener RM Weeks L Helwig M Covidence vs Excel for the title and abstract review stage of a systematic review Int J Evidence-Based Healthcare 2016 14 4 200 201 10.1097/01.xeb.0000511346.12446.f2
54 Babineau J Product review: covidence (Systematic Review Software) J Can Health Libr Assoc 2014 35 2 68 71 10.5596/c14-016
55 Hoffmann TC Glasziou PP Boutron I Milne R Perera R Moher D Altman DG Barbour V Macdonald H Johnston M Lamb SE Dixon-Woods M McCulloch P Wyatt JC Chan A Michie S Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide BMJ 2014 348 mar07 3 g1687 10.1136/bmj.g1687 24609605
56 Peters M Marnie C Tricco A Pollock D Munn Z Alexander L McInerney P Godfrey CM Khalil H Updated methodological guidance for the conduct of scoping reviews JBI Evid Implement 2021 19 1 3 10 10.1097/XEB.0000000000000277 33570328 02205615-202103000-00002 33570328
57 George D Mallery P Descriptive statistics IBM SPSS Statistics 25 Step by Step 2018 UK Routledge 126 134
58 Hsieh H Shannon SE Three approaches to qualitative content analysis Qual Health Res 2005 15 9 1277 1288 10.1177/1049732305276687 16204405 15/9/1277 16204405
59 Nahm ES Advancing telemedicine outreach within a comprehensive cancer center: lessons learned from rapid transformation of care practice and operational changes associated with the COVID-19 pandemic JONS 2021 12
60 Ormel HL van der Schoot GGF Westerink NDL Sluiter WJ Gietema JA Walenkamp AME Self-monitoring physical activity with a smartphone application in cancer patients: a randomized feasibility study (SMART-trial) Support Care Cancer 2018 26 11 3915 3923 10.1007/s00520-018-4263-5 29785635 10.1007/s00520-018-4263-5 29785635
61 Monteiro-Guerra F Signorelli GR Tadas S Zubiete ED Romero OR Fernandez-Luque L Caulfield B A personalized physical activity coaching app for breast cancer survivors: design process and early prototype testing JMIR Mhealth Uhealth 2020 8 7 e17552 10.2196/17552 32673271 v8i7e17552 32673271
62 Zulman DM Jenchura EC Cohen DM Lewis ET Houston TK Asch SM How can eHealth technology address challenges related to multimorbidity? Perspectives from patients with multiple chronic conditions J Gen Intern Med 2015 30 8 1063 1070 10.1007/s11606-015-3222-9 25691239 25691239
63 Allen M Iezzoni LI Huang A Huang L Leveille SG Internet-based coaching to improve patient-clinician communication in primary care AMIA Annu Symp Proc 2007 10 11 861 18693963 18693963
64 Simske NM Breslin MA Hendrickson SB York KP Vallier HA Implementing recovery resources in trauma care: impact and implications OTA Int 2019 2 4 e045 10.1097/OI9.0000000000000045 33937673 OTAI-D-19-00015 33937673
65 Westergaard RP Genz A Panico K Surkan PJ Keruly J Hutton HE Chang LW Kirk GD Acceptability of a mobile health intervention to enhance HIV care coordination for patients with substance use disorders Addict Sci Clin Pract 2017 12 1 1 9 10.1186/s13722-017-0076-y 28441962 10.1186/s13722-017-0076-y 28049542
66 Gehrke A Lee SS Hilton K Ganster B Trupp R McCullough C Mott E Feuerstein M Development of the cancer survivor profile-breast cancer (CSPro-BC) app: patient and nurse perspectives on a new navigation tool J Cancer Surviv 2018 12 3 291 305 10.1007/s11764-017-0668-2 29524014 10.1007/s11764-017-0668-2 29524014
67 Nitsch M Dimopoulos CN Flaschberger E Saffran K Kruger JF Garlock L Wilfley DE Taylor CB Jones M A guided online and mobile self-help program for individuals with eating disorders: an iterative engagement and usability study J Med Internet Res 2016 18 1 e7 10.2196/jmir.4972 26753539 v18i1e7 26753539
68 Moradian S Krzyzanowska MK Maguire R Morita PP Kukreti V Avery J Liu G Cafazzo J Howell D Usability evaluation of a mobile phone-based system for remote monitoring and management of chemotherapy-related side effects in cancer patients: mixed-methods study JMIR Cancer 2018 4 2 e10932 10.2196/10932 30578238 v4i2e10932 30578238
69 Fredriksen EH Harris J Moland KM Web-based discussion forums on pregnancy complaints and maternal health literacy in norway: a qualitative study J Med Internet Res 2016 18 5 e113 10.2196/jmir.5270 27230094 v18i5e113 27230094
70 Loiselle CG Peters O Haase KR Girouard L Körner A Wiljer D Fitch M Virtual navigation in colorectal cancer and melanoma: an exploration of patients' views Support Care Cancer 2013 21 8 2289 2296 10.1007/s00520-013-1771-1 23519565 23519565
71 Sánchez-Ortiz VC House J Munro C Treasure J Startup H Williams C Schmidt U "A computer isn't gonna judge you": a qualitative study of users' views of an internet-based cognitive behavioural guided self-care treatment package for bulimia nervosa and related disorders Eat Weight Disord 2011 16 2 e93 e101 10.1007/BF03325314 21989103 7984 21989103
72 Hinchliffe A Mummery WK Applying usability testing techniques to improve a health promotion website Health Promot J Austr 2008 19 1 29 35 10.1071/he08029 18481929 18481929
73 Burns PB Rohrich RJ Chung KC The levels of evidence and their role in evidence-based medicine Plast Reconstr Surg 2011 128 1 305 310 10.1097/PRS.0b013e318219c171 21701348 00006534-201107000-00046 21701348
74 Kokorelias KM Nelson ML Tang T Gray CS Ellen M Plett D Jarach CM Nie JX Thavorn K Singh H Inclusion of older adults in digital health technologies to support hospital-to-home transitions: secondary analysis of a rapid review and equity-informed recommendations JMIR Aging 2022 5 2 e35925 10.2196/35925 35475971 v5i2e35925 35475971
75 Hossain SN Jaglal SB Shepherd J Perrier L Tomasone JR Sweet SN Luong D Allin S Nelson MLA Guilcher SJT Munce SEP Web-based peer support interventions for adults living with chronic conditions: scoping review JMIR Rehabil Assist Technol 2021 8 2 e14321 10.2196/14321 34032572 v8i2e14321 34032572
76 Fong JH Disability incidence and functional decline among older adults with major chronic diseases BMC Geriatr 2019 19 1 323 10.1186/s12877-019-1348-z 31752701 10.1186/s12877-019-1348-z 31752701
77 Heponiemi T Jormanainen V Leemann L Manderbacka K Aalto A Hyppönen H Digital divide in perceived benefits of online health care and social welfare services: national cross-sectional survey study J Med Internet Res 2020 22 7 e17616 10.2196/17616 32673218 v22i7e17616 32673218
78 Crawford A Serhal E Digital health equity and COVID-19: the innovation curve cannot reinforce the social gradient of health J Med Internet Res 2020 22 6 e19361 10.2196/19361 32452816 v22i6e19361 32452816
79 Wilson-Howard D Vilaro MJ Neil JM Cooks EJ Griffin LN Ashley TT Tavassoli F Zalake MS Lok BC Odedina FT Modave F Carek PJ George TJ Krieger JL Development of a credible virtual clinician promoting colorectal cancer screening via telehealth apps for and by black men: qualitative study JMIR Form Res 2021 5 12 e28709 10.2196/28709 34780346 v5i12e28709 34780346
80 Greene GJ Reidy E Felt D Marro R Johnson AK Phillips G Green E Stonehouse P Implementation and evaluation of patient navigation in Chicago: insights on addressing the social determinants of health and integrating HIV prevention and care services Eval Program Plann 2022 90 101977 10.1016/j.evalprogplan.2021.101977 34373116 S0149-7189(21)00072-0 34373116
81 Freund KM Implementation of evidence-based patient navigation programs Acta Oncol 2017 56 2 123 127 10.1080/0284186X.2016.1266078 28033027 28033027
82 Friel S Marmot MG Action on the social determinants of health and health inequities goes global Annu Rev Public Health 2011 32 1 225 236 10.1146/annurev-publhealth-031210-101220 21219162
83 Sousa C Hagopian A Stoller N Addressing the social determinants of health through public health policy: a case study of US-based advocacy efforts for health justice in occupied Palestinian territory The Lancet 2019 393 Supplement 1 S49 10.1016/s0140-6736(19)30635-x
84 Bierman AS Dunn JR Swimming upstream. Access, health outcomes, and the social determinants of health J Gen Intern Med 2006 21 1 99 10.1111/j.1525-1497.2005.00317.x 16423133 JGI317 16423133
85 Artiga S Hinton E Beyond health care: the role of social determinants in promoting health and health equity Health 2019 20 10 1 13
86 Bambra C Gibson M Sowden A Wright K Whitehead M Petticrew M Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews J Epidemiol Community Health 2010 64 4 284 291 10.1136/jech.2008.082743 19692738 jech.2008.082743 19692738
87 Jandorf L Braschi C Ernstoff E Wong CR Thelemaque L Winkel G Thompson HS Redd WH Itzkowitz SH Culturally targeted patient navigation for increasing African Americans' adherence to screening colonoscopy: a randomized clinical trial Cancer Epidemiol Biomarkers Prev 2013 22 9 1577 1587 10.1158/1055-9965.EPI-12-1275 23753039 1055-9965.EPI-12-1275 23753039
88 Oluyede L Cochran AL Wolfe M Prunkl L McDonald N Addressing transportation barriers to health care during the COVID-19 pandemic: perspectives of care coordinators Transp Res Part A Policy Pract 2022 159 157 168 10.1016/j.tra.2022.03.010 35283561 S0965-8564(22)00057-X 35283561
89 Hamerly D Review of "Inequity in the technopolis: race, class, gender, and the digital divide in Austin" (University of Texas Press, 2012) FM 2012 17 11 10.5210/fm.v17i11.4286
90 Cotterill S Knowles S Martindale AM Elvey R Howard S Coupe N Wilson P Spence M Getting messier with TIDieR: embracing context and complexity in intervention reporting BMC Med Res Methodol 2018 18 1 12 10.1186/s12874-017-0461-y 29347910 10.1186/s12874-017-0461-y 29347910
91 Wilcox B Bruce SD Patient navigation: a "win-win" for all involved Oncol Nurs Forum 2010 37 1 21 25 10.1188/10.ONF.21-25 20044337 M7538225V73U738G 20044337
92 Koorts H Eakin E Estabrooks P Timperio A Salmon J Bauman A Implementation and scale up of population physical activity interventions for clinical and community settings: the PRACTIS guide Int J Behav Nutr Phys Act 2018 15 1 51 10.1186/s12966-018-0678-0 29884236 10.1186/s12966-018-0678-0 29884236
93 Robinson KL Watters S Bridging the communication gap through implementation of a patient navigator program Pa Nurse 2010 65 2 19 22 20666161 20666161
94 Rozario MA Walton A Kang M Padilla BI Colorectal cancer screening: a quality improvement initiative using a bilingual patient navigator, mobile technology, and fecal immunochemical testing to engage hispanic adults CJON 2021 25 4 423 429 10.1188/21.cjon.423-429
95 Vogel WB Morris HL Muller K Huo T Parish A Stoner D Shenkman E Cost-effectiveness of the wellness incentives and navigation (WIN) program Value Health 2021 24 3 361 368 10.1016/j.jval.2020.06.019 33641770 S1098-3015(20)34410-7 33641770
96 Jolly SE Navaneethan SD Schold JD Arrigain S Konig V Burrucker YK Hyland J Dann P Tucky BH Sharp JW Nally JV Development of a chronic kidney disease patient navigator program BMC Nephrol 2015 16 69 10.1186/s12882-015-0060-2 26024966 10.1186/s12882-015-0060-2 26024966
97 Willis A Reed E Pratt-Chapman M Development of a framework for patient navigation: delineating roles across navigator types J Oncol Navig Surviv 2013 4 6 20
98 Luckett R Pena N Vitonis A Bernstein MR Feldman S Effect of patient navigator program on no-show rates at an academic referral colposcopy clinic J Womens Health (Larchmt) 2015 24 7 608 615 10.1089/jwh.2014.5111 26173000 26173000
99 Ranaghan C Boyle K Meehan M Moustapha S Fraser P Concert C Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review JBI Database System Rev Implement Rep 2016 14 8 172 218 10.11124/JBISRIR-2016-003049 27635752 01938924-201608000-00015
100 Sullivan C Dolata J Barnswell K Greenway K Kamps C Marbury Q Pencak J Wilson D Perzynski A Sehgal A Huml A Experiences of kidney transplant recipients as patient navigators Transplant Proc 2018 50 10 3346 3350 10.1016/j.transproceed.2018.02.090 30577205 S0041-1345(18)30260-4 30577205
101 Lubetkin EI Lu W Krebs P Yeung H Ostroff JS Exploring primary care providers' interest in using patient navigators to assist in the delivery of tobacco cessation treatment to low income, ethnic/racial minority patients J Community Health 2010 35 6 618 624 10.1007/s10900-010-9251-8 20336355 20336355
102 Kokorelias KM DasGupta T Hitzig SL Designing the ideal patient navigation program for older adults with complex needs: a qualitative exploration of the preferences of key informants J Appl Gerontol 2022 41 4 1002 1010 10.1177/07334648211059056 34905440 34905440
103 Kokorelias KM Markoulakis R Hitzig SL Considering a need for dementia-specific, family-centered patient navigation in Canada J Appl Gerontol 2023 42 1 19 27 10.1177/07334648221125781 36503280 36503280
