Process evaluation of the NAVKIDS2 patient navigation intervention for children with chronic kidney disease: a mixed method study

Background: Evidence-based interventions to improve access to care in children with chronic kidney disease (CKD) are limited. Patient navigation may help to overcome system barriers, but evidence on its implementation and mechanism of impact in children with CKD is unknown.

Aim: To evaluate the implementation, mechanisms of impact, and context surrounding the intervention delivery of patient navigation in children with CKD.

We invited caregivers of children with CKD, patient navigators and health professionals involved in a patient navigation program (NAVKIDS² trial) to participate in semi-structured interviews and quantitative surveys. We used the Medical Research Council Framework for process evaluation of complex interventions to guide our evaluation and examine the implementation, mechanism and contextual influences of the 6-month intervention delivery. All navigators documented their activities (recording qualitative and quantitative data) in logs. Data on caregiver satisfaction were collected using a Patient Navigator Satisfaction survey. Qualitative data were thematically analysed. Descriptive statistics were calculated for the quantitative data. 

A total of six out of seven navigators, 55 out of 162 caregivers, and 19 healthcare professionals participated in the interviews; 77 caregivers completed the satisfaction survey, and seven navigators completed the activity logs. Over 70% families accessed medical care, allied health and social services. The median number of navigator contacts was 15 (IQR 12–20), with 133 minutes (IQR 77.5–245.5) spent organising services including referrals to nephrologists and coordinating appointments. Over 90% of surveyed caregivers were satisfied overall with the program. We identified six themes mapped to the implementation outcomes of reach, dose, fidelity, acceptability, mechanism and context of intervention delivery. Reach: accessing services by circumventing bottlenecks. Families were able to overcome long-standing barriers to care through navigation and advocacy. Dose: adapting to virtual intervention delivery while maintaining engagement. The shift to virtual delivery during COVID enabled continuity of care, although the intensity and modality of contact varied. Fidelity: Developing navigator competencies through training. Fidelity was preserved by maintaining core functions of navigation, supported through skill development and supervision. Acceptability: Mixed acceptability arising from ambiguity of the navigator's role. Participants were initially uncertain about the navigator’s role; End-of-program benefits varied by caregivers’ familiarity with the health system. Mechanism of impact: Building meaningful connections with families. A trusted relationship between navigators and families enabled confidence in the health system. Contextual influences: Embedding navigators within the care teams promoted rapport, but delivery was affected by limited collaboration, competing workloads and overwhelming family circumstances. 

The NAVKIDS² program reported high uptake and satisfaction among navigators, confirming the feasibility of the service in paediatric CKD care. Successful delivery depended on navigator training, adaptability to virtual platforms, integration within the multi-disciplinary teams, and the ability to address complex family and system barriers.