A Health Navigator intervention to identify and respond to the health-related social needs of an Australian population living with cancer: A mixed-methods feasibility study

A Health Navigator intervention to identify and respond to the health-related social needs of an Australian population living with cancer: A mixed-methods feasibility study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Health Navigator intervention to identify and respond to the health-related social needs of an Australian population living with cancer: A mixed-methods feasibility study Kate Neadley, Joanne Koch, Faye Gough, Annabel Smith, Christopher Hocking, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9287110/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background People living with cancer often require intensive support throughout their cancer journey. While cancer coordination services provide support accessing cancer care and understanding treatment options, many patients experience considerable health-related social needs (e.g. unemployment, financial insecurity) that impact their health and wellbeing. Health Navigator interventions address patients’ health-related social needs through ongoing advocacy to access relevant support organisations outside the health service. This study assessed the feasibility and acceptability of a Health Navigator intervention to address the health-related social needs of a population living with cancer attending an outpatient oncology clinic in Australia. Methods A mixed-methods study design was employed to explore the feasibility and acceptability of a Health Navigator intervention in an outpatient oncology treatment clinic. Participants were patients attending the outpatient clinic and ≥ 18 years old. Eligible participants were screened for health-related social needs using a dedicated screening tool. Participants with health-related social needs who requested assistance were referred to a Health Navigator who co-designed referral plans and provided follow-up in the community for six months. Participants without needs were the comparison group. Primary outcomes were intervention feasibility and acceptability, measured using process measures: 1) recruitment rate, 2) intervention uptake and 3) intervention completion. Focus groups with participants, participants’ carers and clinicians working in the oncology clinic, were used to explore intervention acceptability. Secondary outcomes included reported changes in participants’ health-related social needs and other patient-reported outcome measures. Results Rates of intervention uptake (100%, n = 55/55) and completion (77%, n = 36/47) suggest the intervention may be feasible in this population. Participants, their carers and clinicians reported the intervention was acceptable. Lack of support was the most commonly reported health-related social need (85%, n = 47/55) and the prevalence of all health-related social needs decreased post-intervention. Health Navigators experienced a greater than expected caseload complexity, which limited availability to support some participants. Conclusions The Health Navigator intervention is feasible and acceptable in this population, and reduced participants’ health-related social needs. Further research is required to refine intervention procedures, including exploring optimum caseload numbers for Health Navigators and strategies to maintain Health Navigator wellbeing. Trial Registration: This trial was prospectively registered in the Australian New Zealand Clinical Trials Registry on 8th June 2022 (clinical trial number: ACTRN12622000802707p) (URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384126&isReview=true ). Health services research Health-related social needs Health equity Oncology Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Health systems are increasingly integrating social prescribing initiatives to address the health-related social needs (HRSNs), e.g. housing and financial insecurity, of priority populations. 1 These interventions typically comprise two phases: 1) identifying patients’ HRSNs in a healthcare setting, and 2) providing patients with information to access services to assist with these HRSNs. A subset of interventions employ Health Navigators (HNs) to help prioritise patient’s HRSNs, co-develop referral plans, and provide patients with support in the community to access relevant services. 2 Populations living with cancer face substantial biopsychosocial challenges throughout the cancer journey, as patients undergoing treatment or experiencing adverse treatment effects may reduce earning potential and require wraparound, holistic support services. 3 Yet, HN interventions to address the HRSNs of populations living with cancer are limited. 4 Furthermore, the feasibility and acceptability of HN interventions in cancer settings is largely unexplored, as most interventions occur in primary care. 4 In Australia, integration of HN interventions in healthcare settings is nascent. 5 To our knowledge, here we present the first study in Australia to examine the feasibility and acceptability of a HN intervention to address the HRSNs of a population living with cancer in Australia. Methods Study setting The intervention took place at the Northern Adelaide Cancer Centre, an outpatient cancer treatment clinic at the Lyell McEwin Hospital, which serves one of the most disadvantaged urban populations in Australia. 6 Eligible participants were: Able to provide written, informed consent in English Adults ≥18 years old with any cancer diagnosis Receiving cancer care or follow-up at the Northern Adelaide Cancer Centre Participants were excluded if: Deemed by oncologist to have expected survival <6 months Deemed by the Principal Investigator to be not capable of understanding or complying with study protocol requirements, based on clinical appraisal of patients’ capacity to take part in informed decision making. Participants experiencing mental health crisis, e.g. suicidal ideation, severe depression and anxiety, or adverse treatment effects resulting in ongoing confusion and difficulties communicating with the HN, were excluded. Measures Following the latest UK Medical Research Council guidelines, mixed-methods were employed to gain a robust understanding of intervention feasibility and acceptability. 7 Three quantitative process measures were identified to assess intervention feasibility: 1) recruitment rate, defined by proportion of eligible participants who consented to screening for social needs 2) intervention uptake, proportion of participants who reported needs and consented to HN assistance, and 3) intervention completion, defined as the proportion of participants who received HN assistance that completed follow-up. We selected a success threshold of 80%, lower than similar feasibility studies, 8 to account for potentially lower participation rates that cancer treatment and adverse treatment effects may cause. 9 Intervention acceptability was explored in separate focus groups with participants, carers and clinicians. These focus groups examined experiences with the HN, and potential barriers and enablers to intervention success. Six focus groups were conducted: two with clinicians and four with participants and their carers, with a minimum of three participants per group. For clinicians unable to take part in focus groups due to time constraints, anonymous surveys containing quantitative intervention feasibility and acceptability measures 10 were administered via email. Key to understanding the feasibility of a complex interventions is the identification of appropriate outcome measures. 11 Changes in participants’ HRSNs were selected as a key secondary outcome measure, given their importance in the logic model underlying these interventions, 12 and relative paucity of HRSN outcome data in hospital settings. 13 HRSN data was captured using the Unmet Needs Screening Tool (Appendix Figure 1), which was co-designed and qualitatively validated with a range of clinicians and allied health professionals from the local area, and a population living with cancer attending the same oncology clinic. 14 In a previous study in the same hospital, patients reported feeling comfortable discussing health-related social needs using this screening tool. 15 Three patient-reported measures were selected as additional outcomes: 1) quality of care, measured using the Australian Hospital Patient Experience Question Set (AHPEQS), 16 2) coping with cancer ability, measured using the Cancer Behaviour Inventory- Brief (CBI-B), 17 and 3) health-related quality of life, measured using the Functional Assessment of Cancer Therapy- General (FACT-G). 18 Measures were administered at baseline and at conclusion of the 6-month intervention period. Health Navigator intervention Eligible participants were approached by a researcher to obtain informed consent and conduct baseline measures. Participants who reported HRSNs and requested assistance were referred to the HN. The HN made contact with participants within 14 days in-person in the community or at the hospital, or over the phone. The HN assisted the participant to prioritise their three most important needs and co-developed a referral plan for appropriate community services. HN activities ranged from assisting with paperwork to advocating for participants if requested. The HN conducted follow-up via phone or in-person a minimum of once per month for a total of six months. If participants reported their HRSN was addressed, this HRSN was classified as ‘resolved’. If more time was required with the same service, this was classified as ‘engaged’ and revisited in the next follow-up call. If the resource was not useful or unable to meet the participants’ needs, this was designated as ‘failed’ and another resource was identified by the HN. Participants were classified as ‘lost to follow-up’ if they were unable to be contacted by the HN after three attempts by various methods, i.e. email, phone call, post. Participants who were satisfied with the HN service, or whose needs were resolved prior to the end of the 6-month intervention period, were not required to remain in follow-up and were classified as ‘early intervention exit’. After six months, a researcher contacted participants who received the HN intervention and those who did not to repeat secondary measures. Recruitment occurred from August 2022 to February 2023. Follow-up was conducted on a rolling basis from August 2022 until December 2023. A schematic of study activities is available in Figure 1 and further detail of the intervention can be found in the published study protocol. 19 Analysis Sample size Two HNs serviced a 1.0FTE role. As feasibility studies typically have small sample sizes, power calculations are not recommended. 11 It was essential to provide HNs with sufficient time to conduct research to identify appropriate community organisations for participants, as well as enough opportunity to build rapport with participants to properly understand their individual circumstances. As such, sample size was determined by real-life constraints, balancing HN availability and caseload complexity. Quantitative feasibility measures were administered using Qualtrics software, version XM (Qualtrics, Provo, UT), supplied by Adelaide University. Quantitative feasibility measures were analysed using descriptive statistics. Secondary outcome measures were compared pre/post-intervention between the HN intervention and comparison groups. As there is no formal AHPEQS scoring guideline, quality of care was measured based on Question 12: ‘ Overall, the quality of the treatment and care I received was …’ using a five-point Likert scale ranging from ‘Very Poor’ to ‘Very Good’. Coping with cancer ability was measured by designating composite CBI-B scores of (1–3) as ‘Not Confident’, (4–6) as ‘Moderately Confident’ and (7–9) as ‘Confident’. Health-related quality of life scores were calculated following FACT-G (version 4) scoring guidelines (available at www.facit.org) where higher scores represent better quality of life. Data was analysed August 2023–January 2024. All quantitative analysis was conducted using SPSS Version 25 (IBM SPSS Statistics for Windows, Armonk, Version 25.0, NY: IBM Corp). Qualitative data were analysed using thematic analysis. 20 Initial codes were constructed from the primary study aim of understanding intervention acceptability and feasibility, and then analysis was broadened to include latent themes. To ensure rigorous analysis standards were upheld, two researchers (KN and BP, both with experience in thematic analysis methodologies) coded, discussed and refined data into themes. The number of focus groups conducted was determined by pragmatic constraints such as clinician and participant availability, rather than a pre-defined saturation limit. Qualitative analysis was conducted in NVivo 12 software (QSR International Pty Ltd. Version 12.6.1). Quantitative and qualitative data were integrated using an explanatory sequential design, in which quantitative data was initially collected and guided the collection and analysis of qualitative data. 21 Results Recruitment Of 153 participants approached, 48% were recruited (73/153). Most participants were born in Australia or the United Kingdom, which reflects the demographic makeup of patients presenting to the Cancer Centre during the recruitment period. There was no substantial difference in gender or age between the study sample (n = 73) and general population (n = 2473). The study sample comprised more women (56%) than men (44%) (Appendix Table 1). The primary reason eligible participants reported for non-participation was having no perceived HRSNs (91%, n = 73/80) (Fig. 2 A). Of the 73 recruited participants, 55 reported HRSNs (75%), all of whom requested assistance from the HN intervention, and 77% (36/47) completed the intervention (Fig. 2 B). Although the recruitment rate was lower than the 80% threshold, the high rates of intervention uptake and completion indicates the HN intervention is feasible in this population. Table 1 Focus groups with participants (n = 11), their carers (n = 2) and clinicians (n = 3) exploring experiences of the HN intervention. Theme Example (1) There is a lack of existing support for health-related social needs in the community. (A) “Without [HN service], I wouldn’t’ve had any outreach, I wouldn’t’ve had any information, none of those [community services] would ever have known what I was dealing with” -Participant, F, 48 years (2) Participants valued the emotional, social and administrative support the HN provided. (A) “I wouldn’t’ve known where to start … I had to get um, a lot of letters from doctors and then [the HN], you know, chased it up and got me the paperwork and sorted it out” - Participant, F, 48 years (B) “ [The HN] got me into different groups. Um, like, I have a coffee day out [at community centre], I go to that every fortnight, and I have another one where I can go to [community centre] and have a meal” - Participant, M, 67 years (C) “You mentioned suicide and…without [HN].. I think I would have done something, because I felt like I was an absolute write-off. And [HN] made me feel, like very important” - Participant, F, 71 years (3) A key barrier to the HN intervention is insufficient community resources. (A) “Problem is by the time [the HN] actually found [appropriate resource], we’d actually, the program already stopped” - Carer, F, 32 years (B) “… But this [HN] even contacted [housing advocacy service], but there was nothing they could do either” - Carer, F, 32 years (4) A high caseload with complex participants impacted HNs ability to perform their role. (A) “… I was a bit worried about how much of this [the intervention] they put on themselves…” - Participant, F, 55 years (B) “We lost contact with [the HN] for about two months” - Carer, F, 32 years (5) Clinicians report a lack of knowledge and training surrounding community resources. (A) “Our nursing staff cop a huge amount of the frontline work of dealing with these issues and a lot of them have very limited if, if any training in how to source community services” - Clinician, F, age unavailable (6) There is a gap in community services available suitable for all cancer patients. (A) “Linking with palliative care in the community and that like you know so if they're in that box they'll get a lot of that navigation of like what services are available… but if they don't fit in that box then there's a whole lot of stuff that they're just not being told about” - Clinician, F, age unavailable (7) HN intervention had a positive impact on clinician wellbeing. (A) “I know how to treat this person 's cancer but I can't fix their situation and therefore they are sort of untreatable and I feel helpless ” - Clinician, F, age unavailable (B) “…[the HN service] might have some impact on [clinicians] that they're able to keep working in resource poor settings and providing care… getting like a high turnover and burnout and I'll just go to work in private because it's easier… It’s so much social distress…” - Clinician, F, age unavailable The Health Navigator intervention was acceptable to participants, carers and clinicians Focus groups with participants (n = 11), their carers (n = 2) and clinicians (n = 2 oncologists) provided rich, qualitative data concerning the acceptability, strengths and limitations of the HN intervention. The main themes identified are shown in Table 1 . [Insert Table 1 ] Participants valued the emotional, social and administrative support that the HN provided. Participants expressed feeling unsupported by existing community resources, due to a perceived disconnect between hospital and community services, and uncertainty where to locate appropriate assistance (Table 1 , Themes 1 and 2(A)). Participants highlighted that it was the ongoing rapport-building and strong interpersonal skills of the HN that allowed them to build trust, which in turn enabled HNs to facilitate appropriate connection to services (Table 1 , Theme 2(C)). Clinicians agreed with participants and carers that the intervention filled a distinct gap in service provision by linking their patients from the hospital to the community. Clinicians believed the intervention had a positive impact on clinician wellbeing and expressed sentiments of frustration with their inability to provide optimal care due to patients’ social disadvantage. Clinicians reported the intervention provided them with a sense of hope, that by addressing at least some of their patients’ needs, the treatment they provided might be more effective (Table 1 , Theme 7(A) and (B)). Clinicians unable to participate in focus groups reported the HN intervention to be feasible and acceptable with all respondents (100%) welcoming screening and referral for HRSNs (Appendix Table 2). Two themes were identified in relation to barriers to the HN intervention: 1) insufficient resources and 2) HN workload. Participants reported that the supply of some available resources could not meet their needs, as services were constrained by employee numbers and caseload limits. In some instances, service providers reported their organisations had reached service capacity, i.e. housing (Table 1 , Theme 3(B)). At times the HNs struggled to manage their caseloads, which were psychosocially complex. Due to the rolling nature of recruitment, caseloads reached a maximum of 45 participants per HN working three days per week. HNs experienced substantial vicarious trauma, impacting their capacity to provide optimum support (Table 1 , Themes 4(A) and 4(B)). Secondary outcomes: The Health Navigator intervention addressed health-related social needs The HN intervention had a positive impact on participants’ HRSNs. At baseline, 75% of all participants (n = 55/73) reported at least one HRSN. Support was the most frequently reported need (n = 47/73, 64%) (Table 2 ). Support included family and friends; access to culture, religion, and language; and support from community or health services. Table 2 Prevalence of reported unmet social needs at study baseline and study end All participants Baseline screening Baseline screening vs Study end at 6-month (HN intervention participants with repeated measures) Health-related social needs Population n = 73 (%) Intervention n = 55 (%) Comparison n = 18 (%) Baseline n = 29 (%) Final n = 29 (%) Change (%) Support, n (%) 47 (64) 47 (85) 0 (0) 24 (83%) 6 (21%) ↓ 62% Finances, n (%) 24 (33) 24 (44) 0 (0) 15 (52%) 7 (24%) ↓ 28% Transport, n (%) 17 ( 23 ) 17 (31) 0 (0) 9 (31%) 1 (3%) ↓ 28% Food, n (%) 13 ( 18 ) 13 ( 24 ) 0 (0) 7 (24%) 2 (7%) ↓ 17% Safety, n (%) 7 ( 10 ) 7 ( 13 ) 0 (0) 4 (14%) 0 (0%) ↓ 14% Housing, n (%) 2 ( 3 ) 2 ( 4 ) 0 (0) 1 (3%) 0 (0%) ↓ 3% Downward arrow (↓) indicates a reduction in prevalence post-intervention. A lack of support from community or health services was reported by 96% of participants with HRSNs (n = 45/47) (Fig. 3 A). The most common financial need reported was inability to pay utilities (n = 19/24 participants reporting financial needs, 79%), followed by unstable income (n = 9/24, 38%) and inability to afford internet (n = 4/24, 17%) (Fig. 3 B). Participants reporting food needs included access to sufficient food (5/13, 38%), and limited access to fresh, healthy food (n = 12/13, 92%) (Fig. 3 C). Of the 55 consented participants that reported at least one HRSN at study baseline, three were unable to be contacted by the HN and one withdrew before meeting with the HN, leaving 51 participants in the intervention group. While housing and safety were reported as needs, neither were selected by participants as their most urgent. Overall, support needs were participants’ top priority (32/51; 63%), followed by food (8/51; 16%) and transport (6/51; 12%). Although finances were the third most commonly reported need, participants were less likely to prioritise this for immediate action (Fig. 3 D). [Insert Fig. 3 ] Participants who completed baseline and repeat measures post-intervention (n = 29) reported reductions across all domains of HRSN. The largest reductions were in support needs (62% decrease), followed by finance and transport (28% reduction in each) (Table 2 ). A few participants disclosed new needs post-intervention (Fig. 4 ), which may be a result of participants’ willingness to disclose more needs as their trust in the HN grew, or reflect a change in life circumstances. No conclusions could be drawn as to how cancer or treatment status impacted intervention outcomes as clinical data were not collected. Seven participants completed the intervention but were not able to be contacted for repeat measures. These participants reported a similar burden of HRSNs during their intervention when compared to those who repeated HRSN screening. The non-intervention group reported no change in HRSNs at study end (Table 2 ). [Insert Fig. 4 ] For patient-reported outcome measures, the intervention group (n = 29; 2 participants with missing data) reported a slightly greater improvement in health-related quality of life than the non-intervention group (n = 9) at the end of the study, with median FACT-G scores increased by 8 and 4.8 points, respectively (Appendix Fig. 2A). A small portion of the non-intervention group (n = 3/9, 33%) reported an increase in confidence in their ability to cope with cancer. A similar trend was noted in the intervention group (n = 10/27, 37%), whilst others in this group (n = 2/27, 7%) lost confidence (Appendix Fig. 2B). This loss in confidence may be due to changes in participants’ cancer journey. The Cancer Centre offered a consistently high standard of care for both groups, with 89% (n = 24/27) of the intervention group and 100% (n = 9/9) of the non-intervention group reporting quality of care as ‘Very Good’ at baseline and study end. At study end, the intervention group reported either a small improvement (n = 2/27, 7%) or a slight decrease (n = 1/27, 4%) in quality of care (Appendix Fig. 2C). Discussion To our knowledge, this is one of the first studies to report the feasibility and acceptability of a HN intervention to address the HRSNs of a population living with cancer attending an Australian outpatient setting. Rates of intervention uptake and completion suggest the HN intervention is feasible, and participants, their carers and clinicians reported the intervention to be highly acceptable. Using appropriate indicators of feasibility is key to understanding if a new intervention warrants further exploration. Currently, no feasibility studies in the cancer setting include robust assessments of intervention feasibility and acceptability, 22, 23, 24 so it is difficult to contextualise study findings. We believe the low recruitment rate in this study reflects a flaw in intervention design, as approximately half of all eligible participants declined to participate in the intervention as they reported no HRSNs prior to completing the screening tool (Fig. 1 ). Participants may have elected not to report HRSNs due to overwhelm with treatment and other life stressors, biasing the study sample and outcome measures. Future studies assessing HN intervention feasibility should limit recruitment to only participants reporting HRSNs. In this study, all participants reporting HRSNs requested the HN intervention. Other studies in populations living with cancer report intervention uptake varies from 10% 25 to 78%. 24 Potential mechanisms contributing to the large proportion of intervention uptake in this study may include normalisation of disadvantage in this population, perhaps decreasing the stigma associated with reporting HRSNs. 26 Additionally, clinicians may have leveraged the trusting therapeutic relationship with patients to encourage participation. 22, 23 Support-related HRSNs were the most reported by this population. This may be due to a combination of factors: 1) Participants generally experienced difficulties navigating online resources, 2) The life-changing nature of a cancer diagnosis, and 3) Treatment adverse effects may have limited participants’ capacity to self-advocate. This contrasts with HRSNs data from other populations living with cancer, where social isolation was one of the least reported HRSNs or was not reported. 22,24,25 While in this study participants’ HRSNs reduced post-HN intervention, these effects were limited to a small portion of the sample population who completed both baseline and repeat HRSN screening. Participants experiencing greater social complexity may have experienced more barriers to interacting with the HN and therefore may have been more likely to be lost to follow-up, creating attrition bias. Looking to the future, trials with larger sample sizes may encounter difficulties resolving participants’ HRSNs due to limitations in the supply of community resources. In this study, HNs has experienced greater than anticipated complexity both in the community identifying resources and during participant interactions, particularly those experiencing adverse treatment effects from their cancer treatment. Few hospital-based studies report HN caseload data, 13 which we highlight as a key area for future research to promote HN and participant wellbeing. Additionally, in this study there was no substantial difference between groups for coping with cancer ability or health-related quality of life and our quality-of-care metric was not sufficiently sensitive to detect an effect. We propose identification of appropriate patient-reported outcome measures should be a priority for future trials. Limitations Populations with limited English proficiency were excluded from this study. These populations may be likely to experience more HRSNs than English-speaking populations. Additionally, we did not collect clinical data, such as cancer severity and comorbidities, which may have affected intervention feasibility and outcomes. Conclusions Participants, their carers, and clinicians reported the HN intervention to be acceptable, and early indicators suggest this intervention is feasible in this population. The HN intervention resolved many participants’ HRSNs but had limited effect on patient-reported outcomes. Future research should examine optimum HN caseloads and develop strategies to support HN wellbeing. Abbreviations AHPEQS Australian Hospital Patient Experience Question Set CBI-B Cancer Behaviour Inventory- Brief FACT-G Functional Assessment of Cancer Therapy- General HN Health Navigator HRSN Health-related social needs Declarations Ethics approval and consent to participate In accordance with the Declaration of Helsinki, all human participants provided consent to take part in this study. Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (CALHN HREC ID: 16448) on 5 July 2022. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare they have no competing interests. Funding The authors disclose receipt of the following financial support for the research, support and publication of this article: This work was supported by The Hospital Research Foundation [reference no: 2021/84-QA25232]. Author Contributions Kate Neadley: Conceptualisation, Methodology, Formal analysis, Investigation, Resources, Data curation, Writing- Original Draft, Writing- Review & Editing, Visualisation, Project administration. Joanne Koch : Resources. Faye Gough: Resources. Annabel Smith: Supervision. Christopher Hocking: Supervision, Funding acquisition, Writing- Review & editing. Mark Boyd: Conceptualisation, Methodology, Supervision, Funding acquisition. Lily Chan: Validation, Formal analysis, Data curation, Writing- Review & editing, Supervision. Cheryl Shoubridge: Funding acquisition, Validation, Formal analysis, Resources, Writing- Original Draft, Writing- Review & Editing, Visualisation, Supervision, Project administration. . The funder had no role in study design collection, analysis, and interpretation of data; writing the report; nor the decision to submit the report for publication. Acknowledgements We would like to acknowledge the immense efforts of all team members at the Northern Adelaide Cancer Centre who every day provide the best quality cancer care for their patients. We would like to thank community service providers, without whose trust and collaboration we would have been unable to assist these participants. Finally, we would like to thank Associate Professor Lynette Cusack for their assistance in conducting focus groups. References Morse DF, Sandhu S, Mulligan K, et al. Global developments in social prescribing. 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Supplementary Files AppendixFigure1UnmetNeedsScreeningTool.docx AppendixFigure2patientreportedoutcomes.docx AppendixTable1demographics.docx AppendixTable2Clinicianacceptability.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 19 May, 2026 Reviews received at journal 22 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers invited by journal 08 Apr, 2026 Editor invited by journal 08 Apr, 2026 Editor assigned by journal 07 Apr, 2026 Submission checks completed at journal 07 Apr, 2026 First submitted to journal 01 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9287110","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":621954610,"identity":"c418db56-9c89-4a8f-aecd-5b447ed03976","order_by":0,"name":"Kate Neadley","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Neadley","suffix":""},{"id":621954614,"identity":"809aed67-c1ff-4063-90ee-f1a050e7da29","order_by":1,"name":"Joanne Koch","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Joanne","middleName":"","lastName":"Koch","suffix":""},{"id":621954620,"identity":"aeb6e5d7-2f71-458d-976a-f687aed1220b","order_by":2,"name":"Faye Gough","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Faye","middleName":"","lastName":"Gough","suffix":""},{"id":621954622,"identity":"0c98e94a-096e-49c1-b36a-9147e276c9b0","order_by":3,"name":"Annabel Smith","email":"","orcid":"","institution":"Northern Adelaide Local Health Network","correspondingAuthor":false,"prefix":"","firstName":"Annabel","middleName":"","lastName":"Smith","suffix":""},{"id":621954624,"identity":"97da7564-5aa2-4a22-a6c8-540a99d47a8c","order_by":4,"name":"Christopher Hocking","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Hocking","suffix":""},{"id":621954626,"identity":"7e97e559-ee9b-4fb8-9e32-faae3fa803d9","order_by":5,"name":"Mark Boyd","email":"","orcid":"","institution":"Northern Adelaide Local Health Network","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Boyd","suffix":""},{"id":621954629,"identity":"16db919b-3518-48ac-8aae-bf2328e4ce00","order_by":6,"name":"Brianna Poirier","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Brianna","middleName":"","lastName":"Poirier","suffix":""},{"id":621954630,"identity":"16c1c085-4a5c-4a6d-b730-cd9b000eb5ed","order_by":7,"name":"Lily Chan","email":"","orcid":"","institution":"The University of Adelaide","correspondingAuthor":false,"prefix":"","firstName":"Lily","middleName":"","lastName":"Chan","suffix":""},{"id":621954631,"identity":"64b030a8-3117-4458-a10d-eb677d1d4890","order_by":8,"name":"Cheryl Shoubridge","email":"data:image/png;base64,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","orcid":"","institution":"The University of Adelaide","correspondingAuthor":true,"prefix":"","firstName":"Cheryl","middleName":"","lastName":"Shoubridge","suffix":""}],"badges":[],"createdAt":"2026-04-01 05:53:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9287110/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9287110/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107242851,"identity":"37b8da08-5fb7-43e6-9b7b-64ef90ab7e4c","added_by":"auto","created_at":"2026-04-19 07:45:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":101424,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant journey through the Health Navigator (HN) intervention. Eligible participants complete screening for health-related social needs and other patient-reported outcome measures at study baseline. If the participant reports HRSNs and requests assistance, they were referred to the HN. The HN provided six months of follow-up in the community to address participants’ health-related social needs. Participants who did not report health-related social needs or did not request assistance were the comparison group. After the six-month follow-up period, both the group receiving the HN intervention and the comparison group repeated baseline measures.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/00d74a00403305d62c422a9e.png"},{"id":107484109,"identity":"20f8c74b-56e2-4b01-a5d7-fdb4b92f7dee","added_by":"auto","created_at":"2026-04-22 02:30:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152851,"visible":true,"origin":"","legend":"\u003cp\u003eRecruitment and feasibility outcomes. \u003cstrong\u003eA)\u003c/strong\u003e Flow diagram of participants through the Health Navigator (HN) intervention. \u003cstrong\u003eB)\u003c/strong\u003e Process indicators and feasibility outcomes. A threshold of 80% was set for each process measure to indicate feasibility success.\u003c/p\u003e\n\u003cp\u003eLTFU= Lost to follow-up\u003c/p\u003e\n\u003cp\u003eHRSN= Health-related social need\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/1f2710bf13968a83e723e78d.png"},{"id":107242854,"identity":"92de290a-b415-4e1f-8f6e-97c22fb64b52","added_by":"auto","created_at":"2026-04-19 07:45:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55008,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence and type health-related social needs (HRSNs) reported by participants requesting Health Navigator intervention (n=55). \u003cstrong\u003e(A) \u003c/strong\u003eParticipants with support needs at baseline (n=47) and the type of support needs; \u003cstrong\u003e(B)\u003c/strong\u003e Participants with financial needs at baseline (n=24) and the type of financial needs; \u003cstrong\u003e(C)\u003c/strong\u003e Participants with food needs at baseline (n=13) and the type of food needs. \u003cstrong\u003e(D)\u003c/strong\u003e Participant prioritisation of the most urgent social need for assistance by the Health Navigator (n=51). Although n=55 participants reported social needs at baseline, participants prioritised their needs at a later time with the HN during an initial meeting. Two participants were unable to be contacted and two participants withdrew from the study prior to this initial meeting, leaving a total of n=51.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/0b9e81c04c4ba9bf8789744b.png"},{"id":107482251,"identity":"51bb8766-da22-40df-bfef-e367d3e596f7","added_by":"auto","created_at":"2026-04-22 02:22:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":63007,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in health-related social needs (if any) reported by participants with repeat measures post-Health Navigator (HN) intervention (n=29). Although n=55 completed the social needs tool at screening, only n=29 repeated the tool post-intervention. \u003cstrong\u003e(A)\u003c/strong\u003e Changes in health-related social needs post-HN intervention (n=29); \u003cstrong\u003e(B)\u003c/strong\u003eChange in type of support needs, includes community/health services, culture/religion/language, and support from family and friends \u003cstrong\u003e(C) \u003c/strong\u003eChange in type of financial needs, includes stable income, utilities, and internet data; \u003cstrong\u003e(D)\u003c/strong\u003e Change in type of food needs, includes having enough food and fresh food. One participant did not answer the question concerning internet affordability at follow-up.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/a48149848e08e479444cd3d3.png"},{"id":108804167,"identity":"5b129e98-a089-4607-b62d-86b994a40fbf","added_by":"auto","created_at":"2026-05-08 15:17:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":586413,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/d5a7d81d-f11b-4d91-82b6-347e913dddc5.pdf"},{"id":107242852,"identity":"851dfdb4-500d-4066-b035-0de5d5cc966b","added_by":"auto","created_at":"2026-04-19 07:45:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":567212,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixFigure1UnmetNeedsScreeningTool.docx","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/34b139eca27e0b481ddd06ac.docx"},{"id":107483045,"identity":"75cd3cb3-44ad-4821-83c3-6c3c3b2f3a13","added_by":"auto","created_at":"2026-04-22 02:26:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":154869,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixFigure2patientreportedoutcomes.docx","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/f48530d99a9b4ef4488c2ec9.docx"},{"id":107483023,"identity":"0c7c975e-9772-4a8f-8180-e9dc94d35426","added_by":"auto","created_at":"2026-04-22 02:25:54","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13488,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTable1demographics.docx","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/3a9854b747d55f9124b77a1e.docx"},{"id":108490659,"identity":"71a2b823-56a8-420c-a91e-da10cc040e53","added_by":"auto","created_at":"2026-05-05 09:46:07","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":21729,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixTable2Clinicianacceptability.docx","url":"https://assets-eu.researchsquare.com/files/rs-9287110/v1/71ba277362353a94cb89f019.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Health Navigator intervention to identify and respond to the health-related social needs of an Australian population living with cancer: A mixed-methods feasibility study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth systems are increasingly integrating social prescribing initiatives to address the health-related social needs (HRSNs), e.g. housing and financial insecurity, of priority populations. \u003csup\u003e1\u003c/sup\u003e These interventions typically comprise two phases: 1) identifying patients\u0026rsquo; HRSNs in a healthcare setting, and 2) providing patients with information to access services to assist with these HRSNs. A subset of interventions employ Health Navigators (HNs) to help prioritise patient\u0026rsquo;s HRSNs, co-develop referral plans, and provide patients with support in the community to access relevant services. \u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePopulations living with cancer face substantial biopsychosocial challenges throughout the cancer journey, as patients undergoing treatment or experiencing adverse treatment effects may reduce earning potential and require wraparound, holistic support services. \u003csup\u003e3\u003c/sup\u003e Yet, HN interventions to address the HRSNs of populations living with cancer are limited. \u003csup\u003e4\u003c/sup\u003e Furthermore, the feasibility and acceptability of HN interventions in cancer settings is largely unexplored, as most interventions occur in primary care. \u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn Australia, integration of HN interventions in healthcare settings is nascent. \u003csup\u003e5\u003c/sup\u003e To our knowledge, here we present the first study in Australia to examine the feasibility and acceptability of a HN intervention to address the HRSNs of a population living with cancer in Australia.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy setting\u003c/h2\u003e\n\u003cp\u003eThe intervention took place at the Northern Adelaide Cancer Centre, an outpatient cancer treatment clinic at the Lyell McEwin Hospital, which serves one of the most disadvantaged urban populations in Australia. \u003csup\u003e6\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEligible participants were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAble to provide written, informed consent in English\u003c/li\u003e\n \u003cli\u003eAdults \u0026ge;18 years old with any cancer diagnosis\u003c/li\u003e\n \u003cli\u003eReceiving cancer care or follow-up at the Northern Adelaide Cancer Centre\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eParticipants were excluded if:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDeemed by oncologist to have expected survival \u0026lt;6 months\u003c/li\u003e\n \u003cli\u003eDeemed by the Principal Investigator to be not capable of understanding or complying with study protocol requirements, based on clinical appraisal of patients\u0026rsquo; capacity to take part in informed decision making. Participants experiencing mental health crisis, e.g. suicidal ideation, severe depression and anxiety, or adverse treatment effects resulting in ongoing confusion and difficulties communicating with the HN, were excluded.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eMeasures\u003c/h2\u003e\n\u003cp\u003eFollowing the latest UK Medical Research Council guidelines, mixed-methods were employed to gain a robust understanding of intervention feasibility and acceptability. \u003csup\u003e7\u003c/sup\u003e Three quantitative process measures were identified to assess intervention feasibility: 1) recruitment rate, defined by proportion of eligible participants who consented to screening for social needs 2) intervention uptake, proportion of participants who reported needs and consented to HN assistance, and 3) intervention completion, defined as the proportion of participants who received HN assistance that completed follow-up. We selected a success threshold of 80%, lower than similar feasibility studies, \u003csup\u003e8\u003c/sup\u003e to account for potentially lower participation rates that cancer treatment and adverse treatment effects may cause. \u003csup\u003e9\u003c/sup\u003e Intervention acceptability was explored in separate focus groups with participants, carers and clinicians. These focus groups examined experiences with the HN, and potential barriers and enablers to intervention success. Six focus groups were conducted: two with clinicians and four with participants and their carers, with a minimum of three participants per group.\u0026nbsp;For clinicians unable to take part in focus groups due to time constraints, anonymous surveys containing quantitative intervention feasibility and acceptability measures\u003csup\u003e10 \u0026nbsp;\u003c/sup\u003ewere administered via email.\u003c/p\u003e\n\u003cp\u003eKey to understanding the feasibility of a complex interventions is the identification of appropriate outcome measures. \u003csup\u003e11\u003c/sup\u003e Changes in participants\u0026rsquo; HRSNs were selected as a key secondary outcome measure, given their importance in the logic model underlying these interventions, \u003csup\u003e12\u003c/sup\u003e and relative paucity of HRSN outcome data in hospital settings. \u003csup\u003e13\u003c/sup\u003e HRSN data was captured using the Unmet Needs Screening Tool (Appendix Figure 1), which was co-designed and qualitatively validated with a range of clinicians and allied health professionals from the local area, and a population living with cancer attending the same oncology clinic. \u003csup\u003e14\u003c/sup\u003e In a previous study in the same hospital, patients reported feeling comfortable discussing health-related social needs using this screening tool. \u003csup\u003e15\u003c/sup\u003e Three patient-reported measures were selected as additional outcomes: 1) quality of care, measured using the Australian Hospital Patient Experience Question Set (AHPEQS), \u003csup\u003e16\u003c/sup\u003e 2) coping with cancer ability, measured using the Cancer Behaviour Inventory- Brief (CBI-B), \u003csup\u003e17\u003c/sup\u003e and 3) health-related quality of life, measured using the Functional Assessment of Cancer Therapy- General (FACT-G). \u003csup\u003e18\u003c/sup\u003e Measures were administered at baseline and at conclusion of the 6-month intervention period.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eHealth Navigator intervention\u003c/h2\u003e\n\u003cp\u003eEligible participants were approached by a researcher to obtain informed consent and conduct baseline measures. Participants who reported HRSNs and requested assistance were referred to the HN. The HN made contact with participants within 14 days in-person in the community or at the hospital, or over the phone. The HN assisted the participant to prioritise their three most important needs and co-developed a referral plan for appropriate community services. HN activities ranged from assisting with paperwork to advocating for participants if requested. The HN conducted follow-up via phone or in-person a minimum of once per month for a total of six months. If participants reported their HRSN was addressed, this HRSN was classified as \u0026lsquo;resolved\u0026rsquo;. If more time was required with the same service, this was classified as \u0026lsquo;engaged\u0026rsquo; and revisited in the next follow-up call. If the resource was not useful or unable to meet the participants\u0026rsquo; needs, this was designated as \u0026lsquo;failed\u0026rsquo; and another resource was identified by the HN. Participants were classified as \u0026lsquo;lost to follow-up\u0026rsquo; if they were unable to be contacted by the HN after three attempts by various methods, i.e. email, phone call, post. Participants who were satisfied with the HN service, or whose needs were resolved prior to the end of the 6-month intervention period, were not required to remain in follow-up and were classified as \u0026lsquo;early intervention exit\u0026rsquo;. After six months, a researcher contacted participants who received the HN intervention and those who did not to repeat secondary measures. Recruitment occurred from August 2022 to February 2023. Follow-up was conducted on a rolling basis from August 2022 until December 2023. A schematic of study activities is available in Figure 1 and further detail of the intervention can be found in the published study protocol. \u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo HNs serviced a 1.0FTE role. As feasibility studies typically have small sample sizes, power calculations are not recommended. \u003csup\u003e11\u003c/sup\u003e It was essential to provide HNs with sufficient time to conduct research to identify appropriate community organisations for participants, as well as enough opportunity to build rapport with participants to properly understand their individual circumstances. As such, sample size was determined by real-life constraints, balancing HN availability and caseload complexity.\u003c/p\u003e\n\u003cp\u003eQuantitative feasibility measures were administered using Qualtrics software, version XM (Qualtrics, Provo, UT), supplied by Adelaide University. Quantitative feasibility measures were analysed using descriptive statistics. Secondary outcome measures were compared pre/post-intervention between the HN intervention and comparison groups. As there is no formal AHPEQS scoring guideline, quality of care was measured based on Question 12: \u0026lsquo;\u003cem\u003eOverall, the quality of the treatment and care I received was \u0026hellip;\u0026rsquo;\u003c/em\u003e using a five-point Likert scale ranging from \u0026lsquo;Very Poor\u0026rsquo; to \u0026lsquo;Very Good\u0026rsquo;. Coping with cancer ability was measured by designating composite CBI-B scores of (1\u0026ndash;3) as \u0026lsquo;Not Confident\u0026rsquo;, (4\u0026ndash;6) as \u0026lsquo;Moderately Confident\u0026rsquo; and (7\u0026ndash;9) as \u0026lsquo;Confident\u0026rsquo;. Health-related quality of life scores were calculated following FACT-G (version 4) scoring guidelines (available at www.facit.org) where higher scores represent better quality of life. Data was analysed August 2023\u0026ndash;January 2024. All quantitative analysis was conducted using SPSS Version 25 (IBM SPSS Statistics for Windows, Armonk, Version 25.0, NY: IBM Corp).\u003c/p\u003e\n\u003cp\u003eQualitative data were analysed using thematic analysis. \u003csup\u003e20\u003c/sup\u003e Initial codes were constructed from the primary study aim of understanding intervention acceptability and feasibility, and then analysis was broadened to include latent themes. To ensure rigorous analysis standards were upheld, two researchers (KN and BP, both with experience in thematic analysis methodologies) coded, discussed and refined data into themes. The number of focus groups conducted was determined by pragmatic constraints such as clinician and participant availability, rather than a pre-defined saturation limit. Qualitative analysis was conducted in NVivo 12 software (QSR International Pty Ltd. Version 12.6.1). Quantitative and qualitative data were integrated using an explanatory sequential design, in which quantitative data was initially collected and guided the collection and analysis of qualitative data. \u003csup\u003e21\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eRecruitment\u003c/p\u003e \u003cp\u003eOf 153 participants approached, 48% were recruited (73/153). Most participants were born in Australia or the United Kingdom, which reflects the demographic makeup of patients presenting to the Cancer Centre during the recruitment period. There was no substantial difference in gender or age between the study sample (n\u0026thinsp;=\u0026thinsp;73) and general population (n\u0026thinsp;=\u0026thinsp;2473). The study sample comprised more women (56%) than men (44%) (Appendix Table\u0026nbsp;1). The primary reason eligible participants reported for non-participation was having no perceived HRSNs (91%, n\u0026thinsp;=\u0026thinsp;73/80) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Of the 73 recruited participants, 55 reported HRSNs (75%), all of whom requested assistance from the HN intervention, and 77% (36/47) completed the intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Although the recruitment rate was lower than the 80% threshold, the high rates of intervention uptake and completion indicates the HN intervention is feasible in this population.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFocus groups with participants (n\u0026thinsp;=\u0026thinsp;11), their carers (n\u0026thinsp;=\u0026thinsp;2) and clinicians (n\u0026thinsp;=\u0026thinsp;3) exploring experiences of the HN intervention.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) There is a lack of existing support for health-related social needs in the community.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;Without [HN service], I wouldn\u0026rsquo;t\u0026rsquo;ve had any outreach, I wouldn\u0026rsquo;t\u0026rsquo;ve had any information, none of those [community services] would ever have known what I was dealing with\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cem\u003e-Participant, F, 48 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(2) Participants valued the emotional, social and administrative support the HN provided.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;I wouldn\u0026rsquo;t\u0026rsquo;ve known where to start \u0026hellip; I had to get um, a lot of letters from doctors and then [the HN], you know, chased it up and got me the paperwork and sorted it out\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eParticipant, F, 48 years\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(B) \u0026ldquo; [The HN] got me into different groups. Um, like, I have a coffee day out [at community centre], I go to that every fortnight, and I have another one where I can go to [community centre] and have a meal\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eParticipant, M, 67 years\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(C) \u0026ldquo;You mentioned suicide and\u0026hellip;without [HN].. I think I would have done something, because I felt like I was an absolute write-off. And [HN] made me feel, like very important\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eParticipant, F, 71 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(3) A key barrier to the HN intervention is insufficient community resources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;Problem is by the time [the HN] actually found [appropriate resource], we\u0026rsquo;d actually, the program already stopped\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Carer, F, 32 years\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(B) \u0026ldquo;\u0026hellip; But this [HN] even contacted [housing advocacy service], but there was nothing they could do either\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eCarer, F, 32 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(4) A high caseload with complex participants impacted HNs ability to perform their role.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;\u0026hellip; I was a bit worried about how much of this [the intervention] they put on themselves\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Participant, F, 55 years\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(B) \u0026ldquo;We lost contact with [the HN] for about two months\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eCarer, F, 32 years\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(5) Clinicians report a lack of knowledge and training surrounding community resources.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;Our nursing staff cop a huge amount of the frontline work of dealing with these issues and a lot of them have very limited if, if any training in how to source community services\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eClinician, F, age unavailable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(6) There is a gap in community services available suitable for all cancer patients.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;Linking with palliative care in the community and that like you know so if they're in that box they'll get a lot of that navigation of like what services are available\u0026hellip; but if they don't fit in that box then there's a whole lot of stuff that they're just not being told about\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eClinician, F, age unavailable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(7) HN intervention had a positive impact on clinician wellbeing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(A) \u0026ldquo;I know how to treat this person 's cancer but I can't fix their situation and therefore they are sort of untreatable and I feel helpless\u003cem\u003e\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e- Clinician, F, age unavailable\u003c/em\u003e\u003c/p\u003e \u003cp\u003e(B) \u0026ldquo;\u0026hellip;[the HN service] might have some impact on [clinicians] that they're able to keep working in resource poor settings and providing care\u0026hellip; getting like a high turnover and burnout and I'll just go to work in private because it's easier\u0026hellip; It\u0026rsquo;s so much social distress\u0026hellip;\u0026rdquo;\u003c/p\u003e \u003cp\u003e- \u003cem\u003eClinician, F, age unavailable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe Health Navigator intervention was acceptable to participants, carers and clinicians\u003c/p\u003e \u003cp\u003eFocus groups with participants (n\u0026thinsp;=\u0026thinsp;11), their carers (n\u0026thinsp;=\u0026thinsp;2) and clinicians (n\u0026thinsp;=\u0026thinsp;2 oncologists) provided rich, qualitative data concerning the acceptability, strengths and limitations of the HN intervention. The main themes identified are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e[Insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e Participants valued the emotional, social and administrative support that the HN provided. Participants expressed feeling unsupported by existing community resources, due to a perceived disconnect between hospital and community services, and uncertainty where to locate appropriate assistance (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Themes 1 and 2(A)). Participants highlighted that it was the ongoing rapport-building and strong interpersonal skills of the HN that allowed them to build trust, which in turn enabled HNs to facilitate appropriate connection to services (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Theme 2(C)). Clinicians agreed with participants and carers that the intervention filled a distinct gap in service provision by linking their patients from the hospital to the community. Clinicians believed the intervention had a positive impact on clinician wellbeing and expressed sentiments of frustration with their inability to provide optimal care due to patients\u0026rsquo; social disadvantage. Clinicians reported the intervention provided them with a sense of hope, that by addressing at least some of their patients\u0026rsquo; needs, the treatment they provided might be more effective (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Theme 7(A) and (B)). Clinicians unable to participate in focus groups reported the HN intervention to be feasible and acceptable with all respondents (100%) welcoming screening and referral for HRSNs (Appendix Table\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eTwo themes were identified in relation to barriers to the HN intervention: 1) insufficient resources and 2) HN workload. Participants reported that the supply of some available resources could not meet their needs, as services were constrained by employee numbers and caseload limits. In some instances, service providers reported their organisations had reached service capacity, i.e. housing (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Theme 3(B)). At times the HNs struggled to manage their caseloads, which were psychosocially complex. Due to the rolling nature of recruitment, caseloads reached a maximum of 45 participants per HN working three days per week. HNs experienced substantial vicarious trauma, impacting their capacity to provide optimum support (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Themes 4(A) and 4(B)).\u003c/p\u003e \u003cp\u003eSecondary outcomes: The Health Navigator intervention addressed health-related social needs\u003c/p\u003e \u003cp\u003eThe HN intervention had a positive impact on participants\u0026rsquo; HRSNs. At baseline, 75% of all participants (n\u0026thinsp;=\u0026thinsp;55/73) reported at least one HRSN. Support was the most frequently reported need (n\u0026thinsp;=\u0026thinsp;47/73, 64%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Support included family and friends; access to culture, religion, and language; and support from community or health services.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence of reported unmet social needs at study baseline and study end\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAll participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBaseline screening\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eBaseline screening vs Study end at 6-month\u003c/p\u003e \u003cp\u003e(HN intervention participants with repeated measures)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth-related social needs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;73\u0026nbsp;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;55\u0026nbsp;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComparison\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;18\u0026nbsp;(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;29 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFinal\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;29 (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChange\u003c/p\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 62%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinances, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransport, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 28%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFood, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (24%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 17%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSafety, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousing, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026darr; 3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eDownward arrow (\u0026darr;) indicates a reduction in prevalence post-intervention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA lack of support from community or health services was reported by 96% of participants with HRSNs (n\u0026thinsp;=\u0026thinsp;45/47) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The most common financial need reported was inability to pay utilities (n\u0026thinsp;=\u0026thinsp;19/24 participants reporting financial needs, 79%), followed by unstable income (n\u0026thinsp;=\u0026thinsp;9/24, 38%) and inability to afford internet (n\u0026thinsp;=\u0026thinsp;4/24, 17%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). Participants reporting food needs included access to sufficient food (5/13, 38%), and limited access to fresh, healthy food (n\u0026thinsp;=\u0026thinsp;12/13, 92%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Of the 55 consented participants that reported at least one HRSN at study baseline, three were unable to be contacted by the HN and one withdrew before meeting with the HN, leaving 51 participants in the intervention group. While housing and safety were reported as needs, neither were selected by participants as their most urgent. Overall, support needs were participants\u0026rsquo; top priority (32/51; 63%), followed by food (8/51; 16%) and transport (6/51; 12%). Although finances were the third most commonly reported need, participants were less likely to prioritise this for immediate action (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eParticipants who completed baseline and repeat measures post-intervention (n\u0026thinsp;=\u0026thinsp;29) reported reductions across all domains of HRSN. The largest reductions were in support needs (62% decrease), followed by finance and transport (28% reduction in each) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A few participants disclosed new needs post-intervention (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003e), which may be a result of participants\u0026rsquo; willingness to disclose more needs as their trust in the HN grew, or reflect a change in life circumstances. No conclusions could be drawn as to how cancer or treatment status impacted intervention outcomes as clinical data were not collected. Seven participants completed the intervention but were not able to be contacted for repeat measures. These participants reported a similar burden of HRSNs during their intervention when compared to those who repeated HRSN screening. The non-intervention group reported no change in HRSNs at study end (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[Insert Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFor patient-reported outcome measures, the intervention group (n\u0026thinsp;=\u0026thinsp;29; 2 participants with missing data) reported a slightly greater improvement in health-related quality of life than the non-intervention group (n\u0026thinsp;=\u0026thinsp;9) at the end of the study, with median FACT-G scores increased by 8 and 4.8 points, respectively (Appendix Fig.\u0026nbsp;2A). A small portion of the non-intervention group (n\u0026thinsp;=\u0026thinsp;3/9, 33%) reported an increase in confidence in their ability to cope with cancer. A similar trend was noted in the intervention group (n\u0026thinsp;=\u0026thinsp;10/27, 37%), whilst others in this group (n\u0026thinsp;=\u0026thinsp;2/27, 7%) lost confidence (Appendix Fig.\u0026nbsp;2B). This loss in confidence may be due to changes in participants\u0026rsquo; cancer journey. The Cancer Centre offered a consistently high standard of care for both groups, with 89% (n\u0026thinsp;=\u0026thinsp;24/27) of the intervention group and 100% (n\u0026thinsp;=\u0026thinsp;9/9) of the non-intervention group reporting quality of care as \u0026lsquo;Very Good\u0026rsquo; at baseline and study end. At study end, the intervention group reported either a small improvement (n\u0026thinsp;=\u0026thinsp;2/27, 7%) or a slight decrease (n\u0026thinsp;=\u0026thinsp;1/27, 4%) in quality of care (Appendix Fig.\u0026nbsp;2C).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is one of the first studies to report the feasibility and acceptability of a HN intervention to address the HRSNs of a population living with cancer attending an Australian outpatient setting. Rates of intervention uptake and completion suggest the HN intervention is feasible, and participants, their carers and clinicians reported the intervention to be highly acceptable.\u003c/p\u003e \u003cp\u003eUsing appropriate indicators of feasibility is key to understanding if a new intervention warrants further exploration. Currently, no feasibility studies in the cancer setting include robust assessments of intervention feasibility and acceptability, \u003csup\u003e22, 23, 24\u003c/sup\u003e so it is difficult to contextualise study findings. We believe the low recruitment rate in this study reflects a flaw in intervention design, as approximately half of all eligible participants declined to participate in the intervention as they reported no HRSNs prior to completing the screening tool (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Participants may have elected not to report HRSNs due to overwhelm with treatment and other life stressors, biasing the study sample and outcome measures. Future studies assessing HN intervention feasibility should limit recruitment to only participants reporting HRSNs.\u003c/p\u003e \u003cp\u003eIn this study, all participants reporting HRSNs requested the HN intervention. Other studies in populations living with cancer report intervention uptake varies from 10% \u003csup\u003e25\u003c/sup\u003e to 78%. \u003csup\u003e24\u003c/sup\u003e Potential mechanisms contributing to the large proportion of intervention uptake in this study may include normalisation of disadvantage in this population, perhaps decreasing the stigma associated with reporting HRSNs. \u003csup\u003e26\u003c/sup\u003e Additionally, clinicians may have leveraged the trusting therapeutic relationship with patients to encourage participation. \u003csup\u003e22, 23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSupport-related HRSNs were the most reported by this population. This may be due to a combination of factors: 1) Participants generally experienced difficulties navigating online resources, 2) The life-changing nature of a cancer diagnosis, and 3) Treatment adverse effects may have limited participants\u0026rsquo; capacity to self-advocate. This contrasts with HRSNs data from other populations living with cancer, where social isolation was one of the least reported HRSNs or was not reported. \u003csup\u003e22,24,25\u003c/sup\u003e While in this study participants\u0026rsquo; HRSNs reduced post-HN intervention, these effects were limited to a small portion of the sample population who completed both baseline and repeat HRSN screening. Participants experiencing greater social complexity may have experienced more barriers to interacting with the HN and therefore may have been more likely to be lost to follow-up, creating attrition bias.\u003c/p\u003e \u003cp\u003eLooking to the future, trials with larger sample sizes may encounter difficulties resolving participants\u0026rsquo; HRSNs due to limitations in the supply of community resources. In this study, HNs has experienced greater than anticipated complexity both in the community identifying resources and during participant interactions, particularly those experiencing adverse treatment effects from their cancer treatment. Few hospital-based studies report HN caseload data, \u003csup\u003e13\u003c/sup\u003e which we highlight as a key area for future research to promote HN and participant wellbeing. Additionally, in this study there was no substantial difference between groups for coping with cancer ability or health-related quality of life and our quality-of-care metric was not sufficiently sensitive to detect an effect. We propose identification of appropriate patient-reported outcome measures should be a priority for future trials.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003ePopulations with limited English proficiency were excluded from this study. These populations may be likely to experience more HRSNs than English-speaking populations. Additionally, we did not collect clinical data, such as cancer severity and comorbidities, which may have affected intervention feasibility and outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eParticipants, their carers, and clinicians reported the HN intervention to be acceptable, and early indicators suggest this intervention is feasible in this population. The HN intervention resolved many participants\u0026rsquo; HRSNs but had limited effect on patient-reported outcomes. Future research should examine optimum HN caseloads and develop strategies to support HN wellbeing.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHPEQS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian Hospital Patient Experience Question Set\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBI-B\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCancer Behaviour Inventory- Brief\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFACT-G\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFunctional Assessment of Cancer Therapy- General\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Navigator\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHRSN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth-related social needs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn accordance with the Declaration of Helsinki, all human participants provided consent to take part in this study. Ethics approval was obtained from the Central Adelaide Local Health Network Human Research Ethics Committee (CALHN HREC ID: 16448) on 5 July 2022.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors disclose receipt of the following financial support for the research, support and publication of this article: This work was supported by The Hospital Research Foundation [reference no:\u0026nbsp;2021/84-QA25232].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKate Neadley:\u003c/strong\u003e Conceptualisation, Methodology, Formal analysis, Investigation, Resources, Data curation, Writing- Original Draft, Writing- Review \u0026amp; Editing, Visualisation, Project administration.\u003cstrong\u003eJoanne Koch\u003c/strong\u003e: Resources. \u003cstrong\u003eFaye Gough:\u003c/strong\u003e Resources. \u003cstrong\u003eAnnabel Smith:\u003c/strong\u003e Supervision. \u003cstrong\u003eChristopher Hocking:\u003c/strong\u003e Supervision, Funding acquisition, Writing- Review \u0026amp; editing.\u003cstrong\u003eMark Boyd:\u003c/strong\u003e Conceptualisation, Methodology, Supervision, Funding acquisition. \u003cstrong\u003eLily Chan:\u0026nbsp;\u003c/strong\u003eValidation, Formal analysis, Data curation, Writing- Review \u0026amp; editing, Supervision. \u003cstrong\u003eCheryl Shoubridge:\u003c/strong\u003e Funding acquisition, Validation, Formal analysis, Resources, Writing- Original Draft, Writing- Review \u0026amp; Editing, Visualisation, Supervision, Project administration.\u003csup\u003e.\u0026nbsp;\u003c/sup\u003eThe funder had no role in study design collection, analysis, and interpretation of data; writing the report; nor the decision to submit the report for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the immense efforts of all team members at the Northern Adelaide Cancer Centre who every day provide the best quality cancer care for their patients. We would like to thank community service providers, without whose trust and collaboration we would have been unable to assist these participants. Finally, we would like to thank Associate Professor Lynette Cusack for their assistance in conducting focus groups.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMorse DF, Sandhu S, Mulligan K, et al. Global developments in social prescribing. \u003cem\u003eBMJ Glob Health\u0026nbsp;\u003c/em\u003e2022; 7: 5: e008524.\u003c/li\u003e\n \u003cli\u003eSandhu S, Lian T, Drake C, et al. Intervention components of link worker social prescribing programmes: A scoping review. \u003cem\u003eHealth Soc Care Community\u0026nbsp;\u003c/em\u003e2022; 30: 6: e3761\u0026ndash;e3774.\u003c/li\u003e\n \u003cli\u003eBygrave A, Whittaker K, Paul C, et al. 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Development of Social Determinants of Health Screening Tool (SDoHST): qualitative validation with stakeholders and patients in South Australia. \u003cem\u003eCurr Med Res Opin\u0026nbsp;\u003c/em\u003e2023; 39: 1: 131\u0026ndash;140.\u003c/li\u003e\n \u003cli\u003eVan L, Boyd MA, Neadley KE, et al. Uncovering unmet social needs in oncology patients \u003cem\u003eIMJ\u003c/em\u003e. 2025.\u003c/li\u003e\n \u003cli\u003eAustralian Commission on Safety and Quality in Health Care (ACSQHC). Technical specifications for AHPEQS use. Available from: https://www.safetyandquality.gov.au/sites/default/files/2019-09/australian_hospital_patient_experience_question_set_ahpeqs_technical_specifications_august_2019.pdf. (2019, accessed November 13, 2024)\u003c/li\u003e\n \u003cli\u003eHeitzmann CA, Merluzzi TV, Jean-Pierre P, et al. 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Using thematic analysis in psychology. \u003cem\u003eQual Res Psychol\u0026nbsp;\u003c/em\u003e2006;3:2:77\u0026ndash;101.\u003c/li\u003e\n \u003cli\u003eFetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs-principles and practices. \u003cem\u003eHealth Serv Res\u003c/em\u003e. 2013;48(6): 2134-56.\u003c/li\u003e\n \u003cli\u003eLemon SC, LeClair AM, Christenson E, et al. Implementation of social needs screening for minoritized patients newly diagnosed with breast cancer: a mixed methods evaluation in a pragmatic patient navigation trial. \u003cem\u003eBMC Health Serv Res\u0026nbsp;\u003c/em\u003e2024; 24: 1: 783.\u003c/li\u003e\n \u003cli\u003eHenry T, Hayes M, Eisele CD, et al. Barriers to identifying and addressing health-related social needs in cancer care: Patient and patient navigator perspectives. \u003cem\u003eJ Cancer Policy\u0026nbsp;\u003c/em\u003e2024; 42: 100508.\u003c/li\u003e\n \u003cli\u003eBattaglia TA, Gunn CM, Bak SM, et al. Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study. \u003cem\u003eCancer\u0026nbsp;\u003c/em\u003e2022; 128(S13): 2623\u0026ndash;2635.\u003c/li\u003e\n \u003cli\u003eNoor CN, Posever N, Hsieh TYJ, et al. Implementation of a financial navigation program in gynecologic oncology. \u003cem\u003eGynecol Onco\u0026nbsp;\u003c/em\u003e2024; 189: 119\u0026ndash;124.\u003c/li\u003e\n \u003cli\u003eButler ED, Morgan AU, Kangovi S. Screening for unmet social needs: Patient engagement or alienation? \u003cem\u003eNEJM Catal Innov Care Deliv\u0026nbsp;\u003c/em\u003e2020; 1: 4.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health services research, Health-related social needs, Health equity, Oncology","lastPublishedDoi":"10.21203/rs.3.rs-9287110/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9287110/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePeople living with cancer often require intensive support throughout their cancer journey. While cancer coordination services provide support accessing cancer care and understanding treatment options, many patients experience considerable health-related social needs (e.g. unemployment, financial insecurity) that impact their health and wellbeing. Health Navigator interventions address patients\u0026rsquo; health-related social needs through ongoing advocacy to access relevant support organisations outside the health service. This study assessed the feasibility and acceptability of a Health Navigator intervention to address the health-related social needs of a population living with cancer attending an outpatient oncology clinic in Australia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA mixed-methods study design was employed to explore the feasibility and acceptability of a Health Navigator intervention in an outpatient oncology treatment clinic. Participants were patients attending the outpatient clinic and \u0026ge;\u0026thinsp;18 years old. Eligible participants were screened for health-related social needs using a dedicated screening tool. Participants with health-related social needs who requested assistance were referred to a Health Navigator who co-designed referral plans and provided follow-up in the community for six months. Participants without needs were the comparison group. Primary outcomes were intervention feasibility and acceptability, measured using process measures: 1) recruitment rate, 2) intervention uptake and 3) intervention completion. Focus groups with participants, participants\u0026rsquo; carers and clinicians working in the oncology clinic, were used to explore intervention acceptability. Secondary outcomes included reported changes in participants\u0026rsquo; health-related social needs and other patient-reported outcome measures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRates of intervention uptake (100%, n\u0026thinsp;=\u0026thinsp;55/55) and completion (77%, n\u0026thinsp;=\u0026thinsp;36/47) suggest the intervention may be feasible in this population. Participants, their carers and clinicians reported the intervention was acceptable. Lack of support was the most commonly reported health-related social need (85%, n\u0026thinsp;=\u0026thinsp;47/55) and the prevalence of all health-related social needs decreased post-intervention. Health Navigators experienced a greater than expected caseload complexity, which limited availability to support some participants.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe Health Navigator intervention is feasible and acceptable in this population, and reduced participants\u0026rsquo; health-related social needs. Further research is required to refine intervention procedures, including exploring optimum caseload numbers for Health Navigators and strategies to maintain Health Navigator wellbeing.\u003c/p\u003e\u003ch2\u003eTrial Registration:\u003c/h2\u003e \u003cp\u003eThis trial was prospectively registered in the Australian New Zealand Clinical Trials Registry on 8th June 2022 (clinical trial number: ACTRN12622000802707p) (URL: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384126\u0026amp;isReview=true\u003c/span\u003e\u003cspan address=\"https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=384126\u0026amp;isReview=true\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e","manuscriptTitle":"A Health Navigator intervention to identify and respond to the health-related social needs of an Australian population living with cancer: A mixed-methods feasibility study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:45:50","doi":"10.21203/rs.3.rs-9287110/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"180375450021881029522387751154279437586","date":"2026-05-19T06:52:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T06:08:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317833024976242277780794156158873601795","date":"2026-04-21T00:11:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228774787032164048397487850248305675463","date":"2026-04-20T13:01:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196925442113937897473267560171066760283","date":"2026-04-13T05:22:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T04:48:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T04:29:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T11:28:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-07T11:27:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-04-01T05:44:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ddf5d47c-bc3c-4dc2-9ce1-681d143a265a","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"180375450021881029522387751154279437586","date":"2026-05-19T06:52:07+00:00","index":49,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-19T07:45:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:45:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9287110","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9287110","identity":"rs-9287110","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}