Patient Navigation and Peer Support to Improve Survivorship for Chinese- and Vietnamese-speaking People Affected by Cancer

The PEARL intervention is a non-clinical bilingual patient navigation and peer support program co-designed with cancer survivors, general practitioners, community organisations, multicultural health workers, and oncology clinicians to address language, cultural, and system-level barriers experienced by Chinese- and Vietnamese-speaking people after cancer treatment. The program strategically embeds trained bilingual Patient Navigators (PNs) and Peer Facilitators (PFs) within community and primary care settings to deliver culturally responsive survivorship support, improve coordination across care settings, and strengthen integration with general practice. Prior to participant enrolment, PNs and PFs will complete a structured training program delivered by members of the PEARL research team and senior project staff with expertise in cancer survivorship, patient navigation, and culturally and linguistically diverse (CALD) health. Training will be delivered via a combination of face-to-face workshops and/or videoconference sessions, depending on site location and availability. Training will comprise of three phases: Phase 1 and 3 will be delivered by PEARL staff with duration approximately 3 hours, and will occur at least three-four weeks before program commencement at each site. Phase 2 will involve self-directed completion of the free online George Washington Cancer Center's Oncology Patient Navigation Training course, which will take up to 14 hours (maximum). Core training content includes: the PEARL model and study procedures; roles and boundaries of PNs and PFs; culturally responsive communication; confidentiality and ethical conduct; documentation and data collection requirements; referral pathways; and escalation procedures. Refresher training and ad-hoc support will be provided as required throughout the study. Sites may nominate delegated staff to attend training to support local capacity building and facilitate training of additional PNs/PFs if required. The intervention consists of the following key elements: Initial patient navigation assessment and care planning: A trained bilingual PN will contact participants allocated to the intervention arm and arrange an initial assessment (face-to-face where feasible, otherwise via videoconference). This 30–60-minute meeting (including caregivers if preferred) identifies individual barriers to care—such as language, health literacy, psychosocial, logistical, or system obstacles—and results in a collaboratively developed, individualised care plan. The PN documents needs, establishes goals, and outlines actions to support the participant’s transition from specialist oncology care to primary care. Ongoing navigation and peer support: Following the initial assessment, each participant is linked with a trained PF who shares the participant’s preferred language and cultural background. PFs provide flexible, in-language support through phone, video, in-person meetings, and home visits where needed. Support includes: assisting with appointment booking and transport; helping participants understand medical information or written materials; clarifying clinician instructions; and providing practical and emotional support. PNs and PFs also assist with referrals to community services, allied health, psychosocial support, and other survivorship-related resources. The frequency and mode of contacts are tailored to participant needs and recorded in navigation activity logs. Culturally tailored survivorship education: Intervention participants are invited to attend a 6-week “Supporting People with Cancer” program delivered in Chinese/Vietnamese, offering culturally relevant education on symptoms, self-care, follow-up routines, and available supports. The program involves once-weekly sessions up to two hours long, delivered by a bilingual health professional and facilitator. Primary care integration: A central component of PEARL is strengthening the survivorship care role of general practitioners. GPs receive an enrolment notification, an overview of PEARL services, and contact details for the PN/PF. PNs facilitate communication between oncology teams and general practice and encourage development of chronic disease care plans where appropriate. GPs and practice nurses are offered a 15–30 minute multidisciplinary case conference with the PN, PF, and patient/carer to discuss care plans and clarify roles, following relevant Medicare requirements for case conferencing (e.g., MBS Item 735). This case conference may be offered within one week after participant enrolment. PNs may also visit general practices to support implementation and coordination of recommended follow-up care. Mode, duration, and tailoring: PEARL uses a hub-and-spoke delivery model across hospital, community, and primary care settings. Navigation and peer support are delivered over a 12-month period to align with annual survivorship surveillance. The intervention is tailored to cultural and linguistic needs, individual preferences, and the complexity of identified barriers, with adaptations documented using standard implementation frameworks. Adherence to the program will be assessed by the clinical trial coordinator or CPI on a fortnightly (for the first 3 months) and then monthly basis, by ensuring that the patient navigators are meeting the checklist of survivorship indicators.