Socioecological Determinants of Health and the Quality of Colonoscopy in Rural Alabama

Background: Rural patients suffer higher incidence of and mortality from colorectal cancer. Ensuring high-quality screening is essential to address these disparities.

Objective: To investigate whether socioecological determinants of health are associated with colonoscopy quality in rural Alabama.

Design: Retrospective review.

Setting: Data across three rural hospitals in Alabama from August 2021 to July 2023.

Patients: We included adults (≥18 years) who underwent screening or diagnostic colonoscopy and completed a validated survey that measures socioecological determinants of health.

Main outcome measures: Primary outcomes included bowel preparation quality, cecal intubation, and adenoma detection rate. We linked th e survey responses to these quality metrics to identify factors associated with outcomes. Analyses included the χ 2, Fisher's Exact and Kruskal-Wallis Rank sum tests, with p < 0.05 considered statistically significant.

Results: The 84 patients surveyed were 66.7% male, 50.0% Black, and had a median age of 64 years. Optimal bowel preparation was present in 88.0%, 89.3% had successful cecal intubations, and overall adenoma detection rate was 45.8%. Patients with suboptimal bowel preparation described lower rates of internet access (60.0% vs. 87.4%, p < 0.05), more difficulty understanding written information (30.0% vs. 1.4%, p < 0.05) and lacked a sense of responsibility for their health (30.0% vs. 51.4%, p < 0.05) compared to those having optimal bowel preparation. Those with unsuccessful cecal intubations had lower physician-trust (55.6% vs. 73.3%, p < 0.05), while patients with successful cecal intubations were more confident in preventing health-related problems (53.3% vs. 33.3%, p < 0.05) and had a more supportive social environment (72.0% vs. 66.7%, p < 0.05).

Limitations: Retrospective design and small sample size limiting multivariable analyses.

Conclusion: In rural Alabama, health literacy, internet access, and physician-trust were associated with low-quality colonoscopy, while a higher patient sense of responsibility and a supportive social environment was associated with higher-quality metrics. These findings identify potential targets for improving colonoscopy quality in rural settings. See Video Abstract.