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

BACKGROUND: Rural patients experience a 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 3 rural hospitals in Alabama from August 2021 to July 2023. PATIENTS: We included adults (aged 18 years or older) 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 the survey responses to these quality metrics to identify factors associated with outcomes. Analyses included the chi 2, Fisher exact, and Kruskal-Wallis rank-sum tests, with ap value of < 0.05 considered statistically significant. RESULTS: The 84 patients surveyed were 66.7% men, 50.0% Black, and had a median age of 64 years. Optimal bowel preparation was present in 88.0%, successful cecal intubation was observed in 89.3%, and the 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 in 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), whereas 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, lower health literacy, internet access, and physician trust were associated with low-quality colonoscopy, whereas a higher patient sense of responsibility and a supportive social environment were associated with higher-quality metrics. These findings identify potential targets for improving colonoscopy quality in rural settings.