In our evaluation of sex as a biologic variable, there was no difference in colonoscopy attendance and adequacy of bowel preparation by sex. Female patients had comparable attendance to colonoscopy (RR = 1.01; 95% CI: 0.91–1.13) and similar adequacy of bowel preparation (RR = 1.04; 95% CI: 0.95–1.14) as male patients.
When we restricted our analysis only to subjects whose social contacts were reached and agreed to participate (n = 130), the results were similar to those obtained in the intention-to-treat analysis. There was no difference in the attendance to colonoscopy (80% vs 76.8%; RR = 1.04; 95% CI: 0.93–1.17; P = 0.48), and there was a modest 8.5% increase in the adequacy of bowel preparation (89.4% vs 80.9%; RR = 1.11; 95% CI: 1.00–1.22; P = 0.054).
Other exploratory analysis
In the intervention arm, when we evaluated attendance to scheduled colonoscopy appointment as a function of the relationship of the subjects with their social contacts, there was no difference in the attendance to colonoscopy (82% vs 71.4%; RR = 1.15; 95% CI: 0.94–1.40; P = 0.17) or adequacy of bowel preparation (89% vs 94.3%; RR = 0.94; 95% CI: 0.85–1.05; P = 0.29) when the social contact was an immediate family member compared with when the social contact was a friend or had nonmarital, non-blood relationship. Similarly, there was no difference in colonoscopy attendance and bowel preparation when the social contact was a second-degree relative (71.4% vs 71.4%; RR = 1.00; 95% CI: 0.72–1.38; P = 1.00 and 80% vs 94.3%; RR = 0.85; 95% CI: 0.65–1.11; P = 0.23, respectively) compared with when the social contact was a friend or had nonmarital, non-blood relationship.
We also found that previous colonoscopy experience by the social contact was borderline negatively associated with colonoscopy attendance (75.7% vs 89.4%; RR = 0.85; 95% CI: 0.72–1.00; P = 0.049) compared with when the social contact never had colonoscopy, but there was no association with adequacy of bowel preparation (86.8% vs 90.5%; RR = 0.96; 95% CI: 0.83–1.11; P = 0.57).
Although it is well established that the use of patient navigators hired by healthcare institutions has been associated with an increase in compliance to CRC screening with colonoscopy among underserved populations (14), the use of patient navigators in these settings typically has been through externally funded grants and demonstration projects in many minority-serving institutions. The implication of this is that when such grants or external funds end, the patient navigation program is often terminated due to lack of resources committed to such endeavors in many of these institutions. Therefore, in this randomized controlled study, we evaluated the efficacy of using a patient's self-selected social contact to serve as a facilitator, akin to a patient navigator, for the completion of scheduled outpatient screening colonoscopy. Our premise was that if direct involvement of a patient's social contact person as a facilitator is acceptable to patients and can also increase compliance to scheduled outpatient screening colonoscopy among an underserved population, it will provide a relatively inexpensive and readily available intervention to improve endoscopy delivery to the underserved. The use of social contact facilitators did not increase compliance to the scheduled screening colonoscopy among enrolled underserved blacks in our study, but we noted a modest improvement in the adequacy of bowel preparation, a quality indicator for colonoscopy.
Although the number of social contacts who refused to participate as a facilitator was low at 4% (8 of 201), less than two-thirds of the selected social contacts were eventually engaged in the trial due to not being able to reach them by telephone. Our finding that the participants and their social contacts opined at a high level that the parties were interested in their interactions to achieve a positive outcome was important and 58% of the chosen social contacts also served as an escort on the day of the procedure. Despite the fact that the main objective of our study was not achieved in terms of significant increase in attendance to the colonoscopy screening appointment, the improved bowel preparation quality suggests that there may be some limited roles for patients’ own social network to act as natural helpers in improving healthcare use among underserved blacks. Nonetheless, given the lack of efficacy of social contact facilitators, minority-serving institutions should prioritize the use of sustainable, evidence-based methods to improve the uptake of screening colonoscopy in underserved populations, such as through the use of paid navigators.
Social support and social networks have played and continue to play a substantial role in health as natural helpers (18,19). Studies have suggested that social support from family members was associated with reduced smoking among youth (20) and improved quality of life among those with depression (21). Although survival may not be affected for patients with advanced cancers (22,23), robust social support has been associated with improved quality of life among patients with cancer (24–26). For preventive services use specifically, it has been suggested that discussions between adolescent daughters and their mothers improved cervical cancer screening and may be explored as a health promotion initiative (27). It is noteworthy that social support is mainly derived from family members (28), but important health promotions do occur among African Americans through nonfamily social contacts such as cosmetologists (29) and barbers (30,31). Social networking and personalized contact methods (including word of mouth) have been reported to improve participation in fitness promotion research as well (32). This underscores the importance of the social environment, including interactions with family, friends, and the community as a whole to eliminate disparities in health outcomes (33).
We are not aware of any similar study in which a patient's social contact was engaged to improve outpatient screening colonoscopy for a direct comparison with our study. However, a previous study in which a study employee acted as a peer coach demonstrated 11% increase in attendance when compared with a mailed colonoscopy brochure alone (34), and the use of patient navigators has been reported to increase colonoscopy attendance volume by 56% among Medicaid patients (35). It is noteworthy that studies of interventions to increase CRC screening were performed in different healthcare settings such as primary care setting (34,36) and direct endoscopy access settings (35) and combination of screening options was also used to determine study outcome (36), whereas our study was conducted among patients who were seen in the clinic by the gastrointestinal endoscopists and the outcome was attendance to colonoscopy screening.
An important strength of our study is that we studied an underserved, low-income, urban blacks in a community with high incidence of CRC. It is noteworthy that the District of Columbia has among the highest incidence of CRC in the country (37). Furthermore, we achieved a high rate of participation among eligible patients and their social contacts.
Our study has some limitations. The study was conducted in a tertiary referral center and we focused only on non-Hispanic blacks because this group has the highest burden of the disease. There is also a possibility that the degree of social support influence may vary by race ethnicity and income. We have limited open access endoscopy, and participants in our study underwent face-to-face consultations with the endoscopists, which may increase adherence among the control group and reduce the effect of the intervention. However, the colonoscopy attendance rate (76.8%) and bowel preparation adequacy (80.9%) in the control group closely matched the baseline rate of 78% colonoscopy attendance rate and 80% adequate bowel preparation rate in our system (17). Furthermore, we did not have information on the actual depth of interaction between the social contact and the patient detailing nature, extent, content, and specific duration of their engagement with the patient.
In conclusion, we did not find an increased attendance with patients’ self-selected social contact engagement as facilitators. However, there was a modest improvement in the adequacy of bowel preparation at screening colonoscopy performed among compliant participants. Rather than investing in a social contact facilitators program, minority-serving institutions should invest in sustainable models with a strong evidence base such as supporting paid patient navigators to improve healthcare delivery to underserved blacks. Future studies may evaluate comparison of efficacy of paid patient navigators vs patients' social contact.
CONFLICTS OF INTEREST
Guarantor of the article: Adeyinka O. Laiyemo, MD, MPH, is the guarantor of the article and accepts full responsibility for the study.
Specific author contributions: A.O.L., J.K., C.D.W., J.R., A.K., M.A.J., C.D.H., D.T.S., E.A.P.: planning and/or conducting the study. A.O.L., J.K., C.D.W., J.R., A.K., M.A.J., E.E.L., H.B., H.A., C.D.H., D.T.S., E.A.P.: collecting and/or interpreting the data. A.O.L., J.K., C.D.W., J.R., A.K., M.A.J., E.E.L., H.B., H.A., C.D.H., D.T.S., E.A.P.: drafting/revision of the manuscript. A.O.L., J.K., C.D.W., J.R,. A.K., M.A.J., E.E.L., H.B., H.A., C.D.H., D.T.S., E.A.P.: approval of the final draft of the submitted manuscript.
Financial support: This study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (Grant number: R21DK100875 to Dr Adeyinka O. Laiyemo). The work was independent of the funding source. The funding source did not play any role in the conduct or reporting of this study.
Potential competing interest: None.
Previous presentation: An abstract from this study was presented at the American College of Gastroenterology Meeting in Orlando, Florida, in October 2017 (Am J Gastroenterol 2017; 112(1):S160).
Clinical trial registration: NCT02464618; https://clinicaltrials.gov/ct2/show/NCT02464618
WHAT IS KNOWN
- ✓ Paid patient navigators improved colon cancer screening among underserved populations using externally funded grants.
- ✓ Many minority-serving institutions do not hire paid patient navigators for preventive services delivery due to cost.
- ✓ Information about a contact person is usually collected from patients receiving healthcare services.
WHAT IS NEW HERE
- ✓ A patient's self-selected contact person was not an effective facilitator for improving attendance to screening colonoscopy among underserved blacks.
- ✓ Engagement of a patient's self-selected contact person modestly increased the adequacy of bowel preparation for screening colonoscopy.
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