Non-adherence to colonoscopy (estimated to be about 25% to 45%), contributes to CRC-related morbidity and mortality. Patient navigation has been shown to increase rates of CRC screening as well as colonoscopy completion. A navigator program that consists of laypersons or peers, may be effective in improving adherence to colonoscopy among Veterans. The goals of this The goals of this project (as part of the CDA "Program to Improve Adherence to Colonoscopy: Interviews with Veterans") were to develop a peer coach intervention using laypersons as peer coaches to help Veterans navigate the various steps involved in successful colonoscopy completion.
Our aims included the identification of barriers and facilitators to colonoscopy as perceived by Veterans, development of a Toolkit to serve as a resource manual for peer coaches, development of a recruitment and training program for peer coaches using motivational interviewing skills, and pilot studies to evaluate the feasibility of using telephone-based or face-to face education.
To achieve our aims, we conducted a qualitative study using focus groups and semi-structured interviews to identify barriers to colonoscopy completion. We also conducted a prospective single-center study of patient factors, including psychosocial variables, health literacy, and knowledge that may be associated with adherence to colonoscopy completion. Finally, we developed a training program for peer coaches using findings from these studies.
Barriers to Colonoscopy: A total of 44 Veterans (mean 66.2 years) participated in 7 focus group discussions. The majority of participants were White (83.7%), married or cohabitating (62.8%). Only 32.6% had some college education and 40% lived in rural areas. The mean number of chronic conditions was 7.4 with a range of 2-14; 22% of participants had over 10 chronic conditions. Barriers that emerged from these focus groups included: competing medical priorities, low perceived benefit, prior negative colonoscopy experience, difficulty with bowel cleansing and difficulty with travel, worry about exacerbation of pre-existing conditions, and heightened concerns about potential complications. Facilitators included an informed understanding of colorectal cancer risk, knowledge of the importance of the exam, good communication and strong provider recommendation, trust in the VA health system, and finally having peace of mind after test completion. In a second prospective study of 619 Veterans scheduled for colonoscopy at a single-center, we tried to identify patient factors associated with lack of colonoscopy completion. We found that the odds of colonoscopy completion were higher for Whites than Blacks (OR 1.68, 95%CI 1.08-2.63) and for individuals who were married or living with someone versus single/widowed/divorced individuals (OR 2.12; 95%CI 1.35-3.33). Furthermore, the following variables were associated with higher rates of adherence to colonoscopy: a higher score on a self-efficacy survey, higher perceived importance of the test (salience and coherence) of the test, and a perception of colonoscopy test efficacy.
Toolkit Development: Facilitators identified from the qualitative work were used to develop an initial draft of the Toolkit. This Toolkit contains a menu of different problem-solving strategies that can be offered by Peer Coaches. Additional work on its development and refinement is ongoing.
Peer Coach Training Program: A training program for peer coaches has been developed with the Nurse Educator responsible for teaching motivational interviewing (MI) to PACT teams. In addition to MI training and teaching patient-centered communication skills, this training program includes: knowledge enhancement and formal education (colorectal cancer prevention and colonoscopy preparation) using didactic lectures, a tour the GI endoscopy clinic and viewing of a colonoscopy video.
The incidence of CRC in veterans is currently estimated to be 4,000 cases annually. Programs that successfully improve adherence to colonoscopy completion are critical for reducing CRC-related morbidity and mortality among veterans. Targeting individuals who are more likely to be non-adherent (e.g. individuals who not married or living with someone and/or lacking social support) focusing on tailored patient-centric interventions (e.g. focused on enhancing knowledge, increasing self-efficacy, or mitigating logistical challenges) using peer coaches have the potential to significantly improve adherence rates for colonoscopy.
- Yang D, Summerlee R, Rajca B, Williamson JB, LeLaurin J, McClellan L, Collins D, Sultan S. A pilot study to evaluate the feasibility of implementing a split-dose bowel preparation for inpatient colonoscopy: a single-center experience. BMJ open gastroenterology. 2015 Feb 6; 1(1):e000006.