Rationale: Older African Americans undergoing surgery are a vulnerable and growing population at high risk for poor surgical outcomes and disparities. Few programs have focused on this population due to a fragmented understanding of the needs of this population.

Objectives: While socioecological determinants of health (SEDOH) such as health literacy and socioeconomic status are known drivers of surgical disparities, an estimated 36-47% of surgical disparities remains unexplained. This gap results from limitations of current clinical datasets in capturing SEDOHs. This pilot study aims to fill this gap by (i) collecting granular SEDOH data, (ii) identifying barriers to surgical care for older African Americans, and (iii) establishing a multi-institutional clinical database through a socioecological context. These findings will help understand how SEDOHs drive surgical disparities and inform development of interventions to eliminate them in elderly African Americans.

Design and Methods: Guided by the socioecological model of health, the investigators will use mixed-methods to achieve the objectives. First, the investigators will assess the acceptability and feasibility of a 58-item SEDOH survey based on the NIH PhenX toolkit. After distributing this survey to 36 elderly (≥65 years) African American patients undergoing surgery at 3 rural, UAB-affiliated hospitals (Alex-City, Greenville, Demopolis) the investigators will conduct detailed theory guided assessments of acceptability and feasibility (SA1). Second, the investigators will conduct key informant interviews of individuals from all 5 socioecological levels at each rural hospital (n=10) to identify additional barriers and facilitators to surgical care. The investigators will purposively sample 100% of participants at the patient and caregiver level (n=12) to be elderly African Americans (SA2). Finally, the investigators will link measured SEDOH data with standardized clinical data at each hospital to establish a novel database (SA3). These findings will establish a process to measure SEDOHs across the Deep South and set the foundation for a unique database to study surgical disparities.

Significance: Development of effective multilevel interventions to eliminate surgical disparities in older African Americans is dependent on a clearer understanding of the contextual drivers of these disparities. This pilot study will accelerate understanding of these mechanism(s) through SEDOHs. It will establish a process to measure SEDOHs, identify additional barriers to surgical care not captured by NIH instruments, and build the database to study these relationships. Such findings will have the potential to impact vulnerable surgical populations in the Deep South and support the Deep South RCMAR mission to promote health and optimize health outcomes for older and rural African Americans.

Inclusion Criteria for Patients for Phase 1 and 2

-≥ 65 years old undergoing or having recently undergone colorectal surgery* (<7 days) for colorectal disease**

• All genders
• African American race
• Able to consent
• English-speaking

Exclusion Criteria for Patients for Phase 1 and 2

• <65 years old
• Race other than African American
• Undergoing operation other than colorectal surgery
• Unable to consent
• Limited mental state

Inclusion Criteria for other participants in Phase 2

-≥ 18 years old

• All genders
• All race/ethnicities
• Able to consent English-speaking

Exclusion Criteria for other participants in Phase 2

• Child (<18 years)
• Unable to consent
• Limited mental state

Inclusion Criteria for Phase 3

• ≥ 18 years old undergoing or having recently undergone colorectal surgery* (<7 days) for colorectal disease**
• All genders
• All race/ethnicities
• Able to consent
• English-speaking

Exclusion Criteria for Phase 3

• Child (<18 years)

• Undergoing operation other than colorectal surgery

• Unable to consent

• Limited mental state

  • Includes colectomy/proctectomies. ** Includes colorectal cancer, inflammatory bowel disease and diverticular disease.

Patients for participation in Phases 1, 2, and 3 will be selected from those undergoing colorectal surgery at UAB affiliated sites in Alabama (Demopolis, Greenville, Alexander City).

Additional participants for Phase 2 will come from all other socioecological levels (caregiver, provider, organizational leaders, community leaders, public policy/governmental leaders).

Primary data acquired through the quantitative surveys and other demographics will be collected and managed using REDCap (Research Electronic Data Capture). As the host/coordinating center, UAB REDCap servers are secured through a virtualized environment behind an enterprise grade Palo Alto firewall. Only IRB-approved research team members will have access to the REDCap system through a secure and unique login. UAB REDCap is in compliance with NIST 800-53/800-171 (HIPAA) and FDA CFR21 part 11 guidelines, approved by all authorizing parties at UAB and authorized to operate (ATO) from NIH/NHLBI.