Using Text Messages and Fotonovelas to Increase Return of Home-Mailed Colorectal Cancer Screening Tests: Mixed Methods Evaluation

Abstract

Background Colorectal cancer (CRC) is currently the second leading cause of cancer-related deaths in the United States; however, it is mostly preventable with appropriate screening and is often treatable when detected at early stages. Many patients enrolled in an urban Federally Qualified Health Center (FQHC) clinic were found to be past due for CRC screening. Objective This study described a quality improvement (QI) project to improve CRC screening rates. This project used bidirectional texting with fotonovela comics and natural language understanding (NLU) to encourage patients to mail fecal immunochemical test (FIT) kits back to the FQHC. Methods The FQHC mailed FIT kits to 11,000 unscreened patients in July 2021. Consistent with the usual care, all patients received 2 text messages and a patient navigator call within the first month of mailing. As part of a QI project, 5241 patients who did not return their FIT kit within 3 months, aged 50-75 years, and spoke either English or Spanish were randomized to either usual care (no further intervention) or intervention (4-week texting campaign with a fotonovela comic and remailing kits if requested) groups. The fotonovela was developed to address known barriers to CRC screening. The texting campaign used NLU to respond to patients’ texts. A mixed methods evaluation used data from SMS text messages and electronic medical records to understand the impact of the QI project on CRC screening rates. Open-ended text messages were analyzed for themes, and interviews were completed with a convenience sample of patients to understand barriers to screening and impact of the fotonovela. Results Of the 2597 participants, 1026 (39.5%) in the intervention group engaged with bidirectional texting. Participating in bidirectional texting was related to language preference (χ22=11.0; P=.004) and age group (χ22=19.0; P<.001). Of the 1026 participants who engaged bidirectionally, 318 (31%) clicked on the fotonovela. Furthermore, 54% (32/59) of the patients clicked on the fotonovela and responded that they loved it, and 36% (21/59) of patients responded that they liked it. The intervention group was more likely to get screened (487/2597, 18.75%) than those in usual care (308/2644, 11.65%; P<.001), and this pattern held, regardless of demographic subgroup (sex, age, screening history, preferred language, and payer type). Interview data (n=16) indicated that the text messages, navigator calls, and fotonovelas were well received and not unduly invasive. Interviewees noted several important barriers to CRC screening and offered suggestions for reducing barriers and increasing screening. Conclusions Texting using NLU and fotonovela is valuable in increasing CRC screening as observed by the FIT return rate for patients in the intervention group. There were patterns in which patients did not engage bidirectionally; future work should investigate how to ensure that populations are not left out of screening campaigns.

Tailoring a Text Messaging and Fotonovela Program to Increase Patient Engagement in Colorectal Cancer Screening in a Large Urban Community Clinic Population: Quality Improvement Project

“…This quality improvement project was conducted in a large urban FQHC. Digital fotonovelas were developed by the texting vendor based on prior internal work at the FQHC [ 18 ]. The illustrations and storyline of the fotonovelas focused on depicting role models who were identified as peers of the population of interest: Hispanic or Latinx patients aged 50 to 75 years from a large urban FQHC, with similar cultural and social norms to communicate the message in English or Spanish.…”

“…At the end of September, 5241 patients had still not completed their FIT and were randomized for the next step of the quality improvement project that was previously described. Patients were block randomized by binary sex (male or female), age group (50-60 years and 61-75 years), and prior screening history [ 18 ].…”

“…The average SDOH index score was higher among patients whose preferred language was Spanish (84) compared with English (71; Figure 4). The overall engagement rate with the texting program was 39.51% (1026 patients responded to at least 1 text out of the 2597 patients in the intervention group) [18]. An analysis of responses for week 1 revealed that patients who responded (n=509) typically did so very quickly: 27.3% (139/509) within the first minute, 53.4% (272/509) within 10 minutes, and 86.1% (438/509) within the first hour.…”

“…Other subthemes further confirmed and quantified prior positive patient feedback, including "Understands importance but life gets in the way" and "Putting off or avoiding because it is unpleasant." The FQHC will work toward developing strategies to address these barriers [18]. Patients who remained hard to influence were represented in each of our SDOH bands, suggesting that continued attention to social needs is important in our screening efforts.…”

“…This is relevant to patients eligible for CRC screening, which skews toward the age range of 50 to 75 years. In this Federally Qualified Health Center (FQHC) population, we previously reported that those who engaged in a texting program were more likely to have increased social needs [ 18 ]. In this paper, we further explored the behaviors that could explain this relationship through qualitative data analysis of patients’ SMS text message responses.…”