Using Text Messages and Fotonovelas to Increase Return of Home-Mailed Colorectal Cancer Screening Tests: Mixed Methods Evaluation
Authors: Levitz Carly E , Kuo Elena , Guo Monica , Ruiz Esmeralda , Torres-Ozadali Evelyn , Brar Prayaga Rena , Escaron Anne 
Published: November 2022

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.