Increasing CRC Screening in Community Health Centers Through Mobile Messaging Optimization

This trial is studying optimization of text messages and outreach approaches by community health centers to increase patients' completion of FIT colon cancer screening tests. Text message reminders are a low cost, scalable way to deliver patient reminders that are low burden for staff. The proposed work uses a creative, community-engaged, systems-level approach to improve completion of FIT testing and abnormal follow-up and program sustainment in CHCs.

The study design includes three parts. First, the text messages will be optimized to maximize patient engagement and outreach (Aims 1 \& 2). The study will enroll patients from three partnering CHCs to participate in six focus groups to inform message design. The investigators will also conduct key informant interviews with 5-15 staff per CHC regarding the logistics of ensuring seamless integration into routine clinical operations and perspectives on the intervention activities. Then, a factorial experiment will be conducted, assigning 2,000 patients who have received a stool-based screening kit to different reminder messages. Engagement will be measured as replies or use of ≥1 links, to indicate interaction with the message. The experiment will compare: (1) personalization; (2) concern or negative emotions about screening; and (3) gain framing. In the factorial design patients will not be individually enrolled, this intervention will be tested within the workflows of usual practice. All data for the factorial experiment will be de-identified.

With those tools in place, the investigators will optimize outreach strategies for CRC screening completion. In a second factorial experiment with 5,100 patients, the investigators will optimize outreach strategy for primary screening outcomes of home-based stool screening test completion and screening completion by any guideline-recommended CRC screening test. Secondary outcomes include follow-up care for abnormal stool test results. In this factorial experiment, the investigators will test the impact of three outreach conditions on screening completion: increasing patient autonomy, providing information for accessing resources for impediments to care, and provision of live support. As in the first factorial test, for the second factorial test patients will not be individually enrolled, as the intervention will be tested within the workflows of usual practice. All data will be de-identified.

Finally, the study will assess implementation outcomes and sustainment of intervention components and effects. The investigators will conduct staff interviews and surveys to assess organizational capacity for sustaining the intervention elements being tested as well as the acceptability and feasibility of the text messages and screening tools. Sustainment of the text message outreach intervention elements will be assessed at post intervention and two 6-month intervals post-intervention.

• Personalized Text Message (Behavioral): Message includes personalized content.
• Screening Concerns Text Message (Behavioral): Emotional concerns or barriers related to CRC screening.
• Message Framing Text Message (Behavioral): Use gain-framed language to influence motivation.
• Autonomy Support Outreach (Behavioral): Provide patients with choices or options to increase sense of control.
• Impediments Support Outreach (Behavioral): Include information or resources to help overcome barriers to care.
• Live Support Outreach (Behavioral): Offer access to live assistance.
• Data Reporting and Visualization System Tools (Other): Electronic alerts, dashboards, and tracking systems used to identify and follow up with patients due for CRC screening or abnormal results.

Primary outcomes

• Text message engagement [14 days after reminder message delivery]: Proportion of message recipients who interact with CRC screening reminder messages by reply
• Stool-based CRC screening completion [3 months after reminder message delivery]: Proportion of message recipients with stool-based CRC screening tests resulted in electronic health record

Secondary outcomes

• Time to follow-up care after abnormal stool-based screening test [3 months after date of abnormal result]: Time (days) to follow-up care after abnormal stool-based screening test
• Invalid test results [3 months after reminder message delivery]: Proportion of message recipients with invalid stool-based screening test result

Sex: All, ages: 45 Years to 75 Years, accepts healthy volunteers

Eligibility Criteria for CHC Patients Cohorts

Inclusion Criteria (CHC Patients):

* Adults 45-75 years old
* Receive care in partner CHCs
* Are of average risk for colorectal cancer
* Received a stool-based testing order at their CHC
* Have a mobile phone and can receive text messages (Aim 1 quantitative cohort only)
* Fluent in English, Spanish, or another predominant language to be identified by the PI (applicable to patients focus groups cohort only)

Exclusion Criteria (CHC Patients):

* Personal or family history of CRC or colorectal polyps
* History of inflammatory bowel disease
* Heritable conditions that put them at above average risk for colorectal cancer (e.g., familial adenomatous polyposis)

Eligibility Criteria for CHC Staff Cohorts Inclusion Criteria (CHC Staff)

* Adult employees of participating CHCs
* Job responsibilities include activities related to CRC screening

Exclusion Criteria (CHC Staff)

* None

• Gina Kruse, MD, Principal investigator, University of Colorado, Denver

NIH grants: R01CA293501