Tailoring a text messaging and fotonovela program to increase patient engagement in colorectal cancer screening in a large urban community clinic population: a quality improvement project (Preprint)

Abstract

Appropriate annual screenings for colorectal cancer (CRC) are an essential preventative measure for the second-leading cause of cancer death in the US. Studies have shown that colorectal cancer screening rates are influenced by various social determinants of health (SDOH) factors, including race, ethnicity, and geography. According to 2018 national data, participation in screening is lowest among Hispanic or Latino individuals (56.1%). At an urban Federally Qualified Health Center (FQHC), a quality improvement project was conducted to evaluate a texting program with a motivational fotonovela – a short narrative comic. Fotonovelas have previously been used by programs to improve knowledge about cervical cancer and HPV, vaccinations, and treatments for depression.

This project aimed to encourage Fecal Immunochemical Test (FIT) screening compliance. Patient engagement involved a texting program with fotonovelas informed by behavioral change techniques. The project sought to understand qualitative characteristics about patient motivation, intention, and barriers to completing their screening.

5,241 English or Spanish speaking FQHC patients aged 50 to 75 were randomized to either intervention (a 4-week tailored two-way texting program with a fotonovela comic) or usual care (a text message reminder and patient navigator phone call). The texting vendor used a proprietary algorithm to categorize intervention group patients into SDOH bands based on their home addresses (high impact = high social needs; low impact = low social needs). Over four weeks, patients were texted questions relating to whether they had received and returned their FIT, what barriers they may be experiencing, and their thoughts about the fotonovela.

SDOH index analysis showed that the majority of the patient population were in the SDOH band categories of High Impact (21.4%) and Very High Impact (54.5%). Patients sent 1,969 total responses to the texting system. Thematic analysis found three major themes in these responses: (1) Messages as a reminder, where patients texted back that they were motivated to return the FIT and had already done so, or would do so as soon as possible; (2) Increasing patients’ understanding of screening importance, where patients expressed an increased knowledge about the purpose and importance of the FIT; and (3) Expressing barriers, where patients were willing to share reasons for not completing the FIT.

The texting program and fotonovela engaged a subset of patients in each SDOH band, including the High and Very High Impact bands. Creating messaging that is culturally tailored can encourage patients to engage. This engagement would include: accepting the content of the messaging, confirming intentions to complete their FIT, and sharing insights about barriers to behavior change. In order to better support all patients across the continuum of care with CRC screening, it is important to continue developing and assessing strategies that engage patients who did not return their home-mailed FIT.