Harnessing the Question-Behavior Effect to Enhance Colorectal Cancer Screening in an mHealth Experiment

Effectiveness of health promotion interventions to increase faecal occult blood test uptake rates among older adults with an average-risk of colorectal cancer: A systematic review and meta-analysis

Objective

This review aims to examine the effectiveness of interventions in increasing faecal occult blood test (FOBT) uptake rates among older adults with an average-risk of colorectal cancer (CRC) and to identify essential components of such interventions based on current evidence.

Methods

Five databases were included in a systematic literature search for studies reporting randomized controlled trials (RCT) and interventions aimed at increasing FOBT uptake rates among average-risk individuals aged 50-75. Review Manager 5.4.1 was used for conducting meta-analyses and subgroup analyses.

Results

A meta-analysis of the 20 included studies demonstrated that health promotion interventions led to significant increases in FOBT uptake rates (odds ratio [OR] ​= ​1.55, 95% confidence interval (CI) ​= ​1.30-1.85; I 2 ​= ​95%). Provision of information, mailing of FOBT outreach, and reminders were identified as core components of promotion interventions to increase FOBT uptake rates. Among the different significant reminder strategies, a digital message (via text) plus telephone calls (automated and navigator-initiated) had a larger effect size than a telephone call alone. In addition, there was no significant evidence that financial incentives were associated with FOBT uptake. Most studies included a diverse mixture of components, but only a few studies utilized theoretical framework-based interventions.

Conclusions

Future studies with rigorous methodologies are warranted to examine the effectiveness and understand the mechanisms of theoretical framework-based multi-component educational programmes aimed at increasing FOBT uptake rates.

Systematic review registration

PROSPERO CRD42024520859.

Text Messaging Versus Postal Reminders to Improve Participation in a Colorectal Cancer Screening Program: Randomized Controlled Trial

BACKGROUND

Mobile phone SMS text message reminders have shown moderate effects in improving participation rates in ongoing colorectal cancer screening programs.

OBJECTIVE

This study aimed to assess the effectiveness of SMS text messages as a replacement for routine postal reminders in a fecal immunochemical test-based colorectal cancer screening program in Catalonia, Spain.

METHODS

We conducted a randomized controlled trial among individuals aged 50 to 69 years who were invited to screening but had not completed their fecal immunochemical test within 6 weeks. The intervention group (n=12,167) received an SMS text message reminder, while the control group (n=12,221) followed the standard procedure of receiving a reminder letter. The primary outcome was participation within 18 weeks of the invitation. The trial was stopped early, and a recovery strategy was implemented for nonparticipants in the intervention group. We performed a final analysis to evaluate the impact of the recovery strategy on the main outcome of the trial. Participation was assessed using a logistic regression model adjusting for potential confounders (sex, age, and deprivation score index) globally and by screening behavior.

RESULTS

The trial was discontinued early in September 2022 due to the results of the interim analysis. The interim analysis included 5570 individuals who had completed 18 weeks of follow-up (intention-to-treat). The SMS text message group had a participation rate of 17.2% (477/2781), whereas the control group had a participation rate of 21.9% (610/2789; odds ratio 0.71, 95% CI 0.62-0.82; P<.001). As a recovery strategy, 7591 (72.7%) out of 10,442 nonparticipants in the SMS text message group had an open screening episode and received a second reminder by letter, reaching a participation rate of 23% (1748/7591). The final analysis (N=24,388) showed a participation rate of 29.3% (3561/12,167) in the intervention group, which received 2 reminders, while the participation rate was 26.5% (3235/12,221) in the control group (odds ratio 1.16, 95% CI 1.09-1.23; P<.001).

CONCLUSIONS

Replacing SMS text messages with reminder letters did not increase the participation rate but also led to a decline in participation among nonparticipants 6 weeks after the invitation. However, sending a second reminder by letter significantly increased participation rates among nonparticipants within 6 weeks in the SMS text message group compared with those who received 1 postal reminder (control group). Additional research is essential to determine the best timing and frequency of reminders to boost participation without being intrusive in their choice of participation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04343950; https://www.clinicaltrials.gov/study/NCT04343950.

Effectiveness and Acceptability of Targeted Text Message Reminders in Colorectal Cancer Screening: Randomized Controlled Trial (M-TICS Study)

BACKGROUND

Mobile phone-based SMS text message reminders have the potential to improve colorectal cancer screening participation rates.

OBJECTIVE

This study assessed the effectiveness and acceptability of adding targeted SMS text message reminders to the standard procedure for those who picked up but did not return their screening kit at the pharmacy within 14 days in a colorectal cancer screening program in Catalonia, Spain.

METHODS

We performed a randomized control trial among individuals who picked up a fecal immunochemical test (FIT) kit for colorectal cancer screening at the pharmacy but did not return it within 14 days. The intervention group (n=4563) received an SMS text message reminder on the 14th day of kit pick up and the control group (n=4806) received no reminder. A 30-day reminder letter was sent to both groups if necessary. The main primary outcome was the FIT completion rate within 30, 60, and 126 days from FIT kit pick up (intention-to-treat analysis). A telephone survey assessed the acceptability and appropriateness of the intervention. The cost-effectiveness of adding an SMS text message reminder to FIT completion was also performed.

RESULTS

The intervention group had higher FIT completion rates than the control group at 30 (64.2% vs 53.7%; P<.001), 60 (78.6% vs 72.0%; P<.001), and 126 (82.6% vs 77.7%; P<.001) days. Participation rates were higher in the intervention arm independent of sex, age, socioeconomic level, and previous screening behavior. A total of 339 (89.2%) interviewees considered it important and useful to receive SMS text message reminders for FIT completion and 355 (93.4%) preferred SMS text messages to postal letters. We observed a reduction of US $2.4 per participant gained in the intervention arm for invitation costs compared to the control arm.

CONCLUSIONS

Adding an SMS text message reminder to the standard procedure significantly increased FIT kit return rates and was a cost-effective strategy. SMS text messages also proved to be an acceptable and appropriate communication channel for cancer screening programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04343950; https://www.clinicaltrials.gov/study/NCT04343950.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1371/journal.pone.0245806.

Automated Reminders Enhance Mailed Fecal Immunochemical Test Completion Among Veterans: a Randomized Controlled Trial

BACKGROUND

The Veterans Affairs (VHA) is working to establish a population-based colorectal cancer screening program for average-risk patients using mailed fecal immunochemical testing (FIT). However, low response rates to mailed FIT may hinder success. Key features of mailed FIT programs, including the use of reminders, differ among various national programs, with limited evidence among veterans.

OBJECTIVE

We sought to test whether using reminders, either via telephone call or text message, was effective in improving mailed FIT response rates.

DESIGN

We conducted a prospective, randomized quality improvement trial ( ClinicalTrials.gov NCT05012007). Veterans who had not returned a FIT within 2 weeks of receiving the kit were randomized to one of three groups: (1) control (no reminder); (2) an automated telephone call reminder; or (3) an automated text message reminder.

PARTICIPANTS

A total of 2658 veterans enrolled at VA Puget Sound Health Care System who were aged 45-75 and had an average risk of colorectal cancer.

INTERVENTIONS

A single automated telephone call or text message reminder prompting veterans to return the FIT kit.

MAIN MEASURES

Our primary outcome was FIT return at 90 days and our secondary outcome was FIT return at 180 days.

KEY RESULTS

Participant average age was 62 years, 88% were men, and 66% White. At 90 days, both the phone and text reminder interventions had higher FIT return rates compared to control (intention-to-treat results (ITT): control 28%, phone 39%, text 38%; p<0.001). At 180 days, FIT kit return remained higher in the reminder interventions (ITT: control 32%, phone 42%, text 40%; p<0.001).

CONCLUSIONS

Automated reminders increased colorectal cancer screening completion among average-risk veterans. An automated phone call or text message was equally effective. VHA facilities seeking to implement a mailed FIT program should consider using phone or text reminders, depending on available resources.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors

BACKGROUND AND PURPOSE

Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation).

METHODS AND RESULTS

We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits).

CONCLUSIONS

The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials

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We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening.

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We identified 1027 papers for title and abstract review. 30 studies were eligible for the review.

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The most frequently tested BE intervention was incentives, followed by default principle and salience.

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Default-based interventions were most likely to be effective. Incentives had mixed evidence.

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BE remains a promising field of interest in relation to influencing CRC screening behaviours.

Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis

BACKGROUND

Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening.

METHODS

We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model.

RESULTS

We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types.

CONCLUSIONS

Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2019-035411.

Translational Research in Cancer Screening: Long-Term Population-Action Bridges to Diffuse Adherence

The population-level implementation of innovative, evidence-based medical recommendations for adopting health-behaviors depends on the last link in the translation chain: the users. “User-friendly” medical interventions aimed at engaging users to adopt recommended health behaviors are best developed in a collaborative bio-medical and social sciences setting. In the 1990s, National Breast and Colorectal Cancer Early Detection Programs were launched at the Israeli Department of Community Medicine and Epidemiology. Operating under the largest HMO (Health Maintenance Organization) in Israel (“Clalit Health Services”), the department had direct access to HMO community primary-care clinics’ teams, insured members, and medical records. Academically affiliated, the department engaged in translational research. In a decades-long translational process, this multi-disciplinary unit led a series of interventions built upon basic and applied behavioral/social science phenomena such as framing, “Implementation Intentions,” and “Question-Behavior-Effect”. A heterogeneous team of disciplinary specialists created an integrated scientific environment. In order to enhance screening, the team focused on the establishment of a systematic mechanism actively inviting programs’ “users” (average-risk targeted individuals on the national level), and continuously applied social and health psychology concepts to study individuals’ perceptions, expectations, and needs related to cancer screening. The increase in adherence to screening recommendations was slow and incremental. A decrease in late-stage breast and colorectal cancer diagnoses was observed nationally, but participation was lower than expected. This paper positions screening adherence as a unique challenge and proposes new social and network avenues to enhance future participation.

Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial

BACKGROUND

Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations.

OBJECTIVE

To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates.

DESIGN

A two-armed randomized clinical trial.

PARTICIPANTS

An urban community health center in Philadelphia. Adults aged 50-74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded.

INTERVENTIONS

Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders.

MAIN MEASURES

The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks.

KEY RESULTS

Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001).

CONCLUSIONS

Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population.

TRIAL REGISTRATION

clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03479645 ).

The Effects of Different Invitation Schemes on the Use of Fecal Occult Blood Tests for Colorectal Cancer Screening: Systematic Review of Randomized Controlled Trials

Simple Summary

There is large heterogeneity in invitation schemes and participation rates in colorectal cancer screening programs offering fecal occult blood tests (nowadays mostly fecal immunochemical tests). It is unclear what the most effective invitation strategies are for fecal occult blood tests. In this systematic review, advance notification, mailed fecal occult blood test, and reminders had major, consistent, and complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening. Our findings show that the effectiveness of invitations for fecal occult blood test-based colorectal cancer screening can be substantially increased across several settings by the implementation of comprehensive invitation strategies.

Abstract

Personal invitations for fecal occult blood tests (nowadays mostly fecal immunochemical tests) are increasingly used to raise their usage for colorectal cancer screening. However, there is a large heterogeneity in applied invitation schemes. We aimed to review evidence for the effectiveness of various invitation schemes. The main outcome was the fecal occult blood test usage rate. A systematic search was performed in Medline and Web of Science (up to 9 July 2020). Randomized controlled trials or cluster-randomized controlled trials were eligible, which reported on general invitations for fecal occult blood test-based colorectal cancer screening sent to the general population at average colorectal cancer risk. (PROSPERO 2020 CRD42020169409). Overall, 34 studies were included. Invitations with an attached, i.e., mailed fecal occult blood test consistently increased test usage by 4–19.7% points, compared to other methods of test provision. Likewise, the introduction of advance notification consistently led to a higher usage rate, with an increase of 3.3–10.8% points. Reminders showed positive but varying effects by method. With an increase of 8.5–15.8% points, letter or email reminders were more effective than reminders by phone call or text message (0.6–6.5% points). Inconsistent results were found for financial incentives ((−8.4)–20% points) and for added or changed invitation material ((−3.5)–11.8% points). With 3.5–24.7% points, the strongest increases in use were achieved by multifaceted invitation, implementing multiple components. Any invitation scheme was superior over no invitation. Advance notification, mailing of fecal occult blood test, and reminders were consistently shown to have major, complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening settings.

Text messaging as a tool to improve cancer screening programs (M-TICS Study): A randomized controlled trial protocol

BACKGROUND

Short message service (SMS) based interventions are widely used in healthcare and have shown promising results to improve cancer screening programs. However, more research is still needed to implement SMS in the screening process. We present a study protocol to assess the impact on health and economics of three targeted SMS-based interventions in population-based cancer screening programs.

METHODS/DESIGN

The M-TICs study is a randomized controlled trial with a formal process evaluation. Participants aged 50-69 years identified as eligible from the colorectal cancer (CRC) and breast cancer (BC) screening program of the Catalan Institute of Oncology (Catalonia, Spain) will be randomly assigned to receive standard invitation procedure (control group) or SMS-based intervention to promote participation. Two interventions will be conducted in the CRC screening program: 1) Screening invitation reminder: Those who do not participate in the CRC screening within 6 weeks of invite will receive a reminder (SMS or letter); 2) Reminder to complete and return fecal immunochemical test (FIT) kit: SMS reminder versus no intervention to individuals who have picked up a FIT kit at the pharmacy and they have not returned it after 14 days. The third intervention will be performed in the BC screening program. Women who had been screened previously will receive an SMS invitation or a letter invitation to participate in the screening. As a primary objective we will assess the impact on participation for each intervention. The secondary objectives will be to analyze the cost-effectiveness of the interventions and to assess participants' perceptions.

EXPECTED RESULTS

The results from this randomized controlled trial will provide important empirical evidence for the use of mobile phone technology as a tool for improving population-based cancer screening programs. These results may influence the cancer screening invitation procedure in future routine practice.

TRIAL REGISTRATION

Registry: NCT04343950 (04/09/2020); clinicaltrials.gov.

Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial

Efforts to boost colorectal cancer (CRC) screening rates in underserved populations have been limited by effectiveness and scalability. We evaluate the impact of adding a lottery-based financial incentive to a text messaging program that asks patients to opt-in to receive mailed fecal immunochemical testing (FIT). This is a two-arm pragmatic randomized controlled trial at a community health center in Southwest Philadelphia from April to July 2017. We included CRC screening-eligible patients between ages 50-74 years who had a mobile phone, active health insurance, and at least one visit to the clinic in the past 12 months. Patients received a text message about CRC screening with the opportunity to opt-in to receive mailed FIT. They were randomized 1:1 to the following: (1) text messaging outreach alone (text), or (2) text messaging with lottery for a 1-in-5 chance of winning $100 after FIT completion (text + lottery). The primary outcome was the percentage of patients completing the mailed FIT within 3 months of initial outreach. 281 patients were included in the intent-to-treat analysis. The FIT completion rate was 12.1% (95% CI, 6.7%-17.5%) in the text message arm and 12.1% (95% CI, 6.7%-17.5%) in the lottery arm, with no statistical difference between arms. The majority of post-intervention interview respondents found text messaging to be acceptable and convenient. Opt-in text messaging is a feasible option to promote the uptake of mailed FIT screening, but the addition of a lottery-based incentive did not improve completion rates. Trial Registration: clinicaltrials.gov (NCT03072095).

Effectiveness of Mass and Small Media Campaigns to Improve Cancer Awareness and Screening Rates in Asia: A Systematic Review

PURPOSE

The main objective of this systematic review was to identify whether mass and small media interventions improve knowledge and attitudes about cancer, cancer screening rates, and early detection of cancer in Asia.

METHODS

The review was conducted according to a predefined protocol. Medline, EMBASE, CINAHL, Web of Science, Cochrane Library, and Google Scholar were searched in September 2017, and data extraction and rating of methodologic study quality (according to Joanna Briggs Institute rating procedures) were performed independently by reviewers.

RESULTS

Twenty-two studies (reported across 24 papers) met the inclusion criteria. Most studies (n = 21) were conducted in high or upper-middle income countries; targeted breast (n = 11), cervical (n = 7), colorectal (n = 3), or oral (n = 2) cancer; and used small media either alone (n = 15) or in combination with mass media and other components (n = 5). Studies regarding cancer screening uptake were of medium to high quality and mainly reported positive outcomes for cervical cancer and mixed results for breast and colorectal cancer. The methodologic strength of research that investigated change in cancer-related knowledge and the cost effectiveness of interventions, respectively, were weak and inconclusive.

CONCLUSION

Evidence indicated that small media campaigns seemed to be effective in terms of increasing screening uptake in Asia, in particular cervical cancer screening. Because of the limited number of studies in Asia, it was not possible to be certain about the effectiveness of mass media in improving screening uptake and the effectiveness of campaigns in improving cancer-related knowledge.

Developing SMS Content to Promote Papanicolaou Triage Among Women Who Performed HPV Self-collection Test: Qualitative Study

Background

SMS interventions are effective in promoting a variety of health behaviors; however, there is limited information regarding the use of SMS for cervical cancer screening and follow-up care. The Application of Communication and Information Technologies to Self-Collection study aims to evaluate a multicomponent mobile health intervention to increase triage adherence among women with human papillomavirus (HPV)–positive self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial.

Objective

This study aimed to understand the cultural and contextual elements, women’s beliefs, and perceptions regarding the use of SMS by the health care system and women’s preferences about the message content.

Methods

We conducted five focus groups (FGs), stratified by rural or urban residence and age. All participants were aged 30 years or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification, and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding the SMS content. Messages for both HPV-negative and HPV-positive women were validated through interviews with health authorities and 14 HPV-tested women. The final versions of the messages were pilot-tested.

Results

A total of 48 women participated in the FGs. Participants rejected receiving both negative and positive HPV results by SMS because, for them, the delivery of results should be done in a face-to-face interaction with health professionals. They stressed the importance of the SMS content informing them that results were available for pick up and reflecting the kind of relationship that they have with the community health workers and the nearest health center. Women considered that a personalized SMS was important, as was the use of a formal yet warm tone. Owing to confidentiality issues, not using the word “HPV” was also a key component of the desired SMS content; therefore, the final message included the term “self-collection” without the mention of HPV infection. Results from the validation stage and pilot test showed high acceptability of the final version of the message.

Conclusions

The results suggest that SMS is accepted when notifying women about the availability of the HPV test result, but it should not replace the delivery of results in face-to-face, doctor-patient encounters. In addition, messages must be tailored and must have a persuasive tone to motivate women to adhere to the triage.

Better Ask Than Tell: Responses to mHealth Interrogative Reminders and Associations With Colorectal Cancer Screening Subsequent Uptake in a Prospective Cohort Intervention

BACKGROUND

Text message (short message service, SMS) interrogative reminders were adopted in population screening for the early detection of colorectal cancer (CRC).

OBJECTIVE

This study aims to examine responses to text message (SMS) reminders and associate responses with senders' characteristics, message type (interrogative/declarative), and subsequent screening uptake.

METHODS

We conducted a prospective cohort intervention. Text message (SMS) reminders to undergo CRC screening, randomized into interrogative and declarative phrasing, were sent to nonadherent 40,000 women and men (age 50-74 years) at CRC average risk. We analyzed recipient responses by message phrasing, recipient characteristics, and for content, the latter predicting subsequent CRC screening per program database.

RESULTS

While interrogative text message (SMS) reminders elicited 7.67% (1475/19,227) responses, declarative ones elicited 0.76% (146/19,262) responses. Text message (SMS) responses were content analyzed and grouped into attitudes toward CRC screening (1237/1512, 81.8% positive) and intention to screen (1004/1512, 62.6%). Text message (SMS) respondents screened significantly more than nonrespondents after 6 months (415/1621, 25.6% vs 3322/36,868, 9.0%; χ12=487.5, P<.001); 1 year (340/1621, 21.0% vs 4711/36,868; χ12=91.5, P<.001); and 2 years (225/1621, 13.9% vs 3924/36,868; χ12=16.9, P<.001) following the reminders. In a multivariable logistic regression among text message (SMS) respondents, screening after 6 months was significantly predicted by older age, past sporadic screening, attitudes, and intentions.

CONCLUSIONS

Interrogative text message (SMS) reminders reached previously uninvolved sectors in the CRC target population-men, sporadic-screenees, and the "never-tested" before. This novel application resulted in a population-level, incrementally enhanced screening. Asking patients about their future health behavior may be relevant for enhancing other health behaviors in preventive medicine and clinical settings.

Text Messaging Interventions on Cancer Screening Rates: A Systematic Review

BACKGROUND

Despite high-quality evidence demonstrating that screening reduces mortality from breast, cervical, colorectal, and lung cancers, a substantial portion of the population remains inadequately screened. There is a critical need to identify interventions that increase the uptake and adoption of evidence-based screening guidelines for preventable cancers at the community practice level. Text messaging (short message service, SMS) has been effective in promoting behavioral change in various clinical settings, but the overall impact and reach of text messaging interventions on cancer screening are unknown.

OBJECTIVE

The objective of this systematic review was to assess the effect of text messaging interventions on screening for breast, cervical, colorectal, and lung cancers.

METHODS

We searched multiple databases for studies published between the years 2000 and 2017, including PubMed, EMBASE, and the Cochrane Library, to identify controlled trials that measured the effect of text messaging on screening for breast, cervical, colorectal, or lung cancers. Study quality was evaluated using the Cochrane risk of bias tool.

RESULTS

Our search yielded 2238 citations, of which 31 underwent full review and 9 met inclusion criteria. Five studies examined screening for breast cancer, one for cervical cancer, and three for colorectal cancer. No studies were found for lung cancer screening. Absolute screening rates for individuals who received text message interventions were 0.6% to 15.0% higher than for controls. Unadjusted relative screening rates for text message recipients were 4% to 63% higher compared with controls.

CONCLUSIONS

Text messaging interventions appear to moderately increase screening rates for breast and cervical cancer and may have a small effect on colorectal cancer screening. Benefit was observed in various countries, including resource-poor and non-English-speaking populations. Given the paucity of data, additional research is needed to better quantify the effectiveness of this promising intervention.