Texting, Choice Architecture, and Incentives to Improve Colorectal Cancer Screening Uptake
Chyke Doubeni, MD, MPH
Akinbowale Oyalowo, MD, MSHP
Sarah Huf, MBBS, PhD
Center for Therapeutic Effectiveness Research, University of Pennsylvania
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths among men and women in the United States. It is recommended that individuals begin regular screenings for CRC at the age of 45. Screening can prevent cancer by discovering precancerous polyps that can be removed before they turn into cancer. It can also find CRC early when treatment often leads to a cure.
Patients have several options when it comes to completing screening. The most common are colonoscopy and FIT (fecal immunochemical test).
Unfortunately, millions of people in the United States are not getting screened for CRC.
We conducted a series of clinical trials with patients at the Health Annex, a community health center in Philadelphia, to explore the effects of texting, choice architecture, and financial incentives on CRC screening uptake.
In the initial study, we tested opt-in text messaging outreach with or without a lottery-based financial incentive. Messages were sent to patients eligible for CRC screening and FIT tests were mailed to the homes of individuals who chose to participate.
In a later study, we used text messaging to reach out to patients who were eligible for CRC screening. The intervention group received an opt-out offer for a FIT kit, and those who did not opt out were mailed kits and sent three behaviorally informed text message reminders to complete their screening. Participants in the control group received only a text message telling them that they were overdue for colorectal screening and should contact the clinic.
In the first study, around 30 percent of contacted patients opted into the text messaging program. Patients in both intervention groups had a 12 percent FIT completion rate. This outcome suggests that text messaging can promote CRC screening with mailed FIT kits and that adding a lottery-based incentive does not improve screening rates further. Half of the participants who completed a post-study interview selected text messaging as an acceptable method for receiving CRC screening reminders. A follow-up survey confirmed that, for most of these patients, an incentive would not change their decision to complete CRC screening. Patients for whom an incentive would have mattered were less likely to believe that CRC screening is beneficial. This finding suggests that targeting financial incentive interventions according to patient screening beliefs could be a cost-effective strategy in primary care outreach programs to increase CRC screening.
In the second study, the opt-out intervention led to a CRC screening completion rate nearly ten times higher than that of the simple text message reminder. Notably, the participants in the study were in traditionally difficult-to-reach populations – 88 percent were Black, nearly half were Medicaid beneficiaries, and about one-fifth were uninsured. The study results suggest that the opt-out mailed home test kits paired with serial text messaging can effectively improve CRC screening rates in underserved populations.