Text Message Reminders Improve CRC Screening in FQHCs, With Best Results at 3-Week Frequency

Weekly text message reminders delivered over 3 weeks were associated with higher colorectal cancer (CRC) screening completion rates at federally qualified health centers (FQHCs) in Texas and California, according to a study recently published in the Journal of Medical Internet Research.¹

CRC Screening Guidelines and Persistent Uptake Disparities

CRC remains a major public health burden in the US and is the second leading cause of cancer-related death.^1,2 Since incidence has increased among younger adults, professional societies, including the American Cancer Society and the US Preventive Services Task Force, recommend CRC screening begin at age 45 years for average-risk adults, though earlier screening may be warranted depending on family history.²

Despite these recommendations, screening uptake remains uneven, particularly in medically underserved populations.¹ FQHCs, which serve more than 50 million individuals annually, report substantially lower CRC screening rates than the general population, with estimates of approximately 40% compared with more than 70% nationally. Disparities persist among racial and ethnic minority groups, uninsured individuals, and patients facing structural barriers to preventive care.

Text message reminders have emerged as a scalable tool to improve preventive care uptake. However, prior evidence for CRC screening has been mixed, particularly in safety net settings such as FQHCs. Because of this, investigators conducted a study to evaluate whether text message reminders, including those informed by behavioral theory, could improve screening rates and whether message frequency influenced effectiveness.

The quality improvement study included adults aged 45 years and older receiving care at 2 large FQHC networks in Texas and California. Data were collected from May 2023 to July 2024.

Participants were randomly assigned in equal proportions to 1 of 4 groups. The control group received no text messages; the single-message group received 1 overdue screening reminder; the 3-week group received 1 message per week for 3 weeks; and the 6-week group received 18 total messages over 6 weeks that were informed by behavioral theory and designed to address motivation and screening barriers.

The primary outcome was completion of any CRC screening test within 90 days of the intervention, specifically fecal immunochemical testing, colonoscopy, or Cologuard. The study used multivariable logistic regression models adjusted for demographic, clinical, geographic, and health care access variables, with results reported as adjusted ORs (aORs) with a 95% CI.

Impact of Text Messaging on CRC Screening Uptake

The final sample included 4822 patients, with more than half between the ages of 45 and 59 years (52.97%; n = 2554) and most residing in Texas (76.44%; n = 3686). The majority were female (58.56%; n = 2824) and Hispanic (58.34%; n = 2813). English was the most common primary language (52.26%; n = 2520), followed by Spanish (42.81%; n = 2016). In addition, nearly half of the participants were uninsured (45.17%; n = 2178), reflecting the safety net role of FQHCs.

Of the cohort, 23.7% (n = 1143) were in the control group, 24.74% (n = 1193) in the single-message group, 26.23% (n = 1265) in the 3-message group, and 25.32% (n = 1221) in the 6-week message group. Overall, screening completion rates were 24.06% (n = 275) in the control group, 27.49% (n = 328) in the single-message group, 28.0% (n = 355) in the 3-week message group, and 26.7% (n = 326) in the 6-week message group.

In the combined 3-test model, patients in the single-message group had higher odds of screening completion than the control group (aOR, 1.22; 95% CI, 1.00-1.47). The 3-week group also showed significantly higher odds of screening completion (aOR, 1.27; 95% CI, 1.05-1.53). The 6-week group, however, did not show a statistically significant difference from the control group.

In test-specific analyses, the researchers observed the strongest effects in the Cologuard subgroup, where the 3-week group had an aOR of 7.01 (95% CI, 1.96-25.07) and the 6-week group had an aOR of 5.75 (95% CI, 1.53-21.61).

Similar results were observed in a large FQHC network in New York, where automated, behaviorally informed text message reminders increased fecal immunochemical test completion rates by 9 percentage points compared with nurse-led phone calls.³ The intervention also improved earlier completion rates, reduced staff burden, and was associated with modest gains in detected abnormalities and projected CRC case identification.

Limitations and Future Directions for CRC Screening Interventions

The researchers acknowledged several of their limitations, including that screenings completed outside of the participating health systems may not have been captured, potentially leading to the underestimation of total screening uptake.¹ The study was also conducted in only 2 FQHC networks, which may limit generalizability to other care settings and geographic regions.

Nonetheless, they expressed confidence in their findings, using them to suggest areas for further research.

“In an FQHC study, 3 weekly [theories of behavior change (TOBC)]-informed SMS text messaging reminders most effectively improved CRC screening,” they concluded. “Screening rates also varied by age, language, insurance, obesity, heart disease, and state, underscoring the need to further explore TOBC-informed reminders to promote equitable screening.”

References

1. Angelocci T, Xu T, Talaparthy T, Corral C, Adepoju OE. Leveraging text messaging and behavior theory to improve colorectal cancer screening in federally qualified health centers: cohort study. J Med Internet Res. 2026;28:e86408. doi:10.2196/86408
2. McCormick B. 2026 AC report shows CRC rising in younger adults despite overall decline. AJMC^®. March 3, 2026. Accessed May 17, 2026. https://www.ajmc.com/view/2026-acs-report-shows-crc-rising-in-younger-adults-despite-overall-decline
3. McCormick B. Automated text nudges may offer scalable, low-cost path to closing CRC screening gaps. AJMC. April 28, 2026. Accessed May 17, 2026. https://www.ajmc.com/view/automated-text-nudges-may-offer-scalable-low-cost-path-to-closing-crc-screening-gaps