Behaviorally Informed Text Messaging to Promote Colon Cancer Screening

Importance Colorectal cancer screening rates in the US remain suboptimal, particularly among low-income and minoritized populations, despite the availability of effective, low-cost options such as the fecal immunochemical test (FIT). Scalable outreach strategies are needed to improve uptake and reduce staff burden in safety-net settings. Objective To evaluate whether a behavioral economics–informed, automated text messaging strategy was associated with increased FIT completion compared with nurse-led telephone call outreach. Design, Setting, and Participants This quality improvement randomized clinical trial was conducted from April 7 to June 24, 2025, at 8 Federally Qualified Health Centers (FQHCs) in Brooklyn, New York, within the Family Health Centers at NYU Langone. Participants included adults (aged ≥18 years) with a new FIT order who listed English, Spanish, or Chinese (Mandarin or Cantonese) as their preferred language and had not opted out of text messaging. Intervention Patients were randomized 1:1 to receive either 3 automated, 1-way text message reminders on days 2, 5, and 8 (intervention) or a single nurse-led telephone call reminder on day 8 (usual care). Main Outcomes and Measures The primary outcome was FIT completion within 21 days of the test order, assessed from the electronic health record. Secondary outcomes included completion at 7 and 14 days. FIT completion at 7, 14, and 21 days was compared between groups using χ 2 tests. Results Among 1275 eligible randomized participants, 649 were assigned to the text group (418 female participants 64.4%; mean SD age, 56.4 9.3 years) and 626 to the telephone group (398 female participants 63.6%; mean SD age, 56.7 9.6 years). FIT completion within 21 days was higher in the text group (382 of 649 participants 58.9%) compared with the telephone group (312 of 626 participants 49.8%) with an absolute difference of 9.0 percentage points (95% CI, 3.6-14.5 percentage points; P = .001). Post hoc analyses found no evidence of differential effectiveness by age, sex, race and ethnicity, or patient portal use. Conclusions and Relevance In this quality improvement randomized clinical trial, a behaviorally informed text messaging strategy was associated with significantly improved FIT completion compared with usual nurse-led telephone outreach. Automated messaging may offer a scalable, low-cost strategy to promote preventive care and reduce staff burden in underserved populations. Trial Registration ClinicalTrials.gov Identifier: NCT06632054