Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer death in the U.S. Despite the effectiveness of CRC screenings, only 72.6% of adults aged 50-75 were up to date in 2023, with racial and ethnic minorities bearing a disproportionate burden. Vulnerable populations in under-resourced settings face additional barriers including medical mistrust, information overload, cultural taboos, fatalistic beliefs, and limited access to preventive care. This study examines engagement with a culturally tailored digital decision aid intervention among patients overdue for CRC screening at a rural federally qualified health center (FQHC). Intervention: FQHC patients aged 45-73 who were not up to date on CRC screening received a clinic-branded text message with an embedded hyperlink to mPATH-Cloud, a digital platform delivering decision aids. Patients could select from three culturally tailored videos: a standard “Choice” video, a Spanish, Hispanic-tailored “Opciones” video, and an AIAN-tailored “Hope” video. After viewing, patients were prompted to request a colonoscopy or mailed fecal immunochemical test (FIT). Methods: This cross-sectional observational study analyzed preliminary data from 533 intervention participants at Robeson Health Care Corporation (RHCC) in Robeson County, NC—the poorest county in North Carolina in both health and economic resources. The sample was 25.3% Non-Hispanic White, 24.8% Non-Hispanic Black, 26.3% AIAN, and 20.8% Hispanic. Descriptive statistics were used to analyze text message and video engagement by race/ethnicity. A Fisher's Exact Test assessed differences in culturally concordant video selection. Participant attrition was tracked across five intervention stages. Results: Of 533 participants, 22.3% (n=119) opened the mPATH-Cloud link. Hispanic (30.6%) and Non-Hispanic Black (25.8%) participants had higher rates of opening the link than Non-Hispanic White (18.5%) and AIAN (17.9%) participants. Of those who opened the link, 12.6% (n=15) engaged with a decision aid video, representing only 2.8% of the total sample. Of the 15 who engaged with a video, 14 selected the culturally concordant option. The highest attrition occurred between receiving and opening the text message link (>75% dropout). Ultimately, 19 participants requested CRC screening, as eight additional participants bypassed the decision aid. Implications: Text message outreach alone may have limited effectiveness among vulnerable populations due to medical mistrust and information overload. However, given their low cost and broad reach, text messages remain a practical starting point, with clinics escalating to more intensive approaches for non-responders—such as mailed FIT kits or patient navigation—to maximize engagement while minimizing costs. Culturally tailored decision aids were strongly preferred by those who engaged and attrition was lowest after video engagement, suggesting they may play a vital role in motivating screening requests despite low overall engagement. Future interventions should integrate digital outreach within multi-component strategies while exploring shorter decision aid formats and trust-building approaches to reduce early-stage attrition in FQHC settings.
Stella Smolowitz (Thu,) studied this question.
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