mHealth Navigation using SMS Texting to Improve Colorectal Cancer Screening Among Homeless Persons

Project Summary: Colorectal cancer (CRC) is among the most common cancers, killing tens of thousands in
the US, annually. CRC screening reduces morbidity and mortality by 60%. Despite availability, significant
disparities exist in cancer screening for 3.5 million persons experiencing homelessness (PEH) in the US.
Socio-economically disadvantaged PEH are overwhelmingly from racial and ethnic minorities; many are in their
fifties. Cancer is one of the top two leading causes of death in PEH over 45 years old. PEH have four times the
cancer rates and twice the cancer mortality of the general population. There is low cancer health literacy and
the rates of CRC screening in PEH is as low as 19.7% vs. 71.6% in the general population. In PEH, the usual
route of provider counseling and referral to specialists does not address barriers and is difficult to effectively
incorporate into their routine care. Around 85% of PEH reside in shelters. Shelters are among the very few
places where PEH congregate, are reachable, and can access health promotion programs. Patient navigation
is widely accepted and tested in improving cancer screening among minorities. mHealth strategies have been
tested in the general as well as PEH populations to improve access to care. mHealth-based navigation for
cancer screening has not been tested in PEH. This proposal seeks to evaluate the extent to which an SMS
text-based patient navigation for CRC screening will address some of the barriers to and improve CRC
screening among PEH. A streamlined approach will be carried out through an SMS texting strategy in the
shelter-clinics of a community organization serving PEH, Project Renewal, in NYC: to explain cancer risks and
screening options, provide test instructions and support, identify and address barriers to screening, answer
questions and concerns, make appointments for screening, support screening completion, provide post-screen
counselling, and obtain test results to complete screening loop. The specific aims include; AIM 1) to evaluate
the effect of 6- month SMS text-based patient navigation for CRC screening (INT) versus an attention control
(CL) of general health promotion on the completed rates of CRC screening using a randomized trial design in
shelter-clinics in New York City (NYC): Hypothesis 1) among PEH age 45-75 not up-to-date with CRC screen,
those randomized to the INT (n=294) will have higher CRC screening rates in the magnitude of 10 percentage
point, compared to those randomized to the CL (n=294) at 6 months post-enrollment; AIM 2) to evaluate
perceptions, attitudes and experiences of PEH (n=50), providers and staff (n=20) on SMS texts navigation for
CRC screening in shelter-clinics using semi-structured interviews; AIM 3) to evaluate perceptions and attitudes
of program staff (n=20) from agencies servicing PEH at the NYC and national levels on challenges and
opportunities of implementing SMS text-based navigation for cancer care and control in shelter system using
semi-structured interviews. In this controlled trial, individual level randomization will be employed in shelter-
clinics. The primary outcome is CRC screening (completed colonoscopy/FIT/mt-sDNA) at 6 months.

Grant Number: 1R01MD019112-01A1
NIH Institute/Center: NIH
Principal Investigator: Ramin Asgary