September 04, 2019
3 min read

Q&A: Text message system improves colonoscopy adherence

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Nadim Mahmud
Nadim Mahmud

Despite all the dangers involved with colorectal cancer, many people do not keep up to date with recommended colonoscopy screening. About one-third of individuals are behind. With so many barriers and difficulties in place, researchers are left to find ways to make getting patients to colonoscopy easier.

Nadim Mahmud, MD, a hepatology fellow at the Hospital of the University of Pennsylvania, and colleagues decided to put a text messaging system to the test. For a study published in Health Education & Behavior, they recruited 21 patients scheduled for outpatient colonoscopy to participate in the text message program and compared colonoscopy adherence to 50 control individuals who received usual care.

Individuals in the text arm received messages offering reminders about their appointments, as well as prompts for questions about the procedure. If a patient responded to a question, it was referred to the gastroenterology staff, who answered within 24 hours.

Mahmud and colleagues found that patients in the text messaging arm had higher colonoscopy adherence than the control group (90% vs. 62%; P = .049). Surveys completed after the study indicated that patients were highly satisfied with the program and thought it was quite useful.

Mahmud spoke with Healio Gastroenterology and Liver Disease about why text messages are so helpful in getting people to follow through with colonoscopy appointments, as well as what is next for the program. – by Alex Young

Healio: Why is it so difficult to keep people up to date on CRC screening?

Mahmud: There are many steps to successfully complete a colonoscopy, and there are many potential barriers. In addition to picking up the bowel preparation, patients need to follow instructions that can be confusing to finish the bowel preparation properly. They may also need to take a day off of work and arrange for someone to pick them up after the procedure because they have received sedation. In some cases, patients do not completely understand the rationale for colonoscopy, and thus their motivation to receive the procedure is low. And, as with anything, sometimes patients simply forget about the appointment. Each of these barriers add up, resulting in frequent non-adherence to colonoscopy.

Healio: Is text messaging more effective than other automated methods? If so, why?

Mahmud: Preliminary data suggest that text messaging may be an effective way to improve colonoscopy adherence, and perhaps more so than other methods such as automated phone calls and mailed letters. The vast majority of our patients these days have cell phones that have text messaging capabilities. Unlike a phone call or voicemail which can be missed, text messages are rarely ignored. As such we believe that this mode of communication is a promising way to improve patient adherence, which may extend beyond colonoscopy and apply to other domains of medicine as well.


Healio: Does the way the messages are crafted or composed impact how patients react to them?

Mahmud: Yes, we have found that many aspects of the messages are important. Certainly, the content is paramount, but other elements such as the message timing, length, and frequency also impact the patient response. In our experience, messages should not come at an intrusive time (ie, not too early or too late in the day), should be concise, and should be generally limited to one or two messages per day. Our message content aimed to reinforce the positive reasons for colonoscopy screening, and to focus on individual steps in the preparation process rather than the entire process up front. We also embedded links to more detailed online instructions as well as map links to the endoscopy center, which patients found to be helpful.

Healio: What are the next stages for research/implementation?

Mahmud: We are currently performing a randomized-controlled trial involving 750 patients to more thoroughly evaluate whether our text messaging program will show a benefit in colonoscopy adherence relative to usual care. This is an important step to ensure that no biases impacted the findings of our pilot study. If successful, we will work to roll out the texting program across the University of Pennsylvania system so that all patients may have the opportunity to benefit from this tool. Other endoscopy centers and hospitals may also use our texting intervention as a blueprint to customize their own automated programs.


Mahmud N, et al. Health Educ Behav. 2019;doi:10.1177/1090198119869964.

Disclosures: The authors report no relevant financial disclosures.