Cervical cancer screening has been proven to reduce morbidity and mortality rates of gynecological cancers attributed to sexually transmitted human papillomavirus (HPV) infection in the United States.(1) Worldwide, cervical cancer is the fourth most common cancer, affecting 0.6 million women and resulting in 0.3 million deaths annually.(2) In the United States alone, there are 13,000 cases of cervical cancer and 4,000 attributable deaths annually.(3) There is a strong association between precancerous cervical intraepithelial lesions and cervical carcinomas with HPV infection.(1) However, through early detection and screening methods such as Papanicolau (cytology) testing and HPV testing, it is possible to detect precancerous lesions early and halt their progression into cervical cancer.(1) These tools have made cervical malignancies a highly preventable form of cancer, yet significant disparities remain in early detection and outcomes associated with cervical cancer and HPV infection. Despite high screening rates in the United States, several groups remain heavily underscreened. In addition to racial and ethnic minorities, patients from lower socioeconomic status backgrounds, and those living in rural and remote areas also remain heavily underscreened and at higher risk of cervical cancer–associated morbidity and mortality(3-6)
These disparities persist in the state of New York, where 840 new cases of cervical cancer are detected annually, with 240 deaths each year attributed to cervical cancer.(7) In the state of New York, cervical cancer incidence was found to be higher in non-Hispanic Black women and Hispanic women, and cervical cancer mortality was highest in non-Hispanic Black women.(7) These patterns persist in New York City, where women in boroughs of lower socioeconomic status in which predominantly Black and Hispanic communities reside had a 73% higher incidence of cervical cancer.(8) East Harlem is among these, populated primarily with Black and Hispanic residents and facing higher rates of poverty.(9) These communities are more likely to fall within the underscreened groups and are at higher risk of cervical cancer–related morbidity and mortality.
Underscreening in these marginalized populations can be attributed to many factors. Among these factors are implicit bias, which results in a lack of counseling; limited access to hospitals and clinics; and patients being lost to follow-up after visits. Prior studies at the Center for Comprehensive Health Practice (CCHP) identified some of these causes as sources of underscreening for cervical cancer at the clinic. In response to this new understanding, our study seeks to use a text messaging–based intervention to improve rates of cervical cancer screening at the CCHP and bridge the gap between patients identified as eligible for cervical cancer screening and those who proceed to schedule and undergo appointments for Pap smears and cervical examinations. With the pervasiveness of text message communication and mobile phone usage in our current society, text message reminders serve as a potentially wide-reaching tool for health visits and screening reminders. Prior studies that implemented text message reminders for cervical cancer screening in higher-risk subgroups in the United States found the intervention to be both effective and feasible.(10)
This study aims to utilize a similar low-cost intervention in the East Harlem community with hopes of providing improved early detection and intervention in this higher-risk population. In addition to identifying these marginalized communities and underscreened groups, it is critical to develop targeted interventions to increase access to cervical cancer screening and utilization of screening tools.
Methods
This study was conducted and carried out by the principal investigators. In the first phase of the study, a retrospective chart review was performed of patients’ EMRs at a clinic in East Harlem in New York. Patient eligibility was determined through a brief retrospective chart review using CCHP’s EMR, eClinicalWorks. The target population for this study included all eligible female patients between the ages of 21 and 65 who qualified for cervical cancer screening in accordance with the U.S. Preventive Services Task Force. Investigators filtered and compiled a list of the patients who were eligible for cervical cancer screening within the last three years but did not complete their Pap smear (n = 484). Demographic data were recorded, and then patients were sent text messages through eClinicalWorks to remind them to schedule an appointment for their Pap smear (n = 221). After the intervention period, investigators recorded whether each patient had scheduled their procedure within one month of sending the text message reminder.
During the second phase of the project, after one year of the initial intervention, investigators completed a second chart review of the remaining patients — those who did not complete their Pap smears (n=181) after they were sent the first round of text message reminders. After identifying the patients still due for a Pap smear from this group (n=173), they sent another round of text message appointment reminders to patients through eClinicalWorks as the second phase of the intervention to remind them to schedule an appointment for their Pap smear. After the intervention period, investigators recorded whether each patient had scheduled their procedure within one month of having been sent the text message reminder. These data were collected and analyzed to determine the effectiveness of this intervention within this patient cohort.
Formal statistical analysis was performed in this study post hoc. Because this study was a quality improvement project, there was no official control group. The group of non–text-enabled patients who were excluded from the intervention was used as a comparison in our quantitative statistical analysis tests to determine significance of results (Figure 1).
Figure 1. Flow Chart of Intervention-based Quality Improvement Study
Results
In the first phase of the study, 484 patients were identified as not adherent with their cervical cancer screening based on CCHP’s EMR screening tool, eClinicalWorks. Of these patients, 410 patients were text-enabled. A retrospective chart review showed that 189 patients were actually adherent (46.10%) and 221 patients were not adherent (53.90%). The nonadherent patients were sent text message reminders to schedule an appointment for their Pap smear. Postintervention, within a one-month period, 14 patients (6.33%) scheduled an appointment.
In the second phase of the study, a follow-up retrospective chart review was conducted and showed that 43 patients had scheduled a cervical cancer screening appointment over the past 12 months. Another round of the intervention was then conducted. The same text message reminder was sent via eClinicalWorks to 178 patients identified as nonadherent as an annual reminder and continuation of this intervention. After one month postintervention, an additional five patients had scheduled their Pap smear. A total of 48 patients had successfully scheduled their cervical cancer screening appointment by the conclusion of this study. The cervical cancer screening rates of eligible patients, previously at 46.10% preintervention, increased to 57.80% postintervention, with an absolute increase of 26.51% in the group of nonadherent patients.
At the end of the study, a retrospective chart review also was conducted for the non–text-enabled patients who had no text-messaging intervention (n=74). A total of 15 patients from this group scheduled their cervical cancer screening appointment at the conclusion of the study. The cervical cancer screening rate for this group, 0% at the start of the study, increased to 20.27% by the conclusion of the study.
Despite the observed increase in screening rates, statistical analysis showed that the difference between the text-enabled and non–text-enabled groups was not statistically significant (p = .79). The odds ratio for scheduling a cervical cancer screening appointment after receiving a text message reminder was 1.09 [95% confidence interval = 0.57, 2.09], indicating no significant effect of the intervention (Figures 2 through 4).
Figure 2. Number of Cervical Cancer Screening Adherent Patients Pre and Post-Intervention
Figure 3. Cervical Cancer Screening Adherent Rates Post Chart Review
Figure 4. Contingency Table for Statistical Analysis Tests
Discussion
The findings of this quality improvement study highlight the potential impact of text message reminders in increasing cervical cancer screening rates among underscreened populations. Despite the limited response rate initially, this study demonstrated that mobile health reminders could serve as a valuable addition to other targeted interventions to increase patient adherence with cervical cancer screening guidelines, particularly within a marginalized, high-risk urban community.
In the first phase of the study, the text message reminders sent to patients to schedule cervical cancer screenings resulted in a 6.33% increase in nonadherent to adherent patients to schedule their Pap smears within one month of receiving the text. Although this percentage may seem modest, it represents a step in bridging healthcare disparities in underserved populations, where follow-up and access to primary care services can be challenging. During the second phase of the study, additional reminders led to more appointments being scheduled, further increasing the cervical cancer compliance rate in this cohort. These results align with prior studies demonstrating the feasibility and cost-effectiveness of mobile health interventions, particularly in improving preventive care services in underserved communities.
The incremental improvement observed between the two phases of the project suggests that scheduled set interventions of text messaging reminders may be necessary to increase cervical cancer screening rates in this cohort substantially. Although the absolute percentages of scheduling Pap smear appointments were small in this study, this represents a step in the right direction of improving cervical cancer screening rates in marginalized communities. These patients often face numerous systemic barriers, such as poverty, limited healthcare access, and implicit bias in clinical care. Even modest gains can translate into systemic changes for these populations that will improve access to primary care services and health outcomes.
This study also highlights the role of simple, cost-effective interventions such as text message reminders in addressing healthcare inequities. The widespread use of mobile phones across diverse socioeconomic groups makes text-based communication an accessible and scalable intervention aimed at increasing outreach with patients. Furthermore, the integration of text messaging within most EMR systems demonstrates the practicality and accessibility of embedding such interventions into routine clinical workflows.
However, the limited response rate in this cohort also highlights the need for multifactorial approaches to improve screening adherence. Although text message reminders can serve as an effective intervention, additional strategies such as culturally tailored education, follow-up calls, and community outreach programs may further increase cervical cancer screening compliance rates. Future studies should explore combining these interventions to optimize patient outreach and engagement.
Limitations
Several limitations of the study must be addressed. The intervention did not address other potential barriers such as limited appointment availability in the clinic, language differences, literacy levels, and competing priorities such as work or caregiving responsibilities, all of which could have lowered the effectiveness of text message reminders in increasing cervical cancer screening rates. Future studies should survey patients in the community to assess on a deeper level the specific barriers that populations face that prevent them from completing their preventative screenings.
Additionally, the study relied on EMR data for identifying the eligible patients and cervical cancer screening compliance status, and some of this information may have been outdated or inaccurate. Investigators utilized the screening tool in eClinicalWorks, which identified which eligible patients were up-to-date with their cervical cancer screening based on what providers had entered into the EMR. However, there were some discrepancies between the EMR-generated report and the manual chart review that investigators conducted due to patients reporting Pap smears from outside providers. These circumstances were either recorded by providers in their clinical note or the physical records were scanned into the chart. The screening tool was not able to account for this; hence, the number of adherent patients after the initial retrospective chart review was much higher.
Furthermore, some of the eligible patients who were due for their cervical cancer screening were not text-enabled or had not consented to be contacted via eClinicalWorks, limiting the number of patients that could be included in the intervention. Future studies should evaluate whether these scheduled appointments translate to completed Pap smears and subsequent follow-up care and evaluate the need for tailored interventions for specific needs of the target population.
Conclusion
This study demonstrates that text message reminders can serve as a simple, cost-effective intervention to help improve cervical cancer screening rates among underserved populations. The intervention led to moderate increases in scheduled appointments, highlighting its potential to enhance preventive healthcare access in high-risk communities. This widely available mobile technology is already integrated into most EMR systems and can be used as a seamless, scalable tool in routine clinic practices to address disparities in cervical cancer screenings.
Although text message reminders proved to be a feasible tool for patient outreach, their effectiveness may be further enhanced by combining them with other targeted interventions, such as culturally tailored education, follow-up calls, and community-based outreach programs. Addressing additional barriers — such as language differences, appointment availability, and competing social determinants of health — is crucial in ensuring equitable access to care and subsequently increased screening adherence through patient education. Further research and assessment of individualized barriers that patients in this East Harlem community face would be very helpful in creating targeted interventions that could specifically assist them in overcoming their obstacles and obtain access to the care they need.
Future research should focus on assessing the long-term impact of text message reminders on completed screenings, follow-up care, and overall patient health outcomes. Additionally, these mobile health interventions could be expanded beyond cervical cancer screening to other preventive services such as colon cancer screening, further bridging gaps in care and increasing patient education. Healthcare systems can take a significant step toward improving preventative care efforts and reducing disparities in vulnerable populations through continued efforts to refine and integrate these interventions.
Implications
The findings of this study have several important implications for improving cervical cancer screening rates, particularly among underserved populations. The use of text message reminders as a low-cost and scalable tool demonstrates the potential to bridge gaps in healthcare access when combined with other targeted interventions. Integrating mobile health interventions into routine clinical workflows could serve as a practical solution to address healthcare inequities, such as the significant disparities in cervical cancer screening rates.
One key implication is the feasibility of leveraging existing EMR systems to automate patient outreach. Many EMRs already have mobile communication technology seamlessly integrated within their programs, making this intervention both cost-effective and easily implementable on a larger scale. Future efforts could optimize this approach by incorporating additional features, such as multiple timed reminder messages throughout the year, bidirectional communication for appointment scheduling, and messages in multiple languages to accommodate diverse patient populations.
The effectiveness of text message reminders may be enhanced when combined with other interventions such as follow-up phone calls, community health worker outreach, and educational initiatives tailored to culturally specific barriers. This multifaceted approach will focus on educating communities on the importance of preventative screenings, dissolve patient-perceived barriers, and maximize patient engagement to encourage feedback.
Finally, this study highlights the need for continued evaluation of long-term patient adherence and their health outcomes. Future studies should assess whether increased appointment scheduling for Pap smears translates to completed screenings and appropriate follow-up care. This will ensure that continued research and intervention development can sustain improvements in early detection and treatment of cervical cancer.
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