• Kelly A Hirko, Sue A Lennon, Todd Lucas, David C Miller, Masahito Jimbo, Stephanie J Leibfritz, Suzanne J Knoff, Carol A Janney, and Paul D Berg.
• Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan. Electronic address: khirko@epi.msu.edu.
• Am J Prev Med. 2020 Sep 1; 59 (3): 404-411.

IntroductionColorectal cancer screening has been shown to prevent or detect early colorectal cancer and reduce mortality; yet, adherence to screening recommendations remains low, particularly in rural settings.Study DesignRCT.Setting/ParticipantsAdults (n=7,812) aged 50-75 years and due for colorectal cancer screening in a largely rural health system were randomly assigned to either the intervention (n=3,906) or the control (n=3,906) group in September 2016, with analysis following through 2018.InterventionA mailed motivational messaging screening reminder letter with an option to call and request a free at-home fecal immunochemical screening test (intervention) or the standard invitation letter detailing that the individual was due for screening (control). Multifaceted motivational messaging emphasized colorectal cancer preventability and the ease and affordability of screening, and communicated a limited supply of test kits.Main Outcome MeasuresColorectal cancer screening participation within 6 months after mailed invitation was ascertained from the electronic medical record.ResultsColorectal cancer screening participation was significantly improved in the intervention (30.1%) vs the usual care control group (22.5%; p<0.001). Individuals randomized to the intervention group had 49% higher odds of being screened over follow-up than those randomized to the control group (OR=1.49, 95% CI=1.34, 1.65). A total of 13.2 screening invitations were needed to accomplish 1 additional screening over the usual care. Of the 233 fecal immunochemical test kits mailed to participants, 154 (66.1%) were returned, and 18 (11.7%) tested positive.ConclusionsA mailed motivational messaging letter with a low-cost screening alternative increased colorectal cancer screening in this largely rural community with generally poor adherence to screening recommendations. Mailed colorectal cancer screening reminders using motivational messaging may be an effective method for increasing screening and reducing rural colorectal cancer disparities.Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

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