Pilot Study of a Mobile Health Approach to Reduce Barriers to Cervical Cancer Screening in Tanzania
Condition: Cervical Cancer
MeSH terms: Uterine Cervical Neoplasms
Study type: Interventional

Summary: 
      The purpose of this study is to determine whether motivational text messages and/or travel
      vouchers are effective in increasing cervical cancer screening rates in urban and rural
      regions of Northern Tanzania.
    

Detailed description: 
      Introduction:

      Cervical cancer is the leading cause of cancer-related deaths in Tanzania. The age-adjusted
      incidence rate is estimated to be 54 cases per 100,000 (IARC, 2012) and 80% of Tanzanian
      women affected by cervical cancer will die due to advanced stage at diagnosis (Kahesa, et
      al., 2012). Visual Inspection of the cervix under Acetic Acid (VIA) is an effective
      alternative to the Pap smear, unavailable in most low-resource countries due to weak health
      systems (Palanuwong, 2007). Nurses typically receive 6 days of training before returning to
      their communities to provide VIA; however, they often face a total lack of oversight to
      ensure they are providing quality screening and cryotherapy. This lack of quality control has
      prevented a decline in cervical cancer morbidity and mortality despite significant investment
      and implementation of VIA programs.

      The Kilimanjaro Cervical Cancer Screening Project (KCCP) is a pilot study of 1000 women that
      developed and tested a cervicography (taking a digital photo of the cervix) training method
      using a smartphone camera in the hands of nurses performing cervical cancer screening and
      receiving 'real time' mentorship through a closed user group of image transfer and guidance
      by cervicographers located elsewhere in Tanzania. A pilot study completed in February 2015
      showed that this method provides safe and high quality screening and the method is moving to
      implementation and scale up within multiple VIA programs in late 2015 (Yeates et al.,
      Manuscript in preparation). The KCCP continues to screen patients and this provides a
      significant opportunity to perform further research that will inform the scale-up program.

      Measures to encourage increased uptake of cervical cancer screening in the region, and in
      many low-resource contexts are drastically needed to reduce the burden of cervical cancer in
      these contexts. The prevalence of screening in the Kilimanjaro is 6%(Cunningham et al, 2015),
      which is close to the WHO figure of 5% of women in developing countries having been screened
      in the last five years (World Health Organization, 1986). The largest perceived barriers to
      cervical cancer screening in the Kilimanjaro region were found to be a lack of knowledge that
      screening services were available and women anticipated that they would not be able to afford
      the costs associated with screening, including travel (Cunningham et al, 2015).

      Objectives:

      A) To determine attitudes, barriers and enablers towards smartphone cervicography to ensure
      an accessible, culturally relevant smartphone cervicography screening program

      B) To evaluate the impact of a voucher for return transportation towards increasing cervical
      cancer screening attendance

      C) To evaluate the impact of motivational text messages towards increasing cervical cancer
      screening attendance

      Methodology:

      This study will comprise of a descriptive cross-sectional survey and a randomized controlled
      trial (RCT). Household surveys, capturing baseline characteristics, using stratified
      systematic random sampling in urban and rural areas will be used to recruit participants for
      the RCT. Cross-sectional survey participants will be recruited opportunistically at screening
      clinics associated with the study.

      RCT participants will be randomized into one of three arms. The first arm will be a control
      group and will not receive any correspondence. The second arm will receive a series of
      motivational text messages, including screening dates and locations. The third group will
      receive a travel voucher code via SMS and motivational text messages with the same content as
      the second group.

      A post-screening survey will be conducted following cervical cancer screening at clinics
      participating in the study to evaluate screening attendance and attitudes towards smartphone
      digital cervicography.
    

Intervention name(s): Motivational SMS; Travel Voucher
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Behaviour change messages delivered via SMS developed with the theoretical guidance of the Health Belief Model.; A code for return public transportation to closest cervical cancer screening clinic included in the research.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Screening
Keywords: Behaviour Change; Secondary Prevention; mHealth