SMARTERscreen protocol: a three-arm cluster randomised controlled trial of patient SMS messaging in general practice to increase participation in the Australian National Bowel Cancer Screening Program
Authors: McIntosh Jennifer G. , Emery Jon D. , Wood Anna , Chondros Patty , Goodwin Belinda C. , Trevena Judy , Wilson Carlene , Chang Shanton , Hocking Jane , Campbell Tina , Macrae Finlay , Milley Kristi , Lew Jie-Bin , Nightingale Claire , Dixon Ian , Castelli Makala , Lee Nicholas , Innes Lyle , Jolley Tamara , Fletcher Sabine , Buchanan Lyn , Doncovio Sally , Broun Kate , Austin Glenn , Jiang Joyce , Jenkins Mark A. 
Published: November 2023

Abstract
Background
Australia persistently has one of the highest rates of colorectal cancer (CRC) in the world. Australia’s National Bowel Cancer Screening Program (NBCSP) sends a biennial Faecal Immunochemical Test (FIT)—the ‘NBCSP kit’—to everyone eligible for the programme between 50 and 74 years old; however, participation in the programme is low, especially in the 50- to 60-year-old age group. Our previous efficacy trial (‘SMARTscreen’) demonstrated an absolute increase in uptake of 16.5% (95% confidence interval = 2.02–30.9%) for people sent an SMS with motivational and instructional videos, from their general practice prior to receiving their NBCSP kit, compared to those receiving usual care. Building on the strengths of the SMARTscreen trial and addressing limitations, the ‘SMARTERscreen’ trial will test the effect on participation in the NBCSP of sending either an SMS only or an SMS with online video material to general practice patients due to receive their NBCSP compared to ‘usual care’.

Methods
SMARTERscreen is a three-arm stratified cluster randomised controlled trial involving 63 general practices in two states in Australia. Eligible patients are patients who are aged 49–60 years and due to receive their NBCSP kit within the next 2 weeks during the intervention period. General practices will be equally randomised to three trial arms (21:21:21, estimated average 260 patients/practice). The two interventions include (i) an SMS with an encouraging message from their general practice or (ii) the same SMS with weblinks to additional motivational and instructional videos. The control arm will receive ‘usual care’. Using the intention-to-treat approach, primary analysis will estimate the three pair-wise between-arm differences in the proportion of eligible patients who participate in the NBCSP within 6 months of when their kit is sent, utilising screening data from the Australian National Cancer Screening Register (NCSR). Patient intervention adherence to the interventions will also be evaluated. Findings will be incorporated into the Policy1-Bowel microsimulation model to estimate the long-term health benefits and cost-effectiveness of the interventions.

Discussion
SMARTERscreen will provide high-level evidence determining whether an SMS or an SMS with web-based material sent to general practice patients prior to receiving their NBCSP kit increases participation in bowel cancer screening.

Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12623000036617. Registered on 13 January 2023.
Trial URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385119&isClinicalTrial=False