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SMS behaviour change communication and eVoucher interventions to increase uptake of cervical cancer screening in the Kilimanjaro and Arusha regions of Tanzania: a randomised, double-blind, controlled trial of effectiveness
  1. Erica Erwin1,
  2. Kristan J Aronson2,3,
  3. Andrew Day4,
  4. Ophira Ginsburg5,
  5. Godwin Macheku6,
  6. Agnes Feksi7,
  7. Olola Oneko8,
  8. Jessica Sleeth1,
  9. Best Magoma9,
  10. Nicola West10,
  11. Prisca Dominic Marandu10,
  12. Karen Yeates1,2
  1. 1 Department of Medicine, Queen's University, Kingston, Ontario, Canada
  2. 2 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
  3. 3 Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Ontario, Canada
  4. 4 Kingston General Hospital Research Institute, Queen's University, Kingston, Ontario, Canada
  5. 5 Perlmutter Cancer Center, Department of Population Health, NYU Langone Health, New York University, New York City, New York, USA
  6. 6 Mawenzi Regional Referral Hospital, Moshi, Tanzania
  7. 7 Arumeru District Hospital, Meru, Tanzania
  8. 8 Kilimanjaro Christian Medical University College, Moshi, Tanzania
  9. 9 Health Department, Regional Secretariat - Kilimanjaro, Moshi, Tanzania
  10. 10 Pamoja Tunaweza Women's Center, Moshi, Tanzania
  1. Correspondence to Erica Erwin, Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada; 14ee3{at}


Background Cervical cancer, although almost entirely preventable through cervical cancer screening (CCS) and human papillomavirus vaccination, is the leading cause of cancer deaths among women in Tanzania. Barriers to attending CCS include lack of awareness of CCS, affordability concerns regarding screening and travel cost. We aimed to compare the effectiveness of SMS (short message service) behaviour change communication (BCC) messages and of SMS BCC messages delivered with a transportation electronic voucher (eVoucher) on increasing uptake of CCS versus the control group.

Methods Door-to-door recruitment was conducted between 1 February and 13 March 2016 in randomly selected enumeration areas in the catchment areas of two hospitals, one urban and one rural, in Northern Tanzania. Women aged 25–49 able to access a mobile phone were randomised using a computer-generated 1:1:1 sequence stratified by urban/rural to receive either (1) 15 SMS, (2) an eVoucher for return transportation to CCS plus the same SMS, or (3) one SMS informing about the nearest CCS clinic. Fieldworkers and participants were masked to allocation. All areas received standard sensitisation including posters, community announcements and sensitisation similar to community health worker (CHW) sensitisation. The primary outcome was attendance at CCS within 60 days of randomisation.

Findings Participants (n=866) were randomly allocated to the BCC SMS group (n=272), SMS + eVoucher group (n=313), or control group (n=281), with 851 included in the analysis (BCC SMS n=272, SMS + eVoucher n=298, control group n=281). By day 60 of follow-up, 101 women (11.9%) attended CCS. Intervention group participants were more likely to attend than control group participants (SMS + eVoucher OR: 4.7, 95% CI 2.9 to 7.4; SMS OR: 3.0, 95% CI 1.5 to 6.2).

Trial registration number NCT02680613.

  • cancer
  • mHealth
  • global health
  • Accessible

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  • Contributors All authors have made substantive intellectual contributions to this randomised controlled trial. EE designed the study in collaboration with KJA and KY. AF, GM, OO and PDM made significant contributions to the survey tools and SMS. EE was the main implementer of the study, assisted by KY, JS and NW. PDM led the fieldwork team to conduct all recruitment and data collection. AD assisted with the preparation of the analysis plan, and AD and KJA supervised EE in conducting the analysis. GM and AF managed the screening clinics where participants attended and ensured that clinic data collection proceeded according to protocol. BM facilitated regional cooperation on the trial. EE initiated the first draft of the manuscript, to which a number of iterations followed, with contributions from all authors and particularly significant contributions from OG, KJA, AD, NW, BM and KY. All authors approved the final version of the manuscript.

  • Funding The Terry Fox Foundation and the Canadian Institutes of Health Research provided a studentship to EE through the Training Program in Transdisciplinary Cancer Research. This research was conducted in partial fulfilment of the requirements for a master's degree by EE.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval The study was approved by the Human Ethics Review Board of Queen’s University (60155) and the National Institute of Medical Research, Tanzania (R.8a/Vol. IX/1716).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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