Connected2Care: One-way Text Message Interventions and Cervical Cancer Screening in Tanzania

Research output: ThesisPh.D. thesis

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Cervical cancer is the fourth most common cancer among women in the world, and 70% of the cases occur in low-income countries. In Tanzania, cervical cancer constitutes 38% of all new cancer cases among women. Currently, visual inspection with acetic acid (VIA) is the standard screening method in low-income settings. It gives immediate results and allows for treatment on the spot unless cancer is suspected (screen-and-treat), but it has low sensitivity. Therefore, a more sensitive screening method has been developed for such settings, namely rapid HPV-testing. Yet, it requires follow-up of the women who test HPV- positive. One-way text message interventions are a type of mobile health (mHealth) intervention that can be implemented in various forms with the aim to improve health-related outcomes. The aim of this thesis is to provide an overview of one-way text message trials in Africa and examine if there is evidence of such messages being effective in relation to appointment attendance and medicine adherence (paper I). Further, it aims to assess if one- way text messages can increase the attendance rate to a health provider-initiated follow-up screening appointment among HPV-positive women in Tanzania (paper II-III), and understand what motivates and prevents these women from attending such an appointment (paper IV).

The systematic review (paper I) included 38 one-way text message trials set in Africa within a broad range of clinical conditions. If all trials on appointment attendance and medicine adherence were pooled, a random effects model showed that one-way text messages were effective in increasing attendance (OR: 2.03; 95% CI:1.40–2.95; 12 trials, 6448 participants) and had a marginal effect on medicine adherence (RR: 1.10; 95% CI:0.98–1.23; nine trials, 4213 participants). When data were stratified across clinical areas, one-way text messages had the highest impact on childhood immunisation attendance (OR: 3.69; 95% CI:1.67–8.13; three trials, 1943 participants). Overall, heterogeneity was high, which could be explained by too diverse clinical outcomes being pooled or high risk of bias trials.

The randomised controlled trial (paper II-III) included 705 women who had tested positive to a rapid HPV-test during a patient-initiated screening. They were randomly assigned 1:1 into a one-way text intervention group or control group. The intervention consisted of health educative and reminder text messages. The women were not blinded to the intervention, but the outcome assessors were. Twenty-four percent attended in each group, and one-way text messages were found to have no effect on improving attendance compared to controls (RR: 1.02; 95% CI: 0.79-1.33). After the trial had finished all non-attendees were traced using various tracing methods. It was found that phone call reminders increased attendance with an additional 22%, and a further 30% participated through HPV self-sampling at home- level.

The qualitative study (paper IV) consisted of 15 semi-structured individual interviews with women who had received the one-way text message intervention, and two interviews with nurses working at the screening clinic in Dar es Salaam. It was found that a patient-initiated screening was perceived as having the benefit of both treatment of gynaecologic symptoms and prevention of disease whereas a health provider-initiated follow-up screening merely had the potential to prevent disease. This was an appointment that could be postponed when more contending needs were present. Perceived costs of screening attendance included fear of the disease, fear of the gynaecologic examination as well as direct and indirect economic costs, including transport costs, lost income, and waiting time. Based on the findings, a theoretical model for screening attendance was developed.

When looking at the studies and their findings jointly, they provide a multidisciplinary evaluation of one-way text message interventions and cervical cancer screening attendance in an African context. On a scientific level, it is recommended that mHealth is approached more narrowly, i.e. evaluating one-way text messages interventions separately from other mHealth interventions. From a global health perspective, one-way text messages should be prioritised for childhood immunisation appointments and not for follow-up cervical cancer screening appointments. On a public health and clinical level, rapid HPV-testing may solve the issue of using a primary screening method with poor sensitivity, like VIA. Yet it opens the door to another issue, namely ensuring proper follow-up of women who test HPV- positive. If Tanzania is to switch from VIA to rapid HPV-testing successfully, there is a need to address this issue.
Translated title of the contributionConnected2Care: Envejs-sms interventioner og livmoderhalskræftscreening i Tanzania
Original languageEnglish
  • Rasch, Vibeke, Supervisor
  • Kjaer, Susanne Krüger, Supervisor, External person
  • Mwaiselage, Julius D, Supervisor, External person
  • Andersen, Marianne, Supervisor
  • Gammeltoft, Tine, Supervisor, External person
Publication statusPublished - 28. Nov 2019

Note re. dissertation

Grad tildelt 09-12-2019


  • Cervical cancer
  • Cervical cancer screening
  • Tanzania
  • Global health
  • mHealth
  • sms
  • Africa
  • Randomised trials
  • RCT


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