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Campaign to improve the coverage of
cervical screening in Middlesbrough
2015/16
Evaluation
Improving Public Health
Middlesbrough Council
2
Contents
Page
Executive Summary 3
Background 6
Insight Work 8
Creative Brief 11
The Campaign 12
GP Engagement 16
Promotion / Advertising 18
Community Development 25
Results 31
Coverage 31
System Change 33
Campaign Reach 36
Infographic – Key Points 38
Key Learning Points 39
Recommendations 40
Acknowledgements 42
Report Author: Becky James, Health Improvement Specialist (Prevention and Early Intervention) – Improving Public Health, Middlesbrough Council
3
Executive Summary
Background
In response to the low uptake of regular routine cervical screening amongst women in
Middlesbrough, a local pilot campaign was developed by Middlesbrough Council public
health team, working in partnership with NHS England. Launched in June 2015, the
campaign consisted of a range of activities including, GP engagement and the development
of ‘No Fear’ practices, a radio campaign, bus advertising, town centre adverts, posters,
leaflets, social media targeting, professional information packs for frontline staff and a
range of community development work and events.
Although the campaign reach has been town-wide, it has been developed based on targeted
insight with groups of women who are statistically the typical non-attenders for regular
cervical screening in Middlesbrough, particularly:
Women from BME communities
Women aged 25-35
Women from deprived wards
A range of insight work was carried out with representation from the above groups,
including focus groups and questionnaires aimed at exploring in detail the barriers to
attending and how a campaign could be designed to allay some of these fears and allow
women to make an informed choice around screening.
The primary objectives of the campaign were to:
Raise awareness of the importance of attending regular routine cervical screening
Increase access to cervical screening for all women, regardless of their circumstances
Increase understanding of the needs of local women in accessing cervical screening
services
It became clear from the community insight work that there was a lack of basic awareness
and understanding of cervical screening and a range of myths and misconceptions about
what it involves. This reinforced the need to develop a local approach to increasing
awareness in a clear targeted way and the need for a range of materials and development
activity to get the key messages and information out in a variety of formats to different
groups.
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Results
At the start of the campaign development, coverage was as low as 62% within GP practices in
Middlesbrough with only 2 out of the 26 practices achieving the national achievable target of 80%.
Recent unpublished data up to 31.12.15 shows that 17 out of 26 practices have seen an overall
increase in their practice coverage rates using baseline data taken before the campaign started.
This is shown in the below graph:
All of the ‘No Fear’ practices in Middlesbrough, who were actively engaged in the campaign, have
seen an increase in their coverage rates ranging from 0.1% to 6%.
A number of improvement measures have been implemented within GP practices to
encourage increased coverage and a staff cervical screening clinic at James Cook University
Hospital has been established.
Practice measures implemented within the No fear practices include:
Staff using the bespoke materials to promote positive messages to patients
Increased opening hours to make appointments more accessible
Improved process for following up patients who are overdue their screening
Actively identifying women who could attend opportunistically whilst at the surgery
for other appointments
Adding alerts to repeat prescriptions
Sending out No Fear materials with invitation / follow up letters aimed at allaying
fear
Data Source: NHS England
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Key Recommendations
The insight work showed that local awareness and understanding of cervical
screening is limited. We know that good awareness and understanding is attained
by sustained and consistent messaging and publicity. It is therefore recommended
that the momentum gained to date is not lost. The website will remain live on an
ongoing basis and an annual campaign to coincide with national cervical screening
awareness week in June will be delivered locally.
As part of this annual refresh, a specific promotion should take place across all GP
practices, similar to the flu campaign. This was suggested within the feedback from
those practices engaged to promote the No Fear concept.
As the highest increase in coverage has been observed in the No Fear practices it is
recommended that more targeted work be undertaken directly with low coverage
practices.
Further data (to reflect a full year of campaign activity) will be used, once available,
to provide a more robust assessment of the overall impact on coverage rates.
Additional targeting to different community groups could be developed in the next
wave including production of materials in different languages and implementing the
recommendations from the work with women with learning disabilities and
community training element.
The learning from the campaign will be used to inform the development of other key
public health campaigns locally particularly in relation to cancer prevention and
screening. ‘Screening Saves Lives’ will be used to promote other screening
programmes to keep information in one place in a format that is beginning to be
recognised with key groups.
It is important that knowledge gained from substantial campaigns and interventions
like this is shared. The findings of this evaluation should be shared with other
screening and immunisation teams in England. A copy of the report should be sent
to the director of the National Screen Committee and to local screening and
immunisation teams in the North region.
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Background
NHS Cervical Screening Programme
Women aged between 25 and 65 should routinely be invited to attend cervical screening. The aim
of the NHS Cervical Screening Programme is to reduce the number of women who develop cervical
cancer and the number of women who die from the condition. Since the screening programme was
introduced in the 1980s, the number of cervical cancer cases has decreased by about 7% each year.1
All women who are registered with a GP are automatically invited for cervical screening as follows:
aged 25 to 49 – every three years
aged 50 to 64 – every five years
over 65 – only women who haven't been screened since age 50 or those who have recently
had abnormal tests
Being screened regularly means any abnormal changes in the cells of the cervix can be identified at
an early stage and, if necessary, treated to stop cancer developing.
Screening can prevent around 75% of cervical cancers in women who attend regularly and is
estimated to save around 4,500 lives a year.2
Current picture in Middlesbrough
When the project proposal for the campaign was developed in early 2014, the coverage rate was as
low as 62% in some GP practices in Middlesbrough. The rates vary across different practices across
the town (as shown in figure 1) with only 2 practices hitting the national achievable target coverage
rate of 80%. This shows a significant amount of local women who are at risk by not attending on a
regular basis.
Consistently the picture in Middlesbrough has been 69 -70% average coverage for the last five years
approximately 4-5% lower than the national average and 6-8% lower than the North East regional
average. This is shown in figure 2.
Nationally, the gap between Middlesbrough and the rest of the country is narrowing due to small
increases in coverage in 2014 and 2015 locally, and interestingly, a decline in coverage rates on a
national basis in the same period. However, anecdotal information suggests during this period a
number of young women in the town were diagnosed with cervical cancer with some loss of life thus
having significant impact not only on the individual but also the wider family and community.
1 NHS Choices www.nhs.uk/conditons/cervical-screening-test
2 Peto et al, 2004. The cervical cancer epidemic that screening has prevented in the UK.
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0
10
20
30
40
50
60
70
80
90
100
Cervical Screening Coverage Rates - Middlesbrough Q4 13/14
Practice Coverage% Rate Q4 13/14NEPCSA
Baseline AchievableStandard
GP Practices (anoynomised)
Figure 1 – Cervical screening rates per GP Practice - Middlesbrough
Source: NHS England
Middlesbrough
Figure 2 – National Context – Middlesbrough vs National cervical screening coverage
Source: Public Health Profiles, PHE England
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Campaign proposal
In response to the declining coverage rates and the significant numbers of women at risk by not
attending for regular screening, a project team was established to develop a local campaign that
would run on a pilot basis with a twofold approach:
1) Engagement of GP Practices – looking at changing practice to improve the experience for
women and increase access
2) Community awareness – equipping people with the right knowledge and information to
make informed choices
Although the campaign reach was intended to be town-wide it was to be developed based on
targeted insight with those women who are known to be the typical non-attenders for regular
cervical screening in Middlesbrough (based on local data).
The primary objectives of the campaign were to:
Raise awareness of the importance of attending regular routine cervical screening
Increase early access to cervical screening for all eligible women, regardless of their
circumstances
Increase understanding of the needs of local women in accessing cervical screening services
Partnership Working
The campaign was developed and jointly funded as a partnership between Middlesbrough Council
Public Health and NHS England (as the lead commissioner for cervical screening).
A multiagency steering group was established in the early stages of development to ensure partner
involvement from the start. The steering group was made up of representatives from public health,
NHS, voluntary and community sector, healthy living pharmacies, social care (learning disabilities
team) and the South Tees Clinical Commissioning Group and was responsible for contributing to the
development of materials, sense checking progress and design developments and launching the
campaign to make sure the key messages were distributed far and wide.
Insight Work
In order to gain real insight into the reasons why local women are not attending for regular
screening the following pieces of work were undertaken as part of the project:
Analysis of Mosaic data to determine the most prevalent non-responder groups in
Middlesbrough. The highest numbers of women appeared in the following groups:
Vulnerable young parents
25-34 age group
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Those living in the most deprived areas
South Asian communities
The development of the campaign and subsequent insight work was targeted at these groups to
encourage the greatest impact on coverage rates and work towards overcoming barriers identified.
Focus Groups – open discussion with small groups of 8-10 individuals to gain better
understanding of their views and experiences. Focus sessions were held with the following:
o Group of women who attend weekly group at Thorntree Community Hub
o Two groups of women from BME community
o Group of men from BME community to get their perspectives as potential
influencers on women’s health
Online Questionnaire – sent out via Middlesbrough Council consultation portal and
distributed via local networks, the questionnaire asked a range of questions about cervical
screening including tick box answers as well as the opportunity for respondents to provide
their own comments. The questionnaire received 208 responses.
Literature Review – a literature review was carried out to look at community based
approaches and interventions and to look in more detail at cervical screening processes.
This was used to support and inform the development of the campaign.
Local qualitative data - a comprehensive local study was carried out in 2009 looking at
screening across Tees. A wealth of data specific to cervical screening and the barriers to
attending that women provided were used to support the findings gathered in the current
insight work.
Key Findings from insight
Generally there appeared to be a lack of understanding and awareness of cervical screening – what
it is for, what it involves, who is eligible as well as a range of misconceptions and myths. A key
theme was the confusion about the link to the HPV vaccine and whether there was still a need for
regular screening if previously vaccinated.
The most common barriers and motivating factors that emerged as a result of the insight work are
listed below:
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Barriers:
Embarrassment
Fear of procedure and results
Pain
Language
Convenience / time of
appointments
Confusion around HPV vaccine
Apprehension that a male doctor
or nurse will carry out the
procedure
Association with promiscuity
(stigma)
Myths – the test making women
lose their virginity, being unable
to conceive as a result etc
Taboo subject
Negative experience of others
Low risk perception
Sexual inactivity
Motivators:
Peace of mind
Routine nature of the test
Wanting to catch things early
Celebrity campaign /real life
stories
Family history of cancer
Education / knowledge of the
benefits
Influence of others
Media
A number of suggestions were also made as to how screening could be improved to encourage
more women to attend. These included:
Education /
empowerment
Accessible
information
Support – buddy
appointments
Training for
healthcare staff
Flexible
appointments Peer support Reminder letters Radio campaign
Personal stories
Tailored information
for women with
learning disabilities
Drop in screening
sessions
Social media
campaigns
Parental influence Pre-booked
appointments Text reminders
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It became apparent from speaking to the women that different groups had slightly differing opinions
of screening and the perceived barriers / motivating factors, as one would expect. There was also
varying opinion, in terms of the best way to communicate messages which was a key consideration
when developing key messages and deciding how to get these out into the community. Often
different community groups need a targeted approach. For example, women in the BME focus
groups identified that word of mouth within their own communities was the most effective way of
passing messages on.
Creative Brief
After analysing all the information gathered from the insight work, there were consistent themes to
use as key messages within the campaign. A simple overall strapline for the campaign was needed
to make sure it was obvious what the materials were promoting. To get across the importance of
attending regular screening and to tap into social norms around screening being a routine test for all
women, the following was agreed:
‘Cervical Screening Saves Lives, Don’t be the One Missing Out’
A series of sub-messages which covered the 5 key themes, most commonly identified during the
insight work were also created. Based on the lack of knowledge and misconceptions that were
identified, it made sense to create a simple, easy to understand campaign aimed at putting
information relating to screening in one, easy to access place. The intention was to make it look
different to existing campaigns, be engaging and non-clinical.
Three different designs (shown below) were created and market tested with key groups and
professionals, with the characters chosen as the preferred design. A suite of materials were
subsequently designed in the chosen format.
Option 1: Option 2: Option 3: Characters Real People Word Bursts
12
When testing the materials, respondents were asked to state what they liked about their preferred
design. Answers regarding the characters included:
“Bright” “Eye-catching” “Friendly” “Reassuring and fun”
“Nice to see a different style” “Light hearted” “Would fit with all service user groups”
The Campaign
Campaign Materials
The following materials were produced to promote the key messages:
5 main posters covering the key themes from the insight work:
The use of conversations between the characters in the posters aimed to get the messages across in
an informal, relatable way.
Embarrassment Pain Fear
Family
(motivator)
Procrastination
13
A simple easy to read leaflet covering all basic information and facts. This was to be
presented in areas where people are likely to pass through and pick up information to read
at their leisure. Ideal for reception areas etc:
F
r
e
q
u
e
n
t
Frequently Asked Questions sheet designed for frontline staff who engage with service
users and who might need information to use as a reference guide to talk through concerns
and queries.
Myth busting sheet designed to dispel common myths about cervical screening, particularly
those that came up during the insight phase. The one page poster is good for waiting areas
or the back of toilet doors, places where people have time to read the details.
Simple guide with contact information and opening times of all
available GPs and clinics where screening is available locally, to
help people make informed choices and promote the option of
attending sexual health clinics as well as GP surgeries.
14
Digital banner for use on social media, websites, plasma screens etc to promote the
campaign
Professional packs
To ensure a consistent message across the town, a professional pack was produced for frontline
workers who have contact with local women within the target group. The pack was designed to be
used as a reference guide for staff to use when speaking to women about screening. It included:
Cover letter with information about the campaign
FAQ sheet
Myth busting sheet
Copy of all materials
300 professional packs were distributed across Middlesbrough to a range of organisations including:
Health Visitors
Children’s Centres
Community hubs
GPs
Pharmacies
Schools
Website
The call to action on all materials was the website, designed to host all information about cervical
screening. Hosted within the Middlesbrough Council website, to cover information governance, a
separate domain name was purchased to give it its own unique identity:
www.screeningsaveslives.co.uk
15
The generic name also allows for other screening programmes to be promoted in the future using a
similar approach.
The website was designed in the same format as the campaign materials and includes the following
information:
All campaign materials to view, download or order online
Details of the campaign including community development work
General information about cervical screening
Real life stories from local women to support the key messages and highlight the relevance
Where to go for screening locally
Links for further information / support
Contact details
Launch Event
The campaign was officially launched in June 2015 in line with the national cervical screening
awareness week. A town centre event was held incorporating a cycling challenge – covering the
distance of John o Groats to Lands’ End (874 miles) on 6 stationary bikes. A range of partner
organisations and members of the public took part in the challenge and leaflets and information
were given out to the public on the day.
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Campaign materials and distribution
Over 200 individual organisations and community groups were provided with campaign materials to
display in their venues and promote the campaign to their service users and staff.
GP Engagement
All GP practices in Middlesbrough that were performing below the baseline coverage target (n=16)
were invited to take part in the pilot. 7 practices actively engaged. The practices were each visited
by a cervical screening nurse mentor and a standard set of questions were asked to get a picture of
current procedures / processes.
A practice nurse from one of the best performing practices was invited by the campaign steering
group to share best practice, which was then shared with the 7 practices engaged.
Subsequent action plans were created to improve working practices and encourage an increase in
the number of women attending regularly for their screening.
No Fear
The ‘No Fear’ concept was developed as a way for GP practices to promote the services, in most
cases, that are already being offered, to make screening less daunting for women based on learning
from the insight work.
This included services such as:
Pre-booked appointments
Requesting a female nurse
Taking a friend
Back to back appointments so women could go together for support or share transport /
childcare
Text reminders
The 7 practices were provided with a range of bespoke No Fear materials to display in their surgeries
(personalised to each practice) including:
Pull up banners
Posters
Bunting
T-shirts for staff
Balloons
Mini posters to be sent out with appointment and follow up letters
17
The feedback from all practices engaged has been positive, with all No Fear surgeries reporting that
the bespoke resources were really valuable.
Practice staff stated that the use of promotional materials, especially within the waiting areas was
effective.
Positive feedback on the radio campaign in particular was reported and in one case having the radio
on in the surgery and hearing the adverts, further promoted the messages whilst patients were in
the right setting and also prompted staff to raise the issue.
It was suggested that the campaign could become an annual event within practices, similar to the flu
campaign that is promoted within all surgeries with a variety of promotional materials.
Examples of measures introduced as part of the campaign in No Fear Practices:
Practice 1:
Nurses meet weekly to share lists of
patients who are due a cervical
screening test to be contacted by
phone. Of these identified patients,
those who have appointments already
booked to see their GP about other
matters are booked a joint appointment
to allow them to see the nurse for their
screening straight after they have seen
the GP.
Practice 2:
Staff aim to telephone patients to invite
them for screening (where patient is
overdue) rather than sending out
letters.
Practice 3:
Increased time dedicated to
administration and follow up including
personal phone calls
Practice 4:
Practice extended opening hours to 7.30pm
ensuring more appointments are available with
nurses after usual working hours
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Promotion / Advertising
Radio
Working with TFM radio, key themes from the insight work were portrayed in five different radio
adverts voiced by the actress Michelle Keegan. These adverts were produced and played at various
slots for 18 weeks over the summer months. An example script from one of the adverts is shown
below:
TFM advert – Michelle Keegan - Script 1:
When I had my ears pierced, I screamed like a baby, ooh the pain! And if you’ve ever had your
eyebrows threaded, you’ll know how much that hurts!
Us girls go through all kinds in the name of beauty but many of us put off our cervical screening
appointment because it might be a bit uncomfortable. Now that is crazy!
You might know it as a smear test, either way, if you’re aged 25 to 64 it’s really important, it could
prevent you from developing cervical cancer, even if you’ve had the HPV vaccine!
So, when you get a letter about cervical screening, take the time to save your life! It’s just a simple
check-up and over in a matter of minutes. You’ll have spent longer painting your nails.
Get the facts at screeningsaveslives.co.uk
The radio campaign was supported by Redcar and Cleveland public health team.
One of the adverts featured a real life story from Leanne from Middlesbrough who can be heard on
the advert to give it a local perspective. Leanne was keen to share her story following diagnosis of
cervical cancer which was detected at her first screening test aged 25. Leanne was overdue her test
after initially putting off going and after receiving successful treatment, she is now keen to share her
story as she realises the consequences could have been very different if she had left her test any
longer.
Using a high profile actress to voice the adverts proved to be really successful and created its own
publicity when the adverts went live. The campaign featured in OK magazine and a range of other
articles and social media feeds due to the popularity of Michelle Keegan and her personal
endorsement of the campaign.
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Media coverage linked to Michelle Keegan
1.1 MILLION FACEBOOK LIKES
518,000 TWITTER FOLLOWERS
1,000 ARTICLE SHARES
1.1 MILLION FACEBOOK LIKES
161,000 TWITTER FOLLOWERS
11,000 FACEBOOK LIKES
28,800 TWITTER
FOLLOWERS
1,400 FACEBOOK LIKES
14,500 TWITTER FOLLOWERS
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Michelle Keegan retweeted the tweet by TFM about
the campaign to 3 million followers. The
individual tweet had 784,915 impressions; it was
retweeted 45 times and got 168 likes
Radio impact
Source: TFM data
The above table shows the reach of the radio adverts. 2762 campaign commercials featuring
Michelle Keegan were broadcast on TFM. This campaign reached 332,024 individual people aged 15
+ which equates to 40.3% of the entire population in the TFM transmission area and each of these
individuals heard the campaign on average 24.9 times each. When multiplying the number of people
who heard the campaign by the number of times they heard it, this results in overall impact total of
8,272,602.
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In terms of the reach of the radio campaign, the below graphic shows the transmission area of TFM
showing the messages from the Middlesbrough campaign had the opportunity to have a much wider
impact within the Tees Valley area.
All the radio adverts can be heard on the campaign website at www.screeningsaveslives.co.uk
Buses
The campaign messages were advertised on the rear and sides of local buses for 16 weeks between
June and September 2015.
Bus side:
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Bus rears:
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Digital Media
Facebook campaign
A targeted 2 week Facebook
campaign was carried out in July
2015 where the call to action banner
popped up in people’s news feed
who fit the profile – women from
Middlesbrough aged 25-64. The
advert was seen 22,000 times
during the 2 weeks and resulted in
575 hits to the website. In addition,
women were also liking, sharing and
commenting on the post
encouraging others to go for
screening.
The screenshot shown here shows
some of the comments from women
who had seen the campaign:
24
Website analytics
Overall analysis of the screening saves lives website shows there have been 150-180 views per page
during the campaign. 120 of these are unique views with an average time spent on the site per view
of 2.5 minutes.
Immediately following the 2 week Facebook campaign, there were 533 unique views to the website
with an average time spent of 11 minutes and 29 seconds which shows not only were people
clicking through to look at the site, but they were also taking the time to look through the
information.
Town Centre adverts
Adshel posters were displayed in Middlesbrough town centre in 3 locations over 2 separate time
periods.
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Cost
The campaign cost £35,841. This included:
Insight Work £1,230
Campaign Materials Design & Print £7,785
Advertising £20,111
Events £1,300
Community Development (targeted work with specific communities)
£3,591
Cervical Screening Mentors – GP engagement £1,824
Significant ‘in-kind’ costs were also dedicated to the campaign from all project team and steering
group members.
The original budget for the campaign was £39,000 jointly funded by Middlesbrough Council and NHS
England. There will be some additional costs to cover before year end for ongoing work including
awareness activity during Cervical Cancer Prevention week in January 2016 and further development
work planned by NUR fitness.
TFM have been commissioned to re-run the radio adverts voiced by Michelle Keegan for a 3 month
period from June 2016 in line with national cervical screening awareness week when the campaign
will be reinvigorated.
Community Development
Once the campaign materials were distributed to partner organisations across the town, the next
step was specific targeting to make sure the messages were filtering out to the target groups. A
range of development work took place:
Engaging BME women
Working with NUR fitness – a local community group with extensive links to BME community. All
NUR staff were trained in cervical screening awareness to allow them to pass on key messages to the
women they work with. NUR also themed their annual celebration event under cervical screening to
raise awareness with over 100 women which included the delivery of an Asian drama performance
to cover the key messages which was really well received.
Training for community groups
A number of voluntary organisations with links to marginalised groups were engaged and offered
training as screening champions to pass on positive messages within their communities. Groups
who received the training included:
26
Straightforward
Mano River Union
Easterside Partnership
Divine Community
North East Women in Action
Tees Valley Chinese Community Centre
Branches
NUR fitness
Investing in People and Culture
The training centred on prevention, awareness and early diagnosis of cervical cancer including:
Prevention of cervical cancer
Importance of attending cervical screening
The HPV vaccine- what it is, what it does and why it's important
Early signs and symptoms of cervical cancer
The importance of early presentation to GP about signs and symptoms
In addition to the training, some group were provided with a small grant to enable them to host a
range of activity to utilise the training and raise awareness of cancer. 14 groups were provided with
training and resources and as a result of this over 800 people were contacted or spoken to about
cancer.3
An evaluation of this piece of work made the following observations around things that worked well:
Word of mouth was the most effective way of engaging people, examples were through
social media, religious networks, language classes, community hubs and drop in activities
Preparing people in advance of the events to enable participation
The time of each event was key – ensuring it fit around the community, avoiding childcare
issues, school runs, caring commitments etc.
Creating a supportive environment that enabled people to talk about sensitive issues.
Separate sessions for men and women
Interpretation into other languages
A social focus involving food and games
Having somebody who is willing to talk about their experience of cancer
The groups were asked to pull together a case study to highlight the different approaches taken and
the added value that has been achieved. One example is shown below. Many groups reported
similar issues.
3 Source: Middlesbrough Voluntary Development Agency
27
Case study example:
Divine Communities
Divine Communities is a constituted group which engages Middlesbrough communities in multi-cultural activities to remove barriers between cultures.
Issues identified
A range of health issues affecting the community (ie obesity) are not seen as priorities due to cultural norms
Certain health issues (including cervical screening) are not talked about openly as this may result in a judgement on an individual’s behaviour
The local community is very mixed and there are a range of cultural attitudes and taboos around health and cancer that can prevent people from engaging
Some women are not able to make decisions and access health information and services on their own, without a man present, and this may prevent them from speaking openly
What they did Held a community awareness raising event where information was presented and male and female sessions held on gender specific cancers as well as one-to-one discussions about the various issues relating to cancer and local services. 35 men and women from a range of African, Asian and European countries attended.
Outcomes / added value
A range of information was given out to people to back up the messages presented and discussed during the session
The event helped to build relationships within the local communities
There is now greater understanding of the services and support offered in the UK and awareness of what people are entitled to and where they can go for help
Anecdotal feedback from those who took part showed they felt more able to go to their GP to discuss symptoms and access screening
The women who were involved are more confident about speaking about their own health and accessing help and support
Women with learning disabilities
Women with learning disabilities have a much lower participation
rate in the cervical screening programme than women in the
general population. There are 828 adults living in Middlesbrough
with a learning disability4, known to adult social care which
represents a significant proportion of those eligible for screening
that may well be missing out.
As part of the work to address the needs of specific groups, an
event was held inviting women with learning disabilities to discuss
cervical screening and get a better understanding of what some of
the issues and concerns are for this group of women. 54 people
with learning disabilities attended the event with their families
and carers.
4 Middlesbrough Cervical Screening Awareness event report – Linda Lord, Middlesbrough Council
28
3 screening champions, a practice nurse and the Clinical
Commissioning Group lead for Learning Disabilities
facilitated discussions and were able to answer
questions raised.
The event began by asking the women to all stand up.
They were then asked to sit down if they had never
been for cervical screening. 11 women sat down.
A range of discussion took place around the importance
of attending regular screening and the women were
asked to share their views on what prevents people attending and what could make appointments
better. This included:
The event also included a section around the importance of breast screening.
Learning from this event needs to be built into the campaign as it develops to ensure that the needs
of women with learning disabilities are met to enable access to regular routine screening.
Ramadan Promotion
The BME Network CIC works in partnership with the local Muslim community to organise the annual
Radio Ramadan Broadcast, which is broadcasted via Community Voice FM. The 30 day live radio
broadcast runs at the same time as the Muslim Holy month of Ramadan and usually has between
12,000-14,000 weekly listeners and is popular amongst all age brackets.
To promote awareness of the campaign using this key link to BME communities, a radio Ramadan
advertising campaign was developed. Activity during the 30 days included:
Radio Adverts - Three bespoke radio adverts were produced, which were tailored for the
South Asian, BME and Muslim Audience. One version in Urdu/Punjabi and the other two were
in English. The adverts were aired in excess of 400 times during the course of Ramadan.
Information & Awareness Radio Programmes -These programmes provided an opportunity
to expand on the information provided via the radio adverts as they invited community
members to speak about their experience of screening programmes, and project staff and
Barriers:
Fear
Worry about the test being carried out by a male
Pain
Embarrassment
Improvements suggested:
Female doctors / nurses carrying out the test
Having music played
Friendly / approachable staff
Being able to have it done at home
Letters and information that are easy to read and understand
29
health specialists working in the field, to give insight and alleviate any fears and
concerns.
Social Media – Radio Ramadan used their Facebook pages, which have in excess of 4000
followers to share information about Cervical Screening and promote the Screening Saves
Lives website. A campaign banner was also placed in the radio studio to ensure that when
guest and presenters took photographs for social media status updates then information in
the background was also photographed and shared. Some of the presenters also recorded
short videos about the importance of cervical screening and encouraged women to attend
their appointments, the videos were distributed via Facebook, Snapchat and WhatsApp to
listeners.
Community Based information (Information Banner, Posters and leaflets) -To complement
and support the radio campaign, the BME Network also placed Cervical Screening
information leaflets and posters in over twenty local BME businesses. Kashmir Food Store
and A&K Fashions Fabrics also supported the campaign by allowing the Cervical Screening
pull up banner to be placed within their store, where there is high footfall.
Whilst information and posters were given out by community media volunteers, numerous women
were spoken to (predominantly at Asian grocery stores and clothes shops) about Cervical
Screening. The vast majority confirmed that they heard about the cervical screening campaign on
the radio and were more informed about the issues.
Overall the campaign was very well received. Members of the Sikh community saw the campaign
materials in one of the shops and requested materials to display within the Sikh temple to raise
awareness of the issue there.
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Middlesbrough 10K
In September 2015, the campaign sponsored 40 places at the Middlesbrough 10K event. Those
taking up the places all wore cervical screening t-shirts to make the message really visible to all other
runners and spectators on the day. This was supported by Healthy Living Pharmacies and Marton
Pharmacy. Leaflets were placed in the 5,000 goody bags given out to runners and an information
stand was present in the athlete’s village.
Children’s Centres
Targeted promotion was held across all children’s centres in Middlesbrough by displaying the
messages and actively encouraging women to take on board the information. It was felt that
Children’s Centres provided a useful opportunity to engage with young parents - a key target group
for the campaign.
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The Results
Coverage
Data limitations
The latest national coverage data was published in March 2015. Therefore there is no national data
available at this point in time to cover the campaign period which commenced in June 2015.
For the purposes of the evaluation, local data has been interrogated to explore whether there has
been an impact on coverage rates within Middlesbrough GP practices that could be attributed to the
launch of the campaign. It should be noted that this data is only available up to 31 December 2015 –
7 months into the campaign. Whilst some changes to coverage rates can be seen, this will not
provide the full picture in terms of the overall impact as we assume that key messages will have
taken a while to filter out and time needed for people to start to recognise the campaign materials.
Also a range of community development work has taken place since the campaign began, staggered
over subsequent months and this work will continue beyond the evaluation period.
A follow up data summary will be conducted once coverage data becomes available to show the
impact of the campaign over a one year period. This will allow national data to be used to see how
Middlesbrough compares.
GP Practice data
At the start of the campaign development, coverage was as low as 62% within GP practices in
Middlesbrough with only 2 out of the 26 practices achieving the national achievable target of 80%.
Recent unpublished data up to 31.12.15 shows that 17 out of 26 practices have seen an increase in
their practice coverage rates using baseline data taken before the campaign started. This is shown
in figure 3 over the page.
When comparing the data from Middlesbrough practices with those in Redcar and Cleveland, it can
be seen that coverage rates during the same period have increased in 12 out of 24 practices in the
Redcar and Cleveland area5. This shows that potentially the reach of the campaign did go beyond
the Middlesbrough area (particularly one would assume from the radio and bus advertising which
had a wider geographic reach).
We have used the available unpublished data to provide an early indication of the impact of the
campaign on coverage rates; however a further analysis, ideally based on a full year’s data, would
give a more robust assessment of the overall impact on coverage.
5 NHS England practice coverage data
Figure 3: Middlesbrough Cervical Screening Coverage Rates: pre campaign / after 6 months:
No Fear practices
All of the No Fear practices in Middlesbrough have seen an overall increase in coverage rates from
before the campaign started to after 6 months. These increases range from 0.14% to 6.05% as
shown below:
No Fear Practice (anonymised)
Coverage Increase after 3 months
Total Coverage Increase after 6 months
1 4.99%
6.05%
2 4.31%
2.48%
3 3.46%
4.57%
4 1.62%
1.57%
5 0.89%
0.79%
6 0.70%
1.20%
7 0.61%
0.14%
Coverage rates are determined by the number of eligible women on the practice register. It is
important to note that the number of eligible women may have changed over the evaluation period
and one would expect coverage rates to fluctuate slightly from quarter to quarter due to these
changes.
It will be interesting to note further results as more up to date data is published and there is an
annual data set to look at to give a more accurate picture of campaign impact.
System Change
As shown in the case study examples on page 16/17, a range of interventions have been
implemented within the No Fear practices as a direct result of the campaign. These have included:
Staff using the bespoke materials to promote positive messages to patients
Increased opening hours to make appointments more accessible
Improved process for following up patients who are overdue their screening including
letters or phone calls
Actively identifying women who could attend opportunistically whilst at the surgery for
other appointments
Adding alerts to repeat prescriptions
Sending out No Fear materials with invitation / follow up letters aimed at allaying fear
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South Tees Hospital NHS Foundation Trust – Staff cervical screening clinic
As a direct result of the local campaign, the colposcopy team at James Cook University Hospital have
set up a dedicated clinic for trust and Carillion staff on site at James Cook. This will run as a pilot for
3 months from November 2015 to February 2016, funded from the campaign budget.
The aim of this is to increase access to screening for women,
particularly those where fitting in appointments around their
working hours and shift patterns was identified as a barrier. Staff
will access a structured drop in service by ringing on the day and
being allocated a time slot at a time convenient to them.
The colposcopy department will send a letter to the woman’s GP
to advise that their patient has had a cervical screening test. A
standard operating procedure has been developed to cover the
service.
A really positive response from trust staff was received when the
colposcopy team sent out a short survey to gauge interest in such
a service:
The survey was not sent out to all female staff however 938 female staff completed the survey, this is an overwhelming response rate compared to other recent surveys conducted at the trust.
768 were up to date with their screening
147 were NOT up to date 25-35yrs = 26 36-49yrs = 54 49-64yrs = 67
113 responses for why staff are not up to date mainly included getting time off work and difficulty getting an appointment at GP practice
125 of 147 (87%) staff who are out of date with their cervical screening indicated they would attend if screening appointments were available in the workplace at South Tees – the main reason given was convenience
18 staff who were out of date said they would not attend as it was more convenient to go to their own GP
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Staff clinic outcomes:
To date 40 women have been screened at the staff clinic. 26 of these were overdue for screening
tests and the remainder were due at the time of screening. There have been 2 missed appointments
but both women rang to re-arrange.
Out of the 40 women screened 3 have been reported as abnormal results with subsequent
colposcopy referrals.
All women who attended the staff clinic were asked to provide feedback on the service. The results
are shown below:
RESPONSES
Question Yes No No answer
1. Did we see you at the given appointment time? 40 0 0
2. Was the room you were seen in clean and tidy? 40 0 0
3. Did you feel that your privacy and dignity was maintained during the procedure?
40 0 0
4. Did the staff provide you with all the information you needed?
40 0 0
5. Would you recommend this service to your colleagues?
39 0 1
Some of the comments received by the women included:
“Very easy and convenient”
“The Nurse was lovely, no embarrassment at all and no need for GP visit, very good”
“As this was my first test, it was fairly daunting. The nurse put me at ease, the facilities were
lovely (wipes, spray) and the whole process was made as easy and comfortable as possible!”
“Excellent service thanks. Have been meaning to get my smear done but always used time as an
excuse! This is so convenient, good to see you looking after the staff”
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Campaign Reach
In order to assess the impact of the campaign, all children’s centres, community hubs and the
Lifestore were asked to record a response from all women entering their facility over the same 1
week period. Each woman was asked the following questions and the responses recorded as a tally:
1. Before today have you seen or heard the ‘Screening Saves Lives’ cervical screening
campaign in Middlesbrough?
2. If yes, where have you seen or heard about it?
In total 452 people were asked during the week. Of these 339 (75%) said they had heard about the
campaign.
Most (40%) had heard about it via their GP, with general posters (30%) and radio adverts (24%)
being the next most popular responses.
Campaign Materials feedback
All partner oragnisations who were sent campaign materials to display and promote were asked to
complete a short evaluation form to provide feedback on the materials and give their views on the
campaign.
Of the evaluations completed, all partners
rated the campaign materials either
‘Excellent’ or ‘Very Good’
All partners ‘strongly agreed’ that the
message is understandable and clear and the
campaign materials grab their attention.
Example partner feedback received:
“An excellent campaign with a very good design
of materials.”
“Very good. Hope this helps improve and resolve our locality issues”
“It was well received and service users
understood the importance of it and why there was a need to push it to the forefront in some
people’s minds. It raised awareness and created conversations with friends and families.”
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“I thought the campaign was excellent and well delivered. The posters and leaflets were very eye-catching and the posters were displayed in most areas in Middlesbrough, this showed
the hard work and determination that went into the Cervical Screening campaign. I would be very surprised if awareness in the community wasn’t raised”
“The info on GPs was very useful for signposting and the Myth factsheets are very good at dispelling
some misconceptions.”
“They are bright and eye-catching and a good example of health info.”
“My colleague from London was very impressed with them and said how good they were.”
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Infographic – Key Points
39
Key Learning Points
What worked well?
Partner engagement from the outset was key; this took place during a period of significant
structural change and fragmentation of public sector organisations. This has now been
formally developed in Middlesbrough into the Tackling Cancer Together Partnership.
Developing the steering group to bring key people together around a shared priority was
considered key to the programme’s success. This was crucial in the sharing of data,
developing the campaign and sense checking the suitability of the materials as they were
developed. Finally ensuring a well-established network to disseminate the information once
the campaign went live.
Engaging GP practices as part of the campaign to look at their existing practices ensured that
barriers identified by women could be addressed and that a whole system approach was
implemented.
The design of a different, bespoke campaign based on insight and designed around local
women ensured that the campaign addressed real issues and encourages real and lasting
behaviour change around attitudes to screening.
The use of characters provided non-clinical, eye-catching materials which looked different
and stood out among the range of other information aimed at the target group. Producing
and promoting information in a range of formats assisted in the campaign reach to all
women.
Community development work built on the core work that went into the development of
the campaign materials to really push the messages out there to the target groups and make
sure they didn’t go unheard. In particular the training of community champions to pass on
key messages within their community worked really well and was well received by those
involved as an effective way of empowering individuals and passing on information.
Holding a high profile town centre launch event created a buzz about the campaign, acted as
another opportunity to involve key partners and started the campaign off on a really positive
note.
The targeted Facebook campaign presented the best value for money in terms of the impact
it had – not only the quantitative data around hits to the website and time spent on the site
but the impromptu feedback and comments local women were posting, encouraging others
to attend their screening, something really powerful in terms of encouraging behaviour
change. This presents an opportunity for future campaigns around exploring options of how
we speak to people using digital media – smartphone technology, apps, social media etc.
40
What could be improved?
It would have been interesting in terms of comparing coverage trends and data if we had had
engagement from more GP practices and from a wider geographical spread. From the 7 engaged, 3
were in North Ormesby Health Village, 3 in Linthorpe and 1 in Central Middlesbrough.
It was difficult to engage some practices due to capacity issues and several joined the pilot and then
disengaged after the initial visit.
Challenges
Engaging more GP practices to increase programme reach
Sustainable capacity and resources to continue the programme
Maintaining the high profile of the programme within communities and health professionals
Recommendations
The insight work showed that local awareness and understanding of cervical
screening is limited. We know that good awareness and understanding is attained
by sustained and consistent messaging and publicity. It is therefore recommended
that the momentum gained to date is not lost. The website will remain live on an
ongoing basis and an annual campaign to coincide with national cervical screening
awareness week in June will be delivered locally.
As part of this annual refresh, a specific promotion should take place across all GP
practices, similar to the flu campaign. This was suggested within the feedback from
those practices engaged to promote the No Fear concept.
As the highest increase in coverage has been observed in the No Fear practices it is
recommended that more targeted work be undertaken directly with low coverage
practices.
Further data (to reflect a full year of campaign activity) will be used, once available,
to provide a more robust assessment of the overall impact on coverage rates
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Additional targeting to different community groups could be developed in the next
wave including production of materials in different languages and implementing the
recommendations from the work with women with learning disabilities and
community training element.
The learning from the campaign will be used to inform the development of other key
public health campaigns locally particularly in relation to cancer prevention and
screening. ‘Screening Saves Lives’ will be used to promote other screening
programmes to keep information in one place in a format that is beginning to be
recognised with key groups.
It is important that knowledge gained from substantial campaigns and interventions
like this is shared. The findings of this evaluation should be shared with other
screening and immunisation teams in England. A copy of the report should be sent
to the director of the National Screen Committee and to local screening and
immunisation teams in the North region.
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Acknowledgements
The campaign would not have been a success without the leadership, support and involvement from the following, whose input is greatly appreciated:
The Project Team:
Becky James, Health Improvement Specialist (Prevention and Early Intervention), Middlesbrough Council
Carly Tasker, Marketing and Communication Officer, Middlesbrough Council
Val Lambert, Health Projects Lead, Middlesbrough Environment City
Glen Wilson, Consultant in Public Health, NHS England
Kate Birkenhead, Public Health Commissioning Manager, NHS England
Lisa Edwards, Screening and Immunisation Manager, NHS England Public Health:
Sue Perkin, Head of Public Health, Middlesbrough Council
Alistair Stewart, Public Health Intelligence, Middlesbrough Council
Steering Group:
Victoria Ononeze, Public Health Specialist, Tees Valley Public Health Shared Service
Katie Bannister, Health Awareness and Early Diagnosis Facilitator, Public Health Shared Service
Richie Andrew, Health Improvement Specialist, Workplace Health, Middlesbrough Council
Sarah Slater, Health Improvement Specialist, Healthy Settings, Middlesbrough Council
Philippa Walters, Pharmaceutical Adviser, Tees Valley Public Health Shared Service
Mabel Okeoki, Phd Student, Northumbria University
Key partners:
GP Practices engaged to promote the ‘No Fear’ concept
Twiist Design
Christine Hewitson, Practice Nurse, Parkway Medical Centre
Practice Nurses / Cervical Screening Mentors, NHS
Shazia Noor and the team at NUR fitness
Katrina Jackson, Redcar and Cleveland Borough Council
Lynne Blackburn and the team at the Lifestore
Linda Lord, Adult Social Care, Middlesbrough Council
Middlesbrough Environment City / Cycle Centre
Virgincare
CVFM
Nicola Liddell and Colposcopy team at James Cook University Hospital
The vast range of organisations that supported the campaign and displayed materials / promoted the messages.
