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Increasing Participation in the
NHS Bowel Cancer Screening Programme
“Get Greater Manchester Screening”
Commissioned by Greater Manchester Health & Social Care Partnership as part of the Greater Manchester Cancer Vanguard Programme
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“Get Greater Manchester Screening”
A campaign to ‘Get Greater Manchester Screening’ will launch across our city region in 2017.
Our intent is to initiate conversations with targeted segments of the population eligible for bowel screening (aged 60-74)* to promote the
unknown benefits of bowel screening and overcome identified barriers to participation.
To underpin the existing knowledge and evidence base, Greater Manchester Health & Social Care Partnership commissioned additional social
marketing expertise and qualitative insight research to complement Cancer Research UK (CRUK) and Public Health England (PHE) mass
media campaign that will launch in the North West January 2017. The outcome from the research helped to inform where to prioritise our
efforts. Thus, we have segmented our target audience and identified where we need to focus our attention in Greater Manchester to increase
bowel screening uptake and tackle local health inequalities.
Increased participation today will serve to normalise the desired behaviour which will influence and mobilise people in the future, leading to
sustained increases in participation.
Our efforts will be focussed on a spoken campaign, hinged around conversation
– providing a reason to talk about screening positively and making it easier for
conversations involving the right people to take place.
The insights gathered, audience segmentation and prioritisation and social
marketing campaign strategy are shared in this document.
*A schema of the NHS Bowel Cancer Screening Programme can be found in the appendices.
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‘Get Greater Manchester Screening’ campaign phasing
NOW
NETWORK MOBILISATION
PHASE 1 PHASE 2
Tasks Identifying ‘talkers’
Empowering people to talk/giving
them a reason to talk
Getting commitment and sign-up
from collaborators
Clarifying the message/topics for
discussion (unknown benefits)
Generating and providing
conversation starters, top tips on
how to initiate conversations, tools
to help spread the message,
permission to opt-in mechanics
and development of an intentional
campaign of success stories
Initiating conversations
Spreading the word
Taking part in the
conversations and fuelling
growth of conversation
Reinforcing the message at
every touchpoint
Create ways for our new
‘customers’ to share their
story with everyone else
Inspiring others to change
their behaviour and ‘do it’
Outcome/desired take out
Network mobilised:
“I understand the message and I want
to share it”
Screening reframed:
“This isn’t about knowing I have
cancer and all that comes with it
– this is about bowel health,
prevention of illness, health
protection and wellbeing”
“I now know why I am going to
take part”
Increased participation and
normalising behaviour:
“I did it, it was as easy as they
said to know that I am bowel
healthy and I am going to tell
others about it”
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Commitment and sign-up to ‘Get Greater Manchester Screening’
We need your commitment and sign-up to galvanise this campaign.
- Which secondary audiences will you engage and empower to start conversations with the primary priority audience
segments?
- What partners, community, charity, civic and commercial, will you be getting involved?
The Greater Manchester Health and Social Care Partnership will be informing and sharing this campaign strategy document with a wider
stakeholder group and the heads of organisations will be kept up-to-date of this work, that was commissioned as part of the Greater
Manchester Cancer Vanguard Programme. We will also be providing tools to facilitate collaboration i.e. talker training packs, key message
(unknown benefits bank), resource links etc.
Please can you feedback what you can do to commit to the campaign, so we can provide you with the support you need, when you need it?
You can use the following link https://www.surveymonkey.co.uk/r/3QZ8W3V to electronically express your commitment or contact Caroline
Mattinson: [email protected]
Example of commitment pledged:
Name Role and area of responsibility in
Greater Manchester
Commitment Status By when
Ann Richardson Communications Manager Greater Manchester Health & Social Care Partnership
To develop an intentional
campaign of success
stories to share ‘on
message’ ‘customer’
success stories to reframe
screening and provide
conversation starters
through targeted
publications on and offline
across GM
Briefing meeting held
w/c 5th December
Sourcing case studies
to develop success
stories
Identifying target
publication list
Press
briefings/releases to
go out mid-January
2017
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Who are we talking to?
The original Colorectal Cancer Screening (CCS) pilot1 identified that there were important sub-groups in which uptake was low. gFOBt appeared to be less acceptable to;
• men, • younger people, • those from materially deprived areas, • those belonging to certain ethnic sub-groups.
“There may need to be the focus of tailored recruitment strategies which address the apparent barriers to uptake in these groups”.
National statistics, supplied by the CRUK Cancer Intelligence Unit2
reflect this;
• Female uptake is higher than men • 60-64 year olds have the lowest uptake • The best uptake nationally is in females aged 65-69 • The worst uptake nationally is in males aged 60-64
This picture of non-participators is reflected in the data relevant to GM3;
• A greater number of females aged 65-69 participate in GM • The worst uptake is seen in males aged 60-64
In June 2016, PHE published guidance about improving the prevention and diagnosis of bowel cancer4 and stated; Men are less likely to take up screening (55% compared with 60%
of women) but are more likely to get an abnormal gFOBt result and more likely to be diagnosed with cancer or have polyps found.
Ethnicity and social deprivation are major determinants of bowel cancer screening uptake in the UK, as with many other cancer screening programmes.
Gender is also a determinant in bowel cancer screening in England, with women more likely to take part. PHE also reported that bowel cancer screening uptake in England is lowest in the youngest screening age groups. Uptake is higher in females than males in every age group, though the gap narrows with increasing age.
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Prioritising and segmenting our target audiences
The CRUK/PHE campaign is aimed at 55-74 year olds from lower socioeconomic groups. To support this wide-ranging campaign in Greater Manchester it is neither necessary, nor resource-efficient to target the entire eligible GM population. The GM campaign is focussed on using the latest insights, local population understanding and analysis to identify and prioritise the non-participating segment. Social marketing provides a mechanism for tackling health and social issues and uses behavioural insights to support change amongst specific audiences where the greatest issues lie – to help us address health inequalities. A social marketing campaign relies heavily on having insight into what the ‘customer’ values and wants; what they might be prepared to forego to ‘buy’ into the product or service on offer.
Social marketing; Is based on real understanding of the target audience: who they
are, what they think and believe and what they need or want Uses insight to develop propositions that offer a real benefit
(value) for the audience – a successful campaign will make the
‘customer’ feel that if they ‘buy’ the product, they will receive the
benefit they want that is associated with it
Aims to achieve changes to resistant or persistent behaviours,
not just to provide information
Starts with an understanding of the problem (barriers that may
prevent people from changing their behaviour) and designs the
solutions, to delivering and communicating products and
concepts
Is not limited to narrow definitions of communications or
marketing
Is focused on the behavioural goals of the target audience, not
the internal structure or divisions of the providers
Is about placing focus on the audience agenda – to achieve the
desired change in behaviour
The research5;
Qualitative, behavioural insights
206 people GM wide – represented by all 12 CCGs/LAs
Men and women aged 55-74 People with different screening behaviour
recruited; o Participators – those who have received, successfully
completed and returned their kit o Non-Participators – those who have received their
invitation letter and kit, but have never returned the test o First-Timers - those people who have not received the
invitation letter or kit, usually aged under 60, who will soon be invited to bowel screen for the first-time
All C2DE “Hard-to-reach” Areas of high deprivation and high proportion of ethnic groups From areas where GP practice uptake is known to be low Representative split men and women, marital status,
dependents, ethnic groups 88 IDIs and 13 focus groups including 118 people
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Target audience insights Participators Vs Non-Participators – what makes them different? We found that participators tended to be older, aged 70+ and they seemed to be better connected than the non-participators – most were married, with dependents and seemed to view ‘family’ as a priority (more so than the non-participators). They were also much more likely (than the non-participators) to use their ‘connectivity’ to access health and wellbeing information - mentioning the fact that they listened to others (family and friends and particularly those they knew that were health workers or ex-health workers) more frequently than the non-participators. They were also more involved and conscious about their health and wellbeing than the non-participators.
Whilst this was by no means an excessively healthy group of people – we had recruited from the most deprived areas of GM - they were healthier by comparison to the non-participators and even though the average age of the participators was older, a lower proportion reported dealing with long-term conditions. However, they were still coping with a high number of ailments common in this age group, such as broken bones and knee and hip replacements brought on through osteoarthritis.
The lifestyle of the participators is sedentary – but they were more active than the non-participators and their attitudes towards maintaining health and wellbeing were generally more positive. They also seemed more knowledgeable about the role of the NHS is maintaining good health – and this group was more familiar than non-participators about screening and NHS health checks.
Not surprisingly, the participators also had a more favourable view
of the test. When asked about ‘embarrassment’ or ‘mess’ they were
dismissive and they have clearly ‘bought into’ the ‘it could save your
life’ proposition. Less participators viewed it as test for cancer, in
this group there were far greater number of mentions of prevention
than other segments. They saw the connection between screening
and health protection and had heard of and mentioned polyp
removal more often in this group.
Non-Participators
Overall this group of people, who have previously avoided
screening/never returned their test, differed from those that do
because they were ‘surrounded by more ill health’.
Amongst non-participators there were a greater number of mentions and discussion about long-term conditions and ill health – they had comparatively a greater number of health issues and personal experience of illness and so did their family and friends - which was all contributing to their ‘knowledge’ and perceptions relevant to what a diagnosis of cancer would mean.
They placed high value on NHS, they were using NHS services a lot and know the system well, thus they had a greater number of negative experiences to share too;
• more mentions of and expectation of long waiting times
• delays in getting appointments • length of time from diagnosis of problem to treatment
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The NHS is seen by this group of people as the ‘ill health service’ and a test that is offered by the NHS is more likely to be perceived as something that will diagnose ill health – which in turn will lead to a whole load of negative consequences. Their beliefs were also strongly influenced by past (old) experiences of family members(parents/grandparents) that were negative. That is, they had negative historical experiences/knowledge relating to poor quality/type of treatment and outcomes.
First-Timers (those who have not yet been invited) This group of people were obviously younger, more connected, healthier and although most are still sedentary, many were working and had average levels of activity. Less people in this group had long-term conditions or illness. Overall, they spoke positively about health and there were far fewer mentions about ‘lack of control’ and there was evidence of positive action to maintain health and wellbeing. Of all the groups, this one reported highest influence of others and most commonly, the biggest influences were family. In addition, they are more connected to a range of networks, work and social. This group were describing their intended behaviour and their intentions all seemed good. The majority stated that they were likely to do it. But they had not rationalised why they would do it. When we dug deeper and questioned why they had decided to participate in screening they did not have a lot to say and they knew very little about the test.
This suggests that their actual behaviour (when they receive the test) may be quite different from their intended behaviour (and the uptake data also implies that this would be the case).
Some in this group perceived screening as a diagnostic test for cancer - and we know that this could lead them down a rejection path.
Negative perceptions about treatment was mentioned most often in this group by those who spoke about ‘fear’ and family history was referenced; like the non-participators group but their language was less strong.
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Greater Manchester priority audience segments Our focus will be on Non-Participators (and First-Timers who have the potential to go down the rejection path because they are exhibiting similar characteristics as Non-Participators). Recognising that it will be easier to re-frame negative perceptions about the test in the First-Timers, because they know little about the test and they haven’t made their decision to opt-in or out and rationalise their decision-making process. Emphasis will be placed on the following typologies because the research suggested that if the root cause of their inaction was addressed, then the other expressed barriers are trivialised and so would also be overcome at the same time.
Ageing Averse
Aged 59-62 (about to receive their test or have recently rejected), male and female – but more likely to be men
They’re at the pre-contemplative stage of the journey –aware of the test, but have plenty of reasons why the test isn’t for them. They’re reluctant to see the relevance for them and have rationalised their avoidance - they see why it might be necessary for old aged people at high risk (they believe it is for others) but not for them
This group of people have strong negative emotions around ageing. For them;
The test has connotations of ageing
In their mind, ageing is linked with ill health and so by association, so is the test
They are not ready for old age or (more) ill health yet – they want to stay feeling as well as they do now
This group of Non-Participators have low belief in the test’s wellbeing benefits, to them the test is explicitly given to you when you get old (60+) because there is a chance that you are ill with cancer (and this test will find it if you are)
They are less well connected people than other groups and less likely to value the opinion of others – unless that opinion fits with something they want to hear
Whilst their experience of health is poor, they are OK and the last thing they want is to add to their lives is something as incurable as cancer (their perceptions about cancer and its treatment are negative and it is an illness that is far worse than any other)
They view the test as a ‘test for cancer’ and have lowest belief and knowledge about early detection benefits
Their current action is to avoid on this basis – quite strongly – there were mentions of some people in this group ripping up the test
They defend their decision to avoid by expressing other objections, such as; aversion to dealing with poo and mechanics of doing the test/taking test at home – but the root cause of their inaction is the association of the test to ageing and the worst possible illness to get, which is cancer
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Fearful Contemplators
Aged 59-62 (about to receive their test or have recently not participated), male and female – but more likely to be female
They’re at the contemplative stage of the journey – aware of the test, but are avoiding because of what they believe
This group of people have strong negative emotions around cancer. For them;
o They value health, it is important to them, but they have a low sense of control over it and generally do not have the best of health
o They have busy lives, with “lots going on”; some are still working, looking after grandchildren and dealing with their own or others ill health and caring for family members
o The last thing they need right now is to find out that they have cancer!
o They fear a test result that would tell them they have cancer because they do not have the time to deal with it and its treatment – it would be a burden upon their already extremely busy lives
These Non-Participators have low belief/awareness or knowledge of the benefits of early detection or wellbeing benefits of the test
They associate the test with something that will diagnose cancer – and that a diagnosis of cancer would lead to weeks, months or even years of unpleasant treatment, that they just don’t have time to deal with
They worry about what the diagnosis of cancer would mean, how it would impact upon their daily lives and the lives of their families
They can easily put the test to one side, “out of sight, out of mind” and forget about it because they have so many other things to do – and because they can’t bear the thought of adding another burden to their list
They defend their decision to avoid by expressing other objections such as; aversion to dealing with poo, not having enough time to do the test, too complicated and other priorities taking over – but the root cause of their inaction is the association of the test to a diagnosis of cancer, that will lead to unpleasant and time consuming treatment
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Older Pessimists
This group are an evolution from the other two groups. Aged 70+ and are repeat avoiders – both male and female
They’re contemplating but are consistently dismissive
because of what they believe. They think about the previous avoidance they have made and don’t see the point in changing their behaviour now
This group has a high number of health issues, long-term conditions and mental health issues and so do their friends/family
They use health services provided by the NHS a lot and they’re being treated for many ailments – and have been for many years
They have high levels of cancer around them and a lot of negative emotions towards cancer – they express ‘old’, historical, negative experiences where treatment and outcomes were poor
They place a high value on the NHS – but because of their breadth and frequency of use they have negative experiences to report such as waiting times and length-to-treatment – although they do not blame the NHS for these issues, it is ‘people like them that drain resources’
They are fatalistic and these people for have strong negative emotions around cancer. For them;
o The test is pointless, “I’ve lived long enough”, I am not worth it
o The test is a test for cancer and you can’t prevent it and prognosis is poor, so why bother to find out if you have got it
o Cancer is inevitable in old age anyway – and they don’t want a confirmed diagnosis to lead to treatment and to them being a further burden to the system (NHS) or family or friends
This group of Non-Participators have low belief in the test’s prevention benefit – they believe that cancer is a long death sentence, treatments are horrific plus if you are going to get it, you are going to get it and there is nothing you can do to stop it
Because their experience of health is poor and they already feel that they are being a burden to others, they do not want add a confirmed diagnosis of cancer – particularly “at ‘my age’
They defend their decision to avoid by expressing other objections, such as; not hearing about anyone else doing it, or talking about it and perceived messiness – but the root cause of their inaction is the association of the test to a diagnosis of cancer, that will lead to them being a further burden to others
As repeat avoiders, their behaviour is established and this group will need added reassurance and permission to opt-in to screening (not too late to start)
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South Asian and Pakistani Pre-Contemplatives
Whilst people of South Asian and Pakistani origin do fit into the aforementioned typologies - in terms of what they believe and what is at the root cause of their inaction – there are tangible (physical or practical) barriers expressed by this group that must be addressed, before the emotional barriers can be overcome
That is, they could be contemplating but are not even pre-contemplating because they;
o Don’t know about the test o Haven’t heard anyone speak about it o Claim not to have received the test o Couldn’t read what to do with the test (if they did
receive it) o Misunderstood what to do with the test o Didn’t know who to turn to - to help with
understanding
They use health services and have stronger help seeking behaviour than other groups and they are heavily influenced by family and friends to look after their health
However, they can’t read (even their own language) and so they are in the dark about bowel screening
They have lower health literacy, which includes knowledge of the system and confidence in ‘navigating the system’ – so wouldn’t know who to turn to if they did hear about the test and had bought into the benefits
They do not hear anyone speaking of the test specifically but they have high negative beliefs around cancer treatment and outcomes – again not many talk about it, but when they do it is always a horror story
For this group the right information is vital - the root cause of their inaction is lack of awareness, education and advice that says the right things in a way that reaches and connects with this audience
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South Asian and Pakistani Pre-Contemplatives
Ordinarily, when developing a social marketing campaign strategy, it is acknowledged that if you only address the tangible (practical and physical) barriers that you may not bring about behaviour change. In this case our research has identified a cohort of people
who are re not even thinking about changing their behaviour or acting, because they are generally unaware of the test and so have not entered the decision-making process. They claim not to have received the test, nor have they heard anyone talking about the test. If they have taken delivery of the test, they did not understand what it was because of their inability to read and understand what was received.
Our research found more in common between BME and non-BME audiences than not. Aside from this cohort, who were characterised by the tangible barriers described, most of the people we interviewed (regardless of ethnicity) can be situated in the previously described typologies. However, for this group the tangible barriers must be addressed because we cannot increase the value of the test and make screening attractive to them without informing about the test in the first instance.
Tangible/practical barriers include;
• Not knowing anything about the test or having the confidence or know how to find out something like this
• Not being able to read (including in their own language)
• Not hearing about the test
The biggest barrier with this cohort is language!
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Channelling insight into action
Our research suggests that our target audiences;
do not see the benefits/value of doing the test (screening), there are only perceived costs
have negative views about cancer, its treatment and outcomes that are explicitly associated with the screening test (it is in their eyes a test to confirm cancer) which leads to avoidance and non-participation
are unaware of advances in cancer treatment, the benefits of early detection through screening and its bowel health protection benefits
do not make the link between screening today and maintenance of wellbeing and future health outcomes.
Currently, the cost of doing the test far outweighs the benefits (which are largely unknown).
It is our goal to use our understanding of our audiences to initiate conversations that increase the value of the test and to make screening attractive to our ‘customers’.
It is our aim to
“Get Greater Manchester Screening”
A successful spoken word campaign must be well-planned and certain basic elements need to be in place.
These elements are the: Topics (the unknown benefits), Talkers, Tools and Taking Part.
What do we need to say? Who will share the message about screening?
How can we help the message travel? How can we join the conversation?
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Supporting people on a behaviour-change journey - the power of conversation
Bowel screening uptake has been proven in peer-reviewed studies to increase when those who have not previously responded to the invitation for screening are contacted directly to have a conversation about screening. There is learning from many small-scale and face-to-face projects which have managed to change behaviours relating to screening. For example, studies have shown the positive impact that GPs can have on not only increasing awareness of cancer screening in eligible populations, but also that primary care involvement in the process can often address barriers to participation. One study found that telephone advice and face to face health promotion have also been shown to increase uptake by around 8% and 5% respectively, when used in combination with a GP endorsement letter which was sent two weeks after their screening due date6. The project that incorporated these activities took place in areas of low socio-economic status and high ethnic diversity so these approaches may be able to help address inequalities in bowel screening uptake.
Recent qualitative research conducted by CRUK7 (when developing the ‘Be Clear on Cancer’ North West regional bowel cancer screening campaign that will launch in 2017) found typically, respondents reported holding conversations regarding their health with partners and close relatives, but where there were limited options for discussion and fewer opportunities to ‘normalise’, the barriers to participation appeared to intensify. Some interviewees described benefitting from the research discussions and a few even expressed a newfound intention to complete the test kit a as result of joining the discussion as part of the research.
Indeed, our own research5 clearly indicated that conversations are key to redressing the barriers and influencing our audiences and proposed a spoken campaign because it will work strongest and is the most effective form of communication for each of the priority audience segments identified. Participation in this research positively influenced the intended behaviours of 25% of previous non-participators.
What we’ve unearthed is (reported) behaviour change can be achieved through conversations if;
Occasions to talk are created, initiated People are given the opportunity to have a conversation – this prompts inquisitiveness Messages are targeted, straight-forward and single-minded (focused) Information provided is relevant, negates the issue at the root cause of inaction and reassures General wellbeing benefits/bowel health protection of screening are promoted – we need to detach from being a
cancer diagnostic tool ‘Change aids’ are provided i.e. details about how to request a new kit (freephone number) People talk about ‘doing it’, sharing success stories and normalising participation
Conversation is personal. It’s approaching others with an open mind and empathy for their concerns, not our own. When people converse, a change of opinion is always possible and one-to-one conversations have proved to be one of the most effective strategies for influencing behaviour change. Furthermore, through talking with others, and becoming aware of others’ completion of the gFOBt, studies have shown that uptake was repositioned as a normal activity8.
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What do we need to say?
The value proposition – paying attention to the ‘unknown benefits’
AGEING AVERSE FEARFUL CONTEMPLATORS OLDER PESSAMISTS
ROOT CAUSE OF INACTION
Link test to sign of ageing and the
worst possible illness to get because of its poor treatment and
outcomes, which is cancer
Test is associated with a diagnosis of cancer, that will lead to
unpleasant but more importantly time consuming treatment
Don’t see the point because they link the test to a diagnosis of cancer, that will lead to them being a further burden to others
COST OF DOING THE TEST Sign of old age Upsetting the status quo Burden to others
VALUE PROPOSITION A statement to clearly identify the benefits a consumer gets when ‘buying’ a product or service. It should convince consumers that there is a benefit to using the product and that the benefit outweighs the perceived costs in their mind.
Wellbeing test for maintenance of bowel health; that can even prevent
illness or the need for serious treatment and improve results so
you live life healthier
Quick and easy wellbeing test so you don’t need to worry about your bowel health, that can even prevent life-changing illness or the need for extensive treatment and improve results so you can get on with
your life
Wellbeing test that’s recommended by your GP even in later life, to reduce the chances
of your bowel causing problems and ill health, that can even prevent illness from being life threatening, reduce the need for
extensive, involved treatments and improve results, so you
can get on with life independently (without making a fuss)
The do’s and don’ts for each audience typology are referred to in the appendices. However, please note that key messages (unknown benefits bank) will be circulated to all committed parties in 2017 by the GM Health and Social Care Partnership.
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Who are our talkers?
We’ve acknowledged for our social marketing programme that consultation and dialogue should play a central role - that conversation has the power to change behaviour. To succeed the two most important things we need to do are: 1) Create a straightforward and simple message for our audiences – the value proposition is outlined on page 16 and 2) find (and help) people share it. We acknowledge that ‘we’ cannot intervene face to face with everyone in our target audiences and we need to initiate conversations on an industrial scale.
The campaign research7 conducted in relation to the Be Clear on Cancer campaign that will commence in January 2017 suggests that the TV advertising will heighten awareness of bowel cancer screening and it will address some of the known barriers to participation. We think it will also act as a catalyst for conversation. It is our aim to exploit this opportunity and amplify noise, to do this we need to give people a reason to talk about bowel screening and make it easier for conversations to take place.
We want a natural conversation between real people. We want a genuine ‘consumer’ conversation about screening that we can join in, participate in and make it work for us. We need to feed it, fuel it, put the good stuff (right messages, the unknown truths) out there, and so the conversation will be positive.
Positive experiences are conversation starters
If a ‘customer’ has a positive experience they will be your greatest advertiser. A good experience will typically start conversations. If you have a fantastic product people can’t resist sharing it with everyone. Great customer service makes people want to tell their friends about you. It is even often the case that regardless of how much a company invests in a product or service, that customers do not dare to take a risk on an unproven product. People care more about quality than price and it’s their friends and neighbours’ experiences that will convince them of quality and persuade them to ‘buy’.
Unfortunately, there are many reasons why the odds are against our ‘customers’ sharing their positive experiences such as; the small numbers of people participating, bowels and poo are not seen as pleasant topics of conversation and people don’t like to talk about cancer (and the test is perceived as cancer diagnostic tool).
This means we will struggle to get people eager to tell their friends about their bowel screening experience organically. Consequently, we will be developing an intentional campaign of success stories
with the right message – stories that share the unknown truths to reinforce wellbeing and health protection, prevention or quick and easy successful surgery or treatment and removal of polyps, rather than ‘survivor stories’ that share tales of cancerous tumours, chemotherapy, radiotherapy, complicated surgery and months or years of treatment – these will be great conversation starters to get people talking, reframe screening and get people participating. Following this, in phase 2 we will create ways for our (increased volume of) customers to share their story with everyone else.
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Who are our talkers? Secondary target audiences
Our task is to identify people who’ll talk about bowel screening - we need to find our ‘talkers’. These can be any individual or groups of people who have the enthusiasm and connections to relay our messages - the right messages to the right people. We could call them “influencers” or “advocates” or “evangelists” - but our talkers or conversationalists are just ordinary people - like the above mentioned ‘customers’ (participators) or doctors, nurses, shopkeepers, hairdressers, family, friends and neighbours.
We all know talkers. People who have an opinion about certain things or are considered experts about a particular matter. People who we will turn to for advice because they’re someone we can trust. There’s the neighbour everyone goes to for advice on fixing a leaky tap (because his dad used to be a plumber), the friend whose partner is a nurse or has a cousin who is a doctor and the colleague who always knows where to get the best bargains. Talkers talk because they love to share great ideas and help their friends and family. We can get them to talk about bowel screening if we give them something to talk about. The best talkers are probably people we interact with every day who would love to be given the opportunity to do a little more. They are the believers, the fans and they’ll want to spread the word once we have given them a topic that they are willing to talk about.
Palmer et al found that talking about screening with family and peers was key to participation in screening.
When interviewed participants from all occupational backgrounds who reported they had not initially
participated in screening and then had completed the gFOBt in a subsequent screening described being
influenced by discussions with family members, friends and health professionals8.
The Men’s Health Forum, 2011 found that high value is placed on the GP and primary care staff in
informing personal decision-making relating to health matters, but also for men who have a spouse or
partner, that person is likely to be very influential in their decision making around health9.
The research we conducted in Greater Manchester5 supports this and identified GPs as having a strong influence and suggested that any
person that is broadly connected through their employment in health or social care could play an influential role. This is because they are the
friends and family of our target audiences and as health and social care workers or ex-health workers they are trusted and their opinion highly
valued. GPs and health staff were seen to be of influence to the majority of people we interviewed – the influence of GPs increased with age of
the participant. The TV and direct mail elements of the CRUK/PHE campaign that features GP endorsement and encouragement will get the
most out of this and add weight to the GM campaign that will focus on mobilising a network of additional talkers.
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Who are our talkers?
Who are the right people to deliver our messages? What existing resources (people) can we utilise to have conversations with the prioritised audiences? What community assets are available to us?
To answer this question a workshop was held with key stakeholders on 16th November 2016. The following secondary audiences (messengers)
were named for each of the priority audience segments;
Ageing Averse Fearful Contemplators Older Pessimists South Asian and Pakistani
Pre-Contemplatives
Due to their younger age;
Employers/large organisations
i.e. LA’s/Councils and NHS
Stagecoach buses (large
employer) – men talking to men
Fire and Rescue (large
employer but also in the
community)
Pubs, barbers, betting shops
and bowling alleys/sports clubs
(male oriented places)
Football Clubs
Taxi drives
Housing Associations/Housing
Officers/Wardens
Community nurses
Family members
Due to their younger age;
Employers/large organisations
i.e. LA’s/Councils and NHS and
Park Cakes mentioned as
example
Community Health
Champions/Cancer Champions
Fire service (in the community)
Hairdressers, nail/beauty shops
Other screening programmes
Non-medical NHS staff
Gyms
Faith leaders
Embed early with looked after
children (LACs)
Family
members/friends/neighbours
Pharmacists
At point of NHS health checks
Due to ill health, LTCs, NHS use;
Practice Nurses
District Nurses
Pharmacists
GPs
HCA
Receptionists
Volunteers/CVS
Existing services for LTC
Landlords
Sheltered/social housing
Care homes
Flu clinics
Charity shops
Garden centres
Age UK/Concern
Schools (levers) – grandparents
Community centres/coffee
mornings
Parish halls and
Church/Mosques/Faith
Hairdressers
B&Q pensioner discount days
Local Imams (inter-faith forums)
Children (particularly older
children)
Other direct family and extended
family members i.e. sister-in-law
Community groups/centres
Neighbours
GPs
Pharmacists/pharmacy
assistants
Taxi drivers
Small Businesses/Groups that
are typically owned or
frequented by BME population
i.e. take-a-way, cash and carry,
butchers
Social Housing Associations
Health Trainers
Social care/health improvement
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How do we convince the talkers to deliver the key messages?
Firstly, it is our job and our responsibility to know how to position screening in a way that it is worth talking about – so our both our priority primary audiences and secondary audiences see the value.
But it’s acknowledged that in many instances we will be competing for the time and attention of some of the secondary audiences (our messengers, talkers or conversationalists) – and when this is the case we’ll need to identify how we will empower these people to start conversations by tapping into their basic motivations.
What motivates people to talk?
We won’t be able to start positive conversations until we really understand what will motivates people to talk. There are three basic motivations that drive genuine conversations.
Reason 1
The person likes the product and the service being provided because they have experienced, or can see, its value. They believe that screening is worth talking about. Unfortunately, the day-to-day existence of screening doesn’t provide a reason to talk – a reason that will be of interest to them and encourage them to talk about screening. It’s not a natural part of most people’s day-to-day conversation – so we need to make sure it is.
Reason 2
We want to look smart. A lot of people get their kicks out of being the expert on their favourite subject. When we tell people about what to buy, we’re showing off what we know. Some people do this well, and everyone goes to them for advice. We love to talk to these people when we’re deciding about something, and they love to tell us what they think. Help these people look smarter. Give them inside information, success stories and describe detail of procedure (positioned from a preventative perspective of course) and they’ll love you for it.
Reason 3
The desire to look smart is often paired with a higher-level motivation: to help other people. Some people are so passionate about what they know that they want everyone else to enjoy what they are enjoying. It bugs them to see someone make the wrong or an ill-informed decision. These are the people who come up to you in a shop when you’re trying to decide what to buy and give you an unprompted sales pitch for what they think is the greatest product in the world. Annoying, yes, but driven by a genuine desire to help you out. If we help these people help others: Give them sample kits to share, flyers to distribute, and messages to forward – they’ll be motivated.
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What principles do we need to adopt to get the secondary target audiences identified involved and to start conversations with the primary target audiences? What could their drivers be?
To answer these questions a workshop was held with key stakeholders on 16th November 2016. The following ideas were noted for some of the
key secondary audiences (messengers) named for each of the priority audience segments;
Ageing Averse Fearful Contemplators Older Pessimists South Asian and Pakistani
Pre-Contemplatives
Reinforce it is NOT about cancer
Bowel health/Early diagnosis
toolkit
Large percentage will still be in
employment – across GM large
employers include LAs and
NHS, focus here;
Keeping workforce well
More easily treatable
More acceptable if no
mentions of cancer – put
on prevention agenda
Build into KPIs
Ensure built into sub-
contractors KPIs
Encourage staff to ‘take
it home’
Could we produce a sales aid? A
simple message toolkit for consistent
messaging? It’s about energising
people to share message of it works
to keep you healthy
Embed into social
movement – health and
wellbeing of communities
Making every contact count
HCPs = added value/CPD
Training to embed into
normal everyday
conversations
Good practice
Employers – its free and
done at home and so
doesn’t interfere with
work/open hearts and minds
– prevention role, give
reason to believe why it is
good to do it/less time off
work – good practice, staff
will feel valued
Beauty/Hair and Nails –
branded pens provided to
encourage conversations
(conversation starters) –
they have time to talk
Ideas for social media to
communicate with younger
family members – share
timeline of screening
Tweak existing service specs
and so screening mentions are
included
Give recognition for taking on
extra responsibility and making
a difference
Include in training/CPD
Care homes – keeps your
patients healthier
GPs – cost analysis – cost of a
patient stage one diagnosis Vs
stage four
CVS – reducing social isolation,
connecting with older people –
improves your value in
community, builds rapport and
trust on personal level
Housing associations – saving
money Vs stage four diagnosis
adjustments, shows you care
about your residents
Recognition via local
press/certificates for making a
difference “conversationalist of
the year”
In the workplace/employers –
challenge their viewpoint that
screening will lead to diagnosis
of cancer that will lead to a
person being off sick for
treatment by reframing as
maintenance of staff health and
wellbeing/prevention
To the voluntary sector (who are
facing cut backs) – wellness
agenda could enhance their
repertoire
To primary care teams –
conversations about screening
can be easily be incorporated
into other initiatives i.e. health
awareness days, over 40s
health checks, blood pressure
checks
Provide more culturally
appropriate information
Ambition for ageing –
incorporate BCS awareness
Posters provided for shops
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How can we help the message travel?
What tools could be provided to help convey the message? How do we help people share it?
• How can we facilitate the conversations that our secondary audiences will have with prioritised target audiences?
• How do we keep conversations focussed and single-minded and directed at overcoming the identified barriers?
• What existing resources/assets can we utilise?
To answer these questions a workshop was held with key stakeholders on 16th November 2016. The following ideas were noted for tools that
could be provided to help the secondary audiences (messengers) spread our messages to each of the priority audience segments;
Ageing Averse Fearful Contemplators Older Pessimists South Asian and Pakistani
Pre-Contemplatives
Demo kits (could be part of
toolkit)
Scripts and so conversations are
on message
Business cards with Freephone
number to request new kit
Posters/pictorial – images to
show others doing it to stay
healthy
GPs – make sure promoting
CRUK/PHE (remove the old
campaigns/old messages/out of
date)
Use of ‘branded’ freebies to start
conversations i.e.
Toilet rolls
Air fresheners
Window stickers ‘Bowel
Healthy’
Add key messages to loop TV and
email signatures across workforce
Add messages to pension and
payslips correspondence
Utilise Patient Participation Groups
at GP Practices (to be advocates)
Use of ‘branded’ freebies to start
conversations i.e.
Car air fresheners
Car stickers
Tissues – toilet rolls/partner with
Andrex
Bingo dobbers
Trolley tokens
Spectacle cleaners
Pens
Socks
Re-usable shopping bags
Business card size info
(Freephone number)
Posters, leaflets
Utilise dedicated clinics for non-
responders – have test kits on
display
Make sure audience recognises
themselves in advertising –
more BME representation
More BME case studies/success
stories (this creates local
‘celebs’/advocates)
Utilise BME publications
Provide gloves with kit
Provide basic information that is
health literate appropriate
Provide practical guidance,
advice and instruction i.e.
punnet method for catching
sample
Utilise existing ‘How to take your
sample leaflet’
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Taking part – how can we join the conversation?
The solution to increasing bowel screening uptake and overcoming the barriers that are at the root cause of non-participation will not lie in a single campaign for Greater Manchester. The Be Clear On Cancer campaign that will launch across the North West in January 2017 is a great opportunity for us – not only will it raise awareness and address some of the known barriers, it will fuel conversation. This is an opportunity we need to take advantage of to address our health inequalities.
To amplify this regional campaign, we have drawn upon the insights gathered and propose a spoken ‘word of mouth’ campaign - in which many people will play a part to reframe screening and change the norm in the long-term.
What we have found is that people will not act the way we want them to if they don’t see the benefit and they only have a negative perception of the outcome.
We need to use partners, particularly the voluntary sector, charities and our own workforces to spread good news messages (such as polyp removal to prevent cancer) to reframe, so that people can see a benefit to them in taking the first step towards action.
People need to hear the same (right) message from all those around them – that includes health professionals, councils, local charities, government departments, as well as community voluntary services and their friends and family, the people that they trust and speak to every day.
In consequence, we are assembling a cross-societal collaboration of workforces, local authority departments, local ‘activists’, community leaders and small businesses, who will disseminate a consistent message through conversation. Hence, when our target audiences are contemplating, they feel they can act successfully because they see the value.
The programme also needs to include a variety of mechanisms to stir conversation – face to face, point of sale (i.e. invitations), telephone, television, newspapers (success stories) to get a conversation started with as many eligible people as possible.
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REFERENCES:
1. Evaluation of the UK Colorectal Cancer Screening Pilot Final Report (February 2003, revised May 2003) The UK CRC Screening Pilot Evaluation
Team.
2. Data supplied by Kathryn Weir, CRUK from CRUK Cancer Intelligence Unit Bowel Cancer Screening Data - England, 2006/07 - 2014/15. Supplied by
email to Admire Marketing18 May 2016. See appendices p. 26.
3. Hub data supplied by Lucy Guest 11/08/2016; data cut of persons screened for bowel cancer routine responders % uptake (average of uptake, new
episodes closed from 1/8/15 to 31/7/16 accessed via the hub).
4. https://www.gov.uk/government/publications/health-matters-preventing-bowel-cancer/health-matters-improving-the-prevention-and-detection-of-
bowel-cancer
5. Qualitative Research – Improving Bowel Cancer Screening in Greater Manchester. Outline of Findings November 16th 2016. Adrian Smith, Unique
Improvements, 3rd Floor, Liverpool Business Centre, 23 Goodlass Road, Liverpool L24 9HJ (0151 486 6737)
6. Shankleman J, Massat N, Khagram L et al. Evaluation of a service intervention to improve awareness and uptake of bowel cancer screening in
ethnically-diverse areas Brit J Cancer 2014;23;111(7):1440-7. https://www.ncbi.nlm.nih.gov/pubmed/24983374. Accessed via
http://www.cancerresearchuk.org/health-professional/early-diagnosis-activities/bowel-screening-projects-and-resources/evidence-on-increasing-
bowel-screening-uptake#Bowelcancerscreening0
7. Cancer Research UK Bowel Cancer Screening Creative Testing. Presentation of Research Findings September 2016. Conducted by Research
Works Ltd, Regency House, 219a, Hatfield Road, St Albans, Herts. AL1 4TB (01727 893159)
8. Palmer et al. Reasons for non-uptake and subsequent participation in the NHS Bowel Cancer Screening Programme: a qualitative study. British
Journal of Cancer (2014) 110, 1705–1711. doi:10.1038/bjc.2014.125 www.bjcancer.com Published online 11 March 2014
9. Slow on the uptake? Encouraging male participation in the NHS Bowel Cancer Screening Programme. David Wilkins. Men’s Health Forum. Published
May 2011.
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APPENDICES:
Ref:AM17
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Reference 2: Data supplied by Kathryn Weir, CRUK from CRUK Cancer Intelligence Unit Bowel Cancer Screening Data - England, 2006/07 -
2014/15. Supplied by email to Admire Marketing18 May 2016
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Bowel health screening conversations – do’s and don’ts The main objective for all conversations is to reframe screening as a test for bowel health and wellbeing (do not focus on cancer). Each of our priority primary audience segments do not think they want to take part in the bowel screening programme because they see screening as a test for, and diagnosis of, cancer. Each audience have other related viewpoints, which are connected to this underlying belief, that leads to the undesired behaviour. AGEING ADVERSE: Aim to shift this audience from pre-contemplative to contemplative
Voluntary sector networks are recommended ‘talkers’ for this group
Target communities and segments where the segment will gather i.e. sports clubs, pubs and social clubs
They’re in denial, a rigid/stubborn audience – they’ve rationalised their thinking and believe (due to its link with ageing) that bowel ‘cancer’ screening is not for them - they don’t generally listen to other people unless it’s something they want to hear
They do not want to acknowledge old age but if screening is about health protection, wellbeing maintenance and living life healthier it has a chance of connecting with this audience
Men do not want advice, they want the facts and conversations should be direct and to the point
If ‘evidence’ is given – use facts relating to prevention, such as quick and easy removal of polyps – case studies will work if they deliver the unknown benefits
Be pragmatic and matter of fact and reinforce the ease of testing (little effort) – but do not clutter the conversation with too much detail about how to collect samples
FEARFUL CONTEMPLATORS: Aim to shift this audience from contemplative to intention
Voluntary sector networks are recommended ‘talkers’ for this group
Target communities and segments where the segment will gather i.e. workplaces, libraries, housing offices, GPs, supermarkets
In the contemplation stage, they have made a risk-reward analysis. They’ve considered the pros and cons of their behaviour, and the pros and cons of change – they’re contemplating whether it will be worth it… and now the balance is tipped in favour of the undesired behaviour
This group has been thinking about it and worrying about it and so will tolerate a more informed discussion – but remember they are busy and have better things to do!
Quick and easy plays well to this audience – so ask for a few minutes of their time now that could save them a lot of hassle in the future
If screening is about health protection, wellbeing maintenance and less chance of extensive treatments it means it could prevent future impact on their life and that is reassuring and motivating
Highlight ease and speed of test (and treatment if caught early) - case studies will work if they deliver the unknown benefits
OLDER PESSIMISTS: Aim to shift this ‘contemplating but continually dismissive’ audience to action – give them permission to participate
Voluntary sector networks and GPs are recommended ‘talkers’ for this group
Target communities and segments where the segment will gather i.e. Bingo halls, libraries, housing schemes, NHS services, social services and especially GP waiting areas.
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As time has gone on, this older pessimistic group have shifted from the contemplative stage in the journey, like the fearful contemplators, to active avoidance because they no longer see the point
Their avoidance behaviour is established and not only do their original barriers to participation need to be overcome, they also need permission to opt-in now
With this audience, we need to be firm that prevention of illness and maintenance of bowel health and wellbeing is important at any age
If screening is associated with wellbeing it means maintaining an independent lifestyle - case studies will work if they deliver the unknown benefits/value
Endorsement from Health Care Professionals work well with this group and they can provide the reassurance they need and permission to act today
‘Change aids’ will also serve this audience well – give them the Freephone number or even better assist them to make the call
SOUTH ASIAN & PAKISTANI PRE-CONTEMPLATIVES: Aim to increase awareness of the test and shift to pre-contemplative
BME networks and GPs are recommended ‘talkers’ for this group o Greater Manchester BME Network managed through Greater Manchester Centre for Voluntary Organisations o Greater Manchester Bengali Hindu Cultural Association o Bury Asian Women’s Centre o Bolton Indian Forum o Manchester BME Network o Al-Hilal Community Project in Manchester o Pakistani Community Centre in Oldham o Community Voluntary Association BME network (Tameside BME Network) o Asian Women’s Network in Trafford o Afro-Caribbean over 50s in Trafford o Deeplish Community Centre in Oldham o Cheadle Mosque and Community Centre (Stockport) o Leigh Ethnic Centre (Wigan)
Reduce language barriers and increase awareness – start framing bowel screening in its true light – and benefits don’t have to be discussed later
Use the TV advert to provide GP endorsement and utilise BME community radio
Target communities and segments where the segment will gather i.e. including NHS services and GP waiting areas
Utilise BME specific resources
Family is of great influence and so produce key messages ‘unknown benefits’ for use by children to raise the topic in the right way with the target audience
