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Let's talk about smear tests: Social marketing for the National Cervical Screening Programme
Public Health 123 (2009) e17–e22
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
e-Supplement
Let’s talk about smear tests: Social marketing for the National Cervical Screening Programme G.R. Bethune a, *, H.J. Lewis b a b
Manager, Communications and Marketing, National Screening Unit, Ministry of Health, Auckland, New Zealand Clinical Leader, National Cervical Screening Programme, National Screening Unit, Ministry of Health, Wellington, New Zealand
a r t i c l e i n f o
s u m m a r y
Article history: Received 14 January 2009 Received in revised form 19 May 2009 Accepted 10 June 2009 Available online 8 September 2009
ori and Pacific women in the Objectives: The overall aim of the work was to increase participation by Ma National Cervical Screening Programme (NCSP) in New Zealand using a social marketing informed approach. Key objectives for this target group included: increasing awareness, understanding and discussion of cervical cancer and cervical screening; increasing telephone calls to the NCSP’s 0800 number; and increasing uptake of cervical screening.
Study design: A social marketing intervention with mixed qualitative and quantitative evaluation. Keywords: Cervical cancer Cervical screening Inequalities in cervical screening Social marketing
Methods: Focus groups with priority women and key stakeholder interviews were used to identify a set of key messages from which television, radio and print media advertisements were developed. The advertising campaign was one element of a broader programme of activity, which involved changes to service delivery and improvement to access to services, particularly for the target groups. The campaign was evaluated in three ways: quantitative surveys conducted before, during and after the intervention; monitoring the number of calls to the NCSP’s 0800 number; and monitoring NCSP monthly coverage statistics. Results: The social marketing intervention achieved measurable behavioural impacts with its primary ori (6.8%) and Pacific women target audiences, delivering significant increases in screening uptake by Ma (12.7%) after 12 months. In addition, there was a secondary positive impact on other women (not the immediate target audience) whose rate of update also increased (2.7%). Overall, the intervention helped to reduce inequalities and delivered substantial increases in awareness, understanding and discussion of cervical cancer and cervical screening amongst the target groups. Conclusions: The results demonstrate that social marketing can be effective in targeting marginalized or under-represented groups. The intervention has not only changed the way in which women in New Zealand talk about a previously ‘taboo’ subject, but it has also provided a platform for significant behaviour change which will help to reduce inequalities in the burden of cervical cancer. Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The National Cervical Screening Programme (NCSP) was established in 1990 to reduce the incidence and mortality of cervical cancer in New Zealand. It is managed by the National Screening Unit of the Ministry of Health, and recommends 3-yearly cervical smears for women aged 20–70 years. The NCSP has been highly successful in achieving these goals, having contributed to a 50% reduction in incidence and a 65% reduction in mortality since inception.1 Recent modelling studies
* Corresponding author. Ministry of Health, National Screening Unit, Private Bag 92522, Wellesly Street, Auckland, New Zealand. Tel.: þ64 9 580 9035; fax: þ64 9 580 9001. E-mail address: [email protected] (G.R. Bethune).
estimate that the NCSP prevents about 75% of cases of invasive cervical cancer per year that would have occurred in the absence of screening.2 However, approximately 160 women still develop invasive cervical cancer, and between 60 and 70 women still die from this disease each year. There are also considerable health inequalities. ori and Pacific women is The incidence of cervical cancer among Ma twice the rate among all women, and mortality is three to four times the rate among all women.3 The primary reason for these disparities ori and Pacific is lower rates of screening coverage among Ma women (<50% in August 2007) compared with other women (approximately 80%). Coverage is the percentage of the eligible population who have had a smear test in the previous 3 years. Earlier New Zealand research has identified several factors that discourage women from participating in cervical screening, including
0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.06.006
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a lack of knowledge about the benefits or harms of cervical screening, embarrassment or shyness (exposure of a ‘private’ area of the body, which is disempowering), and fear of the screening process (i.e. having the cervical smear) and of the results.4–6 The evidence of effectiveness of social marketing has been building over the last decade.7,8 However, marketing campaigns have sometimes led to widening inequalities as groups with more resources have been able to respond more to public health messages.9 The aim of the social marketing intervention, therefore, was to increase coverage overall, while reducing inequalities in coverage between different ethnic groups. A social marketing intervention was developed with the objective of addressing the inequalities in screening coverage (and ori and Pacific women, particutherefore outcomes) between Ma larly between 30 and 50 years of age (the priority women), and the rest of the eligible population (all women aged 20–70 years who had not had a smear test in the last 3 years). The challenge was not just to say that these groups mattered, but to put them at the heart of a major new social marketing intervention.
Methods
The campaign involved the development of a new creative strategy to address these issues. The use of humour was identified as one of the strategies to be used, particularly in appealing to Pacific women. The use of compelling, real-life stories was identiori women. fied as another effective strategy, particularly for Ma The new strategy resulted in the production of eight 30-second television advertisements, and radio, outdoor and other advertising material. The campaign was launched by the Prime Minister of New Zealand in September 2007. Whilst the communications campaign was undoubtedly a central component of the social marketing intervention, it was only one element of a much broader programme of activity. This included work across a range of other areas, aimed at influencing changes to service delivery and improving access to services, particularly for the key target groups. Stakeholder engagement Development of the campaign provided a platform for initiating a major stakeholder engagement programme. It provided a focus for discussions, gave NCSP screening providers an opportunity to contribute to the campaign, and helped to ensure their ‘buy-in’ and support. Findings from the prior research were also used to influence improvements in service design, delivery and access.
Social marketing intervention An investigation was undertaken to develop insights into the attitudes and understanding of cervical screening and cervical ori and Pacific women. cancer, particularly among Ma A mix of qualitative and quantitative research methods were used, including individual in-depth interviews, paired interviews ori and Pacific interviewers and researchers and focus groups. Ma were used for the investigation. The sample included a diverse mix of women – urban and rural, enrolled and not enrolled in the NCSP, ori and and all age and ethnic groups, with over-sampling of Ma Pacific women. Structured interviews were also conducted with community leaders and key stakeholders, particularly those involved with ori and Pacific women. providing screening services to Ma The research and its findings enabled the project team to develop valuable insights into the motivations and barriers of the target groups, and to make fundamental changes to service design and delivery. For example, the information was used to educate smear takers on ways to improve the smear-taking experience for women, particularly by addressing cultural issues identified by the research. It was used to improve access to services, by encouraging smear-taking clinics to allow women to attend in groups and to make increased use of home-based smear-taking services for groups of women. The research findings were also used to inform the development of a new national communications campaign, with a high degree of customer segmentation possible due to the sampling methodology used in the research. The objectives for the campaign were to: raise awareness and ‘normalize’ the subject; increase understanding about cervical screening and its benefits; create discussion among families, friends and communities; encourage women to think about participating in cervical screening; increase calls to the 0800 number (a freephone number for information about the NCSP); ori and Pacific women who have increase the number of Ma regular cervical smears and reduce inequalities; and support NCSP health promoters by providing a context for their activity.
Media relations Cervical screening in New Zealand has a backdrop of failure, having been associated with two of the country’s largest health inquiries. The unethical treatment of women with cervical smear abnormalities in the 1980s resulted in a major public inquiry (the Cartwright Inquiry), which in turn led to the establishment of the NCSP. The under-reporting of women with cervical smear abnormalities in the Gisborne region was a significant laboratory failure, which lead to a further public inquiry and report in 2001. These events completely overshadowed the success of the NCSP in reducing the impact of cervical cancer in New Zealand. A key challenge, therefore, was to demonstrate that the NCSP had moved on from these events (without minimizing their significance). Workforce development Workshops were held for more than 50 health promoters who are the local champions for cervical screening and the people on the ground dealing with local media and community networks. The workshops included a campaign update, an introduction to social marketing, media training, and practical planning for ways to leverage off the campaign locally. The training gained buy-in, improved the capability of a key workforce and helped to ensure that the campaign messages were extended into the regions. The workshops provided a further forum to ensure delivery and access to services which were designed to meet the needs of the key target groups. Many providers initiated ‘well women’s pamper days’, which brought women together for a day of pampering combined with a range of health checks. Health education resources The resources of the NCSP were updated to ensure consistency of messages and alignment with the campaign creative. The resources included posters and brochures designed for the general ori and Pacific population, as well as versions targeting Ma women. A wallet reminder card was developed in response to research indicating that many women forget when their next smear test is due. 0800 number The NCSP has an 0800 number which provides women with information on smear-taking services in their region and a list of
G.R. Bethune, H.J. Lewis / Public Health 123 (2009) e17–e22
frequently asked questions. The service was evaluated and opportunities were identified for improving accessibility and flexibility. Extended hours were introduced during the launch period. Free mobile phone access was introduced in recognition of the increased use of mobile phones, particularly by the priority audiences for the campaign. Targeted funding Most women participating in the NCSP are required to pay a part charge, which is usually the cost of visiting their general practitioner or community health clinic. This can vary from $10 to $50 depending on the clinic. Cost was identified by the research as one of the key barriers to address, particularly for the priority audiences for the campaign. Due to funding constraints, universal funding to make all smear tests free was not an option. Instead, the NCSP varied its contracts with a number of regional screening ori, services to provide free smears to high-priority women, i.e. Ma Pacific, the unscreened or under-screened. At the time of writing, analysis was still being undertaken to determine the success of this initiative. Behavioural theory The social marketing intervention developed for the NCSP incorporated elements of two behavioural theories, as follows. Health belief model10 This model seeks to explain why individuals do or do not carry out certain health-related behaviours, such as attending for screening. It suggests that a person’s willingness to change their health behaviour is based on the following factors. Perceived susceptibility: how likely an individual thinks they are to develop a certain condition. Unless they believe they are at risk, an individual is unlikely to change their health behaviours; Perceived severity: how serious the individual believes the condition and its consequences to be; Perceived benefits: what benefits the individual sees in terms of the positive effects of adopting the behaviour, i.e. ‘what’s in it for me?’; and Perceived barriers: how ‘hard’ the individual thinks it will be to change their behaviour, and the costs that are involved – money, but also effort, time, inconvenience, disruption to regular routines etc. The health belief model can be used to predict and prompt health behaviours, and to understand the reasons why individuals do or do not use available services. It recognizes that it is not enough simply to encourage individuals to want to change their health behaviour; there are a range of other factors which affect their intention and ability to change. The intervention developed for the NCSP recognized that a lack of information about cervical screening was preventing women from getting tested. Consequently, it employed carefully targeted advertising (‘cues to action’) to increase awareness and ‘perceived efficacy’. It also recognized that this information and the desired behaviour (screening) needed to be easily accessible, hence modifications to the 0800 service, the delivery and availability of screening services and the primary call to action – ‘Contact your doctor, nurse or local health worker’.
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Table 1 Ethnic composition of the survey sample. Ethnic group
Prior to campaign
6-month survey
12-month survey
ori Ma Pacific Other ethnicity
308 296 456
304 296 473
316 295 464
Total
908
902
903
behaviour as a process rather than an event; it also recognizes that there are different levels of motivation and readiness to change. This model outlines five main stages that individuals go through when adopting a behaviour. Pre-contemplation: an individual does not consider or intend to undertake the behaviour; Contemplation: they understand and consider changing. At this stage, they may seek more information about the behaviour; Preparation: here, an individual undertakes the final steps of consideration, re-affirms their reasons for changing and makes a commitment to do so; Action: change occurs and an individual undertakes the desired behaviour; and Maintenance: the behaviour is sustained and consolidated. However, it could also be that an individual relapses into their original state. Such a model offers a useful segmentation tool and was reflected in the two-phase approach of the intervention. Phase 1 targeted the ‘pre-contemplators’, aiming to create awareness of the benefits of screening, whilst prompting increased understanding and discussion. Phase 2 aimed to progress individuals from contemplation to preparation and action, prompting them to make an appointment and attend for screening. By rewarding this positive behaviour and using community role modelling, ‘maintenance’ will hopefully be achieved.
Evaluation Monitoring surveys A telephone survey of the key audiences was conducted prior to the campaign launch to establish benchmarks for awareness, attitudes and understanding of issues related to cervical screening. Sixand 12-month monitor surveys were undertaken in February 2007 and August 2008, which enabled evaluation of the effectiveness of the campaign. This monitoring is on-going.
16,000 14,000
2006/07
2007/08
12,000 10,000 8000 6000 4000 2000
Trans-theoretical (stages-of-change) model11 The trans-theoretical or stages-of-change model is a wellknown theory of behavioural change. It looks at the different stages that are most common to behavioural change. This theory sees
0 Q1
Q2
Q3
Q4
Figure 1. 0800 telephone calls by quarter, 2006/07 and 2007/08.
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14
Monitoring surveys
12
%
10 8 6 4 2 0
Maori
Pacific
Asian
Other
Total
Figure 2. Percentage increase in screening coverage after 12 months by ethnic group.
0800 number Calls to the NCSP’s 0800 number were monitored on a monthly basis before, during and after the campaign. NCSP monthly coverage statistics The NCSP Register (NCSP-R) is a national database that holds the results of cervical specimens of all women who participate in the NCSP. The NCSP-R is an important support tool for providers of cervical screening in New Zealand, through sending reminder letters to women overdue for a smear test. The NCSP-R is also used to calculate cervical screening coverage, i.e. the proportion of women (aged 20–70 years) with a screening result recorded on the NCSP-R in the last 3 years. Monthly coverage reports are produced routinely and distributed nationally to all NCSP providers to assist with assessment of progress on the initiatives undertaken. The NCSP coverage statistics were used to monitor the effects of the campaign. Results Pre-campaign investigation The pre-campaign research identified several factors likely to reduce women’s participation in cervical screening, including: the cost of a cervical smear for some women; misunderstandings about cervical cancer and the screening process; lack of awareness of the NCSP and cervical cancer generally; embarrassment in having a smear; lack of discussion and ways of talking about the issue of cervical screening; no ‘sense of collective’ – i.e. lack of support from friends or family for women to participate in screening; and a backdrop of failure – the NCSP was perceived as being associated with significant failure in the past, something that resonated strongly with women.
Table 1 shows the ethnic composition of the population surveyed during 2008, before and during the campaign at 6- and 12-month intervals. Women acknowledging multiple identities were included in each group to which they affiliated. The response rate was 82% for the pre-campaign survey, 85% for the 6-month survey and 83% for the 12-month survey. The results from the 6- and 12-month quantitative monitor surveys illustrate that the campaign achieved significant increases in awareness, understanding and attitudes related to cervical cancer and cervical screening. Among priority women, the campaign led to a 117% increase in discussion of cervical screening after 6 months and 54% after 12 months. After 12 months, there was a 75% increase in awareness of 3-yearly screening. The likelihood of priority women being screened in the next 3 years increased by 49% following 12 months of the campaign. Among priority women after 12 months, 59% had thought about making an appointment, 25% had encouraged others to make an appointment and 77% reported taking some sort of action. Among the general population, there were four significant increases over the 12 months on measures influenced by the campaign: 26% increase in awareness of the 3-yearly screening frequency; 20% increase in discussion of smear testing; 8% increase in agreement that cervical cancer can be prevented; and 10% increase in likelihood of being screened in the next 3 years. The campaign received good ‘cut-through’ with all audiences, as reflected by the high level of message recall and awareness of the advertisements. Among all women interviewed, 86% recalled seeing some form of advertising for cervical screening, and this increased to 94% with prompting. Key messages from the campaign – having a test, getting tested regularly, the importance of the test, not putting it off and making an appointment – were mentioned by 75% of the priority women after 12 months.
0800 telephone calls Fig. 1 shows a comparison between the number of calls received each quarter (3-month period) since the commencement of the communications campaign and the corresponding quarter the previous year. In 12 months, the 0800 number received 47,700 calls; an increase of 27% compared with the previous year.
51 50
%
49 48 47 46 45 Aug 07
Sept
Oct
Nov
Dec
Jan 08
Feb
Mar
Apr
May
Jun
Jul
Aug
ori women, August 2007–August 2008. Figure 3. National Cervical Screening Programme screening coverage, Ma
G.R. Bethune, H.J. Lewis / Public Health 123 (2009) e17–e22
e21
53 52 51 50
%
49 48 47 46 45 44 43 Aug 07
Sept
Oct
Nov
Dec
Jan 08
Feb
Mar
Apr
May
Jun
Jul
Aug
Figure 4. National Cervical Screening Programme screening coverage, Pacific women, August 2007–August 2008.
Participation in the NCSP (monthly coverage reports) Fig. 2 shows the percentage increases in screening coverage, by main ethnic group, in the 12 months since the commencement of the communications campaign. The increase was much greater for ori priority women, particularly Pacific women (12.7%) and Ma women (6.8%), than other women (2.7%). However, an increase was also seen for the total eligible population (3.3%). Figs. 3 and 4 show the monthly screening coverage rates for ori and Pacific women, respectively, between August 2007 (prior Ma to launch of the campaign) and August 2008. A steady and significant increase in coverage of priority women since the launch of the campaign is seen. Discussion The campaign was more than 2 years in planning and development, enabling the project team to develop in-depth insights into the key issues and barriers for the priority audiences. The indepth research helped the team to fully understand the issues, ori and Pacific motivations, barriers and current perceptions of Ma women. The research gave the team deep insights into ways of addressing these, using the communications campaign as a major new platform to change the way in which women thought about and discussed cervical cancer and cervical screening. The fact that the project achieved its objectives is clearly evident in the results after 12 months. The campaign has helped to ‘break the ice’ for discussion of a sensitive subject and has improved awareness and understanding of the benefits of regular cervical screening. The use of humour, in particular, in several of the television advertisements proved to be highly effective in creating conversations and discussion among women. Whilst this strategy was initially devised to appeal to Pacific women, the approach found widespread appeal across all ethnicities. The positive impact of the intervention on awareness and discussion has also clearly provided a platform for significant ori and Pacific women behaviour change by the target groups. Ma are not only more aware of the benefits of screening and increasingly talking about it among themselves, but are taking action and attending for screening. Development of the intervention in itself also provided a valuable focal point for efforts by the NCSP to reduce inequalities. It provided the basis for valuable discussions with screening ori and Pacific women. In providers about how to engage with Ma effect, development of the campaign acted as a valuable catalyst for change, and has helped the NCSP to celebrate the significant
progress made in reducing the burden of cervical cancer, whilst signalling new efforts to reduce the burden and the inequalities in who bears the burden even further. The key learning and insight was around the way in which the project team chose to focus all of its efforts on priority groups of women and to ensure that this was reflected in every discussion, decision, resource allocation and aspect of the NCSP. The team were ori and always asking ‘How will this enable us to connect with Ma Pacific women? Will it enable us to reduce the current inequalities?’ The social marketing intervention developed for the NCSP has demonstrated the benefit of focusing on those who experience the greatest health inequalities. It has resulted in increased awareness and understanding of cervical screening, which in turn has led to higher rates of screening coverage for all groups of women. Importantly, greater improvements were seen for priority women, who were the central focus of the campaign, leading to a reduction in inequalities. At the same time, concerns that focusing on priority women might lead to a decrease in participation by other women proved to be groundless. The results achieved for the NCSP add further weight to the body of evidence demonstrating the effectiveness of social marketing as a public health intervention. Acknowledgements The social marketing intervention for the NCSP was delivered in partnership with GSL Network, a specialist social marketing agency, based in Wellington, New Zealand. Ethical approval Multi-region Ethics Committee of the Ministry of Health. Funding None declared. Competing interests None declared. References 1. Ministry of Health, New Zealand. Cervical screening in New Zealand. A brief statistical review of the first decade. Wellington: National Cervical Screening Programme (NCSP). Available from: www.nsu.govt.nz; 2005. 2. Canfell K, Clements M, Harris J. Cost effectiveness of proposed changes to the National Cervical Screening Programme. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2008.
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3. National Cervical Screening Programme. Monthly coverage statistics. Wellington: New Zealand Ministry of Health; 2008. 4. Tautoko Kahui. Literature review – health promotion: breast and cervical screening. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2004. 5. Fisher E, Pipi K, Howearth J. Informing the development of a communications campaign for the National Cervical Screening Programme. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2005. 6. Women’s Health Action Trust. New directions for cervical screening education resources. A report and literature review for the National Cervical Screening Programme. Wellington: New Zealand Ministry of Health; 2000.
7. Maibach E, Shenker A, Singer S. Results of the Delphi survey. J Health Commun 1997;2:304–7. 8. Millett C, Zelenyanszk C, Furlong C, Binysh K. An evaluation of a social marketing campaign to reduce the number of London women who have never been screened for cervical cancer. J Med Screen 2005;12:204–5. 9. Scottish Government. Equally well. Report of the Ministerial Task Force on Health Inequalities. Edinburgh: Scottish Government; 2008. 10. Rosenstock I, Strecher J, Becker M. Social learning theory and the health belief model. Health Educ Behav 1998;15:175–83. 11. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Am Psychol 1992;47:1102–14.
Contents lists available at ScienceDirect
Public Health journal homepage: www.elsevierhealth.com/journals/pubh
e-Supplement
Let’s talk about smear tests: Social marketing for the National Cervical Screening Programme G.R. Bethune a, *, H.J. Lewis b a b
Manager, Communications and Marketing, National Screening Unit, Ministry of Health, Auckland, New Zealand Clinical Leader, National Cervical Screening Programme, National Screening Unit, Ministry of Health, Wellington, New Zealand
a r t i c l e i n f o
s u m m a r y
Article history: Received 14 January 2009 Received in revised form 19 May 2009 Accepted 10 June 2009 Available online 8 September 2009
ori and Pacific women in the Objectives: The overall aim of the work was to increase participation by Ma National Cervical Screening Programme (NCSP) in New Zealand using a social marketing informed approach. Key objectives for this target group included: increasing awareness, understanding and discussion of cervical cancer and cervical screening; increasing telephone calls to the NCSP’s 0800 number; and increasing uptake of cervical screening.
Study design: A social marketing intervention with mixed qualitative and quantitative evaluation. Keywords: Cervical cancer Cervical screening Inequalities in cervical screening Social marketing
Methods: Focus groups with priority women and key stakeholder interviews were used to identify a set of key messages from which television, radio and print media advertisements were developed. The advertising campaign was one element of a broader programme of activity, which involved changes to service delivery and improvement to access to services, particularly for the target groups. The campaign was evaluated in three ways: quantitative surveys conducted before, during and after the intervention; monitoring the number of calls to the NCSP’s 0800 number; and monitoring NCSP monthly coverage statistics. Results: The social marketing intervention achieved measurable behavioural impacts with its primary ori (6.8%) and Pacific women target audiences, delivering significant increases in screening uptake by Ma (12.7%) after 12 months. In addition, there was a secondary positive impact on other women (not the immediate target audience) whose rate of update also increased (2.7%). Overall, the intervention helped to reduce inequalities and delivered substantial increases in awareness, understanding and discussion of cervical cancer and cervical screening amongst the target groups. Conclusions: The results demonstrate that social marketing can be effective in targeting marginalized or under-represented groups. The intervention has not only changed the way in which women in New Zealand talk about a previously ‘taboo’ subject, but it has also provided a platform for significant behaviour change which will help to reduce inequalities in the burden of cervical cancer. Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction The National Cervical Screening Programme (NCSP) was established in 1990 to reduce the incidence and mortality of cervical cancer in New Zealand. It is managed by the National Screening Unit of the Ministry of Health, and recommends 3-yearly cervical smears for women aged 20–70 years. The NCSP has been highly successful in achieving these goals, having contributed to a 50% reduction in incidence and a 65% reduction in mortality since inception.1 Recent modelling studies
* Corresponding author. Ministry of Health, National Screening Unit, Private Bag 92522, Wellesly Street, Auckland, New Zealand. Tel.: þ64 9 580 9035; fax: þ64 9 580 9001. E-mail address: [email protected] (G.R. Bethune).
estimate that the NCSP prevents about 75% of cases of invasive cervical cancer per year that would have occurred in the absence of screening.2 However, approximately 160 women still develop invasive cervical cancer, and between 60 and 70 women still die from this disease each year. There are also considerable health inequalities. ori and Pacific women is The incidence of cervical cancer among Ma twice the rate among all women, and mortality is three to four times the rate among all women.3 The primary reason for these disparities ori and Pacific is lower rates of screening coverage among Ma women (<50% in August 2007) compared with other women (approximately 80%). Coverage is the percentage of the eligible population who have had a smear test in the previous 3 years. Earlier New Zealand research has identified several factors that discourage women from participating in cervical screening, including
0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.06.006
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G.R. Bethune, H.J. Lewis / Public Health 123 (2009) e17–e22
a lack of knowledge about the benefits or harms of cervical screening, embarrassment or shyness (exposure of a ‘private’ area of the body, which is disempowering), and fear of the screening process (i.e. having the cervical smear) and of the results.4–6 The evidence of effectiveness of social marketing has been building over the last decade.7,8 However, marketing campaigns have sometimes led to widening inequalities as groups with more resources have been able to respond more to public health messages.9 The aim of the social marketing intervention, therefore, was to increase coverage overall, while reducing inequalities in coverage between different ethnic groups. A social marketing intervention was developed with the objective of addressing the inequalities in screening coverage (and ori and Pacific women, particutherefore outcomes) between Ma larly between 30 and 50 years of age (the priority women), and the rest of the eligible population (all women aged 20–70 years who had not had a smear test in the last 3 years). The challenge was not just to say that these groups mattered, but to put them at the heart of a major new social marketing intervention.
Methods
The campaign involved the development of a new creative strategy to address these issues. The use of humour was identified as one of the strategies to be used, particularly in appealing to Pacific women. The use of compelling, real-life stories was identiori women. fied as another effective strategy, particularly for Ma The new strategy resulted in the production of eight 30-second television advertisements, and radio, outdoor and other advertising material. The campaign was launched by the Prime Minister of New Zealand in September 2007. Whilst the communications campaign was undoubtedly a central component of the social marketing intervention, it was only one element of a much broader programme of activity. This included work across a range of other areas, aimed at influencing changes to service delivery and improving access to services, particularly for the key target groups. Stakeholder engagement Development of the campaign provided a platform for initiating a major stakeholder engagement programme. It provided a focus for discussions, gave NCSP screening providers an opportunity to contribute to the campaign, and helped to ensure their ‘buy-in’ and support. Findings from the prior research were also used to influence improvements in service design, delivery and access.
Social marketing intervention An investigation was undertaken to develop insights into the attitudes and understanding of cervical screening and cervical ori and Pacific women. cancer, particularly among Ma A mix of qualitative and quantitative research methods were used, including individual in-depth interviews, paired interviews ori and Pacific interviewers and researchers and focus groups. Ma were used for the investigation. The sample included a diverse mix of women – urban and rural, enrolled and not enrolled in the NCSP, ori and and all age and ethnic groups, with over-sampling of Ma Pacific women. Structured interviews were also conducted with community leaders and key stakeholders, particularly those involved with ori and Pacific women. providing screening services to Ma The research and its findings enabled the project team to develop valuable insights into the motivations and barriers of the target groups, and to make fundamental changes to service design and delivery. For example, the information was used to educate smear takers on ways to improve the smear-taking experience for women, particularly by addressing cultural issues identified by the research. It was used to improve access to services, by encouraging smear-taking clinics to allow women to attend in groups and to make increased use of home-based smear-taking services for groups of women. The research findings were also used to inform the development of a new national communications campaign, with a high degree of customer segmentation possible due to the sampling methodology used in the research. The objectives for the campaign were to: raise awareness and ‘normalize’ the subject; increase understanding about cervical screening and its benefits; create discussion among families, friends and communities; encourage women to think about participating in cervical screening; increase calls to the 0800 number (a freephone number for information about the NCSP); ori and Pacific women who have increase the number of Ma regular cervical smears and reduce inequalities; and support NCSP health promoters by providing a context for their activity.
Media relations Cervical screening in New Zealand has a backdrop of failure, having been associated with two of the country’s largest health inquiries. The unethical treatment of women with cervical smear abnormalities in the 1980s resulted in a major public inquiry (the Cartwright Inquiry), which in turn led to the establishment of the NCSP. The under-reporting of women with cervical smear abnormalities in the Gisborne region was a significant laboratory failure, which lead to a further public inquiry and report in 2001. These events completely overshadowed the success of the NCSP in reducing the impact of cervical cancer in New Zealand. A key challenge, therefore, was to demonstrate that the NCSP had moved on from these events (without minimizing their significance). Workforce development Workshops were held for more than 50 health promoters who are the local champions for cervical screening and the people on the ground dealing with local media and community networks. The workshops included a campaign update, an introduction to social marketing, media training, and practical planning for ways to leverage off the campaign locally. The training gained buy-in, improved the capability of a key workforce and helped to ensure that the campaign messages were extended into the regions. The workshops provided a further forum to ensure delivery and access to services which were designed to meet the needs of the key target groups. Many providers initiated ‘well women’s pamper days’, which brought women together for a day of pampering combined with a range of health checks. Health education resources The resources of the NCSP were updated to ensure consistency of messages and alignment with the campaign creative. The resources included posters and brochures designed for the general ori and Pacific population, as well as versions targeting Ma women. A wallet reminder card was developed in response to research indicating that many women forget when their next smear test is due. 0800 number The NCSP has an 0800 number which provides women with information on smear-taking services in their region and a list of
G.R. Bethune, H.J. Lewis / Public Health 123 (2009) e17–e22
frequently asked questions. The service was evaluated and opportunities were identified for improving accessibility and flexibility. Extended hours were introduced during the launch period. Free mobile phone access was introduced in recognition of the increased use of mobile phones, particularly by the priority audiences for the campaign. Targeted funding Most women participating in the NCSP are required to pay a part charge, which is usually the cost of visiting their general practitioner or community health clinic. This can vary from $10 to $50 depending on the clinic. Cost was identified by the research as one of the key barriers to address, particularly for the priority audiences for the campaign. Due to funding constraints, universal funding to make all smear tests free was not an option. Instead, the NCSP varied its contracts with a number of regional screening ori, services to provide free smears to high-priority women, i.e. Ma Pacific, the unscreened or under-screened. At the time of writing, analysis was still being undertaken to determine the success of this initiative. Behavioural theory The social marketing intervention developed for the NCSP incorporated elements of two behavioural theories, as follows. Health belief model10 This model seeks to explain why individuals do or do not carry out certain health-related behaviours, such as attending for screening. It suggests that a person’s willingness to change their health behaviour is based on the following factors. Perceived susceptibility: how likely an individual thinks they are to develop a certain condition. Unless they believe they are at risk, an individual is unlikely to change their health behaviours; Perceived severity: how serious the individual believes the condition and its consequences to be; Perceived benefits: what benefits the individual sees in terms of the positive effects of adopting the behaviour, i.e. ‘what’s in it for me?’; and Perceived barriers: how ‘hard’ the individual thinks it will be to change their behaviour, and the costs that are involved – money, but also effort, time, inconvenience, disruption to regular routines etc. The health belief model can be used to predict and prompt health behaviours, and to understand the reasons why individuals do or do not use available services. It recognizes that it is not enough simply to encourage individuals to want to change their health behaviour; there are a range of other factors which affect their intention and ability to change. The intervention developed for the NCSP recognized that a lack of information about cervical screening was preventing women from getting tested. Consequently, it employed carefully targeted advertising (‘cues to action’) to increase awareness and ‘perceived efficacy’. It also recognized that this information and the desired behaviour (screening) needed to be easily accessible, hence modifications to the 0800 service, the delivery and availability of screening services and the primary call to action – ‘Contact your doctor, nurse or local health worker’.
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Table 1 Ethnic composition of the survey sample. Ethnic group
Prior to campaign
6-month survey
12-month survey
ori Ma Pacific Other ethnicity
308 296 456
304 296 473
316 295 464
Total
908
902
903
behaviour as a process rather than an event; it also recognizes that there are different levels of motivation and readiness to change. This model outlines five main stages that individuals go through when adopting a behaviour. Pre-contemplation: an individual does not consider or intend to undertake the behaviour; Contemplation: they understand and consider changing. At this stage, they may seek more information about the behaviour; Preparation: here, an individual undertakes the final steps of consideration, re-affirms their reasons for changing and makes a commitment to do so; Action: change occurs and an individual undertakes the desired behaviour; and Maintenance: the behaviour is sustained and consolidated. However, it could also be that an individual relapses into their original state. Such a model offers a useful segmentation tool and was reflected in the two-phase approach of the intervention. Phase 1 targeted the ‘pre-contemplators’, aiming to create awareness of the benefits of screening, whilst prompting increased understanding and discussion. Phase 2 aimed to progress individuals from contemplation to preparation and action, prompting them to make an appointment and attend for screening. By rewarding this positive behaviour and using community role modelling, ‘maintenance’ will hopefully be achieved.
Evaluation Monitoring surveys A telephone survey of the key audiences was conducted prior to the campaign launch to establish benchmarks for awareness, attitudes and understanding of issues related to cervical screening. Sixand 12-month monitor surveys were undertaken in February 2007 and August 2008, which enabled evaluation of the effectiveness of the campaign. This monitoring is on-going.
16,000 14,000
2006/07
2007/08
12,000 10,000 8000 6000 4000 2000
Trans-theoretical (stages-of-change) model11 The trans-theoretical or stages-of-change model is a wellknown theory of behavioural change. It looks at the different stages that are most common to behavioural change. This theory sees
0 Q1
Q2
Q3
Q4
Figure 1. 0800 telephone calls by quarter, 2006/07 and 2007/08.
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14
Monitoring surveys
12
%
10 8 6 4 2 0
Maori
Pacific
Asian
Other
Total
Figure 2. Percentage increase in screening coverage after 12 months by ethnic group.
0800 number Calls to the NCSP’s 0800 number were monitored on a monthly basis before, during and after the campaign. NCSP monthly coverage statistics The NCSP Register (NCSP-R) is a national database that holds the results of cervical specimens of all women who participate in the NCSP. The NCSP-R is an important support tool for providers of cervical screening in New Zealand, through sending reminder letters to women overdue for a smear test. The NCSP-R is also used to calculate cervical screening coverage, i.e. the proportion of women (aged 20–70 years) with a screening result recorded on the NCSP-R in the last 3 years. Monthly coverage reports are produced routinely and distributed nationally to all NCSP providers to assist with assessment of progress on the initiatives undertaken. The NCSP coverage statistics were used to monitor the effects of the campaign. Results Pre-campaign investigation The pre-campaign research identified several factors likely to reduce women’s participation in cervical screening, including: the cost of a cervical smear for some women; misunderstandings about cervical cancer and the screening process; lack of awareness of the NCSP and cervical cancer generally; embarrassment in having a smear; lack of discussion and ways of talking about the issue of cervical screening; no ‘sense of collective’ – i.e. lack of support from friends or family for women to participate in screening; and a backdrop of failure – the NCSP was perceived as being associated with significant failure in the past, something that resonated strongly with women.
Table 1 shows the ethnic composition of the population surveyed during 2008, before and during the campaign at 6- and 12-month intervals. Women acknowledging multiple identities were included in each group to which they affiliated. The response rate was 82% for the pre-campaign survey, 85% for the 6-month survey and 83% for the 12-month survey. The results from the 6- and 12-month quantitative monitor surveys illustrate that the campaign achieved significant increases in awareness, understanding and attitudes related to cervical cancer and cervical screening. Among priority women, the campaign led to a 117% increase in discussion of cervical screening after 6 months and 54% after 12 months. After 12 months, there was a 75% increase in awareness of 3-yearly screening. The likelihood of priority women being screened in the next 3 years increased by 49% following 12 months of the campaign. Among priority women after 12 months, 59% had thought about making an appointment, 25% had encouraged others to make an appointment and 77% reported taking some sort of action. Among the general population, there were four significant increases over the 12 months on measures influenced by the campaign: 26% increase in awareness of the 3-yearly screening frequency; 20% increase in discussion of smear testing; 8% increase in agreement that cervical cancer can be prevented; and 10% increase in likelihood of being screened in the next 3 years. The campaign received good ‘cut-through’ with all audiences, as reflected by the high level of message recall and awareness of the advertisements. Among all women interviewed, 86% recalled seeing some form of advertising for cervical screening, and this increased to 94% with prompting. Key messages from the campaign – having a test, getting tested regularly, the importance of the test, not putting it off and making an appointment – were mentioned by 75% of the priority women after 12 months.
0800 telephone calls Fig. 1 shows a comparison between the number of calls received each quarter (3-month period) since the commencement of the communications campaign and the corresponding quarter the previous year. In 12 months, the 0800 number received 47,700 calls; an increase of 27% compared with the previous year.
51 50
%
49 48 47 46 45 Aug 07
Sept
Oct
Nov
Dec
Jan 08
Feb
Mar
Apr
May
Jun
Jul
Aug
ori women, August 2007–August 2008. Figure 3. National Cervical Screening Programme screening coverage, Ma
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53 52 51 50
%
49 48 47 46 45 44 43 Aug 07
Sept
Oct
Nov
Dec
Jan 08
Feb
Mar
Apr
May
Jun
Jul
Aug
Figure 4. National Cervical Screening Programme screening coverage, Pacific women, August 2007–August 2008.
Participation in the NCSP (monthly coverage reports) Fig. 2 shows the percentage increases in screening coverage, by main ethnic group, in the 12 months since the commencement of the communications campaign. The increase was much greater for ori priority women, particularly Pacific women (12.7%) and Ma women (6.8%), than other women (2.7%). However, an increase was also seen for the total eligible population (3.3%). Figs. 3 and 4 show the monthly screening coverage rates for ori and Pacific women, respectively, between August 2007 (prior Ma to launch of the campaign) and August 2008. A steady and significant increase in coverage of priority women since the launch of the campaign is seen. Discussion The campaign was more than 2 years in planning and development, enabling the project team to develop in-depth insights into the key issues and barriers for the priority audiences. The indepth research helped the team to fully understand the issues, ori and Pacific motivations, barriers and current perceptions of Ma women. The research gave the team deep insights into ways of addressing these, using the communications campaign as a major new platform to change the way in which women thought about and discussed cervical cancer and cervical screening. The fact that the project achieved its objectives is clearly evident in the results after 12 months. The campaign has helped to ‘break the ice’ for discussion of a sensitive subject and has improved awareness and understanding of the benefits of regular cervical screening. The use of humour, in particular, in several of the television advertisements proved to be highly effective in creating conversations and discussion among women. Whilst this strategy was initially devised to appeal to Pacific women, the approach found widespread appeal across all ethnicities. The positive impact of the intervention on awareness and discussion has also clearly provided a platform for significant ori and Pacific women behaviour change by the target groups. Ma are not only more aware of the benefits of screening and increasingly talking about it among themselves, but are taking action and attending for screening. Development of the intervention in itself also provided a valuable focal point for efforts by the NCSP to reduce inequalities. It provided the basis for valuable discussions with screening ori and Pacific women. In providers about how to engage with Ma effect, development of the campaign acted as a valuable catalyst for change, and has helped the NCSP to celebrate the significant
progress made in reducing the burden of cervical cancer, whilst signalling new efforts to reduce the burden and the inequalities in who bears the burden even further. The key learning and insight was around the way in which the project team chose to focus all of its efforts on priority groups of women and to ensure that this was reflected in every discussion, decision, resource allocation and aspect of the NCSP. The team were ori and always asking ‘How will this enable us to connect with Ma Pacific women? Will it enable us to reduce the current inequalities?’ The social marketing intervention developed for the NCSP has demonstrated the benefit of focusing on those who experience the greatest health inequalities. It has resulted in increased awareness and understanding of cervical screening, which in turn has led to higher rates of screening coverage for all groups of women. Importantly, greater improvements were seen for priority women, who were the central focus of the campaign, leading to a reduction in inequalities. At the same time, concerns that focusing on priority women might lead to a decrease in participation by other women proved to be groundless. The results achieved for the NCSP add further weight to the body of evidence demonstrating the effectiveness of social marketing as a public health intervention. Acknowledgements The social marketing intervention for the NCSP was delivered in partnership with GSL Network, a specialist social marketing agency, based in Wellington, New Zealand. Ethical approval Multi-region Ethics Committee of the Ministry of Health. Funding None declared. Competing interests None declared. References 1. Ministry of Health, New Zealand. Cervical screening in New Zealand. A brief statistical review of the first decade. Wellington: National Cervical Screening Programme (NCSP). Available from: www.nsu.govt.nz; 2005. 2. Canfell K, Clements M, Harris J. Cost effectiveness of proposed changes to the National Cervical Screening Programme. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2008.
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3. National Cervical Screening Programme. Monthly coverage statistics. Wellington: New Zealand Ministry of Health; 2008. 4. Tautoko Kahui. Literature review – health promotion: breast and cervical screening. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2004. 5. Fisher E, Pipi K, Howearth J. Informing the development of a communications campaign for the National Cervical Screening Programme. Report to the National Screening Unit. Wellington: New Zealand Ministry of Health; 2005. 6. Women’s Health Action Trust. New directions for cervical screening education resources. A report and literature review for the National Cervical Screening Programme. Wellington: New Zealand Ministry of Health; 2000.
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