Don’t Just SAY It Matters
‘Don’t Just SAY It Matters’ addresses ethnicity-based health inequalities in New Zealand. It aims to increase cervical screening amongst New Zealand’s Māori and Pacific women by creating an understanding of the importance of screening and enhancing the service to support uptake.
Funded by the New Zealand National Screening Unit, the three-phase programme launched in September 2007 and is ongoing until 2013. Phase One aimed to start conversations about cervical screening, Phase Two aimed to motivate women to be screened, and Phase Three has built on this work with the introduction of further interventions, such as continued use of humour in the adverts, addressing lingering barriers, and running a web-based competition.
By April 2010, screening coverage was:
- Pacific women – 60 per cent, a relative increase of 29.31 per cent over the course of the campaign (since September 2007)
- Māori women – 54.8 per cent, a relative increase of 15.37 per cent over the course of the campaign
- All women – 75.6 per cent, a relative increase of 7.23 per cent over the course of the campaign
It is estimated that in New Zealand 160 women develop cervical cancer every year and about 60 women die from this largely preventable disease. Around half the women who develop or die from cervical cancer have never been screened and about one-third have only been screened irregularly and infrequently.
The National Cervical Screening Programme (NCSP) was established in 1990 to reduce incidence of and mortality from cervical cancer, following a number of incidents in cervical screening. It was established as a direct result of a national inquiry into the unethical treatment of women with high grade cervical abnormalities by a doctor at National Women’s Hospital in Auckland. There was then a further national inquiry in 2000/01 into the under-reporting of cervical smear abnormalities in the Tairawhiti region of New Zealand. In both cases, the events that led up to the inquiries resulted in the loss of women’s lives through failure of screening services.
Subsequently the NCSP sought to make improvements and had a number of successes, such as a 50 per cent reduction in cervical cancer incidence and a 60 per cent reduction in mortality between 1990 and 2004. Nevertheless, the programme knew it still had to make improvements in certain areas.
In particular, cervical cancer in New Zealand had been identified as an area of significant health inequalities, with Māori and Pacific women experiencing higher incidence and mortality rates, and lower screening rates than other population groups.
In response to this, The National Screening Unit (NSU) decided to fund a three-year social marketing campaign to promote the importance of cervical screening and facilitate its uptake, with a particular focus on Māori and Pacific women. Although the programme would need to acknowledge the importance of cervical screening for all New Zealand women, there was a real risk that a population-based approach targeting all women would worsen inequalities. The programme would consequently need to devise strategies that effectively targeted the following audience segments:
- Māori and Pacific women who have ever been sexually active and who have not had a cervical smear test within the last three years
- Family, friends and community members supporting and influencing these priority women
- All women aged 20 to 69 who have ever been sexually active and who have not had a cervical smear test within the last three years
- Key stakeholders, such as health professionals (to be identified through a stakeholder mapping exercise)
Following the completion of the first three years, the campaign would be assessed to see whether it should be continued for a further three years.
An extensive research programme was carried out to inform the development and implementation of the campaign.
Screening coverage and mortality rates
Statistical research was conducted using data sources from the Programme Register. The Register records the screening histories of all women enrolled in the programme and enables regular reporting against the total eligible population, to identify the percentage of the eligible population that have had a smear test in the last three years (coverage). The figures below illustrate the significant inequalities in coverage at the time the campaign was initiated (September 2007):
- Māori: 46.6 per cent
- Pacific: 42.5 per cent
- Asian: 41.2 per cent
- Other: 80.0 per cent
- All: 69.1 per cent
Information from the New Zealand Cancer Registry, which records incidence and mortality from all reported cancers, identified that Māori and Pacific women were experiencing twice the incidence of cervical cancer and three to four times the mortality rates compared to other women. One of the key contributors to these figures was lower rates of participation in the screening programme.
A mix of qualitative research methods were used, including individual in-depth interviews, paired interviews and focus groups, with sessions usually lasting between two and two and half hours. Māori and Pacific interviewers and researchers were used for the study.
In total, 95 people were interviewed for this component of the research, with 32 Māori, 35 Pacific and 28 other eligible participants in the 20 to 69 year age group. The sample included a diverse mix of urban and rural, enrolled and not enrolled, all ages and ethnic groups.
Qualitative research was also conducted with eight Māori and four Pacific community key informants. These people were identified through community networks as having a good knowledge of their community’s perceptions and attitudes towards cervical screening.
Research with stakeholders was conducted, with 58 telephone interviews undertaken with a range of GPs, practice nurses, gynaecologists, service managers and staff, health promoters, media, women’s health organisations and other NGOs.
The qualitative research identified a range of key insights, including barriers to being screened:
- Lack of awareness of the programme and cervical cancer generally
- Lack of discussion and ways of talking about the issue
- No ‘sense of collective’
- A backdrop of failure
- Perception that clinics were difficult to access and inconvenient
- Worry about a painful procedure
- Worry about the cost, because most women are required to pay a surcharge for a smear test
- Competition for their time was a key issue that prevented women from being screened: “We’re given so many things to do and I would have to prioritise…it’s awful to say, but a cervical smear will have to go to the bottom of the list…it is the last thing for me to worry about.”
The research also identified significant differences between the two key audiences for the programme. For example, Pacific women would be more likely to support their friends in going for regular screening to ensure their friends stayed healthy. Of course, the positive spin-off from this would be that in supporting their friends, they would also be more likely to go themselves. Māori women, on the other hand, would be motivated to go to ensure they stayed healthy for the whānau (Māori for extended family). Humour, used sensitively, could be an effective way of breaking the ice for discussing a sensitive subject.
A comprehensive stakeholder mapping exercise was done, which listed all stakeholders and prioritised them into three categories (A, B and C) based on their strength of interest and influence on the campaign and target audience. ‘A’ stakeholders, who had the greatest interest in and influence on the campaign and target audience, were invited to a series of workshops conducted by the NSU. This helped ensure the programme would be engaged with, supported by and connected to priority audiences. ‘B’ stakeholders received comprehensive written information about the campaign, while ‘C’ stakeholders received written updates, newsletters and copies of media releases.
Key stakeholders included the Government, non-governmental organisations (NGOs), district health boards, primary health organisations, smear-takers, laboratories and health promoters. They became an important secondary audience who would need to be considered when developing and implementing the campaign.
This exercise also highlighted that the campaign would need to stand out from the crowd when surrounded by other health campaigns competing for the target audiences’ attention. In particular it was identified that there was room for crossover with the free breast screening programme, which is also the responsibility of the NSU. Many of the organisations the NSU contract to provide health promotion services, whether for breast or cervical screening, work with Māori and Pacific women. The enhanced focus on these groups would provide an ideal opportunity to ‘cross-sell’ the two screening programmes and avoid detrimental competition.
Collecting baseline data
A telephone survey of the key audiences was conducted in August 2007 to establish benchmarks for awareness, attitudes and understanding of issues related to cervical cancer and cervical screening. The sample consisted of 908 women aged 30 to 69, with over-sampling of Māori (n=308) and Pacific (n=296) to reflect the focus of the communications on these groups.
This research also identified that most Māori and Pacific women either did not have a landline or preferred to use their mobile phone, which would need to be considered when developing improvements to the existing 0800 cervical screening phone service.
Campaign aims and behavioural goals
- Increase awareness and understanding of cervical cancer and the benefits of cervical screening
- Increase discussion about cervical screening, to get support from families, friends and communities for women to have regular smears
- Increase the number of women calling the programme 0800 number for more information
- Increase the number of Māori and Pacific women who make appointments and have smears
To develop interventions that could affectively achieve the aims set out, the development stage began with pretesting of campaign concepts with both the target audiences and key stakeholders, such as frontline health staff.
Developing the campaign
Eleven campaign concepts were developed based on the research insights. These were pretested with Māori and Pacific groups to ensure the programme and the messages resonated with the intended target audiences. Focus groups were used to pretest the concepts, along with audience reference groups made up of Māori and Pacific people with strong connections to their respective ethnic communities. The pretesting process helped identify the eight strongest concepts and led to important changes to the scripts and other conceptual elements.
Pretesting also revealed a range of ethnic-specific insights, including:
- Māori women preferred a direct approach to communicating key messages
- Pacific women valued humour and the idea of ‘going together’
- The concept of staying well for the sake of others, especially family, was important for both groups
- For Māori women there was a strong feeling of individual responsibility
- For Pacific women there was a strong focus on collective responsibility
In response to these insights, campaign materials were developed to be direct and positive, with an emphasis on the collective role of the family and community in supporting women to stay well by having regular smear tests. All promotional material featured a direct call to action, encouraging women to make an appointment to have a smear and telling them how to do this.
Pacific women, in particular, identified the importance of ‘seeing themselves’ in the communications targeting them. One Pacific woman involved in the research summed up this feeling:
“When there is a picture of a Pacific Island family or people, I feel that I belong. I feel good, I feel happy, I feel part of this country.”
An international award-winning female film director of Samoan descent was engaged to direct the filming of the campaign advertisements. This helped ensure real empathy with the audience and the issues. It also brought a real sense of legitimacy and authenticity to the campaign – ‘it’s been directed by one of us’. A decision was made to shoot the television material on 35mm film to ensure high production values, with the underlying message that this is really important and that the audience is important and worth investing in.
The campaign materials would include real life stories in magazines, on the radio and on television, and would be run in English and Māori, making use of media channels that best reach Māori and Pacific peoples.
New health education resources were also developed specifically for the priority ethnic audiences, which aligned with the wider campaign. These included:
- ‘What wāhine [women] need to know’, for Māori women
- ‘What Pacific women need to know’, for Pacific women
It was clear that for the programme to be successful, it would need buy-in from key stakeholders, who would be integral to its delivery. Subsequently, training workshops were held for health professionals to provide them with the opportunity to contribute to the campaign and to develop their capability to support the initiative at the local level. This was important to avoid confusion of messages or competing information being delivered about the campaign.
These workshops established a real sense of ownership by frontline staff, who provided valuable insights to the project team and helped ensure the campaign was picked up and extended into all regions nationally. It also helped ensure that clinics were prepared to respond to increased demand.
An example of an insight given by one of the screening providers during the workforce development was the example of holding ‘smear parties’ as a successful way of engaging with Pacific women. Based on the concept of ‘tupperware parties’, these would be a low-cost, fun and sociable way of bringing particularly Pacific women together, usually at a private home, to support one another in having their smear tests. This idea eventually was used as the concept for one of the campaigns most popular TV commercials.
Improvements to the helpline
Enhancements were made to improve access to the 0800 number. Research had identified that many of the priority women for the campaign either did not have a landline or preferred to use their mobile phones. As a result, the 0800 number was changed to also accept calls from mobiles. Additionally, the 0800 number was usually only staffed Monday to Friday during normal working hours. To make it more accessible, increased hours would be put in place (until 10pm during weekday evenings) from the start of the campaign. The 0800 number would also provide a key measure of effectiveness for the programme.
Private and third sector partnerships
To tie in with Cervical Screening Awareness Month, the campaign would be launched in September to ensure the biggest impact possible. To achieve a national presence, the NSU sought to develop partnerships with other national organisations to support the awareness month. Subsequently, the programme team approached the Cancer Society, Johnson & Johnson, and Progressive Enterprises to broker their support for the campaign and the initiatives run during the awareness month. This way these organisations could advertise the work of the campaign while being able to associate their brand with the work.
These partnerships also aided an initiative to give freebies to women screened during the awareness month. This could play an important part in creating a valued exchange, whereby the costs to screening are minimised and the benefits maximised for the target audience.
The qualitative research had identified the importance of affirming and validating women for participating in a process that “isn’t the number one item on my to-do list!” Research participants emphasised the need to feel affirmed as women. To respond to this, all women attending for a smear test during Cervical Screening Awareness Month (from 2008) would receive affirmation in the form of a free 30ml sample of hand and body lotion.
The benefits of this initiative were many – the sample had intrinsic value; it said to women ‘well done’ and ‘we’re affirming your decision to do this’. It also had value as a pampering product. The 30ml samples were small enough to be carried in a handbag or purse – it was envisaged that this would provide a further stimulus for conversation amongst women and could be used as a tool to encourage others to have their smear tests. Key messages were also printed on the tube such as ‘A smear test every three years could save your life’ to reinforce the campaign messages.
Reducing the cost of screening
Cost was a key barrier to address. Due to funding constraints, universal funding to make all smear tests free was not an option. Instead, the programme would vary its contracts with regional screening services to provide free smears to high priority women – Māori, Pacific, the unscreened or under-screened. The regions with the highest numbers of Māori and Pacific women were chosen for this initiative.
‘Don’t Just SAY It Matters’ was launched in September 2007, by the then Prime Minister, Helen Clark, at a function attended by nearly 200 community leaders, screening workers and other frontline staff. The launch involved Māori and Pacific cultural performances and representation, reflecting the focus of the campaign and the partnerships with these communities. Phase One of the campaign ran from September 2007 to January 2008, with Phase Two running from January to August 2008.
Six television commercials were launched that aimed to encourage women to talk about smear tests and to remind them of the importance of staying healthy, not just for themselves but for their families and whānau.
At this time the 0800 service had extended operating hours until 10pm. While there was some increased demand during the launch phase, analysis of calling patterns indicated that most women called the number during normal working hours, enabling the extended service to be stopped after four weeks. The initial peak in increased demand once the campaign launched also meant that clinics had to extend their opening hours and offer more flexible screening options, which highlighted the importance of having engaged with clinics and health professionals prior to the launch, so they were prepared to deal with this upsurge in demand.
Phase Two of the campaign was launched in January 2008 with the introduction of a further six television adverts. These adverts were designed to motivate and empower women to go for their smear tests and to encourage and support other women in their lives to do the same. The insight about ‘smear test parties’ led to the development of one of the television adverts, ‘The Van’, which called for women to get together with the women they care about and make an appointment for a cervical smear test. This advert in turn led to more providers adopting the concept of group smear test sessions in their regions. There was also an increase in the number of women going to GP clinics together – heeding the call in the adverts. Again, the demand from women for this resulted in practices making screening more readily available.
Free 30ml samples of hand and body lotion were sent to more than 1,200 smear taking practices, to Regional Services and other contracted providers, to give to women having smear tests during Cervical Screening Awareness Month in September 2008. Coming one year after the campaign launch, distribution of the samples provided an invaluable opportunity to reconnect with screening providers, to thank them for their contribution to making the campaign a success and to reinforce the importance of affirming and validating women who attend for smear tests. Based on feedback, the use of the freebies was found to be a great success. It was therefore decided to distribute them again during future Cervical Screening Awareness Month.
Following the first two phases of the campaign, an assessment and evaluation found the campaign had been a great success. The NSU subsequently provided funding to continue the campaign for a further three years.
In March 2010 research was conducted to assess what the target audiences had thought of the previous campaign to inform a refreshed campaign. This involved two focus groups with Māori women and two with Pacific women. The insight from these focus groups overwhelmingly supported the use of humour as effective in encouraging women to have regular smear tests.
Phases One and Two featured a mix of humorous and serious television commercials. The humorous adverts featured Pacific women and the serious adverts featured Māori women. Feedback on the humorous adverts included that their humour made them attention grabbing, that the adverts were ‘real’ and made the process of having a smear seem more normal. The biggest criticism of the adverts during Phases One and Two came from Māori women who said ‘we’re funny too!’ Of the adverts developed for Phases One and Two, the three most popular with women in the priority audience all used humour. These three most popular adverts were continued during Phase Three alongside three new adverts.
Based on these insights, new creative briefs and scripts were developed before being pretested through another set of focus groups (two with Māori women and two with Pacific women) and through testing the scripts online with the target audiences, which had 50 Māori and Pacific women participating.
Phase Three of the campaign was launched in September 2010, coinciding with Cervical Screening Awareness Month, with the release of three new television adverts. Again, freebies were distributed to smear taking practices and other clinics in the form of packs containing:
- Cervical Screening Awareness Month ‘tent cards’ for clinic reception desks
- Samples of Stayfree pads (sanitary towels)
- Cancer Society elements 30ml hand and body lotion samples for distribution to women having a smear test in September
Stayfree pads in participating supermarkets carried cervical screening messages, and awareness month was promoted in Foodtown, Woolworths and Countdown stores. In addition, women were able to enter a web-based competition, in which they could enter a draw to win one of 1000 Neutrogena Lip Glosses. Nearly 10,000 entries were received.
According to results from the screening programme register, as of April 2010 coverage was:
- Pacific women – 60 per cent, a relative change of 29.31 per cent over the course of the campaign (since September 2007)
- Māori women – 54.8 per cent, a relative change of 15.37 per cent over the course of the campaign
- All women – 75.6 per cent, a relative change of 7.23 per cent over the course of the campaign
Surveys were conducted amongst Māori and Pacific women in August 2007 (prior to the launch), February 2007 (6 months), August 2008 (12 months) and October 2009 (after completion of Phases One and Two) to enable measurement of the impact of the campaign on attitudes, awareness and understanding of cervical cancer and cervical screening. These evaluations will continue annually during Phase Three of the campaign.
2008 survey results
Increasing awareness and understanding:
- 13 per cent increase in those who agree that cervical cancer can be prevented
- 14 per cent increase in awareness of smear tests (prompted)
- 75 per cent increase in those who knew the frequency of smear tests
- 70 per cent unprompted recall of advertising
- 54 per cent increase in those who talked about cervical screening with others
Women taking action:
- 59 per cent increase in those who thought about making an appointment
- 49 per cent increase in likelihood of being screened in next three years
- 25 per cent increase in those who would encourage others to be screened
- 77 per cent increase in those who had taken some sort of action as a result of the advertising
2009 survey results
- Since the last survey there was a 7 per cent increase (or a 13 per cent increase on the 2007 benchmark) in the proportion of total Māori and Pacific who had been screened in the last three years (up to 83 per cent)
- Amongst unscreened Māori and Pacific women, there had a 13 per cent increase since the previous survey in having 'encouraged or supported friends or family/whanau to have their smear tests'
- Amongst Māori and Pacific respondents there was a 20 per cent increase in strongly agreeing that 'Looking after my health for the sake of my family encourages me to have smear tests'. Amongst unscreened Māori and Pacific respondents, there was a 24 per cent increase
- Continued high levels of recall of the cervical screening advertising among all women aged 30 to 69 years (87 per cent unprompted and 96 per cent prompted)
In the first 12 months the 0800 number received 47,700 calls, an increase of 27 per cent compared to the previous year. By October 2010 the monthly total for calls to the 0800 number was 4,566 – an 8.6 per cent increase on 12 months previously, but slightly down from the 2008 high. There has been a general upward trend in calls to the number since the launch of the campaign in 2007.
Feedback from the frontline
Feedback from the workforce has been overwhelmingly positive, with the programme clearly providing a stimulus for women to take action:
“…an older woman in her 60s said her grandson (aged 11 years) had been on at her because of the TV ads, saying she had to make sure she was healthy, so when I raised the matter, she was keen to make an appointment for a smear.”
“…what a difference those ads have made, women are actually doing something about it, the smear takers are rushed off their feet. I was at the clinic today and they were talking to me about the ads and were cracking up with the wonderful sense of humour…”
Value for money
The NSU is constantly reviewing value for money for all of the services it procures. The investment in advertising for the NCSP works out at approximately NZ$1.25 per eligible woman per annum.
Having conducted further research in March 2010 into the campaign’s creatives to date, the most successful adverts were continued and new ones developed from this insight. Based on this research, the current creatives and advertisements are planned to run for at least a further two years (until 2013), with continual monitoring through the annual surveys.
The NSU has also regularly shared the learning from this campaign with other government agencies when approached.
Adequate planning and development time
The programme spent more than two years in planning and development, enabling the team to develop in-depth insights into the key issues for the target audience alongside their motivations and current perceptions. Thorough research provided the actionable insights needed to help the development of a strong campaign.
A key learning and insight was about the importance of focusing efforts on priority groups and to ensure this was reflected in every discussion, decision, resource allocation and aspect of the programme. During the development and implementation of the campaign, the project team always asked: “How will this enable us to connect with Māori and Pacific women? Will it enable us to reduce the current inequalities?”
Robust project management framework
An effective project management framework was put in place, based around 10 work streams. This enabled the project to be delivered in full, on time and within agreed budget.
Strong, challenging and regularly updated creatives
The campaign took some calculated risks – the subject matter was sensitive and the programme had a backdrop of intense media and political interest. These calculated risks were necessary at times to ensure the programme connected with its priority audiences. Make sure you do not ‘rest on your laurels’ – continue to refresh the campaign and PR approach.
Integration of campaign with services
The integration and engagement with those providing screening services was essential to the success achieved. Undertake thorough liaison with stakeholders, especially during the process of developing new advertising, and provide them with regular campaign updates.
The importance of evaluation
Develop a strong evaluation plan for the campaign early on, and regularly and widely promote positive results. This ensures the value and effectiveness of the campaign is clear to all stakeholders, including funders.