What's pants, but could save your life?
‘What's pants, but could save your life?' was the first West Midlands-wide NHS programme to adopt a fully integrated social marketing approach. It was the first cervical screening initiative in the UK to directly link data trends, audience segmentation and social behaviour research with the construction of an awareness campaign. It was also the NHS's first region-led cervical screening intervention to identify, measure and achieve tangible behavioural change.
The programme aimed to achieve a sustained increase in cervical screening amongst 25- to 29-year-old women in the West Midlands, in order to reach the national minimum standard of 80 per cent.
The methods mix included: modified and increased service provision, including additional screening clinics; radio, bus and ambient advertising; and direct mail included with routine screening invitation letters.
- At the end of quarter 1 (2008/09), laboratories reported a 16 per cent increase in workload in the gateway age group alone
- However, this initial increase was not sustained and West Midlands did not reach the 80 per cent cervical screening target
According to the 2007 Chief Medical Officer’s (CMO) report, the NHS Cervical Screening Programme, which began in 1988, has contributed significantly to national reductions in the incidence of invasive cervical cancer. In the West Midlands, there were 465 cases of invasive cervical cancer in 1987. By 2006, this had dropped by almost half, to 253.
In October 2004, changes were made to the age at which a woman receives her first invitation for cervical screening, moving it from 20 years to 25 years. This was based on findings that suggested screening was not effective in preventing the rare cases of cervical cancer diagnosed in women under 25.
Reducing the risk of cervical cancer is dependent on achieving a high uptake of cervical screening once women reach 25 years of age, with the incidence rates for cervical cancer beginning to rise rapidly in the 25 to 29 year age group. There has, however, been a decline in screening attendance amongst women aged 25 to 39 years, which had been falling steadily since 2001. Only 76 per cent of eligible women in the West Midlands had a cervical screening test within the last 5 years in 2006/07 – below the national coverage target of 80 per cent. This equates to 23,000 ‘under screened’ women.
The CMO report also showed that a greater proportion of women from deprived areas diagnosed with invasive cervical cancer had previously failed to attend screening. Increased cervical screening coverage of women at highest risk needed to be achieved to prevent the incidence of cervical cancer rising further.
To address this, the West Midlands Cervical Screening Quality Assurance (QA) Reference Centre (part of the West Midlands Cancer Intelligence Unit) proposed that a three-year regional cervical screening intervention should be run across the entire West Midlands region, commencing in April 2008.
After raising this idea with primary care cervical screening leads at their regional meeting in May 2007, the QA Reference Centre team created an initial project plan, searched the background literature, tested their initial messaging ideas and then formally presented a proposal to the screening leads at the next meeting in December 2007. Early in this process, Martin Turner (Head of Communications) and his team from NHS Walsall agreed to provide the required expertise for the marketing element of the programme.
The programme’s regional goals aligned with national policy commitments, including:
- Providing a targeted and effective screening service to all women between the ages of 25 and 64 every 3 to 5 years
- Reducing the number of women who develop invasive cervical cancer
- Reducing the number of women who die from cervical cancer
The behavioural goal was for women aged 25 to 29 in West Midlands to take up cervical screening, in the hopes of raising regional coverage figures for this age group above the national minimum standard of 80 per cent.
The Walsall team conducted two stages of research.
Stage one involved a search of background literature, examining customers’ responses to previous cervical screening campaigns in other regions and looking at broader social behaviour with regard to uptake of screening generally.
Several published studies and local quality assurance-funded primary care studies found the following reasons women did not attend cervical screening:
- The test is uncomfortable
- A lack of knowledge about cervical cancer
- Do not understand the benefits of cervical screening
- Screening not a priority for young women, because of the perception that young people do not get cancer
- Cultural reasons
- Inconvenient appointment times
- Difficulty making an appointment
- Difficulty getting to the clinic
- The possibility of a male smear-taker
A study of declining attendance in the North East and Yorkshire and Humberside found that the rate of decline was associated with deprivation and younger age groups, but the decline was not associated with specific ethnicity or religion. The study recommended that interventions should therefore be targeted at younger women and those living in deprived areas, and if possible be multifaceted – for example including community development, mass media and targeted media.
Further, a report by Telford and Wrekin Primary Care Trust (PCT) investigating reasons for poor cervical screening uptake provided several recommendations for an improved service:
- Identification of a Saturday and evening clinic for cervical smear tests
- Dissemination of ready-made displays in GP practices promoting role of female staff conducting smear tests
- Local media campaign promoting positive health messages about cervical screening
- Production of positive health promotion materials for display in supermarkets and female workplaces
- Targeted health promotion outreach project in the communities served by practices where coverage is below the national average (to reach existing community groups attended by women)
- Additional training sessions for all staff in practices where coverage is low to encourage uptake
Coverage data at this stage revealed that 33 per cent of the region’s women aged 25 to 29 were not responding to invitations to go for screening.
Coverage trends by PCT and by age quintile from the last 5 years of testing in the region also suggested that the low attendance of women aged 25 to 29 continued through the age groups over time, implying that those who avoided attending their first test would most likely not attend another in future.
Stage two saw the use of several research methods:
Examining the process
All existing clinical and non-clinical processes for cervical screening were scrutinised, including the nature and content of the invitation letters. The existing letters followed the national recommended text and were found to be of a high standard, with a personalised approach to patient communication. The physical location and opening times of clinics and other screening centres were also examined.
The NHS Walsall communications team held focus groups with local women to gain understanding of the personal reasons why many women are reluctant to attend screening sessions.
These focus groups indicated that very few women of any age had a real picture of the prevalence of cervical cancer. A surprising proportion of 25- to 29-year-olds described the experience of cervical screening – unprompted – as 'pants', referring to the experience as mildly humiliating and uncomfortable.
On further investigation, the communications team discovered that the experience fell between two categories for most respondents:
- It was not painful enough to fall into the category of 'things which are nasty but important'
- Nor was the process frequent enough to fall into the category of ‘routine’
This research revealed that women did not prioritise cervical screening compared to other healthy behaviours, such as doing the recommended levels of exercise or eating five portions of fruit and vegetables a day.
A focus group was carried out to test initial messaging concepts that were developed from the qualitative research findings. Participants rated the concepts as below:
- ‘What’s pants, but can save your life?’ – 42 per cent
- ‘Cervical cancer’s not pretty’ – 28 per cent
- ‘Service your cervix’ – 17 per cent
- ‘Your cervix needs you’ – 15 per cent
There were concerns amongst some participants that the message ‘What’s pants, but could save your life?’ would not appeal or might be offensive to ethnic communities. The communications team therefore held a further focus group with young Asian women, which revealed that the proposed name was suitable and that the messages did not carry negative sexual connotations.
Based on this consumer attitude the project's creative director produced a draft advertisement entitled 'What's pants, but could save your life?' using images of different kinds of pants as a brand identity.
This went against previous approaches and perceived best practice in the sector, which had attempted to make cervical screening appear as attractive as possible. These more conventional approaches took the form of PR events where gifts such as thongs were distributed and the use of brightly coloured flower imagery was used.
However, through the qualitative research the communications team discovered quickly that there was no chance of making cervical screening an attractive prospect, largely because of the discomfort it involves.
Development of promotional literature
Further pretesting of the advertising materials through focus groups helped the team refine the message as follows:
- References to 'the West Midlands’ were changed to ‘our region’, as it emerged many people were unaware that their town was in the West Midlands
- References to saving one life became ‘the life of one woman’
- The emphasis in the call to action was changed from a simple ‘get tested’ message to one which reflected the need for those over 25 to make an appointment if they had ignored the last invitation from their local health authority. This avoided creating ‘worried well’ groups such as those women under 25 or those who had been tested recently
Pretesting and certain restrictions also influenced the final look and feel of materials:
- Lingerie was found to be inappropriate with some groups and the owner of one local transport company was unwilling to allow this type of underwear to appear on his buses. This led the team to take a more colourful approach, using a variety of garment styles obtained from a local store
- Originally in black, the copy on the materials was changed to magenta, as it was believed to convey femininity, but not sexuality – thus speaking directly to younger women
Having tested the messages and imagery through focus groups, the final ‘What’s pants...?’ materials were developed. Importantly, these materials used thinking outlined by research conducted by the Advertising Standards Agency (ASA), which highlighted that the use of humour and colloquial language can make a significant contribution to the success of a campaign, by ensuring it gains the audience’s respect and is memorable.
The study, which used qualitative research in the form of group discussions, interviewed a cross-section of British society as follows:
- Teenagers – 16-, 17- and 18-year-olds still at school
- Singles – aged 20 to 24
- Parents – with at least 1 child aged 5 to 14
- Empty Nesters – aged 50 to 60
- The Greys – aged 65 to 75
The ASA’s survey found advertising that creates an impact, either good or bad in the consumer’s mind, can become as much a topic of conversation as any other media – with certain phrases being adopted and used within peer groups, particularly 18- to 25-year-olds. In fact, not knowing a key phrase is equivalent to not knowing the latest music or designer label.
The Walsall team saw the use of the colloquial term ‘pants’ as an opportunity to build on this insight.
ASA’s participants readily recalled adverts that entertained them, with the admired advertising and advertiser almost always seen as being humorous, clever and original.
‘Clever’ was a word participants used often, with some talking about advertising they did not at first understand but which drew them in, and which they recalled as a result of finally understanding it. Conversely, too obvious or bland ads were criticised. Humour was mentioned almost as often as clever and was an important element in entertaining and engaging consumers.
Pretesting for the ‘What’s pants...?’ project revealed that audiences did not grasp the meaning of the messaging immediately, but found it funny once they understood it. The insight from the ASA research reinforced the campaign’s use of the phrase ‘pants’ and the images of underwear as a humorous and clever way of acknowledging the mild embarrassment and discomfort associated with cervical screening.
Another key insight provided by the ASA was the ability of adverts – particularly printed ads – to inform. Participants recognised that many adverts provided useful, interesting information that was often hard to find elsewhere. The information that most interested consumers involved new products or services, with the concept of ‘missing out’ being a real fear. Participants also responded well to adverts that provided ‘food for thought’.
The team therefore used nationally published research to calculate the number of lives saved by cervical screening every year, and then translated this into a daily average – giving ‘What’s pants…?’ more impact than its competitors.
The team also used colourful imagery, based on the results of the qualitative research, to ensure that images stood out next to other health-oriented behaviour change campaigns.
The communications materials developed for the project would be used on one-eighth of the region’s adshels and bus sides to spread the word, underpinned by a two-week radio campaign on Heart FM, local press exposure and a comprehensive website – www.pants.nhs.uk.
Posters were created for GP surgeries and other health centres, explaining in more detail how to access cervical screening. Credit card sized cut-outs in the shape of pants displaying key messages were also created to distribute through selected lingerie stores and supermarkets.
Campaign messages were integrated with the cervical screening programme's existing services and a flyer was distributed as part of the established direct mailing, which is sent to all women aged 25 to 64 in the region, inviting them to attend for screening at the appropriate interval.
Since the target success over three years would only be equivalent to reaching national baselines, the project team opted to boost ‘What’s pants…?’ further using adverts on trains, strategically situated posters (such as women’s toilets in workplaces) and press to supplement the ongoing direct mail programme.
Following research with users and providers of other services, it emerged that the location and opening hours of screening centres were crucial to the success of a programme, with out-of-hours screening playing a particularly important role.
Several PCTs amended their service provision, thus providing a large number of additional clinics in different locations across the region, with extended opening times and improvements in the way results were delivered, minimising any potential inconvenience for the target audience.
Some of these clinics were only intended to cope with immediate increase in demand following the launch of the programme. However, due to their success some of these clinics have become permanent, such as the walk-in facility in Stoke-on-Trent.
These additional facilities and alternative screening services were publicised on the campaign website, which also offers further information about cervical screening.
Local promotional activity
At the primary care cervical screening leads regional meeting in December 2007, the project team presented specific PCT data to the screening leads, showing local coverage data and the shortfall in the number of women screened in each area. The screening leads reported finding this useful in planning local activity.
All PCT leads were then asked to submit project plans of targeted local activities, such as establishing stands in shopping centres to raise awareness of the importance of cervical screening, and details of quantities of posters or leaflets required. Sandwell PCT and children's centres, for example, toured with 'The Cervical Monologues' play, which shares stories and experiences of real women to explore life, love, sex and sexuality, as well as demystifying the screening process. The theatre group also distributed the campaign literature and delivered key messages at all performances.
Prior to the launch of the programme in April 2008, a press release was sent to all PCT screening leads along with promotional materials for distribution to all relevant organisations.
Two months after the launch of the campaign, these materials were followed up with a survey about promotional activity, which each of the screening leads completed. The results showed both the press release and promotional materials were put to good use. For example:
- Campaign posters were sent to at least 971 surgeries, 854 chemists, plus family planning and community clinics
- Five of the PCTs distributed posters to retail outlets including Tesco, Asda, Sainsbury’s, Morrisons, La Senza and House of Fraser
- A few PCTs sent the posters to many other locations, including: clothes shops, market stalls, charity shops, hairdressers, beauty salons, food stores, bridal shops, private nurseries, opticians, vets, pubs, bingo halls, zoos, cinemas and large offices such as nPower
- Twelve PCTs distributed posters in public areas such as: main libraries, rural mobile library, leisure centres, private gyms, nightclubs, playgroups, nurseries and childcare centres, Sure Starts, community hospitals, women’s health clinics, outpatient departments and local theatres
Thirteen of the local PCTs made use of local media coverage, and 13 also spread the campaign message at existing health promotion events.
Six PCTs held specific cervical screening promotional events, and at one of these, six ‘Theatre in Health’ performances were held in community venues in areas of low coverage. These were followed by question and answer sessions and an open discussion about women’s health screening. In another PCT, laboratory staff demonstrated cervical cytology under the microscope at a Tesco store and shoppers were invited to look at examples of slides. Another PCT held training sessions and public sessions at Sure Start centres.
The media campaign was found to be successful, particularly the bus advertisements, which later surveys highlighted were the most successful medium for capturing people’s attention. Despite its success, the implementation of the bus advertisements did encounter a small problem in that bus routes did not stay within the West Midlands region, with some travelling as far as Wales, which has a different screening age.
Train advertising began in September 2008, which coincided with the announcement of TV celebrity Jade Goody’s diagnosis with cervical cancer. While screening rates increased following the campaign launch, this effect could not be separated from the media surrounding Jade Goody’s cancer. When the second year of the campaign was launched in April 2009, there was some negative feedback from individual PCT leads, who felt there was no need to spend money on the campaign with the media coverage of Jade Goody’s diagnosis and subsequent death already increasing screening uptake. For this reason, while bus advertisements, posters and leaflets in GP surgeries and screening letters were continued, far fewer localised events were run than in the first year.
“There was the major unforeseen circumstance of Jade Goody’s cervical cancer. That increased the coverage obviously, but it made our campaign evaluation difficult. PCT leads were saying there’s no need to do this because a celebrity has just died from cervical cancer. Max Clifford is issuing daily press releases raising awareness, so there is no need to put our resources in at this current time, because all of the sample takers within the surgeries were absolutely run off their feet and could not cope with any more additional work we may have created. So although our first year was successful, I think it’s fair to say there was a lot less involvement in subsequent years.” (Susie Andrews, QA Development Manager)
The overall effectiveness of the screening programme is monitored and evaluated by the West Midlands Cervical Screening QA Reference Centre, via routinely collected quarterly and annual PCT cervical screening returns, and laboratory workload data.
‘What’s pants...?’ aimed to achieve a 12 per cent uplift in the target 25 to 29 age group by the end of year 3 – based on a model of limited gains in year 1, more substantial gains in year 2 and the highest gains in year 3, once ‘What’s pants…?’ had been established in the minds of the public. This was measured by total annual returns as part of the regular monitoring processes.
Cervical screening coverage for 25- to 29-years-olds
At the end of quarter 1 (2008/09), laboratories reported a 16 per cent increase in workload in the gateway age group alone, although this increase was not sustained.
Cervical screening coverage:
- 2007/08: 66 per cent (prior to campaign)
- 2008/09: 66.6 per cent
- 2009/10: 65.6 per cent
Evaluating the impact of the campaign was challenging in light of the sudden increase (although short-lived) in screening uptake following the diagnosis and death of Jade Goody.
To further evaluate ‘What’s pants…?’, a feedback survey was sent to 7,500 women aged 25 to 39 after year 1 of the campaign. Of the 1,998 women who responded:
- 34 per cent said they were familiar with the campaign (unprompted)
- 41 per cent said they were much more likely to get screened as a result of the campaign
Within the screening services themselves, people who had never been screened before were asked what prompted them to attend. Anecdotally, many of these cited ‘What’s pants…?’ as the main reason.
During year one of the campaign, a young woman who had previously never attended screening was found to have early stage cervical cancer. The ‘What’s pants…?’ poster on a bus had prompted her to go for cervical screening. If it had not been detected at this stage, the cancer could very well have become fatal.
Key findings from the initial research have been incorporated into training for health professionals who conduct cervical screening, to ensure they understand the negative perceptions young women in particular may have of the screening process. It is hoped that this understanding may help health professionals make the screening process as painless as possible.
“We incorporate a lot of the outcomes and feedback from the focus groups in our work. For instance in our training sessions we present the findings to new nurses and point out some of the negative perceptions that young women have of the screening process.” (Susie Andrews, QA Development Manager)
The team behind ‘What’s pants...?’ has been approached by a number of other health providers for permission to use their materials, including NHS Swindon who have adopted the ‘What’s pants..?’ branding and imagery. They have used the materials for posters and compliment slip sized leaflets, giving facts about screening and information on where to get screened. These leaflets have been displayed in the designer outlet centre in Swindon, GP surgeries, the hospital and the PCT. There have also been articles in the press and on the radio, and a three-month radio advertising campaign encouraging women to attend screening, using the ‘What’s pants...?’ message.
The ‘What’s pants…?’ programme was conceived and managed entirely within the NHS, demonstrating the ability of in-house social marketing teams to achieve population-level results.
Its success generated immediate commitment across the region to other joint social marketing projects, and saw requests to create other regional and national social marketing programmes.
In terms of the mechanics of ‘What’s pants…?’, the direct mail was originally intended to only go to women aged 25 to 35. The NHS cervical screening programme uses a call and recall system for women who are registered with a GP. It also keeps track of any follow-up investigation and, if all is well, recalls the woman for screening in three or five years’ time. Unfortunately this approach requires GPs to hold up-to-date contact information for every female patient and relies on members of the target group to notify the doctor of any changes. It was therefore not feasible to target one age group in isolation, so the marketing materials were distributed to other groups too, for whom the materials may not have been so relevant.
“We had hoped to target the ‘What’s pants...?’ information more specifically to young girls, so we weren’t sending the leaflet out with the screening invitations to older women. But specifying a particular age group subset in the call and recall department was not possible due to software limitations, so the leaflets went out to everyone.” (Susie Andrews, QA Development Manager)
Lessons were also learned regarding restrictions imposed by media companies. For example, the campaign was not allowed to feature lingerie on bus sides, which affected the design brief and final result.
Perhaps most important was ensuring that local PCTs were on board, as they were instrumental in leading ‘What’s pants…?’ locally.
“We literally did get them to sign up to the campaign and we got agreement from the directors of public health that they would support the screening leads in their endeavours. I think getting that initial sign up from them all was vital.” (Susie Andrews, QA Development Manager)