Increasing the uptake of cervical screening in low uptake subgroups

Appt Health has partnered with West Yorkshire & Harrogate Cancer Alliance and Imperial College London to increase the uptake of cervical screening in low-uptake subgroups

Appt Health was founded in 2017 to increase the public uptake of preventive healthcare and reduce the impact of health inequalities. Numerous studies have identified disparities in the uptake of cervical screening, with certain subgroups being less likely to attend screening.

Appt Health has partnered with West Yorkshire and Harrogate Cancer Alliance and Imperial College London to carry out a feasibility study into an innovative approach to patient engagement with the potential to reduce disparities in the uptake of cervical screening in West Yorkshire.

Appt Health’s patient engagement service has been shown to increase the uptake of several preventive healthcare programmes

Our software is used in healthcare organisations covering over 650,000 patients to save their services time and money spent on patient engagement, whilst increasing the uptake of the preventive healthcare services they deliver.

In order to address the needs of low uptake sub groups, Appt Health has developed the functionality to target patients with different invitation strategies, dependent on which sub group they belong to. This functionality allows Appt Health to address the barriers shared by these subgroups, making them more likely to book and attend screening.

West Yorkshire & Harrogate Cancer Alliance had already identified a low uptake subgroup who were less likely to attend cervical screening

Analysis of historic cervical screening uptake data in West Yorkshire & Harrogate has identified that women of low socio-economic status (indices of multiple deprivation 1 - 3, meaning the patient’s postcode ranks in the 30% most deprived in the country) who did not speak English as a first-language were less likely to attend cervical screening.

Appt Health, together with researchers from Imperial College London carried out research in West Yorkshire with members of the public who shared the characteristics of this target sub group. On 14th Sept 2023 we travelled to Batley in West Yorkshire to deliver a workshop with an English as a foreign language group at the Indian Muslim’s Centre. The 13 women in attendance were migrants from India/Pakistan, from a range of age groups - the women all identified as Muslim. We had 4 activities during the workshop: Activity 1 looked at barriers to cervical screening uptake. Activity 2 looked at phrases which could used to overcome barriers to cervical screening uptake. Activity 3 looked at information which people need to know before going to their cervical screening. Activity 4 was a brief review of invitation text messages currently in use.

Workshop findings - barriers to uptake

The workshop found that due to socially and religiously conservative values, embarrassment, and fear of having a male doctor were two of the most important barriers to care. As a result, knowing that a female clinician could be requested was seen as a key facilitator to uptake.

Language barriers were also identified as a barrier to uptake – both in terms of understanding the invitation, as well as the screening experience itself. Women reported that they may avoid going for a cervical screen due to a fear that interpretation would not be available during the procedure and that they would have a test done on them without understanding what was happening.

Another key barrier to uptake was a lack of awareness around the need for cervical screening, and women reported that in their home countries of India and Pakistan this was not something they’d come across as a routine health check, and so were not aware it existed until they had received an NHS invitation.

Practical barriers to uptake were also seen as crucial, as women often had several children to look after, making it hard to attend healthcare appointments during regular clinic opening hours.

Messaging co-design

Participants of the workshop were asked to discuss phrases which might help to overcome the different barriers to attending a cervical screening. They were asked to make any changes they wanted to the phrases or to add additional ones. The ranking system used for the barrier cards using stickers, and converting the rank into a total score was repeated – with a high score indicating a phrase which was ranked the highest by participant. Participants were also asked if they particularly liked any words/parts of phrases, and these words have been highlighted in yellow in the table below:

Using an online survey to finalise messaging

Dr Miller is inviting you to do your cervical smear test which is now overdue. Cervical cancer screening saves 4500 lives in England every year. Please call 01977668455 to book a 20-minute appointment to have your test done. Please note it is important that you book and attend this appointment. Thanks. Messaging used in a West Yorkshire and Harrogate GP practice before the study

The participants were also showed the current messaging used by practices and asked to provide feedback. They suggested that the messages could be changed to add in any extra clinic hours which are available, to add in the time/days at which this number can be called, and to use the word nurse which the participants believed indicates a female gendered clinician.

The Imperial College team took the results from this feedback session with Appt to create several ‘behaviour change technique’ messaging snippets which could be evaluated and compared using an online survey, to cross validate the results. In total 31 members of the public responded to the survey which was posted on the Voice platform. It identified the following invitation message and reminder messages as the most preferred:

Onboarding

West Yorkshire and Harrogate Cancer Alliance then identified several practices which were failing to meet the national cervical screening uptake target of 80%. Once a shortlist of suitable GP practices had been created, the Cancer Alliance facilitated introductions to those organisations who expressed interest. After an initial scoping call, the Appt Health team held 30-minute onboarding calls with practice staff. In total, eight practices in West Yorkshire were onboarded to the Appt Health service, which is made up of three platforms, Appt Anza, Appt Recall and Appt Analytics:

Trial Delivery

Appt Health’s platform allowed a cervical screening target to be created with two invitation strategies - one that included default control messaging, and one which included the co-designed targeted strategy.

First Round Results

The trial is structured so that all patients - both in the control and treatment arms - receive two rounds of invitations. The first round of invitation is now complete for 813 non-responsive patients (those who had not responded to the national cervical screening recall programme). We found that the treatment arm of the trial saw a 42.5% improvement in booking rate, and an 80.3% improvement in response rates (which includes patients who actively declined the invitation - saving practice staff time spent chasing up non-responders).