Turning up: increasing cervical cancer screening uptake

woman sitting next to health staff

How do you remember your health appointments? Do you set a reminder on your phone, or wait for a health care provider to send a text? When invited for cancer screening do you book right away, or ignore it or forget as it makes you anxious, or as you have too much else going on?

These are some of the questions Dr Gaby Judah, a psychologist working on behaviour change at the Patient Safety Translational Research Centre at the Institute of Global Health Innovation, considers in her research to encourage people to attend their NHS cancer screening appointments.

Screening services for cancer are important for both patients and the NHS because detecting cancer early gives people a better chance of responding to treatment and therefore recovering from their illness. Dr Judah is particularly interested in how messaging and text messaging can be used to encourage people to turn up to their screening appointments for cervical and breast cancers.

For cervical screening awareness week, we asked Dr Gaby Judah more about her work, which factors are important for people when choosing to attend their appointments, and why attending a cervical smear is so important.

How can we encourage people to turn up to cervical screening appointments?  

Tell us about your work in cervical screening.

Woman looking at camera
Dr Gaby Judah, Institute of Global Health Innovation

My background is in psychology, and I work specifically on health behaviour change, which is about helping people to adopt healthy behaviours. I do this by understanding why people act in certain ways and then designing and testing tools and messaging to change behaviour. Some of my work is on ongoing behaviours, like whether people take their medications as prescribed, my other work is on one-off behaviours like cancer screening. In my cervical screening research, I look at why people don’t attend their screening appointments and design messaging to try to get more people to attend their appointments. This means I work closely with the NHS which sends out letters and texts to people to remind them of their appointments.

In a recently published paper, you looked at the main barriers for people turning up their cervical screening appointments. What did you find?

This research was a survey of 500 women in London. London was the focus because it has some of the lowest cervical screening rates nationally. We looked at many different possible reasons which might affect whether people get screened and measured how often they have been to screening when invited. This meant that we could test which factors predict if someone gets screened. We found that memory (i.e. remembering to make your appointment) and prioritising cervical screening over other tasks were good predictors of getting screened regularly when invited. Practical factors and resources also have an impact, for example available transport, or the journey to an appointment, childcare access or flexible working patterns can all affect uptake. We saw that expecting to be embarrassed, or having had a negative experience of smear tests in the past didn’t affect attendance.

Do these factors overlap with certain groups which could make them less likely to attend?

We did another analysis separated by household income, with those with a household income of £50,000 or more as the higher income group, and a lower-income group of households earning below £50,000. The group with lower household incomes were more strongly affected by practical barriers than those with higher household incomes. The reason for this might be due to people not being able to get time off work to attend their cervical screening appointment or more difficulties with getting to an appointment in terms of travel or transport. However, we couldn’t tell which of these factors were most important.

How did you look at text message reminders to increase attendance to appointments?

A trial led by my colleague Dr Sarah Huf [Clinical Lecturer at IGHI] looked specifically at the impact of text message reminders on cervical screening attendance in London. In younger women receiving their first invitations to screening we compared a text message appointment reminder with no message and found that sending the text message reminder increased uptake by 5%.

Image of great exhibition road festival
Image of the breast screening messages stand at the great exhibition road festival

We also tested different types of messages based on different behavioural science principles, and measured if this affected the numbers of people turning up to their cervical smear. We found that the most effective message was either a simple text or a message including the name of the GP surgery (GP endorsement). What was exciting was that these reminders were adopted as standard practice. Public Health England ran a similar evaluation and also found a 5% increase. This gave them reason to roll out text message reminders as standard practice for NHS cervical cancer screening services and it had a real impact on the screening process.

What upcoming work do you have in this area?

In cervical cancer screening, we were approached by NHS England and Improvement to send catch up texts to a group of women who didn’t attend when they were last invited for screening. Based on our survey and our previous text message trial, we suggested three different messages which are being sent out to 250,000 people and soon we will see results about which messages were the most effective.

I am also doing work on breast cancer screening uptake. My PhD student, Amish Acharya, will soon begin a trial testing the effect of behavioural science text message interventions on breast cancer screening. This includes a link to a short animated video including behaviour change techniques suggested from the results of a survey and interviews about barriers and motivators for screening. We co-designed the video with a diverse group of women.

Recently, we had a stall at the Great Exhibition Road Festival on making better cancer screening messages. We asked people what messages they think would encourage people to attend their appointments, and rate how effective messages were.

Finally, why would you encourage people to attend their cervical screening appointment?

It is estimated that 83% of cervical cancer deaths could be avoided if all eligible people were screened every time they are invited. Early detection is so important for improving outcomes, and this is why we have free screening. Even if it may feel difficult to make an appointment or to go, it is so important to take just a bit of time to put your health first.

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