Cervical Screening Debrief Service Pull and Consumer Push Validation Phase 2

1. Cervical ScreeningDebrief Service Pull and Consumer Push Validation Phase 2 3rd June 2010 1

2. Locations/Sample • Each group consisted of core ACORN group N (Struggling Families) with some ACORN group M& O • Groups conducted in Hull and East Riding on 25th and 26th May 2010 • All four groups were dual moderated by Alison Gilbertson and Julie Neilson • Total of 29 participants each paid £40 incentive as a thank you for their time

3. Insights from Validation Phase 1 5

4. Key Insights from Phase One It can catch cancer early so you can treat it (Motivation) It’s embarrassing and/or uncomfortable (Barrier) Reassure them Cause them to question their justifications Campaign must motivate first and reassure second

5. Key Insights from Phase One • Needs to emotionally connect with these women – well practiced at ignoring communication about their smear test • Good news (clear smear) is no news • What is motivating is the dramatisation of what might happen to them if they don’t take the test • Reassurance in its own is not enough to change behaviour • Cannot assume these women understand the benefits of the test

6. Preferred campaign concept You want to pull him out of there and wipe his tears away…just want to hold him (Reluctant, aged 29, Hull, ACORN N)

7. It Hurts Not Having a Smear   The thought of leaving loved ones (especially children) behind is the idea with the strongest potential to change their attitudes and behaviour 95% statistic balances the tragedy inherent in the headline with hope • Powerfully emotionally engaging (for both those with and without children) • Non verbal responses (silences; excuses to leave the room) • Crying

8. Building on the concept: Language, messages, imagery 10

9. Smear Test vs. Cervical Screening • Creative executions referring to Cervical Screening were rejected by virtually all respondents • Sounds too medical/technical • Sounds more frightening than Smear Test • Colloquially referred to as Smear Test (cervical screening only called that by the doctor/letter) Cervical Screening sounds more dramatic (Older Missed Apps) Cervical Screening , that sounds too medical, too technical, it makes me feel sick (Younger 1st Timer)

10. Cervical Sample Appointment • Cervical Sample Appointment alternative – outright rejection • Sounds like a more complicated medical procedure Cervical sample appointment – oh no [look of horror]! It sounds like a biopsy, like they are going to cut something away (Younger 1st Timer) I just don’t want to think about them taking a sample (Younger Missed App) That’s horrible. It sounds like they’re going to cut something out of you and take it away (Younger Missed App)

11. Initial Gut Reaction • Initial reaction from the vast majority was a sense of deep sadness at the children left behind (some brought to tears in the groups) • Small number (with entrenched smokers attitudes) less swayed by images of children. However they were motivated by the reassurance messages (on the adverts and supporting literature) The thought of leaving my bains, even going to darts on a Wednesday night my bains get upset…so they would be heartbroken (Younger 1st Timer) It’s really hard hitting – it makes you feel really uncomfortable (Older 1st timer) Makes you feel really guilty, especially as I’ve had god knows how many letters & I won’t go (Older Missed Apps) Seen that many ads with kids that I just switch off – I’m getting de-sensitised to them (Younger 1st Timer)

12. Boy with Teddy Bear • Imagery depicts a crying boy, not clearly demonstrating loss • Headline – compelling • For some ‘missed’ more accidental than deliberate • ‘Mummy’ spontaneously preferred to ‘Mum’ – increased emotional pull It is upsetting seeing him like that but he could be crying for anything (Younger Missed App)

13. Boy with Teddy Bear • Headline too ambiguous for the majority • ‘Gone’ • Less compelling than ‘miss her’ • Gone for smear test? Gone shopping? Where’s she gone? Doesn’t mean she’s dead, she could have gone for her smear test (Younger 1st Timer)

14. Boy with Teddy Bear Poster • Less able to see the hurt in his eyes • Not immediately clear it is a teddy bear • Too much separation between message and image It would make you think if you were walking down the street even if you didn’t have any kids (Younger 1st Timer)

15. Boy on Stairs • Immediate emotional reaction from majority • Headline works better here with more emotive image • Conveys a deep sense of loss • From his eyes/the tear • From his age • From his position in the house (stairs/bedtime) He looks lost….on the stairs, in the home where his mother lived. It’s in the middle of the house and now his mum can’t take him to bed (Younger 1st Timer)

16. Man Crying • Not clear who he is – teenager; brother? • Not obviously someone’s boyfriend/partner/husband • Too young • Could be holding wedding/holiday photo • Could be holding small child (broken family) • Not as immediate a connection with this approach as with the use of children • Many single parents with no partner • Sense that the men in their lives would ‘get over’ losing them, the children may not • A truth in that people do say they’ve been for a test when they haven’t • ‘Sue didn’t go for her smear test…can’t believe she’s gone – less impactful (who’s Sue?) • Some interest in concept of depicting effect on other family members other than just children

17. Little Girl Crying • Close up of her eyes visually arresting (but push you away rather than draw you in) • Unsure if she is crying with grief or just having a tantrum • Headline polarising • Significant minority liked the positive sentiment of the line • Associated with the experience of having cancer • ‘Pain’ not connected with the physical pain of having the test She looks like she’s in a mood, but with the little boy on the stairs you just want to give him a cuddle (Older Missed Apps)

18. Older Boy • Not being able to see his eyes means less immediate connection with this execution • Older child broadens the appeal of the campaign – they have more understanding of what has happened • Photograph of mother affecting but needs to be more obvious • Headline • Reference to Nan reminds them who will pick up the pieces • Can read blame into headline • Alternative headline (Jack’s mum missed her smear test) • Who’s Jack – someone else, not me He’ll know why. He’ll understand about the smear test. (Older 1st Timer)

19. Girl on Bed • Girl in bed has strong associations for many • Tuck them up • Kiss goodnight • Important time for a mum & her young children • Image depicts a child at a loss rather than expressing a sense of loss/grief • Headline – without reference to Smear Test • Draws them to investigate what the ad is all about • Not immediately recognised as a Smear Test ad – danger of it being generic She looks lonely but she doesn’t look upset (Older 1st Timer)

20. Support Lines Smear Tests save lives. They find the cells that cause cervical cancer before it’s too late. Couldn’t happen to you? A smear test could save your life. They find the cells that cause cervical cancer before it’s too late. Cuts your chance of getting cervical cancer before. Take your test. • Rhetorical question gets lost on this execution - does not connect with any of the headlines • Your life = personal • Finds the cells = message of hope (new news for first timers) • Before it’s too late – polarising sense of doom for some, whereas for others it connects with ‘catching it early’ • Mentions word chance = not full-proof • Implies 50:50 – why bother then • Take your test – too demanding • Saves lives – other people’s lives not mine

21. Support Lines Smear Tests can reduce deaths from cervical cancer by 75%. Smear Tests can reduce deaths from cervical cancer by up to 95%* *Based on 80% of women going for regular screening. Regular Smear Tests will cut your chance of cervical cancer by over half. Smear Tests help save 4,500 lives every year. • Positive take out for most • 75% sounds immediately encouraging • For some, the immediate thought is the other 25% • Regular = debate on how regular – what if you get cancer the month after your test • Over half = not good odds • High number of individual lives saved • Follow up thought – out of how many? • For the majority it ultimately doesn’t feel like that many • 95% compelling for majority – reassuring and strong message of hope • The actual meaning of 95%/80% is lost • HOWEVER • Small print = manipulated figures

22. Copy • Bullet points have more immediacy than paragraph • All provided a (cumulative) sense of reassurance that works with the tone of the rest of the advert • Exception was modern equipment – scary for some, for others sets up a false expectation Bullet points are straight to the point, it looks like too much information on this one [ paragraph] - I couldn’t be bothered to read it, it’d get bored reading that (Younger 1st Timer)

23. Logo & Strapline • Too demanding and bossy • Test – self test? Reminds them of exams or driving test. • No stand out – what cells? • Save your life – needs more context doesn’t work as strap-line • Mixture of ‘C’ word and an order to take the test • The test can’t promise this Take your test, sounds like you can do it yourself, like pee in a pot. Have your test would be better. (Younger 1st Timer) • Cancer frightening • Over promises • Strong call to action • No mention of the ‘C’ word

24. Call to action • There needs to be a clear call to action on each communication • Sentiment – ‘Don’t put it off - talk to your practice nurse to make an appointment today’ • Direction to other information sources: • Facebook – Marmite effect • Website expected (tone of the leaflet) • Telephone (less desire to talk to anonymised national helpline) If you had a website on there. I’m not saying I’d look at it but I might (Older 1st Timer)

25. Call to action I have such an aversion to Facebook (Older Missed Apps) Facebook - it’s like 21st century. That would probably make me go because I’m obsessed with it. (Younger 1st Timer) Facebook – that’s cool, shows they’ve moved on, going with the times (Older Missed Apps) I wouldn’t want people associating me with smear tests – wouldn’t want “Emma is now a part of this group” (Younger Missed App) Facebook could raise awareness of it with young people (Younger Missed App)

26. Talkability • Interested in a campaign about smear tests – limited information available currently & not enough to persuade them to go and have the test • Surprise that there hasn’t been a campaign • Would prompt discussion with friends If my bains look through magazines, they ask me questions. So if he saw a little boy crying he’d ask me questions and I’d find that a bit awkward (Younger 1st Timer)

27. Ideal Creative Format 38

28. Ideal Creative Format • Imagery • Crucial for them to be able to read the hurt in the eyes • Image should unambiguously convey loss/grief (quiet crying vs. noisy crying) • Close up important • Context helps (stairs/on the bed) • Headline – • Needs to refer to smear test • “My mum missed her smear test now I miss my Mum” most compelling headline of those tested • Support Line • Percentages effectively convey hope • There is also reassurance in ‘Find the cells’ • Needs to be larger and easier to read (not pink on black) • Copy • Bullet points Their eyes tell a story…you look into their eyes and it tells you want they are feeling (Younger 1st Timer) The one that said my mum missed her smear test would probably get me more….to catch me you’d need those words – smear test (Younger 1st Timer) It needs to say why you should have it, then the reassurance that when you do have it you’re likely to be OK (Older 1st Timer)

29. Supporting Leaflet/Letters 40

30. Leaflet

31. Leaflet

32. Reaction to Leaflet I think it’s brilliant…there are stories in it and it’s easy to read (Younger 1st Timer) • Genuinely interesting • Applauded the non NHS style • Pink/girlie • Informative • Easy to read/digest • Testimonials very well received • Read by everyone and often read first • Made them feel they were not alone with their thoughts/worries about the test • Made the test feel more accessible, less daunting • Smear Test could save your life page • Direct and to the point • What can I expect at the test • Liked the step by step approach • Too much ‘medical procedure’ information in for the genuinely scared • Needs more of the service reassurances • Contradicts with testimonial saying it is ‘relatively painless’

33. Leaflet Cover • Preference for less emotional image on the cover of the leaflet • Use of mother and child more engaging than single woman • Liked NHS on front cover

34. Invitation Letters • Reference to Smear Test – clear what the letter is all about • More inviting font – still quite long • If unsure what to expect – positive • Offer to be able to call & talk to a nurse - considerate • Unusual cancer – for some this means they don’t need to bother having the test (no longer a common cancer) • Cervical Screening is not perfect – opt out. Huge negative for those they who are reluctant to take the test • PS – Read but needs to be a new information not repeated text

35. Invitation Letters • Don’t put it off any longer – talks directly to them • Appointment – polarising • For some it gives them the push they need – onus on them to cancel • For others - affront • Specially trained – helps ease their worries • ‘If, like many people, you feel unsure’ – liked the option to call with questions at a specific time or for the pre-appointment (even if unsure this was practical in reality) It sounds like it’s coming from a real person (Younger Missed App)

36. Service Innovations 50

37. Ideal Service Principles (Phase One) Respect Choice Reassurance

38. Ideal Service • Ideal Service – sounds great but sceptical if it can be delivered • Reassurance throughout the process came through strongly and spontaneously • Friendly nurse, willing to talk to you about your fears/concerns • Cup of tea • Music in background • On time…not want to sit and worry whilst waiting for their appointment • Additional Ideas • Pre-appointment chat by phone • Option to talk through worries between test and having the results • Pain relief See Ideal Service in Appendix

39. Ideal Service • You will receive a short & simple invitation letter with a leaflet explaining about the test & a text reminding you when your appointment is. • There will be the option of a pre-appointment so you can come in and chat about the smear test, find out why it is important to have the test, to learn what will happen and to ask any questions you have. • You can have the test done at your local GP’s with a friendly nurse or at a local health centre or at a drop in clinic, all at a time to suit you (during the day or in the evening). • The test itself - you can take a friend to wait with you, and there will be little touches to make it less daunting – for example radio on in the background; magazines to read; and pictures on the walls). It will be done in a private room and the nurse will make sure that no-one comes in. • The nurse will introduce herself and reassure you about having the test. You can ask any questions you want and the test will take about 10 minutes, but will be taken at your pace so you don’t feel too rushed. • After the test the nurse will tell you when you will get your results back and what the test looks for and there will be time to ask any other questions you might have.The results will be back to you in 7-14 days and you can choose to have these results sent to you by letter or by text. If you need to go back for any more tests the nurse will call you personally. • You will also receive a short anonymous feedback questionnaire so that you can tell us what you thought of the smear test. 

40. Key Learnings 55

41. Key Learnings • Integrated campaign catches woman at differing levels of engagement and with differing barriers • Adverts – motivated through emotional connection • Leaflet – provides context and reassurance • Letters – reassurance and direct call to action – initial national reminder followed by personalised local letter (recognising reluctance) • Service – delivering the promised reassurance in practice • Need for the service providers to understand the insights behind the campaign in order to act on them

42. Feel about the smear test now…. That poor bain sat on the stairs, that’s what has stuck in my mind (Older Missed Apps) Makes you more aware and willing to go…slightly given me the edge to ring my doctors….I want to be there for my kids & for my grandchildren too. I couldn’t bear to think of my kids being by themselves (Older Missed Apps) Really upsetting looking at that – I feel really guilty not going for one, I just want to enjoy my kids (Older, Missed Apps) As you are continuously putting everything before yourself, when you see pictures like this you think I could nip to the doctors in my lunch (Older Missed Apps) Children’s pictures don’t affect me at all….but the information on the leaflet I really liked (Younger 1st Timer) Makes you think if you did go and get the test, you’d still be there just for having that 10 minute test (Older Missed Apps) I want to get it done…seeing that little girl and reading that leaflet…it’s the reassurance really (Younger 1st Timer)