The problem
Low uptake of cervical screening among women in the poorest parts of West Lothian: women from ethnic minorities, women with disabilities, and women who don't speak English as a first language.
Case study · NHS National Services Scotland
Cervical screening in West Lothian
About 30% of people in Scotland don't go to their screening appointments, and the poorer the area, the fewer go. In West Lothian I led research with the women least likely to attend, to find out what was in the way and what might help.
At a glance
What I did
Planned and ran 40+ interviews, focus groups and workshops with those women, and made sure the research itself was accessible to them. Then co-designed and prototyped fixes with the team.
What we found
The first contact was the problem. A paper letter was hard to read, easy to lose and hard to act on, and booking or getting support to attend was harder still.
What changed
We co-designed a text-first invitation from your own GP practice. The work was nominated for an award at the NHS Scotland Event and written up as a playbook for other Health and Social Care Partnerships.
The question
Working with the NSS Service Design Hub and the local Health and Social Care Partnership, we set out to answer one question: how might we use personalised communication to get more people in West Lothian to their cervical screening?
There are many reasons people don't go, such as pain, embarrassment, time and fear of the results. A service can't fix all of these. But it can change how people are invited.
46.5%Of women aged 25 to 29 in NHS Lothian went to screening in 2020/21, down from 55.7% in 2016/17
16In-depth interviews of about an hour, mostly with women in the most deprived areas
6Themes from the research, each turned into a question for the workshops
4Personas, one for each stage of not attending
How the work ran
- PlanBudget, stakeholder map and recruitment plan. The hardest part was reaching the right people, so it got the most time.
- WorkshopA first workshop with partners to narrow down where to look.
- Interview16 in-depth interviews by phone or Zoom with women recruited through a research agency, who were paid for their time. Plus interviews and informal conversations with community representatives and GPs, 40+ in total. Each session was adapted to the person's access needs.
- Make sense of itI sorted everything into problems, opportunities, principles and insights (the POPI framework), then checked the themes against published evidence.
- Co-designWe turned the six themes into six “how might we” questions. In workshops with partners, small groups came up with ideas for each one and then prioritised them. A prototyping workshop shaped the best ones.
Who we talked to
Women in the poorest areas
The data showed a clear link between deprivation and missed appointments in West Lothian.
Women with disabilities
Including women with sight loss, for whom a printed letter is a barrier before anything else happens.
Women from ethnic minorities
Including women for whom faith and culture shape how they feel about the test.
Women who don't speak English first
For whom an English-only invitation might as well not arrive.
We also heard from single mothers, for whom time and childcare were the real obstacles. Making the research accessible was a challenge in itself: interpreters, formats and venues all had to fit the people we wanted to hear from.
What the evidence says
What gets in the way
Pain or discomfort. Embarrassment. Time. Not being able to get an appointment. Fear of the results.
What helps
An easy way to book. Peace of mind. Wanting to prevent serious illness. Knowing the risk. Good, kind staff.
The top five reasons from published surveys of women about cervical screening. We used these alongside our own interviews.
“I think it's really frustrating the amount of post. Everything is online via text, and I think that's how most people like to work. If I get anything by mail, it goes in my log burning fire.”
What we learned
- The way people are invited makes screening easy to put offFor many, the invitation letter was the first time they had heard about cervical screening. Letters were easy to ignore, often mistaken for bills, and hard to use for people who need help reading them.
- Booking is one of the biggest barriersFew appointments, phoning only during GP opening hours, and work, childcare and transport to fit around.
- The phone is where people organise their livesText was the preferred way to hear from the NHS. The COVID vaccine had made booking on your phone normal.
- Family and friends decide a lotPeople went to their mum or friends for advice and reassurance, and most learned about screening by word of mouth.
- The thought of the test puts people offEmbarrassment, worry about pain, and past bad experiences. One woman told us the thought of it was worse than the test itself.
- Results should be simple and easy to getPeople chased results by post, worried when they would arrive, and wanted to see them the way they could see their COVID status.
“If I just got this and had no idea what it was, then I don't know if I would have bothered to do anything about it.”
Four personas
Not going to screening isn't one behaviour. Based on Kathryn Robb's research at the University of Glasgow, we built a persona for each of four stages: unaware, unengaged, undecided, and decided not to act. Each needs something different.
Unaware
“I don't understand what I'm being invited for.”
Unengaged
“Screening isn't relevant for me.”
Undecided
“I'm scared what my results might be.”
Decided not to act
“It's too embarrassing.”
What we designed
Ease of booking came top of what helps in the published research, and booking was one of the biggest barriers we heard about. So most of our ideas were about making the first step smaller. My behavioural design background helped here: how and when you ask people affects what they do.
A text, not a letter
The invitation arrives on your phone, from your own GP practice, with a number to call and a link to more.
Every format, one tap away
The link opens easy read, British Sign Language, audio and other languages, so the invite works for whoever gets it.
Booking around your life
Appointments offered by when you're free, with a way to ask for support to attend.
A nudge at the right time
Reminder prompts by phone, so a missed letter no longer means a missed test.
Award nomination
The work was nominated for an award at the NHS Scotland Event, where we presented it on this poster. The wider project also looked at bowel screening in North Lanarkshire, and the approach was written up as a playbook so other Health and Social Care Partnerships could use it.
What I took from it
- The research has to be accessible tooIf the method only works for people who are easy to reach, you learn nothing about the people you're trying to help.
- The first contact decides a lotBefore anyone weighs up pain or fear, they have to get the invitation and understand it. That is easier to fix than what comes after.
- Ideas need a route to deliveryGetting from co-design to a funded roadmap was the hardest part. Next time I'd bring the people who own the budget into the workshops earlier.
With David Proud, Katharine Ross and Sarah Adams at NHS National Services Scotland, the NSS Service Design Hub and West Lothian Health and Social Care Partnership.