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 for the people the letter didn't reach.
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
The short version
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.
The question
Set with the NSS Service Design Hub
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?
The reasons people don't go are tangled. Pain, embarrassment, time, fear of the results. Some of that no service can fix. But some of it was down to how we asked, and that part we could change.
How the work ran
August to April
- 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.
- Interview40+ interviews and informal conversations with community representatives, recruited through a specialist screening service. 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-designFocus groups to generate and prioritise ideas, then a prototyping workshop to shape the best ones with the people who'd use them.
Who we talked to
Design for the hardest case and it works for everyone
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 people told us
Top five of each, in order
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.
“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.”
Four personas
Barriers, motivators and what would help
What we designed
Fix the first step
Ease of booking came top of what helps. So most of our ideas were about making the first step smaller. This is where my behavioural design background came in: change how and when people are asked, and you change 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.
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. Fixing that is cheap compared with 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 the NSS Service Design Hub and West Lothian Health and Social Care Partnership.