Index

Corresponding Author:
Susie Andrews, Cervical Screening QA Development Manager, West Midlands Quality Assurance Reference Centre, West Midlands Cancer Intelligence Unit, Public Health Building, University of Birmingham, Birmingham, B15 2TT, Email: susie.andrews@wmciu.nhs.uk

Suggested citation: Andrews, S and Turner, M. What's Pants, But Could Save Your Life?-Increasing Cervical Cancer Screening Utilization in England. Cases in Public Health Communication & Marketing. 2009; 3:186-203. Available from: www.casesjournal.org/volume3.

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Abstract

The UK's Cervical Screening Programme began in 1988 and entitles all women aged 25 to 64 to free cervical screening. This has contributed significantly to national reductions in the incidence of invasive cervical cancer.

However, there has been a decline in screening utilization among women aged 25 to 39 years, with numbers falling steadily since 2001. In the West Midlands, only 76% of eligible women have had a cervical screening test within the last five year.

To address this, the West Midlands Cervical Screening Quality Assurance Reference Centre proposed that a three year regional cervical screening intervention should be run across the entire West Midlands region, commencing in April 2008.

The result was 'What's pants, but could save your life?' - a social marketing program which raises awareness about the need for cervical screening with the target age group, and provides increased access to and provision of screening services to facilitate uptake. Work has also been done to enhance the service itself, for example, by always offering female screening nurses.

With a budget of £55,000 for 2008 ($77,000 US), the program has achieved an unprecedented increase in cervical screening utilization in the West Midlands region, seeing a 16% screening increase in the gateway age group after Quarter One alone. This puts the program on track to achieve its year one target of 4% increase across all age groups in the region.

Project Overview

The West Midlands region is a metropolitan area in central England with a population of around 5.4 million people.

'What's pants...?' was the first West Midlands-wide National Health Service (NHS) program to adopt a fully integrated social marketing approach. The program also marked the first time the NHS led a regional cervical screening intervention to identify, measure, and achieve tangible behavioral change around cervical screening.

The methods mix included: modified and increased service provision, including additional screening clinics; radio, bus and ambient advertising; and direct mail, including personalized letters of invitation to come in for screening.

Budget
£55,000 for 2008 ($77,000 US)

Results Overview

• Unprecedented increase in cervical screening utilization in the West Midlands region
• By end of quarter one, 16% screening increase in the gateway age group
• Well on track to achieve or exceed year one target of 4% increase across all age groups

Background and Context

According to the 2007 Chief Medical Officer's report ⁱⁱ, the NHS Cervical Screening Programme, which began in 1988, has contributed significantly to national reductions in the incidence of invasive cervical cancer ⁱⁱⁱ.

In the West Midlands, there were 465 cases of invasive cervical cancer in 1987. By 2006, this had dropped by almost half, to 253.

In October 2004, changes were made to the age at which a woman receives her first invitation for cervical screening, moving it from 20 years to 25 years. This was based on studies by Cancer Research UK ^iv, which suggested screening was not effective in preventing the rare cases of cervical cancer diagnosed in women under 25.

Currently, in England all women aged between 25 and 64 are automatically invited for free cervical screening. Those aged 25-49 are invited every 3 years and women aged 50-64 are invited every 5 years. In order to invite women, names are obtained from the lists held by doctors ¹.

Reducing the risk of cervical cancer is dependent on achieving a high uptake of cervical screening once women reach 25 years of age, with the incidence rates for cervical cancer beginning to rise rapidly in the 25 to 29 year age group.

There has, however, been a decline in screening utilization among women aged 25 to 39 years, with numbers falling steadily since 2001. Only 76% of eligible women in the West Midlands have had a cervical screening test within the last five years ² - well below the national coverage target of 80%. This equates to 23,000 'under-screened' women.

The Chief Medical Officer's report also showed that a greater proportion of women from deprived areas diagnosed with invasive cervical cancer had previously failed to attend screening ³. Increased cervical screening coverage of women at highest risk needed to be achieved in order to prevent the incidence of cervical cancer rising further.

To address this, the West Midlands Cervical Screening Quality Assurance (QA) Reference Centre team proposed that a three year regional cervical screening intervention should be run across the entire West Midlands region, commencing in April 2008.

After raising this idea with primary care cervical screening leads at their regional meeting in May 2007, the QA Reference Centre team created an initial project plan, searched the background literature, tested their initial messaging ideas and then formally presented a proposal to the screening leads at December 2007 board meeting. Early in this process, Martin Turner and his communications team from NHS Walsall ^v agreed to provide the required expertise for the marketing element of the program.

The Social Marketing Benchmark Criteria

Benchmark 1: Customer Orientation
Maintains a strong focus on the customer at all times, seeking to understand as much as possible about the presenting issue and the target audience, by using a mix of quantitative and qualitative research.

During the development process, the Walsall team conducted two stages of research.

Stage 1 involved a search of background literature, examining customers' responses to previous cervical screening campaigns in other English regions, and a look at broader social behaviour with regard to uptake of screening generally.

Several published studies and local quality assurance-funded primary care studies ⁴ have shown that the reasons women give for not attending cervical screening include: embarrassment; anxiety; a lack of knowledge about cervical cancer; cultural reasons; inconvenient appointment times; difficulty in making appointment; difficulty getting to the clinic locations and; the possibility of a male nurse carrying out the smear test.

A study of declining attendance in the North East, Yorkshire and Humberside ⁵ also found that the rate of decline was associated with deprivation and younger age groups, with possibly a higher rate in areas of mixed ethnicity; but that the decline was not associated with specific ethnicity or religion. The study recommended that interventions should therefore be targeted at younger women and those living in deprived areas; and multifaceted interventions - such as community development, mass media and targeted media - were most effective.

Coverage data at this stage also revealed that almost 40% of the region's women aged 25-29 years were not responding to invitations to go for screening, presenting a clear challenge for the project delivery team.

Stage 2 saw the use of several methodologies, including quantitative research. Examining coverage trends by Primary Care Trust (PCT) and by age quintile from the last five years of testing in the region suggested that the low attendance of women aged 25-29 years continued through the age groups over time, implying that those who avoided attending their first test would be likely not to attend another appointment in future.

Qualitative research
The Walsall communications team held more focus groups with local women. These revealed the personal reasons why many women are reluctant to attend screening sessions, which reflected those revealed by other regional studies during stage 1.

Examining the process
All existing clinical and non-clinical processes for cervical screening were scrutinized, including the nature and content of the 'invitation to screen' letters. The existing letters followed the national recommended text and were a personalized approach to patient communication. The physical location and hours of operation of clinics and other screening centers were also examined.

Pre-testing of materials was also carried out. A number of initial messaging concepts were shown to a local focus group, and participants were asked to rate the different slogans, with preference responses as follows:

• 'What's pants, but could save your life?': 42%
• 'Cervical cancer's not pretty': 28%
• 'Service your cervix': 17%
• 'Your cervix needs you': 15%

There were concerns among some participants that the messaging would not appeal or might be offensive to ethnic communities. The communications team therefore held a focus group with young Asian women (who represent a considerable proportion of the Walsall population), which revealed that the proposed name was suitable, and that the messages did not carry negative sexual connotations.

Development of promotional literature
Pre-testing materials with focus groups helped the team to refine their message. Original copies of the slogan made reference to the 'West Midlands'. However, this was changed to the more generic 'our region', as it emerged that many people were unaware that their town was actually in the West Midlands.

In addition, the call to action was refined from the original 'get tested' message, to one which reflected the need for those over 25 to make an appointment if they had ignored the last screening invitation from their local health authority. This avoided creating an influx of the 'worried well', such as women under 25, or women who had been tested recently.

Certain practical restrictions also influenced the final look and feel of materials. For instance, the owner of one local transport company was unwilling to allow imagery showing provocative underwear to appear on his buses. This led the team to take a more colorful approach to materials, and to use a variety of 'fun' rather than sexy under garments.

The text for the materials was originally in black but was changed to magenta following focus groups which revealed the color was associated with femininity without conveying sexuality.

Benchmark 2: Insight
Uses the research phase to identify 'actionable insights': key pieces of understanding that will be used to underpin program development.

During the qualitative research phase of interviews, a surprising proportion of 25-29 year olds described the experience of cervical screening - unprompted - as 'pants', referring to the experience as mildly humiliating and mildly uncomfortable.

On further investigation, the communications team discovered that the experience fell between two categories for most respondents. It was not painful enough to fall into the category of 'things which are nasty but important'; however, nor was the process frequent enough to fall into the category of 'routine'.

The team's research also indicated that very few women of any age had a real picture of the prevalence of cervical cancer.

Based on this consumer attitude, the project's creative director produced a draft advertisement entitled 'What's pants, but could save your life?' using images of different kinds of pants (the British word for 'briefs') as a brand identity. This went against previous approaches - and perceived best practice in the sector - which attempted to make cervical screening appear as attractive as possible. However, through customer focus groups and research, the communications team discovered quickly that it would be impossible to make cervical screening seem an attractive prospect, largely because of the discomfort it necessarily involves.

A 2006 report investigating reasons for poor cervical screening uptake by another West Midlands PCT, which covered the areas of Telford and Wrekin provided several insights that would lead to an improved service. These included: the provision of Saturday and evening screening clinics to increase convenience and accessibility; additional training sessions for all staff in practices where coverage was low; use of display items in doctor's practices to promote the fact that female nurses conduct the smear; and a local media and promotion drive to disseminate key cervical screening health information.

Benchmark 3: Behavioral Goals
Focuses on changing people's actual behavior: identifies baselines and sets clear behavioral goals, which, where possible, are specific, measurable and time-bound.

The overall aim of the program was to increase regional cervical screening rates across all age groups.

The specific behavioral goal was to achieve, and then sustain, an increase in cervical screening rates among 25-29 year old women in the West Midlands.

Achieving this target would ensure that regional coverage figures for these age groups were raised above the national minimum standard of 80%.

Benchmark 4: Segmentation
Avoids a 'one size fits all' approach: identifies audience 'segments', which have common characteristics (e.g. socioeconomic; geographic; demographic; attitudinal; behavioral), then tailors interventions appropriately.

An analysis of national data showed that the 25-29 age group was a gateway age group, in that women who did not have their first event at that age generally did not go on to take up opportunities later. A low rate of utilization in the gateway group can be seen in the adjacent older age groups over time as the group progresses through the eligible screening population.

In the West Midlands, the 25-29 year old age group had a 68% screening rate, whereas those aged 44-65 years were above the national target at 82%. In addition, research indicated the lowest screening rates among more deprived communities.

Consequently, the team made the decision to target women aged 25-29, rather than to tailor materials for a wider segmented audience.

In order to target interventions for this audience group, the program team worked with local media organizations, using marketing information to find the key touch points for women aged 25-29 years.

Benchmark 5: Exchange
Considers both the benefits and the costs of adopting a new behavior, aiming to maximize the benefits and minimize the costs to create an attractive exchange.

Several studies had shown that there was a general lack of awareness about cervical cancer and screening, with the main reasons given by women for not attending their cervical screening falling into three groups:

The test is embarrassing, uncomfortable, and I can't see the benefit

'What's pants...?' uses humor and honest messaging to acknowledge the mild embarrassment and discomfort associated with screening. It also addresses the lack of knowledge around the benefits of the test by emphasising its potential to save a person's life.

Inconvenient and difficult to access

Many of the focus groups revealed that they found the clinics' hours, or the difficulty of making an appointment with their local doctor, to be a major barrier. The service provision was therefore modified, offering screening at a wider variety of locations, with extended opening hours and improvements in the way results were delivered – minimizing any potential inconvenience for the target audience.

Screening was not a priority, because 'young people don't get cancer'

The program uses national data to draw attention to the number of lives saved in the West Midlands region by screening every year - one every day - and the website provides factual information and advice about cervical cancer and screening.

Benchmark 6: Competition
Aims to understand what competes for people's time, attention, and inclination to change, and to work with or learn from the competition.

The research stage revealed that women did not prioritize cervical screening compared to other healthy behaviors, such as the recommended levels of exercise or eating five servings a day of fruits and vegetables. The very low rate of awareness led the team to look for a promotional methodology that would have greater impact.

According to research conducted by the UK's Advertising Standards Agency (ASA) ⁶, the use of humor and colloquial language can make a significant contribution to the success of a campaign, by ensuring it gains the audience's respect, and is memorable.

The ASA study, which used qualitative research in the form of group discussions, interviewed a cross section of British society, as follows:

• Teenagers: 16, 17 and 18 year olds still at school
• Singles: aged 20 to 24
• Parents: with at least one child aged 5 to 14
• Empty Nesters: aged 50 to 60
• The Greys: aged 65 to 75

The research cites the importance of a campaign's ability to enter everyday culture, through its informative and entertaining content.

Everyday culture
ASA's survey found that advertising which creates an impact, either good or bad in the consumer's mind, can become as much a topic of conversation as any other media - with certain phrases being adopted and used within peer groups, particularly those of 18-25 year olds. In fact, it was found that not knowing a key phrase is equivalent to not knowing the latest music or designer label.

The Walsall team therefore saw the use of the colloquial term 'pants' as an opportunity to build on this insight.

Entertainment
Participants readily recalled ads which entertained them, with the admired advertising and advertiser almost always seen as being humorous, clever and original.

'Clever' was a word which participants used often, with some talking about advertising that they did not at first understand but which drew them in, and which they recalled as a result. Rewarded comprehension, while not being a term they used, was recognized as effective by some respondents. Conversely, too obvious or bland ads were criticized.

Humor
Participants mentioned humor almost as often as clever. It was important in entertaining and engaging consumers.

Pre-testing of 'What's pants...?' materials revealed that audiences did not grasp the meaning of the messaging immediately, but found it to be funny once they did understand. This insight from the ASA further reinforced the campaign's use of both the phrase 'pants' and the images of underwear.

Information
The third key insight provided by the ASA report was the ability of ads - particularly print ads - to inform. Participants recognized that many ads provided useful, interesting information that was often hard to find elsewhere.

The information that most interested consumers involved new products or services, with the concept of 'missing out' being a real motivator. Participants also responded well to ads which provided 'food for thought'.

The program team, therefore, used nationally published research to calculate the number of lives saved by cervical screening every year in the West Midlands and then translated this into a daily average (one a day) to give 'What's pants...?' more impact than its competitors.

The team also used colorful imagery, based on the results of the feedback survey to ensure that images stood out next to other health-orientated behavior change campaigns.

As 'What's pants...?' began to be implemented, local project leads approached doctors and other health practitioners as key advocates of the program. Some doctors were unwilling to move away from the promotional materials supplied through the NHS Cervical Screening Programme. However, compared to the information the team had gathered from the ASA and user testing, these posters and leaflets were not as appealing for the younger target group of 25-29 years.

Benchmark 7: Methods Mix
Uses a mix of methods to prompt and facilitate behavior change, including education, support, control and design techniques. Does not rely solely on raising awareness.

Service provision
Following research conducted on users and providers of other services, it emerged that the location and opening hours of screening clinics were crucial to the success of the program, with screening available outside of usual working times playing a particularly important role.

Several primary care trusts amended their service provision, thus providing a large number of additional clinics in different locations across the region - and with extended hours - to increase access and convenience for women.

Some of these clinics were only intended to cope with immediate increase in demand following the launch of the program in April. However, due to their success, some of these have become permanent, such as the walk-in facility in the city of Stoke-on-Trent.

These additional facilities and alternative screening services were publicized on a dedicated website (www.pants.nhs.uk), which also offers further information about cervical screening.

Promotional activity
At the primary care cervical screening leads regional meeting in December 2007, the project team presented specific PCT data to the screening leads, showing local coverage data and the shortfall in the number of women screened in each area. The screening leads reported finding this useful in their planning of local activity.

All PCT leads were then asked to submit project plans of targeted local activities and details of quantities of posters/leaflets required.

In spreading the message across the region, materials such as bus, bus shelter and train advertising were used, with the 'What's pants...?' leaflet included with all screening invitations.

Prior to the launch, a press release was sent to all the staff responsible for PCT screening and two supporting documents were also sent for distribution to all relevant organizations.

Two months after the launch of the campaign, these materials were followed up with a survey: each of the screening leads completed a questionnaire about promotional activity. Results showed both the press release and promotional materials were put to good use. For example, campaign posters were sent to at least 971 GP surgeries (outpatient surgical centers) and 854 pharmacies, as well as family planning and community clinics. Five of the PCTs distributed posters to retail outlets including the UK leading supermarkets -Tesco, ASDA, Sainsbury's and Morrisons, as well as the underwear retailer, La Senza, and the upmarket department store, House of Fraser. One PCT also distributed the materials to other clothes shops, market stalls, charity shops, hair salons, tanning salons and large offices. One PCT sent out 147 posters to retail and public locations including hair salons, beauty salons, gyms, female clothes stores, food stores, bridal shops, private nurseries, opticians, veterinary surgeons, and places of entertainment - pubs/bars, zoos, and movie theaters. Twelve PCTs distributed posters in public areas such as libraries, community sports facilities, private gyms, nightclubs, playgroups, nurseries and child care centers, community healthcare organizations, and local theaters.

Thirteen of the local PCTs made use of local media coverage, and thirteen also spread the campaign message at existing health promotion events.

However, six PCTs held specific cervical screening promotional events, and at one of these, six 'Theatre in Health' performances were held in community venues chosen in areas of low coverage. These were followed by Question & Answer sessions and an open discussion about women's health screening.

In another PCT, laboratory staff were present at a local supermarket store to demonstrate cervical cytology under the microscope, with shoppers invited to look at examples of screening slides.

Media communications
The media element of the program included using one eighth of the region's bus stop graphics and bus side panels to spread the word, underpinned by a two week radio campaign, local press exposure and a comprehensive website (www.pants.nhs.uk).

Further development work was done to create posters for doctor's offices and other health centers, explaining in more detail how to access cervical screening. Credit card sized cut-outs in the shape of pants displaying key messages were also created to distribute through selected lingerie stores and supermarkets.

Communications were integrated with the cervical screening program's existing services and a flyer was distributed as part of the established direct mailing, which is sent to all women 25-64 in the region, inviting them to attend for screening at the appropriate interval.

Since the target success over three years would only be equivalent to reaching national baselines, the project team opted to boost 'What's pants...?' by using trains, strategically situated posters (such as in women's bathrooms in workplaces), and press to supplement the ongoing direct mail program.

Alongside this, each PCT developed an action plan, including activities such as establishing stands in shopping centers to raise awareness of the importance of cervical screening.

Several PCTs are currently touring with "The Cervical Monologues" play, which shares stories and experiences of real women to explore life, love, sex and sexuality, as well as demystifying the screening process.

Benchmark 8: Theory
Uses behavioral theories to understand human behavior, and to develop programs around this understanding.

The theory behind 'What's pants...?' is based on Protection Motivation Theory ⁷. This looks at how people can be persuaded to adopt risk reduction behaviors, by considering the influence of fear or persuasion on individuals' thought processes and resultant behaviors.

It states that, when faced with a health threat, individuals react either by adopting adaptive behaviors to minimize risk, such as taking up regular exercise or stopping smoking (i.e. they are motivated to protect themselves); or, by carrying out maladaptive behaviors, which place them at health risk either because they continue a harmful behavior, such as heavy drinking, or because they fail to take a positive step which may reduce health risks, e.g. having a blood pressure check.

Whether individuals choose an adaptive or maladaptive behavior depends on their personal evaluation of four factors:

1. The perceived severity of the threat
2. Their own vulnerability to this risk
3. How effective the recommended preventive behavior might be
4. How confident they are that they will be able to carry out the preventive behavior

'What's pants...?' aimed to apply these theoretical concepts, by raising awareness of cervical cancer as a high-risk disease, but emphasizing the effectiveness of the test and early intervention, compared to its relative discomfort. Simultaneously, the improvements made to service accessibility increased the ability of individuals to carry out the required preventative measure.

Evaluation and Results

The overall effectiveness of the combined approach is monitored and evaluated by the West Midlands Cervical Screening QA Reference Centre, via routinely collected quarterly and annual PCT cervical screening returns.

Laboratory workload data for 25-39 year olds during the first quarter of 2008/09 (i.e. April to June), shows an 8% increase from the previous quarter (January-March) in workload across 12 laboratories, with results ranging from -1% to 21% - and a 17% increase from the same quarter in the previous year.

There are some current influences on screening workloads, such as a recent steady increase in the eligible population and a change in screening interval which was initiated in 2004 (but which is still influencing invitation cycles). However, since the target population is large, and there are no strong seasonal fluctuations in screening demand, it is possible to determine the impact of the project's first year.

The threshold for success was the achievement of a 12% increase in screening in the target 25-29 age group by the end of year three, based on a model of limited gains in year one, more substantial gains in year two, and the highest gains in year three, once 'What's pants...?' had been established in the minds of the public. This would be measured by total annual returns as part of the regular monitoring process.

At the end of quarter one, laboratories reported a 16% increase in the gateway age group alone. The target for the project's first year is a 4% increase across all age groups by the end of year one. The initial figures show the program to be well on track to achieve this, with seven out of 17 PCTs reporting a halt on decreasing attendance, and eight reporting an increase - this is compared to 2007, when attendance at 15 PCTs was on the decline.

To evaluate 'What's pants...?', a feedback survey was designed and sent to 7,500 women aged 25-39, of which 1,998 replied:

• 34% said they were familiar with the campaign, unprompted
• 41% said they were much more likely to get screened as a result of the campaign

Another form of evaluation continues to be carried out through the screening services themselves, where people who have never been screened before are questioned as to what prompted them to attend. Anecdotally, most of these cite 'What's pants...?' as the main reason.

During year one of the campaign, a young woman who had previously never attended screening was found to have early stage cervical cancer. She reported that the 'What's pants...?' poster on a bus had prompted her to go for cervical screening.

The cost of treating one person with cervical cancer is estimated to be £23,000 ($35,000 US). The cost of 'What's pants...?' is estimated at 10 pence (15 cents) per person in the target 25-39 age group. By preventing the need for cancer treatment of just two women, the program will thus have paid for itself.

The ongoing evaluation of screening results will guide development of program into year two. Encouragingly, the team behind 'What's pants...?' has been approached by other health providers, asking for permission to use their materials.

Lessons Learned

The 'What's pants...?' project was conceived and managed entirely within the NHS, demonstrating the ability of in-house social marketing teams to achieve population-level results.

Its success generated immediate commitment across the region to other joint social marketing projects, and also saw requests to create other regional and national social marketing programs.

In terms of the mechanics of 'What's pants...?', it was originally intended that the direct mail should only go to women aged 25-35. The NHS cervical screening program uses a call and recall system for women who are registered with their local family doctor. It also keeps track of any follow-up investigation, and, if all is well, recalls the woman for screening in three or five years' time. Unfortunately this approach requires local doctors to hold up-to-date contact information for every female patient, and relies on members of the target group to notify the doctor of any changes. It was therefore not feasible to target one age group in isolation, so the marketing materials were distributed to other groups too, for whom the materials may not have been so relevant.

Lessons were also learned with regard to restrictions imposed by media companies. For example, the campaign was not allowed to feature provocative lingerie on bus sides, which affected the design brief and final result.

Perhaps most important was ensuring that local PCTs were on board, as they were instrumental in leading 'What's pants...?' locally.

In 2009, the team will be asking project leaders to contribute to program delivery, by putting out a call for creative methods to raise awareness and increase participation. These ideas will be implemented together with the program's existing media presence.

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References

1. West Midlands Cancer Intelligence Unit, screening statistics. Available at: http://www.wmpho.org.uk/wmciu/CQA2.htm. Accessed 12 May 2009.
2. West Midlands Cancer Intelligence Unit, screening statistics. Available at: http://www.wmpho.org.uk/wmciu/CQA2.htm. Accessed 12 May 2009.
3. Donaldson L. 'On the State of Public Health'. Annual Report of the Chief Medical Officer 2007. Available online at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_086176. Accessed 12 May 2009.
4. Walsh J.C. The impact of knowledge, perceived barriers and perceptions of risk on attendance for a routine cervical smear. The European Journal of Contraception and Reproductive Health Care. 2006;11(4)
5. Willoughby B.J. et al. Journal of Public Health. October 2006; 28(4)
6. Ford-Hutchinson S. and Rothwell A. 'The public's perception of advertising in today's society'. Prepared for the Advertising Standards Authority, February 2002. Available online at http://www.asa.org.uk/NR/rdonlyres/A351FFA3-22D2-4A03-942E-F653A700B6EC/0/ASA_Public_Perception_of_Advertising_Feb_2002.pdf. Accessed 12 May 2009.
7. Rogers, R. W. A protection motivation theory of fear appeals and attitude change. Journal of Psychology (1975), 93-114. Rogers, R.W. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In J. Cacioppo & R. Petty (Eds.), Social Psychophysiology. New York: Guilford Press, 1983.

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Author Information

Susie Andrews, Cervical Screening QA Development Manager
After working in the private sector, Susie Andrews has worked in the NHS Cervical Screening Programme since 1995, spending five years in a cytology laboratory as a screener before moving to the West Midlands Quality Assurance (QA) Reference Centre.

Her main role is producing regional guidance, reports and information for health professionals, project managing new local QA initiatives and administering QA schemes such as the assessment of sample staining quality.

Martin Turner, Head of Communications, NHS Walsall
Martin Turner is Head of Communications at NHS Walsall. A member of the Chartered Institute of Public Relations, he graduated from the University of Oxford in 1988, and spent almost ten years working for international youth charity Operation Mobilisation in Belgium.

Subsequently, he was Executive Officer at West Midlands Arts, and European Communications Manager for Lucas Automotive, before joining the NHS in 2001. He has stood twice for the UK Parliament, for the Liberal Democrats, and is the Chair of the party's Parliamentary Candidates Association. He is West Midlands fencing captain, and chairman of Warwickshire County Fencing Union. He attends Riverside Church in Birmingham, and is married to Marjolein Turner-Prins, Dutch translator.