Tackling inequity has long been a key priority for the Screening Division. We report regularly on uptake by deprivation quintile and have explored inequity by different characteristics as part of project work and ongoing community work led by our Screening Engagement Team.
Our aim is to enable all eligible participants to make informed choices about screening. This is complex, influenced by language, community, cultural and economic factors impacting on behaviour, as well as physical access to services. To address existing screening inequity our approach focuses action in five key areas. These key areas build upon our existing strengths and assets within the Screening Division and wider partner network:
Communication
Community and Engagement
Collaboration
Service Delivery
Data and Monitoring
To sustain action to address tackling inequities, a Screening Inequity Framework has been developed. This identifies a series of commitments to progress action across our key areas.
Examples of actions undertaken in 2022-23 in this space include the following:
Our Public Information Development process has been reviewed, including the revision of our toolkit to aid development. The toolkit contains information around ensuring accessibility in language and design, as well as a guide to the development process which starts with assessment of the need for any given product and thought about the format and dissemination, and includes steps around engagement and review.
An audit of our provision of accessible information has been carried out. Our standard is for all resources to be available in Plain English, Welsh, Easy Read, British Sign Language and audio across all the programmes and across all touchpoints in the pathway. The Screening Engagement Team are working with the programmes to prioritise work on areas that need to be strengthened. Alongside this, the team are looking at how best to get information in other formats to people when they need them. In particular, we are looking at Accessible Invitation Letters – these are particularly challenging as the letter is the first point of contact with screening for most people, and we generally do not know communication needs at that point.
Across the programmes we are reviewing our use of language related to gender. Our underlying principles are that we need our messaging to be clear and understandable, as well as accessible and inclusive. Where appropriate, we have adopted an additive approach e.g. referring to women and people with a cervix when talking about cervical screening. However, when producing information for the public we try and personalise it as far as possible e.g. when you are invited for your test.
As part of our Communications strategy, we are looking to build trust in, and understanding of, screening services. In order to do this, we are looking to develop some simple, accessible information that explains the principles of ‘What Is Screening’. We are also building an “asset bank” of messages that will ensure the use of consistent messaging, and allow sharing by our organisation and partners. Learning from previous campaigns, as well as engaging with a range of stakeholders and partners, we are making sure to carry out wide-ranging testing of our messaging with partner organisations and participants once it has been developed.
We have carried out a complete review of our Websites to ensure consistency of layout and approach, based on web best practice and user feedback. We have a particular focus on accessibility and ensuring that users can navigate easily to find what they need. We are conscious of the benefits of digital formats of information including benefits for accessibility and use of tools such as animations to improve how engaging and understandable our content is. We are also very aware of potential digital exclusion, particularly within certain pockets of our communities, and are not aiming to have exclusively digital information provision. Our Antenatal and Newborn programmes are evaluating their use of digital information first, and findings from that work will inform next steps for our other programmes.
The screening division is working with the central teams in Public Health Wales to look at provision of information in other languages, working towards a single approach across the organisation. Recommendations from engagement work with minority ethnic groups carried out by Screening Engagement Team will be used to inform these conversations. Also, the translation functionality of our websites plays an important role.
The Screening Engagement team is also leading on a piece of work for each of the programmes looking at consistent style and wording of key messages, with consistency both within programme resources and across the programmes. We will also translate this into Welsh so that there is consistency in language usage across our Welsh resources too.
Examples of actions undertaken in 2022-23 in this space include the following:
An audit of the Engagement Team Stakeholder Database has been carried out, to ensure that contacts are up to date and look at the breadth and reach of our community partnerships. Conversations are ongoing with other engagement functions within PHW as well as the central PHW engagement team. We are aiming to maximise our reach and impact without over-burdening our partners, ensuring that they engage in the most effective way.
Work has been ongoing with specific community groups in order to better understand barriers and enablers to participation in screening. This year specific pieces of work have been done with the following communities
Trans community – our specific resources have been refreshed as part of an ongoing partnership with community members and health professionals working in that space.
Ethnic minority communities – The aim of this project was to engage with ethnic minority communities across Wales and gather insights into their knowledge and awareness of screening, and identify barriers and opportunities for improving access to screening. The methodology used included face to face and virtual focus groups and one to one interviews conducted by support workers, with the session plans and questions developed in line with the COM-B model of behaviour change. The engagement included representation from a diverse range of ethnic minority communities including Gypsy and travellers; Yemeni, Somali and Sudanese; Afro-Caribbean; South Asian; Chinese; and people seeking sanctuary. The next steps of this work will involve working collaboratively with the Screening Division and wider partners to implement the project report recommendations and develop an ethnic minority communities screening inequity strategy.
Carers – the Screening Engagement Team is leading a comprehensive engagement piece of work around carers and enabling them to support the people they care for to make an informed decision on their screening offer, as well as supporting them to take up the offer of screening themselves. The work includes administering a survey, running focus groups with carers, and engaging with screening staff to identify any key challenges and barriers from the operational perspective too. The findings of this work are being analysed and, when published, will provide insight into knowledge, attitudes and barriers and inform our approach.
Learning Disability – the Screening Division has worked with Learning Disability Wales to explore specific aspects around the delivery of screening programmes. A collaborative session with partners from across the organisation has facilitated sharing learning and the development of an action plan specifically for this group of participants, structured using the priorities from our Equity Strategy.
Time to Talk Public Health is Public Health Wales’s nationally representative panel of 2,500 residents across Wales. By sharing their experiences and views each month, panel members will help to shape public health policy and decision-making, and contribute to improving health and well-being across Wales. The Screening Division is part of the Advisory Board for the panel and has so far submitted questions around general screening knowledge and awareness, and also specifically about bowel screening. Time to Talk Public Health Panel Publications - Public Health Wales (nhs.wales)
Community training and education is being delivered by the Screening Engagement to community partners across Wales. The training has been well received and well attended with over 350 participants over the last year across 30 sessions. The training is currently being evaluated - the outcome of the evaluation will give us an opportunity to learn from the current programme of work and make any amendments and improvements going forward. Community Training and Education - Public Health Wales (nhs.wales)
A key next step for us is working with our partners to ensure that we use all the sources of insight and bring them together to inform action.
Examples of actions undertaken in 2022-23 in this space include the following:
Following the positive engagement carried out by the Screening Engagement Team, a Screening Engagement Network will be established. It is planned that a network event will be held twice a year. This will be open to third sector partners and Local Public Health Team Senior Practitioners and Practitioners.
The Screening and Inequalities group, continues to meet regularly every other month, with representatives from Local Public Health Teams and the Screening Division. The group is a forum for sharing learning about local and national work and new developments within the programmes, and has expanded its remit to look at inequity across the pathway, not just in uptake.
Key partners for us in screening are colleagues in Primary care. The Screening Engagement Team has undertaken a survey of cluster leads, looking at what data and information would be helpful for them and also at the best methods of communication. These findings are being discussed with leads from the PHW Primary Care Division in PHW as well as internally in screening.
As part of work with primary care, the division has rolled out invitation and reminder letters for the Bowel Screening Wales programme that are endorsed by the service user’s own GP. This is because of published evidence that shows that endorsement by the GP improves uptake and reduces inequity in uptake. Over 90% of Practices have opted in to and this approach started in February 2023 and only a few practices opting out or not having responded. This was only rolled out earlier this year and is yet to be formally evaluated. Findings will be shared with primary care partners to hopefully show the benefit of the intervention and encourage greater roll out of this evidence based approach to reduce inequity.
Information for professionals intranet sites have been set up for each of the screening programmes, using a consistent template based on web best practice principles. One of the key next steps this coming year will be around the programmes further developing this information based on engagement with key stakeholder groups. One of these groups is primary care and we aspire to be able to provide a trusted and easily accessible source of information that will present evidence-based interventions that can be carried out locally.
Examples of actions undertaken in 2022-23 in this space include the following:
Each programme has a nominated Equity Champion. These key members of programme staff attend regular divisional equity meetings and link learning back into operational programme delivery. A role descriptor has been devised which sets out expectations.
One issue raised by service users and partner organisations is the importance of having multiple methods of communication for service users to contact the programmes. An audit was carried out of methods offered in letters and on the internet against the standard of having a phone, email address and postal address as a minimum, and support given to programmes that still needed to improve. This will be re-audited in the new year.
We are continuing to work to embed Equality and Health Impact Assessment (EHIA) as part of routine practice in the Screening Division. The tool that we use has been developed by the Screening Engagement Team, working with the central PHW team, to have something that is both thorough and also easy to use and guides users towards actions and next steps.
Some groups of people who are eligible for screening are not easy to identify and invite as they are not registered with GPs in the same way as the general population. These groups include people in prisons, some people in long term care facilities, and people in the Military that are registered with Defence Medical Services. For each of these groups, there is work ongoing to ensure that we are made aware of eligible people in a timely way and that they can be offered screening.
We are looking to map the service user journey across all of the screening programmes in order to address barriers in opportunity and access for service users at all stages in the pathway.
Examples of actions undertaken in 2022-23 in this space include the following:
The publication of this Equity report is one of our commitments, sharing data but also an update on our actions to date following the publication of the strategy last year.
We are working hard to explore different ways of getting more measures with which to look at equity of uptake of screening, the main one being ethnicity.
The actions described above are not all that we are doing in the Screening Division and with our partners to tackle inequity across the screening pathway. However, they provide a good set of examples of the type of work we are doing, under our five priority areas, and actions taken in response to priorities identified in our Equity Strategy.