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I’ll have what she’s having. Later.

Fiona PannellIt’s free, easy to do, will possibly save your life and you are encouraged and frequently reminded to do it. Why then do some women still not go for their cervical screening?

An 80% uptake isn’t bad but considering how early detection and treatment can prevent up to 75% of cervical cancers it is important for 100% of women to be tested. The current process of getting women into the clinic is fairly costly and long winded. I think there are ways to improve this which will lead to an increase in the number of women being checked.

But first a quick explanation of the current process

Stage 1 – The woman is sent a letter telling her that it is time to be screened

Stage 2 – If the woman does not respond to her first letter she will be sent a reminder

Stage 3  – In addition, the woman’s GP will receive up to two notifications informing him/her of the woman’s failure to respond

In an ideal world, a world full of rational women who weigh up the costs of getting tested against the benefits, there will be no need for stage 2 or 3. But our world is not full of rational women (or men!). The role of behavioural biases in the difficulty people have in planning for their health in later years should not be ignored when planning for health and policy.  “Predictions are difficult, especially about the future” (Bohr) and the first and biggest challenge is paying attention to the future long enough to make a plan. Given a choice between watching television and making a phone call to book an unpleasant screening, people will watch television now and plan to book the appointment next week. However, when next week arrives, they do the same thing—indulging their current self now and promising virtuous choices for the future self.

Another barrier to us booking that appointment is a behavioural bias called “present-biased preferences” where we think in abstract and general terms when looking at our future, with an unavoidable overlay of rosy optimism; where ovarian cancer does not exist.

So how can we tackle this and get more women booking appointments? Long-term planning is an unnatural act that requires outsmarting the brain’s natural focus on the present and near-future. This is difficult to do so I would not propose that we try and change our natural instincts. Instead we need to work with our brain’s instincts and allow it to be lazy by giving no thought or effort to the appointment. This is where behavioural economics comes in.

Elephant mother and calfMy first suggestion is an opt-out booking system. This system utilises the understanding that humans are lazy. Rather than issuing a letter (or two or three or four) requesting one to book an appointment, instead a letter is sent with the information that the appointment has been booked for the 10th September at 4pm and to phone to cancel. This opt-out method has worked for organ donations where countries choosing opt-in have a rate ranging between 4 and 27 % but for countries employing the opt-out process the numbers are hovering above 98%. Using the system that I am proposing, I predict that women will go along with the date and time given to them because not phoning to cancel is the path of least resistance. You don’t have to do anything other than turn up on the day. True there will be issues with people not being able to make the date and time and not bothering to cancel but a smart contingency plan can be constructed for this.

My second suggestion utilises social influence. A study by Goldstein into towel re-usage in hotels found that communicating the social norm of towel re-usage to guests boosted the likelihood of towel reuse even higher. In this experiment hotel rooms contained a sign broadcasting the social norm of guests who had stayed in the same room “66% of guests in this room reuse their towel”. This produced a 33% increase in towel-reuse participation compared to the standard environmental appeal. We can employ this social proof technique in our letters by telling females that 80% of women in their town have been checked in the last 3 years. This may be even more effective than rudimentary towel re-usage because getting screened can be a daunting prospect for some so to know that other women are doing it might get us closer to our desired 100% screening rates.

References: Goldstein, Noah J., Robert B. Caldini, Vladas Griskevicus. (1991). A room with a viewpoint: The role of situational similarity in Motivating Conformity to Social Norms.

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