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HARNESSING DIVERSITY

Using Diversity Interventions to Increase Cervical Screening of Lesbian and Bisexual Women Lynne Carter, BA, Lesley Hedges, MSc, MA, and Shirley Congdon, RGN, DipN, BSc, MA

Despite increasing recognition and acceptance in many areas, lesbians, gay men, and bisexual people are still unnoticed service users whose needs the National Health Service (NHS) has not recognized and served well. This article reports the first stages of a small-scale, practitioner-led action research study undertaken to increase access to cervical screening for lesbian and bisexual women by planning and delivering service enhancements following in-depth individual and small-group interviews with local lesbians and bisexual women. These interviews provided rich data that provided insight into the women’s health beliefs and experiences related to cervical screening. These experiences directly informed the enhancements made to cervical screening services. The authors describe the factors that made this action research successful, which may have multiple applications across other diversity interventions.

Introduction This paper reports the first stages of a small-scale, practitioner-led action research study undertaken to increase access to cervical screening for lesbian and bisexual women. More specifically, the study explored how equality and diversity interventions can counteract commonly held misconceptions and myths regarding this aspect of women’s well-being. The five sections of this article represent the key stages of the action research study: deconstruction of the problem related to access to cervical screening by lesbian and bisexual women; detailing the action research approach adopted for this study; outlining the planning for enhancement and description of implementation of the planned changes; and detailing the key features of the enhancement. The conclusion reflects on the action research study by considering how these enhancements can be maintained and describing learning that can be used to inform other diversity interventions. Journal of Psychological Issues in Organizational Culture, Volume 3, Number S1, 2013 © 2013 Bridgepoint Education, Inc. and Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) • DOI: 10.1002/jpoc.21093 This article was originally published in Volume 3, Number 2 of the Journal of Psychological Issues in Organizational Culture.

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Deconstructing the Problem “Lesbians and bisexual women have often been ‘invisible patients’ within health services and their needs poorly understood” (Fish, 2009, p. 6) The literature in this area is sparse but shows consistent results across several decades and countries, as reported in reviews by Fish in the United Kingdom (2009), O’Hanlan in the United States (1995), and Saphira and Glover in New Zealand (2000). These three studies show that lesbians are less likely to come in for screening and that they have experienced negative attitudes toward their sexuality from healthcare providers. More recent research has described the continuing significant health inequalities experienced by people from the lesbian, gay, bisexual, and transgender (LGBT) communities in the United States (Buffie, 2011) and the United Kingdom (Fish, 2009) compared with the population at large. Although the UK 2010 Equality Act offers some protection against unfavorable treatment in public services, including the National Health Service (NHS), alone it cannot address deep-seated misconceptions and myths about lesbian and bisexual sexual health needs. Access to cervical screening for bisexual and lesbian women was the subject of a systematic literature review undertaken by Fish (2009). Fish undertook this review in response to the NHS Cancer Reform Strategy, which had a key target of reducing inequalities in access to screening and treatment for cancer. Fish’s review (2009) highlighted that lesbians are less likely to come in for cervical screening and yet are still at risk of contracting human papilloma virus (HPV) through either previous heterosexual sex or sex with women. “Lesbians were 10 times less likely to have had a test in the last 3 years” (p. 4). And: HPV has been diagnosed among lesbian and bisexual women with prevalence rates

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ranging from 3.3% to 30%. Among lesbian and bisexual women with no reported history of heterosexual sex, prevalence of HPV was 19%. Certain known risk factors for cervical cancer may be more common in this population (smoking prevalence rates among lesbians exceeded U.S. national norms for women). (Fish, 2009, p. 4) This important work has directed these practitioners’ action research project. Within the context of the authors’ everyday work as equality and diversity public health professionals, many myths related to lesbian and bisexual women’s sexual health needs have become known. Reed and Proctor (1995) highlight the importance of practitioner researchers using their context, which brings a unique, tacit perspective to their research. The authors have openly drawn upon experience to inform this project. The following are quotations heard in practice. Women who have sex with women are not at risk of contracting HPV, the virus which underlies nearly all cases of cervical cancer, and therefore do not need cervical screening. Many health professionals and lesbian and bisexual women have believed and relayed this inaccurate message. Our sexual orientation is private, no one else’s business, and is not of relevance in the vast majority of health care settings. Many participants in the equality and diversity training delivered by one of the authors of this paper have expressed this view, and many colleagues have responded with this argument to counter her recommendation to profile the sexual

orientation of staff and service users. Markowe (2002) studied coming out, that is, being open about being a lesbian, and found there were drawbacks attributable to negative stereotypes, but also that some lesbians feel it is important to be out and known for who they really are. If sexual orientation is kept private, the assumption is that people are heterosexual, which has immediate effects for those about whom wrong assumptions are made and contributes to the invisibility of lesbian, gay, and bisexual (LGB) people. If it has to do with LGB people, then “equality and diversity” will deal with it. They do that specialist work. Although it is a legal requirement for public sector bodies to work proactively to improve equality for people in “protected groups,” including LGB people, as deemed by the Equality Act 2010, overly bureaucratic processes and the marginalization of equalities’ staff and work have weakened efforts to perform this work effectively. In response to the direct question during a staff induction session, “Whose responsibility is equality and diversity?”, groups of new staff agree that the onus is on all staff members to ensure equality of access and experience and to reduce health inequalities. When asked at subsequent training sessions how they do this, most staff members are unable to provide proof of any tangible actions they have taken. The Equality and Human Rights Commission’s July 2011 policy paper “The Public Sector Equality Duty: A Way Forward for the Health Sector” reviewed equality work in the NHS and confirmed, “There was little evidence of equality having been mainstreamed into strategies, plans and programs. . . . When promising activity appeared to be happening, there was no sense of whether any practical outcomes were being achieved” (p. 2).

Interviews To inform the action for enhancement further, the authors planned focus groups with lesbian and bisexual women. Focus groups “generate data through group interaction on a topic determined by the researcher” (Krueger, 1994; Morgan, 1997; Morgan & Krueger, 1998). As Krueger (1994) points out, such an approach requires the researcher to pay close attention to the diversity of views held by individual group members rather than seeking a consensus view from the group. The researcher aimed to ensure that interactions between focus group members generated critical debate rather than a collection of individual descriptive accounts. One of the researchers gave enough information about herself to make it clear that she identified as a lesbian for the purpose of ensuring that the group members functioned interactively rather than in an interview conducted by a detached and objective professional (Kvale, 1996). The interviews provided a wealth of useful information about how to make cervical screening and other health services more LGB-friendly. The researchers interviewed five women alone or in pairs. There are large gaps in the evidence base concerning the health of lesbians and bisexual women. Many studies show a low response rate, and in the absence of known populations of lesbians and bisexual women, sampling methods such as snowball are usually used. The current work found additional problems in that women were reluctant to talk about cervical screening and their experiences. Several of those who agreed to participate in the groups did not attend, sometimes calling with reasons why they could not come but more often not turning up, so the number of participants was small despite vigorous efforts at recruitment. Other studies have had low response rates, such as 29% in New Zealand (Saphira & Glover, 2000). The refusal of the Office of National Statistics to include a question

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about sexual orientation in the 2001 and 2011 U.K. censuses has not assisted in collecting data. The interviewed women provided rich information and sometimes shared the experience and histories of other lesbian and bisexual women. The women’s accounts mirrored the belief that lesbians do not require cervical screening. They described poor experiences of using health services and other public services, which they felt had led to a lower uptake of this universally available service by lesbians and bisexual women. The researchers asked the participants whether they had gone in for cervical screening (formerly called a smear test) and whether they regularly went when they received an invitation from their general practitioner (GP). All said they had attended recently, but all five had gone for long periods, as much as 10 years or even longer, without having had the screening. Participants in our interviews gave recent examples of practice nurses telling women that they did not need a test because they were lesbians. Knowledge about cervical screening among the participants in our study varied. Some had thought at some time that they did not need cervical screening. One participant thought for many years that because she had never had a sexual relationship with a man she did not need a test, saying, “You know I hadn’t been told no different.” When this participant did attend recently after an invitation for screening, she came out as a lesbian and was told by the nurse that she did not need a screening. She had to convince the nurse that she did. She went for the test because she had been to a talk about cervical screening at the Equity Centre, and this gave her the confidence to convince the practice nurse that she did need screening. Another participant said she knew she was “low risk but not no risk,” commenting, “If you are having sex at all, there is going to be some risk factor somewhere.”

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Experience of screening varied, with some of our interviewees having found that staff put them at ease and gave them choices. For one, this meant she could sit up and see what was happening with a mirror. One participant reported a bad experience when she was young with a practice nurse forcing a speculum into her when she was not relaxed and treating her “like a baby.” Not being given choices was related to lack of control as an issue for some of the participants. They felt better when they could influence what was happening during their own smear test, as in the example mentioned. The offer of different options was important in many ways and was seen to counter the lack of control. Another area in which choosing between alternatives was important was where participants attended for screening, with some saying they would not go to the Sexual Health Department (Trinity Centre) or CASH (Contraception and Sexual Health) clinics, while others said they would rather go to a clinic than the GP. Some participants perceived genitourinary medicine clinics as destinations for those who have acquired sexually transmitted infections. One woman said she “wouldn’t dream” of going there because of its outdated reputation as the “clap clinic,” and others said they would only go to such clinics if they thought they had acquired a sexually transmitted infection. There were also views that the clinics cater only to heterosexual people. Although CASH has made some efforts to welcome women who have sex with women, there are still signs referring to “family planning,” even though this name has been changed. One said, “They can say they are gay friendly, but it’s all women with families.” Another woman said she preferred to go to a clinic, as she could walk in and be tested without having to register with a GP. Two participants had received inaccurate information about sexually transmitted infection. One

had received the wrong advice about bacterial vaginosis, about which she inquired because her partner was immunocompromised. This led to an infection. The doctor had said that bacterial vaginosis could not be sexually transmitted between women and that she should not worry about safe sex. She later found more information from a Gay Pride stall run by the Leeds group Women’s Health Matters. Some participants avoid health care of any kind. This is partly due to their experience and anticipation of health establishments as not gayfriendly, even as hostile or prejudiced. Some thought a healthcare worker’s religion might lead to this, and Catholic, Presbyterian, and Muslim staff members were mentioned. Participants stated that they need proof that a practice or clinic is gayfriendly. One said she would not have treatment for anything from a doctor who was homophobic. A significant number of women in the study were not registered with a doctor, had not been registered for long periods, or had not told the practice of a change of address. Some avoided GP practices and medical care. Tjepkema (2008) also found that the proportion of lesbian and bisexual women in Canada (although not gay and bisexual men) without a regular doctor was lower than the proportion of heterosexual women. Two of our interviewees said they had avoided going to a GP when they had a health problem, which resulted in delayed treatment. This replicated findings from other research such as that reported in O’Hanlan’s review (1995). Reasons given for not going to GPs ranged from those encountered in the general population, such as not liking to waste the doctor’s time and the difficulty of making appointments with a preferred doctor, to those more specific to lesbian and bisexual women. All participants said that on at least some occasions they found it difficult to be open about

their sexual orientation to practice staff. None had experienced outright homophobia, but they did anticipate a negative response. One had told a member of staff at the practice who said that they do not record this information, so being open about her sexual orientation would mean coming out every time she sees a member of the practice team. The participants were uncomfortable about the choice they had to make between coming out or keeping quiet and having false assumptions made about them. One participant mentioned that if people are shy, they are disempowered. It was thought that women who have sex with women need to be very confident to be out. This was borne out by their own experience that they had tended to be more open as they became more confident. One highlighted that it “comes to fore if it’s a gynecological problem; ‘how open should I be because it might be important.’” She said the staff members have an important influence on one’s treatment, so one is naturally guarded. Some participants feared they would receive worse treatment if they were open with someone who was homophobic. One woman had recently come out to a practice nurse when attending a smear test and was told she did not need one. Others feared that nurses would be concerned about touching women in their genital area when they know that they have sex with women. They said that this was based on the experience of other lesbians. In summary, feedback from the women involved in this study shows clearly that while lesbian and bisexual women have some information about cervical screening and the need to attend, they are reluctant to do so. This is partly due to the unpleasantness of the experience of the test itself, but their expectations and previous interactions with health service staff have exacerbated the situation. All had overcome this

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reluctance at some point, as all had been screened, but not all intended to go for future appointments, and one had no intention of registering with a GP and so would not be invited. Our findings are in line with those of Bjorkman and Maltrud (2009), who emphasize the importance of three dimensions within the approach of healthcare workers: awareness and ability to facilitate disclosure, respect for lesbians, and knowledge of healthcare issues for lesbians. LGB Health Inequalities Data gathered from our focus groups mirror the literature reviewed by Fish (2009), which shows that lesbians and bisexual women are less likely to have cervical screening yet are at risk of cervical cancer. According to Fish (2009), not attending screening is likely to increase the risk of contracting a potentially life-threatening disease: Cervical screening has been estimated to prevent approximately 5,000 deaths each year in the UK over the next 30 years (Peto et al. 2004 [cited in Fish]); it continues to be the important screening tool used to diagnose and prevent cervical cancer. Many women who develop cervical cancer have never been screened (or have been inadequately screened). Despite the emphasis on the relationship between heterosexual sex and cervical cancer the greatest risk factor for the disease, is not sex, but not being screened (NHSCSP, 2004 [cited in Fish]). (Fish, 2009, p. 7) The focus groups show that lesbian and bisexual women sometimes avoid accessing health services because of previous experiences. Another study in Bradford and Airedale supports this finding. In 2009, the Equity Partnership carried

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out an LGB Health Needs Assessment. The Challenge for Change: Health Needs of Lesbian, Gay and Bisexual People in Bradford and District (2010) built on the work of a previous health needs assessment carried out in Bradford in 2007 and shows the following health inequalities experienced by local LGB people: • Over half of respondents were “out” to their GP; 10% more than in 2007. However, in response to questions about specific services, apart from sexual health services the majority of LGB people were not open about their sexual orientation. • Over a third of respondents were smokers; this is higher than the general smoking prevalence rate for Bradford and is 13% more than in 2007. • 6% of women had been advised that cervical screening was not necessary because of their sexual orientation. • 20% of women were not having regular cervical or breast screening nor examining themselves for breast lumps (higher than for women in general). • 57% found screening staff to be helpful but lacking understanding of lesbian and bisexual women. • 55% had experienced mental ill health; a higher proportion than for the general population. (Equity Partnership, 2010) Lesbians, gay men, and bisexual people are often “invisible” members of society and unnoticed service users, and health service institutions have not taken adequate measures to understand and meet their needs. At the start of this action research, one of the researchers discovered that

the NHS Cancer Screening web site only included information for women who have sex with women under the heading “For women who are not sexually active.” The administrator amended the site after publication of Fish’s literature review (2009). For example, neither the National Strategy for Sexual Health and HIV (DH, 2001 [cited in Fish]) or the recent update (IAG, 2008 [cited in Fish]) includes reference to lesbian or bisexual women. Henderson et al. (2002 [cited in Fish]) argue that the omission is symbolic of the invisibility of lesbian and bisexual women in sexual health services: it is widely considered that they do not engage in risky sexual behavior. (Fish, 2009, p. 27) Lesbian and bisexual women comprise an invisible population: they are hidden as service users unless they disclose their sexual orientation, they have been unacknowledged in research and their exclusion from statistical data has meant that little is known about their demographic characteristics. (Fish, 2009, p. 33) The authors take every opportunity to publicize work on cervical screening and lesbians to counter this invisibility and to highlight to those commissioning and providing health services that there are health inequalities that relate specifically to LGB people.

practitioner-led action research project to address the low proportion of a marginalized group attending for cervical screening. The foundational concepts of action research are collaboration and participatory approaches to decision making (Carr & Kemmis, 1986), and many consider action research particularly suitable to address real-world problems (Robson, 2002). Action research is an ideal research approach to assist practitioners to understand problems in their area of practice and to identify, implement, and evaluate actions to improve their practice. This practitioner-led project sought, via directly engaging service users as partners in the action research project, to improve access to cervical screening for lesbian and bisexual women (Meyer, 2000). Action researchers take a cyclical approach. In this project, the researchers followed a plan, do, study, act cycle. Grundy and Kemmis (1981) state there are three conditions necessary for action research: 1. “The project takes as its subject matter a social practice, regarding it as a strategic action susceptible to improvement,” in this case lesbian and bisexual access to cervical screening. Access in this case is taken to include acceptability of the service to lesbian and bisexual women.

Study Design: Action Research Approach

2. “The project proceeds through a spiral of cycles of planning, acting, observing and reflecting: these stages are interrelated.” This article reports on only one cycle.

Although traditional research approaches aim to develop a generalizable body of knowledge, the authors’ primary aim was to improve professional performance at a local level through a

3. “The project involves those responsible for the practice in each of the moments of activity and gradually includes others affected by the practice” (Grundy &

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Kemmis, 1981, as cited in Grundy, 1988, p. 353). This project took place in Bradford and Airedale in Yorkshire, England, and was funded through the Department of Health Pacesetters initiative. Partnership work between NHS Bradford and Airedale and the Equity Partnership implemented the action research project. The former is the local Primary Care Trust (PCT), which is the organization that commissions health care for the approximately 500,000 people living in Bradford and Airedale. The Equity Partnership is a charity that supports LGB people in Bradford and the surrounding district to have social spaces to meet and keep in touch with news concerning their communities. They also work to ensure that local health and social service organizations, such as the NHS and Council, understand and meet the needs of diverse LGB people. The Equity Partnership’s coresearcher’s involvement ensured the participation of local lesbian and bisexual women in this project, and the PCT researcher was able to facilitate the involvement of relevant health professionals. As a service improvement project, this project had the full support of commissioners and providers of the service. To ensure its success, the project required the participation of gay and bisexual women. This participation was in the form of indepth interviews. The participants gave full written consent before the interviews. The researchers gave assurances of anonymity. Data that could be attributed to any specific participant was not used.

Planning to Enhance the Service Having considered the literature on this subject, the local health data, and the information gathered through interviews about barriers to attendance at screening, it was important to implement

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service enhancements to improve access. Both health professionals and lesbian and bisexual women seemed to have been influenced by the myth that lesbians do not require cervical screening. Therefore, the study focused on the provision and dissemination of accurate information about lesbian and bisexual women and cervical screening among health professionals as well as potential service users. Training sessions, meetings with service managers, and talks to groups of staff were carried out, and two targeted leaflets were specifically designed: one for women who have sex with women and one for health professionals who work in the field of sexual health. Our interviewees suggested improvements to both the format and content of a draft leaflet aimed at lesbians and bisexual women to provide a consistent message and style. Improvements included a more narrative flow through the leaflet, so that reasons for screening were given followed by a description of the test and where it is available; a diagram was included; photos of women of different ages and ethnic backgrounds were used to illustrate the leaflet; and examples of the ways women could exercise choice during their tests were listed. The leaflet informing lesbians and bisexual women of the need for screening and an associated poster were distributed through GP practices, sexual health clinics, and LGB venues and publicized at Bradford’s Gay Pride event in 2010. The leaflet aimed at local health professionals reinforces the message that lesbians and bisexual women do need cervical screening and includes tips on how to be LGB-friendly. It arose from earlier stages of the research, as work with the lesbians and bisexual women interviewed highlighted the importance of better-informed staff. One of the researchers arranged meetings with groups of staff responsible for cervical screening

from the clinics and GP surgeries to discuss the drafted leaflet. Changes were suggested and these were acted on, such as presenting the information in an order that made more sense to the staff, including experiences and quotations from the interviews to show why a more accepting attitude was needed, and ways to make the experience of being tested more pleasant for women. It was distributed to GP practices and others responsible for providing cervical screening and supplemented by posters and a report based on the findings from the interviews. The project worker contacted GP practice managers by phone to discuss whether the posters and leaflets had been made available and, when necessary, to explain their importance and encourage the practice manager to make them available to patients. Most surgeries had displayed the poster and leaflets, and several asked for more copies of the leaflet, but few were giving it to patients in a targeted way; most were left in the waiting room with other leaflets. The project manager and worker also attended update training sessions for cervical screeners to present their work, raise awareness, and encourage use of the materials. They also attended regional and national events focusing on LGB health to share best practices.

Key Features of Enhancement This section details the factors that facilitated the success of this project. These factors are transferable to other diversity interventions and have multiple applications. To measure the specific impact of this work on the uptake of cervical screening among local LGB women and whether they feel more welcomed and accepted by local health services, NHS Bradford and Airedale and the Equity Partnership will conduct a survey of local lesbians

asking if they have had or intend to have cervical screening and if they now feel greater trust in the local NHS in 2012. The authors anticipate that greater numbers of women are likely to participate in an anonymous written questionnaire than in face-to-face interviews. The publicizing of this project complements work steered and monitored by our local LGB Health Improvement Group to respond to recommendations based on the findings of The Challenge for Change: Health Needs of Lesbian, Gay and Bisexual People in Bradford and District (2010). Through work with key stakeholders, the authors are raising the profile of LGB health inequalities and how to reduce them. The following are critical factors in the success of the project. Evidence Base The project has raised the profile of the evidence base surrounding this aspect of women’s health and made it more accessible. Information gathered locally and nationally showed a clear inequality in numbers of lesbian and bisexual women going in for cervical screening. The experiences women shared in the focus groups gave more detail about the causes of this inequality and suggestions of ways to reduce it. This article will add to the sparse body of evidence concerning the health inequalities experienced by lesbians and bisexual women. Start Small The researchers began with a small focused intervention to address evidence-based inequality. The focused nature of the project was successful, as it concentrated the project team’s energies on getting some quick wins. Then, if the results were good, the researchers worked on spreading and sustaining the work.

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Initially, the researchers held interviews and produced a leaflet aimed at local lesbian and bisexual women. The interviews provided broader information, particularly about lesbian and bisexual women’s experiences of health services in general, and showed that there was a need for information for health professionals. As the project leaflets, reports, and poster were produced in phases, we disseminated them in waves to the health professionals who carry out cervical screening tests. This incremental approach and repetition of key messages is important in countering the invisibility of LGB people and their health needs. Community Engagement and Listening to Patients’ Experience The fact that a lesbian employed by the Equity Partnership undertook the work helped create an atmosphere of trust within the interviews. The interviewees provided a wealth of useful information about how to make cervical screening and other health services more LGB-friendly. This study built on previous outreach work undertaken by the Equity Partnership to inform local gay women of the need to access cervical screening. Codesign Feedback from the lesbian and bisexual women interviewed led to many changes in the leaflet, and discussions with cervical screening nurse mentors identified the content of the leaflet for health professionals. This approach ensures a greater level of service user involvement. Sherry Arnstein’s typology (Arnstein, 1969) of eight levels of citizen participation uses a ladder of participation to show how the lower-level activities that organizations often describe as participatory would be more accurately described as nonparticipation or tokenism. The approach that the researchers adopted ensured higher levels of participation.

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Project Management The steering group ensured that the right people from the community and from the NHS were involved and worked together as equals. The project leader produced action-focused minutes that were reviewed at each steering group meeting to ensure maintenance of focus and momentum. Relationship Building The project leader and worker made personal contact with people working in cervical screening locally, regionally, and nationally, within local GP practices and sexual health clinics, and with the local LGB community to ensure the project was not operating “in a silo” and influenced mainstream service delivery. Training Being involved in the update training for staff members taking cervical screening samples was a key method of sustaining and widening the impact of the work. Open Discussion Ensuring that there was space for open discussion in the training sessions enabled the countering of any views that could have halted study progress. For example, one participant felt that it would not be appropriate to display posters aimed at women who have sex with women in practices with significant numbers of Muslim patients. The project worker and lead who were delivering the training listened to this view and encouraged discussion, during which a South Asian participant expressed a very different view. The group reached consensus that it would only be a minority of Muslim patients (and indeed some other patients) who objected, and that this is an important health message that needs to be communicated clearly, as well as the fact that a key purpose of the posters

is to counter the invisibility of LGB people, which perpetuates heterosexist assumptions. Spread the Word In addition to “spreading the word” at local training, the researchers produced press releases and articles for internal newsletters and presented the outcomes and learning from the project at regional and national conferences. Evaluation of Impact In early 2012, the researchers will carry out a survey with local lesbians asking if they have had or intend to have cervical screening and if they now feel greater trust in the local NHS.

Conclusion This practitioner-led action research study has successfully challenged the commonly believed myths that (a) lesbians are not at risk of cervical cancer and therefore do not require regular cervical screening, and (b) sexual orientation should be seen solely as a private matter that generally does not affect health and health care practices. The fact that a lesbian employed by the Equity Partnership undertook the work helped create an atmosphere of trust within the participant interviews. This approach ensured high levels of service user involvement and the generation of much useful information about how to make cervical screening and other health services more LGB-friendly. Enhancements to the current universal screening service were planned and delivered, and they have provided useful, accurate information for both health professionals and potential service users. Telephone conversations with GP practice managers and open discussion during training sessions supplemented written information.

The approach developed by this project to address low uptake of a screening service is now being developed and extended as part of the mainstream work of NHS Bradford and Airedale. This project is to continue to feature in the local update training for cervical screeners, and NHS Bradford’s and Airedale’s screening team are now identifying ways to work with other groups of women who have lower-than-average uptake and are planning to simulate the action focus approach with breast and bowel screening. Contact between the screening manager and Equity Partnership has led to NHS Bradford and Airedale’s team of health trainers focusing on LGB equality by accessing Equity Partnership training and establishing ongoing links with Equity Partnership. Equity Partnership and the breast screening lead from Bradford Teaching Hospitals Foundation Trust have also forged links. The factors that facilitated success in this study have multiple applications and are transferable to other diversity interventions. ◆ References Arnstein, S. R. (1969). A ladder of citizen participation. Journal of the American Planning Association, 35(4), 216–224. Buffie, W. C. (2011). Public health implications of same-sex marriage. American Journal of Public Health, 101(6), 986–990. Bjorkman, M., & Maltrud, K. (2009). Lesbian women’s experience with healthcare: A qualitative study. Scandinavian Journal of Primary Healthcare, 27, 238–243. Carr, W., & Kemmis, S. (1986). Becoming critical: Education, knowledge and action research. Lewes, UK: Falmer Press.

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Equality and Human Rights Commission. (2011). The public sector equality duty: A way forward for the health sector. Retrieved from www.equalityhumanrights.com /uploaded_files/EqualityAct/PSED/health_policy_web .pdf Equity Partnership. (2010). The challenge for change: Health needs of lesbian, gay and bisexual people in Bradford and District. Retrieved from www.equitypartnership.org .uk/wp-content/uploads/2011/09/ The-Challange-for-Change-2010-HNA-report-finalpost-design-PDF-june-2010.pdf Fish, J. (2009). Cervical screening in lesbians and bisexual women: A review of the worldwide literature using systematic methods. Leicester, UK: De Montfort University. Retrieved from www.cancerscreening.nhs.uk /cervical/publications/screening-lesbians-bisexual -women.pdf Grundy, S. (1988). Three modes of action research. In S. Kemmis (Ed.), The action research reader (3rd ed, pp. 353–364). Victoria, Australia: Deakin University Press. Grundy, S., & Kemmis, S. (1981). Educational action research in Australia: The state of the art. Paper presented at the Annual Meeting of the Australian Association for Research in Education, Adelaide. Krueger, R. A. (1994). Focus groups: A practical guide for applied research (2nd ed.). London, UK: Sage Publications. Kvale, S. (1996). InterViews. London, UK: Sage Publications. Markowe, L. A. (2002). Coming out as a lesbian. In A. Coyle & C. Kitzinger (Eds.), Lesbian and gay psychology (pp. 63–80). Oxford, UK: Blackwell.

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Lynne Carter, BA, is a senior associate, equality & diversity at NHS West and South Yorkshire and Bassetlaw Commissioning Support Unit. Her professional experience has been in community and adult education and in equality and diversity. She is interested in how to reduce discrimination, particularly institutional inequalities. She can be reached at lynne. [email protected].

Lesley Hedges, MSc, MA, is a women’s health worker with the Equity Partnership. Her research interests are in public health, LGBTI issues, and counseling, with an emphasis on women’s, especially lesbians’, health. Previous research topics have included menopause and lesbian health needs. She can be reached at lesley. [email protected]. Shirley Congdon, RGN, DipN, BSc, MA, is professor of educational development and pro vice chancellor

(Learning and Teaching) at the University of Bradford. Her professional and academic expertise lies within the area of service modernization and cultural change, research methods and evidence-based practice. She also has significant experience of working with NHS Trusts and the Department of Health developing and delivering programs associated with the modernization process. She can be reached at s.congdon@bradford. ac.uk.

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