https://orcid.org/0009-0000-0361-5439
Figures
Abstract
Introduction
Cervical cancer is almost entirely preventable through vaccination and screening, but screening rates still lag targets. Communication campaigns can encourage screening; however, the types of message content that are most effective are unknown.
Methods
We conducted an online randomized experiment testing messages within four themes aligned with previously identified screening barriers: cancer fatalism, inconvenience, lack of knowledge about risk factors, and unawareness of screening guidelines. A national convenience sample of US participants aged 21–65 years and assigned female at birth (n = 1,536) viewed one of three messages from each theme assigned at random and one control message in random order. We measured perceived effectiveness to encourage cervical cancer screening, anticipated social interactions, and self-reported learning. Mixed-effects linear models examined the impact of message theme on each outcome on a scale from 1 (low) to 5 (high).
Results
All four barrier-focused themes encouraged cervical cancer screening more than the control (perceived message effectiveness mean and standard deviation: cancer fatalism = 3.44 (1.21); convenience = 3.43 (1.23); risk factors = 3.25 (1.23); screening guidelines = 3.44 (1.19); control message = 2.45 (1.35), p < .001). Barrier-focused messages similarly outperformed the control on anticipated social interactions and self-reported learning (all p < .001). Messages were less effective for participants who had never been screened or were out-of-date. However, regardless of screening status, barrier-focused messages outperformed the control.
Citation: Halvorson-Fried SM, Higgins IC, Gilkey MB, Lazard AJ, Hall MG (2025) Perceived effectiveness of messages to address cervical cancer screening barriers: An online experiment. PLoS One 20(11): e0336693. https://doi.org/10.1371/journal.pone.0336693
Editor: Onaedo Ilozumba, University of Birmingham, UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
Received: May 30, 2025; Accepted: October 29, 2025; Published: November 14, 2025
Copyright: © 2025 Halvorson-Fried et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All files are available from the Harvard Dataverse data repository (https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/XKMAUT).
Funding: This project was supported by Wellcome Trust, Grant ID #216042/Z/19/Z (https://wellcome.org/). SMHF was supported by the Cancer Control Education Program, a grant from the UNC Lineberger Comprehensive Cancer Center, which is funded by the National Cancer Institute of the National Institutes of Health (T32CA057726) (https://www.cancer.gov/). ICAH was further supported by the NICHD-NRSA Population Research Training Grant (T32HD007168) (https://www.nichd.nih.gov/). The funders played no role in study design, data collection, data analysis and interpretation, writing the manuscript, or the decision to submit the research for publication. There was no additional external funding received for this study.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Cervical cancer rates have decreased more than 70% since the 1950s, a success attributed to cervical cancer screening practices [1,2]. Furthermore, with screening and the advent of the human papillomavirus (HPV) vaccine, 93% of cervical cancer cases are now preventable [3]. Despite these advances, nearly 14,000 new cases of cervical cancer and over 4,000 deaths from cervical cancer were expected in the United States (US) in 2024 [4]. Over half of new cervical cancers occur in women who are considered overdue for screening [3]. Despite increased health care access because of the Affordable Care Act [5], the proportion of US women overdue for screening increased more than 8 percentage points from 2005 to 2019 [6]. Furthermore, notable sociodemographic disparities exist in cervical cancer screening, incidence, and mortality rates. Women who are younger, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Hispanic, included in “other race” categories, LGBQ + , live in rural areas, have lower education, or do not have health insurance are more likely to be overdue for screening [6–10].
Identified barriers to cervical cancer screening include lack of knowledge or awareness about cervical cancer screening [6,11–13]; financial and logistical barriers such as cost and inconvenience [6,13,14]; and psychosocial barriers such as fear, anxiety, and embarrassment [13–15]. A majority of 2019 National Health Interview Survey participants who were overdue for screening reported that the primary reason they had not been screened was being unaware of screening recommendations or not receiving a recommendation from a provider [6]. This finding suggests that many people may not be adhering to screening guidelines due to lack of awareness. Public health messages can increase knowledge and awareness [16] and have the potential to increase screening rates and decrease the burden of cervical cancer [17]. Such messages could be delivered through text message and social media campaigns, public service announcements, or through medical providers. Previous research suggests that messages can increase cervical cancer screening rates and screening intentions regardless of loss or gain framing (i.e., placing message emphasis on potential losses from not being screened vs. potential gains from being screened) [18,19]. In addition, a recent online experiment found that videos focused on knowledge barriers about Pap tests were perceived as more effective than videos focused on psychological barriers [20]. However, no studies have examined potential differences in effectiveness among a wider variety of message themes, including additional types of barriers that messages can address.
In this study, we aimed to fill this gap by testing messages designed to address four identified barriers to cervical cancer screening: cancer fatalism (the belief that developing cancer is out of one’s control [21]), inconvenience, lack of knowledge of risk factors, and unawareness of screening guidelines. We aimed to examine the perceived message effectiveness, or how much the message encourages screening, of each message theme compared to a control message. Perceived message effectiveness is both predictive of behavior change [22,23] and sensitive to small differences among messages [24], which is helpful because different messages can be compared. We also examined anticipated social interactions (the likelihood of discussing message content with others) and self-reported learning (the extent to which the message taught the participant something they did not already know), two potential mechanisms by which messages may influence individuals to receive screening. In addition, we examined whether cervical cancer screening status moderated perceived effectiveness. Finally, we examined sociodemographic predictors of perceived effectiveness to examine if certain groups were more responsive to messages overall.
Methods
Message development
To develop messages for the experiment, we first reviewed the literature on key barriers to cervical cancer screening uptake and adherence. We focused on barriers that can be addressed at the individual level rather than structural barriers (e.g., no insurance coverage). The four key barriers identified included cancer fatalism, inconvenience, lack of knowledge about risk factors for cervical cancer, and lack of awareness of screening guidelines [25–30]. We developed three messages for each barrier (Table 1) and one general statement for the control (“Schedule your screening today”).
Participants and procedures
We conducted an online experiment as a supplement to a study that primarily tested the impacts of taxes and warning labels on red meat purchases, which have been linked to cancer and cardiovascular disease [31] (i.e., the “parent study”) [32]. Participants were a convenience sample recruited from Cloud Research Prime Panels, a survey research firm commonly used for social science research. Participants were eligible for the parent study if they were aged 18 years or older, resided in the United States, and reported eating red meat at least once per week during the past 30 days and doing at least 50% of the grocery shopping for their household [32]. Participants were additionally eligible to participate in the current study about cervical cancer screening messages if they were assigned female at birth and aged 21–65, since screening is recommended every 3 years for people with cervixes aged 21–29 and every 5 years for those aged 30–65 [33]. For the current study, 1,587 individuals completed the experimental task; 51 were excluded from analysis because after inclusion they reported not having a cervix due to surgery, resulting in an analytic sample of 1,536 participants.
After completing all sections of the parent study survey, except for the sociodemographic section, participants were screened for eligibility for the current study. Those who were eligible viewed and rated five messages: one of three messages from each of the four barrier-focused message themes (randomly selected from each theme) and one control message. All messages were displayed in random order and were presented as black, centered text on a white screen. Participants then completed the sociodemographic section of the survey. Recruitment and data collection occurred from March 11 to October 21, 2021.
Measures
The primary outcome for this study was perceived message effectiveness, which we measured with one survey item: “How much does this message encourage you to get screened for cervical cancer?” with five response options: not at all (coded as 1), a little bit (2), somewhat (3), quite a bit (4), and very much (5). We assessed two secondary outcomes: anticipated social interactions and self-reported learning, which are mechanisms by which public health campaigns can affect behavior [34–36]. The survey measured anticipated social interactions with the question “How likely are you to talk about this message with others in the next week?” Response options were not at all likely (coded as 1), a little likely (2), somewhat likely (3), very likely (4), and extremely likely (5). The survey assessed self-reported learning with the question “How much did you learn something new from this message that you did not already know?” Response options were not at all (coded as 1), a little bit (2), somewhat (3), quite a bit (4), and very much (5) [37].
The survey measured sociodemographic characteristics, including cervical cancer screening status, baseline screening intentions, sex, gender, age, race, income, sexual orientation, education, self-reported health, usual place of care, usual provider, insurance status, and cancer fatalism, using survey items developed in previous research [11,38–43]. In addition, we asked participants about reasons for not being up to date with screening (S1 Table) and their desired channel for cervical cancer screening messages (S2 Table).
Ethics
This study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill (protocol 19–3349). Participants provided written informed consent. Participants received cash, gift cards, or reward points as incentives for completing the study.
Statistical analysis
Analyses used Stata version 18 [44] (College Station, TX) and a two-sided alpha value of 0.05. We used mixed-effects linear models with the control as the reference group to examine the impact of message theme (versus control) on the primary and secondary outcomes to account for repeated measures. We estimated separate models for each outcome. We then used postestimation commands to compare the effects of the message themes to each other for all outcomes.
Next, we used a mixed-effects multivariable linear model to examine whether barrier-focused messages remained effective when controlling for person-level characteristics. Person-level characteristics included in the model were age, race/ethnicity, health insurance status, income, educational attainment, sexual orientation, self-reported health, having a usual medical provider, baseline cancer fatalism, screening status within the past five years, and baseline screening intentions. Predictors were chosen based on associations with screening rates [6–8]. For education, race, income, sexual orientation, self-reported health, having a usual provider, and health insurance status, we collapsed categories for interpretability or because of small cell sizes. Though we planned to include gender in the model, we dropped this variable because over 99% of the sample identified as women. We used listwise deletion to handle missing data.
Finally, we examined whether the perceived effectiveness of each barrier-focused theme was moderated by having had a cervical cancer screening within the past five years and having ever had a screening. For these analyses, we ran two separate mixed-effects linear models (one for each moderator), regressing perceived message effectiveness on message theme, the moderator, and the interaction of message theme with the moderator. We used a Wald chunk test to test the statistical significance of the interaction term. Analyses were conducted in 2024.
Study predictions, measures, and the analytic plan were pre-registered prior to data collection at AsPredicted.org (protocol 58390).
Results
The average age of participants was 43.4 years old (Table 2). Most participants identified as White (70%), while 11% identified as Black, 10% as Latine, 4% as Asian, and 5% as another race or multiracial. Around one-third (36%) had attained a high school education or lower, 24% had some college, and 40% had a bachelor’s degree or higher. Approximately one-fifth (22%) of participants reported that they had never been screened for cervical cancer and nearly one-third (32%) reported that they had not received a screening in the past five years, meaning they were not up to date with screening. Almost half (48%) reported that they would definitely get screened if recommended. Most participants had a usual health care provider (81%) and health insurance (90%). Missing data ranged from 0% (0 participants) to 1.95% (30 participants).
Impact of barrier-focused message themes on primary and secondary outcomes
All barrier-focused message themes were more encouraging of cervical cancer screening than the control message (mean perceived message effectiveness range 3.25–3.44 versus 2.45, all ps < .001) (Fig 1). In addition, all barrier-focused message themes elicited higher anticipated social interactions than the control (mean range 2.52–2.63 versus 2.06, all ps < . 001) and higher self-reported learning (mean range 2.53–2.92 versus 1.96, all ps < .001). Full unadjusted results can be found in S3 Table and perceived effectiveness of each individual message can be found in Table 1.
Error bars indicate 95% confidence intervals. Estimates are adjusted for arm in parent study.
In pairwise comparisons, messages in the cancer fatalism, convenience, and screening guidelines themes elicited higher perceived message effectiveness than those in the risk factors theme (mean range 3.43–3.44 versus 3.25, all ps < .001) (Table 3). The cancer fatalism, convenience, and screening guidelines themes also elicited higher anticipated social interactions than the risk factors theme (2.60–2.63 vs. 2.52, all ps < .001). However, messages in the screening guidelines and risk factors themes elicited higher self-reported learning than cancer fatalism and convenience (2.69–2.92 versus 2.53–2.57, all ps < .001). Messages focused on screening guidelines elicited higher self-reported learning than those focused on risk factors (2.92 vs. 2.69, p < .001). In the multivariable regression model, all barrier-focused message themes led to significantly higher perceived effectiveness than the control message when controlling for sociodemographic characteristics (β range 0.81–1.01, all ps < .001) (S4 Table).
Moderation by screening status
All barrier-focused message themes outperformed the control message regardless of participants’ screening status. However, barrier-focused messages were less effective for participants who were out-of-date with screening or had never been screened compared to those who were up to date or had been screened before (interaction term ps < .001, Fig 2). All barrier-focused themes were perceived as less effective by those who were out-of-date with screening; perceived effectiveness of the control message was similar for both groups (Fig 2A). Participants who had never been screened rated the messages focused on cancer fatalism and screening guidelines as less effective and the control message as more effective than those who had. However, perceived effectiveness did not vary by ever screened status for messages on convenience or risk factors (Fig 2B).
Error bars indicate 95% confidence intervals. Wald chunk test. p < .001. PME = perceived message effectiveness.
Reasons for out of date screening and desired channels for receiving messages
Participants reported that reasons for not being up to date with screening recommendations were primarily related to lack of awareness (e.g., “I didn’t know that I am supposed to have routine cervical cancer screening”) as well as incorrect understanding of risk factors (e.g., “I am not sexually active” and “I have only 1 sexual partner”) (S1 Table). Regarding desired channels for receiving messages, 72% of participants indicated that they would like to receive messages from their doctor, 49% indicated social media, 44% television, 23% magazines, newspapers, billboards, or posters, and 21% indicated their family (S2 Table).
Discussion
We examined the effectiveness of messages addressing barriers to cervical cancer screening among a sample of US adults recommended for routine cervical cancer screening. All barrier-focused message themes—cancer fatalism, convenience, risk factors, and screening guidelines—encouraged cervical cancer screening more than a generic control message (“Schedule your screening today”). All barrier-focused themes were perceived as more effective compared with the control in both unadjusted models and models that controlled for sociodemographic factors. In addition, all barrier-focused themes elicited higher anticipated social interactions and more self-reported learning than the control. Messages focused on increasing knowledge of risk factors were associated with lower perceived effectiveness and anticipated social interactions than messages in the other themes, but higher self-reported learning. Messages focused on increasing awareness of screening guidelines were associated with the highest self-reported learning.
These findings suggest that messages addressing a variety of screening barriers hold promise for motivating individuals to seek cervical cancer screening. Similar to previous work that has found no difference in effectiveness among messages with gain or loss framing [18,19], we found that messages within all four themes were perceived as effective, with only slight differences in comparisons across themes. This finding suggests that campaigns could use a variety of themes to improve cervical cancer screening rates. Given that lack of knowledge or awareness is a primary reason people do not get screened [6,11,12], it is encouraging that messages focused on increasing knowledge of risk factors and awareness of screening guidelines both led to self-reported learning and were perceived by participants as effective. Messages focused on increasing awareness of screening guidelines performed the best out of all message themes across all three outcomes. This finding aligns with a recent study in which TikTok videos addressing knowledge barriers about Pap tests elicited higher perceived message effectiveness than videos addressing pain and discomfort [20]. Taken together, although differences in outcomes between the themes were small, our findings indicate that messages focused on screening guidelines may have co-benefits of informing people and potentially changing their behavior. Cancer fatalism and convenience are also promising themes for inclusion in health communication materials, while risk factor messages that emphasize the importance of screening even for people who are currently low risk may be less effective (e.g., “Even if you received the HPV vaccine, it’s still important to get routine cervical cancer screening”).
Participants in our sample expressed interest in receiving messages from a variety of sources, including medical providers, social media, and traditional media, suggesting the potential scalability of these messages through distinct channels. Campaigns could consider focusing on provider recommendations, which have consistently been associated with increased screening rates [45]; text message campaigns, which have been found to increase rates of different cancer screenings [46]; as well as advertisements on television, social media, and in public places.
Moderation analyses showed that although participants consistently rated barrier-focused messages higher than the control message regardless of screening status, those who were out-of-date for screening perceived all barrier-focused messages as less effective than those who were up to date. Similarly, participants who had never received a screening rated messages focused on cancer fatalism and screening guidelines as less effective than those who had. These findings indicate that messages may be least effective for those who would most benefit from them, mirroring previous work [47,48]. This may be because regardless of an individual’s desire to receive screening, structural barriers (e.g., lack of transportation, lack of health insurance) may prevent them from doing so. Multilevel interventions may be needed to ensure that structural barriers are addressed in tandem with campaigns encouraging individuals to seek screening.
Key strengths of this study are the use of randomization and pre-registration prior to data collection. A key limitation is that we examined perceived effectiveness rather than actual effectiveness, limiting our ability to assess the effects of the messages on actual behavior. However, perceived message effectiveness has been found to correlate strongly with intentions and behavior change for other health behaviors [22,23]. Self-reported learning scores could reflect the amount of novel information messages contained, or the amount of knowledge participants already had; we were not able to distinguish between these two possibilities. In addition, we used a convenience sample potentially limiting the generalizability of study findings, though experimental findings in convenience samples tend to mirror the pattern in nationally representative samples [49]. Although we excluded participants from analysis if they reported not having a cervix due to surgery (e.g., hysterectomy), we did not explicitly ask about this and it is possible that people assigned female at birth who no longer have a cervix were included in the sample. Furthermore, our sample did not have enough gender diversity to test for differences by gender identity, which is needed because trans men have lower rates of screening than cis women [50,51]. Future studies should consider including more gender diverse samples or focusing on trans men and non-binary people with cervixes. We also did not measure urbanicity. Given that cervical cancer screening and incidence rates are higher in rural areas [6,8], this should be considered in future studies.
Conclusions
Multiple types of cervical cancer screening messages that addressed common barriers to screening were perceived to be effective by participants in an online experiment, and influenced anticipated social interactions and self-reported learning, two behavior change mechanisms. Public health messaging campaigns addressing a variety of barriers to cervical cancer screening hold promise for increasing cervical cancer screening uptake and adherence.
Supporting information
S1 Table. Reasons for not being up to date with screening (n = 487).
Participants could select more than one response, so percentages do not total 100%.
https://doi.org/10.1371/journal.pone.0336693.s001
(DOCX)
S2 Table. Preferred channels for receiving messages about cervical cancer screening (n = 1,535).
Participants could select more than one response, so percentages do not total 100%.
https://doi.org/10.1371/journal.pone.0336693.s002
(DOCX)
S3 Table. Unadjusted primary and secondary outcomes for control message and by barrier-focused theme (n = 1,536).
SD = standard deviation.
https://doi.org/10.1371/journal.pone.0336693.s003
(DOCX)
S4 Table. Adjusted impact of barrier-focused message theme on perceived message effectiveness, controlling for person-level characteristics (n = 1,483).
Associations are adjusted for arm in parent study (p = 0.168–0.372). Boldface indicates statistical significance (p < .05).
https://doi.org/10.1371/journal.pone.0336693.s004
(DOCX)
Acknowledgments
The authors would like to thank Amienata Fatajo for her assistance with reviewing literature.
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