The role of nocebo effects in women’s experience of cervical screening procedures: implicationsfor interventions to improve cervical screening attendance.

In England, around 3000 women are diagnosed with cervical cancer each year (Cancer Research UK,
2018). Cervical screening is a way of preventing cancer. It tests for a virus called high risk human
papilloma virus (HPV) which can cause cervical cells to become abnormal. Most cases of cervical
cancer are linked to high risk HPV. In 2017 cervical screening uptake hit a 20-year low, and although
since then uptake has increased to 71.9%, this is far below the 80% target.
The introduction of the HPV vaccination is expected to substantially reduce cervical cancer incidence
in vaccinated women, however as a result the epidemiology of cervical cancer is projected to
change, with the peak age of a cervical cancer diagnosis in England expected to shift from late 20s to
late 50s (Castanon et al., 2018). For women born before 1991 in England, and therefore who did not
receive the HPV vaccine, participation in cervical screening is their predominant means of preventing
cervical cancer. However cervical screening coverage for women aged 50-64 is suboptimal and has
continued to decline over the last 10 years (NHS Digital, 2017).
A recent study by Marlow et al. (2019) investigated the barriers to cervical screening among older
women. Interestingly, practical barriers to screening did not appear to be a prominent barrier to
screening in any of the focus groups. Instead barriers focused on the experience of the procedure
such as worry and concerns about embarrassment and pain. In most cases the decision not to go for
screening in the future was based on previous bad experiences. This is also the case for other
women who may not necessarily be in the older age bracket but have also declined to participate in
cervical screening due to negative previous experiences which focus on pain (Marlow et al. 2018).
These painful experiences can also impact those who are undecided or intend to attend their first
screening through negative expectations about the procedure passed on through stories from other
women.
Factors such as the health professionals ‘bedside manner’, level of empathy and negative
expectations about the procedure could be contributing to women’s negative screening experiences
through nocebo effects whereby negative expectations and anxiety regarding the procedure can
cause it to have a more negative effect than it otherwise would have (Webster et al., 2016). Indeed
reviews have shown that empathetic and positive communication in healthcare consultations can
have small benefits for a range of clinical conditions, especially pain (Howick et al., 2018); and
positive suggestions and informational preparation seem to lower patients’ pain to clinical
procedures (Mistiaen et a., 2016). This reflects what is seen in the literature in which women
comment that the health professional’s ability to develop a rapport, and ensure they felt ‘at ease’
are important in creating a positive screening experience, and that they might benefit if the health
professional informed them that discomfort is normal, therefore normalising their experience
(Marlow et al., 2019).
There is a need to take this research forward and apply it in the context of cervical screening
procedures in an effort to improve women’s experience of cervical screening and future screening
attendance. This is particularly important for those women who are in the pre-HPV vaccination
cohort. However, it is still important for those who have had the HPV vaccination to attend cervical
screening appointments as the vaccine does not protect against all types of HPV that can cause
cervical cancer. As such their experience and expectations regarding the procedure are still

important to address especially as negative experiences/expectations may play a bigger part in their
decisions not to attend screening if they already feel protected from the vaccine.
We envisage this PhD will employ mixed methods in order to understand in more detail what makes
the cervical screening procedure a positive or negative experience for women, the results of which
can be used to design a questionnaire and collect quantitative data in order to quantify the
prominence of identified themes. This will help inform the avenue and design of an intervention to
be tested in a feasibility study.