Mental distress modifies the association between cost-related barriers and cervical cancer screening adherence: interaction and stratified analyses of BRFSS 2024

Background: Cost-related barriers and mental distress may jointly influence preventive service use, but their combined association with cervical cancer screening adherence is not well characterized in recent U.S. surveillance data. Methods: We analyzed 2024 Behavioral Risk Factor Surveillance System (BRFSS) data among female respondents. The primary outcome was Pap-related cervical cancer screening adherence (_RFPAP37); a sensitivity outcome used Pap+HPV adherence (_PAPHPV1). Mental distress was categorized as low, moderate, or high using _MENT14D, and cost-related barriers were defined by MEDCOST1. We fitted unadjusted and adjusted logistic regression models including an interaction term, adjusting for age group, education, income, marital status, race/ethnicity, insurance coverage, personal doctor status, and routine checkup. We also estimated stratified effects, adjusted predicted probabilities, and absolute risk differences. Results: The primary analytic sample included 101,580 women; 66,417 were included in complete-case adjusted models. Overall Pap adherence was 66.6% and was lower among women reporting cost-related barriers (54.5% vs 68.6%). Cost-related barriers were associated with lower Pap adherence in unadjusted (OR 0.52, 95% CI 0.49–0.56) and adjusted models (OR 0.83, 95% CI 0.76–0.90). Mental distress showed a graded inverse association with adherence (adjusted trend OR 0.96, 95% CI 0.94–0.99). Adjusted predicted probabilities showed lower adherence across distress strata among women with cost-related barriers, with absolute differences of about 3.3–3.8 percentage points. Findings were directionally consistent for the Pap+HPV outcome. Conclusions: In BRFSS 2024, cost-related barriers and mental distress were independently associated with lower cervical cancer screening adherence. Financial navigation and mental health–informed outreach may help improve screening uptake.