perception of cervical cancer risk and screening behavior: a literature review

Perception of Cervical Cancer Risk andScreening Behavior: A Literature ReviewCarmen W. H. Chan, RN, MPhil, PhD, Sheng-Bo Yang, MD, PhD, Can Gu, RN, MPhil, PhD, Xiuhua Wang, RN, PhD, andLijian Tao, MD, PhD

Carmen W. H. Chan, RN, MPhil, PhD, is a Professor of the Nethersole School of Nursing, The Chinese University of HongKong, Hong Kong, Sheng-Bo Yang, MD, PhD, is an Associate Professor of Department of Dermatology, Third XiangyaHospital, Can Gu, RN, MPhil, PhD, is a Postdoctoral Fellow of Department of Medicine, Xiangya Hospital and Lecturer,School of Nursing, Xiuhua Wang, RN, PhD, is an Associate Professor of School of Nursing, and Lijian Tao, MD, PhD, is aProfessor of Department of Medicine, Xiangya Hospital, Central South University, Changsha, China.

Search terms:Cervical cancer, cervical screening,literature review, nursing, riskperception

Author contact:[email protected], with a copyto the Editor: [email protected]

Funding: This research was fundedby Young Faculty DevelopmentProject of Central South University,China (contract grant number:2177721500084) and Chia FamilyHealth Fellowship Award (contractgrant number: 2012CF01).Conflict of interest statement: Theauthors have no conflicts ofinterest to disclose.

PURPOSE: This review examines women’s risk perception of cervical cancer, thefactors influencing this perception, and the relationship between risk perceptionof cervical cancer and screening behavior.METHODS: Integrative literature review method was used.FINDINGS: The search procedure resulted in the identification of 42 studies,including 1 literature review and 41 primary studies. Trends and discrepancies inthe literature are presented with interpretations and recommendations.CONCLUSION: Existing theories of health behavior appear inadequate for under-standing screening behavior, and further studies are recommended to enrich theknowledge base of nursing diagnoses in knowledge deficit and health-seekingbehavior.IMPLICATIONS FOR NURSING PRACTICE: Efforts would be made to improvenurses’ understanding of risk perception of cervical cancer within specific culturalcontext.

目的: 本文综述了女性对宫颈癌的危险性的感知，影响这种感知的因素，及对对宫

颈癌的危险性的感知和宫颈癌筛查行为的关系。

方法: 本研究应用综合文献综述方法

结果: 查文献共发现了42篇相关文献，包括一篇综述和41篇论著。本文对文献中的

趋同和差异进行了阐述和分析。

结论: 现有的健康行为理论不能对宫颈癌筛查行为作出充分的解释，因此需要进行

进一步的研究，以充实与知识缺乏和健康寻求行为等护理诊断相关的内容。

对护理实践的意义: 我们需要让我们的护士更多的了解在特定文化背景下女性对宫

颈癌的危险性的感知和其相关因素。

Cervical cancer is the second most prevalent canceramong women, with an estimated 530,232 new cases and275,008 deaths globally each year (Globocan, 2010).According to a World Health Organization (WHO, 2008)update in 2004, cervical cancer is the most prevalentcancer in Africa and Southeast Asia, although it occurs onlyin women. Moreover, other developing countries with insuf-ficient medical services carry a heavier burden of cervicalcancer because of the lack of accessible screening services(American Cancer Society, 2006).

The perception of risk, which is defined as an individual’sassessment of the likelihood or probability of harm, is con-sidered a crucial factor in promoting precautionary healthbehavior. It is also an essential component of different theo-retical models of health behavior, such as Protection Moti-vation Theory (PMT; Armitage & Conner, 2001; Floyd,Prentice-Dunn, & Rogers, 2000; Montano, 2008). For

instance, in the case of breast cancer screening, those whoperceived a higher likelihood or probability of developingbreast cancer were more likely to undertake cancer screen-ing and be involved in cancer risk reduction activities(Katapodi, Lee, Facione, & Dodd, 2004). However, with cer-vical cancer, it is unclear whether an individual’s awarenessof her risk of the disease influences the likelihood of herparticipating in the screening. Nurses involved in the pro-grams for cervical cancer screening need to have theunderstanding of women’s risk perception to facilitate theidentification of accurate nursing diagnosis, and subse-quently develop appropriate intervention strategies. There-fore, the research team critically reviewed the publishedliterature on the perception of cervical cancer risks and therelationship between risk perception and cervical screeningattendance. The results would enrich the nursing knowl-edge base in health protection that is closely associated

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1© 2014 NANDA International, Inc.International Journal of Nursing Knowledge Volume ••, No. ••, •• 2014

mailto:[email protected]

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with the diagnoses of knowledge deficit and health-seekingbehavior.

The Review

Aim

The aim was to elucidate the trends of women’s percep-tion of cervical cancer risk, the factors influencing risk per-ception, and the relationship between the perception ofcervical cancer risk and the screening behavior, whichcould help nurses to develop appropriate health protectioncare plan for women.

Design

An integrative review was undertaken to synthesize thestudy characteristics and findings. The integrative review isa specific method that could include all different studydesigns (i.e., quantitative and qualitative research methods)and has the potential to inform future research and practice(Whittemore & Knafl, 2005). This selective and criticalreview of the literature centered on issues related towomen’s risk perception of cervical cancer and cervicalscreening behavior. Risk perception of cervical cancer andits relationship with women’s cervical screening participa-tion was systematically reviewed and discussed. Criticalreviews of individual studies were described in terms ofstudy characteristics, subject characteristics, measurementstrategies of risk perception employed in the studies, andoutcome characteristics. After identifying trends and dis-crepancies from the literature and offering some prelimi-nary interpretations, implications for future work andjustification for the current study in terms of theoreticalframework, study variables, study population, and studydesign were discussed.

Search Methods

The literature review combined search articles fromPubMed, Ovid MEDLINE, CLINAL, EMBASE, PsycINFO, andthe Cochrane database of systematic reviews. We includedarticles that met the following inclusion criteria: the studieshad to be empirical studies that used a qualitative or quan-titative research design, designated cervical cancer screen-ing as the primary health-promoting behavior studied,written in English, and published between 1990 and 2012.

The relevant subject areas in the critical review includedwomen’s perception of cervical cancer risk, the factorsinfluencing women’s risk perception, and the relationshipbetween the perception of cervical cancer risk and thescreening behavior. The following keywords were used inthe database search: “cervical cancer,” “uterine cervixcancer,” “uterine cervix neoplasms,” “cervical cancer andrisk perception,” “cervical cancer screening,” “cervicalscreening and risk perception,” “perceived risk,” “riskperception,” “perceived vulnerability,” “perceived suscepti-

bility,” “perceived likelihood,” and “subjective risk percep-tion.” A supplementary search of the reference lists ofarticles in the Ovid MEDLINE, PubMed, and PsycINFO data-bases was conducted using the keywords “risk perception,”“perceived risk,” and “cervical screening.” The findingsfrom each database were reviewed and compared, withdouble findings deleted.

Search Outcome

The initial database search identified 96 articles. Wereviewed the abstracts and back-checked the referencelists of 96 articles identified from the initial database searchto examine other studies that may have initially beenmissed. If we could not decide whether to include or excludethis study through reviewing abstract, the full text of thosestudies will be further reviewed for final decision. Weexcluded research that involved risk perception of healthproviders (7 studies), epidemiological studies about riskfactors of cervical cancer (8 studies), meeting and disser-tations abstracts (3 studies), studies about factors influenc-ing cervical screening attendance that failed to involvedrisk perception into their studies (15 studies), studies aboutfactors influencing human papilloma virus (HPV) vaccina-tion (5 studies), studies involved women diagnosed withcervical cancer (6 studies), studies about factors influenc-ing general screening behavior (3 studies), duplicationstudies (4 studies), as well articles published in a languageother than English (3 studies). This search procedureresulted in the identification of 42 studies, comprising oneliterature review (Vernon, 1999) and 41 primary studies. Theliterature review (Vernon, 1999) was included because itexamines the research findings on risk perception relatedto cancer screening behavior, including cervical screening.Two reviewers critically reviewed all 42 articles indepen-dently and discussed the similarities and differences in theircomments until a consensus was reached.

Data Abstraction

The corresponding author initially abstracted data, andthe first author and corresponding author criticallyassessed the characteristics and main findings of the rel-evant studies.

Quality Appraisal

The selected studies were evaluated by the primaryinvestigator and cross-checked by a co-investigator using achecklist adapted from Mols et al. (2005). The checklist wasmodified to fit the aim of the present review. This checklistconsisted of 14 items, comprising 14 predefined criteria. Thischecklist consisted of five domains: study population (threeitems), study design (three items), follow-up (three items),measurements (three items), and analysis strategies (twoitem). A selected study received 1 for meeting one criterionand 0 for not meeting the criterion or describing insuffi-

Risk Perception and Screening Behavior C. W. H. Chan et al.

2

ciently. Thus, possible scores for each study ranged from 0(low quality) to 14 (high quality). Studies scoring 10 orhigher were considered to be of “high quality.”

Results

Methodological Quality and Characteristics ofSelected Studies

The scores of methodological quality are summarized inTable 1. The mean quality score of 41 studies is 11.3, with arange of 10–13. Methodological weakness mainly concernedthe lack of valid and consistent measurement of risk per-ception of cervical cancer and the response rate. Theselected studies, all of which were published between 1995and 2011, and their characteristics are outlined in Table 1.The focus of the review was to examine how the constructthat is interchangeably called “perceived risk,” “risk per-ception,” “perceived vulnerability,” or “perceived suscepti-bility” relates to cervical cancer screening behavior. Apartfrom one literature review (Vernon, 1999), the researchdesigns of the 41 studies were varied and included cross-sectional surveys (26 studies), face-to-face interviews (5studies), prospective research (2 studies), case-controlledstudies (3 studies), a longitudinal study (1 study), experi-mental studies (3 studies), and secondary data analyses (1study).

Selected Theoretical Models

Theoretical frameworks were described in 39.4% (n = 13)of the studies; the frameworks included the Health BeliefModel (HBM) (eight studies), Health Belief Framework (onestudy), PMT (three studies), PEN-3 (a conceptual frameworkfor health education programs), and Interaction Model ofClient Health Belief (one study). One study used a compli-ance model that incorporated four existing theoreticalframeworks, including the Theory of Planned Behavior, theHBM, Social Cognitive Theory, and the TranstheoreticalModel and Stages of Changes. Another study used a modelof preventive behavior that incorporated two existing theo-retical models, the HBM and the Andersen BehavioralModel.

Subject Characteristics

The sample size and sampling techniques of the studiesvaried. Convenience sampling was used most frequently(59%, 24 studies), followed by random sampling (27%, 11studies) and purposive sampling (14%, 6 studies); thesample sizes of five qualitative studies ranged from 7 to 147.The sample size of the remaining 36 studies ranged from 70to 3,221. Although the age of the study participants rangedfrom 18 to 75 years, four studies were conducted in a selec-tively younger female population aged between 12 and 25years (Byrd, Peterson, Chavez, & Heckert, 2004; Eiser &Cole, 2002; Kahn, Goodman, Slap, Huang, & Emans, 2001;Saules et al., 2007). Most of the studies examined Cauca-

sian or Western populations, and only seven studiesinvolved Asian populations from Taiwan (Hou, Fernandez,Baumler, Parcel, & Chen, 2003), Singapore (Lee, Seow, Ling,& Peng, 2002; Seow, Wong, Smith, & Lee, 1995), Laos(Phongsavan, Phengsavanh, Wahlström, & Marions, 2010),Thailand (Boonpongmanee & Jittanoon, 2007), and main-land China (Gu, Chan, Twinn, & Choi, 2012; Gu et al., 2013).Fourteen studies were conducted in America, 7 studieswere conducted in England, and 20 studies were conductedin other regions of the world.

Strategies for the Measurement of Risk Perception

A wide range of methods was used to assess risk percep-tions of cancer, resulting in apparently contradictory find-ings. Five qualitative studies used face-to-face interview toobtain in-depth information about women’s understandingabout cervical cancer risk. The most common measures ofperceived risk employed by remaining 36 studies were asfollows: a comparative measure employing a six-pointrating scale ranging from “less likely” to “more likely” thatasked participants either “Are you more likely or less likelyto suffer from cervical cancer in the future than otherwomen of the same age?” or to rate their perceived risk ofdeveloping cervical cancer on a five-point rating scaleranging from “much higher than average” to “much lowerthan average” (Eiser & Cole, 2002; French, Maissi, &Marteau, 2004; Marlow, Waller, & Wardle, 2009; Marteau,Hankins, & Collins, 2002); an absolute measure using afive-point rating scale ranging from “strongly agree” to“strongly disagree” that asked participants to respond tothe statement “I’m at risk of developing cervical cancer”(Abotchie & Shokar, 2009; Denny-Smith, Bairan, & Page,2006; Walsh, 2006); a quantitative rating of personal riskand general population risk (0–100%) (Taylor et al., 2002);a verbal measure such as “very low” to “very high” or“large risk” and “not large risk” (Eaker, Adami, & Sparen,2001; Kim et al., 2008; Merrill & Madanat, 2002).

Most of the studies assessed women’s perceived risk ofcervical cancer with one or two questions regarding likeli-hood, such as comparative and verbal measures. Althoughthe response choices for these questions always used quan-tified multi-point scales anchored by numbers, verbalphrases, or comparisons with other people, this traditionalmeasurement of risk assumes that the variable is constant.However, evidence indicates that the anchors for subjectiveand comparative measures, such as verbal expression andquantitative rating, and even the standard “language ofrisk,” can have different meanings to different individualsand even to the same individual in varying contexts(Wallsten, Budescu, Rapoport, Zwick, & Forsyth, 1986;Walter & Britten, 2002).

Outcome Characteristics

Because risk perception is thought to be an importantmotivator of cervical screening behavior, it is imperative to

C. W. H. Chan et al. Risk Perception and Screening Behavior

3

Table

1.S

um

mary

of

41

Res

earc

hS

tudie

s

Au

thor

an

dy

ear

Stu

dy

des

ign

an

dpopu

lati

on

Sam

ple

size

Ou

tcom

em

easu

reR

esu

ltC

om

men

tsS

tudy

qu

ality

1.A

bo

tch

iean

dS

ho

kar

(20

09

)G

han

a

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

olle

ge

stu

den

tsag

ed18

year

san

dab

ove

(n=

157

)K

no

wle

dg

eo

fce

rvic

alca

nce

rri

skfa

cto

rsC

ervi

cal

can

cer

hea

lth

bel

iefs

Ab

ou

th

alf

per

ceiv

edth

emse

lves

tob

eat

risk

(52

.5%

).T

he

pre

vale

nt

bar

rier

sw

ere

lack

of

per

ceiv

edb

enefi

ts(i

tis

imp

ort

ant

for

aw

om

anto

hav

ea

Pap

test

sosh

ew

illkn

ow

ifsh

eis

hea

lth

y:8

7.6

%),

con

cern

sab

ou

tw

hat

oth

ers

may

thin

k(m

yp

artn

erw

ou

ldn

ot

wan

tm

eto

hav

ea

Pap

test

:4

0.6

%),

and

lack

of

info

rmat

ion

(hav

ing

cerv

ical

can

cer

wo

uld

mak

ea

wo

man

’slif

eve

ryd

iffi

cult

:73

.6%

).P

erce

ived

risk

was

no

tas

soci

ated

wit

hsc

reen

ing

up

take

.

Th

isst

ud

yh

igh

ligh

ted

that

alit

erat

ep

op

ula

tio

no

fco

lleg

ew

om

enla

cked

info

rmat

ion

abo

ut

cerv

ical

can

cer

and

its

risk

fact

ors

and

the

mo

stsi

gn

ifica

nt

infl

uen

ceo

fp

erce

ived

bar

rier

so

nsc

reen

ing

beh

avio

r.C

ross

-sec

tio

nal

des

ign

can

no

tm

ake

cau

sal

infe

ren

ces

of

asso

ciat

ion

bet

wee

nri

skp

erce

pti

on

and

scre

enin

gb

ehav

ior.

11

2.

Ack

erso

net

al.(

20

08

)U

nit

edS

tate

s

Qu

alit

ativ

ere

sear

chFa

ce-t

o-f

ace

inte

rvie

wL

ow

-in

com

eA

fric

anA

mer

ican

wo

men

(21–

37

year

s)

(n=

7)

Per

ceiv

edri

skS

cree

nin

gu

pta

keW

om

enp

erce

ived

eith

erh

igh

or

low

risk

of

cerv

ical

can

cer.

Th

ree

wo

men

bel

ieve

dth

atri

sko

fce

rvic

alca

nce

rw

asd

ue

toh

avin

ga

fam

ilyh

isto

ry.

Wo

men

wh

op

erce

ived

low

risk

did

no

to

bta

ina

scre

enin

g.S

oci

alin

flu

ence

fro

mfa

mily

and

ph

ysic

ian

san

dp

revi

ou

sh

ealt

hca

reex

per

ien

ces

infl

uen

ced

scre

enin

gat

ten

dan

ce.

Th

isq

ual

itat

ive

stu

dy

hig

hlig

hte

dth

eb

ackg

rou

nd

vari

able

so

fso

cial

sup

po

rtan

dp

revi

ou

sh

ealt

hca

reex

per

ien

cein

exp

lain

ing

wo

men

’ssc

reen

ing

beh

avio

r.M

ost

of

par

tici

pan

tsw

ere

fro

mth

eS

TD

clin

icw

her

eth

eyw

ere

seek

ing

hea

lth

care

serv

ices

for

ST

D,n

ot

cerv

ical

scre

enin

g.T

hes

ew

om

enm

ayh

ave

felt

con

fusi

ng

bet

wee

nS

TD

test

and

Pap

test

.Sm

all

sam

ple

size

(n=

7)

was

use

dan

dn

oin

form

atio

no

nd

ata

satu

rati

on

was

rep

ort

ed.

11

3.

Ben

-Nat

anan

dA

dir

(20

09

)Is

rael

i

Co

rrel

atio

nal

qu

anti

tati

vest

ud

yIs

rael

ile

sbia

nw

om

enag

ed18

–41

year

s

(n=

108

)H

ealt

hB

elie

fM

od

el(H

BM

)va

riab

les

Cer

vica

lsc

reen

ing

beh

avio

r

Per

ceiv

edb

enefi

ts(p

=.0

0)

and

bar

rier

s(p

<.0

5)

wer

eas

soci

ated

wit

hac

tual

scre

enin

gu

pta

ke.

Per

ceiv

edri

sk(p

<.0

5),

per

ceiv

edb

enefi

ts(p

=.0

0),

and

gen

eral

hea

lth

mo

tiva

tio

n(p

<.0

5)

wer

eas

soci

ated

wit

hin

ten

tio

nto

be

scre

ened

.

Th

isst

ud

yh

igh

ligh

ted

pro

vid

ing

kno

wle

dg

eab

ou

tce

rvic

alsc

reen

ing

,ra

isin

gp

hys

icia

n’s

awar

enes

so

fo

ffer

ing

the

test

tole

sbia

nan

dw

om

en-b

ased

med

ical

team

inp

rom

oti

ng

scre

enin

gam

on

gth

issa

mp

le.S

elf-

rep

ort

edd

ata

hav

eaf

fect

edac

tual

rate

so

fce

rvic

alsc

reen

ing

.Res

earc

hp

op

ula

tio

nw

asn

ot

rep

rese

nta

tive

bec

ause

of

the

use

of

con

ven

ien

cesa

mp

lean

din

volv

ing

on

lyle

sbia

nw

om

en.

10

4.

Bo

on

po

ng

man

eean

dJ

itta

no

on

(20

07

)T

hai

lan

d

Cro

ss-s

ecti

on

alre

sear

chd

esig

nW

ork

ing

wo

men

inB

ang

kok

(25

–55

year

s)

(n=

189

)P

erce

ived

risk

Per

ceiv

edb

enefi

tsan

db

arri

ers

for

cerv

ical

scre

enin

g

Per

ceiv

edb

arri

ers

wer

esi

gn

ifica

nt

pre

dic

tors

of

cerv

ical

scre

enin

g(O

R:.

88

;p

<.0

01)

Per

ceiv

edri

skw

asn

ot

asso

ciat

edw

ith

scre

enin

gu

pta

ke.

Th

isst

ud

yid

enti

fied

the

spec

ific

bar

rier

sth

atw

ork

ing

wo

men

inT

hai

lan

dto

eng

agin

gin

scre

enin

gw

ere

emb

arra

ssm

ent,

fear

,tim

eco

nst

rain

ts,k

no

wle

dg

ed

efici

t,an

dco

st,h

igh

ligh

tin

gcu

ltu

ral

issu

esin

scre

enin

gu

tiliz

atio

n.T

he

fin

din

gm

ayn

ot

be

gen

eral

ized

tou

nem

plo

yed

wo

men

.

11

5.

Byr

det

al.

(20

04

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

nH

isp

anic

wo

men

(18

–25

year

so

ld)

(n=

189

)H

BM

vari

able

sS

cree

nin

gu

pta

keM

ajo

rity

of

wo

men

wer

eaw

are

of

thei

rsu

scep

tib

ility

of

cerv

ical

can

cer

(th

ere

are

effe

ctiv

etr

eatm

ents

for

cerv

ical

can

cer:

93

.7%

),th

ese

rio

usn

ess

of

cerv

ical

can

cer

(hav

ing

cerv

ical

can

cer

wo

uld

mak

ea

wo

man

’slif

ed

iffi

cult

:72

%),

and

the

ben

efits

of

scre

enin

g(i

tis

imp

ort

ant

for

aw

om

anto

hav

ea

Pap

test

tokn

ow

ifsh

eis

hea

lth

y).B

ut

no

asso

ciat

ion

bet

wee

np

erce

ived

risk

and

scre

enin

gu

pta

ke.P

erce

pti

on

sab

ou

tP

apte

sts

po

sed

bar

rier

sto

un

der

go

scre

enin

g(i

tis

too

emb

arra

ssin

gto

hav

ea

Pap

test

:3

9.4

;th

eP

apte

stis

pai

nfu

l:3

2.4

%).

Th

isst

ud

yh

igh

ligh

ted

that

alth

ou

gh

wo

men

un

der

sto

od

the

risk

and

seri

ou

snes

so

fce

rvic

alca

nce

r,th

eir

per

ceiv

edb

arri

ers

asso

ciat

edw

ith

scre

enin

gm

ayh

ave

infl

uen

ced

scre

enin

gp

arti

cip

atio

n.

Par

tici

pan

tsw

ere

sele

cted

fro

ma

gro

up

of

you

ng

wo

men

.Sel

f-re

po

rted

pri

or

exp

erie

nce

of

Pap

test

sw

asn

ot

valid

ated

.

12


4

6.

Den

ny-

Sm

ith

etal

.(2

00

6)

Un

ited

Sta

tes

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

on

ven

ien

cesa

mp

le(1

9–5

8ye

ars)

(n=

24

0)

Hea

lth

Bel

ief

Mo

del

vari

able

s,H

PV

/cer

vica

lca

nce

rkn

ow

led

ge,

sexu

alb

ehav

ior,

cerv

ical

scre

enin

gb

ehav

ior

Par

tici

pan

tsd

emo

nst

rate

da

low

kno

wle

dg

ele

vel

(10

.2ra

ng

eo

f1–

15;S

D:2

.4),

low

per

ceiv

edri

sk(2

0.6

ran

ge

of

9–3

7;S

D:

6.2

),an

dlo

wp

erce

ived

seri

ou

snes

so

fce

rvic

alca

nce

r(1

7.7

ran

ge

of

9–2

7;S

D:

2.8

).N

ore

lati

on

ship

bet

wee

np

revi

ou

ssc

reen

ing

beh

avio

ran

dp

erce

ived

susc

epti

bili

tyan

dp

erce

ived

seri

ou

snes

s.P

osi

tive

rela

tio

nsh

ipb

etw

een

per

ceiv

edri

skan

dn

um

ber

of

par

tner

s(r

:.2

3,p

=.0

01)

.

Th

isst

ud

yh

igh

ligh

ted

that

ala

cko

fkn

ow

led

ge

com

bin

edw

ith

low

per

cep

tio

no

fsu

scep

tib

ility

and

seri

ou

snes

sto

HP

Van

dce

rvic

alca

nce

rm

ade

colle

ge

wo

men

mo

relik

ely

toco

ntr

act

ST

Ds,

incl

ud

ing

HP

V,

and

incr

ease

the

risk

of

cerv

ical

can

cer.

Th

em

ajo

rity

of

sam

ple

sw

ere

mar

ried

and

fin

din

gs

may

be

dif

fere

nt

com

par

edw

ith

sin

gle

stu

den

ts.

11

7.

Eak

eret

al.

(20

01)

Sw

eden

Cas

e-co

ntr

ol

stu

dy

Po

pu

lati

on

-bas

edsa

mp

le(n

on

-att

end

ees

and

atte

nd

ees)

43

0n

on

-scr

een

edan

d5

14sc

reen

ed

(n=

94

4)

HB

Mva

riab

les

Scr

een

ing

beh

avio

rA

tten

dan

cew

asp

osi

tive

lyas

soci

ated

wit

hp

erce

ived

seve

rity

of

cerv

ical

can

cer

(OR

:1.9

95

%C

I:1.1

–3.4

)an

dsa

tisf

acto

ryb

enefi

ts(O

R:.

79

5%

CI:

.6–.

8)

bu

tn

egat

ive

asso

ciat

edw

ith

pra

ctic

alb

arri

ers

(tim

e-co

nsu

min

g:O

R:1

.29

5%

CI:

1.1–1

.5;e

con

om

icb

arri

ers:

OR

:1.7

95

%C

I:1.2

–2.5

)P

erce

ived

risk

was

no

ta

pre

dic

tor

of

scre

enin

gu

pta

ke.

Th

est

ren

gth

of

the

stu

dy

was

the

po

pu

lati

on

-bas

edd

esig

nan

dac

cess

eda

dat

abas

eco

veri

ng

all

cyto

log

ical

scre

enin

gin

the

area

.Im

po

rtan

td

iffe

ren

ces

inat

titu

des

and

bel

iefs

exis

ted

bet

wee

nn

on

-att

end

ees

and

atte

nd

ees.

Ho

wev

er,t

he

stu

dy

was

limit

edb

yth

elo

wre

spo

nse

rate

(71%

)p

arti

cula

rly

amo

ng

no

n-a

tten

dee

s(6

9%

).

12

8.

Eis

eran

dC

ole

(20

02

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

on

ven

ien

cesa

mp

leC

olle

ge

wo

men

aged

20

–25

year

s

(n=

70

)P

erce

ived

risk

Kn

ow

led

ge

abo

ut

cerv

ical

can

cer

and

scre

enin

gS

cree

nin

gb

ehav

ior

Op

tim

isti

cb

ias

was

fou

nd

(p<

.00

1).

No

rela

tio

nsh

ipb

etw

een

per

ceiv

edri

skan

dsc

reen

ing

inte

nti

on

san

dac

tual

up

take

.N

ore

lati

on

ship

bet

wee

np

erce

ived

risk

and

kno

wle

dg

eab

ou

tce

rvic

alca

nce

ran

dsc

reen

ing

.Co

gn

itiv

ecl

osu

rew

asa

sig

nifi

can

tfa

cto

rin

flu

enci

ng

scre

enin

gb

ehav

ior

(p<

.01)

.

Alt

ho

ug

hp

arti

cip

ants

wer

ea

sele

ctiv

eyo

un

ger

wo

men

sam

ple

,th

isst

ud

yh

igh

ligh

ted

that

wo

men

’sra

tin

go

fre

lati

veri

skse

emed

nei

ther

tog

uid

eb

ehav

ior,

no

rto

be

bas

edo

nre

leva

nt

kno

wle

dg

eab

ou

tce

rvic

alca

nce

ran

dsu

gg

este

dp

sych

olo

gic

alfa

cto

rsin

det

erm

inin

gw

om

en’s

mo

tiva

tio

nto

do

asc

reen

ing

.

10

9.

Fern

and

ezet

al.(

20

09

)U

nit

edS

tate

s

Exp

erim

enta

lst

ud

yu

sin

gan

edu

cati

on

alin

terv

enti

on

Wo

men

50

year

san

do

lder

wh

ow

ere

no

adh

eren

tto

cerv

ical

scre

enin

g

(n=

24

3)

Scr

een

ing

beh

avio

rA

ccu

ltu

rati

on

Per

ceiv

edp

ros

and

con

sP

erce

ived

risk

Sel

f-ef

fica

cy

Scr

een

ing

com

ple

tio

nw

ash

igh

eram

on

gin

terv

enti

on

gro

up

.T

he

inte

rven

tio

nin

crea

sed

cerv

ical

scre

enin

gse

lf-e

ffica

cy,p

erce

ived

ben

efits

,an

dsu

bje

ctiv

en

orm

s,b

ut

itd

idn

ot

chan

ge

scre

enin

gkn

ow

led

ge

and

per

ceiv

edri

sk.

Th

isst

ud

yad

ded

toth

eev

iden

ceco

nce

rnin

gth

eef

fect

iven

ess

of

lay

hea

lth

wo

rker

inte

rven

tio

nfo

rin

crea

sin

gce

rvic

alsc

reen

ing

,bu

tth

ein

terv

enti

on

was

pro

ved

no

tto

infl

uen

cep

erce

ived

susc

epti

bili

tyo

fce

rvic

alca

nce

r,an

dth

est

ud

yd

idn

ot

rep

ort

the

rela

tio

nsh

ipb

etw

een

per

ceiv

edsu

scep

tib

ility

and

scre

enin

gb

ehav

ior.

10

10.

Fort

etal

.(2

011

)M

alaw

i

In-d

epth

inte

rvie

ws

of

wo

men

inru

ral

Mal

awi

(n=

20

)B

arri

ers

toce

rvic

alca

nce

rsc

reen

ing

Maj

or

bar

rier

sto

seek

ing

pre

ven

tati

vesc

reen

ing

incl

ud

edlo

wkn

ow

led

ge

leve

ls,

low

per

ceiv

edsu

scep

tib

ility

,an

dlo

wp

erce

ived

ben

efits

fro

mth

ese

rvic

e.

Th

isst

ud

yre

com

men

ded

that

hea

lth

care

pro

vid

ers

and

hea

lth

edu

cato

rsta

rget

edas

pec

tso

fp

erce

ived

susc

epti

bili

tyam

on

gth

isp

op

ula

tio

n,i

ncl

ud

ing

kno

wle

dg

ele

vels

and

per

son

alri

skas

sess

men

t.

11

11.

Fren

chet

al.

(20

04

)U

nit

edK

ing

do

m

Pro

spec

tive

rese

arch

des

ign

Co

nve

nie

nce

sam

ple

22

6w

om

enw

ith

no

rmal

test

resu

lt18

0 no

n-c

on

secu

tive

inad

equ

ate

test

resu

lts

(n=

40

6)

Per

ceiv

edri

skC

ervi

cal

scre

enin

gre

sult

Wo

men

wit

hin

adeq

uat

esm

ear

test

resu

ltp

erce

ived

hig

her

risk

of

cerv

ical

can

cer

than

wo

men

wit

hn

orm

alte

stre

sult

(p=

.016

).R

ecei

vin

gan

inad

equ

ate

smea

rte

stre

sult

rais

edst

ate

anxi

ety

(p=

.02

5,)

and

con

cern

(p<

.00

1)an

dan

xio

us

wo

men

wer

ele

sslik

ely

toat

ten

dfo

ra

rep

eat

smea

rte

st(p

=.0

11).

Th

isst

ud

yh

igh

ligh

ted

that

info

rmin

gw

om

enw

ho

had

anin

adeq

uat

esm

ear

test

resu

ltw

asas

soci

ated

wit

hra

ised

leve

lo

fp

erce

ived

risk

and

anxi

ety

abo

ut

the

test

.T

he

stu

dy

was

ob

serv

atio

nal

ind

esig

n;

itw

asn

ot

po

ssib

leto

infe

rth

eca

usa

las

soci

atio

ns

bet

wee

nva

riab

les.

11


5

Table

1.C

on

tin

ued

Au

thor

an

dy

ear

Stu

dy

des

ign

an

dpopu

lati

on

Sam

ple

size

Ou

tcom

em

easu

reR

esu

ltC

om

men

tsS

tudy

qu

ality

12.

Gar

cés-

Pal

acio

and

Sca

rin

ci(2

012

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alsu

rvey

Wo

men

wer

e3

0±

6.8

year

so

ldan

dw

ere

mai

nly

fro

mM

exic

o(8

9.2

%)

(n=

74

3)

Per

ceiv

edsu

scep

tib

ility

toce

rvic

alca

nce

ran

dfa

cto

rsas

soci

ated

wit

hp

erce

ived

susc

epti

bili

ty

1.E

du

cati

on

alat

tain

men

t,th

inki

ng

they

may

hav

eb

een

exp

ose

dto

anS

TI

inth

ep

ast,

thin

kin

gth

eym

ayb

eat

risk

of

HP

Vcu

rren

tly,

hav

ing

had

aP

apsm

ear

wit

hin

the

last

year

,an

dh

avin

ga

rela

tive

wit

hca

nce

rw

ere

sig

nifi

can

tly

asso

ciat

edw

ith

per

ceiv

edsu

scep

tib

ility

.2

.G

reat

erkn

ow

led

ge

abo

ut

cerv

ical

can

cer

risk

fact

ors

red

uce

dth

eu

nce

rtai

nty

abo

ut

per

ceiv

edsu

scep

tib

ility

.3

.P

erce

ived

susc

epti

bili

tyto

cerv

ical

can

cer

seem

sto

be

infl

uen

ced

mo

reim

po

rtan

tly

by

the

curr

ent

or

pas

tp

erce

pti

on

of

HP

V/S

TI

exp

osu

re,a

nd

by

hav

ing

are

lati

vew

ith

can

cer.

Th

est

ud

ysh

ow

edth

atp

erce

ived

susc

epti

bili

tyto

cerv

ical

can

cer

seem

edto

be

infl

uen

ced

mo

stly

by

the

curr

ent

or

pas

tp

erce

pti

on

of

HP

V/S

TI

exp

osu

re,a

nd

by

hav

ing

are

lati

vew

ith

can

cer.

Yet

the

qu

esti

on

nai

rew

asse

lf-r

epo

rted

and

may

hav

eb

iase

s.

12

13.

Go

ldm

anan

dR

isic

a(2

00

4)

Un

ited

Sta

tes

Qu

alit

ativ

ere

sear

chd

esig

nu

sin

gfa

ce-t

ofa

cein

terv

iew

Do

min

ican

san

dP

uer

toR

ican

sin

Rh

od

eIs

lan

d(1

8ye

ars

and

old

er)

(n=

147

)P

erce

pti

on

abo

ut

cerv

ical

can

cer

and

scre

enin

g

Cer

vica

lca

nce

rri

sks

wer

em

ost

lyat

trib

ute

dto

care

less

nes

sab

ou

th

ealt

hca

rean

dse

xual

beh

avio

rb

yin

terv

iew

ees.

Ast

ron

gse

nse

of

fata

lism

and

feel

ing

so

fem

bar

rass

men

tco

exis

tw

ith

firm

bel

iefs

abo

ut

the

imp

ort

ance

of

scre

enin

g,a

nd

incr

easi

ng

no

rmal

izat

ion

of

atle

ast

the

idea

of

Pap

test

.

Th

efi

nd

ing

sfr

om

this

qu

alit

ativ

est

ud

yu

nd

ersc

ore

dth

eco

mp

lexi

tyo

fth

eis

sues

con

cern

ing

can

cer

per

cep

tio

ns

and

beh

avio

rs,a

nd

pro

vid

em

ean

ing

and

con

text

that

hel

pex

pla

inso

me

of

the

con

flic

tin

gp

erce

pti

on

s.N

oin

form

atio

nab

ou

tw

om

en’s

per

ceiv

edp

erso

nal

risk

of

cerv

ical

can

cer

was

dis

cuss

edin

this

stu

dy.

12

14.

Gu

etal

.(2

012

)C

hin

a

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

on

ven

ien

cesa

mp

leo

fC

hin

ese

wo

men

(25

–50

year

so

ld)

(n=

167

)P

rote

ctio

nM

oti

vati

on

Th

eory

vari

able

s,kn

ow

led

ge

abo

ut

cerv

ical

can

cer

and

scre

enin

g,

scre

enin

gb

ehav

ior

All

wo

men

con

sid

ered

them

selv

esat

low

risk

of

cerv

ical

can

cer.

No

sig

nifi

can

tas

soci

atio

nw

aso

bse

rved

bet

wee

np

erce

ived

risk

and

pre

vio

us

scre

enin

gb

ehav

ior.

Ap

erce

pti

on

that

visi

tin

gd

oct

ors

reg

ula

rly

isim

po

rtan

tto

hea

lth

,av

erag

ean

dh

igh

leve

lso

fkn

ow

led

ge

abo

ut

cerv

ical

scre

enin

gw

ere

sig

nifi

can

tly

asso

ciat

edw

ith

hav

ing

bee

nre

ceiv

edsc

reen

ing

.

Th

isst

ud

yh

igh

ligh

ted

the

sig

nifi

can

ceo

fkn

ow

led

ge

and

cult

ura

llyre

leva

nt

hea

lth

beh

avio

ran

db

elie

fsab

ou

tce

rvic

alsc

reen

ing

for

Ch

ines

ew

om

enin

det

erm

inin

gsc

reen

ing

beh

avio

r.T

he

use

of

con

ven

ien

cesa

mp

lelim

ited

gen

eral

izin

gth

ese

resu

lts

toth

ew

ho

leC

hin

ese

po

pu

lati

on

.R

epo

rted

exp

erie

nce

sw

ere

retr

osp

ecti

ve,w

hic

hle

aded

tore

call

bia

s.

11

15.

Gu

etal

.(2

013

)C

hin

a

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

on

ven

ien

cesa

mp

leo

fC

hin

ese

wo

men

(25

–50

year

so

ld)

(n=

167

)P

rote

ctio

nM

oti

vati

on

Th

eory

vari

able

s,kn

ow

led

ge

abo

ut

cerv

ical

can

cer

and

scre

enin

g,

Sex

ual

his

tory

,M

oti

vati

on

tore

ceiv

efu

ture

scre

enin

g

Th

em

ajo

rity

of

wo

men

stat

edth

eyin

ten

ded

tore

ceiv

efu

ture

scre

enin

g,a

nd

resp

on

seef

fica

cyw

assi

gn

ifica

ntl

yas

soci

ated

wit

hth

eir

inte

nti

on

.Can

cer

inre

lati

ves,

ap

erce

pti

on

that

visi

tin

ga

do

cto

rre

gu

larl

yis

imp

ort

ant

toh

ealt

h,a

nd

ever

atte

nd

ing

for

cerv

ical

scre

enin

gd

uri

ng

the

pre

vio

us

thre

eye

ars

wer

esi

gn

ifica

ntl

yas

soci

ated

wit

hw

om

en’

mo

tiva

tio

nto

rece

ive

futu

resc

reen

ing

.

Th

isst

ud

yh

igh

ligh

ted

the

imp

ort

ant

role

of

wo

men

’sb

elie

fsin

the

valu

eo

fce

rvic

alsc

reen

ing

and

pre

vio

us

scre

enin

gex

per

ien

cein

mo

tiva

tin

gth

emto

rece

ive

asc

reen

ing

.Wo

men

wer

ere

cru

ited

fro

mfo

ur

wo

rkp

lace

san

dd

idn

ot

hav

eto

pay

for

thei

rsc

reen

ing

,res

ult

ing

ina

bia

sed

sam

ple

.Sm

all

sam

ple

size

was

ano

ther

con

cern

.Th

esu

bse

qu

ent

actu

alu

pta

keo

fsc

reen

ing

was

no

tas

sess

edin

this

stu

dy.

11

16.

Ho

etal

.(2

00

5)

Un

ited

Sta

tes

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

on

ven

ien

cesa

mp

leo

fw

om

en2

0–8

8ye

ars

old

(n=

20

9)

HB

Mva

riab

les

Scr

een

ing

up

take

Per

ceiv

edri

skw

asn

ot

ap

red

icto

ro

fsc

reen

ing

up

take

.P

erce

ived

seve

rity

was

asi

gn

ifica

nt

pre

dic

tor

of

scre

enin

gu

pta

ke.

Th

est

ud

yfo

un

dm

any

sig

nifi

can

tp

red

icto

rso

fP

apte

stan

din

form

edth

efu

ture

stu

dy

toad

dre

ssth

ese

fact

ors

inth

en

ext

adh

eren

cest

ud

y.T

he

dat

aw

ere

colle

cted

by

po

stal

surv

ey,w

hic

hw

asn

ot

valid

ated

;8

6-i

tem

qu

esti

on

nai

rem

ayh

ave

cau

sed

feel

ing

of

tire

dn

ess

and

bo

rin

gfo

rit

was

no

tva

lidat

ed.

11


6

17.

Ho

llow

ayet

al.(

20

03

)U

nit

edK

ing

do

m

Clu

ster

-ran

do

miz

edco

ntr

olle

din

terv

enti

on

rese

arch

;th

ein

terv

enti

on

com

pri

sed

ab

rief

spec

ific

cou

nse

ling

sess

ion

.W

om

enw

ere

recr

uit

edw

hen

atte

nd

ing

for

cerv

ical

scre

enin

g

(n=

1,89

0)

Sh

ort

-ter

mo

utc

om

ew

asst

ated

pre

fere

nce

for

futu

resc

reen

ing

inte

rval

.L

on

g-t

erm

ou

tco

me

was

actu

alsc

reen

ing

beh

avio

rat

4-y

ear

follo

wu

p.

Inte

rven

tio

ng

rou

pw

asle

sslik

ely

toex

pre

ssa

pre

fere

nce

of

ash

ort

erth

anre

com

men

ded

inte

rval

(OR

:.5

19

5%

CI:

.41–

.64

;p<

.00

01)

and

less

likel

yto

atte

nd

for

scre

enin

gso

on

erth

anth

eir

reco

mm

end

edre

call

(5%

hav

ing

sho

rter

than

reco

mm

end

edin

terv

als)

.Th

eim

pac

to

fp

erce

ived

risk

on

actu

alsc

reen

ing

beh

avio

rw

aseq

uiv

oca

l.

Th

est

ren

gth

of

this

stu

dy

was

the

larg

esa

mp

lesi

zean

dlo

ng

itu

din

alex

per

imen

tal

stu

dy.

Th

isst

ud

ysu

gg

este

dth

atri

skp

erce

pti

on

of

wo

men

reg

ard

ing

cerv

ical

scre

enin

gw

ere

amen

able

toin

div

idu

aliz

edri

skco

mm

un

icat

ion

inte

rven

tio

n.T

his

inte

rven

tio

nw

asp

rove

dto

ben

efit

scre

enin

gp

rog

ram

and

may

relie

vean

xiet

y.D

iffe

ren

ces

inn

um

ber

sb

etw

een

the

inte

rven

tio

nan

dco

ntr

ol

gro

up

(63

0vs

.82

9)

bec

ause

of

dif

fere

nt

attr

itio

nra

tem

ayaf

fect

the

com

par

abili

tyb

etw

een

two

gro

up

s.

13

18.

Ho

qu

eet

al.

(20

09

)B

ots

wan

a

Cro

ss-s

ecti

on

alre

sear

chd

esig

nW

om

enw

ho

wer

eab

ove

18ye

ars

old

(n=

30

0)

Per

ceiv

edse

veri

tyS

cree

nin

gu

pta

keS

ixty

per

cen

to

fn

on

-scr

een

edw

om

enh

adlo

wp

erce

ived

seve

rity

wh

ile3

3%

of

scre

ened

had

hig

hp

erce

ived

seve

rity

.N

ore

lati

on

ship

bet

wee

np

erce

ived

seve

rity

and

scre

enin

gu

pta

ke(Χ

2=

1.07

95

;p=

.29

88

).

Par

tici

pan

tsw

ere

ase

lect

edw

om

enp

op

ula

tio

nw

ho

atte

nd

eda

dis

tric

th

osp

ital

.Par

tici

pan

tsm

ayh

ave

felt

sen

siti

veto

rep

ort

neg

ativ

ere

sult

ssu

chas

per

ceiv

edb

arri

ers,

intr

od

uci

ng

self

-bia

s.

10

19.

Ho

uet

al.

(20

03

)T

aiw

an

Cro

ss-s

ecti

on

alre

sear

chd

esig

nA

con

ven

ien

cesa

mp

leo

fw

om

enw

ith

mea

nag

ew

as3

8ye

ars

inT

aiw

an

(n=

125

)P

rio

rsc

reen

ing

exp

erie

nce

sP

erce

ived

pro

san

dco

ns

of

ate

stP

erce

ived

no

rms

Per

ceiv

edri

skK

no

wle

dg

eo

fce

rvic

alca

nce

ran

dsc

reen

ing

Scr

een

ing

adh

eren

cew

asas

soci

ated

wit

hkn

ow

led

ge,

per

ceiv

edp

ros,

con

s,an

dn

orm

so

fce

rvic

alsc

reen

ing

.Fi

nal

log

isti

cre

gre

ssio

nm

od

eld

idn

ot

sup

po

rtp

erce

ived

risk

asa

succ

essf

ul

pre

dic

tor.

Th

isst

ud

yid

enti

fied

imp

ort

ant

psy

cho

log

ical

fact

ors

asso

ciat

edw

ith

scre

enin

gu

pta

keam

on

gC

hin

ese

wo

men

inT

aiw

an,w

hic

hco

uld

be

tailo

red

for

futu

rein

terv

enti

on

effo

rts.

Bec

ause

all

wo

men

volu

nta

rily

agre

edto

par

tici

pat

ein

the

stu

dy,

volu

nte

erb

ias

may

hav

eex

iste

d.B

ecau

sew

om

enw

ere

recr

uit

edfr

om

ah

osp

ital

sett

ing

,th

ese

wo

men

may

be

mo

reo

pen

toh

ealt

h-r

elat

edin

form

atio

n.

11

20

.K

ahn

etal

.(2

00

1)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

n12

–24

-yea

r-o

ldw

om

en

(n=

49

0)

Co

mp

lian

ceM

od

elva

riab

les

Scr

een

ing

beh

avio

r

Per

ceiv

edri

skw

asn

ot

asso

ciat

edw

ith

inte

nti

on

tore

turn

for

cerv

ical

scre

enin

g.

Per

son

alb

elie

fso

fce

rvic

alsc

reen

ing

(OR

:1.0

79

5%

CI:

1.02

–1.11

),p

erce

pti

on

so

fo

ther

’sb

elie

fs(O

R:1

.93

95

%C

I:1.3

8–2

.74

),an

dcu

esto

acti

on

(OR

:1.3

19

5%

CI:

1.08

–1.6

0)

wer

eas

soci

ated

wit

hin

ten

tio

nto

retu

rn.

Th

isst

ud

yid

enti

fied

man

ysi

gn

ifica

nt

fact

ors

that

wer

eas

soci

ated

wit

hin

ten

tio

nto

retu

rnfo

rsc

reen

ing

.H

ow

ever

,par

tici

pan

tsw

ere

ase

lect

ive

you

ng

erw

om

enp

op

ula

tio

nan

dp

red

icte

din

ten

tio

nto

retu

rnfo

rsc

reen

ing

may

no

tex

pla

inac

tual

retu

rn.T

he

scal

esth

atm

easu

red

kno

wle

dg

e,p

erce

ived

risk

,an

dse

veri

tyw

ere

skew

edan

dd

idn

ot

adju

stth

en

orm

alit

y.T

hes

ere

sult

sw

ere

dic

ho

tom

ized

for

anal

ysis

,wh

ich

limit

edth

eab

ility

tod

etec

tsi

gn

ifica

nce

.

10

21.

Kav

anag

han

dB

roo

m(1

99

8)

Au

stra

lia

Qu

alit

ativ

ere

sear

chd

esig

nu

sin

gfa

ceto

face

inte

rvie

w.

Wo

men

wh

oh

adan

abn

orm

alP

apsm

ear

(19

–70

year

so

ld).

(n=

29

)W

om

en’s

un

der

stan

din

go

fth

en

atu

reo

fth

eir

cerv

ical

abn

orm

alit

y,an

dh

ow

they

mad

ese

nse

of

abn

orm

alit

yin

the

con

text

of

thei

rev

eryd

ayliv

es.

Th

em

ult

iplic

ity

of

mea

nin

gs

of

“ris

k”co

mp

licat

edth

eef

fort

so

fp

ub

lich

ealt

h.

Man

yw

om

enh

adn

ot

con

sid

ered

them

selv

esto

be

atri

sko

fce

rvic

alca

nce

rb

efo

reth

eir

abn

orm

alP

apsm

ear.

Th

isst

ud

yh

igh

ligh

ted

that

the

no

un

“ris

k”h

asm

ult

idim

ensi

on

alm

ean

ing

for

ind

ivid

ual

san

dsu

gg

este

dth

en

eed

so

fp

eop

leto

inte

gra

teh

ealt

hth

reat

sin

toth

eir

dai

lyp

erso

nal

lives

.H

ow

ever

,th

est

ud

yas

soci

ated

wo

men

’su

nd

erst

and

ing

of

the

risk

wit

hh

ealt

hri

sk,b

ut

itd

idn

ot

asso

ciat

eth

eir

un

der

stan

din

go

fth

eri

skw

ith

cerv

ical

scre

enin

gat

ten

dan

ce.

beh

avio

r.

11


7

Table

1.C

on

tin

ued

Au

thor

an

dy

ear

Stu

dy

des

ign

an

dpopu

lati

on

Sam

ple

size

Ou

tcom

em

easu

reR

esu

ltC

om

men

tsS

tudy

qu

ality

22

.K

imet

al.

(20

08

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

nW

om

enfr

om

fou

ret

hn

icg

rou

ps

of

wh

ite,

Afr

ican

Am

eric

an,L

atin

a,an

dC

hin

ese

(50

–80

year

s)

(n=

1,16

0)

Per

ceiv

edri

skS

elf-

rep

ort

edsc

reen

ing

beh

avio

r

Co

mp

ared

wit

hw

hit

ew

om

en,L

atin

asp

erce

ived

ah

igh

risk

of

cerv

ical

can

cer

Ch

ines

eh

ada

low

per

ceiv

edri

sk.

No

rela

tio

nsh

ipb

etw

een

risk

per

cep

tio

nfo

rce

rvic

alca

nce

ran

dsc

reen

ing

up

take

was

iden

tifi

ed.

Th

isst

ud

yco

mp

ared

risk

per

cep

tio

no

fce

rvic

alca

nce

ran

dsc

reen

ing

beh

avio

ram

on

gd

iver

sew

om

enin

clu

din

gC

hin

ese

Am

eric

ans

and

fou

nd

sig

nifi

can

td

iffe

ren

cein

risk

per

cep

tio

nb

etw

een

Ch

ines

ean

do

ther

eth

nic

gro

up

s.A

llw

om

enw

ere

esta

blis

hed

pat

ien

tsin

clin

ics

wit

hp

rim

ary

care

clin

icia

ns

and

had

visi

ted

acl

inic

inth

ep

ast

2ye

ars,

resu

ltin

gin

sele

ctiv

eb

ias.

12

23

.K

uit

toet

al.

(20

10)

Ger

man

y

Cro

ss-s

ecti

on

alre

sear

chd

esig

nR

and

om

lyse

lect

edw

om

enag

ed14

–65

year

s

(n=

76

0)

Det

erm

inan

to

fu

pta

keo

fp

reve

nti

vem

easu

res

agai

nst

cerv

ical

can

cer

1.A

tten

dan

ceb

oth

atsc

reen

ing

and

atH

PV

vacc

inat

ion

was

bes

tp

red

icte

db

yat

titu

din

alfa

cto

rs.

2.

Att

end

ance

atsc

reen

ing

and

HP

Vva

ccin

atio

nw

asas

soci

ated

wit

hp

osi

tive

con

no

tati

on

so

fca

nce

rp

reve

nti

on

mea

sure

san

du

tilit

yex

pec

tati

on

s,fe

aro

fca

nce

ran

dh

igh

sub

ject

ive

risk

per

cep

tio

n.

3.

Scr

een

ing

atte

nd

ance

was

less

reg

ula

ram

on

gw

om

eno

flo

wer

soci

oec

on

om

icst

atu

s.

Up

take

rate

sfo

rex

isti

ng

pri

mar

yan

dse

con

dar

yp

reve

nti

on

mea

sure

sag

ain

stce

rvic

alca

nce

rco

uld

be

enh

ance

db

yfo

ster

ing

per

cep

tio

ns

of

uti

lity

and

po

siti

veco

nn

ota

tio

ns

of

reg

ula

rsc

reen

ing

.Ho

wev

er,t

he

nu

mb

ero

fre

spo

nd

ents

inag

eg

rou

po

f14

–26

was

low

,an

dd

etai

led

mu

ltiv

aria

tean

alys

esin

this

age

gro

up

sw

ere

faile

dto

con

du

ct.A

lso

,fu

rth

eran

alys

iso

nth

ere

lati

on

ship

bet

wee

nkn

ow

led

ge,

atti

tud

esto

war

dp

reve

nti

on

beh

avio

ran

du

tilit

yex

pec

tati

on

sw

asn

eed

ed.

11

24

.L

eeet

al.

(20

02

)S

ing

apo

re

Cro

ss-s

ecti

on

alre

sear

chd

esig

nP

op

ula

tio

n-b

ased

sam

ple

of

Asi

anw

om

en(3

0–5

9ye

ars)

(n=

72

6)

Kn

ow

led

ge,

atti

tud

e,an

dp

ract

ices

of

cerv

ical

scre

enin

g.

Rea

son

sfo

rn

ot

adh

eren

tto

reg

ula

rsc

reen

ing

Th

ep

rim

ary

reas

on

for

reg

ula

rsc

reen

ing

atte

nd

ance

was

likel

yto

be

scre

enin

go

ras

ap

art

of

hea

lth

chec

kup

s(6

7%

).C

hie

fb

arri

ers

tore

gu

lar

scre

enin

gw

ere

low

per

ceiv

edri

sk(4

6.5

%)

and

low

acce

ssib

ility

(37

.1%).

Th

isst

ud

yh

igh

ligh

ted

the

imp

ort

ant

fact

ors

infl

uen

cin

gw

om

en’s

adh

eren

ceto

reg

ula

rsc

reen

ing

incl

ud

ing

hea

lth

serv

ice-

rela

ted

fact

ors

and

per

ceiv

edri

sko

fce

rvic

alca

nce

r.W

om

enw

ho

cou

ldn

ot

be

con

tact

edo

nth

ree

atte

mp

tsco

nst

itu

ted

asi

zeab

lep

rop

ort

ion

of

the

no

n-r

esp

on

den

ts,b

ut

the

stu

dy

did

no

tm

easu

reth

ed

iffe

ren

ceb

etw

een

them

.

11

25

.M

arlo

wet

al.(

20

09

)U

nit

edK

ing

do

m

An

exp

erim

enta

lre

pea

ted

mea

sure

sd

esig

nB

riti

shw

om

enag

ed16

–75

year

s

(n=

96

5)

HP

Vaw

aren

ess

Ris

kp

erce

pti

on

Cer

vica

lsc

reen

ing

beh

avio

r

Ove

rall,

HP

Vin

form

atio

nd

idn

ot

hav

ean

effe

cto

np

erce

ived

risk

.Bu

tH

PV

info

rmat

ion

affe

cted

wo

men

’sce

rvic

alca

nce

rri

skp

erce

pti

on

sin

the

you

ng

erw

om

en(p

<0

.00

1).T

her

ew

asal

soa

sig

nifi

can

tti

me

by

scre

enin

gat

ten

dan

cein

tera

ctio

n,w

ith

anin

crea

sein

per

ceiv

edri

skam

on

gw

om

enw

ho

did

no

tre

gu

larl

yat

ten

dsc

reen

ing

(p=

.02

2).

Th

isst

ud

yco

ntr

ibu

ted

toth

ekn

ow

led

ge

abo

ut

the

effe

cto

fH

PV

info

rmat

ion

on

per

ceiv

edri

sko

fce

rvic

alca

nce

rac

ross

dif

fere

nt

po

pu

lati

on

gro

up

.H

ow

ever

,th

ere

lati

on

ship

bet

wee

nri

skp

erce

pti

on

and

scre

enin

gb

ehav

ior

was

no

tas

sess

ed.R

esp

on

sera

tew

asm

od

est,

and

no

con

tro

lg

rou

pw

asu

sed

.Wo

men

rate

dth

eir

per

ceiv

edri

skim

med

iate

lyaf

ter

read

ing

info

rmat

ion

abo

ut

HP

V,a

nd

itw

asp

oss

ible

that

the

PR

wo

uld

be

dif

fere

nt

inth

elo

ng

erte

rm.

10

26

.M

arte

auet

al.(

20

02

)U

nit

edK

ing

do

m

Cro

ss-s

ecti

on

alre

sear

chd

esig

nsm

oke

rsan

dn

on

smo

kers

(20

–64

year

so

ld)

(n=

72

2)

Per

ceiv

edri

skS

mo

kin

gb

ehav

ior

Scr

een

ing

up

take

Per

ceiv

edri

skw

asa

pre

dic

tor

of

inte

nti

on

toat

ten

dfo

rsc

reen

ing

(OR

:1.5

95

%C

I:1.0

–2.1)

.S

mo

kers

wer

eu

naw

are

of

thei

rin

crea

sed

risk

so

fce

rvic

alca

nce

r(p

<.0

00

1).

Th

isst

ud

yin

dic

ated

that

smo

kers

seem

edu

naw

are

of

thei

rin

crea

sed

risk

of

cerv

ical

can

cer;

eval

uat

ion

so

nin

terv

enti

on

alst

ud

yw

ere

nee

ded

.B

ecau

seth

em

easu

reo

fsm

oki

ng

was

ind

irec

t,it

was

un

cert

ain

of

ho

wb

iase

sin

resp

on

din

gm

igh

th

ave

affe

cted

the

resu

lts.

Th

est

ud

ysa

mp

lew

asle

ssed

uca

ted

than

the

gen

eral

po

pu

lati

on

.

12


8

27

.M

atej

icet

al.(

20

11)

Au

stra

lia

Six

ty-t

wo

-ite

mse

lf-a

dm

inis

tere

dq

ues

tio

nn

aire

wit

hca

se-c

on

tro

ld

esig

nW

om

enag

ed18

–70

year

s,w

ho

dem

on

stra

ted

anin

itia

tive

for

aP

AP

smea

r

n=

26

7fo

rst

ud

yg

rou

pan

dn

=2

67

for

con

tro

lg

rou

pFa

cto

rsd

eter

or

stim

ula

teth

ew

om

ento

par

tici

pat

ein

scre

enin

gac

tivi

ties

Ad

her

ence

toce

rvic

alca

nce

rsc

reen

ing

pra

ctic

esis

sig

nifi

can

tly

rela

ted

tob

ette

rfi

nan

cial

stat

us

(OR

:10

.8p

=.0

01)

,no

gen

der

pre

fere

nce

for

ag

ynec

olo

gis

t(O

R:

3.1

p=

.015

),co

nsu

ltat

ion

sw

ith

ag

ynec

olo

gis

t(O

R:4

.7p

=.0

29

),co

nve

rsat

ion

wit

hth

ew

om

enw

ith

cerv

ical

can

cer

abo

ut

that

dis

ease

(OR

:2

.8p

=.0

29

),h

igh

erm

edia

exp

osu

reto

info

rmat

ion

abo

ut

cerv

ical

can

cer

pre

ven

tio

n(O

R:5

.0p

=.0

04

),an

dh

igh

erp

erso

nal

risk

per

cep

tio

n(O

R:3

.6,p

=.0

01)

.

Th

est

ud

yu

rged

that

op

enco

mm

un

icat

ion

,so

cial

net

wo

rks,

and

imp

rovi

ng

soci

al-e

con

om

icst

atu

so

fw

om

enw

ere

the

mo

stp

rom

inen

tfa

cto

rsaf

fect

ing

the

par

tici

pat

ion

insc

reen

ing

acti

viti

es.Y

etth

eco

ntr

ol

gro

up

incl

ud

edw

om

enw

ho

did

no

tp

rese

nt

for

scre

enin

gre

gu

larl

yra

ther

than

tho

sew

ho

had

nev

erb

een

scre

ened

.

12

28

.M

cMu

llin

etal

.(2

00

5)

Un

ited

Sta

tes

Qu

alit

ativ

ere

sear

chS

emi-

stru

ctu

red

face

-to

-fac

ein

terv

iew

Pu

rpo

sive

sam

ple

of

Mex

ican

Am

eric

ans

(mea

nag

ew

as3

9ye

ars)

(n=

20

)B

elie

fsab

ou

tth

ero

leo

fse

xual

acti

viti

esin

cerv

ical

can

cer

etio

log

yan

dth

eim

pac

to

fth

eb

elie

fso

nsc

reen

ing

up

take

Th

em

ajo

rity

of

wo

men

had

limit

edkn

ow

led

ge

abo

ut

cerv

ical

can

cer

and

no

kno

wle

dg

eab

ou

tH

PV

;bel

ieve

dth

atin

fect

ion

sca

use

db

yp

hys

ical

trau

ma,

cert

ain

sexu

alac

tivi

ties

,an

dp

oo

rh

ygie

ne

cau

sed

cerv

ical

can

cer.

Wo

men

exp

ress

edth

atif

they

did

no

ten

gag

ein

un

wis

eb

ehav

iors

,th

eyw

ou

ldb

en

ot

atri

sko

fce

rvic

alca

nce

ran

db

ele

sslik

ely

tog

eta

scre

enin

g.

Th

isst

ud

ysu

gg

este

dth

atcu

ltu

rally

rela

ted

bel

iefs

abo

ut

the

etio

log

yo

fce

rvic

alca

nce

rp

laye

da

role

inth

ed

ecis

ion

too

bta

ina

scre

enin

gfo

rL

atin

aim

mig

ran

ts.

Th

est

ud

yfo

cuse

dsp

ecifi

cally

on

bel

iefs

abo

ut

sexu

alb

ehav

iors

and

scre

enin

gu

pta

ke.O

ther

risk

fact

ors

wer

en

ot

dis

cuss

edin

the

stu

dy.

Itco

uld

no

tco

mm

ent

on

the

rela

tive

imp

ort

ance

of

sexu

alb

ehav

iors

com

par

edw

ith

oth

erri

skfa

cto

rsfo

rce

rvic

alca

nce

rin

the

min

ds

of

the

resp

on

den

tso

rth

em

agn

itu

de

of

the

imp

act

on

scre

enin

gu

pta

ke.

11

29

.M

erri

llan

dM

adan

at(2

00

2)

Un

ites

Sta

tes

Cro

ss-s

ecti

on

alre

sear

chd

esig

nW

om

enag

ed18

year

san

do

lder

(n=

3,2

21)

Rel

igio

np

refe

ren

ceC

hu

rch

acti

vity

Scr

een

ing

up

take

Per

ceiv

edri

sk

Th

ere

lati

on

bet

wee

nre

ligio

us

pre

fere

nce

,ch

urc

hac

tivi

ty,a

nd

scre

enin

gu

pta

kew

asd

epen

den

to

nm

arit

alst

atu

s(f

or

un

mar

ried

wo

men

of

hav

ing

aP

apsm

ear

inth

ela

sttw

oye

ars,

com

par

edw

ith

relig

iou

sly

acti

veL

DS

,OR

:2.3

99

5%

CI:

1.30

–4.0

9;f

or

less

relig

iou

sly

acti

veL

DS

,O

R:2

.30

95

%C

I:1.1

0–4

.82

;fo

rre

ligio

usl

yac

tive

no

n-L

DS

,OR

:1.6

59

5%

CI:

0.9

1–2

.99

)fo

rle

ssre

ligio

usl

yac

tive

no

n-L

DS

,an

dO

R:5

.35

95

%C

I:2

.50

–11.4

3fo

rw

om

enw

ith

no

relig

iou

sp

refe

ren

ce).

Alo

wri

skp

erce

pti

on

may

resu

ltin

the

low

use

of

cerv

ical

scre

enin

g.

Th

isst

ud

yin

corp

ora

ted

relig

iou

sp

refe

ren

ce,c

hu

rch

acti

vity

,an

dri

skp

erce

pti

on

into

un

der

stan

din

gw

om

en’s

scre

enin

gb

ehav

ior,

wh

ich

pro

vid

edn

ewin

sig

ht

into

the

issu

est

ud

ied

.T

he

stu

dy

was

limit

edb

ecau

seo

fth

eu

seo

fcr

oss

-sec

tio

nal

tele

ph

on

esu

rvey

.Th

irty

-th

ree

per

cen

to

fw

om

ench

ose

no

tto

par

tici

pat

e;se

lf-s

elec

ted

bia

sm

ayh

ave

infl

uen

ced

the

resu

lts.

12

30

.O

rbel

lan

dS

hee

ran

(19

98

)U

nit

edK

ing

do

m

Alo

ng

itu

din

alst

ud

yA

ran

do

msa

mp

leo

fu

nsc

reen

edw

om

enag

ed2

0–6

4ye

ars

(n=

166

)P

rote

ctio

nM

oti

vati

on

Th

eory

vari

able

s,sc

reen

ing

beh

avio

r

Per

ceiv

edri

skw

asa

pre

dic

tor

of

mo

tiva

tio

nto

take

asc

reen

ing

.M

oti

vati

on

,hig

hp

erce

ived

risk

,les

sw

orr

y,an

dh

igh

resp

on

seef

fica

cyw

ere

sig

nifi

can

tp

red

icto

rso

fac

tual

scre

enin

gu

pta

keat

1-ye

arfo

llow

-up

.

Th

isst

ud

yh

igh

ligh

ted

that

PM

Tm

od

elp

rovi

ded

au

sefu

lfr

amew

ork

for

pre

dic

tin

gb

oth

will

ing

nes

sto

un

der

go

cerv

ical

scre

enin

gan

dac

tual

up

take

of

the

test

.Th

em

easu

reem

plo

yed

inth

isst

ud

yw

asva

lidat

edb

yth

ew

ork

of

Orb

ell

(19

96

).T

he

actu

alu

pta

keo

fsc

reen

ing

was

mea

sure

do

bje

ctiv

ely

fro

mm

edic

alre

cord

.

11

31.

Orb

ell

(19

96

)U

nit

edK

ing

do

m

Cro

ss-s

ecti

on

alre

sear

chd

esig

nW

om

enag

ed2

0–6

0ye

ars

(n=

27

6)

Beh

avio

ral

risk

Pre

vio

us

test

exp

erie

nce

sB

ehav

iora

lex

pec

tati

on

Th

reat

app

rais

al(p

erce

ived

risk

,p

erce

ived

seve

rity

,AN

Dfe

ar)

Mo

stw

om

enw

ere

will

ing

tou

nd

erg

ofu

ture

test

s(8

2%

).Fu

ture

scre

enin

gex

pec

tati

on

sw

ere

exp

lain

edn

ot

by

per

ceiv

edri

sk,b

ut

by

ase

nse

of

ob

ligat

ion

toat

ten

d(p

<.0

1)an

dav

ersi

ven

ess

of

cerv

ical

scre

enin

gp

roce

du

re(p

<.0

5).

Th

isst

ud

ysu

gg

este

dth

eim

po

rtan

ceo

fa

sen

seo

fm

ora

lo

blig

atio

nan

dp

erce

pti

on

of

cerv

ical

scre

enin

gp

ract

ice

inm

oti

vati

ng

wo

men

tota

kea

scre

enin

g.H

ow

ever

,th

eva

rian

ceex

pla

ined

inb

ehav

iora

lex

pec

tati

on

sw

asm

od

est

(22

%);

itw

assu

gg

este

dfo

rfu

ture

exp

lora

tio

no

fp

erce

pti

on

of

risk

and

cerv

ical

scre

enin

gfr

om

wo

men

’sp

ersp

ecti

ves.

12


9

Table

1.C

on

tin

ued

Au

thor

an

dy

ear

Stu

dy

des

ign

an

dpopu

lati

on

Sam

ple

size

Ou

tcom

em

easu

reR

esu

ltC

om

men

tsS

tudy

qu

ality

32

.O

rbel

let

al.

(19

95

)U

nit

edK

ing

do

m

Cas

e-co

ntr

ol

des

ign

(30

7sc

reen

edan

d3

07

no

n-s

cree

ned

)2

0–6

4-y

ear-

old

wo

men

(n=

614

)S

cree

nin

gb

ehav

ior,

beh

avio

ral

risk

,at

titu

des

,an

db

elie

fsco

nce

rnin

gce

rvic

alsc

reen

ing

,p

ract

ical

dif

ficu

ltie

s,an

dso

cial

clas

s

No

n-s

cree

ned

wo

men

and

wo

men

wit

hlo

wcl

ass

wer

ele

sslik

ely

tob

elie

veth

atth

eyw

ere

atri

sko

fce

rvic

alca

nce

r.

Th

est

ud

yh

igh

ligh

ted

soci

ocu

ltu

ral

fact

ors

such

asso

cial

clas

sin

mo

tiva

tin

gw

om

ento

take

asc

reen

ing

follo

win

ga

reg

ion

alca

llp

rog

ram

.T

he

low

resp

on

sera

te(7

7.5

%)

may

resu

ltin

resp

on

seb

ias.

11

33

.P

ho

ng

sava

net

al.(

20

10)

Lao

s

Cro

ss-s

ecti

on

alst

ud

yL

aow

om

enag

ed18

–55

year

s

(n=

80

0)

Wo

men

’sp

erce

pti

on

of

cerv

ical

can

cer

1.T

hir

ty-e

igh

tp

erce

nt

con

sid

ered

tob

eat

risk

bu

tle

ssth

an5

%h

adev

erh

ada

Pap

test

.2

.S

ixty

-tw

op

erce

nt

bel

ieve

dth

atit

was

po

ssib

leto

pre

ven

tce

rvic

alca

nce

r,an

dth

atva

ccin

atio

nm

ayb

ea

suit

able

met

ho

d,b

ut

on

ly14

%kn

ow

abo

ut

risk

fact

ors

.3

.L

ack

of

sub

ject

ive

sym

pto

ms

was

the

mai

nre

aso

nfo

rw

om

ento

refr

ain

fro

mg

ynec

olo

gic

alex

amin

atio

ns.

Th

isst

ud

yin

dic

ated

that

rura

lw

om

enin

Lao

sh

ave

limit

edkn

ow

led

ge

abo

ut

cerv

ical

can

cer

and

even

less

abo

ut

scre

enin

gan

dp

reve

nti

on

.Ho

wev

er,

no

cau

sal

fact

ors

wer

eex

amin

edfo

rth

ep

oo

rkn

ow

led

ge

inL

aos.

12

34

.S

aule

set

al.

(20

07

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

nC

olle

ge

fem

ale

stu

den

t(1

8–2

4ye

ars

old

)

(n=

135

)S

mo

kin

gb

ehav

ior

Scr

een

ing

up

take

Per

ceiv

edri

sk

Cu

rren

tsm

oke

rp

erce

ived

ah

igh

risk

of

cerv

ical

can

cer.

Ab

no

rmal

scre

enin

gh

isto

ryw

asa

pre

dic

tor

of

risk

per

cep

tio

n.

Rel

atio

nsh

ipb

etw

een

risk

per

cep

tio

nan

dsc

reen

ing

par

tici

pat

ion

was

no

tre

po

rted

.

Th

isst

ud

yex

amin

edw

om

en’s

smo

kin

gb

ehav

ior

and

per

ceiv

edri

sko

fce

rvic

alca

nce

r,an

din

ten

tio

nto

qu

itsm

oki

ng

.Ho

wev

er,i

td

idn

ot

exam

ine

wo

men

’sce

rvic

alsc

reen

ing

beh

avio

rin

rela

tio

nto

thes

efa

cto

rs.S

mo

kin

gb

ehav

ior

was

colle

cted

by

self

-rep

ort

,in

tro

du

cin

gse

lf-b

ias.

10

35

.S

cari

nci

etal

.(2

00

3)

Un

ited

Sta

tes

Cro

ss-s

ecti

on

alre

sear

chd

esig

nlo

w-i

nco

me

Lat

ina

imm

igra

nts

(18

–42

year

so

ld)

(n=

22

5)

Eth

nic

dif

fere

nce

sre

gar

din

gce

rvic

alca

nce

rkn

ow

led

ge

and

soci

o-c

ult

ura

lfa

cto

rsas

soci

ated

wit

hce

rvic

alsc

reen

ing

All

no

n-L

atin

aw

om

enh

adce

rvic

alsc

reen

ing

inth

ep

ast

com

par

edw

ith

81%

of

Lat

ina

wo

men

.Lat

ina

wo

men

dis

pla

yed

sig

nifi

can

tly

less

kno

wle

dg

ere

gar

din

gce

rvic

alca

nce

rth

ann

on

-Lat

ina

(p<

.00

1).

Wo

men

per

ceiv

edth

eyw

ere

no

tat

risk

for

cerv

ical

can

cer

sin

ceth

eyd

on

ot

hav

e“p

erce

ived

risk

fact

ors

.”

Th

isst

ud

yh

igh

ligh

ted

that

Lat

ina

imm

igra

nts

ten

ded

tod

isp

lay

cult

ura

llyb

ased

kno

wle

dg

ean

db

elie

fsre

gar

din

gce

rvic

alca

nce

ran

dsc

reen

ing

that

infl

uen

ced

scre

enin

gat

ten

dan

ce.

Giv

enth

ato

nly

20

wo

men

did

no

th

ave

asc

reen

ing

,th

isst

ud

yd

idn

ot

hav

een

ou

gh

po

wer

toex

amin

efu

rth

erco

mp

aris

on

amo

ng

wo

men

wh

oev

erh

ada

scre

enin

gan

dth

eo

nes

wh

oh

adn

ot.

11

36

.S

eow

etal

.(1

99

5)

Sin

gap

ore

Cro

ss-s

ecti

on

alre

sear

chd

esig

n2

1–6

5-y

ear-

old

wo

men

(Ch

ines

ew

om

enac

cou

nti

ng

for

80

%)

(n=

56

8)

HB

Mva

riab

les

Scr

een

ing

beh

avio

rO

vera

ll,p

erce

ived

risk

isve

ryh

igh

(58

.9%

per

ceiv

eda

hig

hri

sk).

Am

on

gw

om

enw

ho

had

nev

erb

een

scre

ened

,per

ceiv

edri

skw

asan

imp

ort

ant

pre

dic

tor

of

thei

rw

illin

gn

ess

tob

esc

reen

ed(o

nly

58

.9%

felt

them

selv

esat

equ

alri

sko

fg

etti

ng

can

cer

aso

ther

s).

Th

est

ud

yin

volv

edC

hin

ese

wo

men

inS

ing

apo

re,a

cco

un

tin

gfo

rab

ou

t8

0%

of

the

tota

lsa

mp

lean

dh

igh

ligh

ted

cult

ure

-sp

ecifi

ch

ealt

hb

elie

fsan

dat

titu

de

inin

crea

sin

gth

eac

cep

tan

ceo

fth

eP

apsm

ear.

Ho

wev

er,t

he

pre

dic

tive

valu

eo

fH

BM

was

limit

edb

ecau

seit

was

inh

eren

tly

ap

sych

oso

cial

mo

del

and

neg

lect

edco

nte

xtu

alfa

cto

rsan

dn

orm

ativ

eb

elie

fs.

12


10

37

.T

acke

net

al.(

20

07

)D

utc

h

Cro

ss-s

ecti

on

alre

sear

chd

esig

nA

two

-sta

ge

clu

ster

sam

ple

of

wo

men

wh

ow

ere

elig

ible

for

the

Du

tch

po

pu

lati

on

-bas

edsc

reen

ing

pro

gra

m(3

0–6

0ye

ars

old

)

(n=

1,39

2)

Scr

een

ing

up

take

Wo

men

’sle

vel

vari

able

s:p

erce

ived

risk

,p

erso

nal

mo

ral

ob

ligat

ion

,n

orm

ativ

eb

elie

fs.

Pra

ctic

ele

vel

vari

able

s

Bel

iefs

abo

ut

cerv

ical

scre

enin

gan

dat

ten

dan

cein

clu

din

gp

erso

nal

mo

ral

ob

ligat

ion

and

no

rmat

ive

bel

iefs

of

oth

ers

imp

acte

do

nth

eu

pta

kera

te(p

<.0

1).

Org

aniz

atio

nal

fact

ors

also

infl

uen

ced

on

scre

enin

gu

pta

ke,b

ut

per

ceiv

edri

skw

asn

ot

asso

ciat

edw

ith

scre

enin

gu

pta

ke.

Bec

ause

the

resp

on

sera

tew

asse

lect

ive,

an

on

resp

on

sest

ud

yw

asp

erfo

rmed

.It

ind

icat

edth

atw

om

enw

ho

dro

pp

edo

ut

of

the

pre

ven

tio

np

rog

ram

per

ceiv

edlo

wri

sko

fce

rvic

alca

nce

ran

dw

ere

mo

reco

nvi

nce

dth

atth

eca

nce

rw

asfa

tal.

Th

isst

ud

yh

igh

ligh

ted

that

cerv

ical

scre

enin

gra

tes

wer

elik

ely

tob

ein

flu

ence

db

yb

elie

fsab

ou

tce

rvic

alsc

reen

ing

and

org

aniz

atio

nal

fact

ors

.

13

38

.T

aylo

ret

al.

(20

04

)U

nit

edS

tate

s

Cro

ss-s

ecti

on

alre

sear

chd

esig

nV

ietn

ames

eA

mer

ican

wo

men

(18

–64

year

s)

(n=

35

2)

Hea

lth

Bel

ief

Fram

ewo

rkva

riab

les

Scr

een

ing

up

take

No

asso

ciat

ion

bet

wee

np

erce

ived

risk

and

adh

eren

ceto

cerv

ical

scre

enin

g.B

ein

gm

arri

ed,k

no

win

gP

apte

stw

asn

eces

sary

for

asym

pto

mat

icw

om

en,d

oct

or

had

reco

mm

end

edte

stin

g,a

nd

had

aske

dd

oct

or

for

test

ing

wer

efa

cto

rsas

soci

ated

wit

hsc

reen

ing

par

tici

pat

ion

(p<

.05

).

Th

isst

ud

yco

nfi

rmed

low

leve

lso

fce

rvic

alsc

reen

ing

amo

ng

Vie

tnam

ese

wo

men

and

dem

on

stra

ted

the

imp

ort

ance

of

ph

ysic

ian

–pat

ien

tco

mm

un

icat

ion

inin

crea

sin

gsc

reen

ing

par

tici

pat

ion

.T

he

dif

fere

nce

bet

wee

nst

ud

ysa

mp

lean

du

nre

ach

edan

dre

fuse

dp

arti

cip

atio

nw

ere

no

tre

po

rted

.

12

39

.W

alsh

(20

06

)Ir

elan

d

Pro

spec

tive

qu

anti

tati

ved

esig

nW

om

enag

ed2

5–6

0in

Iris

h

(n=

1,114

)A

tten

dan

cefo

rce

rvic

alsc

reen

ing

,kn

ow

led

ge

and

acce

ssto

info

rmat

ion

abo

ut

cerv

ical

can

cer,

exp

erie

nce

of

cerv

ical

scre

enin

g,

per

ceiv

edri

sk,

bar

rier

sto

atte

nd

ance

Wo

men

hav

ep

oo

rle

vels

of

kno

wle

dg

eab

ou

tce

rvic

alca

nce

ran

dsc

reen

ing

(48

%st

ated

that

the

pu

rpo

seo

fa

cerv

ical

smea

ris

top

reve

nt

cerv

ical

can

cer)

.Fa

cto

rsin

flu

enci

ng

wo

men

’sd

ecis

ion

toat

ten

dfo

ra

scre

enin

gin

clu

ded

that

incr

ease

dp

erce

pti

on

of

risk

(p<

.05

),le

vel

of

un

der

stan

din

gab

ou

tce

rvic

alsc

reen

ing

(p=

.00

1),a

nd

per

ceiv

edb

arri

ers

(th

ep

erce

pti

on

of

hav

ing

ace

rvic

alsm

ear

test

asti

me

con

sum

ing

p<

.01;

cau

sin

gg

reat

erd

istr

ess

p<

.01

and

bei

ng

mo

reaf

raid

of

the

test

p<

.05

).

Th

est

ren

gth

so

fth

isst

ud

yw

ere

larg

esa

mp

lesi

ze,a

nd

the

com

pu

teri

zed

reco

rds

fro

mth

ecy

tolo

gy

lab

wer

eu

sed

asan

ob

ject

ive

mea

sure

of

scre

enin

gat

ten

dan

ce.T

his

stu

dy

iden

tifi

edm

any

sig

nifi

can

tfa

cto

rsin

flu

enci

ng

scre

enin

gu

pta

ke,

sug

ges

tin

gan

urg

ent

nee

dfo

rh

ealt

hp

rovi

der

toad

dre

ssth

ese

fact

ors

infu

ture

.

12

40

.W

ere

etal

.(2

011

)K

enya

Cro

ss-s

ecti

on

alq

ues

tio

nn

aire

surv

eyN

on

-pre

gn

ant

wo

men

(n=

219

)P

erce

pti

on

so

fri

skan

db

arri

ers

toce

rvic

alca

nce

rsc

reen

ing

1.W

om

eno

fo

ver

30

year

sw

ere

mo

relik

ely

toh

ave

scre

ened

bef

ore

(p=

.012

).2

.P

erce

pti

on

of

bei

ng

atri

skw

assi

gn

ifica

ntl

yas

soci

ated

wit

ha

felt

nee

dfo

rsc

reen

ing

(p=

0.0

02

).3

.Fe

aro

fab

no

rmal

resu

lts

and

lack

of

fin

ance

sw

ere

the

com

mo

nes

tb

arri

ers

tosc

reen

ing

rep

ort

edb

y2

2.4

%an

d11

.4%

of

resp

on

den

ts,r

esp

ecti

vely

.

Th

est

ud

yh

igh

ligh

ted

ah

igh

lysi

gn

ifica

nt

rela

tio

nsh

ipb

etw

een

ap

erce

pti

on

of

ow

nri

sko

fd

evel

op

ing

cerv

ical

can

cer

and

anex

pre

ssed

nee

dfo

rce

rvic

alca

nce

rsc

reen

ing

.H

ow

ever

,th

est

ud

yp

op

ula

tio

nw

asal

sose

lect

edfo

rth

ew

om

enw

ho

wer

eal

read

yac

cess

ing

the

clin

icse

rvic

esin

Mo

iT

each

ing

and

Ref

erra

lH

osp

ital

.

11

41.

Zh

ang

etal

.(2

00

7)

Un

ited

Sta

tes

Sec

on

dar

yd

ata

anal

ysis

usi

ng

asu

bse

tsa

mp

leo

fa

cro

ss-s

ecti

on

alst

ud

yE

lder

lyw

om

en(≧

65

year

s)

(n=

1,04

4)

Inte

nt

toh

ave

asc

reen

ing

,p

revi

ou

sg

ynec

olo

gic

his

tory

,b

enefi

t/at

titu

des

rela

ted

toce

rvic

alsc

reen

ing

Am

on

gw

om

enw

ho

had

no

tu

nd

erg

on

ea

hys

tere

cto

my

per

ceiv

edri

sk(O

R:4

.27

95

%C

I:1.2

7–1

4.3

3),

pre

vio

us

Pap

smea

rte

st(O

R:1

9.2

89

5%

CI:

10.15

–37

.10),

per

ceiv

edp

ain

of

the

test

(OR

,0.5

2;9

5%

CI,

.28

–.9

9),

and

per

ceiv

edim

po

rtan

ce(O

R:4

.00

95

%C

I:1.3

2–1

2.10

)w

ere

po

siti

veco

rrel

ates

of

inte

nti

on

toh

ave

asc

reen

ing

.

Th

isst

ud

yco

ntr

ibu

ted

too

ur

kno

wle

dg

eo

fce

rvic

alsc

reen

ing

bec

ause

of

its

dif

fere

nti

atio

nb

etw

een

eld

erly

wo

men

wh

oh

adan

dh

adn

ot

un

der

go

ne

ah

yste

rect

om

y.T

he

stu

dy

on

lyas

sess

edin

ten

tio

nto

hav

ea

Pap

test

rath

erth

anac

tual

up

take

,bu

tin

ten

tio

nw

asn

ot

alw

ays

tran

slat

edin

toac

tual

acti

on

.

12

CI,

con

fid

ence

inte

rval

;HP

V,h

um

anp

apill

om

avi

rus;

LD

S,L

atte

r-d

ayS

ain

t;O

R,o

dd

sra

tio

;PR

,per

ceiv

edri

sk;S

TD

,sex

ual

lytr

ansm

itte

dd

isea

se;S

TI,

sexu

ally

tran

smit

ted

infe

ctio

n.


11

identify both the determinants of risk perception and thepattern of the relationship between perceived risk and cer-vical screening behavior. The outcome variables of theselected studies focused on women’s risk perception, thefactors affecting their risk perception, and the correlationbetween risk perception and screening participation. Thereare limited studies that have directly addressed the linkagebetween the outcome measurements and the nursingprocess, in particular, the nursing diagnoses of knowledgedeficit and health-seeking behavior were seldom mentionedin these studies.

Women’s perception of cervical cancer risk. Women’sperception of cervical cancer risk varied between thestudies; several studies demonstrated that women ratedtheir relative risk of susceptibility to cervical cancer asbelow average (Eiser & Cole, 2002; Kavanagh & Broom,1998; Marteau et al., 2002; Seow et al., 1995; Taylor et al.,2004). Kavanagh and Broom (1998) found that manywomen did not believe they were at risk of cervical cancerbefore an abnormal Pap smear, while for others, a cervicalabnormality signified their vulnerability and made themconsider the risk of developing cervical cancer. Smokersseemed to have no knowledge of their increased risk ofcervical cancer and disregarded their higher need ofregular screening (Marteau et al., 2002). Taylor et al.(2004) found that 77% of Vietnamese women believed thatthey were less likely to contract cervical cancer than Cau-casian women. Another study involving Chinese women inSingapore (Seow et al., 1995) also reported that only 58.9%of women believed that they were equally susceptible tocontracting cervical cancer, while a substantial proportion(48.7%) of women believed that cancer could not beprevented.

However, there were some contradictory findings. A highproportion (73%) of women were concerned about cervicalcancer, and a very significant proportion (68%) of youngwomen perceived a moderate to high risk of developingcervical cancer (Moreira et al., 2006). Byrd et al. (2004)discovered that up to 90% of Latina women aged 18–25years believed that they were at risk of developing cervicalcancer. Kim et al. (2008) detected a significant difference inthe perception of cancer risk in a diverse sample of womenfrom English, Spanish, and Chinese ethnic groups. Thesedifferences in the perception of cervical cancer risk per-sisted after controlling for demographics, numeracy, andpersonal and family history. Compared with Caucasianwomen, Asian women perceived a lower risk of cervicalcancer, in contrast to Latina women, who perceived theirrisk to be higher.

Most of the studies involved risk perception as a possiblefactor influencing cervical screening behavior, but they didnot explore the factors that influenced women’s risk per-ception. Limited evidence showed that smoking behavior,number of sexual partners, inconclusive screening results,screening experience, social class, perceived severity, per-ceptions of HPV/sexually transmitted disease (STD) expo-

sure, and family history of cancer were factors thatinfluenced the perception of cervical cancer risk(Denny-Smith et al., 2006; French et al., 2004;Garcés-Palacio & Scarinci, 2012; Marlow et al., 2009; Orbell,Crombie, Robertson, Johnston, & Kenicer, 1995; Sauleset al., 2007). Marlow et al. (2009) found that providing HPVinformation enabled women to accurately estimate theirpredisposition to cervical cancer. Increased awareness ofcervical cancer risk was observed in younger women oncethey became cognizant of the sexually transmitted nature ofHPV and the significance of cervical screening. However,Eiser and Cole (2002) and Fernandez et al. (2009) sug-gested that perceived risk rating is not based on relativeunderstanding of cervical cancer and its causes. Fernandezet al. also assessed the effectiveness of intervention inincreasing cervical cancer screening among low-incomeLatina women and found that educational intervention sig-nificantly increased the self-efficacy of cervical screening,the perceived benefits of screening, subjective beliefs, andthe perception of cancer survivability; however, it did notalter the perception of cervical cancer risk. Because of thelimited amount of evidence, it is difficult to reach conclu-sions about trends in the perception of cervical cancer riskand the factors that influence it.

Women’s risk perception and cervical screeningbehavior. The relationship between women’s perception ofcervical cancer risk and their screening behavior is alsoinconclusive among the studies. Some studies supportedthe hypothesis that the perceived risk of the disease plays asubstantial role in the prediction of women’s screeningbehavior (Ackerson, Pohl, & Low, 2008; Fort, Makin, Siegler,Ault, & Rochat, 2011; Kuitto, Pickel, Neumann, Jahn, &Metelmann, 2010; Lee et al., 2002; Marteau et al., 2002;Matejic, Vukovic, Pekmezovic, Kesic, & Markovic, 2011;McMullin, Alba, Chavez, & Hubbell, 2005; Merrill & Madanat,2002; Orbell & Sheeran, 1998; Scarinci, Beech, Kovach, &Bailey, 2003; Seow et al., 1995; Walsh, 2006; Were, Nyaberi,& Buziba, 2011; Zhang, Borders, & Rohrer, 2007), whichinclude three qualitative studies. Women’s beliefs in theirprobability of developing cervical cancer were identified asa fundamental promoter of screening behavior. Womenwho believed that they were at a low risk were less likely tohave been screened previously and were less likely toundergo screening in the future. McMullin et al. (2005) con-ducted a qualitative study with a purposive sample of 20Mexican women and found that physical trauma resultingfrom an abortion or unprotected sex, an infection from apartner, and poor hygiene were factors that Hispanicwomen believed increased an individual’s risk of cervicalcancer. If Latina and African American women did notbelieve that they were at a risk of cervical cancer, then theywere less likely to participate in screening (McMullin et al.,2005; Scarinci et al., 2003). A previous longitudinal study(Orbell & Sheeran, 1998) also discovered that the con-structs of PMT, such as perceived risk, fear arousal, andresponse efficacy, were significant independent variables


12

associated with women’s actual screening behavior andthat the perception of cervical cancer risk was also a suc-cessful predictor of women’s motivation to be screened inthe future.

However, several studies detected no relationshipbetween the perception of cervical cancer risk and screen-ing behavior (Abotchie & Shokar, 2009; Ben-Natan & Adir,2009; Boonpongmanee & Jittanoon, 2007; Byrd et al.,2004; Denny-Smith et al., 2006; Eaker et al., 2001; Eiser &Cole, 2002; Goldman & Risica, 2004; Gu et al., 2012; Hoet al., 2005; Hoque, Ibekwe, & Ntuli-Ngcobo, 2009; Houet al., 2003; Kahn et al., 2001; Kim et al., 2008; Orbell, 1996;Tacken et al., 2007; Taylor et al., 2004). In these studies,risk perception did not predict screening participation orfuture intention to participate in screening. For example,Orbell’s (1996) study claimed that future intention to bescreened was best explained by a sense of responsibility toattend the screening and not by the anxiety associated withcervical cancer risks. Similarly, other studies failed to iden-tify an association between the perception of cervicalcancer risk and the screening behavior (Fernandez et al.,2009; French et al., 2004; Garcés-Palacio & Scarinci, 2012;Kavanagh & Broom, 1998; Marlow et al., 2009; Saules et al.,2007).

The existing quantitative studies fail to fully evaluatewhether the subjects over- or underestimated their riskbecause they do not include valid assessments of the actualrisk of cervical cancer (Vernon, 1999). Currently, there ismuch controversy regarding options for risk perceptionmeasurements for clinical applications and research. Thereare no gold standards for very low- or high-risk perception,particularly within the context of cervical cancer risk. Theconclusion drawn by Vernon (1999) is that there are notenough data to ascertain and quantify the relationshipbetween perceived cervical cancer risk and screeningbehavior.

Discussion

The review of the selected studies reveals major gaps inthe relevant knowledge and methodological approaches.

Theoretical Framework

Although the variables specified in PMT and the HeathBelief Model have received considerable empirical supportin previous studies (Ben-Natan & Adir, 2009; Eaker et al.,2001; Ho et al., 2005; Marteau et al., 2002; Orbell &Sheeran, 1998; Walsh, 2006), various controversies andcriticisms are presented in several of the theoretical andempirical studies. It has been observed that the predictivevalue of the HBM is limited because it is essentially a psy-chosocial model and disregards environmental factors(including the accessibility of services) and normativebeliefs (the perception of how others view behavior)(Seow et al., 1995). While the HBM may identify subjects

who are willing to participate in the screening, it does notpredict actual behavior or long-term adherence (Ho et al.,2005). Researchers have also criticized the model for itsoveremphasis on the rationality of behavior without con-sidering emotional variables that could affect screeningdecisions (Orbell, 1996). Three studies employed PMT tostudy cervical screening behavior; for example, Orbell andSheeran (1998) conducted a longitudinal study to applyPMT to a group of non-screened women to understand therelationship between the motivation to be screened andthe subsequent behavior. The study supported the sugges-tion that PMT variables were successful predictors of bothmotivation to participate in screening and subsequentuptake. However, two other studies (Gu et al., 2012, 2013)contradicted the above findings and did not find PMT vari-ables to be effective predictors of either the motivationto be screened in the future or the previous screeningbehavior.

Orbell and Sheeran (1998) found that the relationshipbetween motivation to undergo screening and actual actionwas far from perfect. This finding indicates that PMT vari-ables may not be sufficient to explain the action of womenwhose positive intention to be screened did not translateinto screening uptake. Other studies argued that elementsor factors other than those described in PMT and the HBMshould be addressed to obtain better insight into health-related motivation. Several empirical studies in this criticalreview proposed a variety of factors other than those speci-fied by the PMT that were successful predictors of women’sscreening behavior; these included the social influence offamily members and physicians (Ackerson et al., 2008;Taylor et al., 2004), previous healthcare experiences(Ackerson et al., 2008), cognitive closure (Eiser & Cole,2002), a sense of fatalism and the normalization of the ideaof cervical screening (Goldman & Risica, 2004), the norma-tive beliefs of others (concern about what others may think)(Abotchie & Shokar, 2009; Kahn et al., 2001; Tacken et al.,2007), contextual factors such as screening as part of ahealth check-up (Lee et al., 2002), religious preference(Merrill & Madanat, 2002), and personal moral obligation(Orbell, 1996; Tacken et al., 2007). For example, Orbell(1996) study showed that the inclusion of personal moralobligation in the regression analysis could better explainthe variance in the intention to be screened. This findingsuggests that threat- and coping-appraisal variables are notenough to determine the motivation to engage in preven-tive behavior. Tacken et al. (2007) reported similar findingsregarding the direct effects of personal moral obligation onthe intention to undergo screening. Other studies sug-gested that for a more comprehensive understanding ofscreening behavior, an emphasis on the social processes ofmotivation and culture-related beliefs would be more ben-eficial than the variables included in either the HBM orthe PMT. This review demonstrated that nursing care inthe area of cervical screening practice would address thecomplex nature of women’s health-seeking behavior. Thefindings from this review indicated that women’s health-


13

seeking behavior in the area of cervical cancer preventionwould be influenced by complex factors that have or havenot been described in existing theoretical models. Thisassertion highlights the need for developing a culturallyrelevant and empirically based theoretical model that couldexplain and predict screening uptake. In order to encouragehealth-seeking behavior, nurses should address suchfactors when organizing the provision of health educationfor cervical cancer prevention. The results from this reviewsuggest that, while providing accurate information is impor-tant, it is equally important to ensure that women’s beliefsand their social-constructed meaning of screening behaviorare included in nursing assessment and evaluation ofchanges resulting from any nursing interventions.

Study Variables

Most of the studies in the review only quantitatively mea-sured the perception of cervical cancer risk and assessedknowledge about risk factors for the disease with simpleyes/no questions (Gu et al., 2012, 2013; Hou et al., 2003).These studies did not appear to adequately explore eitherthe meaning of risk among the women themselves or therole of personal risk factors and cultural context in deter-mining screening behavior. For individuals to engage in arational evaluation of personal risk and subsequent copingstrategies, they must first have an understanding of the riskfactors related to the disease (Marlow et al., 2009). Indeed,the low-risk perception of cervical cancer among Asianwomen identified in this review might be partly explained bya lack of factual information about the risk and risk factorsfor cervical cancer (Herdman, 2012), which concur with thenursing diagnosis of knowledge deficit. Regarding the riskfactors associated with this nursing diagnosis, contextualfactors, including ethical, social, and cultural issues, mustbe properly addressed to in this area of nursing care.Women’s understanding of the risk factors for cervicalcancer and the sexually transmitted nature of HPV andunsafe sex would importantly impact on how women per-ceive the risk of cervical cancer, and subsequent decision-making process of cervical screening behavior. Forexample, Holroyd, Twinn, and Adab (2004) found that asubstantial proportion of Chinese women associated therisk of cervical cancer with multiple sexual partners, beingmarried, youth or old age, and their partner’s poor hygiene.Another study (Martinez, Chavez, & Hubbell, 1997) arguedthat Latina females’ understanding of the risk factors ofcervical cancer was significantly influenced by moral obli-gation. Women who engaged in “unnatural” and “immoral”behavior, including having extramarital partners, havingsex during their menstrual period, and having abortions,were at a higher risk of cervical cancer than others. It hasbeen suggested that emphasizing the association betweencervical cancer and sexual behavior may lead to a sense ofstigma and guilt among women who develop the disease;for example, women who tested positive for HPV experi-enced feelings of anxiety and stigma (McCaffery et al.,

2004). Thus, fear of moral judgment and the stigma asso-ciated with STD may impede screening uptake and informa-tion seeking regarding cervical cancer prevention(Friedman & Shepeard, 2006; Twinn, Holroyd, & Adab,2006). Further nursing research is warranted to under-stand how women comprehend their personal risk and therisk factors of cervical cancer and how the correlationbetween these beliefs affects their screening behavior.Such explorative studies could identify more underling riskfactors associated with the nursing diagnosis of knowledgedeficit and health-seeking behavior. Effective and culturallysensitive nursing care plan would improve communicationabout cervical cancer risk and help promote cervicalscreening among diverse ethnic groups. An improvedunderstanding of the connection between managing therisk of HPV infection and managing cervical cancer riskshould also be addressed in future studies.

Study Population

The majority of the reviewed studies were carried out inWestern populations, and the knowledge obtained fromthese studies may not be applicable to other cultural groupssuch as Asian and African women. Cultural values havebeen found to affect cancer communication and screeningamong several ethnic minorities (Liang, Yuan, Mandelblatt,& Pasick, 2004). The importance of providing cervicalscreening services in a culturally appropriate manner is wellestablished (Hislop et al., 2003; Holroyd et al., 2004; Tayloret al., 2002). For example, traditional Asian cultural views,including fatalism, beliefs regarding a balanced diet, matu-rity, modesty, and self-reliance, contribute to the avoidanceof healthcare visits (Kwok, Sullivan, & Cant, 2006; Lianget al., 2008). Moreover, in Asian cultures (Chen, 1996),health is considered to be a state of physical harmony withthe environment, and an emphasis on the effectiveness oftraditional Chinese medicine and a preference for usingEastern herbs over Western medicine have been demon-strated in Asian populations (Liang et al., 2004; Simpson,2003). These beliefs may constitute a barrier to seekingmedical help through Western medicine, including regularscreening, among Asian women (Hoeman, Ku, & Ohl, 1996;Liang et al., 2004; Yamashiro & Matsuoka, 1997).

Design

Because of the variety of measurement strategiesemployed in the studies, it is difficult to compare women’sperception of cervical cancer risk across the studies.Indeed, the most serious criticism of risk perceptionresearch is that “studies record snapshots of risk judg-ments outside of the specific social contexts in whichpeople live out their day-to-day lives” (Rogers, 1975). Riskperception is not static; rather, it tends to be altered indifferent contexts and influenced by individuals’ knowledgeand life experiences (Bellaby, 1990).


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The studies examined in this review have several limita-tions, including limited study population size, inadequatedata collection methods, and a lack of in-depth explorationof risk perception from the women’s perspective. Becausemost of the studies were cross-sectional and retrospective,it is difficult to establish any causal association betweenwomen’s perception of cervical cancer risk and their futurescreening behavior. The majority of the reviewed studiesassessed women’s perception of cervical cancer risk withone or two likelihood questions, but evidence shows thatsuch quantitative measurements do not sufficiently capturean individual’s complex feelings and perceptions about therisk of cervical cancer (Slovic, Finucane, Peters, &MacGregor, 2002). These limitations with respect tocurrent risk perception measurements may be more seriouswithin specific cultural contexts. Indeed, cultural contextsare influenced by multiple health, social, and financialissues, which may exert a profound impact on the percep-tion of cancer risk (Huerta & Macario, 1999). A review ofcurrent developments in risk research claimed that newermethods place more emphasis on the significance of socialand cultural context in comprehending cancer risk(Taylor-Gooby & Zinn, 2006). From the literature on cervi-cal cancer perception and prevention decision making,quantitative approaches alone prove inadequate to explaininconsistent findings or to gain in-depth understanding ofcervical cancer risk and subsequent screening behavior.This inadequacy suggests the need for alternative researchmethods, such as mixed method designs and studies indifferent cultural contexts.

Conclusion

The evidence from the 1 review article and 41 primarystudies shows that comparing studies and drawing conclu-sions about the perception of cervical cancer risk andscreening behavior is difficult because of theoretical inad-equacy, measurement variability, the use of culturallyinsensitive measurement strategies, and the use of incon-sistent measurements. Previous works have made fewattempts to examine the feelings related to cervical cancerrisk and how women understand their personal risk factorsin depth. An alternative approach using multiple designsand data sources, rather than a quantitative or a qualitativemethod alone, is recommended to gain a more comprehen-sive understanding of these social phenomena (Greene,Benjamin, & Goodyear, 2001). Alternative study methodsare of particular importance, given that little attention haspreviously been paid to the undoubtedly complex issue ofthe perception of cervical cancer risk, particularly withinspecific cultural contexts. Such efforts would improvenurses’ understanding of the perception of cervical cancerrisk and empower them to develop accurate nursing diag-nosis and appropriate care plan to promote women’s atten-dance at and long-term adherence to cervical screening.Nurses involved in the programs for cervical cancer andscreening should address factors in relation to the nursing

diagnosis of health-seeking behavior and knowledge deficitidentified in this review. This critical review recommendinterventions to raise women’s risk perception involvingspecial efforts to educate women regarding the risk of cer-vical cancer, the meaning of precursors, the causes andsymptoms of cervical cancer, so as to help them makeinformed decisions. In view of the fact that variables speci-fied in existing theoretical frameworks have been proved tobe insufficient to explain cancer screening behavior, futureresearch is needed to find out different facets of the womenawareness and perception of the risk of cervical cancer inrelation to preventive behavior within specific culturalcontext.

Acknowledgment. The authors would like to thank Profes-sor Sheila Twinn for her contribution to this research.

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