Funding: This research was funded by Young Faculty Development Project of Central South University, China (contract grant number: 2177721500084) and Chia Family Health Fellowship Award (contract grant number: 2012CF01).
Perception of Cervical Cancer Risk and Screening Behavior: A Literature Review
Article first published online: 27 MAR 2014
© 2014 NANDA International, Inc.
International Journal of Nursing Knowledge
Volume 26, Issue 1, pages 2–18, January 2015
How to Cite
Chan, C. W. H., Yang, S.-B., Gu, C., Wang, X. and Tao, L. (2015), Perception of Cervical Cancer Risk and Screening Behavior: A Literature Review. Int Jnl Nurs Knowledge, 26: 2–18. doi: 10.1111/2047-3095.12028
Conflict of interest statement: The authors have no conflicts of interest to disclose.
- Issue published online: 13 JAN 2015
- Article first published online: 27 MAR 2014
- Young Faculty Development Project of Central South University, China. Grant Number: 2177721500084
- Chia Family Health Fellowship Award. Grant Number: 2012CF01
- Cervical cancer;
- cervical screening;
- literature review;
- risk perception
This review examines women's risk perception of cervical cancer, the factors influencing this perception, and the relationship between risk perception of cervical cancer and screening behavior.
Integrative literature review method was used.
The search procedure resulted in the identification of 42 studies, including 1 literature review and 41 primary studies. Trends and discrepancies in the literature are presented with interpretations and recommendations.
Existing theories of health behavior appear inadequate for understanding screening behavior, and further studies are recommended to enrich the knowledge base of nursing diagnoses in knowledge deficit and health-seeking behavior.
Implications for Nursing Practice
Efforts would be made to improve nurses' understanding of risk perception of cervical cancer within specific cultural context.
Cervical cancer is the second most prevalent cancer among women, with an estimated 530,232 new cases and 275,008 deaths globally each year (Globocan, 2010). According to a World Health Organization (WHO, 2008) update in 2004, cervical cancer is the most prevalent cancer in Africa and Southeast Asia, although it occurs only in women. Moreover, other developing countries with insufficient medical services carry a heavier burden of cervical cancer because of the lack of accessible screening services (American Cancer Society, 2006).
The perception of risk, which is defined as an individual's assessment of the likelihood or probability of harm, is considered a crucial factor in promoting precautionary health behavior. It is also an essential component of different theoretical models of health behavior, such as Protection Motivation Theory (PMT; Armitage & Conner, 2001; Floyd, Prentice-Dunn, & Rogers, 2000; Montano, 2008). For instance, in the case of breast cancer screening, those who perceived a higher likelihood or probability of developing breast cancer were more likely to undertake cancer screening and be involved in cancer risk reduction activities (Katapodi, Lee, Facione, & Dodd, 2004). However, with cervical cancer, it is unclear whether an individual's awareness of her risk of the disease influences the likelihood of her participating in the screening. Nurses involved in the programs for cervical cancer screening need to have the understanding of women's risk perception to facilitate the identification of accurate nursing diagnosis, and subsequently develop appropriate intervention strategies. Therefore, the research team critically reviewed the published literature on the perception of cervical cancer risks and the relationship between risk perception and cervical screening attendance. The results would enrich the nursing knowledge base in health protection that is closely associated with the diagnoses of knowledge deficit and health-seeking behavior.
The aim was to elucidate the trends of women's perception of cervical cancer risk, the factors influencing risk perception, and the relationship between the perception of cervical cancer risk and the screening behavior, which could help nurses to develop appropriate health protection care plan for women.
An integrative review was undertaken to synthesize the study characteristics and findings. The integrative review is a specific method that could include all different study designs (i.e., quantitative and qualitative research methods) and has the potential to inform future research and practice (Whittemore & Knafl, 2005). This selective and critical review of the literature centered on issues related to women's risk perception of cervical cancer and cervical screening behavior. Risk perception of cervical cancer and its relationship with women's cervical screening participation was systematically reviewed and discussed. Critical reviews of individual studies were described in terms of study characteristics, subject characteristics, measurement strategies of risk perception employed in the studies, and outcome characteristics. After identifying trends and discrepancies from the literature and offering some preliminary interpretations, implications for future work and justification for the current study in terms of theoretical framework, study variables, study population, and study design were discussed.
The literature review combined search articles from PubMed, Ovid MEDLINE, CLINAL, EMBASE, PsycINFO, and the Cochrane database of systematic reviews. We included articles that met the following inclusion criteria: the studies had to be empirical studies that used a qualitative or quantitative research design, designated cervical cancer screening as the primary health-promoting behavior studied, written in English, and published between 1990 and 2012.
The relevant subject areas in the critical review included women's perception of cervical cancer risk, the factors influencing women's risk perception, and the relationship between the perception of cervical cancer risk and the screening behavior. The following keywords were used in the database search: “cervical cancer,” “uterine cervix cancer,” “uterine cervix neoplasms,” “cervical cancer and risk perception,” “cervical cancer screening,” “cervical screening and risk perception,” “perceived risk,” “risk perception,” “perceived vulnerability,” “perceived susceptibility,” “perceived likelihood,” and “subjective risk perception.” A supplementary search of the reference lists of articles in the Ovid MEDLINE, PubMed, and PsycINFO databases was conducted using the keywords “risk perception,” “perceived risk,” and “cervical screening.” The findings from each database were reviewed and compared, with double findings deleted.
The initial database search identified 96 articles. We reviewed the abstracts and back-checked the reference lists of 96 articles identified from the initial database search to examine other studies that may have initially been missed. If we could not decide whether to include or exclude this study through reviewing abstract, the full text of those studies will be further reviewed for final decision. We excluded research that involved risk perception of health providers (7 studies), epidemiological studies about risk factors of cervical cancer (8 studies), meeting and dissertations abstracts (3 studies), studies about factors influencing cervical screening attendance that failed to involved risk perception into their studies (15 studies), studies about factors influencing human papilloma virus (HPV) vaccination (5 studies), studies involved women diagnosed with cervical cancer (6 studies), studies about factors influencing general screening behavior (3 studies), duplication studies (4 studies), as well articles published in a language other than English (3 studies). This search procedure resulted in the identification of 42 studies, comprising one literature review (Vernon, 1999) and 41 primary studies. The literature review (Vernon, 1999) was included because it examines the research findings on risk perception related to cancer screening behavior, including cervical screening. Two reviewers critically reviewed all 42 articles independently and discussed the similarities and differences in their comments until a consensus was reached.
The corresponding author initially abstracted data, and the first author and corresponding author critically assessed the characteristics and main findings of the relevant studies.
The selected studies were evaluated by the primary investigator and cross-checked by a co-investigator using a checklist adapted from Mols et al. (2005). The checklist was modified to fit the aim of the present review. This checklist consisted of 14 items, comprising 14 predefined criteria. This checklist consisted of five domains: study population (three items), study design (three items), follow-up (three items), measurements (three items), and analysis strategies (two item). A selected study received 1 for meeting one criterion and 0 for not meeting the criterion or describing insufficiently. Thus, possible scores for each study ranged from 0 (low quality) to 14 (high quality). Studies scoring 10 or higher were considered to be of “high quality.”
Methodological Quality and Characteristics of Selected Studies
The scores of methodological quality are summarized in Table 1. The mean quality score of 41 studies is 11.3, with a range of 10–13. Methodological weakness mainly concerned the lack of valid and consistent measurement of risk perception of cervical cancer and the response rate. The selected studies, all of which were published between 1995 and 2011, and their characteristics are outlined in Table 1. The focus of the review was to examine how the construct that is interchangeably called “perceived risk,” “risk perception,” “perceived vulnerability,” or “perceived susceptibility” relates to cervical cancer screening behavior. Apart from one literature review (Vernon, 1999), the research designs of the 41 studies were varied and included cross-sectional surveys (26 studies), face-to-face interviews (5 studies), prospective research (2 studies), case-controlled studies (3 studies), a longitudinal study (1 study), experimental studies (3 studies), and secondary data analyses (1 study).
|Author and year||Study design and population||Sample size||Outcome measure||Result||Comments||Study quality|
1. Abotchie and Shokar (2009)
Cross-sectional research design
College students aged 18 years and above
|(n = 157)|| |
Knowledge of cervical cancer risk factors
Cervical cancer health beliefs
About half perceived themselves to be at risk (52.5%).
The prevalent barriers were lack of perceived benefits (it is important for a woman to have a Pap test so she will know if she is healthy: 87.6%), concerns about what others may think (my partner would not want me to have a Pap test: 40.6%), and lack of information (having cervical cancer would make a woman's life very difficult: 73.6%).
Perceived risk was not associated with screening uptake.
|This study highlighted that a literate population of college women lacked information about cervical cancer and its risk factors and the most significant influence of perceived barriers on screening behavior. Cross-sectional design cannot make causal inferences of association between risk perception and screening behavior.||11|
2. Ackerson et al. (2008)
Low-income African American women (21–37 years)
|(n = 7)|| |
Women perceived either high or low risk of cervical cancer.
Three women believed that risk of cervical cancer was due to having a family history. Women who perceived low risk did not obtain a screening. Social influence from family and physicians and previous healthcare experiences influenced screening attendance.
This qualitative study highlighted the background variables of social support and previous healthcare experience in explaining women's screening behavior.
Most of participants were from the STD clinic where they were seeking healthcare services for STD, not cervical screening. These women may have felt confusing between STD test and Pap test. Small sample size (n = 7) was used and no information on data saturation was reported.
3. Ben-Natan and Adir (2009)
Correlational quantitative study
Israeli lesbian women aged 18–41 years
|(n = 108)|| |
Health Belief Model (HBM) variables
Cervical screening behavior
Perceived benefits (p = .00) and barriers (p < .05) were associated with actual screening uptake.
Perceived risk (p < .05), perceived benefits (p = .00), and general health motivation (p < .05) were associated with intention to be screened.
|This study highlighted providing knowledge about cervical screening, raising physician's awareness of offering the test to lesbian and women-based medical team in promoting screening among this sample. Self-reported data have affected actual rates of cervical screening. Research population was not representative because of the use of convenience sample and involving only lesbian women.||10|
4. Boonpongmanee and Jittanoon (2007)
Cross-sectional research design
Working women in Bangkok (25–55 years)
|(n = 189)|| |
Perceived benefits and barriers for cervical screening
Perceived barriers were significant predictors of cervical screening (OR: .88; p < .001)
Perceived risk was not associated with screening uptake.
|This study identified the specific barriers that working women in Thailand to engaging in screening were embarrassment, fear, time constraints, knowledge deficit, and cost, highlighting cultural issues in screening utilization. The finding may not be generalized to unemployed women.||11|
5. Byrd et al. (2004)
Cross-sectional research design
Hispanic women (18–25 years old)
|(n = 189)|| |
|Majority of women were aware of their susceptibility of cervical cancer (there are effective treatments for cervical cancer: 93.7%), the seriousness of cervical cancer (having cervical cancer would make a woman's life difficult: 72%), and the benefits of screening (it is important for a woman to have a Pap test to know if she is healthy). But no association between perceived risk and screening uptake. Perceptions about Pap tests posed barriers to undergo screening (it is too embarrassing to have a Pap test: 39.4; the Pap test is painful: 32.4%).|| |
This study highlighted that although women understood the risk and seriousness of cervical cancer, their perceived barriers associated with screening may have influenced screening participation.
Participants were selected from a group of young women. Self-reported prior experience of Pap tests was not validated.
6. Denny-Smith et al. (2006)
Cross-sectional research design
Convenience sample (19–58 years)
|(n = 240)||Health Belief Model variables, HPV/cervical cancer knowledge, sexual behavior, cervical screening behavior||Participants demonstrated a low knowledge level (10.2 range of 1–15; SD: 2.4), low perceived risk (20.6 range of 9–37; SD: 6.2), and low perceived seriousness of cervical cancer (17.7 range of 9–27; SD: 2.8). No relationship between previous screening behavior and perceived susceptibility and perceived seriousness. Positive relationship between perceived risk and number of partners (r: .23, p = .001).||This study highlighted that a lack of knowledge combined with low perception of susceptibility and seriousness to HPV and cervical cancer made college women more likely to contract STDs, including HPV, and increase the risk of cervical cancer. The majority of samples were married and findings may be different compared with single students.||11|
7. Eaker et al. (2001)
Population-based sample (non-attendees and attendees)
430 non-screened and 514 screened
|(n = 944)|| |
Attendance was positively associated with perceived severity of cervical cancer (OR: 1.9 95% CI: 1.1–3.4) and satisfactory benefits (OR: .7 95% CI: .6–.8) but negative associated with practical barriers (time-consuming: OR: 1.2 95% CI: 1.1–1.5; economic barriers: OR: 1.7 95% CI: 1.2–2.5)
Perceived risk was not a predictor of screening uptake.
|The strength of the study was the population-based design and accessed a database covering all cytological screening in the area. Important differences in attitudes and beliefs existed between non-attendees and attendees. However, the study was limited by the low response rate (71%) particularly among non-attendees (69%).||12|
8. Eiser and Cole (2002)
Cross-sectional research design
College women aged 20–25 years
|(n = 70)|| |
Knowledge about cervical cancer and screening
Optimistic bias was found (p < .001).
No relationship between perceived risk and screening intentions and actual uptake.
No relationship between perceived risk and knowledge about cervical cancer and screening. Cognitive closure was a significant factor influencing screening behavior (p < .01).
|Although participants were a selective younger women sample, this study highlighted that women's rating of relative risk seemed neither to guide behavior, nor to be based on relevant knowledge about cervical cancer and suggested psychological factors in determining women's motivation to do a screening.||10|
9. Fernandez et al. (2009)
Experimental study using an educational intervention
Women 50 years and older who were no adherent to cervical screening
|(n = 243)|| |
Perceived pros and cons
Screening completion was higher among intervention group.
The intervention increased cervical screening self-efficacy, perceived benefits, and subjective norms, but it did not change screening knowledge and perceived risk.
|This study added to the evidence concerning the effectiveness of lay health worker intervention for increasing cervical screening, but the intervention was proved not to influence perceived susceptibility of cervical cancer, and the study did not report the relationship between perceived susceptibility and screening behavior.||10|
10. Fort et al. (2011)
|In-depth interviews of women in rural Malawi||(n = 20)||Barriers to cervical cancer screening||Major barriers to seeking preventative screening included low knowledge levels, low perceived susceptibility, and low perceived benefits from the service.||This study recommended that healthcare providers and health educators targeted aspects of perceived susceptibility among this population, including knowledge levels and personal risk assessment.||11|
11. French et al. (2004)
Prospective research design
226 women with normal test result
180 non-consecutive inadequate test results
|(n = 406)|| |
Cervical screening result
|Women with inadequate smear test result perceived higher risk of cervical cancer than women with normal test result (p = .016). Receiving an inadequate smear test result raised state anxiety (p = .025,) and concern (p < .001) and anxious women were less likely to attend for a repeat smear test (p = .011).|| |
This study highlighted that informing women who had an inadequate smear test result was associated with raised level of perceived risk and anxiety about the test.
The study was observational in design; it was not possible to infer the causal associations between variables.
12. Garcés-Palacio and Scarinci (2012)
Women were 30 ± 6.8 years old and were mainly from Mexico (89.2%)
|(n = 743)||Perceived susceptibility to cervical cancer and factors associated with perceived susceptibility|| ||The study showed that perceived susceptibility to cervical cancer seemed to be influenced mostly by the current or past perception of HPV/STI exposure, and by having a relative with cancer. Yet the questionnaire was self-reported and may have biases.||12|
13. Goldman and Risica (2004)
|Qualitative research design using face-to face interview Dominicans and Puerto Ricans in Rhode Island (18 years and older)||(n = 147)||Perception about cervical cancer and screening|| |
Cervical cancer risks were mostly attributed to carelessness about health care and sexual behavior by interviewees.
A strong sense of fatalism and feelings of embarrassment coexist with firm beliefs about the importance of screening, and increasing normalization of at least the idea of Pap test.
|The findings from this qualitative study underscored the complexity of the issues concerning cancer perceptions and behaviors, and provide meaning and context that help explain some of the conflicting perceptions. No information about women's perceived personal risk of cervical cancer was discussed in this study.||12|
14. Gu et al. (2012)
Cross-sectional research design
Convenience sample of Chinese women (25–50 years old)
|(n = 167)||Protection Motivation Theory variables, knowledge about cervical cancer and screening, screening behavior||All women considered themselves at low risk of cervical cancer. No significant association was observed between perceived risk and previous screening behavior. A perception that visiting doctors regularly is important to health, average and high levels of knowledge about cervical screening were significantly associated with having been received screening.||This study highlighted the significance of knowledge and culturally relevant health behavior and beliefs about cervical screening for Chinese women in determining screening behavior. The use of convenience sample limited generalizing these results to the whole Chinese population. Reported experiences were retrospective, which leaded to recall bias.||11|
15. Gu et al. (2013)
Cross-sectional research design
Convenience sample of Chinese women (25–50 years old)
|(n = 167)||Protection Motivation Theory variables, knowledge about cervical cancer and screening, Sexual history, Motivation to receive future screening||The majority of women stated they intended to receive future screening, and response efficacy was significantly associated with their intention. Cancer in relatives, a perception that visiting a doctor regularly is important to health, and ever attending for cervical screening during the previous three years were significantly associated with women' motivation to receive future screening.||This study highlighted the important role of women's beliefs in the value of cervical screening and previous screening experience in motivating them to receive a screening. Women were recruited from four workplaces and did not have to pay for their screening, resulting in a biased sample. Small sample size was another concern. The subsequent actual uptake of screening was not assessed in this study.||11|
16. Ho et al. (2005)
Cross-sectional research design
Convenience sample of women 20–88 years old
|(n = 209)|| |
Perceived risk was not a predictor of screening uptake.
Perceived severity was a significant predictor of screening uptake.
The study found many significant predictors of Pap test and informed the future study to address these factors in the next adherence study.
The data were collected by postal survey, which was not validated; 86-item questionnaire may have caused feeling of tiredness and boring for it was not validated.
17. Holloway et al. (2003)
Cluster-randomized controlled intervention research; the intervention comprised a brief specific counseling session.
Women were recruited when attending for cervical screening
|(n = 1,890)|| |
Short-term outcome was stated preference for future screening interval.
Long-term outcome was actual screening behavior at 4-year follow up.
|Intervention group was less likely to express a preference of a shorter than recommended interval (OR: .51 95% CI: .41–.64; p < .0001) and less likely to attend for screening sooner than their recommended recall (5% having shorter than recommended intervals). The impact of perceived risk on actual screening behavior was equivocal.||The strength of this study was the large sample size and longitudinal experimental study. This study suggested that risk perception of women regarding cervical screening were amenable to individualized risk communication intervention. This intervention was proved to benefit screening program and may relieve anxiety. Differences in numbers between the intervention and control group (630 vs. 829) because of different attrition rate may affect the comparability between two groups.||13|
18. Hoque et al. (2009)
Cross-sectional research design
Women who were above 18 years old
|(n = 300)|| |
Sixty percent of non-screened women had low perceived severity while 33% of screened had high perceived severity.
No relationship between perceived severity and screening uptake (Χ2 = 1.0795; p = .2988).
|Participants were a selected women population who attended a district hospital. Participants may have felt sensitive to report negative results such as perceived barriers, introducing self-bias.||10|
19. Hou et al. (2003)
Cross-sectional research design
A convenience sample of women with mean age was 38 years in Taiwan
|(n = 125)|| |
Prior screening experiences
Perceived pros and cons of a test
Knowledge of cervical cancer and screening
Screening adherence was associated with knowledge, perceived pros, cons, and norms of cervical screening.
Final logistic regression model did not support perceived risk as a successful predictor.
This study identified important psychological factors associated with screening uptake among Chinese women in Taiwan, which could be tailored for future intervention efforts.
Because all women voluntarily agreed to participate in the study, volunteer bias may have existed. Because women were recruited from a hospital setting, these women may be more open to health-related information.
20. Kahn et al. (2001)
Cross-sectional research design
|(n = 490)|| |
Compliance Model variables
|Perceived risk was not associated with intention to return for cervical screening. Personal beliefs of cervical screening (OR: 1.07 95% CI: 1.02–1.11), perceptions of other's beliefs (OR: 1.93 95% CI: 1.38–2.74), and cues to action (OR: 1.31 95% CI: 1.08–1.60) were associated with intention to return.||This study identified many significant factors that were associated with intention to return for screening. However, participants were a selective younger women population and predicted intention to return for screening may not explain actual return. The scales that measured knowledge, perceived risk, and severity were skewed and did not adjust the normality. These results were dichotomized for analysis, which limited the ability to detect significance.||10|
21. Kavanagh and Broom (1998)
Qualitative research design using face to face interview.
Women who had an abnormal Pap smear (19–70 years old).
|(n = 29)||Women's understanding of the nature of their cervical abnormality, and how they made sense of abnormality in the context of their everyday lives.|| |
The multiplicity of meanings of “risk” complicated the efforts of public health.
Many women had not considered themselves to be at risk of cervical cancer before their abnormal Pap smear.
This study highlighted that the noun “risk” has multidimensional meaning for individuals and suggested the needs of people to integrate health threats into their daily personal lives.
However, the study associated women's understanding of the risk with health risk , but it did not associate their understanding of the risk with cervical screening attendance. behavior.
22. Kim et al. (2008)
Cross-sectional research design
Women from four ethnic groups of white, African American, Latina, and Chinese (50–80 years)
|(n = 1,160)|| |
Self-reported screening behavior
Compared with white women, Latinas perceived a high risk of cervical cancer
Chinese had a low perceived risk.
No relationship between risk perception for cervical cancer and screening uptake was identified.
This study compared risk perception of cervical cancer and screening behavior among diverse women including Chinese Americans and found significant difference in risk perception between Chinese and other ethnic groups.
All women were established patients in clinics with primary care clinicians and had visited a clinic in the past 2 years, resulting in selective bias.
23. Kuitto et al. (2010)
Cross-sectional research design
Randomly selected women aged 14–65 years
|(n = 760)||Determinant of uptake of preventive measures against cervical cancer|| ||Uptake rates for existing primary and secondary prevention measures against cervical cancer could be enhanced by fostering perceptions of utility and positive connotations of regular screening. However, the number of respondents in age group of 14–26 was low, and detailed multivariate analyses in this age groups were failed to conduct. Also, further analysis on the relationship between knowledge, attitudes toward prevention behavior and utility expectations was needed.||11|
24. Lee et al. (2002)
Cross-sectional research design
Population-based sample of Asian women (30–59 years)
|(n = 726)|| |
Knowledge, attitude, and practices of cervical screening.
Reasons for not adherent to regular screening
|The primary reason for regular screening attendance was likely to be screening or as a part of health checkups (67%). Chief barriers to regular screening were low perceived risk (46.5%) and low accessibility (37.1%).||This study highlighted the important factors influencing women's adherence to regular screening including health service-related factors and perceived risk of cervical cancer. Women who could not be contacted on three attempts constituted a sizeable proportion of the non-respondents, but the study did not measure the difference between them.||11|
25. Marlow et al. (2009)
An experimental repeated measures design
British women aged 16–75 years
|(n = 965)|| |
Cervical screening behavior
|Overall, HPV information did not have an effect on perceived risk. But HPV information affected women's cervical cancer risk perceptions in the younger women (p < 0.001). There was also a significant time by screening attendance interaction, with an increase in perceived risk among women who did not regularly attend screening (p = .022).||This study contributed to the knowledge about the effect of HPV information on perceived risk of cervical cancer across different population group. However, the relationship between risk perception and screening behavior was not assessed. Response rate was modest, and no control group was used. Women rated their perceived risk immediately after reading information about HPV, and it was possible that the PR would be different in the longer term.||10|
26. Marteau et al. (2002)
|Cross-sectional research design smokers and nonsmokers (20–64 years old)||(n = 722)|| |
Perceived risk was a predictor of intention to attend for screening (OR: 1.5 95% CI: 1.0–2.1).
Smokers were unaware of their increased risks of cervical cancer (p < .0001).
This study indicated that smokers seemed unaware of their increased risk of cervical cancer; evaluations on interventional study were needed.
Because the measure of smoking was indirect, it was uncertain of how biases in responding might have affected the results.
The study sample was less educated than the general population.
27. Matejic et al. (2011)
Sixty-two-item self-administered questionnaire with case-control design
Women aged 18–70 years, who demonstrated an initiative for a PAP smear
|n = 267 for study group and n = 267 for control group||Factors deter or stimulate the women to participate in screening activities||Adherence to cervical cancer screening practices is significantly related to better financial status (OR: 10.8 p = .001), no gender preference for a gynecologist (OR: 3.1 p = .015), consultations with a gynecologist (OR: 4.7 p = .029), conversation with the women with cervical cancer about that disease (OR: 2.8 p = .029), higher media exposure to information about cervical cancer prevention (OR: 5.0 p = .004), and higher personal risk perception (OR: 3.6, p = .001).||The study urged that open communication, social networks, and improving social-economic status of women were the most prominent factors affecting the participation in screening activities. Yet the control group included women who did not present for screening regularly rather than those who had never been screened.||12|
28. McMullin et al. (2005)
Semi-structured face-to-face interview
Purposive sample of Mexican Americans (mean age was 39 years)
|(n = 20)||Beliefs about the role of sexual activities in cervical cancer etiology and the impact of the beliefs on screening uptake||The majority of women had limited knowledge about cervical cancer and no knowledge about HPV; believed that infections caused by physical trauma, certain sexual activities, and poor hygiene caused cervical cancer. Women expressed that if they did not engage in unwise behaviors, they would be not at risk of cervical cancer and be less likely to get a screening.|| |
This study suggested that culturally related beliefs about the etiology of cervical cancer played a role in the decision to obtain a screening for Latina immigrants.
The study focused specifically on beliefs about sexual behaviors and screening uptake. Other risk factors were not discussed in the study. It could not comment on the relative importance of sexual behaviors compared with other risk factors for cervical cancer in the minds of the respondents or the magnitude of the impact on screening uptake.
29. Merrill and Madanat (2002)
Cross-sectional research design
Women aged 18 years and older
|(n = 3,221)|| |
|The relation between religious preference, church activity, and screening uptake was dependent on marital status (for unmarried women of having a Pap smear in the last two years, compared with religiously active LDS, OR: 2.39 95% CI: 1.30–4.09; for less religiously active LDS, OR: 2.30 95% CI: 1.10–4.82; for religiously active non-LDS, OR:1.65 95% CI: 0.91–2.99) for less religiously active non-LDS, and OR: 5.35 95% CI: 2.50–11.43 for women with no religious preference). A low risk perception may result in the low use of cervical screening.|| |
This study incorporated religious preference, church activity, and risk perception into understanding women's screening behavior, which provided new insight into the issue studied.
The study was limited because of the use of cross-sectional telephone survey. Thirty-three percent of women chose not to participate; self-selected bias may have influenced the results.
30. Orbell and Sheeran (1998)
A longitudinal study
A random sample of unscreened women aged 20–64 years
|(n = 166)||Protection Motivation Theory variables, screening behavior|| |
Perceived risk was a predictor of motivation to take a screening.
Motivation, high perceived risk, less worry, and high response efficacy were significant predictors of actual screening uptake at 1-year follow-up.
|This study highlighted that PMT model provided a useful framework for predicting both willingness to undergo cervical screening and actual uptake of the test. The measure employed in this study was validated by the work of Orbell (1996). The actual uptake of screening was measured objectively from medical record.||11|
31. Orbell (1996)
Cross-sectional research design
Women aged 20–60 years
|(n = 276)|| |
Previous test experiences
Threat appraisal (perceived risk, perceived severity, AND fear)
Most women were willing to undergo future tests (82%).
Future screening expectations were explained not by perceived risk, but by a sense of obligation to attend (p < .01) and aversiveness of cervical screening procedure (p < .05).
|This study suggested the importance of a sense of moral obligation and perception of cervical screening practice in motivating women to take a screening. However, the variance explained in behavioral expectations was modest (22%); it was suggested for future exploration of perception of risk and cervical screening from women's perspectives.||12|
32. Orbell et al. (1995)
Case-control design (307 screened and 307 non-screened)
|(n = 614)||Screening behavior, behavioral risk, attitudes, and beliefs concerning cervical screening, practical difficulties, and social class||Non-screened women and women with low class were less likely to believe that they were at risk of cervical cancer.|| |
The study highlighted sociocultural factors such as social class in motivating women to take a screening following a regional call program.
The low response rate (77.5%) may result in response bias.
33. Phongsavan et al. (2010)
Lao women aged 18–55 years
|(n = 800)||Women's perception of cervical cancer|| ||This study indicated that rural women in Laos have limited knowledge about cervical cancer and even less about screening and prevention. However, no causal factors were examined for the poor knowledge in Laos.||12|
34. Saules et al. (2007)
Cross-sectional research design
College female student (18–24 years old)
|(n = 135)|| |
Current smoker perceived a high risk of cervical cancer.
Abnormal screening history was a predictor of risk perception.
Relationship between risk perception and screening participation was not reported.
|This study examined women's smoking behavior and perceived risk of cervical cancer, and intention to quit smoking. However, it did not examine women's cervical screening behavior in relation to these factors. Smoking behavior was collected by self-report, introducing self-bias.||10|
35. Scarinci et al. (2003)
Cross-sectional research design
low-income Latina immigrants (18–42 years old)
|(n = 225)||Ethnic differences regarding cervical cancer knowledge and socio-cultural factors associated with cervical screening||All non-Latina women had cervical screening in the past compared with 81% of Latina women. Latina women displayed significantly less knowledge regarding cervical cancer than non-Latina (p < .001). Women perceived they were not at risk for cervical cancer since they do not have “perceived risk factors.”|| |
This study highlighted that Latina immigrants tended to display culturally based knowledge and beliefs regarding cervical cancer and screening that influenced screening attendance.
Given that only 20 women did not have a screening, this study did not have enough power to examine further comparison among women who ever had a screening and the ones who had not.
36. Seow et al. (1995)
Cross-sectional research design
21–65-year-old women (Chinese women accounting for 80%)
|(n = 568)|| |
Overall, perceived risk is very high (58.9% perceived a high risk).
Among women who had never been screened, perceived risk was an important predictor of their willingness to be screened (only 58.9% felt themselves at equal risk of getting cancer as others).
|The study involved Chinese women in Singapore, accounting for about 80% of the total sample and highlighted culture-specific health beliefs and attitude in increasing the acceptance of the Pap smear. However, the predictive value of HBM was limited because it was inherently a psychosocial model and neglected contextual factors and normative beliefs.||12|
37. Tacken et al. (2007)
Cross-sectional research design
A two-stage cluster sample of women who were eligible for the Dutch population-based screening program (30–60 years old)
|(n = 1,392)|| |
Women's level variables: perceived risk, personal moral obligation, normative beliefs.
Practice level variables
|Beliefs about cervical screening and attendance including personal moral obligation and normative beliefs of others impacted on the uptake rate (p < .01). Organizational factors also influenced on screening uptake, but perceived risk was not associated with screening uptake.||Because the response rate was selective, a nonresponse study was performed. It indicated that women who dropped out of the prevention program perceived low risk of cervical cancer and were more convinced that the cancer was fatal. This study highlighted that cervical screening rates were likely to be influenced by beliefs about cervical screening and organizational factors.||13|
38. Taylor et al. (2004)
|Cross-sectional research design Vietnamese American women (18–64 years)||(n = 352)|| |
Health Belief Framework variables
|No association between perceived risk and adherence to cervical screening. Being married, knowing Pap test was necessary for asymptomatic women, doctor had recommended testing, and had asked doctor for testing were factors associated with screening participation (p < .05).|| |
This study confirmed low levels of cervical screening among Vietnamese women and demonstrated the importance of physician–patient communication in increasing screening participation.
The difference between study sample and unreached and refused participation were not reported.
39. Walsh (2006)
Prospective quantitative design
Women aged 25–60 in Irish
|(n = 1,114)||Attendance for cervical screening, knowledge and access to information about cervical cancer, experience of cervical screening, perceived risk, barriers to attendance|| |
Women have poor levels of knowledge about cervical cancer and screening (48% stated that the purpose of a cervical smear is to prevent cervical cancer).
Factors influencing women's decision to attend for a screening included that increased perception of risk (p < .05), level of understanding about cervical screening (p = .001), and perceived barriers (the perception of having a cervical smear test as time consuming p < .01; causing greater distress p < .01 and being more afraid of the test p < .05).
|The strengths of this study were large sample size, and the computerized records from the cytology lab were used as an objective measure of screening attendance. This study identified many significant factors influencing screening uptake, suggesting an urgent need for health provider to address these factors in future.||12|
40. Were et al. (2011)
Cross-sectional questionnaire survey
|(n = 219)||Perceptions of risk and barriers to cervical cancer screening|| ||The study highlighted a highly significant relationship between a perception of own risk of developing cervical cancer and an expressed need for cervical cancer screening. However, the study population was also selected for the women who were already accessing the clinic services in Moi Teaching and Referral Hospital.||11|
41. Zhang et al. (2007)
Secondary data analysis using a subset sample of a cross-sectional study
Elderly women (≧65 years)
|(n = 1,044)||Intent to have a screening, previous gynecologic history, benefit/attitudes related to cervical screening||Among women who had not undergone a hysterectomy perceived risk (OR: 4.27 95% CI: 1.27–14.33), previous Pap smear test (OR: 19.28 95% CI: 10.15–37.10), perceived pain of the test (OR, 0.52; 95% CI, .28–.99), and perceived importance (OR: 4.00 95% CI: 1.32–12.10) were positive correlates of intention to have a screening.||This study contributed to our knowledge of cervical screening because of its differentiation between elderly women who had and had not undergone a hysterectomy. The study only assessed intention to have a Pap test rather than actual uptake, but intention was not always translated into actual action.||12|
Selected Theoretical Models
Theoretical frameworks were described in 39.4% (n = 13) of the studies; the frameworks included the Health Belief Model (HBM) (eight studies), Health Belief Framework (one study), PMT (three studies), PEN-3 (a conceptual framework for health education programs), and Interaction Model of Client Health Belief (one study). One study used a compliance model that incorporated four existing theoretical frameworks, including the Theory of Planned Behavior, the HBM, Social Cognitive Theory, and the Transtheoretical Model and Stages of Changes. Another study used a model of preventive behavior that incorporated two existing theoretical models, the HBM and the Andersen Behavioral Model.
The sample size and sampling techniques of the studies varied. Convenience sampling was used most frequently (59%, 24 studies), followed by random sampling (27%, 11 studies) and purposive sampling (14%, 6 studies); the sample sizes of five qualitative studies ranged from 7 to 147. The sample size of the remaining 36 studies ranged from 70 to 3,221. Although the age of the study participants ranged from 18 to 75 years, four studies were conducted in a selectively younger female population aged between 12 and 25 years (Byrd, Peterson, Chavez, & Heckert, 2004; Eiser & Cole, 2002; Kahn, Goodman, Slap, Huang, & Emans, 2001; Saules et al., 2007). Most of the studies examined Caucasian or Western populations, and only seven studies involved 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 mainland China (Gu, Chan, Twinn, & Choi, 2012; Gu et al., 2013). Fourteen studies were conducted in America, 7 studies were conducted in England, and 20 studies were conducted in other regions of the world.
Strategies for the Measurement of Risk Perception
A wide range of methods was used to assess risk perceptions of cancer, resulting in apparently contradictory findings. Five qualitative studies used face-to-face interview to obtain in-depth information about women's understanding about cervical cancer risk. The most common measures of perceived risk employed by remaining 36 studies were as follows: a comparative measure employing a six-point rating scale ranging from “less likely” to “more likely” that asked participants either “Are you more likely or less likely to suffer from cervical cancer in the future than other women of the same age?” or to rate their perceived risk of developing cervical cancer on a five-point rating scale ranging from “much higher than average” to “much lower than average” (Eiser & Cole, 2002; French, Maissi, & Marteau, 2004; Marlow, Waller, & Wardle, 2009; Marteau, Hankins, & Collins, 2002); an absolute measure using a five-point rating scale ranging from “strongly agree” to “strongly disagree” that asked participants to respond to the statement “I'm at risk of developing cervical cancer” (Abotchie & Shokar, 2009; Denny-Smith, Bairan, & Page, 2006; Walsh, 2006); a quantitative rating of personal risk and 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 of cervical cancer with one or two questions regarding likelihood, such as comparative and verbal measures. Although the response choices for these questions always used quantified multi-point scales anchored by numbers, verbal phrases, or comparisons with other people, this traditional measurement of risk assumes that the variable is constant. However, evidence indicates that the anchors for subjective and comparative measures, such as verbal expression and quantitative rating, and even the standard “language of risk,” can have different meanings to different individuals and even to the same individual in varying contexts (Wallsten, Budescu, Rapoport, Zwick, & Forsyth, 1986; Walter & Britten, 2002).
Because risk perception is thought to be an important motivator of cervical screening behavior, it is imperative to identify both the determinants of risk perception and the pattern of the relationship between perceived risk and cervical screening behavior. The outcome variables of the selected studies focused on women's risk perception, the factors affecting their risk perception, and the correlation between risk perception and screening participation. There are limited studies that have directly addressed the linkage between the outcome measurements and the nursing process, in particular, the nursing diagnoses of knowledge deficit and health-seeking behavior were seldom mentioned in these studies.
Women's perception of cervical cancer risk
Women's perception of cervical cancer risk varied between the studies; several studies demonstrated that women rated their relative risk of susceptibility to cervical cancer as below 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 many women did not believe they were at risk of cervical cancer before an abnormal Pap smear, while for others, a cervical abnormality signified their vulnerability and made them consider the risk of developing cervical cancer. Smokers seemed to have no knowledge of their increased risk of cervical cancer and disregarded their higher need of regular screening (Marteau et al., 2002). Taylor et al. (2004) found that 77% of Vietnamese women believed that they were less likely to contract cervical cancer than Caucasian women. Another study involving Chinese women in Singapore (Seow et al., 1995) also reported that only 58.9% of women believed that they were equally susceptible to contracting cervical cancer, while a substantial proportion (48.7%) of women believed that cancer could not be prevented.
However, there were some contradictory findings. A high proportion (73%) of women were concerned about cervical cancer, and a very significant proportion (68%) of young women perceived a moderate to high risk of developing cervical cancer (Moreira et al., 2006). Byrd et al. (2004) discovered that up to 90% of Latina women aged 18–25 years believed that they were at risk of developing cervical cancer. Kim et al. (2008) detected a significant difference in the perception of cancer risk in a diverse sample of women from English, Spanish, and Chinese ethnic groups. These differences in the perception of cervical cancer risk persisted after controlling for demographics, numeracy, and personal and family history. Compared with Caucasian women, Asian women perceived a lower risk of cervical cancer, in contrast to Latina women, who perceived their risk to be higher.
Most of the studies involved risk perception as a possible factor influencing cervical screening behavior, but they did not explore the factors that influenced women's risk perception. Limited evidence showed that smoking behavior, number of sexual partners, inconclusive screening results, screening experience, social class, perceived severity, perceptions of HPV/sexually transmitted disease (STD) exposure, and family history of cancer were factors that influenced 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; Saules et al., 2007). Marlow et al. (2009) found that providing HPV information enabled women to accurately estimate their predisposition to cervical cancer. Increased awareness of cervical cancer risk was observed in younger women once they became cognizant of the sexually transmitted nature of HPV and the significance of cervical screening. However, Eiser and Cole (2002) and Fernandez et al. (2009) suggested that perceived risk rating is not based on relative understanding of cervical cancer and its causes. Fernandez et al. also assessed the effectiveness of intervention in increasing cervical cancer screening among low-income Latina women and found that educational intervention significantly increased the self-efficacy of cervical screening, the perceived benefits of screening, subjective beliefs, and the perception of cancer survivability; however, it did not alter the perception of cervical cancer risk. Because of the limited amount of evidence, it is difficult to reach conclusions about trends in the perception of cervical cancer risk and the factors that influence it.
Women's risk perception and cervical screening behavior
The relationship between women's perception of cervical cancer risk and their screening behavior is also inconclusive among the studies. Some studies supported the hypothesis that the perceived risk of the disease plays a substantial role in the prediction of women's screening behavior (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), which include three qualitative studies. Women's beliefs in their probability of developing cervical cancer were identified as a fundamental promoter of screening behavior. Women who believed that they were at a low risk were less likely to have been screened previously and were less likely to undergo screening in the future. McMullin et al. (2005) conducted a qualitative study with a purposive sample of 20 Mexican women and found that physical trauma resulting from an abortion or unprotected sex, an infection from a partner, and poor hygiene were factors that Hispanic women believed increased an individual's risk of cervical cancer. If Latina and African American women did not believe that they were at a risk of cervical cancer, then they were 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 constructs of PMT, such as perceived risk, fear arousal, and response efficacy, were significant independent variables associated with women's actual screening behavior and that the perception of cervical cancer risk was also a successful predictor of women's motivation to be screened in the future.
However, several studies detected no relationship between the perception of cervical cancer risk and screening 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; Ho et al., 2005; Hoque, Ibekwe, & Ntuli-Ngcobo, 2009; Hou et 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 or future intention to participate in screening. For example, Orbell's (1996) study claimed that future intention to be screened was best explained by a sense of responsibility to attend the screening and not by the anxiety associated with cervical cancer risks. Similarly, other studies failed to identify an association between the perception of cervical cancer 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 evaluate whether the subjects over- or underestimated their risk because they do not include valid assessments of the actual risk of cervical cancer (Vernon, 1999). Currently, there is much controversy regarding options for risk perception measurements for clinical applications and research. There are no gold standards for very low- or high-risk perception, particularly within the context of cervical cancer risk. The conclusion drawn by Vernon (1999) is that there are not enough data to ascertain and quantify the relationship between perceived cervical cancer risk and screening behavior.
The review of the selected studies reveals major gaps in the relevant knowledge and methodological approaches.
Although the variables specified in PMT and the Heath Belief Model have received considerable empirical support in 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 and criticisms are presented in several of the theoretical and empirical studies. It has been observed that the predictive value of the HBM is limited because it is essentially a psychosocial model and disregards environmental factors (including the accessibility of services) and normative beliefs (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 not predict actual behavior or long-term adherence (Ho et al., 2005). Researchers have also criticized the model for its overemphasis on the rationality of behavior without considering emotional variables that could affect screening decisions (Orbell, 1996). Three studies employed PMT to study cervical screening behavior; for example, Orbell and Sheeran (1998) conducted a longitudinal study to apply PMT to a group of non-screened women to understand the relationship between the motivation to be screened and the subsequent behavior. The study supported the suggestion that PMT variables were successful predictors of both motivation to participate in screening and subsequent uptake. However, two other studies (Gu et al., 2012, 2013) contradicted the above findings and did not find PMT variables to be effective predictors of either the motivation to be screened in the future or the previous screening behavior.
Orbell and Sheeran (1998) found that the relationship between motivation to undergo screening and actual action was far from perfect. This finding indicates that PMT variables may not be sufficient to explain the action of women whose positive intention to be screened did not translate into screening uptake. Other studies argued that elements or factors other than those described in PMT and the HBM should be addressed to obtain better insight into health-related motivation. Several empirical studies in this critical review proposed a variety of factors other than those specified by the PMT that were successful predictors of women's screening behavior; these included the social influence of family 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 idea of cervical screening (Goldman & Risica, 2004), the normative 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 a health 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 moral obligation in the regression analysis could better explain the variance in the intention to be screened. This finding suggests that threat- and coping-appraisal variables are not enough to determine the motivation to engage in preventive behavior. Tacken et al. (2007) reported similar findings regarding the direct effects of personal moral obligation on the intention to undergo screening. Other studies suggested that for a more comprehensive understanding of screening behavior, an emphasis on the social processes of motivation and culture-related beliefs would be more beneficial than the variables included in either the HBM or the PMT. This review demonstrated that nursing care in the area of cervical screening practice would address the complex nature of women's health-seeking behavior. The findings from this review indicated that women's health-seeking behavior in the area of cervical cancer prevention would be influenced by complex factors that have or have not been described in existing theoretical models. This assertion highlights the need for developing a culturally relevant and empirically based theoretical model that could explain and predict screening uptake. In order to encourage health-seeking behavior, nurses should address such factors when organizing the provision of health education for cervical cancer prevention. The results from this review suggest that, while providing accurate information is important, it is equally important to ensure that women's beliefs and their social-constructed meaning of screening behavior are included in nursing assessment and evaluation of changes resulting from any nursing interventions.
Most of the studies in the review only quantitatively measured the perception of cervical cancer risk and assessed knowledge about risk factors for the disease with simple yes/no questions (Gu et al., 2012, 2013; Hou et al., 2003). These studies did not appear to adequately explore either the meaning of risk among the women themselves or the role of personal risk factors and cultural context in determining screening behavior. For individuals to engage in a rational evaluation of personal risk and subsequent coping strategies, they must first have an understanding of the risk factors related to the disease (Marlow et al., 2009). Indeed, the low-risk perception of cervical cancer among Asian women identified in this review might be partly explained by a lack of factual information about the risk and risk factors for cervical cancer (Herdman, 2012), which concur with the nursing diagnosis of knowledge deficit. Regarding the risk factors associated with this nursing diagnosis, contextual factors, including ethical, social, and cultural issues, must be properly addressed to in this area of nursing care. Women's understanding of the risk factors for cervical cancer and the sexually transmitted nature of HPV and unsafe sex would importantly impact on how women perceive the risk of cervical cancer, and subsequent decision-making process of cervical screening behavior. For example, Holroyd, Twinn, and Adab (2004) found that a substantial proportion of Chinese women associated the risk of cervical cancer with multiple sexual partners, being married, youth or old age, and their partner's poor hygiene. Another study (Martinez, Chavez, & Hubbell, 1997) argued that Latina females' understanding of the risk factors of cervical cancer was significantly influenced by moral obligation. Women who engaged in “unnatural” and “immoral” behavior, including having extramarital partners, having sex during their menstrual period, and having abortions, were at a higher risk of cervical cancer than others. It has been suggested that emphasizing the association between cervical cancer and sexual behavior may lead to a sense of stigma and guilt among women who develop the disease; for example, women who tested positive for HPV experienced feelings of anxiety and stigma (McCaffery et al., 2004). Thus, fear of moral judgment and the stigma associated with STD may impede screening uptake and information seeking regarding cervical cancer prevention (Friedman & Shepeard, 2006; Twinn, Holroyd, & Adab, 2006). Further nursing research is warranted to understand how women comprehend their personal risk and the risk factors of cervical cancer and how the correlation between these beliefs affects their screening behavior. Such explorative studies could identify more underling risk factors associated with the nursing diagnosis of knowledge deficit and health-seeking behavior. Effective and culturally sensitive nursing care plan would improve communication about cervical cancer risk and help promote cervical screening among diverse ethnic groups. An improved understanding of the connection between managing the risk of HPV infection and managing cervical cancer risk should also be addressed in future studies.
The majority of the reviewed studies were carried out in Western populations, and the knowledge obtained from these studies may not be applicable to other cultural groups such as Asian and African women. Cultural values have been found to affect cancer communication and screening among several ethnic minorities (Liang, Yuan, Mandelblatt, & Pasick, 2004). The importance of providing cervical screening services in a culturally appropriate manner is well established (Hislop et al., 2003; Holroyd et al., 2004; Taylor et al., 2002). For example, traditional Asian cultural views, including fatalism, beliefs regarding a balanced diet, maturity, modesty, and self-reliance, contribute to the avoidance of healthcare visits (Kwok, Sullivan, & Cant, 2006; Liang et al., 2008). Moreover, in Asian cultures (Chen, 1996), health is considered to be a state of physical harmony with the environment, and an emphasis on the effectiveness of traditional Chinese medicine and a preference for using Eastern herbs over Western medicine have been demonstrated in Asian populations (Liang et al., 2004; Simpson, 2003). These beliefs may constitute a barrier to seeking medical help through Western medicine, including regular screening, among Asian women (Hoeman, Ku, & Ohl, 1996; Liang et al., 2004; Yamashiro & Matsuoka, 1997).
Because of the variety of measurement strategies employed in the studies, it is difficult to compare women's perception of cervical cancer risk across the studies. Indeed, the most serious criticism of risk perception research is that “studies record snapshots of risk judgments outside of the specific social contexts in which people live out their day-to-day lives” (Rogers, 1975). Risk perception is not static; rather, it tends to be altered in different contexts and influenced by individuals' knowledge and life experiences (Bellaby, 1990).
The studies examined in this review have several limitations, including limited study population size, inadequate data collection methods, and a lack of in-depth exploration of risk perception from the women's perspective. Because most of the studies were cross-sectional and retrospective, it is difficult to establish any causal association between women's perception of cervical cancer risk and their future screening behavior. The majority of the reviewed studies assessed women's perception of cervical cancer risk with one or two likelihood questions, but evidence shows that such quantitative measurements do not sufficiently capture an individual's complex feelings and perceptions about the risk of cervical cancer (Slovic, Finucane, Peters, & MacGregor, 2002). These limitations with respect to current risk perception measurements may be more serious within specific cultural contexts. Indeed, cultural contexts are influenced by multiple health, social, and financial issues, which may exert a profound impact on the perception of cancer risk (Huerta & Macario, 1999). A review of current developments in risk research claimed that newer methods place more emphasis on the significance of social and cultural context in comprehending cancer risk (Taylor-Gooby & Zinn, 2006). From the literature on cervical cancer perception and prevention decision making, quantitative approaches alone prove inadequate to explain inconsistent findings or to gain in-depth understanding of cervical cancer risk and subsequent screening behavior. This inadequacy suggests the need for alternative research methods, such as mixed method designs and studies in different cultural contexts.
The evidence from the 1 review article and 41 primary studies shows that comparing studies and drawing conclusions about the perception of cervical cancer risk and screening behavior is difficult because of theoretical inadequacy, measurement variability, the use of culturally insensitive measurement strategies, and the use of inconsistent measurements. Previous works have made few attempts to examine the feelings related to cervical cancer risk and how women understand their personal risk factors in depth. An alternative approach using multiple designs and data sources, rather than a quantitative or a qualitative method alone, is recommended to gain a more comprehensive understanding of these social phenomena (Greene, Benjamin, & Goodyear, 2001). Alternative study methods are of particular importance, given that little attention has previously been paid to the undoubtedly complex issue of the perception of cervical cancer risk, particularly within specific cultural contexts. Such efforts would improve nurses' understanding of the perception of cervical cancer risk and empower them to develop accurate nursing diagnosis and appropriate care plan to promote women's attendance at and long-term adherence to cervical screening. Nurses involved in the programs for cervical cancer and screening should address factors in relation to the nursing diagnosis of health-seeking behavior and knowledge deficit identified in this review. This critical review recommend interventions to raise women's risk perception involving special efforts to educate women regarding the risk of cervical cancer, the meaning of precursors, the causes and symptoms of cervical cancer, so as to help them make informed decisions. In view of the fact that variables specified in existing theoretical frameworks have been proved to be insufficient to explain cancer screening behavior, future research is needed to find out different facets of the women awareness and perception of the risk of cervical cancer in relation to preventive behavior within specific cultural context.
The authors would like to thank Professor Sheila Twinn for her contribution to this research.
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