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Perception of Cervical Cancer Risk and

Screening Behavior: A Literature Review
Carmen W. H. Chan, RN, MPhil, PhD, Sheng-Bo Yang, MD, PhD, Can Gu, RN, MPhil, PhD, Xiuhua Wang, RN, PhD, and
Lijian Tao, MD, PhD
Carmen W. H. Chan, RN, MPhil, PhD, is a Professor of the Nethersole School of Nursing, The Chinese University of Hong
Kong, Hong Kong, Sheng-Bo Yang, MD, PhD, is an Associate Professor of Department of Dermatology, Third Xiangya
Hospital, 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 a
Professor of Department of Medicine, Xiangya Hospital, Central South University, Changsha, China.

Search terms:
Cervical cancer, cervical screening,
literature review, nursing, risk
perception
Author contact:
gucan_cs@csu.edu.cn, with a copy
to the Editor: journal@nanda.org
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).
Conflict of interest statement: The
authors have no conflicts of
interest to disclose.
PURPOSE: 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.
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 in
the 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 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.
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 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 insuf-
ficient 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 con-
sidered a crucial factor in promoting precautionary health
behavior. 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 who
perceived a higher likelihood or probability of developing
breast 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 awareness
of her risk of the disease influences the likelihood of her
participating in the screening. Nurses involved in the pro-
grams for cervical cancer screening need to have the
understanding of women’s risk perception to facilitate the
identification of accurate nursing diagnosis, and subse-
quently develop appropriate intervention strategies. There-
fore, 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 knowl-
edge base in health protection that is closely associated

2 © 2014 NANDA International, Inc.

International Journal of Nursing Knowledge Volume 26, No. 1, January 2015
C. W. H. Chan et al.
with the diagnoses of knowledge deficit and health-seeking
behavior.
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 of
cervical cancer risk and the screening behavior, which
could help nurses to develop appropriate health protection
care plan for women.
Design
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 participa-
tion 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 dis-
crepancies from the literature and offering some prelimi-
nary 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.
Search Methods
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 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 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 suscepti-
Risk Perception and Screening Behavior
bility,” “perceived likelihood,” and “subjective risk percep-
tion.” A supplementary search of the reference lists of
articles in the Ovid MEDLINE, PubMed, and PsycINFO data-
bases 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.
Search Outcome
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 disser-
tations abstracts (3 studies), studies about factors influenc-
ing cervical screening attendance that failed to involved
risk perception into their studies (15 studies), studies about
factors influencing human papilloma virus (HPV) vaccina-
tion (5 studies), studies involved women diagnosed with
cervical cancer (6 studies), studies about factors influenc-
ing 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 indepen-
dently and discussed the similarities and differences in their
comments until a consensus was reached.
Data Abstraction
The corresponding author initially abstracted data, and
the first author and corresponding author critically
assessed the characteristics and main findings of the rel-
evant studies.
Quality Appraisal
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 insuffi-
3
Risk Perception and Screening Behavior
ciently. 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.”
Results
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 per-
ception 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 per-
ception,” “perceived vulnerability,” or “perceived suscepti-
bility” 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), experi-
mental studies (3 studies), and secondary data analyses (1
study).
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 compli-
ance 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 theo-
retical models, the HBM and the Andersen Behavioral
Model.
Subject Characteristics
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 selec-
tively 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 Cauca-
4
C. W. H. Chan et al.
sian 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 main-
land 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 percep-
tions of cancer, resulting in apparently contradictory find-
ings. 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 likeli-
hood, such as comparative and verbal measures. Although
the response choices for these questions always used quan-
tified 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).
Outcome Characteristics
Because risk perception is thought to be an important
motivator of cervical screening behavior, it is imperative to
 Table 1. Summary of 41 Research Studies

Study design and Study

Author and year population Sample size Outcome measure Result Comments quality

1. Abotchie Cross-sectional (n = 157) Knowledge of About half perceived themselves to be at This study highlighted that a literate 11
and Shokar research design cervical cancer risk (52.5%). population of college women lacked
(2009) College students risk factors The prevalent barriers were lack of information about cervical cancer and
Ghana aged 18 years and Cervical cancer perceived benefits (it is important for a its risk factors and the most
above health beliefs woman to have a Pap test so she will significant influence of perceived
know if she is healthy: 87.6%), concerns barriers on screening behavior.
about what others may think (my partner Cross-sectional design cannot make
C. W. H. Chan et al.

would not want me to have a Pap test: causal inferences of association

40.6%), and lack of information (having between risk perception and
cervical cancer would make a woman’s screening behavior.
life very difficult: 73.6%).
Perceived risk was not associated with
screening uptake.
2. Ackerson Qualitative research (n = 7) Perceived risk Women perceived either high or low risk of This qualitative study highlighted the 11
et al. (2008) Face-to-face Screening uptake cervical cancer. background variables of social
United States interview Three women believed that risk of cervical support and previous healthcare
Low-income African cancer was due to having a family history. experience in explaining women’s
American women Women who perceived low risk did not screening behavior.
(21–37 years) obtain a screening. Social influence from Most of participants were from the STD
family and physicians and previous clinic where they were seeking
healthcare experiences influenced healthcare services for STD, not
screening attendance. 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 Correlational (n = 108) Health Belief Model Perceived benefits (p = .00) and barriers (p This study highlighted providing 10
and Adir quantitative (HBM) variables < .05) were associated with actual knowledge about cervical screening,
(2009) study Cervical screening screening uptake. raising physician’s awareness of
Israeli Israeli lesbian behavior Perceived risk (p < .05), perceived benefits offering the test to lesbian and
women aged (p = .00), and general health motivation women-based medical team in
18–41 years (p < .05) were associated with intention promoting screening among this
to be screened. 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.
4. Boonpongmanee Cross-sectional (n = 189) Perceived risk Perceived barriers were significant This study identified the specific 11
and Jittanoon research design Perceived benefits predictors of cervical screening (OR: .88; barriers that working women in
(2007) Working women in and barriers for p < .001) Thailand to engaging in screening
Thailand Bangkok (25–55 cervical screening Perceived risk was not associated with were embarrassment, fear, time
years) screening uptake. constraints, knowledge deficit, and
cost, highlighting cultural issues in
screening utilization. The finding may
not be generalized to unemployed
women.
5. Byrd et al. Cross-sectional (n = 189) HBM variables Majority of women were aware of their This study highlighted that although 12
(2004) research design Screening uptake susceptibility of cervical cancer (there are women understood the risk and
United States Hispanic women effective treatments for cervical cancer: seriousness of cervical cancer, their
(18–25 years old) 93.7%), the seriousness of cervical perceived barriers associated with
cancer (having cervical cancer would screening may have influenced
make a woman’s life difficult: 72%), and screening participation.
the benefits of screening (it is important Participants were selected from a group
for a woman to have a Pap test to know if of young women. Self-reported prior
she is healthy). But no association experience of Pap tests was not
between perceived risk and screening validated.
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%).

5
Risk Perception and Screening Behavior
6
Table 1. Continued

Study design and Study

Author and year population Sample size Outcome measure Result Comments quality

6. Denny-Smith Cross-sectional (n = 240) Health Belief Model Participants demonstrated a low knowledge This study highlighted that a lack of 11
et al. (2006) research design variables, level (10.2 range of 1–15; SD: 2.4), low knowledge combined with low
United States Convenience HPV/cervical perceived risk (20.6 range of 9–37; SD: perception of susceptibility and
sample (19–58 cancer 6.2), and low perceived seriousness of seriousness to HPV and cervical
years) knowledge, cervical cancer (17.7 range of 9–27; SD: cancer made college women more
sexual behavior, 2.8). No relationship between previous likely to contract STDs, including HPV,
cervical screening screening behavior and perceived and increase the risk of cervical
behavior susceptibility and perceived seriousness. cancer. The majority of samples were
Positive relationship between perceived married and findings may be different
risk and number of partners (r: .23, p = compared with single students.
.001).
7. Eaker et al. Case-control study (n = 944) HBM variables Attendance was positively associated with The strength of the study was the 12
(2001) Population-based Screening behavior perceived severity of cervical cancer (OR: population-based design and accessed
Sweden sample 1.9 95% CI: 1.1–3.4) and satisfactory a database covering all cytological
(non-attendees benefits (OR: .7 95% CI: .6–.8) but screening in the area. Important
and attendees) negative associated with practical differences in attitudes and beliefs
430 non-screened barriers (time-consuming: OR: 1.2 95% CI: existed between non-attendees and
and 514 screened 1.1–1.5; economic barriers: OR: 1.7 95% CI: attendees. However, the study was
1.2–2.5) limited by the low response rate
Risk Perception and Screening Behavior

Perceived risk was not a predictor of (71%) particularly among

screening uptake. non-attendees (69%).
8. Eiser and Cross-sectional (n = 70) Perceived risk Optimistic bias was found (p < .001). Although participants were a selective 10
Cole (2002) research design Knowledge about No relationship between perceived risk and younger women sample, this study
United States Convenience cervical cancer screening intentions and actual uptake. highlighted that women’s rating of
sample and screening No relationship between perceived risk and relative risk seemed neither to guide
College women Screening behavior knowledge about cervical cancer and behavior, nor to be based on relevant
aged 20–25 years screening. Cognitive closure was a knowledge about cervical cancer and
significant factor influencing screening suggested psychological factors in
behavior (p < .01). determining women’s motivation to
do a screening.
9. Fernandez Experimental study (n = 243) Screening behavior Screening completion was higher among This study added to the evidence 10
et al. (2009) using an Acculturation intervention group. concerning the effectiveness of lay
United States educational Perceived pros and The intervention increased cervical health worker intervention for
intervention cons screening self-efficacy, perceived increasing cervical screening, but the
Women 50 years Perceived risk benefits, and subjective norms, but it did intervention was proved not to
and older who Self-efficacy not change screening knowledge and influence perceived susceptibility of
were no adherent perceived risk. cervical cancer, and the study did not
to cervical report the relationship between
screening perceived susceptibility and screening
behavior.
10. Fort et al. In-depth interviews (n = 20) Barriers to cervical Major barriers to seeking preventative This study recommended that 11
(2011) of women in rural cancer screening screening included low knowledge levels, healthcare providers and health
Malawi Malawi low perceived susceptibility, and low educators targeted aspects of
perceived benefits from the service. perceived susceptibility among this
population, including knowledge levels
and personal risk assessment.
11. French et al. Prospective (n = 406) Perceived risk Women with inadequate smear test result This study highlighted that informing 11
(2004) research design Cervical screening perceived higher risk of cervical cancer women who had an inadequate smear
United Kingdom Convenience result than women with normal test result (p = test result was associated with raised
sample .016). Receiving an inadequate smear test level of perceived risk and anxiety
226 women with result raised state anxiety (p = .025,) and about the test.
normal test result concern (p < .001) and anxious women The study was observational in design;
180 were less likely to attend for a repeat it was not possible to infer the causal
non-consecutive smear test (p = .011). associations between variables.
inadequate test
results
C. W. H. Chan et al.
 12. Garcés-Palacio Cross-sectional (n = 743) Perceived 1. Educational attainment, thinking they may The study showed that perceived 12
and Scarinci survey susceptibility to have been exposed to an STI in the past, susceptibility to cervical cancer
(2012) Women were 30 ± cervical cancer thinking they may be at risk of HPV seemed to be influenced mostly by
United States 6.8 years old and and factors currently, having had a Pap smear within the current or past perception of
were mainly from associated with the last year, and having a relative with HPV/STI exposure, and by having a
Mexico (89.2%) perceived cancer were significantly associated with relative with cancer. Yet the
C. W. H. Chan et al.

susceptibility perceived susceptibility. questionnaire was self-reported and

2. Greater knowledge about cervical cancer may have biases.
risk factors reduced the uncertainty
about perceived susceptibility.
3. Perceived susceptibility to cervical
cancer seems to be influenced more
importantly by the current or past
perception of HPV/STI exposure, and by
having a relative with cancer.
13. Goldman Qualitative research (n = 147) Perception about Cervical cancer risks were mostly attributed The findings from this qualitative study 12
and Risica design using cervical cancer to carelessness about health care and underscored the complexity of the
(2004) face-to face and screening sexual behavior by interviewees. issues concerning cancer perceptions
United States interview A strong sense of fatalism and feelings of and behaviors, and provide meaning
Dominicans and embarrassment coexist with firm beliefs and context that help explain some of
Puerto Ricans in about the importance of screening, and the conflicting perceptions. No
Rhode Island (18 increasing normalization of at least the information about women’s perceived
years and older) idea of Pap test. personal risk of cervical cancer was
discussed in this study.
14. Gu et al. Cross-sectional (n = 167) Protection All women considered themselves at low This study highlighted the significance 11
(2012) research design Motivation risk of cervical cancer. No significant of knowledge and culturally relevant
China Convenience Theory variables, association was observed between health behavior and beliefs about
sample of knowledge about perceived risk and previous screening cervical screening for Chinese women
Chinese women cervical cancer behavior. A perception that visiting in determining screening behavior.
(25–50 years old) and screening, doctors regularly is important to health, The use of convenience sample
screening average and high levels of knowledge limited generalizing these results to
behavior about cervical screening were the whole Chinese population.
significantly associated with having been Reported experiences were
received screening. retrospective, which leaded to recall
bias.
15. Gu et al. Cross-sectional (n = 167) Protection The majority of women stated they intended This study highlighted the important 11
(2013) research design Motivation to receive future screening, and response role of women’s beliefs in the value of
China Convenience Theory variables, efficacy was significantly associated with cervical screening and previous
sample of knowledge about their intention. Cancer in relatives, a screening experience in motivating
Chinese women cervical cancer perception that visiting a doctor regularly them to receive a screening. Women
(25–50 years old) and screening, is important to health, and ever attending were recruited from four workplaces
Sexual history, for cervical screening during the previous and did not have to pay for their
Motivation to three years were significantly associated screening, resulting in a biased
receive future with women’ motivation to receive future sample. Small sample size was
screening screening. another concern. The subsequent
actual uptake of screening was not
assessed in this study.
16. Ho et al. Cross-sectional (n = 209) HBM variables Perceived risk was not a predictor of The study found many significant 11
(2005) research design Screening uptake screening uptake. predictors of Pap test and informed
United States Convenience Perceived severity was a significant the future study to address these
sample of women predictor of screening uptake. factors in the next adherence study.
20–88 years old 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.

7
Risk Perception and Screening Behavior
8
Table 1. Continued

Study design and Study

Author and year population Sample size Outcome measure Result Comments quality

17. Holloway Cluster-randomized (n = 1,890) Short-term Intervention group was less likely to express The strength of this study was the large 13
et al. (2003) controlled outcome was a preference of a shorter than sample size and longitudinal
United Kingdom intervention stated preference recommended interval (OR: .51 95% CI: experimental study. This study
research; the for future .41–.64; p < .0001) and less likely to suggested that risk perception of
intervention screening attend for screening sooner than their women regarding cervical screening
comprised a brief interval. recommended recall (5% having shorter were amenable to individualized risk
specific Long-term outcome than recommended intervals). The impact communication intervention. This
counseling was actual of perceived risk on actual screening intervention was proved to benefit
session. screening behavior was equivocal. screening program and may relieve
Women were behavior at anxiety. Differences in numbers
recruited when 4-year follow up. between the intervention and control
attending for group (630 vs. 829) because of
cervical screening different attrition rate may affect the
comparability between two groups.
18. Hoque et al. Cross-sectional (n = 300) Perceived severity Sixty percent of non-screened women had Participants were a selected women 10
(2009) research design Screening uptake low perceived severity while 33% of population who attended a district
Botswana Women who were screened had high perceived severity. hospital. Participants may have felt
above 18 years No relationship between perceived severity sensitive to report negative results
old and screening uptake (Χ2 = 1.0795; p = such as perceived barriers,
Risk Perception and Screening Behavior

.2988). introducing self-bias.

19. Hou et al. Cross-sectional (n = 125) Prior screening Screening adherence was associated with This study identified important 11
(2003) research design experiences knowledge, perceived pros, cons, and psychological factors associated with
Taiwan A convenience Perceived pros and norms of cervical screening. screening uptake among Chinese
sample of women cons of a test Final logistic regression model did not women in Taiwan, which could be
with mean age Perceived norms support perceived risk as a successful tailored for future intervention
was 38 years in Perceived risk predictor. efforts.
Taiwan Knowledge of Because all women voluntarily agreed
cervical cancer to participate in the study, volunteer
and screening 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. Cross-sectional (n = 490) Compliance Model Perceived risk was not associated with This study identified many significant 10
(2001) research design variables intention to return for cervical screening. factors that were associated with
United States 12–24-year-old Screening behavior Personal beliefs of cervical screening (OR: intention to return for screening.
women 1.07 95% CI: 1.02–1.11), perceptions of However, participants were a
other’s beliefs (OR: 1.93 95% CI: selective younger women population
1.38–2.74), and cues to action (OR: 1.31 and predicted intention to return for
95% CI: 1.08–1.60) were associated with screening may not explain actual
intention to return. 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.
21. Kavanagh Qualitative research (n = 29) Women’s The multiplicity of meanings of “risk” This study highlighted that the noun 11
and Broom design using face understanding of complicated the efforts of public health. “risk” has multidimensional meaning
(1998) to face interview. the nature of Many women had not considered for individuals and suggested the
Australia Women who had an their cervical themselves to be at risk of cervical needs of people to integrate health
abnormal Pap abnormality, and cancer before their abnormal Pap smear. threats into their daily personal lives.
smear (19–70 how they made However, the study associated women’s
years old). sense of understanding of the risk with health
abnormality in risk , but it did not associate their
the context of understanding of the risk with
their everyday cervical screening attendance.
lives. behavior.
C. W. H. Chan et al.
 22. Kim et al. Cross-sectional (n = 1,160) Perceived risk Compared with white women, Latinas This study compared risk perception of 12
(2008) research design Self-reported perceived a high risk of cervical cancer cervical cancer and screening
United States Women from four screening Chinese had a low perceived risk. behavior among diverse women
ethnic groups of behavior No relationship between risk perception for including Chinese Americans and
white, African cervical cancer and screening uptake was found significant difference in risk
American, Latina, identified. perception between Chinese and
and Chinese other ethnic groups.
(50–80 years) All women were established patients in
C. W. H. Chan et al.

clinics with primary care clinicians

and had visited a clinic in the past 2
years, resulting in selective bias.
23. Kuitto et al. Cross-sectional (n = 760) Determinant of 1. Attendance both at screening and at HPV Uptake rates for existing primary and 11
(2010) research design uptake of vaccination was best predicted by secondary prevention measures
Germany Randomly selected preventive attitudinal factors. against cervical cancer could be
women aged measures against 2. Attendance at screening and HPV enhanced by fostering perceptions of
14–65 years cervical cancer vaccination was associated with positive utility and positive connotations of
connotations of cancer prevention regular screening. However, the
measures and utility expectations, fear of number of respondents in age group
cancer and high subjective risk of 14–26 was low, and detailed
perception. multivariate analyses in this age
3. Screening attendance was less regular groups were failed to conduct. Also,
among women of lower socioeconomic further analysis on the relationship
status. between knowledge, attitudes toward
prevention behavior and utility
expectations was needed.
24. Lee et al. Cross-sectional (n = 726) Knowledge, The primary reason for regular screening This study highlighted the important 11
(2002) research design attitude, and attendance was likely to be screening or factors influencing women’s
Singapore Population-based practices of as a part of health checkups (67%). Chief adherence to regular screening
sample of Asian cervical barriers to regular screening were low including health service-related
women (30–59 screening. perceived risk (46.5%) and low factors and perceived risk of cervical
years) Reasons for not accessibility (37.1%). cancer. Women who could not be
adherent to contacted on three attempts
regular screening constituted a sizeable proportion of
the non-respondents, but the study
did not measure the difference
between them.
25. Marlow An experimental (n = 965) HPV awareness Overall, HPV information did not have an This study contributed to the knowledge 10
et al. (2009) repeated Risk perception effect on perceived risk. But HPV about the effect of HPV information
United Kingdom measures design Cervical screening information affected women’s cervical on perceived risk of cervical cancer
British women aged behavior cancer risk perceptions in the younger across different population group.
16–75 years women (p < 0.001). There was also a However, the relationship between
significant time by screening attendance risk perception and screening
interaction, with an increase in perceived behavior was not assessed. Response
risk among women who did not regularly rate was modest, and no control
attend screening (p = .022). 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.
26. Marteau Cross-sectional (n = 722) Perceived risk Perceived risk was a predictor of intention This study indicated that smokers 12
et al. (2002) research design Smoking behavior to attend for screening (OR: 1.5 95% CI: seemed unaware of their increased
United Kingdom smokers and Screening uptake 1.0–2.1). risk of cervical cancer; evaluations on
nonsmokers Smokers were unaware of their increased interventional study were needed.
(20–64 years old) risks of cervical cancer (p < .0001). 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.

9
Risk Perception and Screening Behavior
10
Table 1. Continued

Study design and Study

Author and year population Sample size Outcome measure Result Comments quality

27. Matejic Sixty-two-item n = 267 for study group and Factors deter or Adherence to cervical cancer screening The study urged that open 12
et al. (2011) self-administered n = 267 for control group stimulate the practices is significantly related to better communication, social networks, and
Australia questionnaire women to financial status (OR: 10.8 p = .001), no improving social-economic status of
with case-control participate in gender preference for a gynecologist (OR: women were the most prominent
design screening 3.1 p = .015), consultations with a factors affecting the participation in
Women aged 18–70 activities gynecologist (OR: 4.7 p = .029), screening activities. Yet the control
years, who conversation with the women with group included women who did not
demonstrated an cervical cancer about that disease (OR: present for screening regularly rather
initiative for a 2.8 p = .029), higher media exposure to than those who had never been
PAP smear information about cervical cancer screened.
prevention (OR: 5.0 p = .004), and higher
personal risk perception (OR: 3.6, p =
.001).
28. McMullin Qualitative research (n = 20) Beliefs about the The majority of women had limited This study suggested that culturally 11
et al. (2005) Semi-structured role of sexual knowledge about cervical cancer and no related beliefs about the etiology of
United States face-to-face activities in knowledge about HPV; believed that cervical cancer played a role in the
interview cervical cancer infections caused by physical trauma, decision to obtain a screening for
Risk Perception and Screening Behavior

Purposive sample etiology and the certain sexual activities, and poor hygiene Latina immigrants.
of Mexican impact of the caused cervical cancer. Women expressed The study focused specifically on beliefs
Americans (mean beliefs on that if they did not engage in unwise about sexual behaviors and screening
age was 39 screening uptake behaviors, they would be not at risk of uptake. Other risk factors were not
years) cervical cancer and be less likely to get a discussed in the study. It could not
screening. 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 Cross-sectional (n = 3,221) Religion preference The relation between religious preference, This study incorporated religious 12
Madanat research design Church activity church activity, and screening uptake was preference, church activity, and risk
(2002) Women aged 18 Screening uptake dependent on marital status (for perception into understanding
Unites States years and older Perceived risk unmarried women of having a Pap smear women’s screening behavior, which
in the last two years, compared with provided new insight into the issue
religiously active LDS, OR: 2.39 95% CI: studied.
1.30–4.09; for less religiously active LDS, The study was limited because of the
OR: 2.30 95% CI: 1.10–4.82; for religiously use of cross-sectional telephone
active non-LDS, OR:1.65 95% CI: survey. Thirty-three percent of
0.91–2.99) for less religiously active women chose not to participate;
non-LDS, and OR: 5.35 95% CI: 2.50–11.43 self-selected bias may have
for women with no religious preference). influenced the results.
A low risk perception may result in the
low use of cervical screening.
30. Orbell and A longitudinal study (n = 166) Protection Perceived risk was a predictor of motivation This study highlighted that PMT model 11
Sheeran A random sample of Motivation to take a screening. provided a useful framework for
(1998) unscreened Theory variables, Motivation, high perceived risk, less worry, predicting both willingness to
United Kingdom women aged screening and high response efficacy were undergo cervical screening and actual
20–64 years behavior significant predictors of actual screening uptake of the test. The measure
uptake at 1-year follow-up. employed in this study was validated
by the work of Orbell (1996). The
actual uptake of screening was
measured objectively from medical
record.
C. W. H. Chan et al.
 31. Orbell Cross-sectional (n = 276) Behavioral risk Most women were willing to undergo future This study suggested the importance of 12
(1996) research design Previous test tests (82%). a sense of moral obligation and
United Kingdom Women aged 20–60 experiences Future screening expectations were perception of cervical screening
years Behavioral explained not by perceived risk, but by a practice in motivating women to take
expectation sense of obligation to attend (p < .01) and a screening. However, the variance
Threat appraisal aversiveness of cervical screening explained in behavioral expectations
(perceived risk, procedure (p < .05). was modest (22%); it was suggested
perceived for future exploration of perception
severity, AND of risk and cervical screening from
fear) women’s perspectives.
C. W. H. Chan et al.

32. Orbell et al. Case-control design (n = 614) Screening behavior, Non-screened women and women with low The study highlighted sociocultural 11
(1995) (307 screened behavioral risk, class were less likely to believe that they factors such as social class in
United Kingdom and 307 attitudes, and were at risk of cervical cancer. motivating women to take a
non-screened) beliefs screening following a regional call
20–64-year-old concerning program.
women cervical The low response rate (77.5%) may
screening, result in response bias.
practical
difficulties, and
social class
33. Phongsavan Cross-sectional (n = 800) Women’s 1. Thirty-eight percent considered to be at This study indicated that rural women in 12
et al. (2010) study perception of risk but less than 5% had ever had a Pap Laos have limited knowledge about
Laos Lao women aged cervical cancer test. cervical cancer and even less about
18–55 years 2. Sixty-two percent believed that it was screening and prevention. However,
possible to prevent cervical cancer, and no causal factors were examined for
that vaccination may be a suitable the poor knowledge in Laos.
method, but only 14% know about risk
factors.
3. Lack of subjective symptoms was the
main reason for women to refrain from
gynecological examinations.
34. Saules et al. Cross-sectional (n = 135) Smoking behavior Current smoker perceived a high risk of This study examined women’s smoking 10
(2007) research design Screening uptake cervical cancer. behavior and perceived risk of
United States College female Perceived risk Abnormal screening history was a predictor cervical cancer, and intention to quit
student (18–24 of risk perception. smoking. However, it did not examine
years old) Relationship between risk perception and women’s cervical screening behavior
screening participation was not reported. in relation to these factors. Smoking
behavior was collected by self-report,
introducing self-bias.
35. Scarinci Cross-sectional (n = 225) Ethnic differences All non-Latina women had cervical This study highlighted that Latina 11
et al. (2003) research design regarding cervical screening in the past compared with 81% immigrants tended to display
United States low-income Latina cancer knowledge of Latina women. Latina women displayed culturally based knowledge and
immigrants and socio-cultural significantly less knowledge regarding beliefs regarding cervical cancer and
(18–42 years old) factors cervical cancer than non-Latina (p < .001). screening that influenced screening
associated with Women perceived they were not at risk attendance.
cervical screening for cervical cancer since they do not have Given that only 20 women did not have
“perceived risk factors.” 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. Cross-sectional (n = 568) HBM variables Overall, perceived risk is very high (58.9% The study involved Chinese women in 12
(1995) research design Screening behavior perceived a high risk). Singapore, accounting for about 80%
Singapore 21–65-year-old Among women who had never been of the total sample and highlighted
women (Chinese screened, perceived risk was an important culture-specific health beliefs and
women predictor of their willingness to be attitude in increasing the acceptance
accounting for screened (only 58.9% felt themselves at of the Pap smear. However, the
80%) equal risk of getting cancer as others). predictive value of HBM was limited
because it was inherently a
psychosocial model and neglected
contextual factors and normative
beliefs.

11
Risk Perception and Screening Behavior
12
Table 1. Continued

Study design and Study

Author and year population Sample size Outcome measure Result Comments quality

37. Tacken Cross-sectional (n = 1,392) Screening uptake Beliefs about cervical screening and Because the response rate was 13
et al. (2007) research design Women’s level attendance including personal moral selective, a nonresponse study was
Dutch A two-stage cluster variables: obligation and normative beliefs of others performed. It indicated that women
sample of women perceived risk, impacted on the uptake rate (p < .01). who dropped out of the prevention
who were eligible personal moral Organizational factors also influenced on program perceived low risk of cervical
for the Dutch obligation, screening uptake, but perceived risk was cancer and were more convinced that
population-based normative beliefs. not associated with screening uptake. the cancer was fatal. This study
screening Practice level highlighted that cervical screening
program (30–60 variables rates were likely to be influenced by
years old) beliefs about cervical screening and
organizational factors.
38. Taylor et al. Cross-sectional (n = 352) Health Belief No association between perceived risk and This study confirmed low levels of 12
(2004) research design Framework adherence to cervical screening. Being cervical screening among Vietnamese
United States Vietnamese variables married, knowing Pap test was necessary women and demonstrated the
American women Screening uptake for asymptomatic women, doctor had importance of physician–patient
(18–64 years) recommended testing, and had asked communication in increasing
doctor for testing were factors associated screening participation.
Risk Perception and Screening Behavior

with screening participation (p < .05). The difference between study sample
and unreached and refused
participation were not reported.
39. Walsh Prospective (n = 1,114) Attendance for Women have poor levels of knowledge The strengths of this study were large 12
(2006) quantitative cervical about cervical cancer and screening sample size, and the computerized
Ireland design screening, (48% stated that the purpose of a records from the cytology lab were
Women aged 25–60 knowledge and cervical smear is to prevent cervical used as an objective measure of
in Irish access to cancer). screening attendance. This study
information about Factors influencing women’s decision to identified many significant factors
cervical cancer, attend for a screening included that influencing screening uptake,
experience of increased perception of risk (p < .05), suggesting an urgent need for health
cervical level of understanding about cervical provider to address these factors in
screening, screening (p = .001), and perceived future.
perceived risk, barriers (the perception of having a
barriers to cervical smear test as time consuming p <
attendance .01; causing greater distress p < .01 and
being more afraid of the test p < .05).
40. Were et al. Cross-sectional (n = 219) Perceptions of risk 1. Women of over 30 years were more likely The study highlighted a highly 11
(2011) questionnaire and barriers to to have screened before (p = .012). significant relationship between a
Kenya survey cervical cancer 2. Perception of being at risk was perception of own risk of developing
Non-pregnant screening significantly associated with a felt need cervical cancer and an expressed
women for screening (p = 0.002). need for cervical cancer screening.
3. Fear of abnormal results and lack of However, the study population was
finances were the commonest barriers to also selected for the women who
screening reported by 22.4% and 11.4% were already accessing the clinic
of respondents, respectively. services in Moi Teaching and Referral
Hospital.
41. Zhang et al. Secondary data (n = 1,044) Intent to have a Among women who had not undergone a This study contributed to our 12
(2007) analysis using a screening, hysterectomy perceived risk (OR: 4.27 knowledge of cervical screening
United States subset sample of previous 95% CI: 1.27–14.33), previous Pap smear because of its differentiation between
a cross-sectional gynecologic test (OR: 19.28 95% CI: 10.15–37.10), elderly women who had and had not
study history, perceived pain of the test (OR, 0.52; 95% undergone a hysterectomy. The study
Elderly women benefit/attitudes CI, .28–.99), and perceived importance only assessed intention to have a Pap
(≧65 years) related to (OR: 4.00 95% CI: 1.32–12.10) were test rather than actual uptake, but
cervical screening positive correlates of intention to have a intention was not always translated
screening. into actual action.

CI, confidence interval; HPV, human papilloma virus; LDS, Latter-day Saint; OR, odds ratio; PR, perceived risk; STD, sexually transmitted disease; STI, sexually transmitted infection.
C. W. H. Chan et al.
C. W. H. Chan et al.
identify both the determinants of risk perception and the
pattern of the relationship between perceived risk and cer-
vical 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 Cau-
casian 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 per-
sisted 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 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-
Risk Perception and Screening Behavior
sure, 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) sug-
gested 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 sig-
nificantly 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 conclu-
sions 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) con-
ducted 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 con-
structs of PMT, such as perceived risk, fear arousal, and
response efficacy, were significant independent variables
13
Risk Perception and Screening Behavior
associated with women’s actual screening behavior and
that the perception of cervical cancer risk was also a suc-
cessful 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 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; 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 iden-
tify 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.
Discussion
The review of the selected studies reveals major gaps in
the relevant knowledge and methodological approaches.
Theoretical Framework
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 psy-
chosocial 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
14
C. W. H. Chan et al.
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 con-
sidering 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 sugges-
tion 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 vari-
ables 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 vari-
ables 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 speci-
fied 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 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 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 preven-
tive behavior. Tacken et al. (2007) reported similar findings
regarding the direct effects of personal moral obligation on
the intention to undergo screening. Other studies sug-
gested that for a more comprehensive understanding of
screening behavior, an emphasis on the social processes of
motivation and culture-related beliefs would be more ben-
eficial 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-
C. W. H. Chan et al.
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 impor-
tant, 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.
Study Variables
Most of the studies in the review only quantitatively mea-
sured 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 deter-
mining 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 per-
ceive 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 obli-
gation. 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 experi-
enced feelings of anxiety and stigma (McCaffery et al.,
Risk Perception and Screening Behavior
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 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.
Study Population
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, matu-
rity, 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 demon-
strated 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).
Design
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 judg-
ments 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).
15
Risk Perception and Screening Behavior
The studies examined in this review have several limita-
tions, 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 percep-
tion 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 cervi-
cal 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.
Conclusion
The evidence from the 1 review article and 41 primary
studies shows that comparing studies and drawing conclu-
sions about the perception of cervical cancer risk and
screening behavior is difficult because of theoretical inad-
equacy, measurement variability, the use of culturally
insensitive measurement strategies, and the use of incon-
sistent 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 comprehen-
sive 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 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 and
screening should address factors in relation to the nursing
16
C. W. H. Chan et al.
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 cer-
vical 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 speci-
fied 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.
Acknowledgment. The authors would like to thank Profes-
sor Sheila Twinn for her contribution to this research.
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