Prevalence of CCS
Nearly half of people had high enthusiasm for CCS and most screening behavior was effective, which means that since the implementation of the CCS program women's knowledge and awareness of cervical cancer has increased observably [28]. However, for those aged 65 or older, more than half of the women's screening behaviors may be inefficient. Current cervical cancer incidence and mortality data suggest that inappropriate cervical cancer screening (e.g., over-screening) can result in unnecessary medical procedures and worse health outcomes [29]. Previous research has also suggested the importance of effective CCS [28]. In the view of the two screening dimensions proposed in this study, most women at 21-29 years old whose screening behaviors were active and effective. However, a small number of people in the 30-65 age group had an ineffective screening, and over-screening may exist in the 65 or older age group. This indicates that there are indeed invalid screening behaviors in different age groups that have caused health disparity [2, 20, 30].
Determinants and mechanisms of CCS
Our research found that disparities existed in CCS behavior across sociodemographic factors such as age, race, income, and education. Compared with those aged 21-29, women aged 65 or older were less likely to take the CCS test regardless of effective screening or active screening. In addition, non-Hispanic black women were more active in screening compared to non-Hispanic white, but there was no significant association with effective screening by race. Particularly, there were significant differences in screening behaviors between different education levels: the higher the level of education, the less inclined to conduct effective screening, but the more inclined to active screening for cervical cancer. This phenomenon can be interpreted as evidence of over-screening, as supported by previous studies [20]. These sociodemographic factors that influence whether to implement CCS have been discussed in previous studies, but little attention has been paid to the factors other than sociodemographic factors and little research has focused on the influencing mechanisms that actually affect effective screening [31, 32].
HBM and SCT are two widely accepted theories in explaining health behavior. After controlling for sociodemographic factors, we were somewhat surprised by our finding that none of the factors based on health belief model had a significant effect on effective screening, and only self-efficacy had a positive effect on active screening. According to the HBM, screening behavior is influenced by women's perception of their disease risk, perceived benefits of and barriers to participation, cues to action; and women's self-efficacy to participate [33]. We can thus explain in this study that women's self-efficacy is a key determinant of active CCS participation. These results may suggest that as the trial implementation of various screening programs progresses, women's knowledge of cervical cancer and screening awareness has generally increased. However, the HBM framework is primarily aimed at explaining the occurrence of healthy behaviors from the perspective of cognition and psychological perception [34, 35], and can no longer fully explain the behavioral mechanisms of reasonableness.
Based on the effect of environmental factors on the behavior proposed by SCT, we view health information acquisition channels as environmental factors that influence screening. Patient-provider communication proved to be an important offline channel, and high-quality communication between health care providers and their patients contributes to more adults receiving cervical and breast cancer screenings [36]. Nevertheless, our survey results suggest an insignificant correlation between patient-provider communication channels and respondents' screening behavior [37]. Information technology platforms such as social media have become popular communities and a key source of information for people to receive and share health experiences. Our research considers social media participation as a factor influencing women's cancer screening behaviors, and the statistical results confirm our view. Furthermore, this study found that online health information seeking behavior and social media participation significantly negatively impact effective screening. Through the mediation analyses, we found that social networking participation fully mediates the negative impact of online health information seeking on effective screening. However, this result is inconsistent with some previous studies which showed that social media engagement could promote positive healthy behavior [38–40]. Though the reasons for these associations are not entirely clear, it is possible that the sample of this study was dominated by high-skilled and high-paying people, who preferred to search for health information online and pay more attention to health information on social network visiting. A large amount of health information available online, which has caused information overload that can mislead people. It is difficult for people to identify the information they really need and use it effectively, which could account for the third stage of digital divide, empowerment divide [41, 42]. Therefore, few people truly understand the power that digital technologies can give them, and it is unclear what they can do with the information technologies they use to promote their health. Many of them accept misleading information provided online, which has negative impacts on effective screening behavior.
In addition, health communication on the social media can affect the individual's health behavior, which can be explained by risk communication [43, 44] and social norms [45, 46]. People’s awareness and knowledge have enhanced by years due to the cancer risk information communication, but overload cancer information may cause the avoidance of cancer screening [47, 48] or ineffective screening. For decades now, the main communication about cancer screening consisted of conveying to people that it was a good thing to do and that they should participate in it. However, as a result, the more women take part in social networking, the more difficult it is to conduct effective screening. Lenior’s research also showed the clinical impact of a Twitter campaign to increase cervical cancer screening is yet to be evaluated [3]. We found that health information disseminated through social media may not be effective in a meaningful way. The engagement of users as information sources in social media greatly promotes the communication of health information. However, when compared with patient-provider professional health communication [36, 49], interpersonal communication via the Internet and social media made a significant difference in women's effective screening behavior. Those who attempt to search for screening information through social media or are exposed to the communication of such screening information may be unable to choose advice appropriate and therefore have experienced ineffective CCS.
Implications
These findings have shown some implications. On the one hand, it is a main trend that people seek health-related information and support online. However, information overload and misinformation could mislead people. Our data provide evidence that the effectiveness of Internet access still needs considerable attention when developing Internet-based public health interventions and communications. The government should work to improve the health information literacy of users and reduce the digital divide. On the other hand, social media would have a great potential to improve behavior change as interactive tools that encourage participation in CCS. To encourage effective screening behavior, we cannot ignore the role of opinion leaders in interpersonal health communication. Therefore, health care providers could filter relevant CCS information and forward it to their social media followers, thereby facilitating effective screening uptake [44, 50].
Strengths and Limitations
Among the strengths of this study was the use of nationally representative samples to evaluate the disparity between women’s active screening and effective screening of cervical cancer. Moreover, we uncovered the potential influence mechanism of women's effective screening. Specifically, our results reflect that the analysis of influence mechanism based on health theoretical frameworks is reliable, which provided the implications for government or health departments to design effective intervention plans and health promotion actions. Notably, our study extends previous studies that examined the influencing factors of CCS [51] by providing an in-depth understanding of women's behavior from an information technology perspective of effective screening.
Our study had several limitations. First, given the cross-sectional nature of our data, we are unable to make causal interpretations. Second, cervical cancer screening behaviors were assessed from the respondents' self-reports, which may cause bias. Third, measures of CCS in HINTS only considered the adoption of a pap test that could not fully demonstrate screening behavior. In general, HPV test can combine or replace the pap test to screen for cervical cancer. Further investigation data may be needed to characterize and evaluate the behavior of CCS. Even so, our study sheds light on the importance of further research.