Cervical Cancer Screening Beliefs Questionnaire: Development and Psychometric Assessment With Immigrants in Australia

Abstract

Background:

A body of literature consistently highlights that women from minority cultures have been an underserved group in cervical screening.

Objective:

We aimed to report the development and psychometric assessment of the Cervical Cancer Screening Beliefs Questionnaire (CCSBQ), a culturally sensitive questionnaire for measuring immigrant women’s beliefs, knowledge, and attitudes towards cervical cancer and its screening.

Methods:

A convenience sample of 871 women, recruited from various ethnic organizations for this study, was split into 2 sets for development and validation of the CCSBQ. Items for the questionnaire were drawn from a literature review and a preliminary study conducted by the team. A panel of professional experts and lay women evaluated face and content validity. Multi-trait analysis and Cronbach’s alpha were used to assess its factor structure, convergent-divergent validity, internal consistency and construct validity.

Results:

A17-item, 3-subscale version of the CCSBQ was formed. Psychometric examination confirmed its 3-factor structure. All items showed a correlation coefficient ≥0.39 with its subscale score. Cronbach’s alpha of the 3 subscales ranged from 0.71 to 0.88. Women, who had ever heard of cervical cancer and cervical screening, and screening participation, including ever attended, attended in the last 5 years as recommended and having intention to attend in the near future, had more proactive attitudes to health check-ups, better knowledge about cervical cancer and its screening, and perceived fewer barriers to cervical screening.

Conclusion:

The CCSBQ is culturally appropriate, valid and reliable for measuring immigrant women’s attitudes, beliefs, and knowledge about cervical cancer and its screening practice.

Keywords

cervical cancer cancer screening immigrant cultural beliefs instrument development psychometrics

Introduction

Cervical cancer, ranked as the fourth most prevalent malignancy among women worldwide,¹ continues to pose a substantial public health challenge. Given the significant role of early detection by means of screening and the introduction of vaccination, mortality rates have been reduced significantly over the last 2 decades, particularly in developed countries where national cervical screening programs have been implemented.^2-4 In Australia, for example, the age-standardized mortality rate has dropped from 6 to 1.5 per 100 000 females from 1990 to 2022.⁵ A similar promising pattern has been observed in the USA,² Canada,³ and the UK.⁴

Despite the significant advantages of screening, the decision to participate remains a personal choice for each woman. Similar to other cancer screening practices, such as mammograms and bowel screenings,⁶ international studies consistently highlighted that women from minority cultures have been an underserved group in cervical screening.^6,7 Idehen and colleagues reported that the participation rates among immigrant women who were from Russian, Somali, and Kurdish backgrounds were significantly lower than for the general population in Finland,⁸ with similar disparities noted in immigrant women in Australia⁹ and Canada.¹⁰ Therefore, effectively promoting cervical screening among immigrant women calls for urgent attention.

A remarkable research effort has been made to examine factors influencing cervical screening participation among immigrant women. A recent systematic review highlights the intricate interplay of personal, cultural, psychological, and logistical aspects shaping screening behaviors.¹¹ Among personal factors, a lack of knowledge about cervical cancer emerges as a significant barrier to participation.^11-13 For instance, as reported by Gu and colleagues, Chinese women often perceive cervical cancer as a risk only for those with multiple sexual partners.¹⁴ Additionally, the absence of symptoms is frequently cited by immigrant women, including Chinese, Vietnamese, Arabic, and Korean, as a reason for non-participation, viewing screening as unnecessary.^11,15

In terms of cultural influence, cancer, particularly associated with reproductive organs, remains a sensitive topic in certain cultures. Korean women perceive that attending a cervical screening test implies promiscuity,¹⁶ while some Asian women believe cervical cancer happens because of fate.¹⁷ Furthermore, cervical screening procedures, involving exposure of private parts, cause embarrassment and reluctance to attend, demonstrated by studies conducted among Vietnamese¹⁸ and Chinese women.¹⁹ Logistical barriers, including language barriers and lack of clinician recommendations, are frequently reported as factors associated with non-compliance in cervical screening among immigrant women in Australia,⁹ the USA,²⁰ and Canada.²¹

Although there are a number of measures developed to examine cervical screening behaviors, they are targeted at the Caucasian population.^22-24 As described above, the substantial evidence points to the fact that there are some culturally based beliefs regarding cancer and screening and barriers that are unique to immigrant women preventing them from attending cervical screening. Despite the significant population of immigrants in Western countries²⁵ and cancer control having been targeted as one of the priority areas in the global health domain,²⁶ no researchers have systematically examined the impact of culture on cervical cancer beliefs and screening behaviors among immigrant women. To address this gap in the literature, our study aimed to report the development and examination of the psychometric properties of the Cervical Cancer Screening Beliefs Questionnaire (CCSBQ), designed as a culturally-sensitive questionnaire to measure immigrant women’s beliefs, knowledge, and attitudes towards cervical cancer and its screening practices.

Methods

A cross-sectional survey was designed and conducted to develop the CCSBQ. The instrument development process consisted of 2 phases. The first phase involved item generation, assessment of content validity and cultural appropriateness, and translation. The second phase examined the psychometric properties of the instrument. The study was approved by the Human Research Ethics Committee of Western Sydney University in March 2023 (H14772).

Phase 1

Item Generation

To ensure cultural sensitivity and conceptual relevance, the initial item pool for the CCSBQ was generated using a comprehensive review of existing literature, including a previous study conducted on Chinese-Australian women by the research team.¹⁹ It was first generated in English. The initial CCSBQ was a 29-item instrument designed to investigate immigrant women’s attitudes, beliefs, and knowledge about cervical cancer and its screening.

The items are grouped into 3 subscales, namely the Attitudes towards and perceptions about cervical cancer subscale (hereafter referred to as the Attitudes subscale; 9 items), the Knowledge about cervical cancer and its screening subscale (Knowledge subscale; 9 items) and the Perceived barriers to cervical screening practices subscale (Barriers subscale; 11 items). Each item is rated on a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree); therefore, a higher score indicates a more positive attitude, better knowledge, or less perceived barriers toward cervical cancer and cervical screening.

Assessment of Content Validity and Cultural Appropriateness

To establish content validity, items were then reviewed through expert consultation. The panel comprised 5 health professional experts, including 2 professors (one in psychology and one in nursing), a nurse practitioner working in cancer care, one health professional working in a multicultural education center, and a research scholar in women’s health. The expert panel members were asked to give constructive criticism of the questionnaire items, including careful review of each item for relevance and appropriateness. The health experts gave feedback on the extent to which the items would capture information about knowledge, beliefs, and attitudes about cervical cancer and its screening. In addition, the expert panel was asked to evaluate item wording, response format, and instrument length. All items were considered by the experts to be relevant and appropriate.

In addition, to establish face validity and further ensure cultural appropriateness, a panel of 4 lay representatives from each cultural group was convened. These women varied in background characteristics such as length of residency in Australia, age and educational level, and were recruited through a number of ethnic community organizations. Members of the panel were asked to review the items and provide feedback on the clarity, relevance, and cultural appropriateness of the wording, helping to ensure that the instrument was meaningful and acceptable across diverse immigrant groups.

The processes described above, together with the literature review, helped to establish the content equivalence of the instrument from both professional and cultural perspectives. Consensus on the items was achieved through vigorous discussion rather than the calculation of a content validity index (CVI). Expert discussion allows for contextual and cultural considerations that a purely quantitative CVI may not fully capture. This approach was particularly appropriate given that the instrument was designed to be culturally sensitive, ensuring that the final items are both professionally relevant and culturally appropriate for the target population. To obtain as comprehensive an assessment as possible of immigrant women’s attitudes, beliefs, knowledge, perspectives, and cervical screening practices, the scale consisted of generalized items such as “I don’t believe I am at risk of developing cervical cancer,” and personalized items, such as “I don’t want to have a cervical screening because I would need to take off my clothes and expose my private parts.”

Translation

After the questionnaire items were assessed for content and face validity, the back-translation technique was employed to translate the English version of CCSBQ into Arabic, Chinese, and Vietnamese. Initially, the English version of the CCSBQ was first translated into each target language by the authors, who are bilingual in either Arabic, Chinese, or Vietnamese. A second professional bilingual translator then independently back-translated these versions into English. The back-translated and original English versions were subsequently compared for equivalence, revealing near-identical content and preserving the original meaning. As a result, no modifications were required. This process ensured the semantic equivalence of the instrument. The Chinese version was written in traditional and simplified Chinese, given the fact that they are the most common written languages among the Chinese in general.

Phase 2

Sample

The target population was women aged over age 18 years who self-identified as being of Arabic, Chinese, or Vietnamese heritage and were born outside Australia. These cultural groups were selected as they represent the largest immigrant populations in Australia.²⁶ The term “immigrant women” refers to any woman who was born in another country. To minimize potential bias, individuals with a history of cervical cancer or who had their whole uterus removed were excluded, as their personal experiences could influence their beliefs, knowledge, and attitudes toward cervical cancer and screening practices.

Recruitment and Data Collection

A convenience sample of the target population, immigrant women who are from Arabic, Chinese, or Vietnamese background, was recruited through face-to-face methods and online channels. In collaboration with various ethnic community organizations, including churches and community service centers, female members were invited to participate in the study. Research team members, who shared the respondents’ cultural and linguistic backgrounds, attended women’s meetings hosted by these organizations to personally extend invitations. Respondents were invited to self-administer a questionnaire including the CCSBQ as well as some questions about their demographics and experience in cervical screening.

During the initial contact, the study’s objectives, methodology, potential risks and benefits, and confidentiality measures were thoroughly explained. Respondents were encouraged to ask questions and were fully informed that their involvement was entirely voluntary. Women interested in participating received both an English and a translated version of the questionnaire, along with the Study Information Statement. They had the option to complete and return the questionnaire immediately or return it later in a sealed box placed at the organization’s reception. Returning the questionnaire was considered an indication of informed consent. The questionnaire took approximately 20 minutes to complete.

For the online format, an advertisement containing a link to the questionnaire, using Qualtrics, was posted across various social media platforms such as Facebook and Instagram, targeting female-focused groups such as the Vietnamese Mothers’ Group and the Chinese Sports Group. Before beginning the questionnaire, respondents were provided with study information in their chosen languages, detailing the research purpose and procedures. Additionally, they had the flexibility to navigate backward through the questionnaire to review or modify their responses as needed.

Sample Size

The sample size of this study was based on the requirements for conducting a factor analysis. There is no generally agreed consensus as to the minimum number required. A sample of 300 respondents satisfied the recommendations of a total sample of 300 subjects²⁷ and 5 to 10 subjects per item.²⁸ After accounting for ineligible respondents and incomplete or problematic responses, we targeted to recruit 450 women for the development of the CCSBQ instrument. Another sample of the same size was also recruited for the validation. As a result, we planned to recruit 900 women, 300 from each ethnic group. Over a 6-month period in 2023, we received a total of 930 completed questionnaires, with 588 submitted in hard copy and 342 collected online.

Data Analysis

The data analysis was divided into 2 parts. The whole sample was correspondingly split into a development set and a validation set. The demographics between the 2 sets of respondents were summarized and compared. In Part 1, we aimed to reduce the number of items in the CCSBQ instrument from 29 to 20 or fewer using the development set, without compromising the psychometric properties. In Part 2, we validated the shortened final version of the CCSBQ and examined its psychometric properties using the validation set. All analyses were conducted using SAS OnDemand for Academics (SAS Institute Inc., Cary, NC, USA).

Part 1 – Item Selection

The initial 29-item CCSBQ was shortened through multistage procedures to maintain the interconnection between items.²⁹ Firstly, the corrected item-total correlation (CITC) between each item and the subscale it belonged to was computed. Items with CITC <0.2 were removed. Secondly, for each item, the Cronbach’s alpha based on the other 28 items was compared with the Cronbach’s alpha based on the whole instrument. Items showing an improvement in Cronbach’s alpha after its removal were also excluded from the shortened version. Thirdly, all items were fitted in an exploratory factor analysis (EFA) with 3 factors (corresponding to the 3-subscale structure of the instrument) using SAS PROC FACTOR with principal component extraction method applied to the Pearson correlation matrix. Factors were rotated using varimax orthogonal rotation. Items with a magnitude of loading <0.4 in all varimax-rotated factors were not selected. The remaining items formed the shortened version of the CCSBQ. If the instrument was longer than 20 items, more stringent benchmarks such as increasing the cutoff value of the CITC (<0.3) and the factor loading (<0.5) in the EFA, with justification by theoretical support, would be employed to further reduce the number of items until a sufficiently short final version was obtained.

Finally, a confirmatory factor analysis (CFA) of a 3-factor model was fitted on the final version using the development set by SAS PROC CALIS with unweighted least squares estimation applied to the Pearson correlation matrix. Goodness-of-fit indices were generated for assessment. These indices include the root mean square error of approximation (RMSEA; close to 0.06 or lower), standardized root mean square residual (SRMR; close to 0.08 or lower), goodness of fit index (GFI; close to 0.95 or higher), comparative fit index (CFI; close to 0.95 or higher), and non-normed fit index (NNFI, closer to 0.95 or higher), addressing the parsimony correction, absolute fit, and comparative or incremental fit.³⁰ The phrase “close to” was used because of the fluctuation of the cutoff value under different modeling conditions and other fit indices used. Addition of between-item covariances was made based on the largest modification indices to improve model fit.³¹

Part II – Psychometric Properties

In the validation process, the above-mentioned CFA and its assessment criteria were first applied to the validation set to examine whether the 3-factor structure was still satisfactory. The CITC for each item and the Cronbach’s alpha for the 3 subscales in the final CCSBQ version were also computed. It was expected that the correlation of each item with its own subscale would be at least moderate (correlation coefficient >0.4) and stronger than the correlation between this item and the competing subscales. Good item consistency was reflected by Cronbach’s alpha between 0.7 and 0.9 because a low alpha value indicates a low degree of homogeneity among the items, whereas a high value indicates item redundancy.³²

The subscale score for each subscale was then calculated by the average of all items within that subscale and then re-scaled to a range between 0 and 100. Half-rule was applied, that is, if at least half of the items in that subscale were answered and valid, missing values would be imputed by the mean of the responses in the same subscale. The distribution of the subscale scores as well as the ceiling and floor effects were evaluated. Construct validity was examined by testing hypotheses regarding the association of the subscales with the perception and behaviors in cervical screening. These included whether the respondents ever heard of cervical cancer and cervical screening, ever attended such screening, and the most recent and the next attendance to screening. It was hypothesized that those who ever heard of cervical cancer/cervical screening and those who attended screening more frequently would have higher subscale scores. Moreover, it was also hypothesized that women with a higher education level would score higher in the Knowledge subscale.

Results

A total of 930 women, comprising 340 Chinese, 296 Vietnamese, and 294 Arabic, were recruited and returned the questionnaire. However, 59 respondents were not eligible for this study, of which 37 were born in Australia, 16 had a history of cervical cancer, 3 did not answer whether they had such history, and 3 had removed their uterus despite having no cervical cancer. The remaining 871 respondents were randomly split into 2 sets with equal probability. As a result, 436 and 435 respondents were allocated to the development and validation sets, respectively.

Their demographics were summarized and compared in Table 1. The respondents had an average age of 44.8 years and had lived in Australia for 12.8 years. Most of them were married (69.8%), were well-educated (61.7% technical and further education (TAFE)/College/Tertiary or above), and engaged in full-time (28.7%) or part-time work (37.5%). The respondents also reported varying degrees of English proficiency, which was deemed to represent varying levels of acculturation. The development and validation sets were similar in all aspects of demographics (all P-values >.05).

Table 1.

Demographics of the 871 Participating Women.

Characteristics	Whole sample (N = 871)	Development set (n = 436)	Validation set (n = 435)	P ^a
Age in years
Mean (standard deviation)	44.8 (13.0)	44.3 (12.9)	44.4 (13.0)	.221
Median (interquartile range)	45 (35, 55)	44 (35, 54)	46 (36, 55)
Country of birth, n (%) (missing: 1)
China	333 (38.3%)	161 (37.0%)	172 (39.5%)	.332
Egypt	181 (20.8%)	89 (20.5%)	92 (21.2%)
Vietnam	281 (32.3%)	140 (32.2%)	141 (32.4%)
Others	75 (8.6%)	45 (10.3%)	30 (6.9%)
Years in Australia (missing: 1)
Mean (standard deviation)	12.8 (11.1)	13.3 (10.9)	12.3 (11.3)	.197
Median (interquartile range)	9 (5, 18)	10 (5, 18)	8 (4, 18)
Marital status, n (%) (missing: 1)
Married/Defacto	607 (69.8%)	308 (70.6%)	299 (68.9%)	.763
Single	119 (13.7%)	56 (12.8%)	63 (14.5%)
Divorced/Separated/Widowed	144 (16.6%)	72 (16.5%)	72 (16.6%)
Education level, n (%) (missing: 1)
Primary or below	84 (9.7%)	36 (8.3%)	48 (11.0%)	.338
High school	250 (28.7%)	119 (27.4%)	131 (30.1%)
TAFE/College	338 (38.9%)	177 (40.7%)	161 (37.0%)
Tertiary or above	198 (22.8%)	103 (23.7%)	95 (21.8%)
Employment, n (%) (missing: 4)
Working, full-time	249 (28.7%)	134 (30.9%)	115 (26.6%)	.607
Working, part-time	325 (37.5%)	161 (37.1%)	164 (37.9%)
Seeking work	71 (8.2%)	36 (8.3%)	35 (8.1%)
Housewife	140 (16.2%)	64 (14.8%)	76 (17.6%)
Retired	82 (9.5%)	39 (9.0%)	43 (9.9%)
English proficiency, n (%)
Very good	162 (17.8%)	71 (16.3%)	61 (14.0%)	.196
Good	229 (25.2%)	122 (28.0%)	106 (24.4%)
Average	256 (28.2%)	126 (28.9%)	124 (28.5%)
Little/Not at all	261 (28.7%)	117 (26.8%)	144 (33.1%)

Comparison between Development and Validation sets, two-sample t-test for continuous variables, chi-squared test for discrete variables.

Development of the Instrument

Using the development set, the corrected correlation of each item with its subscale exceeded the pre-specified cutoff of 0.2 for all items in the Attitude and Barriers subscales. Nevertheless, 3 items in the Knowledge subscale did not meet this criterion and were removed. The Cronbach’s alpha based on the whole 29-item instrument was 0.91. Improved Cronbach’s alphas were found by removing 1 item in the Attitude subscale and 4 items in the Knowledge subscale (3 of them were removed by the CITC above). Hence, 2 items were further excluded from the shortened version. In the EFA of a 3-factor model, after varimax rotation, all items showed a factor loading >0.4 except for 1 item in the Barriers subscale. This item was then removed, leaving 23 items remaining in the shortened version. This version, however, was still longer than the target length of 20 items.

Therefore, more stringent benchmarks of CITC >0.3 and factor loading >0.5 were considered, while items with loading close to 0.5 were also assessed qualitatively. These benchmarks further excluded 3 items in the Attitude subscale and 3 items in the Barriers subscale. Specifically, 2 items “If a woman is fated to get cervical cancer she will get cervical cancer, there is nothing she can do to change fate” and “I do not want to attend cervical screening test because it would be difficult to arrange transport,” having a factor loading of 0.48 and 0.49, respectively, were excluded since they were considered not relevant based on literature review. In contrast, another item “I never attended cervical screening test because I do not have enough knowledge about cervical cancer and cervical screening test” was retained in the final version despite a loading of 0.49. Finally, the shortened CCSBQ was formed by 17 selected items, consisting of 5 items in the Attitude subscale (renumbered as A1 to A5), 5 items in the Knowledge subscale (K1 to K5), and 7 items in the Barriers subscale (B1 to B7) (Table S1).

A CFA fitting the corresponding structure to the 3 subscales of the 17 items was performed based on the development set. Covariances between items A1 and A2 and between A3 and A4 were added to the model to improve model fit. A final 3-factor model is shown in Figure 1 and Table S2, and its goodness-of-fit indices are presented in Table 2. The indices were satisfactory, with some of them not strictly fulfilling the pre-specified criteria but close to the cutoff values.

Figure 1.

Path diagram of the confirmatory factor model on the final version Cervical Cancer Screening Beliefs Questionnaire using 436 respondents in the development set.

Table 2.

Goodness-Of-Fit Indices Assessing the Model Fit of the Confirmatory Factor Analysis.

Goodness-of-fit indices	Development set (n = 436)	Validation set (n = 435)	Whole sample (N = 871)
RMSEA estimate	0.067	0.056	0.059
95% confidence interval	0.059-0.076	0.047-0.064	0.053-0.064
SRMR	0.049	0.044	0.043
GFI	0.914	0.933	0.94
CFI	0.930	0.953	0.947
NNFI	0.916	0.944	0.937

Abbreviations: CFI, comparative fit index; GFI, goodness of fit index; NNFI, non-normed fit index; RMSEA, root mean square error of approximation; SRMR, standardized root mean square residual.

Psychometric Properties

Table 2 also presents the goodness-of-fit indices of the CFA applying to the validation set and to the whole sample. It was revealed that, compared to that based on the development set, the performance of the CFA was better based on the validation set.

The (corrected) correlations between each item and the 3 subscale scores of the final version of the CCSBQ are shown in Table 3. For the validation set, the corrected correlation coefficient between each item and its own subscale ranged from 0.39 to 0.76, reflecting moderate to strong correlations except 1 item (K3). Moreover, all but 2 (A5 and K1) items correlated with their own subscale more strongly than with the 2 competing subscales. Similar findings were obtained from the analysis based on the development set and the whole sample.

Table 3.

Corrected Item-Total Correlation for the Subscales of the Final Version Cervical Cancer Screening Beliefs Questionnaire.

Items	Development set (n = 436)			Validation set (n = 435)			Whole sample (N = 871)
Items	Attitudes	Knowledge	Barriers	Attitudes	Knowledge	Barriers	Attitudes	Knowledge	Barriers
Attitudes towards health check-up and cervical cancer
A1	0.71	0.37	0.52	0.75	0.45	0.61	0.73	0.41	0.57
A2	0.80	0.44	0.64	0.74	0.48	0.65	0.77	0.46	0.65
A3	0.76	0.38	0.57	0.76	0.42	0.58	0.76	0.40	0.57
A4	0.74	0.37	0.58	0.73	0.44	0.58	0.73	0.41	0.58
A5	0.57	0.40	0.57	0.58	0.44	0.58	0.57	0.42	0.57
Knowledge about cervical cancer and its screening
K1	0.47	0.52	0.52	0.49	0.46	0.48	0.48	0.49	0.49
K2	0.44	0.61	0.52	0.50	0.60	0.52	0.47	0.60	0.52
K3	0.18	0.42	0.30	0.19	0.39	0.25	0.18	0.40	0.28
K4	0.31	0.41	0.40	0.34	0.40	0.39	0.32	0.40	0.39
K5	0.23	0.42	0.34	0.32	0.48	0.38	0.28	0.45	0.36
Perceived barriers to cervical screening practices
B1	0.50	0.39	0.57	0.54	0.46	0.58	0.52	0.43	0.57
B2	0.51	0.37	0.57	0.49	0.37	0.53	0.50	0.37	0.55
B3	0.43	0.27	0.46	0.49	0.31	0.50	0.46	0.29	0.48
B4	0.46	0.43	0.57	0.52	0.43	0.54	0.49	0.43	0.56
B5	0.51	0.44	0.66	0.54	0.48	0.65	0.53	0.46	0.65
B6	0.56	0.56	0.66	0.57	0.49	0.66	0.57	0.53	0.66
B7	0.48	0.54	0.55	0.46	0.49	0.53	0.47	0.51	0.54

The Cronbach’s alphas of the Attitude, Knowledge and Barriers subscales were 0.88, 0.71, and 0.83, respectively, for both development and validation sets (Table 4). The subscale scores were then computed and summarized in Table 4 (Guidelines for computing the subscale scores can be found in Table S3). Two respondents in the validation set (and 3 in the development set) had missing values in one or more subscales beyond imputation by half-rule, hence the relevant subscale scores of these respondents were not included in the analysis. For the validation set, the mean (standard deviation) of the 3 subscales were 43.7 (25.1), 54.0 (17.1), and 56.0 (21.0), which were not much different from their respective median (40, 50, and 57.1). While the Attitude subscale showed some floor effect (9.4%), the Knowledge and Barriers subscales showed no (0%) floor effects. All 3 subscales did not encounter the problem of ceiling effects (1.6% to 1.8%).

Table 4.

Cronbach’s Alpha and Score Distribution of the Subscales of the Final Version Cervical Screening Beliefs Questionnaire.

Summary statistics	Development set (n = 436)	Validation set (n = 435)	Whole sample (N = 871)
Attitudes towards health check-up and cervical cancer
Cronbach’s alpha	0.88	0.88	0.88
Mean	45.6	43.7	44.7
Standard deviation	25.3	25.1	25.2
Median	45	40	40
Interquartile range	(25, 65)	(25, 65)	(25, 65)
n (%) at floor	39 (8.9%)	41 (9.4%)	80 (9.2%)
n (%) at ceiling	9 (2.1%)	7 (1.6%)	16 (1.8%)
Knowledge about cervical cancer and its screening
Cronbach’s alpha	0.71	0.71	0.71
Mean	53.9	54.0	54.0
Standard deviation	17.6	17.1	17.4
Median	50	50	50
Interquartile range	(40, 65)	(40, 65)	(40, 65)
n (%) at floor	0 (0%)	0 (0%)	0 (0%)
n (%) at ceiling	9 (2.1%)	8 (1.8%)	17 (2.0%)
Perceived barriers to cervical screening practices
Cronbach’s alpha	0.83	0.83	0.83
Mean	57.1	56.0	56.5
Standard deviation	21.2	21.0	21.1
Median	57.1	57.1	57.1
Interquartile range	(39.3, 75)	(39.3, 75)	(39.3, 75)
n (%) at floor	1 (0.2%)	0 (0%)	1 (0.1%)
n (%) at ceiling	13 (3.0%)	7 (1.6%)	20 (2.3%)

The mean subscale scores of various subgroups of the respondents were compared to investigate the construct validity of the CCSBQ (Table 5). The data showed that, for respondents in the validation set, the scores were significantly higher in the subgroups who (a) ever heard of cervical cancer, (b) ever heard of cervical screening, (c) ever attended cervical screening, (d) attended her most recent cervical screening within the last 5 years, and (e) intended to attend cervical screening in near future, for all 3 subscales (all P-values <.001). The mean difference was at least 10 points in all comparisons for the Attitude and Barriers subscales, and in most comparisons for the Knowledge subscale. It was also revealed that (f) respondents who attained a higher education level tended to score higher in the Knowledge subscale (P-value for trend <.001), although those who attained TAFE/college (50.4) obtained only a negligibly higher mean score than those who attained high school (50.7).

Table 5.

Construct Validity of the Final Version Cervical Screening Beliefs Questionnaire.

Validation criteria	Development set				Validation set				Whole sample
	Mean (SD)				Mean (SD)				Mean (SD)
	n	Attitudes	Knowledge	Barriers	n	Attitudes	Knowledge	Barriers	n	Attitudes	Knowledge	Barriers
Ever heard of cervical cancer
Yes	369	50.2 (22.0)	55.0 (17.5)	60.2 (19.5)	362	48.6 (21.9)	55.3 (17.1)	59.4 (19.3)	731	49.4 (21.9)	55.2 (17.3)	59.8 (19.4)
No	67	20.2 (27.4)	47.9 (17.3)	39.5 (21.9)	73	19.3 (25.9)	47.6 (16.1)	39.3 (21.0)	140	20.1 (26.7)	47.8 (16.6)	39.4 (21.4)
P-value for difference^a		<.001	.002	<.001		<.001	<.001	<.001		<.001	<.001	<.001
Ever heard of cervical screening
Yes	341	52.1 (21.8)	56.2 (18.0)	62.0 (19.0)	340	50.2 (22.0)	56.7 (17.4)	61.4 (18.6)	681	51.1 (21.9)	56.5 (17.7)	61.9 (18.8)
No	95	22.6 (23.3)	45.8 (13.3)	39.3 (19.2)	95	20.7 (21.8)	44.3 (12.2)	37.0 (17.7)	190	21.7 (22.6)	45.0 (12.7)	38.1 (18.4)
P-value for difference^a		<.001	<.001	<.001		<.001	<.001	<.001		<.001	<.001	<.001
Ever attended cervical screening
Yes	214	58.7 (21.2)	61.1 (16.6)	68.2 (16.4)	200	58.6 (21.2)	61.4 (15.6)	69.6 (15.9)	414	58.6 (21.1)	61.3 (16.1)	68.9 (16.2)
No	127	41.0 (18.0)	47.9 (17.4)	51.7 (18.7)	140	38.2 (17.2)	50.1 (17.6)	49.5 (15.6)	267	39.4 (17.6)	49.1 (17.5)	50.5 (17.2)
P-value for difference^a		<.001	<.001	<.001		<.001	<.001	<.001		<.001	<.001	<.001
Most recent cervical screening
Within the last 5 years	117	64.6 (20.3)	66.5 (16.3)	74.4 (14.8)	106	65.0 (19.5)	65.6 (15.7)	76.6 (12.6)	223	64.8 (19.9)	66.0 (16.0)	75.5 (13.8)
More than 5 years ago	97	51.6 (20.1)	54.7 (14.5)	60.7 (15.1)	94	51.4 (20.7)	56.6 (14.2)	61.6 (15.6)	191	51.5 (20.3)	55.6 (14.3)	61.2 (15.3)
P-value for difference^a		<.001	<.001	<.001		<.001	<.001	<.001		<.001	<.001	<.001
Intend to attend cervical screening in near future
Yes	219	54.5 (22.8)	60.9 (16.8)	66.0 (18.8)	194	57.3 (22.0)	63.3 (16.7)	69.0 (16.7)	413	55.8 (22.4)	62.0 (16.8)	67.4 (17.9)
No	217	36.8 (24.5)	46.8 (15.5)	48.1 (19.8)	241	32.8 (22.0)	46.6 (13.6)	45.6 (18.1)	458	34.7 (23.3)	46.7 (14.5)	46.8 (18.9)
P-value for difference^a		<.001	<.001	<.001		<.001	<.001	<.001		<.001	<.001	<.001
Education level (missing: 1)
Primary or below	36		43.6 (18.1)		36		46.5 (17.1)		85		45.2 (17.5)
High school	119		52.5 (15.9)		134		50.4 (14.5)		262		51.4 (15.2)
TAFE/College	177		50.1 (15.7)		174		50.7 (14.6)		347		50.4 (15.1)
Tertiary or above	103		65.5 (17.2)		108		68.6 (16.7)		213		66.9 (17.0)
P-value for trend^b			<.001				<.001				<.001

Two-sample t-test.

Cuzick’s non-parametric test for trend.

Discussion

Enhancing equitable health outcomes among racially and ethnically diverse populations, including immigrant communities in Western countries, requires cancer screening promotion interventions to be culturally sensitive.³³ Establishing a valid and reliable instrument is a crucial initial step toward the effective promotion of cervical screening among immigrant women. To our knowledge, the CCSBQ is the first culturally sensitive tool of its kind, representing a significant contribution to the existing literature on cancer prevention and health equity.

Psychometric examination of the shortened final-version CCSBQ demonstrated that the instrument is a culturally appropriate, valid and reliable for measuring immigrant women’s attitudes, beliefs, and knowledge about cervical cancer and its screening practice. The validation results supported a 3-factor structure encompassing attitudes and knowledge about cervical cancer and its screening, and perceived barriers toward cervical screening. These 3 subscales were thoroughly conceptualized to capture the complex interrelation of personal, cultural, psychological, and logistical influences that shape screening behaviors among immigrant women. In the CFA, 2 pairs of items in the Attitude subscale were found to be closely correlated, which warranted the inclusion of error covariance terms to improve model fit. We examined the conceptual rationale of the between-item associations and retained the covariance terms in the factor model. Specifically, the pair A1 (“If I feel well, it is not necessary for a health check-up e.g. cervical screening test”) and A2 (“If I follow a healthy lifestyle such as diet and exercise, I don’t feel it is necessary to have regular health check-up e.g. cervical screening test”) both negate the need for cervical screening when the respondent feels well or lives healthy, reflecting conceptually similar attitudes toward preventive health. The other pair, A3 (“I see a doctor or have my health check-up only when I have signs and symptoms”) and A4 (“If I feel alright, I do not need to see a doctor for health check-up”), both endorse symptom-driven health care, rejecting asymptomatic check-ups.

The final-version CCSBQ showed no more than 3% ceiling effects in all 3 subscales, and almost no floor effect in the Knowledge and Barriers subscales, but the floor effect for the Attitude subscale was a bit higher at approximately 9%. Nevertheless, according to the commonly used quality criteria recommended by Terwee et al,³⁴ it is acceptable if less than 15% of respondents achieved the lowest (floor effect) or highest (ceiling effect) possible score. Therefore, we believe that the sensitivity to distinguish between respondents or to detect longitudinal changes would not be substantially impacted.

In addition to displaying the minimal floor effects, the CCSBQ demonstrated strong internal consistency reliability, as evidenced by Cronbach’s alpha coefficients ranging from 0.71 to 0.88 across the 3 subscales, with no indication of item redundancy. Further support for internal consistency was shown by satisfactory corrected item-total correlations. It is noteworthy, however, that item A5 “I do not believe I am at risk of cervical cancer” and item K1 “If I have a regular sexual partner, I do not need to have cervical screening” appear to have similar correlation patterns across the other 2 subscales. This may be attributed to the conceptual overlap of A5 with both the knowledge and perceived barriers domains, as risk perception is often shaped by limited knowledge about cervical cancer and may consequently serve as a perceived barrier to screening.³⁵ Similarly, item K1, the association between having a regular partner and the need of cervical screening, may reflect underlying attitudes toward screening while also acting as a barrier to participation. This interpretation is supported by studies conducted among Korean American.³⁶ and Chinese Australian women,¹⁹ which reported that some individuals perceived that undergoing cervical screening implies sexual promiscuity, such as having multiple or frequent partners. Such perception can potentially serve as a significant deterrent to screening, particularly among women in committed relationships.

In terms of construct validity, the results indicated that the 3 subscales had a significant association with women who had ever heard of cervical cancer and cervical screening, and screening participation including ever attended and intention to attend in the near future. Notably, women who had undergone cervical screening within the recommended 5-year interval were more likely to have proactive attitudes toward general health check-ups, demonstrate better knowledge of cervical cancer and its screening, and perceive fewer barriers to participation. These associations offer valuable insights for informing the development of effective strategies to promote cervical screening practices among immigrant women, both in Australia and across other Western countries.

The significant association observed between the knowledge subscale and education level aligns with international studies, indicating that a higher educational level is a strong predictor of health knowledge,^37,38 including awareness of cancer and screening practices.^39,40 This relationship is particularly true among immigrant women. Given that education level is also closely linked to English proficiency, a key barrier for accessing health services,⁴¹ as such immigrant women with greater English proficiency are likely to have better access or understanding of health information, thereby increasing their likelihood of participating in cancer screening programs,⁴² including cervical screening. Therefore, targeted efforts are warranted to engage immigrant populations with lower levels of educational level, who may be at greater risk of limited access to health information and preventive services including cervical screening.

The study had several limitations. First, the participants were a convenience sample recruited exclusively from ethnic community organizations in Sydney, which means that socially isolated or less acculturated women were very likely underrepresented. Thus, the results cannot be generalized to the overall immigrant population. Second, because the study utilized self-reported measures of cervical screening practices, it was not possible to assess the accuracy of whether they were overreported or underreported. Further studies with adequate verification of self-reported information built into their design are warranted. Third, since this study primarily focused on the development and validation of the CCSBQ instrument, the recruitment of respondents from 3 ethnic groups was meant to form a good representative sample of immigrant minorities in Australia. Hence, the sample size was not sufficient for the comparison among the 3 ethnic groups and cross-cultural equivalence cannot be demonstrated. Lastly, the test-retest reliability of the instrument was not evaluated due to the cross-sectional study design. Future validation studies properly powered for cross-cultural comparison with a longitudinal setting are warranted.

Conclusion

For cervical screening to be effectively promoted among immigrant women, a reliable and valid instrument is essential for identifying the factors associated with their screening behaviors. As evidenced by the psychometric examination, we conclude that CCSBQ is culturally appropriate, valid and reliable for measuring immigrant women’s attitudes, beliefs, and knowledge about cervical cancer and its screening practice.

Supplemental Material

sj-docx-1-wjn-10.1177_01939459261440462 – Supplemental material for Cervical Cancer Screening Beliefs Questionnaire: Development and Psychometric Assessment With Immigrants in Australia

Supplemental material, sj-docx-1-wjn-10.1177_01939459261440462 for Cervical Cancer Screening Beliefs Questionnaire: Development and Psychometric Assessment With Immigrants in Australia by Cannas Kwok, Gihane Endrawes and Chun Fan Lee in Western Journal of Nursing Research

Footnotes

Acknowledgements

Our research team would like to acknowledge the community leaders and organizations who offered assistance in recruitment and the participants for their time to complete the questionnaire.

ORCID iD

Cannas Kwok

Ethical Considerations

The study was approved by the Human Research Ethics Committee of Western Sydney University with approval number (H14772). Returning the questionnaire was considered an indication of informed consent.

Author Contributions

All authors have contributed significantly to this manuscript and agree with its content. CK, GE, and CFL designed the study. GE collected the data. CFL analyzed the data. CK and CFL prepared the manuscript. All authors approved the final version for submission.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Women’s Fellowship, Western Sydney University and the Establishment Grant, Faculty of Science and Health, Charles Sturt University.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental Material for this article is available online.

References

World Health Organization. Cervical cancer. Accessed May 19, 2025. https://www.who.int/health-topics/cervical-cancer#tab=tab_1

National Cancer Institute. Cervical cancer screening. Accessed May 19, 2025. https://www.cancer.gov/types/cervical/screening

Canadian Partnership Against Cancer. Eliminating cervical cancer in Canada. Accessed May 19, 2025. https://cancer.ca/en/cancer-information/cancer-types/cervical

Cancer Research UK. Cervical cancer statistics. Accessed May 19, 2025. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer

Australian Institute of Health and Welfare. National Cervical Screening Program monitoring report 2023, catalogue number CAN 157, AIHW, Australian Government; 2023.

Lei

Lee

Cancer screening rates among Asian Americans: a cross-sectional secondary data analysis study. Cancer Control. 2023;30:10732748231202462. doi:10.1177/10732748231202462

Bolarinwa

Holt

Barriers to breast and cervical cancer screening uptake among Black, Asian, and Minority Ethnic women in the United Kingdom: evidence from a mixed-methods systematic review. BMC Health Serv Res. 2023;23(1):390. doi:10.1186/s12913-023-09410-x

Idehen

Koponen

Härkänen

Kangasniemi

Pietilä

Korhonen

Disparities in cervical screening participation: a comparison of Russian, Somali and Kurdish immigrants with the general Finnish population. Int J Equity Health. 2018;17(1):56. doi:10.1186/s12939-018-0768-2

Alam

Shafiee Hanjani

Dean

Janda

Cervical cancer screening among immigrant women residing in Australia: a systematic review. Asia Pac J Public Health. 2021;33(8):816-827. doi:10.1177/10105395211006600

10.

Benjamin

Lamberti

Cooke

Predictors of non-adherence to cervical cancer screening among immigrant women in Ontario, Canada. Prev Med Rep. 2023;36:102524. doi:10.1016/j.pmedr.2023.102524

11.

Rosato

Dalla Zuanna

Tricarico

Barbiellini Amidei

Canova

Adherence to cervical cancer screening programs in migrant populations: a systematic review and meta-analysis. Int J Environ Res Public Health. 2023;20(3):2200. doi:10.3390/ijerph20032200

12.

Moreno

Nogueira

Delgado

, et al. Misconceptions and knowledge gaps about HPV, cervical cancer, and HPV vaccination among central American immigrant parents in the United States. Hum Vaccin Immunother. 2025;21(1):2494452. doi:10.1080/21645515.2025.2494452

13.

Silva

Gama

Fronteira

Marques

Dias

Knowledge and attitudes towards cervical cancer and screening among migrant women: a qualitative study in Portugal. BMJ Open. 2024;20;14(12):e082538. doi:10.1136/bmjopen-2023-082538

14.

Chen

Zhang

, et al. Exploring Chinese women’s perception of cervical cancer risk as it impacts screening behavior: a qualitative Study. Cancer Nurs. 2017;40(4):E17-E25. doi:10.1097/NCC.0000000000000400

15.

Ozturk

Hossain

Mackey

Adam

Brennan

HPV and cervical cancer awareness and screening practices among migrant women: A narrative review. Healthcare (Basel). 2024;12(7):709. doi:10.3390/healthcare12070709

16.

Lee

MH.

Barriers to cervical cancer screening and prevention in young Korean immigrant women: Implications for intervention development. J Transcult Nurs. 2016;28(4):353-362. doi:10.1177/1043659616649670

17.

Salehiniya

Momenimovahed

Allahqoli

Momenimovahed

Alkatout

Factors related to cervical cancer screening among Asian women. Eur Rev Med Pharmacol Sci. 2021;25(19):6109-6122. doi:10.26355/eurrev_202110_26889

18.

Donnelly

TT.

The health-care practices of Vietnamese-Canadian women: cultural influences on breast and cervical cancer screening. Can J Nurs Res. 2006;38(1):82-101.

19.

Kwok

White

Roydhouse

JK.

Chinese-Australian women’s knowledge, facilitators and barriers related to cervical cancer screening: a qualitative study. J Immigr Minor Health. 2011;13(6):1076-1083. doi:10.1007/s10903-011-9491-4

20.

Amuta-Jimenez

Smith

GPA

Brown

KK.

Patterns and correlates of cervical cancer prevention among Black immigrant and African American women in the USA: the role of ethnicity and culture. J Cancer Educ. 2022;37(3):798-805. doi:10.1007/s13187-020-01884-1

21.

Ojerinde

Thorne

Howard

Kazanjian

Cervical cancer screening uptake and experiences of Black African immigrant women in Canada. Glob Qual Nurs Res. 2024;11:23333936241266997. doi:10.1177/23333936241266997

22.

Haward

Tatar

Zhu

, et al. Development and validation of the cervical cancer knowledge scale and HPV testing knowledge scale in a sample of Canadian women. Prev Med Rep. 2022;30:102017. doi:10.1016/j.pmedr.2022.102017

23.

Griffin-Mathieu

Haward

Tatar

, et al. Ensuring a successful transition from cytology to Human Papillomavirus-Based primary cervical cancer screening in Canada by investigating the psychosocial correlates of women’s intentions: protocol for an observational study. JMIR Res Protoc. 2022;11(6):e38917. doi:10.2196/38917

24.

Tatar

Haward

Zhu

, et al. Understanding the challenges of HPV-Based cervical screening: development and validation of HPV testing and self-sampling attitudes and beliefs scales. Curr Oncol. 2023;30(1):1206-1219. doi:10.3390/curroncol30010093

25.

United Nations. International migrant stock 2024. Accessed May 19, 2025. https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/undesa_pd_2025_intlmigstock_2024_key_facts_and_figures_advance-unedited.pdf

26.

Australian Bureau of Statistics. Australia population by country of birth. 2025. Accessed May 18, 2025. https://www.abs.gov.au/statistics/people/population/australias-population-country-birth/latest-release

27.

Tabachnick

Fidell

Using Multivariate Statistics. 4th ed. Allyn & Bacon; 2001.

28.

Burns

Grove

The Practice of Nursing Research: Conduct, Critique and Utilization. 5th ed. WB Saunders; 2005.

29.

Loose

Hou

Berinsky

AJ.

Achieving efficiency without losing accuracy: strategies for scale reduction with an application to risk attitudes and racial resentment. Social Science Quarterly. 2018;99(2):563-582. doi:10.1111/ssqu.12414

30.

Bentler

Cutoff criteria for fit indices in covariance structure analysis: conventional criteria versus new alternatives. Struct Equat Model. 1999;6(1):1-55. doi:10.1080/10705519909540118

31.

Brown

TA.

Confirmatory Factor Analysis for Applied Research. Guilford Press; 2006.

32.

Streiner

Norman

Health Measurement Scales. A Practical Guide to Their Development and Use. 2nd ed. Oxford University Press; 2008.

33.

Power

Ussher

Hawkey

, et al. Co-designed, culturally tailored cervical screening education with migrant and refugee women in Australia: a feasibility study. BMC Womens Health. 2022;22(1):353. doi:10.1186/s12905-022-01936-2

34.

Terwee

Bot

SDM

de Boer

, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42. doi:10.1016/j.jclinepi.2006.03.012

35.

Chan

Yang

Wang

Tao

Perception of cervical cancer risk and screening behavior: a literature review. Int J Nurs Knowl. 2015;26(1):2-18. doi:10.1111/2047-3095.12028

36.

Lee

SY.

Cultural factors associated with breast and cervical cancer screening in Korean American women in the US: an integrative literature review. Asian Nurs Res (Korean Soc Nurs Sci). 2015;9(2):81-90. doi:10.1016/j.anr.2015.05.003

37.

Ahmed

Kehyayan

Abdou

Bougmiza

Prevalence and determinants of health literacy among the adult population of Qatar. Front Public Health. 2023;11:1278614. doi:10.3389/fpubh.2023.1278614

38.

Liu

Zhang

Zeng

Xie

Health literacy and its associated factors among the population in two schistosomiasis-endemic villages in Jiangxi Province, China. Medicine (Baltimore). 2024;103(31):e39107. doi:10.1097/MD.0000000000039107

39.

Kwok

Lee

CF.

The role of education in breast cancer beliefs and screening practices among Korean women – a quantitative study. J Transcult Nurs. 2022;33(3):287-296. doi:10.1177/10436596211066812

40.

Anwar

Tampubolon

Van Hemelrijck

, et al. Determinants of cancer screening awareness and participation among Indonesian women. BMC Cancer. 2018;18(1):208. doi:10.1186/s12885-018-4125-z

41.

Unger

Orr

Avraham Alpert

Davidovitch

Shoham-Vardi

Social and structural determinants and their associations with patient experience in the emergency department. Int Emerg Nurs. 2022;61:101131. doi:10.1016/j.ienj.2021.101131

42.

Lee

Ewing

Holmes

Barriers and facilitators to colorectal cancer screening in South Asian immigrants: a systematic review. Asian Pac J Cancer Prev. 2023;24(5):1463-1475. doi:10.31557/APJCP.2023.24.5.1463

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.19 MB

0.00 MB