Introduction
Cervical cancer is the fourth-most prevalent cancer among women worldwide. It is a significant public health issue, resulting in approximately 604,000 new cases and 342,000 deaths in 2020 [
1].Moreover, about 90% of cervical cancer cases and deaths occur in low- and middle-income countries [
2]. In 2016, China reported 32,000 cervical cancer cases and 10,000 deaths, ranking it the eighth leading cause of cancer-related deaths in women[
3].Over the past decade, China has experienced an increase in cervical cancer incidence from 5.4 to 12.3 per 100,000 and mortality rates from 1.1 to 3.5 per 100,000, contributing to a growing disease burden [
4].
Human papillomavirus (HPV) infection causes 90% percent of cervical cancers. Thus, the adoption of primary and secondary prevention methods can effectively prevent cervical cancer [
5,
6]. The World Health Assembly adopted a global strategy in August 2020 to eliminate cervical cancer. This strategy set a goal for all countries to achieve and maintain an incidence rate of less than four per 100,000 women. Additionally, the plan proposed adopting a tertiary prevention strategy by 2030 to eliminate cervical cancer in the future [
7]. Notably, developed countries have witnessed a decline in cervical cancer incidence due to the implementation of effective cervical screenings and the provision of free HPV vaccinations [
8‐
10]. Cervical cancer screening and free HPV vaccination have reduced cervical cancer mortality rates. However, the success of these programs relied heavily on public awareness of cervical cancer prevention [
11].
The concept of cervical cancer health literacy refers to individuals’ capacity to obtain, process, and comprehend basic health information and services that will enable them to make appropriate health decisions. Improving cervical cancer health literacy levels is one of the keys to preventing cervical cancer [
12]. Several studies have shown that an increased level of cervical cancer health literacy is associated with improved HPV vaccination, cervical cancer screening, and treatment [
13‐
15]. In China, the HPV vaccine is not part of the national immunization program. However, a cervical cancer screening program was initiated in 2009 for rural women aged 35–64 as part of primary healthcare. Despite this, a recent study found that only 25.7% of women aged 20–64 in China had undergone previous screening for cervical cancer in 2015 [
16]. Based on the number of HPV vaccine doses administered nationwide, it is estimated that, in 2020, the HPV vaccination rate for women aged 9–45 years was 2.24% in China [
17]. However, rates of HPV vaccine uptake and cervical cancer screening in China are low, indicating a lack of health literacy. Despite the crucial role of health literacy in cervical cancer prevention, adult women in many regions are estimated to have limited or basic cervical cancer health literacy levels [
18‐
22]. A valid and reliable instrument for assessing cervical cancer health literacy is the first step in developing interventions to increase knowledge and uptake of cervical cancer prevention services. In China, most cervical cancer health literacy surveys use self-developed questionnaires that have not been developed following a comprehensive, integrated, and systematic process [
23‐
25]. Furthermore, foreign evaluation tools are also not suitable for Chinese women [
26]. Therefore, this study sought to create an evaluation indicator for cervical cancer health literacy in order to assess women’s knowledge about the tertiary prevention of cervical cancer and to provide a more scientific basis for the development of assessment tools.
Discussion
Based on both rounds of modified Delphi consultation, we developed a system for evaluating Chinese women’s cervical cancer health literacy and determined the weights of all indicators. There are 4 first-level indicators, 9 second-level indicators, and 32 third-level indicators in this system, which provides a scientific reference for improving cervical cancer health literacy among Chinese women.
In terms of research methods, the response rates in both rounds of Delphi consultation were high, indicating that the experts were committed to this project and appreciated its significance. The study’s experts were all highly educated and had extensive work experience in diverse fields, including women’s health, cervical cancer diagnosis and treatment research, health education, and disease prevention. There was a robust result, as the authoritative coefficient was 0.93. The Kendall’s W test scores ranged between 0.168 and 0.248 in both rounds, indicating that the results of the indicator system are reliable and can describe and explain the level of cervical cancer health literacy among Chinese women scientifically, accurately, and reliably.
In terms of indicator content, the indicator system includes basic knowledge and attitudes about primary, secondary, and tertiary prevention measures of cervical cancer, and it focuses on all aspects of tertiary prevention of cervical cancer and can serve as a reference for cervical cancer prevention efforts, enabling a more comprehensive assessment of cervical cancer health literacy. In other countries, cervical cancer health literacy scales have been developed, but these scales primarily focus on perceptions of cervical cancer’s severity and susceptibility as well as health behavior [
20,
27,
32]. As a result, they do not provide a comprehensive view of the cervical cancer tertiary prevention process as a whole. In some studies, both primary and secondary prevention of cervical cancer were examined; one used a questionnaire for measuring knowledge about cervical cancer among women in Oman aged 20–65 years that contained four main domains of knowledge, including knowledge about general cervical cancer, knowledge about risk factors associated with the disease, and knowledge about primary and secondary prevention [
33]. In contrast to the evaluation system we developed for cervical cancer health literacy among Chinese women, this earlier questionnaire did not include information on tertiary prevention of cervical cancer, such as seeking medical attention on time to treat early cervical cancer. Several assessments of cervical cancer knowledge and prevention are also available, but they focus primarily on female high school and university students [
34,
35].
Among the four first-level indicators in this study, the weights of basic knowledge and attitudes about cervical cancer, cervical cancer primary prevention literacy, cervical cancer secondary prevention literacy, and cervical cancer tertiary prevention literacy were 0.257, 0.249, 0.251, and 0.243, respectively. According to the weighted indicators, cervical cancer secondary prevention literacy (0.251) received the highest score, which indicates that women need to be educated on cervical cancer screening, early detection, and the symptoms of cervical cancer. Meanwhile, cervical cancer tertiary prevention literacy received the lowest weighted indicator (0.243), which indicates that experts believe that knowledge regarding seeking timely medical care after a cervical cancer diagnosis is relatively less important for the average woman. This is in line with the needs of health education work and suggests that cervical cancer patients could be the focus of this part of the work.
The assessment indicators prioritized tertiary prevention to reduce cervical cancer incidence and mortality in Chinese women. It identified knowledge gaps in cervical cancer prevention and provided targeted educational materials and interventions to increase awareness of cervical cancer and its risk factors. This evaluation indicator can give a more comprehensive assessment of cervical cancer health knowledge among Chinese women. It can help policymakers assess the effectiveness of prevention efforts, identify areas of low ability, and inform targeted policies and interventions. Collaboration between researchers, healthcare providers, and policymakers is crucial for effectively implementing the evaluation system in China’s cervical cancer prevention and health education programs. We suggested integrating the system with existing prevention efforts, using culturally appropriate indicators, and continuously evaluating program effectiveness. This study developed an indicator system suitable for Chinese women for cervical cancer health literacy by fully incorporating existing knowledge indicators for tertiary prevention of cervical cancer. We conducted an extensive literature review and expert interviews to ensure comprehensiveness and representativeness. The inclusion of experts in various fields of cervical cancer prevention assured the authority and validity of the Delphi survey data. However, as Chinese women lack knowledge about cervical cancer prevention, we did not interview them for cervical cancer health knowledge indicators. Instead, experts were asked to select indicators from the perspective of the average Chinese woman. Although the indicator system has not yet been implemented in a large sample of Chinese women, we plan to validate its reliability and validity in a follow-up study.
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