Decisional balance and self-efficacy mediate the association among provider advice, health literacy and cervical cancer screening

Kyounghae Kim, Qian Li Xue, Benita Jeanne Walton Moss, Marie T. Nolan, Hae Ra Han

Research output: Contribution to journalArticlepeer-review


Purpose Health literacy has emerged as a potential determinant of cancer screening, yet limited literature has investigated the pathways which health literacy influences Pap tests among immigrant women who experience a higher incidence of cervical cancer. This study aimed to test a health literacy-focused sociocognitive model which proposes motivational (knowledge, decisional balance) and volitional (self-efficacy) factors mediating the association between health literacy and triennial Pap tests. Methods Using structural equation modeling, we conducted a secondary analysis of baseline data obtained from a randomized controlled trial to promote breast and cervical cancer screenings among 560 Korean American women 21–65 years of age. They were interviewed on demographics such as education and English proficiency, provider advice, health literacy, knowledge of cervical cancer, decisional balance for Pap tests, self-efficacy, and Pap test use. Results Higher health literacy predicted high level of knowledge and high decisional balance score, and greater self-efficacy and then only decisional balance and self-efficacy affected Pap tests. High level of knowledge predicted Pap tests through its impact on the decisional balance score. Receiving provider advice both directly and indirectly predicted Pap tests through high level of health literacy, high level of decisional balance and greater self-efficacy. Conclusions Findings from this study suggest possible pathways through which provider advice and health literacy affect Pap tests. Interventions targeting immigrant women with limited English proficiency should consider skill-based approaches such as health literacy training, promoting patient-provider communications and emphasizing decisional balance and self-efficacy as potentially sustainable ways of promoting Pap tests.

Original languageEnglish (US)
Pages (from-to)55-62
Number of pages8
JournalEuropean Journal of Oncology Nursing
StatePublished - Feb 2018


  • Health literacy
  • Immigrant women
  • Pap test use
  • Provider advice
  • Psychosocial determinants
  • Structural equation modeling

ASJC Scopus subject areas

  • Oncology(nursing)


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