Background: Cervical cancer is the second most common cancer among women, and mortality from cervical cancer is especially high among women in low and middle-income countries(LMICs). In absence of well-organized vaccination programs, prevention of cervical cancer in LMICs largely relies on screening, yet participation in screening is often low. In addition to health system characteristics, socio-demographic factors, and individual perceptions, screening uptake may also depend on poor health literacy. This study aimed to explore the role of health literacy as a determinant of cervical cancer screening, in addition to socio-demographic factors, knowledge, attitudes, perceived norms and perceived control. 

Methods: This cross-sectional study included 607 sexually active women aged 20-60yrs, recruited through a stratified approach. A self-administered questionnaire was used based on the Health Belief Model and the Theory of Care Seeking Behaviour, consisting of items measuring knowledge about cervical cancer and screening, attitude, perceptions, health literacy, past cervical screening and screening intentions. Bivariate regression analysis was applied to identify the factors that predicted cervical cancer screening behaviour and intention.

Results:  About 11% of the women in the sample had undergone cervical screening in the past and 70% intended to get screened in the future. 57% (n=344) of the participants were unsure about the procedure, and 48%(n=289) were shy to undergo screening. The overall knowledge about cervical cancer and screening was low. The presence of symptoms and having heard of cervical cancer were significant predictors of past screening uptake, while knowledge about the test and accessibility of a screening facility were the most significant predictors of screening intention. The Health belief model was a best predictor of past screening uptake, and the Theory of Care Seeking Behaviour predicted screening intention. Health literacy was significantly associated with screening intention.

Discussion: Several factors like individual beliefs, knowledge can be modified to increase uptake. The application of health behaviour theories helps to understand screening behaviour and can be used to improve screening uptake. The variables included in these models are moderated by the health literacy status, suggesting that improving health literacy can help to increase preventive behaviour and health outcomes of Indian women.