participants were chinese women with a hong kong permanent identity card who were : 
 aged 1865 years;able to read chinese or english;not pregnant . able to read chinese or english ; the study was approved by the institutional review board of the university of hong kong . a total of 379 women were recruited in a private medical center in hong kong . those who consented to take part were given a set of questionnaires to be completed while waiting to see the doctors , and these completed questionnaires were returned to the researcher directly . a validated scale was used to assess women s health perception , knowledge about cervical screening and the risk factors of cervical cancer . the original questionnaire was developed by seow and associates in singapore.18 the scale was translated into chinese and used in studies in hong kong.13,19,20 minor modifications were made from a telephone survey to a self - administered questionnaire for this study . the questionnaire consisted of the following sections : 
 health perception and health behavior;general knowledge on cervical screening , cervical cancer and the risk factors;socio - demographic characteristics . health perception and health behavior ; general knowledge on cervical screening , cervical cancer and the risk factors ; socio - demographic characteristics . section a consisted of 11 questions including how the respondents perceived their own health , perceived control over health , their concerns about family / relatives health and the influence of family / relatives health . section b consisted of 9 items to test the participants on their general knowledge of cervical screening and cervical cancer , and 9 items on the risk factors . cronbach s alphas were 0.62 , 0.60 and 0.63 for general knowledge , knowledge on risk factors and total knowledge scales , respectively . section c consisted of demographics data including age , education level , monthly household income , marital status , number of children , and regular sources of health care . pearson s correlation was examined for the relationships between cervical screening and age , education , income , knowledge , and health perception . the  test was used to examine the relationships between screening and non - parametric variables . differences between screening and non - screening for knowledge were demonstrated by independent t - test . logistic regression was used to indicate health perception , knowledge , and risk of cervical cancer as well as demographic factors associated with cervical cancer screening . factors included in the logistic model were age , education , income , perceived health , perceived controlled over health , concerns about family / relatives health , and health behaviors influenced by their health , general knowledge on cervical screening and cancer , and knowledge on risk factors . the hosmer and lemeshow  test of goodness - of - fit was used to test the overall fit of the logistic model . participants were chinese women with a hong kong permanent identity card who were : 
 aged 1865 years;able to read chinese or english;not pregnant . able to read chinese or english ; the study was approved by the institutional review board of the university of hong kong . a total of 379 women were recruited in a private medical center in hong kong . those who consented to take part were given a set of questionnaires to be completed while waiting to see the doctors , and these completed questionnaires were returned to the researcher directly . a validated scale was used to assess women s health perception , knowledge about cervical screening and the risk factors of cervical cancer . the original questionnaire was developed by seow and associates in singapore.18 the scale was translated into chinese and used in studies in hong kong.13,19,20 minor modifications were made from a telephone survey to a self - administered questionnaire for this study . the questionnaire consisted of the following sections : 
 health perception and health behavior;general knowledge on cervical screening , cervical cancer and the risk factors;socio - demographic characteristics . health perception and health behavior ; general knowledge on cervical screening , cervical cancer and the risk factors ; socio - demographic characteristics . section a consisted of 11 questions including how the respondents perceived their own health , perceived control over health , their concerns about family / relatives health and the influence of family / relatives health . section b consisted of 9 items to test the participants on their general knowledge of cervical screening and cervical cancer , and 9 items on the risk factors . cronbach s alphas were 0.62 , 0.60 and 0.63 for general knowledge , knowledge on risk factors and total knowledge scales , respectively . section c consisted of demographics data including age , education level , monthly household income , marital status , number of children , and regular sources of health care . pearson s correlation was examined for the relationships between cervical screening and age , education , income , knowledge , and health perception . the  test was used to examine the relationships between screening and non - parametric variables . differences between screening and non - screening for knowledge were demonstrated by independent t - test . logistic regression was used to indicate health perception , knowledge , and risk of cervical cancer as well as demographic factors associated with cervical cancer screening . factors included in the logistic model were age , education , income , perceived health , perceived controlled over health , concerns about family / relatives health , and health behaviors influenced by their health , general knowledge on cervical screening and cancer , and knowledge on risk factors . the hosmer and lemeshow  test of goodness - of - fit was used to test the overall fit of the logistic model . 385 were eligible and agreed to participate giving a response rate of 92% and 35 found to be ineligible and/or unwilling to participate . more than half of the participants ( n = 194 , 51.2% ) were educated to tertiary or higher level , almost half of them ( n = 183 , 48.3% ) had received secondary education and only 2 ( 0.5% ) had received no formal education . 54.4% ( n = 206 ) of the participants were married and 41.4% ( n = 157 ) were single . sixty - nine ( 18.2% ) of the participants had never attended screening and 33 ( 8.7% ) said that they never thought of having such a test . table 1 shows the frequencies of health perception on self and families , age and education , and their correlations with cervical screening . screening was also significantly correlated with knowledge on cervical screening , cervical cancer and risk factors ( table 1 ) . the mean total knowledge score was higher for screening than non - screening ( t = 6.47 , p < 0.001 ) . do nt know  answers to each item on general knowledge and knowledge of risk factors . only about one - fifth of the women ( 19.3% ) received a full score on general knowledge and only 0.3% had a full score on the risk factors . high percentages of women reported they did not know whether some items were risk factors ( 17.9% to 41.2% for 5 out of the 9 risk factors ) . more than half of the participants ( 66.2% ) considered themselves healthy and only 5.5% reported themselves as not healthy . less than one - third of the participants ( 28.5% ) believed that they did not have control of their health . very high percentages ( 95.3% ) were concerned about family or relatives health and half of the participants reported that their health behaviors were influenced by family or relatives health . cervical screening was significantly correlated with health perception except when influenced by family / relatives health ( table 1 ) . hosmer and lemeshow goodness - of - fit test indicated a good fit of the logistic model (  = 4.734 , df = 8 , p = 0.786 ) . nagelkertke s r was 0.608 which was an index of approximation to r from ols regression . the significant factors identified were age , education , control over their own health , and knowledge on risk factors , after controlling for all other factors in the model . younger participants ( 37 years ) , had attained tertiary education , perceived having control over their own health , and had better knowledge of risk factors were more likely to attend cervical screening . 385 were eligible and agreed to participate giving a response rate of 92% and 35 found to be ineligible and/or unwilling to participate . more than half of the participants ( n = 194 , 51.2% ) were educated to tertiary or higher level , almost half of them ( n = 183 , 48.3% ) had received secondary education and only 2 ( 0.5% ) had received no formal education . 54.4% ( n = 206 ) of the participants were married and 41.4% ( n = 157 ) were single . sixty - nine ( 18.2% ) of the participants had never attended screening and 33 ( 8.7% ) said that they never thought of having such a test . table 1 shows the frequencies of health perception on self and families , age and education , and their correlations with cervical screening . screening was also significantly correlated with knowledge on cervical screening , cervical cancer and risk factors ( table 1 ) . the mean total knowledge score was higher for screening than non - screening ( t = 6.47 , p < 0.001 ) . do nt know  answers to each item on general knowledge and knowledge of risk factors . only about one - fifth of the women ( 19.3% ) received a full score on general knowledge and only 0.3% had a full score on the risk factors . high percentages of women reported they did not know whether some items were risk factors ( 17.9% to 41.2% for 5 out of the 9 risk factors ) . more than half of the participants ( 66.2% ) considered themselves healthy and only 5.5% reported themselves as not healthy . less than one - third of the participants ( 28.5% ) believed that they did not have control of their health . very high percentages ( 95.3% ) were concerned about family or relatives health and half of the participants reported that their health behaviors were influenced by family or relatives health . cervical screening was significantly correlated with health perception except when influenced by family / relatives health ( table 1 ) . table 3 shows odds ratios of the predictors on cervical screening with logistic regression . hosmer and lemeshow goodness - of - fit test indicated a good fit of the logistic model (  = 4.734 , df = 8 , p = 0.786 ) . nagelkertke s r was 0.608 which was an index of approximation to r from ols regression . the significant factors identified were age , education , control over their own health , and knowledge on risk factors , after controlling for all other factors in the model . younger participants ( 37 years ) , had attained tertiary education , perceived having control over their own health , and had better knowledge of risk factors were more likely to attend cervical screening . this study reports the determinants of cervical screening among demographic variables , knowledge on cervical screening and cancer and health perception . in this study , females aged 37 years or younger were more likely to attend cervical screening . however , statistics in hong kong showed that the average age - specific incidence rate of cervical cancer increased sharply after 55 years of age with a peak at aged 65 over the period of 2003 to 2007 , and the cervical cancer was the eighth most common cause of registered death in females in 2007.9 more active health promotion and education efforts should target females approaching 40 years and older . the 3 questions most often answered correctly in the general knowledge section were : 
 it has to be done routinely to be effective;screening was still needed even if they had not had sex for years;getting old was not a reason to not attend cervical screening . it has to be done routinely to be effective ; screening was still needed even if they had not had sex for years ; getting old was not a reason to not attend cervical screening . however , many participants thought that once women reach menopause , cervical screening was not needed . these apparent contradicting findings showed that participants might define menopause as an indicator of being  old enough  to be spared from cervical screening . education on menopause and screening should be emphasized by doctors and nurses engaged in health - promoting activities . our findings also showed that participants were aware of the importance of having regular screening and a healthy lifestyle . however , quite a number of participants did not have accurate knowledge on risk factors and had a higher chance of failing to attend cervical screening . such knowledge deficits probably explain why a significant number of women do not take advantage of cervical screening even though its efficacy is well known . these results also lend support to a recent qualitative study among african americans which found that personal beliefs on screening , perception of vulnerability , and providing correct information might increase screening rates.21 the majority of participants correctly identified that having a previous abnormal cervical smear was one of the risk factors . the next most commonly identified risk factors were : having sex at early age ; many different sexual partners ; and sexually transmitted disease . this finding was somewhat different from reports in the united kingdom in which only 14% of the population sample were aware of a link between cervical cancer and sexual transmission.22 another qualitative study on women who took part in human papillomavirus ( hpv ) testing also found that many participants did not recognize the link between cervical cancer and sex or sexually transmitted disease.23 authors in those earlier studies conjectured that generally women were aware of the link between cervical cancer and sexual activity but did not clearly conceptualize the linkage between cervical cancer and hpv . they thus emphasized the role of healthcare providers in providing clear and consistent information of the sexually transmitted nature of cervical cancer . the findings in this current study agreed with kemm and close s concept of internal locus of control.24 most of the participants ( 71.5% ) perceived they have control of their health , which concurred with the high cervical screening . this group of women is more likely to take the initiative to engage in health - promoting activities such as cervical screening . women s knowledge on cervical cancer and risk factors affected their perception of the severity of illness and their own susceptibility to it . health care providers need to take into account women s knowledge and health perception when developing a cervical screening program . accurate information must be readily available to women to increase their knowledge , especially on the risk factors associated with cervical cancer , to guide them on the importance of regular screening . health professionals also need to further explore women s perceived ability to their control health and the effect on changing their beliefs of clearer information on the treatability and significant reduction in mortality and morbidity with early detection . women educated to higher level are more likely to have a better knowledge of cervical screening and cervical cancer , leading to their participation in cervical screening . women with a higher level of education are more likely to gather new information by themselves or have a faster channel to reach up - to - date information . more active promotion strategies ought to be channeled through media that are appropriate to reach women with less education . publicity through different means should be considered , such as tv , radio commercials and newspapers . health education through trained lay persons in community centers could also be considered as this has been reported to be an effective method in several studies.2527 this study has limitations on the design and sampling . it was a cross - sectional study with some longitudinal data for identifying prediction of screening at follow - up . there were a number of issues where this sampling methodology could be improved : 
 participants were recruited with convenience sampling and showed to have higher percentage with tertiary education compared to the general populations which raises some questions about generalizing these findings to the greater hong kong population.screening was self - reported data without comparison to any objective medical records and thus the identified factors may be different from those related to the actual cervical screening.the questionnaires did not assess participants knowledge on human papilloma virus which was important information relating to cervical screening . participants were recruited with convenience sampling and showed to have higher percentage with tertiary education compared to the general populations which raises some questions about generalizing these findings to the greater hong kong population . screening was self - reported data without comparison to any objective medical records and thus the identified factors may be different from those related to the actual cervical screening . the questionnaires did not assess participants knowledge on human papilloma virus which was important information relating to cervical screening . the study identifies that the lack of knowledge particularly on risk factors of cervical cancer and the importance of perceived control over health are significant factors influencing cervical cancer screening among chinese . this study can contribute to the development of a multi - strategy health program that will take into account women s perceptions of cervical screening and cancer and emphasize a non - stigmatizing approach to encourage chinese women to attend cervical screening . the role of nurses in cervical screening programs needs to be further explored as public health nurses are commonly the ones who take smears.28 women need to accept the correct concept at an earlier stage , thus normalizing the behavior of taking part in health - promoting activities such as cervical screening .