Modeling breast cancer screening hesitancy among Chinese women: integrating the Knowledge-Attitude-Practice, health belief, and 5 C frameworks.
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BACKGROUND: Breast cancer screening hesitancy remains a major public health concern in China, where institutional screening resources are unevenly distributed. Breast self-examination is a simple, low-cost method suitable for resource-limited settings, yet participation remains suboptimal. Previous studies have predominantly focused on knowledge and beliefs in isolation, with limited integration of broader psychological constructs. This study examined psychological mechanisms by integrating the Knowledge-Attitude-Practice framework, the Health Belief Model, and a 5 C hesitancy model. METHODS: A multistage cross-sectional survey of 849 Chinese women aged 18-70 years in Guizhou Province used three validated instruments: a 19-item Knowledge-Attitude-Practice questionnaire, a 22-item HBM scale, and a 20-item 5 C hesitancy scales. Structural equation modeling (SEM) assessed direct and mediated pathways among knowledge, practice, health beliefs, and hesitancy. Moderation analyses and multi-group invariance tests evaluated psychosocial and sociodemographic influences. RESULTS: The item-level structural equation model demonstrated acceptable fit (CFI = 0.938, TLI = 0.934, RMSEA = 0.069, SRMR = 0.085). Knowledge and practice were significantly associated with Health Belief Model constructs, which subsequently showed distinct patterns of association with the five dimensions of the 5 C framework. The model demonstrated adequate explanatory capacity for key belief- and hesitancy-related constructs. Moderation analyses indicated that several structural relationships varied by self-efficacy, income, and education. Multi-group structural equation modeling supported structural invariance across demographic groups. CONCLUSION: Self-efficacy, perceived barriers, and cues to action were the strongest determinants of BSE hesitancy. The integrative KAP-HBM-5 C framework clarified the cognitive-belief-motivation pathways linking knowledge and practice to screening behavior. These findings highlight potential psychological leverage points for future intervention development, particularly with respect to strengthening self-efficacy, reducing perceived barriers, and enhancing actionable cues to promote sustainable screening behavior in community settings.