Background: Cervical cancer is a preventable yet persistent threat to women's health in India, ranking as the second most common cancer among women nationwide. Despite the proven efficacy of early screening methods like Pap smears and preventive tools such as HPV vaccination, awareness and uptake remain critically low, especially in semi-urban and rural areas like Kangra, Himachal Pradesh. Sociocultural taboos, limited health education, and misconceptions surrounding cervical cancer and its risk factors hinder early detection and timely intervention. Materials and Methods: This cross-sectional study was conducted from October to December 2024 across urban and rural areas of Kangra district. A total of 400 adults aged 18 years and above participated through a mixed sampling strategy. Data were collected using a pre-tested bilingual questionnaire that assessed demographic characteristics, cervical cancer knowledge, screening awareness, HPV-related understanding, and perception toward preventive care. Online responses were gathered. Statistical analysis was performed using SPSS v 26.0 to generate descriptive summaries. Results: Among the participants, 77.8% were female, and 56.5% resided in rural areas. While 78.0% correctly identified cervical cancer as a malignancy of the cervix and 75.3% recognized HPV as the leading cause, notable misconceptions remained: only 66.8% knew HPV vaccination is not gender-specific, and just 67.5% supported screening for unmarried women. Overall, 38.8% demonstrated very good knowledge, 40.3% good, 15.3% fair, and 5.8% poor. Encouragingly, 79.8% expressed willingness to attend screening camps, suggesting openness to preventive action if access and stigma are addressed. Conclusion: Although baseline awareness of cervical cancer and its prevention in Kangra is relatively high, significant informational and cultural gaps persist, particularly regarding HPV transmission, vaccine eligibility, and attitudes toward screening. To improve outcomes, interventions must go beyond basic education and focus on debunking myths, normalizing gynecological care, and integrating services within existing community health frameworks. Inclusive, gender-sensitive strategies and rural outreach are key to empowering individuals and reducing the cervical cancer burden.
Cervical cancer remains one of the leading causes of cancer-related morbidity and mortality among women worldwide, despite being largely preventable and treatable when detected early. It is the fourth most common cancer in women globally and ranks second in India, where it accounts for a significant proportion of female cancer deaths each year. Caused primarily by persistent infection with high-risk strains of the human papillomavirus (HPV), cervical cancer develops slowly over time, offering a crucial window for screening, early diagnosis, and preventive intervention. Yet, in many parts of India-particularly rural and semi-urban regions-awareness of cervical cancer, its risk factors, and available screening tools remains alarmingly low [1-4].
In districts like Kangra, Himachal Pradesh, multiple socio-cultural and systemic factors contribute to the underutilization of cervical cancer screening services. These include a lack of awareness about the disease, limited access to gynecological care, low prioritization of women's preventive health, misconceptions about HPV and its vaccine, and cultural stigma surrounding gynecological examinations. Women often remain unaware of the Pap smear and visual inspection with acetic acid (VIA)-cost-effective and proven screening methods-or may avoid these services due to fear, embarrassment, or social restrictions. The HPV vaccine, a cornerstone of cervical cancer prevention, also suffers from poor uptake due to limited public education and concerns about safety, side effects, and appropriateness for adolescent girls [5-7].
Early detection through regular screening and timely HPV vaccination are critical in reducing the cervical cancer burden, yet both require a foundation of community awareness and favorable perception. Understanding how women and communities perceive cervical cancer, their knowledge of its prevention, and their willingness to participate in screening programs is essential for designing effective public health interventions [8-10].
This study aims to assess the level of awareness, attitudes, and perceptions regarding cervical cancer screening and prevention among adults in Kangra. By identifying knowledge gaps, behavioral barriers, and informational needs, the findings will help inform more targeted, culturally sensitive educational campaigns and strengthen cervical cancer control efforts in underserved populations.
Study Design
This research employed a descriptive, cross-sectional study design to evaluate the awareness, knowledge, and perception of cervical cancer screening and prevention among adults in Kangra district, Himachal Pradesh. The study design enabled the collection of data at a single point in time, providing a comprehensive snapshot of community-level understanding and attitudes toward cervical cancer and its preventive strategies, including HPV vaccination and routine screening.
Study Area and Population
The study was conducted in Kangra, a predominantly rural district in Himachal Pradesh, characterized by a mix of urban townships, semi-urban settlements, and remote villages. The target population included adult residents (aged 18 years and above) of Kangra, with a focus on individuals assigned female at birth. The inclusion of both genders was aimed at gauging community-wide perceptions, recognizing the role of male family members in influencing women’s health decisions in traditional households.
Table 1: Socio-Demographic Characteristics of Participants (Kangra)
Variable | Category | Frequency (n) | Percentage |
Age Group (Years) | 18–25 | 83 | 20.8% |
26–35 | 144 | 36.0% | |
36–45 | 117 | 29.3% | |
46 and above | 56 | 14.0% | |
Gender | Female | 311 | 77.8% |
Male | 89 | 22.3% | |
Education Level | No formal education | 17 | 4.3% |
Primary school | 52 | 13.0% | |
Secondary school | 124 | 31.0% | |
Undergraduate degree | 147 | 36.8% | |
Postgraduate degree | 60 | 15.0% | |
Occupation | Homemaker | 102 | 25.5% |
Office Worker | 91 | 22.8% | |
Teacher | 60 | 15.0% | |
Healthcare Professional | 49 | 12.3% | |
Student | 57 | 14.3% | |
Other | 41 | 10.3% | |
Residential Setting | Urban | 174 | 43.5% |
Rural | 226 | 56.5% |
Study Duration
The data collection was carried out over a three-month period from October to December 2024, allowing sufficient time for both in-person and digital outreach across varying geographic and accessibility zones within Kangra.
Sample Size and Sampling Technique
A total of 400 participants were included in the study. The sample size was calculated using a 95% confidence interval, 5% margin of error, and an assumed awareness prevalence of 50%, with a 10% addition to account for non-responses and incomplete questionnaires. Convenience sampling was employed for broader community engagement.
Inclusion and Exclusion Criteria
Inclusion Criteria
Adults aged 18 years and above
Permanent residents of Kangra district
Able to comprehend and respond in Hindi or English
Provided informed consent for participation
Exclusion Criteria
Individuals with formal medical training in oncology, gynecology, or public health
Individuals with cognitive impairments or language barriers
Incomplete or duplicate survey submissions
Data Collection Tool
A structured, pre-tested questionnaire was developed in consultation with gynecologists, public health educators, and social scientists. The tool was made available in Hindi and English for accessibility and included three key sections:
Socio-Demographic Profile
Age, gender, education level, occupation, income group, marital status, and residential setting (urban/rural).
Knowledge and Awareness Assessment
A set of 20 multiple-choice and true/false questions addressing key topics including causes of cervical cancer, symptoms, risk factors (e.g., HPV infection), availability and purpose of screening tests (Pap smear, VIA), and HPV vaccination.
Attitudes and Perception
Questions assessing beliefs, fears, and willingness related to screening and vaccination, perceived barriers (e.g., embarrassment, cost, cultural stigma), and sources of information about cervical cancer.
Scoring and Classification
Each correct answer in the knowledge section was awarded one point. Total scores were converted into percentage values and categorized into four levels:
Very Good Knowledge: ≥80%
Good Knowledge: 60–79%
Fair Knowledge: 41–59%
Poor Knowledge: <40%
Table 2: Public Knowledge and Perception of Cervical Cancer Screening and Prevention
No. | Question | Options | Correct Responses (n) | Percentage |
1 | What is cervical cancer? | a) Cancer of ovaries, b) Cancer of cervix, c) Vaginal infection, d) Urinary cancer | 312 | 78.0 |
2 | What virus causes most cervical cancers? | a) HIV, b) HPV, c) Hepatitis, d) Dengue virus | 301 | 75.3 |
3 | Can cervical cancer be prevented? | a) No, b) Yes, c) Only with surgery, d) Not sure | 289 | 72.3 |
4 | What is a Pap smear test? | a) Pregnancy test, b) Diabetes test, c) Cervical screening test, d) Blood test | 317 | 79.3 |
5 | When should cervical screening start? | a) After menopause, b) At 15 years, c) Around 21 years, d) After childbirth | 278 | 69.5 |
6 | How often should a Pap smear be done? | a) Monthly, b) Every 3 years, c) Every 10 years, d) Once in a lifetime | 284 | 71.0 |
7 | What is the purpose of HPV vaccine? | a) Treat cancer, b) Prevent HPV infection, c) Control blood sugar, d) Boost fertility | 308 | 77.0 |
8 | Is HPV vaccine only for women? | a) Yes, b) No, c) Only for older women, d) Only during pregnancy | 267 | 66.8 |
9 | Can HPV be sexually transmitted? | a) No, b) Yes, c) Only through blood, d) Only during childbirth | 296 | 74.0 |
10 | Does early detection improve survival? | a) No, b) Yes, c) Only in young women, d) Rarely | 322 | 80.5 |
11 | Are menstrual irregularities a sign of cervical cancer? | a) Always, b) Possibly, c) Never, d) Only in teens | 263 | 65.8 |
12 | Can cervical cancer be asymptomatic in early stages? | a) No, b) Yes, c) Always painful, d) Only in elderly | 287 | 71.8 |
13 | What age group is most at risk for cervical cancer? | a) 10–20, b) 30–50, c) 60–70, d) All ages equally | 273 | 68.3 |
14 | Can poor hygiene alone cause cervical cancer? | a) Yes, b) No, c) Always in villages, d) Only without vaccines | 276 | 69.0 |
15 | Is cervical cancer curable in early stages? | a) Never, b) Yes, c) Only with surgery, d) Only in cities | 301 | 75.3 |
16 | Do you need Pap smear after HPV vaccination? | a) No, b) Yes, c) Only after 40, d) Only in hospitals | 279 | 69.8 |
17 | Can males be carriers of HPV? | a) No, b) Yes, c) Only with symptoms, d) Rarely | 284 | 71.0 |
18 | Should unmarried women get screened? | a) No, b) Yes, c) Only after childbirth, d) Only if symptomatic | 270 | 67.5 |
19 | Is awareness about cervical screening low in rural areas? | a) No, b) Yes, c) Only in elderly, d) Not important | 266 | 66.5 |
20 | Would you consider attending a cervical screening camp? | a) No, b) Maybe, c) Yes, d) Only if free | 319 | 79.8 |
Data Collection Procedure
Data were collected through online method (Google Forms). The digital form was disseminated via community WhatsApp groups, local educational institutions, and social media channels. Informed consent was obtained from all participants, and anonymity was ensured throughout the process.
Data Analysis
Responses were entered into Microsoft Excel and analyzed using IBM SPSS version 26.0. Descriptive statistics such as frequencies, means, and percentages were used to summarize socio-demographic data and knowledge scores.
Ethical Considerations
All participants were briefed about the study's objectives, assured of confidentiality, and informed of their voluntary participation and right to withdraw at any point. No personally identifiable information was collected, and data were used solely for academic and public health planning purposes.
The study included 400 participants from Kangra district, representing a broad and diverse demographic profile. The age distribution showed that the majority of respondents were between 26–35 years (36.0%) and 36–45 years (29.3%), followed by younger adults aged 18–25 years (20.8%) and individuals aged 46 years and above (14.0%). Women constituted the majority of the study population at 77.8%, reflecting the gender-specific focus on cervical cancer, while 22.3% of participants were male, providing insights into broader community-level perceptions. Education levels were encouraging, with 36.8% of respondents holding undergraduate degrees and 31.0% having completed secondary school, while only a small fraction (4.3%) reported no formal education. In terms of occupation, homemakers (25.5%) and office workers (22.8%) made up the largest segments, followed by teachers (15.0%), students (14.3%), and healthcare professionals (12.3%). A majority of participants (56.5%) resided in rural areas, while 43.5% were from urban settings, capturing a comprehensive mix of both community types essential for understanding awareness disparities.
Table 3: Knowledge Score Classification on Cervical Cancer Awareness
Knowledge Level | Score Range (Correct) | Number of Respondents (n) | Percentage |
Very Good Knowledge | ≥80% | 155 | 38.8% |
Good Knowledge | 60–79% | 161 | 40.3% |
Fair Knowledge | 41–59% | 61 | 15.3% |
Poor Knowledge | <40% | 23 | 5.8% |
The knowledge assessment revealed a strong baseline awareness of cervical cancer and its prevention among the Kangra population. A large proportion of respondents correctly identified cervical cancer as cancer of the cervix (78.0%) and recognized HPV as the primary causative virus (75.3%). Awareness of preventive strategies was also encouraging: 72.3% knew the disease is preventable, and 79.3% correctly identified the Pap smear as a cervical screening test. Most participants (69.5%) were aware that screening should start around age 21, and 71.0% knew it should be repeated every three years. Understanding of the HPV vaccine was high (77.0%), although only 66.8% correctly noted that it is not limited to women. A strong 80.5% acknowledged the role of early detection in improving survival, and 75.3% believed cervical cancer is curable in its early stages. However, certain misconceptions persisted-only 65.8% recognized that menstrual irregularities may signal cervical issues, and just 66.5% agreed that awareness is low in rural areas. Encouragingly, 79.8% expressed willingness to attend cervical screening camps, indicating a readiness to act if educational and logistical barriers are addressed.
Analysis of overall knowledge scores showed that a significant majority of participants demonstrated a commendable understanding of cervical cancer screening and prevention. Of the 400 respondents, 155 individuals (38.8%) scored in the “Very Good” category (≥80% correct responses), while another 161 (40.3%) fell into the “Good” category (60–79%), together comprising nearly 80% of the total sample. Meanwhile, 61 participants (15.3%) exhibited “Fair” knowledge (41–59%), and only 23 individuals (5.8%) had “Poor” knowledge (<40%). This distribution suggests that while the general level of awareness is promising, targeted educational initiatives are still needed for nearly one in five individuals who may be at risk of misinformation or disengagement, particularly in underserved or less educated segments of the population.
This study offers critical insights into the current state of public awareness and perception of cervical cancer screening and prevention among adults in Kangra district, Himachal Pradesh. Despite the preventable nature of cervical cancer and the availability of effective screening and vaccination options, the disease continues to take a significant toll on women’s health in India-particularly in underserved, rural, and semi-urban communities. By exploring knowledge levels, attitudes, and perceived barriers, the findings not only underscore progress in public health education but also reveal persistent knowledge gaps and cultural challenges that need to be addressed for meaningful impact.
The socio-demographic data (Table 1) reflect a relatively young, female-dominant, and moderately educated population. The majority of respondents fell within the reproductive and working-age bracket (26–45 years), which is a key demographic for cervical cancer prevention efforts. Encouragingly, more than two-thirds of the participants held at least a secondary-level education, which may have contributed to the high overall knowledge scores observed. However, the presence of respondents with only primary education or no formal schooling (17.3%)-particularly from rural areas (56.5%)-highlights the need for targeted outreach strategies that cater to low-literacy populations and bridge geographic inequities in health information dissemination. The inclusion of 22.3% male participants is also noteworthy, signaling a slowly emerging shift toward inclusive reproductive health conversations and the potential for male advocacy in women’s health-seeking behaviors.
A detailed analysis of the knowledge and perception data (Table 2) reveals that a strong foundation of cervical cancer awareness exists among the respondents. An overwhelming 78% correctly identified cervical cancer as a malignancy of the cervix, and 75.3% recognized HPV as the causative virus. The high awareness of Pap smears (79.3%), HPV vaccines (77.0%), and the role of early detection in improving survival (80.5%) is encouraging and reflects the impact of national and regional health campaigns, digital media exposure, and possibly school-based health education. However, deeper conceptual understanding remains limited in several key areas. Only 66.8% of participants knew that HPV vaccination is not limited to females, and 67.5% agreed that unmarried women should also undergo screening-both reflecting persistent misconceptions rooted in gender norms and stigma.
Similarly, while 74% knew HPV is sexually transmitted, awareness regarding the asymptomatic nature of cervical cancer in its early stages (71.8%) and the role of menstrual irregularities as potential warning signs (65.8%) was comparatively lower. These gaps are particularly concerning as they may lead to delays in seeking care and a false sense of security in asymptomatic individuals. The perception that poor hygiene alone causes cervical cancer-though identified correctly by 69.0%-suggests ongoing confusion between hygiene-related reproductive tract infections and HPV-related pathologies. Moreover, only 66.5% acknowledged that awareness is significantly lower in rural areas, despite data and experience pointing to rural women being among the least informed and most vulnerable to late-stage diagnoses.
The assessment of knowledge scores (Table 3) further contextualizes these findings. A commendable 79.1% of respondents fell into the "Very Good" or "Good" knowledge categories, indicating successful penetration of basic cervical health messages. Nevertheless, the remaining 20.9% with fair to poor knowledge-comprising nearly one in five individuals-cannot be overlooked. These respondents likely represent harder-to-reach populations who may face linguistic, economic, geographic, or cultural barriers to healthcare access. Their limited understanding may be compounded by embarrassment, fear of diagnosis, reliance on myths, or hesitancy to discuss gynecological health openly-factors that are particularly entrenched in conservative or rural societies.
One of the most promising findings from this study is the high proportion of participants (79.8%) expressing willingness to attend cervical screening camps. This reflects an openness to health interventions when access, affordability, and education are addressed in tandem. It also offers a strategic opportunity for policymakers, healthcare providers, and NGOs to conduct mobile screening drives, community education sessions, and HPV vaccination camps in local languages and culturally safe settings. The integration of cervical cancer screening into existing maternal and child health programs, as well as outreach through Accredited Social Health Activists (ASHAs), could further enhance acceptability and reach.
To effectively build on these findings, a multifaceted approach is essential. First, awareness campaigns must go beyond superficial messaging to explain the natural history of cervical cancer, the importance of regular screening regardless of symptoms, and the safety and efficacy of HPV vaccines. Second, gender-inclusive and culturally sensitive communication strategies are needed to involve men, address stigma, and normalize gynecological health as a topic of public conversation. Third, community health workers must be trained not only in clinical skills but also in counseling and myth-busting to facilitate trust-based engagement with hesitant individuals. Fourth, school and college curricula should include age-appropriate reproductive health education, ensuring that the next generation is informed from an early age [10-13].
Finally, robust government policies are needed to subsidize HPV vaccination, ensure widespread availability of screening infrastructure (especially VIA and Pap smear services), and mandate the inclusion of cervical cancer prevention in routine primary care checkups. Building digital health literacy and leveraging mobile technology can also be transformative-through reminders, telehealth consults, and educational content dissemination.
This study reveals that while foundational awareness of cervical cancer and its prevention is steadily improving in Kangra, substantial gaps remain in both depth of knowledge and practical application. Misconceptions about HPV transmission, screening eligibility, and the scope of preventive care indicate a need for more nuanced, inclusive education strategies. Encouragingly, the strong willingness among participants to engage in screening initiatives presents a vital opportunity. Moving forward, localized efforts that demystify screening procedures, normalize conversations around women’s reproductive health, and extend HPV vaccine access-especially in rural and underserved communities-will be essential to fostering early detection, timely intervention, and long-term cancer prevention.
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