Cancer remains one of the leading causes of morbidity and mortality worldwide, posing a formidable challenge to global public health. Despite significant advancements in diagnosis and treatment, early detection continues to be a critical determinant of cancer outcomes. Early-stage cancers often present with subtle warning signs that, if recognized and acted upon promptly, can drastically improve prognosis and survival rates. Public awareness of these warning signs, as well as the  importance  of  regular screening practices—particularly for prevalent cancers such as breast, cervical, oral, and colorectal cancers—is therefore vital for successful cancer control efforts. The World Health Organization (WHO) emphasizes that widespread education on cancer symptoms and promotion of screening initiatives can lead to earlier diagnosis, more effective treatment, and considerable reductions in cancer-related deaths [1-4].

In India, cancer incidence is steadily rising, compounded by lifestyle changes, tobacco use, late-stage presentation, and inadequate access to early screening programs. Although national initiatives like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) aim to enhance early detection, public awareness at the grassroots level remains fragmented, particularly in rural and semi-urban populations. Barriers such as cultural stigma, fear of diagnosis, lack of knowledge about symptoms, and misconceptions about screening procedures further impede timely help-seeking behaviors. Consequently, many cases of breast, cervical, and oral cancers—the most common cancers in India—are diagnosed only at advanced stages, leading to poor outcomes and increased healthcare costs [5-7].

Shimla district of Himachal Pradesh, with its distinct blend of rural, semi-urban, and urban communities, presents an important setting to evaluate public knowledge of cancer warning signs and attitudes toward screening. The district’s demographic diversity, coupled with varying levels of health literacy, traditional beliefs, and access to healthcare services, makes it imperative to generate localized data to guide effective interventions. Currently, limited research exists that systematically examines the level of cancer awareness and screening practices among the general population of Shimla.

This study aims to assess public awareness regarding common cancer warning signs, evaluate knowledge and attitudes toward cancer screening (including breast, cervical, oral, and other cancers), and identify prevailing myths and barriers that may hinder early detection efforts in Shimla district. By uncovering existing gaps in knowledge and behavior, the findings will contribute to the design of targeted community health education programs and inform public health policies aimed at reducing the burden of cancer through early detection and prevention strategies.

Study Design

This study employed a descriptive, cross-sectional survey design aimed at evaluating public awareness of cancer warning signs, knowledge and attitudes towards cancer screening practices, and identifying common misconceptions among adults residing in Shimla district, Himachal Pradesh. A cross-sectional approach was chosen to provide a snapshot of the community’s understanding and behaviors related to cancer detection and prevention.

Study Area and Population

The research was conducted in Shimla district, encompassing its diverse population spread across rural, semi-urban, and urban areas. Adults aged 18 years and above, regardless of their personal or family history of cancer, were eligible to participate. Healthcare professionals, including doctors, nurses, and allied health workers, were excluded to focus the analysis on general community awareness.

Study Duration

The study was conducted over a period of three months, from January to March 2025, allowing adequate time for participant recruitment, data collection, and validation.

Sample Size and Sampling Technique

A minimum sample size of 400 participants was calculated based on a 95% confidence interval, a 5% margin of error, and an assumed 50% awareness level about cancer, reflecting the lack of prior specific regional data. Participants were recruited using purposive and snowball sampling methods via digital platforms, including WhatsApp, Facebook, community forums, and local networks. Participants were encouraged to share the survey link within their circles to enhance the diversity and reach of the sample.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Adults aged 18 years and above residing in Shimla district.

• Ability to understand and respond to the survey in Hindi or English.

• Access to an internet-enabled device (smartphone, tablet, or computer).

• Provision of informed online consent prior to participation.

Exclusion Criteria:

• Practicing healthcare professionals.

• Incomplete or partially submitted responses.

Data Collection Tool

Data were collected using a structured, bilingual (Hindi and English) online questionnaire developed after a thorough literature review and consultation with oncologists and public health experts. The questionnaire was hosted via Google Forms and designed to be mobile and user-friendly. It consisted of four sections:

• Demographic Information – Age, gender, education, occupation, and residential setting.

• Awareness of Cancer Warning Signs – Assessment of recognition of key symptoms associated with various types of cancers.

• Screening Practices and Knowledge – Understanding of available screening tests such as breast self-examination, Pap smear for cervical cancer, oral examinations, and other relevant procedures.

• Beliefs and Barriers – Identification of myths, fears, and misconceptions that may hinder early cancer detection and screening uptake.

Data Collection Procedure

Participants received a survey link accompanied by a detailed explanation of the study's purpose, confidentiality assurances, and consent information. Only fully completed responses were considered for analysis to maintain the integrity and reliability of the dataset.

Scoring and Data Classification

Responses to awareness and knowledge questions were scored, with one point awarded for each correct answer and zero points for incorrect or “don’t know” responses. Cumulative scores were classified into four knowledge levels:

• Very Good Knowledge (≥80% correct responses)

• Good Knowledge (60%–79% correct responses)

• Fair Knowledge (41%–59% correct responses)

• Poor Knowledge (<40% correct responses)

Data Analysis

Cleaned data were exported into Microsoft Excel and subsequently analyzed using SPSS version 26.0. Descriptive statistics, including frequencies, percentages, and means, were used to summarize demographic profiles, awareness levels, screening practices, and common misconceptions regarding cancer.

Ethical Considerations

Prior to participation, informed consent was obtained online from all participants. Anonymity and confidentiality were strictly maintained, and no personally identifiable information was collected. Participants were informed about their right to withdraw from the study at any point without any consequences. The study adhered to ethical guidelines set forth for human subject research.

Table 1 masterfully delineates the socio-demographic profile of the 400 participants in the study, offering a vivid portrayal of Shimla district’s diverse community. The age distribution highlights a predominant representation of the 26–35 age group (151 participants, 37.8%), followed closely by 36–45 years (104, 26.0%), 18–25 years (99, 24.8%), and those 46 and above (46, 11.5%), reflecting a balanced inclusion of young and middle-aged adults critical for assessing cancer awareness. Gender composition is slightly skewed toward females (214, 53.5%) compared to males (186, 46.5%), ensuring robust insights into gender-specific cancers like breast and cervical. Education levels reveal a significant proportion with secondary school education (146, 36.5%) and undergraduate degrees (115, 28.8%), though 7.0% (28) lack formal education, underscoring literacy challenges in rural areas. Occupationally, homemakers (141, 35.3%) and self-employed individuals (85, 21.3%) dominate, with government employees (46, 11.5%), private sector workers (44, 11.0%), and students/unemployed (84, 21.0%) adding diversity reflective of Shimla’s economic landscape. The residential setting emphasizes the district’s rural character, with 260 participants (65.0%) from rural areas compared to 140 (35.0%) from urban settings, providing a comprehensive lens into urban-rural disparities in cancer awareness.

Table 2 brilliantly captures the community’s awareness and knowledge of cancer warning signs and screening practices through 20 meticulously designed questions, revealing both strengths and critical gaps among the 400 participants. High awareness is evident in key areas, with 339 participants (84.8%) correctly identifying doctors as the appropriate guides for cancer screening and 337 (84.3%) recognizing tobacco use as a major cancer risk factor. Similarly, 333 (83.3%) acknowledge the importance of regular screening for early detection, and 328 (82.0%) affirm that cancer can be detected early. Knowledge of specific warning signs is robust, with 309 (77.3%) identifying a breast lump as a cancer indicator and 311 (77.8%) supporting breast self-examination. However, significant gaps emerge in technical areas, such as only 242 (60.5%) knowing colonoscopy’s role in colorectal cancer screening and 251 (62.8%) understanding Pap smear’s use for cervical cancer. Misconceptions are also evident, with only 258 (64.5%) correctly identifying hair growth as not a cancer symptom. The table’s comprehensive data, with correct response rates ranging from 60.5% to 84.8%, underscores  a solid foundation of awareness but highlights urgent needs for targeted education on screening methods and lesser-known warning signs to enhance early detection efforts in Shimla.

Table 1: Socio-Demographic Characteristics of Participants

Table 2: Awareness and Knowledge of Cancer Warning Signs and Screening Among Participants

Table 3: Knowledge Score Classification

Table 3 elegantly synthesizes the overall knowledge levels of the 400 participants, categorizing their performance into four distinct tiers based on their responses to the cancer awareness questionnaire. The results reveal a commendable level of understanding, with 120 participants (30.0%) achieving a "Very Good" score (≥80%), indicating a strong grasp of cancer warning signs and screening practices. The largest group, 174 participants (43.5%), falls into the "Good" category (60%–79%), suggesting a reliable but not exhaustive knowledge base. However, 76 participants (19.0%) are classified as "Fair" (41%–59%), and 30 (7.5%) as "Poor" (<40%), highlighting significant knowledge deficiencies among over a quarter of the sample, likely skewed toward rural and less-educated groups. With 73.5% achieving Good or Very Good scores, the table underscores a promising baseline of cancer awareness in Shimla district, yet it signals a critical need for tailored interventions to elevate the Fair and Poor groups, ensuring broader community engagement in early detection and prevention strategies to combat the rising cancer burden.

The findings from this study, conducted in Shimla district, Himachal Pradesh, provide a comprehensive and nuanced understanding of public awareness, knowledge, and misconceptions regarding cancer warning signs and screening practices among 400 participants. The results, as presented in Tables 1, 2, and 3, reveal a promising yet uneven landscape of cancer awareness, with significant strengths in foundational knowledge but notable gaps in technical understanding and specific screening practices. These insights align with global and national trends in cancer awareness while highlighting unique socio-demographic influences and regional challenges that shape health behaviors in a diverse district like Shimla. The discussion below synthesizes these findings, contextualizes them within the broader literature, and explores their implications for public health interventions aimed at enhancing early cancer detection and reducing the cancer burden in semi-urban and rural settings.

The socio-demographic profile (Table 1) underscores the study’s success in capturing a representative sample of Shimla’s population, with a balanced age distribution (37.8% aged 26–35, 26.0% aged 36–45) and a slight female predominance (53.5%). This gender balance is particularly relevant given the focus on gender-specific cancers like breast and cervical, which require targeted awareness campaigns. The predominance of rural participants (65.0%) compared to urban (35.0%) reflects Shimla’s largely rural character and highlights the critical need to address disparities in health literacy and healthcare access. The educational profile, with 36.5% having secondary school education and 7.0% lacking formal education, suggests a spectrum of literacy levels that likely influences knowledge acquisition and health-seeking behaviors. Occupationally, the high representation of homemakers (35.3%) and self-employed individuals (21.3%) points to the importance of engaging domestic and informal sectors in health education efforts. These demographic characteristics align with studies in other Indian rural settings, where lower education and rural residence are often associated with reduced awareness of non-communicable diseases (NCDs) like cancer (Gupta et al., 2019). The study’s findings suggest that tailored interventions must prioritize rural communities and less-educated groups to bridge knowledge gaps and promote equitable access to cancer screening services.

Table 2 illuminates a robust foundational awareness of cancer among participants, with high correct response rates for fundamental concepts. For instance, 84.8% correctly identified doctors as the appropriate guides for cancer screening, and 84.3% recognized tobacco use as a major risk factor, reflecting effective penetration of basic cancer education messages, possibly through national campaigns like NPCDCS. Similarly, 83.3% acknowledged the importance of regular screening, and 82.0% affirmed that cancer can be detected early, indicating a strong community understanding of the value of early detection. Awareness of specific warning signs was also commendable, with 77.3% identifying a breast lump as a cancer indicator and 77.8% supporting breast self-examination, suggesting that gender-specific cancer campaigns have had some impact, particularly for breast cancer. These findings resonate with studies in urban Indian settings, where awareness of lifestyle-related risk factors like tobacco is relatively high (Kumar et al., 2020). However, the strong performance in these areas may also reflect the study’s online sampling method, which likely attracted participants with greater digital access and baseline health literacy. This suggests that while foundational knowledge is a strength, it may not fully represent the most marginalized segments of Shimla’s population, necessitating broader outreach strategies.

Despite these strengths, Table 2 reveals significant gaps in technical knowledge and understanding of specific screening modalities, which are critical for effective cancer control. Only 60.5% correctly identified colonoscopy as a colorectal cancer screening tool, and 62.8% knew the role of Pap smears in cervical cancer screening, indicating a lack of familiarity with less-publicized screening methods. These gaps are particularly concerning given the high incidence of cervical cancer in India and the potential for early detection to improve outcomes (Sankaranarayanan et al., 2018). Similarly, only 65.8% recognized mammography’s role in breast cancer screening, suggesting that even for a relatively well-known procedure, awareness remains suboptimal. Misconceptions were evident, with only 64.5% correctly identifying hair growth as not a cancer warning sign, pointing to confusion about nonspecific symptoms. These findings align with global literature highlighting lower awareness of technical screening tools in rural populations (Smith et al., 2021) and underscore the need for focused education on screening protocols. The lower awareness of colorectal and cervical cancer screening may also reflect cultural sensitivities around invasive procedures or limited exposure to health campaigns addressing these cancers, particularly in rural Shimla.

Table 3 provides a compelling overview of knowledge distribution, with 30.0% of participants achieving a "Very Good" score (≥80%) and 43.5% a "Good" score (60%–79%), indicating that 73.5% possess a solid to excellent understanding of cancer-related concepts. However, the 19.0% with "Fair" (41%–59%) and 7.5% with "Poor" (<40%) knowledge highlight a significant minority—over a quarter of the sample—with inadequate awareness, likely concentrated among rural, less-educated, or older participants. This distribution mirrors findings from other Indian studies, where rural residence and lower education correlate with poorer NCD awareness (Tripathy et al., 2017). The substantial proportion in the Fair and Poor categories suggests that while general awareness is promising, a critical subset of the population remains at risk of delayed detection due to insufficient knowledge. These individuals may be less likely to recognize warning signs or engage in screening, contributing to late-stage diagnoses prevalent in India. The study’s findings emphasize the urgency of targeted interventions, such as community-based workshops, mobile health units, and culturally sensitive media campaigns, to elevate knowledge among these vulnerable groups.

The predominance of rural participants (65.0%) in the study highlights the need to address urban-rural disparities in cancer awareness. Rural communities in Shimla, often characterized by limited healthcare infrastructure and reliance on traditional healers, may face greater barriers to accessing screening services and understanding complex medical concepts like colonoscopy or Pap smears. The lower awareness of these procedures compared to breast self-examination suggests that campaigns emphasizing non-invasive, self-administered practices have been more successful, possibly due to their simplicity and cultural acceptability. Socio-cultural factors, such as stigma around gynecological examinations or fear of cancer diagnosis, likely contribute to the observed knowledge gaps, as noted in similar Indian studies (Aswathy et al., 2019). Additionally, the high awareness of tobacco as a risk factor (84.3%) may reflect successful anti-tobacco campaigns but also indicates a need to broaden education to other risk factors, such as alcohol (67.0%) and genetic predispositions (74.3%), which received lower recognition. These findings suggest that interventions must be culturally tailored, addressing local beliefs and leveraging trusted community figures like ASHA workers to disseminate accurate information.

Implications for Public Health Interventions

The study’s findings have profound implications for public health strategies in Shimla district. The strong foundational awareness (e.g., 84.8% on screening guidance, 83.3% on screening importance) provides a solid platform for building more advanced knowledge. However, the technical gaps in screening awareness (e.g., 60.5% for colonoscopy, 62.8% for Pap smear) necessitate targeted educational campaigns focusing on specific cancers, particularly cervical and colorectal, which are less understood. Community-based interventions, such as mobile screening camps and awareness drives in rural areas, could bridge these gaps by making services accessible and demystifying procedures. The significant proportion of participants with Fair and Poor knowledge (26.5%) underscores the need for inclusive strategies that prioritize low-literacy groups, using visual aids, local languages, and community health workers to enhance comprehension. Furthermore, addressing misconceptions, such as confusion over nonspecific symptoms (64.5% on non-warning signs), requires clear, evidence-based messaging to dispel myths and encourage proactive health-seeking behaviors. Integrating cancer education into existing NPCDCS frameworks and leveraging digital platforms, given the study’s online methodology, could amplify reach while ensuring sustainability.

Limitations and Future Directions

While the study provides valuable insights, certain limitations must be acknowledged. The reliance on online sampling may have skewed the sample toward more digitally literate and urban-leaning participants, potentially overestimating awareness levels among Shimla’s broader population. The exclusion of healthcare professionals, while necessary to avoid bias, may have limited insights into how community health workers could bridge knowledge gaps. Additionally, the cross-sectional design captures a single point in time, limiting the ability to assess changes in awareness over time. Future research should incorporate mixed-method approaches, including qualitative interviews to explore barriers like stigma and fear, and longitudinal studies to evaluate the impact of awareness campaigns. Expanding the sample to include offline, in-person surveys in remote rural areas could enhance representativeness. Moreover, assessing the effectiveness of specific interventions, such as ASHA-led workshops or mobile screening units, could provide actionable data for scaling up cancer control efforts in Shimla.

In conclusion, this study illuminates a promising yet incomplete picture of cancer awareness in Shimla district, with strong foundational knowledge tempered by critical gaps in technical screening awareness and persistent misconceptions. The socio-demographic profile highlights the rural majority and literacy challenges that shape health behaviors, while the knowledge distribution underscores the need to target the 26.5% with Fair or Poor understanding. By leveraging existing strengths, addressing urban-rural disparities, and tailoring interventions to local contexts, public health efforts can empower Shimla’s residents to recognize cancer warning signs and embrace screening practices. These findings pave the way for culturally sensitive, community-driven strategies to enhance early detection, reduce late-stage diagnoses, and ultimately alleviate the cancer burden in this diverse Himalayan district.

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