Awareness, attitude, and practice towards cancer cervix prevention among rural women in southern India: A community-based study

Cervical cancer remains a leading cause of cancer-related mortality among women globally, with a disproportionate burden in low- and middle-income countries (LMICs). India contributes roughly one-fourth of the global cervical cancer burden, and most cases are diagnosed at advanced stages due to low uptake of screening and limited organized screening services. Although national screening guidelines exist, screening is often opportunistic, and stigma, lack of awareness, and limited access impede early detection. In line with WHO’s elimination strategy (screening 70% of women by ages 30 and 45 with a high-performance test), this study aimed to assess baseline awareness, attitudes, and practices (KAP) regarding cervical cancer, its risk factors, and prevention via screening among rural women in southern Karnataka, India, to inform interventions that may improve screening uptake and reduce disease burden.

Study design and setting: Community-based cross-sectional survey conducted January–December 2017 in rural areas of Udupi district, southern Karnataka, India. Ethical approval obtained from the Institutional Ethics Committee (ECR/146/Inst/KA/2013; IEC-23/2017). Written informed consent was obtained from all participants. Participants and sampling: 1100 married women aged 20–65 years residing in the study area were surveyed via house-to-house visits by a trained study team. The survey formed part of a larger project estimating HPV and other DNA viral infections of the cervix in the general population; the overall sample size was determined for HPV prevalence. For the KAP assessment, only women who reported having heard of “cervical cancer” were administered the detailed KAP questionnaire (n=737). Data collection tools and variables: A pre-designed, semi-structured interviewer-administered questionnaire captured socio-demographic details (age, marital status, education, occupation, socio-economic status using modified Udai Pareek scale) and KAP toward cervical cancer and screening (risk factors, prevention, early detection, sources of information, attitudes toward screening and service availability, prior Pap test). Scoring and definitions: Awareness was assessed via items on risk factors, prevention, and early detection methods. Scoring: correct answer = +1, incorrect = −1, “do not know/not sure” = 0. Adequate knowledge defined as cumulative score ≥4 (based on the distribution of knowledge scores); inadequate knowledge <4. Attitude was assessed via items on perceived need for screening, importance of local screening service availability, willingness to receive more education, and willingness to undergo screening; favorable attitude defined as cumulative attitude score ≥2. Practice was considered satisfactory if the participant had undergone any cervical screening (Pap test) at least once prior to the survey. Data management and analysis: Data were entered and analyzed using SPSS v16.0. Descriptive statistics included frequencies, percentages, and means with standard deviation. Associations between knowledge adequacy and socio-demographic factors were evaluated using univariate and multivariable logistic regression. Variables with p<0.20 in univariate analysis were included in multivariable models; results reported as crude and adjusted odds ratios (OR) with 95% confidence intervals (CI). Statistical significance in multivariable analysis was set at p<0.05.

- Sample: 1100 rural women (mean age 43.1±9.2 years); 89.7% currently married; 8.1% had no formal schooling; 54.5% homemakers; 62.8% middle socio-economic status. - Awareness reach: 67% (737/1100) had heard of “cervical cancer”; only these 737 were assessed for KAP. - Preventability and early detection: 47.9% (353/737) believed cervical cancer can be prevented. Only 17.2% were aware it can be detected early (narrative text); despite a conflicting table, the text and discussion indicate low awareness of early detection. - Risk factor awareness (among 737): poor genital hygiene 41.4%, early age at sexual intercourse 35.4%, viral infection 19.3%, OCP use 15.3%, high parity 14.8%, multiple sexual partners 13.7%, smoking 5.0%; 49.1% did not know any risk factor. A small fraction (0.4%) incorrectly believed condom use is a risk factor. - Sources of information: relatives/friends 73.7%, mass media 71.5%, health education 46.3%, doctor 24.7%, health workers 18.6%. - Composite scores (n=737): Adequate awareness 35.7% (263/737); mean awareness score 1.57±2.74. Favorable attitude 99.9% (736/737); mean attitude score 2.96±0.20. Satisfactory practice (ever Pap test) 0.9% (7/737). - Factors associated with inadequate awareness (reference groups in parentheses): • Age >30 years vs ≤30: adjusted OR 2.14 (95% CI 1.24–3.67), p=0.006 (older age associated with higher odds of inadequate awareness). • Education nil–primary vs >middle school: adjusted OR 8.17 (4.23–15.78), p<0.001 (low education strongly associated with inadequate awareness). • Homemaker vs employed: adjusted OR 4.29 (3.03–6.07), p=0.013 (homemakers had higher odds of inadequate awareness). • Low vs medium socio-economic status: adjusted OR 1.65 (1.11–2.46), p<0.05 (low SES associated with inadequate awareness).

The study demonstrates a substantial gap between positive attitudes toward cervical cancer screening and actual knowledge and uptake of screening among rural women in southern Karnataka. While nearly all participants expressed favorable attitudes and willingness to be educated and to undergo screening if available, only about one-third had adequate knowledge and fewer than 1% had ever been screened. This disconnect suggests that structural and informational barriers persist despite readiness to engage. Key determinants of inadequate awareness included older age, lower education, being a homemaker, and lower socio-economic status, indicating that socio-demographic disadvantages are linked to poorer knowledge. These findings underscore the need for targeted health education strategies that prioritize less educated, older, and lower-SES women, and that leverage both mass media and interpersonal networks (friends/family) which were the most common information sources. Improving awareness of preventability and early detection is critical to increasing screening uptake. Ensuring availability of screening services at primary/rural health centers, as desired by nearly all respondents, is likely to enhance participation when combined with tailored education and outreach. The results align with broader evidence from LMICs showing low screening coverage and late-stage diagnosis and support WHO’s elimination targets by highlighting the necessity of both demand-generation (awareness) and supply-strengthening (accessible services).

Despite an overwhelmingly favorable attitude toward cervical cancer screening, awareness and screening practices among rural women in southern Karnataka were suboptimal. Interventions should include tailored health awareness programs focusing on risk factors, preventability, and early detection, alongside establishing and promoting accessible screening services at primary healthcare facilities. Such strategies are vital to improving screening uptake and reducing the cervical cancer burden in this population. Future research should explore barriers and facilitators to screening uptake, including the role of media exposure and healthcare access, to inform more effective, context-specific interventions.

- Potential selection bias due to under-representation of women who were away for work during household visits. - Information bias may have occurred for sensitive questions about sexual and reproductive risk factors. - Absence of organized screening services limited the ability to assess perceived barriers and beliefs regarding screening. - Important potential confounders (e.g., media exposure intensity, general healthcare access) could not be evaluated. - Inconsistencies between tabulated and narrative reporting for early detection awareness suggest possible data reporting error in the table.