Cervical cancer is a significant global health issue, ranking as the fourth most common cancer among women and posing a substantial disease burden, especially in LMICs [1]. High mortality rates, particularly in LMICs, are attributed to factors such as population aging, growth, and socioeconomic disparities influencing risk factor prevalence and distribution [2, 3]. In 2020, approximately 0.6 million new cervical cancer cases were reported globally, a majority of which occurred in Asia [4], with LMICs bearing the brunt of mortality [1]. India, alone, accounts for roughly one-third of Asia's cervical cancer burden, with 0.9 million cases and 60,000 deaths in 2020 [5]. While most cancers are challenging to prevent due to multiple causal agents [6], cervical cancer prevention is possible through strategies such as consistent condom use to prevent Human Papillomavirus (HPV) transmission [7] and HPV vaccination [8]. However, vaccine implementation in LMICs is hindered by high costs [9] and other factors like low social acceptance, incomplete protection against all HPV strains, and uncertainty regarding vaccine duration [10, 11]. Therefore, screening remains the primary prevention strategy in many LMICs, including India. Despite the feasibility of WHO-recommended cervical cancer screening methods in India and the initiation of programs like the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke (NPCDCS), screening uptake remains low [12, 13]. This low participation is likely due to a combination of structural barriers within the healthcare system [14] and psychological and social factors, such as inadequate knowledge, negative attitudes, and lack of partner support [15, 16]. Men play a critical role in HPV transmission and yet receive minimal attention in education campaigns, despite WHO recommendations for male involvement [17]. Studies consistently show that women's screening decisions are heavily influenced by their partners' opinions, particularly in LMICs like India where husbands often dominate health-related decisions [15, 18, 19, 20]. Although studies indicate low knowledge of cervical cancer among men in LMICs [21, 22, 23, 24], research evaluating male attitudes and knowledge regarding prevention is limited. This study aimed to identify factors determining male partners' support for their wives' cervical cancer screening. We considered knowledge of cervical cancer and screening, health literacy, attitude, perceived norms, perceived barriers, and health habits. Health literacy is defined as the ability to access, understand, and apply health-related information for informed decision-making [25]. Poor health literacy correlates with reduced screening participation [26] and suboptimal preventive care [27]. Attitude, perceived norms, and perceived barriers are central to established health behavior theories like the Health Belief Model (HBM) [28], Protection Motivation Theory (PMT) [29], and Theory of Planned Behavior (TPB) [30]. These models predict cancer screening behaviors [31, 32], with TPB being particularly effective in predicting intentions [33]. The TPB identifies attitudes, subjective norms, and perceived behavioral control as determinants of behavior, with additional constructs such as habit and structural barriers improving predictive power [35, 36]. A prior study using a modified TPB model, incorporating these factors, effectively predicted Indian women's intentions towards cervical cancer screening [36]. This study tested the applicability of the modified TPB model to predict Indian men's intentions to support their wives' cervical cancer screening. We also examined the moderating roles of health literacy and education on the model's effects.

The existing literature highlights the significant global burden of cervical cancer, particularly in LMICs. Several studies underscore the critical role of male partners in influencing women's decisions regarding cervical cancer screening. Low levels of knowledge and awareness of cervical cancer and screening options among men in LMICs are consistently reported. The Theory of Planned Behavior (TPB) and related models, such as the Health Belief Model (HBM), have been used to study health-related behaviors, including cancer screening. Prior research showed that a modified version of TPB, including perceived barriers and habitual health-seeking behavior, can effectively predict intentions toward cervical cancer screening in women. This study builds upon this foundation by applying a similar modified TPB model to explore the factors influencing male partners' support for cervical cancer screening, accounting for the influence of knowledge, attitudes, perceived norms, perceived barriers, habits, health literacy, and the moderating role of education.

A cross-sectional survey was conducted among 500 sexually active men aged 20-60 in Karnataka, India, between April and August 2020. The sample size (385) was calculated using Cochran's formula, accounting for a 50% response rate. Participants were recruited consecutively from two regions (one with and one without easy access to a cervical cancer screening center) within Karnataka. Data collection was performed by trained community health workers (ASHAs). A structured questionnaire, translated into Kannada and English, was used. It comprised sections on socio-demographic characteristics, knowledge of cervical cancer and screening, and measures of the constructs from the modified TPB model: attitude towards screening (7 items, 5-point Likert scale), subjective norms (6 items, 5-point Likert scale), perceived structural barriers (5 items, 5-point Likert scale), and habit of routine health check-ups (dichotomous). Health literacy was assessed using the HLS-IND-KAN-Q16/HLS-IND-ENG-Q16 (16 items, 5-point Likert scale), yielding a Health Literacy index score. Intention to support the wife's screening was measured using a dichotomous scale (yes/no). Data analysis was performed using SPSS version 25.0. Descriptive statistics (frequencies, means, standard deviations) were calculated. Bivariate analysis (chi-square, independent samples t-tests) examined associations between variables and intention to support screening. Logistic regression analyses assessed the contribution of different factors to the intention, with model fit evaluated using the Hosmer-Lemeshow test. Moderation analyses (PROCESS macro) examined the influence of health literacy and education on the relationships between predictor variables and intention.

The majority (68%) of participants intended to support their partners' screening. However, knowledge of cervical cancer and screening was poor; 66% had never heard of the disease and 95.4% were unaware of screening procedures. The mean health literacy score was 29.05 (below the adequate level of 33). Men with a positive intention to support screening had significantly higher health literacy scores (30.6) than those without (25.6). Most men held negative attitudes toward screening; many felt anxious, uncomfortable, or afraid of the procedure or its outcome. Bivariate analysis showed that better knowledge correlated with increased awareness, health literacy, positive attitudes, and higher subjective norms. Men with a positive intention to support screening were more aware of the screening procedure, held more positive attitudes, perceived fewer structural barriers, and had higher health literacy levels. Multivariate analysis (logistic regression) showed that in Model 1 (knowledge and awareness only) explained 3.9% of variance in intention. Model 2 (including attitude, subjective norms, habit, and structural barriers) explained 19% of variance. Attitude (OR = 1.18) and habit (OR = 3.04) were significant predictors of intention. A reduced model (awareness, attitude, and habit) provided a better fit (16% variance explained). Moderation analysis revealed a significant interaction between education and knowledge/awareness on attitude. Higher education levels amplified the effect of knowledge and awareness on positive attitudes. Health literacy was not a significant moderator. The most frequently cited barriers were health system-related issues.

This study demonstrates the substantial influence of several factors on men's willingness to support cervical cancer screening for their partners. While the low level of knowledge and awareness regarding cervical cancer and screening highlights an urgent need for targeted educational interventions, the results underscore the importance of addressing attitudes towards the screening procedure. The finding that men who habitually engage in routine health check-ups were more likely to support their partner's screening indicates the significance of addressing men's general health habits. This highlights the importance of integrating cervical cancer screening into broader health promotion and education initiatives rather than treating it in isolation. The significant role of education as a moderator of the relationship between knowledge, awareness, and attitude toward screening emphasizes the need to target health education efforts towards less educated men in particular.

Improving cervical cancer screening uptake requires engaging both women and their male partners. This study emphasizes the importance of targeted interventions addressing men's knowledge deficits, negative attitudes towards screening, and perceived barriers, while also promoting positive health habits. Future research should focus on evaluating the effectiveness of such interventions and exploring the long-term impact on screening uptake.

This study's cross-sectional design limits causal inferences. Social desirability bias may have influenced responses. The use of community health workers for data collection could have introduced some bias. Furthermore, the study focused on intentions rather than actual behavior. Future longitudinal studies are needed to examine the translation of intentions into actions and to further explore the interplay between the identified factors.