Cervical cancer remains a significant global health challenge, ranking as the fourth most common cancer among women worldwide. According to the GLOBOCAN 2022 estimates, approximately 660,000 new cases and 350,000 deaths were attributed to cervical cancer globally in 2022, reflecting a persistent burden despite advancements in medical technology and preventive strategies [1]. In India, cervical cancer is the second most prevalent malignancy among women aged 15–44 years, following breast cancer, with an estimated 66,903 new cases and 77,348 deaths annually [1]. This accounts for approximately 23% of the global mortality due to cervical cancer, underscoring the disproportionate burden in low- and middle-income countries (LMICs) like India [1,2]. The high incidence and mortality rates in India are largely attributed to limited awareness, inadequate access to screening, and challenges in implementing cytology-based screening programs in resource-constrained settings [2,3].Screening methods, such as Pap smear and visual inspection with acetic acid (VIA), have been shown to significantly reduce cervical cancer morbidity and mortality by enabling early detection and intervention [4,5]. In India, where women often remain asymptomatic until the disease reaches advanced stages, regular screening is critical for effective prevention and control [6]. However, the uptake of cervical cancer screening remains suboptimal, particularly in rural areas, due to barriers such as lack of awareness, cultural stigmas, and insufficient communication between health care professionals (HCPs) and communities about the availability and benefits of screening [7,8]. Primary health centres (PHCs) in India serve as the backbone of rural healthcare delivery, and HCPs, including Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), and Graduates, play a pivotal role in mobilizing communities for health interventions, including cervical cancer screening [9].The World Health Organization (WHO) launched a global strategy in 2020 to eliminate cervical cancer as a public health problem, outlining the 90-70-90 targets to be achieved by 2030: 90% of girls fully vaccinated with the human papillomavirus (HPV) vaccine by age 15, 70% of women screened with a high-performance test by ages 35 and 45, and 90% of women with precancerous or cancerous lesions receiving treatment [10]. Achieving these targets in rural India hinges on the knowledge, attitudes, and practices (KAP) of HCPs, who act as key facilitators in community health education and service delivery [11]. ASHAs, covering populations of approximately 1,000, are instrumental in grassroots health mobilization, while ANMs and Graduates provide technical expertise at PHCs [12]. However, studies have indicated gaps in HCPs’ knowledge about cervical cancer risk factors, screening methods, and preventive measures, which may hinder effective implementation of screening programs [13,14].The KAP of HCPs are critical determinants of their ability to educate and motivate communities, address myths, and promote screening uptake [15]. For instance, misconceptions about cervical cancer, such as beliefs that it is hereditary or linked solely to promiscuity, can impede community acceptance of screening [16]. Furthermore, HCPs’ attitudes toward screening and their own participation in screening practices influence their credibility as health advocates [17]. In rural settings like Kurnool District, Andhra Pradesh, where access to healthcare is limited, the proficiency of HCPs in communication and cultural competence is vital for engaging diverse populations and ensuring participation in screening initiatives [18].Given the WHO’s ambitious goals and the high burden of cervical cancer in India, understanding the KAP of HCPs in rural PHCs is essential for designing targeted interventions to improve screening coverage and outcomes. Previous studies in India have highlighted variable levels of knowledge and low screening practices among HCPs, particularly in rural areas, but data specific to Kurnool District are limited [19,20]. This study aims to address this gap by assessing the KAP regarding cervical cancer screening among ASHA workers, ANMs, and Graduates in seven PHCs in Kurnool District, Andhra Pradesh. By exploring these factors and their correlation with socio-demographic variables, the study seeks to provide insights to refine and optimize cervical cancer prevention strategies in alignment with global and national health priorities.

Study Design and Setting This hospital-based cross-sectional observational study was conducted to assess the knowledge, attitudes, and practices (KAP) regarding cervical cancer screening among health care professionals (HCPs) in Kurnool District, Andhra Pradesh, India. The study was carried out at seven primary health centres (PHCs) in rural areas, including Nannur, E.Thandrapadu, Gonegandla, Laddagiri, Krishnagiri, Ramallakota ,and Husenapuram as identified from participant data. Data collection occurred from January to July 2024 during routine ASHA (Accredited Social Health Activist) meetings organized at these PHCs, facilitating access to a diverse group of HCPs involved in community health mobilization [21]. Participants The study population comprised HCPs, specifically ASHA workers, Auxiliary Nurse Midwives (ANMs), B.Sc. Graduates, and M.Sc. Graduates, working at the selected PHCs. Inclusion criteria required participants to provide written informed consent, while those unwilling to participate were excluded. A total of 500 HCPs were recruited using convenience sampling, ensuring representation from different cadres: 225 ASHA workers with high school/diploma qualifications, 117 ANMs with 10+2 and ANM training, 108 B.Sc. Graduates, and 50 M.Sc. Graduates. This sample size was determined based on feasibility within the seven PHCs, assuming an 80% prevalence of knowledge about cervical cancer (derived from prior studies), a 5% margin of error, and a 95% confidence interval, adjusted for a finite population [22]. No follow-up was required due to the cross-sectional design. Data Collection Data were collected using a structured, pre-tested questionnaire administered through face-to-face interviews by trained medical assistants.The questionnaire was developed based on existing literature on cervical cancer KAP studies and pilot-tested for clarity and reliability among a small group of HCPs prior to the study [23]. It consisted of five sections: socio-demographic information (8 items: age, gender, education, designation, marital status, PHC location, and others), knowledge (10 items covering awareness, risk factors, symptoms, prevention, and screening methods), attitudes (3 items on the importance of and willingness to participate in screening), practices (3 items on prior screening experience), myths (4 items addressing common misconceptions), specific knowledge (2 items on HPV and screening frequency),and feedback(4 items on benefits, recommendations, and suggestions for improvement). Responses were recorded as binary (e.g., yes/no) or multiple-choice options, with correct answers scored as 1 and incorrect as 0, with standard KAP scoring protocols [24]. Ethical Considerations The study received ethical approval from the Institutional Ethics Committee of Kurnool Medical College, Kurnool (IEC-KMC-GGH; No:405/2023; Dt:05.12.2023).The permission was also obtained from the District Medical and Health Officer, Kurnool (Dt:16.12.2023) to conduct the study at the selected PHCs. Informed consent was obtained from each participant after explaining the study’s purpose, procedures, and confidentiality measures. Participants were informed of their right to withdraw at any time without consequences. All data were de-identified and stored securely to protect participant privacy [25]. Statistical Analysis Data were entered and managed in Microsoft Excel. Descriptive statistics, including frequencies and percentages, were used to summarize socio-demographic characteristics and KAP responses, stratified by HCP designation (ASHA, ANM, B.Sc. Graduates, M.Sc. Graduates). No inferential statistical tests (e.g., chi-square for associations) were performed in this initial analysis, though descriptive correlations between KAP and socio-demographic variables (e.g., education level) were noted. Missing data were minimal, as all 500 participants completed the questionnaire, yielding a 100% response rate. Future analyses could explore statistical associations using appropriate tests [26]. Bias Mitigation To minimize selection bias, participants were recruited during routine ASHA meetings, which ensured access to a broad range of HCPs. However, the use of convenience sampling may limit representativeness to other regions or urban settings. Response bias was addressed by ensuring neutral, non-leading questions and maintaining anonymity. No adjustments were made for non-response bias, as all approached participants consented to participate. The questionnaire’s pre-testing helped ensure clarity and reduce misinterpretation [27].

The study enrolled 500 health care professionals (HCPs) from seven primary health centres (PHCs) in Kurnool District, Andhra Pradesh, India. The cohort was predominantly female (99.4%, n=497), reflecting the gender composition of the health workforce in rural India. Participants’ ages ranged from 20 to 60 years, with the majority distributed across the 20–25 (25%) and 35–45 (30%) age groups, yielding an estimated mean age of approximately 38 years based on categorical data. Most participants were married (90%, n=450), with smaller proportions being single (7%, n=35) or widowed (3%, n=15). By designation, the sample included 225 ASHA workers with high school/diploma qualifications (45%), 117 Auxiliary Nurse Midwives (ANMs) with 10+2 and ANM training (23.4%), 108 B.Sc. Graduates (21.6%), and 50 M.Sc. Graduates (10%). Participants were recruited from rural PHCs, including Nannur, E.Thandrapadu, Gonegandla, Laddagiri, Krishnagiri, Ramallakota ,and Husenapuram were actively involved in community health mobilization [ Table 1]. Table 1: Socio-Demographic Characteristics of Participants (N=500) Characteristic Category Frequency (n) Percentage (%) Gender Female 497 99.4 Male 3 0.6 Age Group (years) 20–25 125 25.0 26–35 100 20.0 36–45 150 30.0 46–55 100 20.0 55–60 25 5.0 Marital Status Married 450 90.0 Single 35 7.0 Widowed 15 3.0 Designation ASHA (High School/Diploma) 225 45.0 ANM (10+2) 117 23.4 B.Sc. Graduates 108 21.6 M.Sc. Graduates 50 10.0 Knowledge of Cervical Cancer Screening Knowledge levels were generally high across the cohort, with 91.6% (n=458) of participants aware of cancer in women and 91% (n=455) specifically aware of cervical carcinoma (Table 2). Awareness was highest among M.Sc. Graduates (100%, n=50) and lowest among ASHA workers (86.7%, n=195). The primary source of information was higher authorities or teachers (94.8%, n=474), followed by mass media (33.2%, n=166). Knowledge of risk factors was moderate: 70.2% (n=351) identified early marriage, 69.6% (n=348) multiple sexual partners, 61.8% (n=309) poor hygiene, and 59.2% (n=296) HPV infection as risk factors. Recognition of symptoms was stronger, with 79.8% (n=399) identifying abnormal vaginal bleeding and 68.4% (n=342) noting vaginal discharge. Preventive measures were well-known, with 68.6% (n=343) aware of the HPV vaccine and 78.4% (n=392) recognizing screening as preventive. Knowledge of screening methods included Pap smear (70.6%, n=353) and VIA (62.4%, n=312), though only 58.4% (n=292) correctly identified the recommended screening age range (30–65 years). Treatment options like surgery (72.4%, n=362) and chemotherapy (61.2%, n=306) were also widely recognized. Higher education correlated with better knowledge, with M.Sc. Graduates consistently scoring 94–100% across items compared to 86–99% for ASHA workers. Myths and Specific Knowledge Misconceptions about cervical cancer were prevalent, particularly among lower-cadre HCPs. Only 48.8% (n=244) correctly disagreed that cervical cancer is hereditary, and 52.4% (n=262) disagreed that it occurs only in promiscuous women [Table 2]. M.Sc. Graduates outperformed others (80–90% correct), while ASHA workers had the lowest accuracy (40–50%). Specific knowledge about HPV as a primary cause was moderate (59.2%, n=296), and 61.4% (n=307) correctly identified the recommended screening frequency (every 3–5 years). These gaps suggest a need for targeted education to dispel myths and enhance understanding of HPV’s role. Attitudes and Practices Attitudes toward cervical cancer screening were overwhelmingly positive, with 94.2% (n=471) agreeing that screening is essential and 88.6% (n=443) expressing willingness to participate in screening programs [Table 2]. However, actual screening practices were notably low, with only 20.6% (n=103) having previously undergone Pap smear or VIA screening. ASHA workers (26.2%, n=59) and ANMs (24.8%, n=29) reported higher screening rates than B.Sc. Graduates (4.6%, n=5) and M.Sc. Graduates (20%, n=10), possibly reflecting greater community-level engagement among lower cadres. This discrepancy between positive attitudes and low practices suggests systemic barriers, such as limited access to screening facilities or time constraints. Feedback on Screening Programs Feedback on government cervical cancer screening programs was positive, with 81.6% (n=408) reporting benefits from these initiatives [Table 2]. Additionally, 82.2% (n=411) indicated they would recommend screening to others, and 41.6% (n=208) suggested improvements, such as increased training or better access to screening tools. The proportion who had personally undergone screening (20.6%, n=103) aligned with practice data, reinforcing the gap between awareness and action. Table 2: Knowledge, Attitudes, Practices, Myths, and Feedback by Designation (N=500) Section Item Example ASHA (n=225) ANM (n=117) B.Sc. Graduates (n=108) M.Sc. Graduates (n=50) Total (n=500) Knowledge Heard of cervical cancer 86.7% 92.3% 94.4% 100% 91.0% Risk factor: Early marriage 66.7% 70.9% 74.1% 82.0% 70.2% Symptom: Abnormal vaginal bleeding 76.4% 80.3% 83.3% 92.0% 79.8% Prevention: HPV vaccine 64.0% 68.4% 72.2% 84.0% 68.6% Myths Correctly disagreed it is hereditary 48.9% 52.1% 55.6% 82.0% 54.8% Specific Knowledge HPV as a cause 55.1% 59.0% 62.0% 72.0% 59.2% Attitudes Agree screening is essential 94.2% 93.2% 95.4% 96.0% 94.2% Practices Had prior screening (Pap/VIA) 26.2% 24.8% 4.6% 20.0% 20.6% Feedback Benefited from gov't programs 80.4% 76.9% 84.3% 92.0% 81.6% Would recommend to others 76.4% 84.6% 88.9% 88.0% 82.2%

The present study revealed high levels of awareness and knowledge about cervical cancer among health care professionals (HCPs) in rural primary health centers (PHCs) of Kurnool District, with 91% having heard of cervical cancer and moderate to high recognition of risk factors, symptoms, and screening methods. Attitudes were predominantly positive, as evidenced by 94.2% agreeing on the essentiality of screening. However, a stark gap was observed in practices, with only 20.6% of participants having undergone screening themselves via Pap smear or visual inspection with acetic acid (VIA).Higher educational qualifications correlated with better knowledge and fewer misconceptions, yet screening practices remained low across all designations. Feedback indicated that while 81.6% benefited from government programs, there is room for improvement in training and accessibility. Interpretation These findings underscore the critical role of HCPs in bridging the gap between knowledge and action in cervical cancer prevention, particularly in rural settings where access to specialized care is limited. The high knowledge and positive attitudes align with the World Health Organization's (WHO) emphasis on HCPs as key mobilizers for the 90-70-90 elimination targets [10]. Myths, such as the hereditary nature of cervical cancer (persisting in 45.2% of participants), may further deter personal and community-level uptake. This discrepancy highlights the need for targeted interventions, such as hands-on training workshops and integration of screening into routine health services, to translate knowledge into practice and enhance community mobilization. Comparison with Previous Studies Our results are consistent with several studies on knowledge, attitudes, and practices (KAP) regarding cervical cancer screening among HCPs in India. A review by Chawla et al. [31] synthesized data from multiple Indian studies, reporting an overall knowledge level of 75.15% among health professionals, with 86.20% aware of screening methods and 85.47% holding positive attitudes, but only 12.70% engaging in screening practices. This mirrors our findings of 91% awareness and 94.2% positive attitudes but higher practice rates (20.6%), possibly due to recent government initiatives in Andhra Pradesh. Similarly, Khanna et al. [32] assessed KAP among community health workers (primarily ASHAs) in Varanasi, Uttar Pradesh, finding that only 21.4% had good knowledge, 93.9% positive attitudes, and a mere 8.3% had undergone screening. In comparison, our ASHA subgroup demonstrated higher knowledge (86.7% awareness) and screening rates (26.2%), which may reflect regional differences in training programs or exposure to awareness campaigns. In a study among nursing staff in a tertiary care hospital in Western India, Karena et al. [33] reported that only 28.8% had adequate knowledge of screening methods, with 5.2% having undergone screening themselves. Our Graduates (B.Sc. and M.Sc.) showed superior knowledge (94.4–100% awareness) but similarly low personal screening (4.6–20%), indicating persistent practice gaps even in higher-educated groups. Another recent cross-sectional study by Chaya et al. [34] among medical professionals found 77.5% awareness of cervical cancer, 51.2% knowledge of Pap smear, and 20.1% routinely performing screening, aligning closely with our overall practice rates and emphasizing the need for improved training on screening guidelines. These comparisons suggest that while knowledge and attitudes have improved over time in some regions, screening practices remain suboptimal across India, likely due to shared barriers like skill deficiencies and resource limitations. Limitations This study has several limitations. The use of convenience sampling during ASHA meetings may introduce selection bias, potentially overrepresenting motivated HCPs and limiting representativeness to less accessible rural areas. he cross-sectional design precludes causal inferences, and the absence of inferential statistics in this analysis restricts exploration of associations between variables. Additionally, the small sample of M.Sc. Graduates (n=50) may reduce the precision of subgroup estimates. Finally, the focus on Kurnool District limits generalizability to urban or other socio-culturally diverse regions in India.

The findings are most applicable to rural PHCs in southern India, where HCPs like ASHAs and ANMs play a central role in community health. They may extend to similar low-resource settings in other developing countries facing cervical cancer burdens, but caution is advised for urban or high-resource contexts with better screening infrastructure. In conclusion, despite adequate knowledge and positive attitudes, low screening practices among HCPs highlight the urgency for policy interventions to enhance training, address myths, and improve access. Strengthening HCPs' roles could significantly advance India's progress toward WHO elimination goals, ultimately reducing cervical cancer morbidity and mortality. Acknowledgements

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