1. INTRODUCTION:

Cervical cancer remains a substantial public health challenge worldwide, particularly affecting women in low- and middle-income countries (LMICs). Recent data from the World Health Organization indicate that over 90% of new cervical cancer cases and related deaths occur in LMICs, where access to preventive services, screening programs, and HPV vaccination remains inadequate.^1,2 Despite being largely preventable through early detection and vaccination, cervical cancer continues to impose significant morbidity and mortality burdens on women in resource-constrained settings. The disparity in healthcare resource distribution, compounded by socioeconomic and cultural barriers, substantially undermines the effectiveness of prevention initiatives in these regions.³

Effective screening programs coupled with timely intervention constitute critical components in reducing cervical cancer burden. Evidence from high-income nations demonstrates that widespread implementation of HPV testing and Pap smear screening has successfully reduced both incidence and mortality rates.⁴ However, these successes have not been uniformly replicated in rural and resource-limited settings. In developing nations such as India, rural women encounter numerous obstacles to screening participation, including inadequate healthcare infrastructure, transportation difficulties, financial constraints, gender-related stigma, and insufficient awareness of preventive health services.^5,6These barriers collectively result in delayed diagnosis and reduced screening program participation, emphasizing the urgent need to develop strategies that enhance both awareness and accessibility.

Understanding how knowledge and attitudes influence screening behavior is essential for improving participation rates and designing effective interventions. Public health behavioral research consistently demonstrates that attitudes and perceptions toward screening directly affect women's care-seeking willingness.^7,8 Therefore, measuring these psychosocial variables through valid and reliable instruments is imperative. While several existing tools assess awareness and attitudes toward cervical cancer screening, many lack contextual sensitivity to the sociocultural realities of rural populations.

The present study seeks to develop and validate a structured questionnaire specifically designed to assess rural women's knowledge and attitudes concerning cervical cancer screening. Path analysis is employed to examine theoretical relationships among variables and ensure construct validity and reliability of measurement items. This analytical approach enables deeper understanding of direct and indirect associations between knowledge, attitudes, and screening behavior. Identifying these relationships not only improves measurement precision but also supports targeted intervention planning.

The significance of this investigation lies in its potential to address existing gaps in psychometric evaluation and behavioral assessment related to cervical cancer screening among rural women. A validated tool will facilitate cross-regional comparisons, help identify common misconceptions, and guide the formulation of culturally appropriate health promotion strategies. Ultimately, this study aims to strengthen community-based prevention efforts, encourage proactive health-seeking behaviors, and contribute to achieving WHO's global cervical cancer elimination goals for 2030.

2. METHODOLOGY:

2.1 Study Design:

This cross-sectional investigation was conducted among rural women residing in Tenkasi district, Tamil Nadu, India—a region characterized by disparities in cervical cancer screening awareness and limited healthcare accessibility. A stratified random sampling approach was implemented to ensure representative inclusion of women across diverse age groups and socioeconomic categories, thereby minimizing selection bias and reflecting the demographic heterogeneity of the region.

Inclusion Criteria:

· Female participants aged 25-65years

· Permanent residents of rural areas within Tenkasi district

· Ability to comprehend study procedures and provide informed consent

· Willingness to participate voluntarily

Exclusion Criteria:

· Women with history of hysterectomy or previous cervical cancer treatment

· Individuals unable to provide informed consent due to cognitive impairment or other limitations

2.2 Sample Size Determination:

Appropriate sample size determination is essential for ensuring analytical validity and statistical power. Following standard recommendations for path analysis—which require adequate subject-to-variable ratios for reliable model estimation—this study recruited 80 participants. This sample size aligns with established guidelines suggesting 5-10 observations per estimated parameter, providing sufficient power for stable path coefficient estimation and discriminant validity assessment among questionnaire constructs. This approach aims to generate robust, generalizable findings for validating the knowledge and attitude assessment instrument.

2.3 Data Collection Procedures:

Participants completed a structured questionnaire containing validated items addressing cervical cancer risk factor knowledge, screening method awareness, and attitudes toward screening participation. Data collection was conducted through face-to-face interviews by trained field investigators using the participants' native language to ensure comprehension and response accuracy. All investigators received standardized training in interview techniques and ethical research practices prior to data collection.

2.4 Statistical Analysis:

Path analysis was performed using SPSS AMOS software to evaluate relationships between knowledge, attitudes, and screening behaviors. This methodology enabled assessment of direct and indirect effects among latent variables while ensuring construct validity and reliability of questionnaire items. Model adequacy was determined using multiple fit indices including Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and chi-square statistics. Descriptive statistics characterized participant demographics and questionnaire responses, while inferential statistics explored associations with screening uptake patterns.

3. RESULTS AND DISCUSSION:

3.1 participant demographic profile:

Table 1 presents demographic characteristics of the 80 participants included in the path analysis examining knowledge and attitudes toward cervical cancer screening among rural women in Tenkasi district.

Table 1: Demographic Characteristics of Study Participants (N=80)

Characteristic	Category	Frequency (n)	Percentage (%)
Age	Mean (SD)	38.2 (7.5) years	Range: 24-57 years
Educational Attainment	Primary	12	15.0
	Secondary	30	37.5
	Higher Secondary	22	27.5
	Graduate and above	16	20.0
Marital Status	Married	55	68.8
	Unmarried	18	22.5
	Divorced	7	8.8
Employment Status	Employed	26	32.5
	Self-employed	14	17.5
	Homemaker	40	50.0
Monthly Income	<Rs. 5,000	26	32.5
	Rs. 5,000-10,000	47	58.8
	>Rs. 10,000	7	8.8

The demographic analysis revealed a mean participant age of 38.2 years (SD=7.5), with ages ranging from 24 to 57 years—predominantly within the recommended cervical cancer screening age range of 25-45 years. Educational attainment varied considerably, with 15.0% completing primary education, 37.5% secondary education, 27.5% higher secondary education, and 20.0% holding graduate degrees or higher qualifications. This educational diversity suggests varying levels of health literacy that may influence cervical cancer screening comprehension and participation.

Regarding marital status, most participants were married (68.8%), while 22.5% were unmarried and 8.8% divorced, indicating diverse social support structures potentially influencing health behaviors. Employment patterns showed 32.5% in formal employment, 17.5% self-employed, and half (50.0%) identifying as homemakers—reflecting typical rural occupational distributions and potential economic constraints affecting healthcare access.

Monthly income distribution indicated 32.5% earned below Rs. 5,000, 58.8% earned Rs. 5,000-10,000, and 8.8% earned above Rs. 10,000, highlighting socioeconomic heterogeneity potentially impacting healthcare service utilization. These demographic characteristics provide essential context for interpreting path analytic findings and emphasize the need for interventions tailored to diverse educational, social, occupational, and economic realities in rural settings.

3.2 Theoretical Framework and Hypothesis Development:

Understanding community knowledge, attitudes, and practices regarding diseases including cervical cancer provides critical opportunities for developing comprehensive prevention and control strategies. This necessitates investigating interrelationships between socioeconomic factors and cervical cancer screening knowledge and attitudes.

Age and Knowledge-Attitude Relationships:

Previous research indicates that basic cervical cancer knowledge increases with age,⁹ though younger women may demonstrate higher awareness regarding risk factors and symptoms.¹⁰ However, this awareness often relates more to personal experiences than systematic health education exposure.

Hypothesis 1: Age demonstrates a significant relationship with screening attitudes, mediated by cervical cancer knowledge.

Socioeconomic Disparities:

Cervical cancer incidence and mortality disproportionately affect socioeconomically disadvantaged populations globally. Studies demonstrate persistent screening disparities related to race, ethnicity, age, education, insurance status, and rural residence.^11,12

Hypothesis 2: Community context exhibits significant association with screening attitudes, mediated by cervical cancer knowledge.

Educational Influence:

Education emerges as a key determinant influencing cervical cancer knowledge, attitudes, and screening behavior. Literature consistently demonstrates positive associations between educational attainment and screening awareness and acceptance.^13,14,15

Hypothesis 3: Educational attainment demonstrates significant positive correlation with screening attitudes, mediated by cervical cancer knowledge.

Employment Status Impact:

Employment often reflects greater health awareness and healthcare access. Research indicates employed women, particularly in formal sectors, demonstrate higher screening service utilization.^16,17

Hypothesis 4: Employment status shows significant association with screening attitudes, mediated by cervical cancer knowledge.

Income and Healthcare Access:

Socioeconomic status, particularly income disparities, strongly influences cervical cancer outcomes and screening access.^18,19 Low-income women face multiple barriers including limited healthcare access and inadequate social support, resulting in lower screening participation.²⁰

Hypothesis 5: Income level exhibits significant correlation with screening attitudes, mediated by cervical cancer knowledge.

Table 2: Model Fit Indices for Structural Equation Model

Fit Index	Obtained Value	Recommended Threshold	Reference
Chi-square (CMIN)	3.796 (p=0.975)	≤5.00	Hair et al., 1998
Comparative Fit Index (CFI)	1.00	>0.90	Hu and Bentler, 1999
Goodness of Fit Index (GFI)	1.00	>0.90	Hair et al., 2006
Adjusted GFI (AGFI)	0.989	>0.90	Daire et al., 2008
Normed Fit Index (NFI)	0.997	≥0.90	Hu and Bentler, 1999
Incremental Fit Index (IFI)	0.998	Approaches 1.0	—
RMSEA	0.000	<0.08	Hair et al., 2006

3.3 Path Analysis Results:

The interrelationships among selected socioeconomic variables, knowledge, and attitudes regarding cervical cancer screening were examined using Structural Equation Modeling (SEM). An initial default model was constructed based on preliminary investigations to conceptualize relevant study variables (Figure 1).

Table 2 presents model fit indices computed via AMOS software. The chi-square value achieved significance at p=0.975 (exceeding 0.05 threshold), indicating excellent model fit. The GFI value of 1.00 and AGFI value of 0.989 (both exceeding 0.90) reflect commendable fit. Additionally, calculated NFI (0.997) and CFI (1.00) values further confirm excellent model fit, while RMSEA value of 0.000 (below 0.08 threshold) affirms ideal fit. Collectively, these goodness-of-fit indices substantiate model adequacy and structural model acceptability.

Figure 2 illustrates the standardized solution for the default model, depicting path coefficients from the respondents' perspective.

Figure 2: Standardized Solution of the Path Model

Table 3: Path Coefficients in the Extracted Model

Path	Unstandardized Estimate	Standardized Estimate (β)	S.E.	C.R.	p-value	Hypothesis Decision
Knowledge ← Age	1.085	0.119	0.810	1.339	0.181	Not Supported
Knowledge ← Community	0.741	0.170	0.388	1.906	0.057	Not Supported
Knowledge ← Education	3.214	0.522	0.548	5.867	<0.001***	Supported
Knowledge ← Employment	-0.446	-0.146	0.271	-1.643	0.100	Not Supported
Knowledge ← Income	-1.290	-0.189	0.606	-2.127	0.126	Not Supported
Attitude ← Knowledge	0.786	0.462	0.170	4.630	<0.001***	Supported

***p<0.001

Standardized coefficients revealed that educational attainment (β=0.522, p<0.001) significantly predicted women's cervical cancer knowledge, which subsequently influenced screening attitudes (β=0.462, p<0.001). These findings indicate that increased educational attainment significantly enhances knowledge, which in turn fosters positive screening attitudes.

These conclusions align with previous research demonstrating that women with higher educational attainment possess enhanced communication skills and greater capacity for information assimilation.^15,14,24 Women with cervical cancer knowledge are more inclined to pursue early detection and seek timely medical consultation. Furthermore, positive attitudes were observed as women demonstrated willingness to participate in screening programs when opportunities were available. Therefore, implementing effective information, education, and communication strategies is imperative for elevating women's awareness regarding cervical cancer and screening services.

4. CONCLUSION:

This study examined interrelationships among socioeconomic variables, knowledge, and attitudes regarding cervical cancer screening using Structural Equation Modeling. Model fit statistics demonstrated excellent fit of the theoretical framework linking socioeconomic characteristics with knowledge and attitudes toward cervical cancer screening. Goodness-of-fit indices confirmed structural model acceptability, leading to the conclusion that increased educational attainment is associated with enhanced cervical cancer knowledge, which subsequently fosters positive screening attitudes.

Standardized path coefficients revealed educational status as the primary significant predictor of knowledge (β=0.522, p<0.001), which in turn substantially influenced screening attitudes (β=0.462, p<0.001). These findings emphasize that enhancing women's education significantly improves their cervical cancer knowledge and consequently develops favorable attitudes toward screening participation.

5. IMPLICATIONS FOR PRACTICE:

Study findings have important implications for designing cervical cancer prevention interventions in rural settings. Educational interventions should be prioritized, particularly targeting women with limited formal education. Community-based health education programs, utilizing culturally appropriate methods and local languages, may effectively bridge knowledge gaps and modify attitudes. Healthcare providers and policymakers should recognize education's central role in shaping health behaviors and develop comprehensive strategies addressing educational disparities while simultaneously improving screening service accessibility.

Study Limitations:

Several limitations warrant consideration. The cross-sectional design precludes causal inference regarding relationships between variables. The relatively modest sample size (n=80), while adequate for path analysis, may limit generalizability to other rural populations. Future research should employ longitudinal designs with larger, more diverse samples to confirm these findings and examine temporal relationships between education, knowledge, attitudes, and actual screening behaviors.

6. DECLARATIONS:

Ethics Approval and Consent:

This study received ethical approval and all participants provided informed consent prior to participation.

7. COMPETING INTERESTS:

The authors declare no competing interests.

8. ACKNOWLEDGMENTS:

The authors thank all study participants for their valuable time and cooperation.

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Received on 15.11.2025 Revised on 24.12.2025

Accepted on 27.01.2026 Published on 30.04.2026

Available online from May 02, 2026

Asian J. Nursing Education and Research. 2026;16(2):123-128.

DOI: 10.52711/2349-2996.2026.00025

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.