Prostate cancer is one of the most prevalent malignancies affecting men globally and has steadily emerged as a significant health concern in India, particularly with the gradual aging of the population and increasing life expectancy [1,2]. While prostate cancer is often slow-growing and potentially curable when detected early, the disease remains underdiagnosed in many developing regions due to a lack of awareness, social stigma and limited access to routine screening. In India, prostate cancer is now among the top ten cancers affecting men, yet public understanding of its risk factors, symptoms and preventive strategies continues to lag behind other more widely discussed health issues [3,4].

Shimla, a mountainous district in the northern Indian state of Himachal Pradesh, presents a unique socio-cultural and demographic context that influences men’s health-seeking behaviors. The combination of traditional masculinity norms, limited health outreach in rural areas and insufficient dialogue around male-specific illnesses creates an environment where prostate health is often neglected. In such communities, subtle symptoms like frequent urination, nocturia, or pelvic discomfort are often normalized or dismissed, delaying early detection. Additionally, myths and misconceptions surrounding digital rectal examinations, Prostate-Specific Antigen (PSA) testing and the fear of cancer diagnosis contribute to a culture of silence and avoidance [5,6].

Although national health programs such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) have begun addressing male cancers, prostate cancer awareness remains a relatively uncharted frontier. The absence of structured awareness campaigns, routine screening facilities and culturally sensitive educational resources in semi-urban and rural areas further exacerbates the challenge [7,8]. Particularly in Shimla, where healthcare access can be hindered by geographic and climatic constraints, the need to educate men about prostate cancer is both urgent and significant.

This study seeks to explore the level of awareness, knowledge and perceptions related to prostate cancer among adult men in Shimla. By examining how age, education, occupation and residential setting influence awareness, the study aims to uncover informational gaps and behavioral patterns that may impact early diagnosis and treatment. The insights derived will inform the development of more targeted, gender-sensitive health promotion strategies designed to empower men to take a proactive role in safeguarding their prostate health.

Study Design

This research was designed as a descriptive, cross-sectional survey aimed at evaluating the level of awareness, understanding and perceptions related to prostate cancer among adult men in Shimla district, Himachal Pradesh. The primary focus was to assess knowledge of prostate cancer symptoms, risk factors, early detection methods and preventive behaviors.

Study Area and Target Population

The study was conducted in Shimla, a hilly district located in the northern part of India, characterized by a blend of urban hubs and remote rural communities. The district’s unique topography and socio-cultural diversity provided a relevant context for assessing male-specific health awareness in underrepresented populations. The target group included men aged 18 years and above, across varying socio-economic and educational backgrounds, residing in both urban and rural areas of Shimla.

Study Duration

The data collection spanned a three-month period from January to March 2025. This duration allowed for sustained outreach and ensured inclusivity across different working-class and age demographics.

Sample Size and Sampling Technique

A total of 400 adult male participants were recruited for the study. The sample size was calculated using a 95% confidence level, a 5% margin of error and an estimated 50% prevalence of prostate cancer awareness-ensuring statistical adequacy and representativeness. A mixed-method sampling approach was used: purposive sampling ensured the inclusion of diverse occupational and educational groups, while convenience sampling enabled practical outreach through online and community networks.

Inclusion Criteria:

• Males aged 18 years and above

• Permanent residents of Shimla district

• Able to understand and respond in either Hindi or English

• Willing to provide informed digital consent

Exclusion Criteria:

• Men previously diagnosed with prostate cancer

• Incomplete or inconsistent responses in the survey

• Individuals who declined to participate or did not provide consent

Study Tool – Structured Questionnaire

Data were collected through a structured, pre-tested questionnaire developed in collaboration with urologists, oncologists and public health professionals. The questionnaire was bilingual (Hindi and English) to maximize accessibility and comprehensibility and consisted of three major sections:

• Socio-Demographic Profile: Capturing details such as age, education level, occupation, marital status and residential location

• Knowledge and Awareness: Including 20 multiple-choice questions to assess participants' knowledge of prostate cancer symptoms (e.g., urinary changes, pelvic discomfort), risk factors (e.g., age, family history, smoking) and detection methods (e.g., PSA test, digital rectal exam)

• Perceptions and Preventive Attitudes: Exploring beliefs about masculinity and health-seeking behavior, willingness to undergo screening and awareness of available diagnostic services

Scoring and Classification

Each correct answer in the knowledge section was awarded one point. Based on the total scores, participants were categorized into four levels of awareness:

• Very Good Knowledge (≥80%)

• Good Knowledge (60–79%)

• Fair Knowledge (41–59%)

• Poor Knowledge (<40%)

This classification facilitated comparative analysis across different demographic subgroups and informed targeted intervention planning.

Data Collection Procedure

The survey was administered digitally using Google Forms. Links were shared via WhatsApp groups, Facebook pages, community forums and male-oriented professional networks. A brief preface to the survey explained the purpose of the study, ensuring informed participation. Consent was obtained digitally and no personal identifiers were collected, preserving respondent anonymity.

Data Analysis

Data were exported into Microsoft Excel for cleaning and organization. Descriptive statistics, including frequency and percentage distributions, were used to summarize demographic details and knowledge levels. Comparative analyses were performed to assess patterns across age, education and urban-rural residence, using cross-tabulation methods.

Ethical Considerations

The study adhered to standard ethical protocols for online health research. Participation was entirely voluntary, digital informed consent was obtained and data confidentiality was maintained throughout. No incentives were provided and respondents retained the right to withdraw at any point.

The study encompassed a total of 400 male participants from Shimla district, reflecting a diverse socio-demographic profile. The majority of respondents (32.0%) were within the 26–35 years age group, followed by those aged 36–45 years (27.0%), 18–25 years (26.0%) and 15.0% aged 46 years and above. Educational levels varied notably, with the highest proportions holding secondary and undergraduate degrees (28.0% each), followed by postgraduate education (14.0%), primary schooling (17.0%) and no formal education (13.0%). In terms of occupation, office workers (23.0%) and students (20.0%) constituted a significant share, along with teachers (19.0%) and healthcare professionals (11.0%). A smaller fraction were homemakers (5.0%), while 22.0% were engaged in other forms of employment. Geographically, the sample was slightly skewed toward rural areas, with 58.0% residing in rural settings and 42.0% in urban regions-ensuring a balanced reflection of community-level perspectives across varying lifestyles and access to healthcare infrastructure (Table 1).

Participants demonstrated a generally high level of awareness across core domains related to prostate cancer. A substantial 78.0% correctly identified prostate cancer as a malignancy of the prostate gland and 76.0% recognized that age over 50 is a significant risk factor. Symptom recognition was strong, with 80.0% aware of difficulty urinating as a common sign. Knowledge of familial risk was affirmed by 74.0% of respondents, while 75.0% identified surgery as a standard treatment for early-stage prostate cancer. Regarding diagnostic tools, 76.0% were familiar with the PSA blood test and 71.0% acknowledged the role of digital rectal exams. While 72.0% understood the importance of early detection, fewer respondents (69.0%) knew that the disease can initially be asymptomatic. Other important insights included recognition of metastasis as a risk of untreated disease (74.0%), obesity and smoking as risk factors (73.0% and 72.0%, respectively) and blood in urine as a symptom (65.0%). Only 58.0% were aware that prostate cancer could recur after treatment-highlighting a significant knowledge gap. These results suggest that while general awareness is encouraging, more nuanced aspects of the disease and its progression require targeted educational reinforcement (Table 2).

When classified by knowledge level, 33.0% of participants achieved very good scores (≥80% correct responses), while the largest proportion (38.0%) demonstrated good knowledge, scoring between 60–79%. Fair knowledge was observed in 20.0% of respondents and 9.0% were categorized under poor knowledge with scores below 40%. This distribution indicates that over 70% of the surveyed male population in Shimla had a solid understanding of prostate cancer and its detection methods. However, the presence of nearly 30% with only fair or poor awareness signals an urgent need to strengthen educational initiatives-especially among subgroups likely impacted by lower literacy, limited healthcare access, or cultural barriers to discussing male reproductive health (Table 3).

Table 1: Socio-Demographic Characteristics of Participants (Shimla)

Table 2: Public Knowledge and Awareness of Prostate Cancer and Its Detection

Table 3: Knowledge Score Classification on Prostate Cancer and Its Detection

This cross-sectional study provides a nuanced and timely examination of prostate cancer awareness and knowledge among men in Shimla, a region where socio-cultural taboos and geographic barriers often intersect to limit access to preventive healthcare. The results indicate a promising overall awareness level, with 71% of participants demonstrating good to very good knowledge of prostate cancer, yet also highlight persistent gaps that could undermine early detection and timely intervention.

The demographic distribution of the sample was diverse and representative. The largest age group was 26–35 years (32.0%), followed closely by those aged 36–45 (27.0%) and 18–25 (26.0%). This reflects a predominantly younger and potentially more health-literate population, a factor that may explain the generally encouraging awareness levels. Importantly, educational attainment was fairly balanced: while 28.0% had either secondary or undergraduate education, 13.0% of participants had no formal education and 17.0% had only primary schooling. This broad spectrum allowed for an inclusive evaluation of knowledge disparities. Occupational diversity added further value, with substantial input from office workers, students, teachers and healthcare professionals. The higher representation of rural residents (58.0%) ensured that the study captured the challenges and realities faced by populations often marginalized in public health programming.

In terms of disease-specific knowledge, a commendable 78.0% of respondents correctly identified prostate cancer as a malignancy of the prostate gland and 76.0% were aware that age over 50 is a significant risk factor. These findings suggest that foundational knowledge has permeated public consciousness to a degree, possibly aided by digital health campaigns or broader exposure to health narratives via media. Recognition of common symptoms, particularly difficulty urinating (80.0%) and familiarity with diagnostic methods such as PSA testing (76.0%) and digital rectal examinations (71.0%), also reflect encouraging trends. However, it is concerning that only 69.0% were aware that prostate cancer can be asymptomatic in early stages-a critical knowledge gap that could delay diagnosis and increase mortality risk. Similarly, awareness of disease recurrence was relatively low at 58.0%, suggesting a limited understanding of long-term disease management and the importance of post-treatment monitoring.

Perceptions surrounding risk factors were mixed. While 74.0% recognized the influence of family history and 73.0% understood obesity as a contributor, only 65.0% correctly identified blood in urine as a potential symptom, indicating insufficient awareness of less common but clinically significant warning signs. Moreover, despite strong recognition of smoking as a general health risk (72.0%), the direct association with prostate cancer appears less well understood compared to other cancer types, warranting targeted messaging.

The classification of participants by knowledge level reinforces the need for strategic educational interventions. While 33.0% exhibited very good awareness and 38.0% demonstrated good knowledge, a notable 29.0% fell into the fair or poor categories. These individuals are likely to be concentrated among the less educated, older and rural subgroups-demographics that typically face structural barriers to healthcare access, digital literacy and preventive health practices. The correlation between limited education and lower awareness aligns with findings from similar studies across rural India, where health misinformation and stigma remain prevalent.

Behavioral attitudes and cultural norms also play a vital role in shaping health-seeking behavior among men in Shimla. Traditional masculinity ideals, discomfort with discussing urogenital symptoms and fear of invasive procedures or cancer diagnoses contribute to a reluctance to pursue screening. This cultural silence often leads to late-stage diagnosis when treatment options are more complex, costly and less effective. Additionally, stigma around rectal exams and misconceptions about fertility loss post-treatment can deter men from undergoing routine checks, even if symptomatic.

The mode of data collection-an online survey-proved efficient in engaging younger and digitally connected individuals, but likely excluded older adults, non-literate populations and residents in remote hamlets without internet access. These are precisely the groups most vulnerable to undiagnosed prostate cancer. Future studies should consider incorporating on-ground, community-based data collection methods to better reach these marginalized segments and gain a more holistic understanding of awareness gaps.

From a public health perspective, the findings of this study advocate for a multipronged approach to prostate cancer education in Shimla. Efforts must extend beyond basic awareness to include comprehensive education on asymptomatic progression, recurrence risks and the critical role of screening tools like PSA and DRE. Community health workers, male peer educators and local influencers can be mobilized to destigmatize conversations around prostate health, especially in rural areas where gender norms may inhibit open dialogue. Integrating prostate cancer awareness into broader Non-Communicable Disease (NCD) campaigns under the NPCDCS umbrella could also enhance outreach and sustainability [9,10].

While the study reflects a reasonably informed male population in Shimla with respect to prostate cancer, it also uncovers critical blind spots that could hinder early diagnosis and effective treatment. Bridging these gaps through culturally sensitive, locally driven and demographically tailored educational initiatives is essential to transforming prostate cancer from a silent threat into a preventable and manageable condition in the region.

This study highlights a moderately high yet incomplete level of prostate cancer awareness among men in Shimla, with over 70% demonstrating good to very good knowledge of its risk factors, symptoms and detection methods. While awareness of core concepts such as the role of age, urinary difficulties, PSA testing and early treatment options is promising, critical knowledge gaps persist regarding asymptomatic progression, disease recurrence and less overt symptoms like hematuria. These deficiencies, especially prevalent among individuals with lower education levels and rural backgrounds, emphasize the urgent need for inclusive, culturally sensitive educational campaigns that address not only clinical facts but also social stigmas and misconceptions. Strengthening grassroots outreach through community health workers, male role models and localized health messaging can foster more open dialogue and proactive health-seeking behavior. To effectively shield the future, prostate cancer prevention strategies in Shimla must evolve into comprehensive public health efforts that inform, empower and engage men across all socio-demographic strata.

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