Cancer remains one of the most formidable challenges in public health, accounting for a significant proportion of global morbidity and mortality. Early detection is crucial in improving the prognosis and survival rates for many types of cancer, as it often leads to more effective and less invasive treatment options. Recognizing the warning signs and symptoms of cancer is a critical component of early detection, enabling individuals to seek timely medical intervention and thereby potentially saving lives. However, public awareness and knowledge about these early indicators can vary widely, influenced by factors such as education, access to healthcare, and cultural beliefs.^1-6

Shimla, the capital of Himachal Pradesh, provides a unique environment to study the level of awareness and knowledge about cancer's warning signs and symptoms. This district, with its mix of urban and rural populations, offers a comprehensive view of how cancer awareness is distributed across different segments of society. Given the increasing incidence of cancer in India, it is essential to understand how well the residents of Shimla are informed about this critical health issue.

The primary objective of this study was to gauge the awareness and knowledge about the warning signs and symptoms of cancer among the general public in District Shimla. By identifying gaps in awareness and common misconceptions, this research aimed to inform and guide public health initiatives and educational programs designed to promote early cancer detection. Understanding the community’s knowledge and perceptions about cancer symptoms is vital for developing targeted interventions that can enhance early detection efforts and improve health outcomes.

In light of the growing cancer burden and the paramount importance of early detection, this study was both timely and essential. It sought to provide valuable insights into the current state of cancer awareness among Shimla’s residents, thereby informing future health policies and community-based awareness campaigns. The findings from this research were intended to support efforts in creating a more informed and proactive community capable of recognizing early signs of cancer and seeking appropriate medical care promptly.

Through this research, we aimed to contribute to the broader effort of reducing cancer-related morbidity and mortality through enhanced public awareness. By highlighting the importance of recognizing cancer's warning signs and identifying key areas for intervention, this study aspired to improve public health outcomes and the quality of life for the residents of Shimla. The insights gained would serve as a foundation for sustainable health promotion strategies tailored to the unique needs and cultural context of this region.

The primary objective is to gauge awareness and knowledge about Warning Signs and Symptoms among general public of District Shimla ,Himachal Pradesh.

• Research Approach -Descriptive

• Research Design- Cross-sectional survey design

• Study area: District Shimla , Himachal Pradesh

• Study duration- between January  2024 to May 2024

• Study population: The study's target population encompassed all adults aged 18 and above who had been residents of District Shimla Himachal Pradesh for a minimum of 12 months

• Sample size- A robust sample size of 400 adults was determined using a 95% confidence level, an estimated knowledge level of 50% regarding Warning Signs and Symptoms , a precise 5% absolute error margin, and a conservative 5% non-response rate. 

• Study tool: A google form questionnaire consisting of questions regarding socio-demography and knowledge regarding Warning Signs and Symptoms was created. The questionnaire was initially pre-tested on a small number of participants to identify any difficulty in understanding by the respondents. 

• Description of Tool- 

1. Demographic data survey instrument: The demographic form elicited information on participants’ background: age, marital status, religion, employment, education and many more.

2. Questionnaire: The questionnaire contains 20 structured knowledge related questions regarding Warning Signs and Symptoms. One mark was given for each correct answer and zero for incorrect answer. The maximum score was 20 and minimum score was zero. Scoring was done on the basis of marks as >80%(16-20)=very good,60-79%(12-15) =Good,41-59% ( 8-11)=Fair,<40% (< 8)=poor

• Validity of tool - by the experts in this field

• Data collection- Data was collected under the guidance of supervisors. The google form questionnaire was circulated among the residents of District Shimla Himachal Pradesh for responses using online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin till the 400 responses were collected. 

• Data analysis- Data was collected and entered in Microsoft excel spread sheet, cleaned for errors and analyzed with Epi Info V7 Software with appropriate statistical test in terms of frequencies and percentage. 

• Ethical Considerations- Participants confidentiality and anonymity was maintained.

The study conducted in District Shimla, Himachal Pradesh, aimed to assess the awareness and knowledge regarding cancer warning signs and symptoms among the general public. Data was collected from a sample of 400 adults using a structured questionnaire, and the results are summarized in three tables: Socio-Demographic Variables, Knowledge Regarding Cancer Warning Signs and Symptoms, and Overall Knowledge Score Categories.

Table 1 provides an overview of the socio-demographic characteristics of the participants. The age distribution reveals that 29.8% of participants were aged 18-30 years, 25.3% were 31-40 years, 23% were 41-50 years, and 22% were over 50 years old. Gender distribution shows that 45% were male and 55% were female respondents. Regarding marital status, 40% of the participants were single, 55% were married, and 5% fell into other categories.

Religious affiliation was predominantly Hindu (84.8%), followed by Muslims (4.8%), Sikhs (7.5%), and others (3%). Employment status indicated that 44.5% of participants were employed, 25.5% were unemployed, and 30% were students. Educational attainment varied, with 20% having education below high school, 30.3% completing high school, 34.8% being graduates, and 15% having postgraduate or higher qualifications.

Table 1: Socio-Demographic Variables of the Study Population (N=400)

Table 2 highlights the participants' knowledge about cancer warning signs and symptoms. A substantial 75% of respondents were knowledgeable about persistent cough as a warning sign, while 71.3% were aware of unexplained weight loss. Understanding of changes in bowel or bladder habits was noted in 67.5% of participants, and 65% had knowledge about unusual bleeding or discharge. Awareness of thickening or lump in the breast or elsewhere was present in 72.5%, and 68.8% understood indigestion or difficulty swallowing as a symptom.

Knowledge of an obvious change in a wart or mole was reported by 61.3%, while 64.5% were aware of nagging cough or hoarseness. Understanding of skin changes or unusual growths was known by 60%, and 55% recognized fatigue as a potential symptom. Awareness of persistent pain was reported by 66.3%, and 72.5% understood the importance of regular screenings. Knowledge of family history as a risk factor was known by 68.8%, and 70% were aware of prevention methods like a healthy diet.

The impact of smoking and alcohol on cancer risk was understood by 65%, while knowledge of HPV and its link to cancer was present in 57.5% of participants. Awareness of occupational hazards was reported by 52.5%, and 67.5% understood the role of physical activity in cancer prevention. Knowledge of cancer-related fatigue was known by 60%, and 77.5% were aware of the need for early medical consultation.

Table 2: Knowledge Regarding Cancer Warning Signs and Symptoms (N=400)

Table 3 categorizes the overall knowledge scores of the participants. Based on their scores, 25.3% of participants fell into the "Very Good" category (16-20 points), demonstrating a high level of knowledge. The majority, 37%, were classified as having "Good" knowledge (12-15 points). Those with "Fair" knowledge (8-11 points) comprised 24.5% of the respondents, while 13.3% had "Poor" knowledge, scoring below 8 points.

Table 3: Overall Knowledge Score Categories

These results indicate that while a significant portion of the population in Shimla has a good understanding of cancer warning signs and symptoms, there are still areas with notable knowledge gaps. Addressing these gaps through targeted educational programs and public health initiatives could enhance awareness and early detection of cancer, ultimately improving health outcomes in the region.

The study conducted in District Shimla, Himachal Pradesh, provides crucial insights into the awareness and knowledge of cancer warning signs and symptoms among the general public. The findings underscore both the strengths and the areas needing improvement in public health education concerning cancer awareness in this region.

The socio-demographic analysis reveals a diverse participant base, with a nearly even distribution across different age groups and a slight predominance of female respondents. The religious composition is reflective of Shimla’s demographic, with a majority Hindu population followed by Muslims and Sikhs. The employment and educational data show a substantial portion of the population being employed and having at least high school education, which is significant as these factors often correlate with better health literacy and access to healthcare resources.

The results indicate a commendable level of awareness among Shimla residents regarding several key cancer warning signs and symptoms. Notably, high awareness was observed for persistent cough (75%), unexplained weight loss (71.3%), and the presence of a lump or thickening in the breast or elsewhere (72.5%). These findings suggest that public health messages about these particular symptoms may be reaching the population effectively.

However, the awareness was not uniform across all symptoms. Knowledge about more subtle or less commonly discussed symptoms, such as changes in a wart or mole (61.3%), fatigue (55%), and the link between HPV and cancer (57.5%), was comparatively lower. This discrepancy highlights specific areas where public health initiatives could focus more efforts to bridge these knowledge gaps. For instance, increasing public education about the role of HPV in cancer development could enhance vaccination uptake and preventative measures.

The categorization of overall knowledge scores further elucidates the community's understanding of cancer warning signs and symptoms. While 25.3% of participants demonstrated a very good level of knowledge, and 37% were categorized as good, it is concerning that 13.3% had poor knowledge scores. This variance indicates a need for targeted interventions to uplift those with lesser awareness to ensure a more uniformly informed population.

The study's findings have significant implications for public health strategies in Shimla. Firstly, there is a clear necessity for comprehensive cancer awareness programs that address both the well-known and the lesser-known symptoms of cancer. These programs should be tailored to reach diverse segments of the population, leveraging local languages and culturally relevant materials.^7-10

Given the high percentage of respondents who are students or employed, educational institutions and workplaces could serve as pivotal points for disseminating information. Collaborations with local healthcare providers and community leaders could further enhance the reach and impact of these programs.^10,11

Additionally, leveraging digital platforms, as evidenced by the study's data collection method, can be an effective strategy for spreading awareness. Social media campaigns and online educational resources can complement traditional methods, ensuring broader coverage and engagement.1^1,12

While this study provides valuable insights, it also has limitations. The use of a self-reported questionnaire may introduce bias, as participants might overestimate their knowledge. Future research could benefit from more diverse methodologies, including in-person interviews and focus groups, to gain deeper qualitative insights.

Moreover, exploring the reasons behind the knowledge gaps—whether due to lack of access to information, cultural beliefs, or other barriers—could provide a more comprehensive understanding of the issue. Longitudinal studies could also track the effectiveness of implemented awareness programs over time.

This study underscores the importance of continued and enhanced public health education regarding cancer in Shimla. While there is a solid foundation of awareness, targeted interventions addressing specific knowledge gaps are essential. By fostering a well-informed community, early detection and timely medical intervention can be significantly improved, ultimately reducing cancer-related morbidity and mortality. The insights gained from this research serve as a critical foundation for developing effective, culturally sensitive, and sustainable health promotion strategies tailored to the unique needs of Shimla's residents.

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10. Fotedar S, Bhardwaj V, Manchanda K, Fotedar V, Sarkar AD, Sood N. Knowledge, attitude and practices about oral cancers among dental students in H.P Government Dental College, Shimla-Himachal Pradesh. South Asian J Cancer. 2015 Apr-Jun;4(2):65-7.

11. Kala G, Mir MS, Pandey N, Shrivastava S, Sharma S, Purohit JS. Knowledge, awareness and attitude towards cancer: An intervention-based study among the students of the University of Delhi, India. J Public Hlth Dev [Internet]. 2023 Oct 10 [cited 2024 Jul 2];21(3):246-59.

12. Kumari J, Raj A. Unlocking awareness: exploring cancer warning signs knowledge in District Bilaspur, Himachal Pradesh. IAR J Anaesthesiol Crit Care. 2023 Sep;4(5):16-21.