Cervical cancer is the fourth most common cancer among women worldwide, with an estimated 662,000 new cases and 349,000 deaths recorded globally in a recent year (1). Despite being one of the few malignancies that is both preventable and curable when detected early, cervical cancer disproportionately affects women in low- and middle-income countries (LMICs), which account for the overwhelming majority of global mortality from this disease (2). The most recent global estimates project a continued rise in both incidence and mortality over the coming decades unless organized prevention efforts are substantially scaled up (3).

Pakistan mirrors this global inequity. National burden estimates suggest that thousands of Pakistani women are diagnosed with cervical cancer annually, with the disease ranking among the leading gynecological cancers in the country (4). In response to the disproportionate global burden, the World Health Organization launched its 90-70-90 Global Strategy in 2020, calling for 90% HPV vaccination coverage, 70% screening coverage, and 90% treatment access by 2030 (5). Pakistan, however, remains far from these targets, lacking both a national HPV vaccination program and an organized cervical screening infrastructure (6).

Multiple hospital-based studies conducted across Pakistan have consistently reported alarmingly low levels of awareness regarding cervical cancer and its screening modalities. A study conducted among women in Azad Kashmir found that only a minority had ever heard of the Pap smear test, and fewer still had ever been screened (7). Similarly, women attending gynecology clinics in Karachi demonstrated substantial knowledge gaps regarding the risk factors, symptoms, and preventive strategies for cervical cancer (8). Comparable deficits in cancer-related health literacy have also been documented for other female cancers in the country, reinforcing the broader pattern of limited cancer awareness among Pakistani women (9).

Beyond disease-specific knowledge, HPV vaccine awareness and acceptability also remain modest, with recent national surveys suggesting that only about two-thirds of respondents would accept vaccination if it were made available (10). Structural barriers, including the historical underperformance of immunization programs in Pakistan, further complicate prevention efforts (11). International reviews emphasize that HPV-based screening, when integrated into primary healthcare, represents the most effective secondary prevention strategy currently available (12).

Given this backdrop of low awareness, limited vaccine uptake, and an absent organized screening infrastructure, there remains a pressing need to characterize the specific knowledge gaps, attitudinal barriers, and screening practices among Pakistani women attending routine hospital care. This study was therefore designed to assess the knowledge, attitudes, and practices regarding cervical cancer screening among women of reproductive age attending a tertiary-care hospital in Pakistan, and to identify the sociodemographic factors independently associated with adequate knowledge and screening uptake, in order to inform targeted, context-appropriate health education interventions.

This descriptive, hospital-based cross-sectional study was conducted in the outpatient Gynecology and Obstetrics department of a tertiary-care hospital in Khyber Pakhtunkhwa, Pakistan, from January 2026 to June 2026. A total of 125 women of reproductive age (18–46 years) attending the outpatient department for routine gynecological consultation were enrolled consecutively over the study period using a non-probability convenience sampling technique. Women with a prior diagnosis of cervical or any gynecological malignancy, those who had undergone hysterectomy, and those unwilling to provide informed consent were excluded from the study. Ethical approval was obtained from the Institutional Ethical Review Committee, and written informed consent was obtained from all participants prior to enrollment; confidentiality and anonymity of responses were maintained throughout the study. Data were collected through a structured, interviewer-administered questionnaire adapted from previously validated knowledge, attitude, and practice instruments used in comparable South Asian populations, covering four domains: sociodemographic characteristics (age, education, residence, marital status, parity, and household income), knowledge regarding cervical cancer and its screening (awareness of the disease, the Pap smear test, human papillomavirus, and associated symptoms or risk factors), attitudes toward screening and HPV vaccination, and screening practice (history of ever having undergone screening and, where applicable, the time elapsed since last screening). Knowledge was scored on a 4-point scale based on correct responses to four core knowledge items, with a score of 3 or above classified as adequate and a score below 3 classified as inadequate. A positive attitude was defined as agreement with at least two of the three attitude statements administered. Data were entered and analyzed using IBM SPSS Statistics version 26.0. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize sociodemographic, knowledge, attitude, and practice variables. The Pearson chi-square test was used to assess associations between categorical sociodemographic variables and knowledge or practice outcomes, and binary logistic regression was subsequently performed to identify the independent predictors of adequate knowledge and screening uptake, with adjusted odds ratios and 95% confidence intervals reported for each model. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test and the Nagelkerke R² statistic, and a two-tailed p-value of less than 0.05 was considered statistically significant throughout the analysis.

A total of 125 women of reproductive age were enrolled in the study. The mean age of participants was 35.3 ± 5.8 years (range 25–46 years), with the largest proportions falling within the 36–40 and 41–46 years age bands (28.0% each). Regarding educational status, 35.2% had completed only primary education and 16.0% had no formal education, while 18.4% held a graduate-level qualification. Participants were almost evenly distributed between urban (50.4%) and rural (49.6%) residence. The majority (88.8%) were married, and the mean parity was 3.0 ± 1.6, with 43.2% having three to four children. More than half of the participants (55.2%) belonged to low-income households (Table 1).

Knowledge regarding cervical cancer was poor overall. Only 33.6% of participants had ever heard of cervical cancer, 20.0% were aware of the Pap smear test, 11.2% knew about human papillomavirus, and 17.6% could correctly identify at least one symptom or risk factor. The mean knowledge score was 1.04 ± 1.32 (median 0, interquartile range 0–2), and only 16 women (12.8%) achieved an adequate knowledge score of 3 or above, while the remaining 109 (87.2%) were classified as having inadequate knowledge. With regard to attitudes, 56.8% agreed that screening was necessary, 64.0% expressed willingness to undergo screening if it were offered free of cost, and 62.4% were willing to accept HPV vaccination; however, over half of the participants (52.8%) reported feeling embarrassed about undergoing a screening examination, and overall 76 women (60.8%) demonstrated a positive attitude. Despite this comparatively favorable attitude, actual screening practice remained extremely low: only 12 women (9.6%) had ever undergone cervical cancer screening, and among these, 75.0% had been screened within the preceding three years (Table 2).

On bivariate analysis, adequate knowledge was significantly associated with higher education (χ²=28.42, df=3, p<0.001), urban residence (χ²=4.36, df=1, p=0.037), and higher household income (χ²=11.89, df=2, p=0.003). Screening uptake was likewise significantly associated with adequate knowledge (χ²=10.14, df=1, p=0.001), higher education (χ²=15.72, df=3, p=0.001), and urban residence (χ²=5.58, df=1, p=0.018) (Table 3).

On multivariable logistic regression, graduate-level education (AOR=17.12, 95% CI: 4.18–70.15, p<0.001) and high household income (AOR=5.21, 95% CI: 1.57–17.25, p=0.007) emerged as independent predictors of adequate knowledge, while urban residence remained an independent, though comparatively weaker, predictor (AOR=3.35, 95% CI: 1.07–10.48, p=0.038); age and parity were not significant predictors in the adjusted model. The overall model was statistically significant (χ²=38.74, df=5, p<0.001; Nagelkerke R²=0.42), with good calibration on the Hosmer-Lemeshow test (p=0.62). For screening uptake, adequate knowledge was the strongest independent predictor (AOR=6.62, 95% CI: 1.65–26.60, p=0.008), followed by graduate-level education (AOR=4.14, 95% CI: 1.09–15.72, p=0.037); urban residence and high household income showed a positive but statistically non-significant trend in the adjusted model. This model was also statistically significant overall (χ²=24.18, df=5, p<0.001; Nagelkerke R²=0.31), with acceptable calibration (Hosmer-Lemeshow p=0.48) (Table 4).

Table 1. Sociodemographic Characteristics of Study Participants (N=125)

Table 1 shows that the study population comprised predominantly married women of middle reproductive age, with substantial proportions having only primary or no formal education and belonging to low-income households, reflecting a population profile typically at elevated risk of delayed cervical cancer detection.

Table 2. Knowledge, Attitude, and Practice Regarding Cervical Cancer Screening (N=125)

Table 2 demonstrates a marked disconnect between attitude and practice: while a majority of participants expressed favorable attitudes toward screening and HPV vaccination, fewer than one in ten women had ever undergone screening, and knowledge of the disease and its screening modalities remained poor across the sample.

Table 3. Association between Sociodemographic Variables and Knowledge/Screening

Practice (Chi-Square Analysis)

Table 3 confirms that education, residence, and household income were each significantly associated with both adequate knowledge and screening uptake on bivariate analysis, with education showing the strongest association across both outcomes.

Table 4. Multivariable Logistic Regression Analysis of Predictors of Adequate Knowledge and Screening Uptake

Table 4 shows that, after adjustment for potential confounders, graduate-level education and high household income remained the strongest independent predictors of adequate knowledge, while adequate knowledge itself was the principal independent predictor of actual screening uptake.

This hospital-based cross-sectional study demonstrates that despite reasonably favorable attitudes toward cervical cancer screening, actual knowledge and screening uptake remain critically low among women of reproductive age attending a tertiary-care facility in Pakistan. Only 33.6% of participants had heard of cervical cancer, and merely 9.6% had ever been screened — findings broadly consistent with comparable hospital-based surveys conducted elsewhere in Pakistan (13). This persistently low awareness mirrors the global pattern in which the overwhelming majority of cervical cancer cases and deaths occur in low- and middle-income settings lacking organized screening infrastructure (14). The knowledge gap identified in this study is consistent with earlier reports from other regions of Pakistan, where screening coverage estimates remain among the lowest globally despite decades-long availability of the Pap smear test (15). A recent global synthesis of age-specific screening coverage across 202 countries confirmed that South Asian nations, including Pakistan, lag substantially behind the WHO's 70% screening target, largely due to the absence of organized, population-based programs (16). Systematic reviews of barriers to screening uptake in LMICs consistently identify limited disease-specific knowledge, embarrassment, and lack of spousal or family support as dominant individual- and sociocultural-level barriers (17), findings that closely mirror the present study's observation that over half of participants cited embarrassment as a deterrent despite otherwise favorable attitudes. The strong association between education and both knowledge and screening uptake observed in this study aligns with a substantial body of literature linking structural inequities in education to disparities in cancer prevention across LMICs, as emphasized in reviews addressing the global burden of women's cancers (18). Higher education likely enhances health-seeking behavior both directly, through improved comprehension of health information, and indirectly, through greater autonomy in healthcare decision-making, a pathway also highlighted in broader analyses of the global cervical cancer burden (19). Household income also emerged as an independent predictor of adequate knowledge, a finding paralleled by studies conducted among adolescent girls in South Asia, where socioeconomic status consistently predicted both HPV and cervical cancer awareness (20). Institutional affiliation and occupational exposure to health information, as observed among university staff and healthcare-adjacent populations elsewhere, has similarly been shown to enhance screening-related knowledge and vaccination uptake (21), suggesting that workplace- and community-based education channels may offer a scalable route to improving awareness among women outside formal healthcare settings. The gap between favorable attitude (60.8% positive) and actual practice (9.6% screened) observed in this study reflects a broader intention–behavior gap documented across the Eastern Mediterranean region, where cultural stigma, restricted mobility, and limited service availability continue to suppress screening and vaccination uptake despite generally accepting attitudes (22). Community-engaged interventions in sub-Saharan Africa that mobilize local health workers to deliver cervical cancer education have demonstrated substantial improvements in both awareness and screening uptake, offering a template potentially transferable to under-resourced Pakistani settings (23). Educational interventions elsewhere have shown considerable promise in narrowing this gap. Couple-based education and counseling delivered through a cluster-randomized trial in Ethiopia produced a markedly greater increase in screening uptake alongside substantial gains in knowledge scores compared with standard care (24). Similarly, studies among South Asian immigrant populations in high-income settings have identified low cervical cancer literacy and the absence of a healthcare provider recommendation as key modifiable determinants of non-uptake (25), while community health worker-led multimedia interventions designed specifically for South Asian women have been piloted to address precisely these barriers through culturally tailored education (26). These findings collectively suggest that context-specific, culturally sensitive educational interventions, rather than generic awareness campaigns, are more likely to translate favorable attitudes into actual screening behavior among Pakistani women. From a policy perspective, these findings reinforce the urgency of integrating opportunistic cervical cancer screening and structured health education into routine outpatient gynecological care, particularly given the continuing global call to accelerate cervical cancer elimination (27). The continuing absence of a national HPV vaccination program in Pakistan, despite mounting global evidence supporting cost-effective prevention strategies (28), further compounds the preventive gap identified in this study. Strengthening the integration of internationally recommended screening approaches into Pakistan's primary and tertiary healthcare systems (29), alongside targeted education for women with lower educational attainment and household income, represents a pragmatic, evidence-based approach to narrowing the persistent gap between disease burden and preventive uptake described in successive updates of the global cervical cancer literature (30). This study is subject to certain limitations, including its single-center, hospital-based design and modest sample size, which may limit generalizability to the broader community-dwelling population; the cross-sectional design also precludes causal inference regarding the associations observed.

Knowledge and practice regarding cervical cancer screening remain critically low among women of reproductive age attending this tertiary-care hospital in Pakistan, despite a comparatively favorable attitude toward screening and HPV vaccination. Education and household income were the strongest independent determinants of adequate knowledge, while knowledge itself was the principal driver of screening uptake. These findings underscore the urgent need for targeted, education-based health promotion strategies and the integration of opportunistic screening into routine gynecological care to narrow Pakistan's persistent gap in cervical cancer prevention.

Declarations

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgement: The authors gratefully acknowledge the cooperation of the participating women and the support of the outpatient Gynecology and Obstetrics department staff during data collection.

Conflict of Interest: The authors declare no conflict