Stigma, Misconceptions, and Emotional Avoidance as Psychosocial Barriers to Cancer Risk Perception Among Indian Tertiary Students: A Cross-Sectional Study

Stigma, Misconceptions, and Emotional Avoidance as Psychosocial Barriers to Cancer Risk Perception Among Indian Tertiary Students: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Stigma, Misconceptions, and Emotional Avoidance as Psychosocial Barriers to Cancer Risk Perception Among Indian Tertiary Students: A Cross-Sectional Study Eric Kwasi Elliason, Kulvir Singh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9255760/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Cancer incidence is rising globally, with a particularly high burden in low- and middle-income countries. Psychosocial factors, including stigma, misconceptions, and emotional avoidance, can shape how individuals perceive their risk of cancer and engage in preventive behaviours. Research on these factors among young adults in India is limited. Objective To examine the association between cancer-related stigma, misconceptions, emotional avoidance, and cancer risk perception among tertiary students in Punjab, India. Methods A cross sectional survey was conducted with 601 tertiary students from six districts of Punjab. Data were collected using a structured questionnaire specifically designed to measure cancer risk perception and three psychosocial constructs: stigma, misconceptions, and emotional avoidance. Sociodemographic information, including gender, financial status, and family history of cancer, was also collected. Data were analysed using descriptive statistics, independent-samples t tests, one-way analysis of variance, and multiple linear regression in IBM SPSS Statistics version 26. Results The regression model was statistically significant and explained 23.8 percent of the variance in cancer risk perception (adjusted R² = 0.238, p < 0.001). Stigma (β = −0.168, p = 0.001), misconceptions (β = −0.141, p < 0.001), and emotional avoidance (β = −0.203, p < 0.001) were negatively associated with cancer risk perception. Female gender (β = 0.102, p = 0.003) and family history of cancer (β = 0.076, p = 0.039) were positively associated with perceived risk. Conclusion Psychosocial barriers significantly influence how tertiary students perceive their risk of cancer. Interventions that address stigma, misconceptions, and emotional avoidance may enhance risk awareness and support preventive behaviours among young adults. Cancer risk perception cancer stigma emotional avoidance psychosocial barriers tertiary students cancer prevention Figures Figure 1 Figure 2 Figure 3 1. Introduction Cancer is a leading public health issue globally, and its burden is continually increasing in low- and middle-income countries. As per the World Health Organisation, there were about ten million cancer deaths worldwide in 2020 alone and it is one of the main causes of death globally. ¹ In India, for instance, progressive epidemiological transitions such as population ageing and lifestyle changes are leading to an increase in cancer incidence and mortality. The international agency for research on cancer even estimates that the overall burden of cancer will continue to increase considerably over the next few decades — most markedly in developing regions where both preventative services and early detection programs are still lacking. ² The burden of cancer has progressively grown in India over the past two decades. According to the National Cancer Registry Programme data, the anticipated incidence of cancer in India in the near future is expected to show a substantial increase due not only to population growth but also ageing and shifting patterns of risk factors (such as tobacco use, diet, and physical inactivity). ³ National-level analyses of cancer show substantial variation by geography across the U.S. reflecting regional differences in lifestyle patterns, environmental exposures, and access to health services. ⁴ While cancer is widely considered to affect older groups, many postpression factors contributing to carrying the disease are established much earlier in life. However, young adulthood is a pivotal time when individuals begin to establish lifestyle behaviors that can shape long-term health outcomes. These behaviours include tobacco and alcohol consumption, dietary behaviour, physical activity levels and use of preventive health services. ⁵ ⁶ For this reason, university students are a vital target population for cancer prevention initiatives since this period is often marked by increased autonomy and the establishment of lifelong health behavior patterns. Cancer risk perception is defined as an individual’s subjective judgement about the probability of him/her getting cancer. This perception is critical to many health behaviour theories, including the Health Belief Model which states that individuals are more likely to adopt behaviours that prevent a disease if they believe (increased susceptibility) that they will be affected by it. ⁷ ⁸ Research has indicated that higher perceived risk for cancer is correlated with the greater participation in screening programmes, increased attention to cancer relevant information, and better uptake of preventive health behaviours. ⁹ ¹⁰ Risk perception is critical, but psychosocial factors may affect how individuals perceive cancer related information. Among these factors, stigma, misperceptions and emotional avoidance are increasingly recognized in the context of cancer prevention research. Degenerative Solutions to Cancer related stigma. This stigma can result in fear, social distancing, and avoidance of open discussion of cancer among community members. Stigma has been found to deter people from seeking screening or disclosing symptoms out of concern for social judgment or discrimination. ¹¹ ¹² There are even widespread misconceptions about cancer in many populations. Such misconceptions could include false beliefs regarding the reasons behind cancer, overblown fears about treatment results, or misunderstandings surrounding the efficacy of prevention and screening techniques. Studies indicate that misconceptions regarding cancer risk factors can fuel fatalistic attitudes, decreasing individuals’ incentives to engage in preventive behaviours. ¹³ ¹⁴ When people attribute cancer as being primarily due to fate or unavoidable causes, they may view preventive actions as less meaningful. People’s emotional reactions to cancer can also influence how people engage with health information. Emotional avoidance is the inclination to shy away from thinking about or talking about cancer due to fear, anxiety, or psychological distress. While avoidance may decrease distress in the short term, it fragments contact with preventive health information and attenuates realization of a personal risk. Fear related avoidance may lead to reduced participation in cancer screening programmes and delayed help seeking when symptoms occur ¹⁵ ¹⁶ While some studies have explored cancer awareness and knowledge among university students, fewer have examined psychosocial determinants of cancer risk perception in this demographic. In Indian context, the studies exploring emotional reactions and cancer related stigma in young adults are scanty. Considering that the cancer burden is increasing in the country, and that early prevention strategies play a key role in this, it becomes vital to know how psychosocial barriers may lead to differences among young adults regarding perception of own risk with respect to cancer. Hence, this study was conducted to explore the relationship between cancer related stigma and misconceptions; emotional avoidance and perception of cancer risk among tertiary students in Punjab, India. Identifying psychosocial factors associated with lower perceived cancer risk will provide important knowledge which can be used for targeted health education and prevention programs aimed at strengthening cancer awareness and promoting healthier behaviours among young adults. 2. Conceptual Framework This study is informed by concepts derived from the Health Belief Model, which emphasizes the role of perceived susceptibility in motivating preventive health behaviour. According to this model, individuals are more likely to adopt protective health actions when they believe they are personally at risk of developing a disease. Perceived susceptibility therefore plays an important role in shaping engagement with preventive practices such as seeking health information, participating in screening programmes, and adopting healthier lifestyles.¹⁷ ¹⁸ Cancer risk perception represents an important psychological expression of perceived susceptibility. Individuals who believe that they may be vulnerable to cancer are generally more likely to pay attention to cancer related information and engage in behaviours that reduce their risk. Previous research has shown that higher perceived cancer risk is associated with increased participation in screening and greater motivation to adopt preventive health behaviours.¹⁹ ²⁰ However, perceptions of risk are influenced not only by knowledge but also by psychosocial and emotional factors. Cancer related stigma can discourage open discussion of the disease and may reduce individuals’ willingness to acknowledge personal vulnerability. In some settings, stigma surrounding cancer has been linked to fear of social judgment and reluctance to engage with screening or early detection services.²¹ Misconceptions about cancer may also distort individuals’ understanding of risk. Incorrect beliefs about the causes of cancer, exaggerated perceptions of treatment failure, or fatalistic views that cancer is unavoidable can contribute to inaccurate assessments of personal susceptibility. These beliefs may weaken motivation to adopt preventive behaviours or participate in screening programmes.²² Emotional avoidance represents another important psychosocial factor that may influence cancer risk perception. Fear or anxiety associated with cancer may lead some individuals to avoid thinking about the disease or engaging with cancer related information. Although avoidance can temporarily reduce emotional distress, it may also limit opportunities for individuals to reflect on their own risk and seek preventive information.²³ Based on these theoretical perspectives and previous empirical findings, the present study proposes that cancer related stigma, misconceptions, and emotional avoidance are associated with cancer risk perception among tertiary students. Figure 1 illustrates the conceptual framework guiding the study. Figure 1 . Conceptual framework illustrating the relationship between psychosocial barriers (stigma, misconceptions, and emotional avoidance) and cancer risk perception among tertiary students. 3. Methods 3.1 Study Design This study adopted a cross sectional quantitative design to examine the influence of psychosocial barriers, specifically stigma, misconceptions, and emotional avoidance, on cancer risk perception among tertiary students in Punjab, India. Cross sectional studies are widely used in public health research to assess attitudes, beliefs, and behavioural determinants within a defined population at a specific point in time. Such designs are particularly useful for identifying associations between psychological factors and health related perceptions in population groups²⁴ ²⁵. 3.2 Study Setting and Participants The study was conducted among tertiary students in six districts of Punjab, India, namely Patiala, Mansa, Tarn Taran, Sangrur, Gurdaspur, and Shri Muktsar Sahib. These districts were selected to capture geographic and social diversity within the state. Participants were recruited from universities and colleges using a multistage approach. In the first stage, districts were purposively selected. In the second stage, students within the selected districts were recruited using convenience sampling at participating institutions. Convenience sampling is commonly applied in student health research when complete sampling frames are not available²⁶. A total of 700 students participated in the study. The sample size was considered adequate to examine relationships among psychosocial variables and health perceptions using multivariate statistical techniques²⁷. In the final analysis, 601 completed questionnaires were included, yielding a response rate of 85.9 percent. 3.3 Data Collection Instrument Data were collected using a structured, self-administered questionnaire composed of four sections. The first section collected demographic information including gender, district of residence, family history of cancer, and financial status. The second section assessed cancer related stigma. Items were adapted from previously developed stigma measurement tools used in cancer research, including the Cancer Stigma Scale, which has been widely used to measure stigmatizing attitudes toward individuals affected by cancer²⁸. The third section assessed misconceptions about cancer. These items reflected commonly reported myths related to cancer causation, transmission, and treatment outcomes that have been documented in earlier studies examining cancer awareness in India²⁹ ³⁰. The fourth section evaluated emotional avoidance and perceived risk of cancer. The development of these items was informed by constructs derived from established behavioural theories, including the Health Belief Model and Social Cognitive Theory. These frameworks highlight the importance of perceived susceptibility, cognitive beliefs, and emotional responses in shaping health related behaviours³¹ ³². Most questionnaire items were measured using Likert type response categories ranging from strong disagreement to strong agreement. It is important to note that this study is part of a larger research project examining cancer awareness, risk perception, stigma, and health behaviours among tertiary students in Punjab, India. In the broader study, items from the Cancer Awareness Measure and the Health Promoting Lifestyle Profile II were included to capture a comprehensive understanding of students’ knowledge, attitudes, and health related behaviours²⁷ ²⁹. For the purposes of the present paper, the focus is specifically on psychosocial barriers, including stigma, misconceptions, and emotional avoidance, and their relationship with cancer risk perception. Including awareness and health behaviour items during the larger study helped refine the questionnaire and improve the cultural relevance and reliability of the psychosocial scales, although these additional measures are not reported in this analysis. 3.4 Pilot Testing and Reliability Prior to the main survey, the questionnaire was pilot tested among a small group of tertiary students to assess clarity, comprehension, and cultural relevance. Feedback obtained during the pilot phase was used to revise ambiguous items and improve the overall structure of the questionnaire. The internal consistency of the questionnaire scales was assessed using Cronbach’s alpha, a commonly used indicator of reliability in behavioural and social science research²⁷. The pilot study indicated acceptable reliability for all retained subscales. 3.5 Data Collection Procedure Data collection was conducted in participating institutions after obtaining permission from relevant academic authorities. Students who met the eligibility criteria were invited to participate. After providing informed consent, participants completed the questionnaire anonymously. This approach encouraged honest responses, particularly for questions related to stigma and emotional reactions. 3.6 Data Analysis Data were analysed using IBM SPSS Statistics version 26³³. Descriptive statistics were calculated to summarise demographic characteristics and the distribution of psychosocial variables. Inferential statistical analyses were then performed to examine relationships among the variables. One sample t tests were used to assess whether cancer risk perception differed significantly from the theoretical midpoint of the scale. Analysis of variance was conducted to determine whether psychosocial variables differed across districts. When statistically significant differences were observed, Tukey post hoc tests were applied to identify specific group differences. Multiple linear regression analysis was performed to evaluate the predictive influence of stigma, misconceptions, and emotional avoidance on cancer risk perception while controlling for relevant demographic characteristics. Statistical significance was assessed at a probability level below 0.05. Scores for stigma, misconceptions, and emotional avoidance were derived from Likert type items. For descriptive analysis, mean item scores were calculated for each subscale to allow comparison across constructs. For group comparisons, including district level analyses, summed scale scores were used to preserve variability and enhance statistical sensitivity in multi item psychometric scales²⁷. 3.7 Ethical Considerations The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Desh Bhagat University. Written informed consent was obtained from all participants. Participants were informed about the purpose of the study, the voluntary nature of participation, and their right to withdraw at any time. Measures were taken to protect participant privacy and minimize potential psychological distress due to the sensitive nature of the questions. 3. Results 3.1. Participant Characteristics A total of 700 questionnaires were distributed , of which 601 were completed and suitable for analysis , yielding a response rate of 85.9 percent . The demographic characteristics of the participants are presented in Table 1 . Table 1 Demographic Characteristics of Respondents (N = 601) Variable Frequency (n) Percentage (%) Gender Male 319 53.1 Female 282 46.9 Educational Level Undergraduate 446 74.2 Postgraduate 155 25.8 Residential Background Rural 404 67.2 Urban 197 32.8 Monthly Family Income (INR) Below ₹10,000 233 38.8 ₹10,001 – ₹20,000 248 41.3 Above ₹20,000 120 19.9 District Gurdaspur 91 15.1 Mansa 104 17.3 Patiala 118 19.6 Sangrur 93 15.5 Tarn Taran 79 13.1 Shri Muktsar Sahib 116 19.3 As shown in Table 1 , the sample consisted of 319 male students (53.1 percent) and 282 female students (46.9 percent). Most respondents were undergraduate students (74.2 percent), while 25.8 percent were enrolled in postgraduate programmes. With respect to residential background, two thirds of the participants (67.2 percent) reported coming from rural areas, whereas 32.8 percent were from urban settings. The income distribution indicated that 41.3 percent of respondents reported a monthly family income between ₹10,001 and ₹20,000, while 38.8 percent reported an income below ₹10,000. Only 19.9 percent of participants reported family incomes above ₹20,000 per month. Students were drawn from six districts across Punjab. The largest proportion of respondents came from Patiala (19.6 percent) and Shri Muktsar Sahib (19.3 percent), followed by Mansa (17.3 percent), Sangrur (15.5 percent), Gurdaspur (15.1 percent), and Tarn Taran (13.1 percent). In addition, 45.3 percent of respondents reported that a family member, friend, or neighbour had previously been diagnosed with cancer. Exposure to cancer related information through media campaigns, institutional programmes, or other communication channels was reported by 39.8 percent of participants. Overall, the sample reflects a predominantly undergraduate student population with a strong rural representation and varied socioeconomic backgrounds. The geographic distribution of participants across the six districts is illustrated in Fig. 1 . 3.2. Psychosocial Barriers to Cancer Engagement Descriptive statistics for the psychosocial variables are presented in Table 2 . The analysis examined three dimensions derived from the Cancer Stigma Scale subscales: stigma, misconceptions, and emotional avoidance. Table 2 Descriptive Statistics of Psychosocial Barriers Variable Mean (M) Standard Deviation (SD) Stigma 2.99 0.51 Misconceptions 2.80 0.45 Emotional Avoidance 3.20 0.53 As shown in Table 2 , the mean score for stigma was 2.99 (SD = 0.51). This indicates a moderate level of discomfort or distancing attitudes toward individuals affected by cancer within the student population. The mean score for misconceptions was 2.80 (SD = 0.45), suggesting that inaccurate beliefs about cancer remain present among some students. These beliefs include misunderstandings related to cancer causation, transmission, and treatment outcomes. Among the three variables, emotional avoidance recorded the highest mean score, with an average of 3.20 (SD = 0.53). This pattern indicates that emotional disengagement from cancer related information or discussion is relatively common among respondents The distribution of mean scores across the three psychosocial barriers is shown in Fig. 2 . 3.3. Gender Differences in Psychosocial Barriers Gender differences in stigma, misconceptions, and emotional avoidance were examined using independent samples t tests. The results are presented in Table 3 . Table 3 Gender Differences in Psychosocial Barriers (Independent Samples t-test) Variable Gender Mean (M) SD t-value df p-value Stigma Male 3.39 0.67 1.45 599 0.148 Female 3.45 0.71 Misconceptions Male 3.14 0.80 -1.02 599 0.307 Female 3.08 0.76 Emotional Avoidance Male 3.37 0.75 -3.52 599 0.001** Female 3.58 0.65 **statistically significant As shown in Table 3 , the mean stigma score among female students (M = 3.45, SD = 0.71) was slightly higher than that of male students (M = 3.39, SD = 0.67). However, the difference was not statistically significant, t (599) = 1.45, p = .148. Similarly, no significant gender difference was observed in misconceptions about cancer. Male students reported a mean score of 3.14 (SD = 0.80), while female students reported 3.08 (SD = 0.76), t (599) = − 1.02, p = .307. In contrast, a significant gender difference emerged for emotional avoidance. Female students reported higher levels of emotional avoidance (M = 3.58, SD = 0.65) compared with male students (M = 3.37, SD = 0.75). This difference was statistically significant, t (599) = − 3.52, p = .001. Overall, the findings indicate that gender differences were evident only in emotional avoidance, while stigma and misconceptions were comparable across male and female students. 3.4. District Differences in Psychosocial Barriers Differences in psychosocial barriers across the six study districts were examined using one way analysis of variance (ANOVA). The results are presented in Table 4 . Table 4 Differences in Psychosocial Barriers by District (One-Way ANOVA) Variable F-value df (Between, Within) p-value Stigma 3.74 (5, 595) 0.003** Misconceptions 2.29 (5, 595) 0.045* Emotional Avoidance 4.18 (5, 595) 0.001** ** statistically significant As shown in Table 4 , statistically significant differences were observed across districts for all three psychosocial variables. Stigma scores differed significantly between districts, F (5, 595) = 3.74, p = .003. Misconceptions also showed significant variation across districts, F (5, 595) = 2.29, p = .045. Similarly, emotional avoidance differed significantly among respondents from the six districts, F (5, 595) = 4.18, p = .001. These results indicate that levels of stigma, misconceptions, and emotional avoidance were not uniform across districts. To identify the specific group differences responsible for the observed variation in stigma scores, post hoc comparisons using the Tukey HSD test were conducted. The results of these comparisons are presented in Table 5 . 3.5. Post Hoc Comparisons of Stigma Scores Across Districts Following the significant ANOVA result for stigma, Tukey HSD post hoc comparisons were conducted using summed stigma scale scores to determine which districts differed significantly. The results are presented in Table 5 . Table 5 Post Hoc Comparison of Stigma Scores Across Districts (Tukey HSD Test) District N Mean Stigma Score Subset 1 Subset 2 Patiala 118 79.07 ✅ Mansa 104 83.63 ✅ ✅ Tarn Taran 79 84.18 ✅ ✅ Sangrur 93 88.16 ✅ Shri Muktsar Sahib 116 91.94 ✅ Gurdaspur 91 94.00 ✅ Note : Values represent summed stigma scale scores used for district comparisons . As shown in Table 5 , respondents from Patiala reported the lowest mean stigma score (M = 79.07) among the six districts. In contrast, the highest stigma scores were observed in Gurdaspur (M = 94.00) and Shri Muktsar Sahib (M = 91.94). The Tukey test identified two homogeneous subsets at the 0.05 significance level. Patiala formed a separate subset with comparatively lower stigma scores, while Gurdaspur and Shri Muktsar Sahib were grouped in a subset reflecting higher stigma levels. The remaining districts, including Mansa, Tarn Taran, and Sangrur, showed intermediate scores with partial overlap between the two subsets. These results indicate that stigma levels varied across districts, with lower scores observed in Patiala and higher scores recorded in Gurdaspur and Shri Muktsar Sahib. 3.6. Predictors of Cancer Risk Perception To examine the influence of psychosocial barriers on cancer risk perception, a multiple linear regression analysis was conducted. Stigma, misconceptions, and emotional avoidance were included as predictor variables, while gender, family history of cancer, and financial status were entered as control variables. The results of the regression analysis are presented in Table 6 . Table 6 Multiple Regression Analysis – Predicting Cancer Risk Perception Predictor B SE Beta t p-value Stigma -0.213 0.062 -0.168 -3.44 .001** Misconceptions -0.187 0.053 -0.141 -3.53 .000** Emotional Avoidance -0.264 0.059 -0.203 -4.47 .000** Gender (Female) 0.145 0.049 0.102 2.96 .003** Family History (Yes) 0.118 0.057 0.076 2.07 .039* Income (Low) -0.097 0.051 -0.067 -1.90 .058 Note: B = unstandardized regression coefficient; SE = standard error; β = standardized coefficient. Adjusted R² indicates the proportion of variance explained by the model. Significance levels: p < .05*, p < .01**. The results of the multiple linear regression analysis are shown in Table 6 . The model was statistically significant, F(6, 594) = 31.12, p < .001, with an adjusted R² of 0.238, indicating that approximately 23.8 percent of the variance in cancer risk perception was explained by the variables included in the model. All three psychosocial variables were significant predictors of cancer risk perception. Stigma was negatively associated with perceived risk (B = − 0.213, β = −0.168, p = .001), and misconceptions also showed a significant negative relationship (B = − 0.187, β = −0.141, p < .001). Emotional avoidance was the strongest negative predictor (B = − 0.264, β = −0.203, p < .001). Among the control variables, female gender was positively associated with risk perception (B = 0.145, β = 0.102, p = .003), and having a family history of cancer was also positively associated (B = 0.118, β = 0.076, p = .039). Financial status did not reach statistical significance (p = .058). These findings indicate that psychosocial barriers, particularly emotional avoidance, stigma, and misconceptions, are linked to lower perceived cancer risk among university students. 4. Discussion This study examined how psychosocial barriers influence cancer risk perception among tertiary students in Punjab, India. The findings show that stigma, misconceptions, and emotional avoidance are present among students and are significantly associated with lower perceived risk of cancer. These results suggest that efforts to improve cancer prevention among young adults should address not only gaps in knowledge but also the emotional and social factors that shape how students interpret cancer-related information. Descriptive analyses revealed moderate levels of stigma, misconceptions, and emotional avoidance among participants. While these levels were not extreme, their presence indicates that cancer remains a topic associated with discomfort and uncertainty for many young adults. Previous research has shown that stigma can discourage open discussion and delay preventive actions, such as screening or early consultation¹⁰ ¹¹. Among students, these attitudes may be influenced by cultural narratives that portray cancer as fatal or socially isolating. Such perceptions can lead to social distancing from individuals affected by cancer and reduce engagement with prevention messages. Misconceptions about cancer were also evident. Similar findings have been reported in studies showing that inaccurate beliefs about cancer causes and treatment outcomes persist even among relatively educated populations²⁹ ³⁰. These misconceptions may arise from incomplete health education, reliance on informal information sources, or the circulation of myths within communities. When students believe that cancer is unavoidable or always fatal, preventive behaviours may seem less meaningful, weakening perceived susceptibility and reducing motivation to adopt protective practices. Among the psychosocial factors studied, emotional avoidance had the highest average score and was the strongest negative predictor of cancer risk perception in the regression analysis. This suggests that some students cope with cancer-related anxiety by distancing themselves emotionally from the topic. Emotional avoidance is a common response to threatening health information³³. Individuals who feel fear or discomfort may avoid seeking information or discussing cancer, which can reduce immediate stress but also limit awareness and opportunities for early detection or preventive action. Gender differences were observed for emotional avoidance, with female students reporting higher levels than male students. Stigma and misconceptions did not differ significantly by gender, but the greater emotional avoidance among female students may reflect differences in emotional processing or perceived vulnerability to health threats. Research in behavioural decision making suggests that emotional responses play a key role in shaping risk perception and health-related behaviour³⁴ ³⁵. Women may therefore experience stronger emotional reactions to cancer information, which can influence how they interpret and respond to risk. The study also found differences in psychosocial barriers across districts. These variations suggest that local social environments shape how students perceive and respond to cancer-related information. Differences in community awareness, access to health campaigns, and exposure to cancer education programmes may contribute to these patterns. Previous research has shown that social norms and community-level influences can shape attitudes toward illness and affect health behaviour³⁶ ³⁷. Interventions aimed at reducing psychosocial barriers should therefore be sensitive to the cultural and social contexts of the target population. Regression analyses provided further insight into determinants of cancer risk perception. Stigma, misconceptions, and emotional avoidance all negatively predicted perceived risk, even after accounting for demographic characteristics. These findings align with behavioural health theories that emphasize the role of cognitive and emotional processes in shaping health behaviour³¹ ³². Students who hold stigmatizing beliefs, misunderstand cancer, or avoid emotionally challenging information may be less likely to recognize their own vulnerability. In contrast, female gender and family history of cancer were positively associated with risk perception. Individuals with direct or indirect experience of cancer often have greater awareness and may perceive themselves to be more susceptible⁸. Previous studies have similarly shown that personal or familial exposure to illness can increase perceived risk and encourage engagement with preventive behaviours. Taken together, these findings highlight the need to integrate psychosocial considerations into cancer awareness programmes targeting young adults. Many educational initiatives focus primarily on delivering factual information about risk factors and prevention. The present results indicate that knowledge alone may not be sufficient to influence risk perception. Addressing emotional responses, confronting stigma, and correcting misconceptions are essential for effective cancer prevention communication. Universities and colleges offer ideal settings for such interventions because they bring together large populations of young adults during a formative period for long-term health behaviours. Educational programmes that combine accurate information with opportunities for open discussion can help reduce fear and normalize conversations about cancer. Peer-led initiatives, awareness campaigns, and collaboration with health professionals may further create supportive environments that encourage engagement with cancer prevention strategies. 5. Policy Relevance for Cancer Prevention in India The findings of this study have important implications for cancer prevention strategies in India. The presence of stigma, misconceptions, and emotional avoidance among university students suggests that awareness programmes need to go beyond simply providing factual information. National initiatives, such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, focus on early detection and reducing behavioural risk factors. However, psychosocial barriers may limit the effectiveness of these initiatives if they are not addressed directly³⁸. Young adults are a key population for prevention because many behaviours that increase cancer risk develop during early adulthood. Integrating psychosocial education into university health programmes, public health campaigns, and digital awareness platforms could strengthen existing prevention efforts. Evidence from previous studies indicates that culturally sensitive communication and community-based education can improve cancer awareness and encourage earlier engagement with preventive services³⁹ ⁴⁰. 6. Strengths and Limitations This study has several strengths. First, it examined psychosocial barriers to cancer risk perception using a relatively large sample of tertiary students from multiple districts in Punjab. This geographic diversity allowed us to capture variations in attitudes and perceptions across different social contexts. Second, the study considered multiple psychosocial constructs, including stigma, misconceptions, and emotional avoidance, offering a broader understanding of how cognitive and emotional factors shape cancer risk perception among young adults. Third, the use of multivariable regression analysis allowed us to assess the independent influence of these factors while controlling for demographic characteristics. Several limitations should also be acknowledged. The cross-sectional design prevents us from drawing conclusions about causality between psychosocial barriers and cancer risk perception. Longitudinal research would provide a better understanding of how these factors evolve over time and influence preventive behaviours. In addition, the use of convenience sampling may limit the generalisability of the findings beyond the participating institutions. Although students were recruited from several districts, the sample may not fully represent the broader population of tertiary students in Punjab or other regions of India. The study also relied on self-reported responses, which could be affected by recall bias or social desirability bias. Future research incorporating qualitative methods could provide deeper insight into how students interpret cancer-related information and how emotional responses influence engagement with prevention messages. 7. Implications for Practice and Future Research The results highlight several implications for cancer prevention and health promotion. Educational institutions can play a central role in improving awareness among young adults. Universities may consider integrating health literacy initiatives, awareness campaigns, and peer education programmes into student activities and campus health services. Such initiatives can create supportive environments that encourage open discussion about cancer and reduce stigma associated with the disease. Public health communication strategies should also recognise the emotional dimensions of cancer awareness. Messages that combine accurate information with empathetic and supportive communication may reduce fear-based avoidance and encourage greater engagement with health information. Research has shown that approaches which acknowledge emotional concerns while providing clear preventive guidance can improve public responses to health risks⁴¹ ¹¹. Future studies should explore additional psychosocial factors that may influence cancer risk perception among young adults, including health literacy, perceived social support, and exposure to digital health information. Longitudinal research could also examine whether improvements in awareness and reductions in stigma lead to measurable changes in preventive behaviours, such as participation in screening programmes and adoption of healthier lifestyles. 8. Conclusion This study examined how psychosocial barriers influence cancer risk perception among tertiary students in Punjab, India. The findings indicate that stigma, misconceptions, and emotional avoidance remain present among young adults and are associated with lower perceived susceptibility to cancer. Emotional avoidance emerged as the strongest predictor, highlighting the role of emotional responses in shaping how students interpret their personal health risks. In contrast, female gender and a family history of cancer were linked to higher perceived risk. These findings underscore the need for cancer awareness initiatives that go beyond the simple dissemination of information. Educational and public health programmes should address emotional and social barriers while correcting misconceptions about cancer. Universities and colleges provide ideal platforms for such interventions, as they offer opportunities to reach large numbers of young adults during a formative stage of health behaviour development. Strengthening psychosocial engagement in cancer education may help improve risk awareness and support the adoption of preventive health behaviours among students. Declarations Conflict of Interest The authors declare that there are no conflicts of interest related to this study. Funding This research received no external funding. Data Availability The datasets generated and analysed during the current study are available from the corresponding author upon reasonable request. Ethical Approval This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee of Desh Bhagat University, Mandi Gobindgarh. Written informed consent was obtained from all participants prior to data collection Author Contributions Conceptualization: E.K.E. Methodology: E.K.E., K.S. Data Curation: E.K.E., K.S. Software and Validation: E.K.E. Investigation and Analysis: E.K.E., K.S. Visualization: E.K.E. Writing – Original Draft: E.K.E. Writing – Review and Editing: E.K.E., K.S. Resources: K.S. Supervision: K.S. Project Administration: K.S. Funding Acquisition: Not applicable. Artificial Intelligence Use Artificial intelligence tools were used only to assist with language editing and improvement of clarity. All data analysis, interpretation, and scientific content were developed and verified by the authors. Availability of Dataset The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References World Health Organization. Cancer. Geneva: World Health Organization; 2022. https://www.who.int/news-room/fact-sheets/detail/cancer Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–249. doi:10.3322/caac.21660 International Agency for Research on Cancer. Global cancer observatory: cancer today. Lyon: IARC; 2021. https://gco.iarc.fr/today Kushi LH, Doyle C, McCullough M, Rock CL, Demark Wahnefried W, Bandera EV, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention. CA Cancer J Clin. 2012;62(1):30–67. doi:10.3322/caac.20140 McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments for motivating smoking cessation. Health Educ Res. 2003;18(2):156–170. doi:10.1093/her/18.2.156 Champion VL, Skinner CS. The Health Belief Model. In: Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: theory, research, and practice. 4th ed. San Francisco: Jossey Bass; 2008. p. 45–65. Katapodi MC, Lee KA, Facione NC, Dodd MJ. Predictors of perceived breast cancer risk and the relation between perceived risk and screening. Cancer Nurs. 2004;27(6):409–418. doi:10.1097/00002820-200411000-00003 Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior. Health Psychol. 2007;26(2):136–145. doi:10.1037/0278-6133.26.2.136 Else Quest NM, LoConte NK, Schiller JH, Hyde JS. Perceived stigma and barriers to care in lung cancer patients. Oncologist. 2009;14(8):822–829. doi:10.1634/theoncologist.2009-0050 Marlow LAV, Wardle J. Development of a scale to assess cancer stigma in the non patient population. BMC Cancer. 2014;14:285. doi:10.1186/1471-2407-14-285 Powe BD, Finnie R. Cancer fatalism: the state of the science. Cancer Nurs. 2003;26(6):454–465. doi:10.1097/00002820-200311000-00004 Niederdeppe J, Levy AG. Fatalistic beliefs about cancer prevention and three prevention behaviors. Cancer Epidemiol Biomarkers Prev. 2007;16(5):998–1003. doi:10.1158/1055-9965.EPI-06-0953 Vrinten C, McGregor LM, Heinrich M, von Wagner C, Waller J, Wardle J, et al. What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population. Psychooncology. 2017;26(8):1070–1079. doi:10.1002/pon.4122 Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening behavior. Cancer Epidemiol Biomarkers Prev. 2004;13(4):501–510. doi:10.1158/1055-9965.EPI-03-0230 Katapodi MC, Northouse LL, Milliron KJ, Liu G, Merajver SD. Individual and family characteristics associated with BRCA1/2 genetic testing in high risk families. Psychooncology. 2013;22(6):1336–1343. doi:10.1002/pon.3114 Rosenstock IM. Why people use health services. Milbank Mem Fund Q. 1966;44(3):94–127. doi:10.2307/3348967 Becker MH. The Health Belief Model and personal health behavior. Health Educ Monogr. 1974;2:324–473. Champion VL. Instrument development for health belief model constructs. ANS Adv Nurs Sci. 1984;6(3):73–85. doi:10.1097/00012272-198404000-00008 Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. 4th ed. San Francisco: Jossey Bass; 2008. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363–385. doi:10.1146/annurev.soc.27.1.363 Waller J, Marlow LAV, Wardle J. The association between knowledge of cancer symptoms and anticipated delay in help seeking. Br J Cancer. 2014;111(12):246–252. doi:10.1038/bjc.2014.472 Vrinten C, Wardle J, Marlow LAV. Cancer fear and fatalism among ethnic minority women in the United Kingdom. Br J Cancer. 2016;114(5):597–604. doi:10.1038/bjc.2015.453 Mann CJ. Observational research methods. Research design II: cohort, cross sectional, and case control studies. Emerg Med J. 2003;20(1):54–60. doi:10.1136/emj.20.1.54 Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 4th ed. Thousand Oaks, CA: SAGE Publications; 2014. Sedgwick P. Convenience sampling. BMJ. 2013;347:f6304. doi:10.1136/bmj.f6304 Field A. Discovering statistics using IBM SPSS statistics. 5th ed. London: SAGE Publications; 2018. Powe BD. Cancer fatalism among elderly African American women: predictors of the intensity of the perceptions. J Psychosoc Oncol. 1995;13(3):69–85. doi:10.1300/J077v13n03_05 Mishra SI, Luce PH, Baquet CR. Increasing Pap smear utilization among urban minority women. J Natl Med Assoc. 2009;101(2):195–202. doi:10.1016/S0027-9684(15)30354-2 Nayak S, Pradhan B, Mahapatra S. Awareness about cancer and its prevention among college students in India. Asian Pac J Cancer Prev. 2017;18(6):1595–1600. doi:10.22034/APJCP.2017.18.6.1595 Janz NK, Becker MH. The Health Belief Model: a decade later. Health Educ Q. 1984;11(1):1–47. doi:10.1177/109019818401100101 Bandura A. Self efficacy: the exercise of control. New York: W.H. Freeman; 1997. IBM Corp. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp; 2019. Ferrer RA, Klein WMP. Risk perceptions and health behavior. Curr Opin Psychol. 2015;5:85–89. doi:10.1016/j.copsyc.2015.03.012 Loewenstein GF, Weber EU, Hsee CK, Welch N. Risk as feelings. Psychol Bull. 2001;127(2):267–286. doi:10.1037/0033-2909.127.2.267 Link BG, Phelan JC. Social conditions as fundamental causes of disease. J Health Soc Behav. 2006;47:80–94. doi:10.2307/3644316 Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010;376(9748):1261–1271. doi:10.1016/S0140-6736(10)60809-4 Ministry of Health and Family Welfare. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). New Delhi: Government of India; 2021. Gupta A, Shridhar K, Dhillon PK. A review of breast cancer awareness among women in India. Breast. 2015;24(5):663–671. doi:10.1016/j.breast.2015.06.003 Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast examination: preliminary results from a cluster randomized controlled trial in India. J Natl Cancer Inst. 2010;102(19):1476–1480. doi:10.1093/jnci/djq330 Peters E, McCaul KD, Stefanek M, Nelson W. A heuristics approach to understanding cancer risk perception. Cancer Epidemiol Biomarkers Prev. 2013;22(6):1037–1043. doi:10.1158/1055-9965.EPI-12-1323 Additional Declarations No competing interests reported. Supplementary Files DataCollectionLetter.pdf FinalQuestionnaire.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Apr, 2026 Reviewers invited by journal 24 Apr, 2026 Editor invited by journal 03 Apr, 2026 Editor assigned by journal 03 Apr, 2026 Submission checks completed at journal 03 Apr, 2026 First submitted to journal 03 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9255760","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617621378,"identity":"c6d8397a-bb97-46dc-8c61-b4f2ceb7d7c0","order_by":0,"name":"Eric Kwasi Elliason","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIie3RvQrCMBDA8QsH1yXU1aDWV4gUHOurKAUnB8FFcbBScPVtMlc6uBRnwcWPJ+ggKDiYKjo4tHUTzH84bsgPEgJgMv1iUTYkcEI23+uV22WJY1sYy4xQOQLgOhXqV7OtkNi7iJ3GQ6+3QN6enAdenQAPx20OEZsuthLpP8iuoXx9MXLdQQ6RCZAIZPQkQqEmnGoFxLq+yEioWSlCTBOXkPosVXExEQkL9cV8hxDjGlNr/UEFb7ETXKXBzePN5WqeXtW0U7HCwymPALDgvSJ/zNzjn/ryzWmTyWT6m+6uxD5PcrBDRAAAAABJRU5ErkJggg==","orcid":"","institution":"Desh Bhagat University","correspondingAuthor":true,"prefix":"","firstName":"Eric","middleName":"Kwasi","lastName":"Elliason","suffix":""},{"id":617621379,"identity":"5a1bbb9f-cc00-40f7-a36d-33ba6a83ad23","order_by":1,"name":"Kulvir Singh","email":"","orcid":"","institution":"Desh Bhagat University","correspondingAuthor":false,"prefix":"","firstName":"Kulvir","middleName":"","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2026-03-29 01:23:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9255760/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9255760/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106403534,"identity":"e5ed42e9-6727-4276-848f-0bfb2799afae","added_by":"auto","created_at":"2026-04-08 09:14:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":110618,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eConceptual framework illustrating the relationship between psychosocial barriers (stigma, misconceptions, and emotional avoidance) and cancer risk perception among tertiary students.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/abeee5714b5daa8f78f3b0f9.png"},{"id":106402551,"identity":"e76a4615-1d45-440f-9533-e5b384a3cac4","added_by":"auto","created_at":"2026-04-08 09:12:17","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":97443,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1. Distribution of respondents by district (N = 601).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/ea846bef55c9c20c44d6ad96.png"},{"id":106206341,"identity":"fb1d90dd-99d3-47ab-8239-9ab1785cdf51","added_by":"auto","created_at":"2026-04-06 05:42:26","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":83365,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 2. Mean scores of psychosocial barriers among tertiary students (N = 601).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/4fea8c892d70724633f4c376.png"},{"id":106405822,"identity":"0ad07fdc-65d7-4335-8885-231ed18823ed","added_by":"auto","created_at":"2026-04-08 09:28:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1519626,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/ed1fe8ad-54ad-40fb-871a-8fbf2ab701b1.pdf"},{"id":106206338,"identity":"82a4fc75-a8b7-4186-87b2-5f2a5fd8b710","added_by":"auto","created_at":"2026-04-06 05:42:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":313458,"visible":true,"origin":"","legend":"","description":"","filename":"DataCollectionLetter.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/0d74e48c63f2da76391eb69d.pdf"},{"id":106402864,"identity":"11a113c2-8dc9-4276-9189-5dd3913c07fb","added_by":"auto","created_at":"2026-04-08 09:13:04","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":288959,"visible":true,"origin":"","legend":"","description":"","filename":"FinalQuestionnaire.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9255760/v1/99d31bc01183acf917cb6d95.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Stigma, Misconceptions, and Emotional Avoidance as Psychosocial Barriers to Cancer Risk Perception Among Indian Tertiary Students: A Cross-Sectional Study","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eCancer is a leading public health issue globally, and its burden is continually increasing in low- and middle-income countries. As per the World Health Organisation, there were about ten million cancer deaths worldwide in 2020 alone and it is one of the main causes of death globally. \u0026sup1; In India, for instance, progressive epidemiological transitions such as population ageing and lifestyle changes are leading to an increase in cancer incidence and mortality. The international agency for research on cancer even estimates that the overall burden of cancer will continue to increase considerably over the next few decades \u0026mdash; most markedly in developing regions where both preventative services and early detection programs are still lacking. \u0026sup2;\u003c/p\u003e \u003cp\u003eThe burden of cancer has progressively grown in India over the past two decades. According to the National Cancer Registry Programme data, the anticipated incidence of cancer in India in the near future is expected to show a substantial increase due not only to population growth but also ageing and shifting patterns of risk factors (such as tobacco use, diet, and physical inactivity). \u0026sup3; National-level analyses of cancer show substantial variation by geography across the U.S. reflecting regional differences in lifestyle patterns, environmental exposures, and access to health services. ⁴\u003c/p\u003e \u003cp\u003eWhile cancer is widely considered to affect older groups, many postpression factors contributing to carrying the disease are established much earlier in life. However, young adulthood is a pivotal time when individuals begin to establish lifestyle behaviors that can shape long-term health outcomes. These behaviours include tobacco and alcohol consumption, dietary behaviour, physical activity levels and use of preventive health services. ⁵ ⁶ For this reason, university students are a vital target population for cancer prevention initiatives since this period is often marked by increased autonomy and the establishment of lifelong health behavior patterns.\u003c/p\u003e \u003cp\u003eCancer risk perception is defined as an individual\u0026rsquo;s subjective judgement about the probability of him/her getting cancer. This perception is critical to many health behaviour theories, including the Health Belief Model which states that individuals are more likely to adopt behaviours that prevent a disease if they believe (increased susceptibility) that they will be affected by it. ⁷ ⁸ Research has indicated that higher perceived risk for cancer is correlated with the greater participation in screening programmes, increased attention to cancer relevant information, and better uptake of preventive health behaviours. ⁹ \u0026sup1;⁰\u003c/p\u003e \u003cp\u003eRisk perception is critical, but psychosocial factors may affect how individuals perceive cancer related information. Among these factors, stigma, misperceptions and emotional avoidance are increasingly recognized in the context of cancer prevention research. Degenerative Solutions to Cancer related stigma. This stigma can result in fear, social distancing, and avoidance of open discussion of cancer among community members. Stigma has been found to deter people from seeking screening or disclosing symptoms out of concern for social judgment or discrimination. \u0026sup1;\u0026sup1; \u0026sup1;\u0026sup2;\u003c/p\u003e \u003cp\u003eThere are even widespread misconceptions about cancer in many populations. Such misconceptions could include false beliefs regarding the reasons behind cancer, overblown fears about treatment results, or misunderstandings surrounding the efficacy of prevention and screening techniques. Studies indicate that misconceptions regarding cancer risk factors can fuel fatalistic attitudes, decreasing individuals\u0026rsquo; incentives to engage in preventive behaviours. \u0026sup1;\u0026sup3; \u0026sup1;⁴ When people attribute cancer as being primarily due to fate or unavoidable causes, they may view preventive actions as less meaningful.\u003c/p\u003e \u003cp\u003ePeople\u0026rsquo;s emotional reactions to cancer can also influence how people engage with health information. Emotional avoidance is the inclination to shy away from thinking about or talking about cancer due to fear, anxiety, or psychological distress. While avoidance may decrease distress in the short term, it fragments contact with preventive health information and attenuates realization of a personal risk. Fear related avoidance may lead to reduced participation in cancer screening programmes and delayed help seeking when symptoms occur \u0026sup1;⁵ \u0026sup1;⁶\u003c/p\u003e \u003cp\u003eWhile some studies have explored cancer awareness and knowledge among university students, fewer have examined psychosocial determinants of cancer risk perception in this demographic. In Indian context, the studies exploring emotional reactions and cancer related stigma in young adults are scanty. Considering that the cancer burden is increasing in the country, and that early prevention strategies play a key role in this, it becomes vital to know how psychosocial barriers may lead to differences among young adults regarding perception of own risk with respect to cancer.\u003c/p\u003e \u003cp\u003eHence, this study was conducted to explore the relationship between cancer related stigma and misconceptions; emotional avoidance and perception of cancer risk among tertiary students in Punjab, India. Identifying psychosocial factors associated with lower perceived cancer risk will provide important knowledge which can be used for targeted health education and prevention programs aimed at strengthening cancer awareness and promoting healthier behaviours among young adults.\u003c/p\u003e"},{"header":"2. Conceptual Framework","content":"\u003cp\u003eThis study is informed by concepts derived from the Health Belief Model, which emphasizes the role of perceived susceptibility in motivating preventive health behaviour. According to this model, individuals are more likely to adopt protective health actions when they believe they are personally at risk of developing a disease. Perceived susceptibility therefore plays an important role in shaping engagement with preventive practices such as seeking health information, participating in screening programmes, and adopting healthier lifestyles.\u0026sup1;⁷ \u0026sup1;⁸\u003c/p\u003e \u003cp\u003eCancer risk perception represents an important psychological expression of perceived susceptibility. Individuals who believe that they may be vulnerable to cancer are generally more likely to pay attention to cancer related information and engage in behaviours that reduce their risk. Previous research has shown that higher perceived cancer risk is associated with increased participation in screening and greater motivation to adopt preventive health behaviours.\u0026sup1;⁹ \u0026sup2;⁰\u003c/p\u003e \u003cp\u003eHowever, perceptions of risk are influenced not only by knowledge but also by psychosocial and emotional factors. Cancer related stigma can discourage open discussion of the disease and may reduce individuals\u0026rsquo; willingness to acknowledge personal vulnerability. In some settings, stigma surrounding cancer has been linked to fear of social judgment and reluctance to engage with screening or early detection services.\u0026sup2;\u0026sup1;\u003c/p\u003e \u003cp\u003eMisconceptions about cancer may also distort individuals\u0026rsquo; understanding of risk. Incorrect beliefs about the causes of cancer, exaggerated perceptions of treatment failure, or fatalistic views that cancer is unavoidable can contribute to inaccurate assessments of personal susceptibility. These beliefs may weaken motivation to adopt preventive behaviours or participate in screening programmes.\u0026sup2;\u0026sup2;\u003c/p\u003e \u003cp\u003eEmotional avoidance represents another important psychosocial factor that may influence cancer risk perception. Fear or anxiety associated with cancer may lead some individuals to avoid thinking about the disease or engaging with cancer related information. Although avoidance can temporarily reduce emotional distress, it may also limit opportunities for individuals to reflect on their own risk and seek preventive information.\u0026sup2;\u0026sup3;\u003c/p\u003e \u003cp\u003eBased on these theoretical perspectives and previous empirical findings, the present study proposes that cancer related stigma, misconceptions, and emotional avoidance are associated with cancer risk perception among tertiary students. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the conceptual framework guiding the study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. \u003cem\u003eConceptual framework illustrating the relationship between psychosocial barriers (stigma, misconceptions, and emotional avoidance) and cancer risk perception among tertiary students.\u003c/em\u003e\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Study Design\u003c/h2\u003e \u003cp\u003eThis study adopted a cross sectional quantitative design to examine the influence of psychosocial barriers, specifically stigma, misconceptions, and emotional avoidance, on cancer risk perception among tertiary students in Punjab, India. Cross sectional studies are widely used in public health research to assess attitudes, beliefs, and behavioural determinants within a defined population at a specific point in time. Such designs are particularly useful for identifying associations between psychological factors and health related perceptions in population groups\u0026sup2;⁴ \u0026sup2;⁵.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Study Setting and Participants\u003c/h2\u003e \u003cp\u003eThe study was conducted among tertiary students in six districts of Punjab, India, namely Patiala, Mansa, Tarn Taran, Sangrur, Gurdaspur, and Shri Muktsar Sahib. These districts were selected to capture geographic and social diversity within the state.\u003c/p\u003e \u003cp\u003eParticipants were recruited from universities and colleges using a multistage approach. In the first stage, districts were purposively selected. In the second stage, students within the selected districts were recruited using convenience sampling at participating institutions. Convenience sampling is commonly applied in student health research when complete sampling frames are not available\u0026sup2;⁶.\u003c/p\u003e \u003cp\u003eA total of 700 students participated in the study. The sample size was considered adequate to examine relationships among psychosocial variables and health perceptions using multivariate statistical techniques\u0026sup2;⁷. In the final analysis, 601 completed questionnaires were included, yielding a response rate of 85.9 percent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Data Collection Instrument\u003c/h2\u003e \u003cp\u003eData were collected using a structured, self-administered questionnaire composed of four sections. The first section collected demographic information including gender, district of residence, family history of cancer, and financial status.\u003c/p\u003e \u003cp\u003eThe second section assessed cancer related stigma. Items were adapted from previously developed stigma measurement tools used in cancer research, including the Cancer Stigma Scale, which has been widely used to measure stigmatizing attitudes toward individuals affected by cancer\u0026sup2;⁸.\u003c/p\u003e \u003cp\u003eThe third section assessed misconceptions about cancer. These items reflected commonly reported myths related to cancer causation, transmission, and treatment outcomes that have been documented in earlier studies examining cancer awareness in India\u0026sup2;⁹ \u0026sup3;⁰.\u003c/p\u003e \u003cp\u003eThe fourth section evaluated emotional avoidance and perceived risk of cancer. The development of these items was informed by constructs derived from established behavioural theories, including the Health Belief Model and Social Cognitive Theory. These frameworks highlight the importance of perceived susceptibility, cognitive beliefs, and emotional responses in shaping health related behaviours\u0026sup3;\u0026sup1; \u0026sup3;\u0026sup2;. Most questionnaire items were measured using Likert type response categories ranging from strong disagreement to strong agreement.\u003c/p\u003e \u003cp\u003eIt is important to note that this study is part of a larger research project examining cancer awareness, risk perception, stigma, and health behaviours among tertiary students in Punjab, India. In the broader study, items from the Cancer Awareness Measure and the Health Promoting Lifestyle Profile II were included to capture a comprehensive understanding of students\u0026rsquo; knowledge, attitudes, and health related behaviours\u0026sup2;⁷ \u0026sup2;⁹. For the purposes of the present paper, the focus is specifically on psychosocial barriers, including stigma, misconceptions, and emotional avoidance, and their relationship with cancer risk perception. Including awareness and health behaviour items during the larger study helped refine the questionnaire and improve the cultural relevance and reliability of the psychosocial scales, although these additional measures are not reported in this analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Pilot Testing and Reliability\u003c/h2\u003e \u003cp\u003ePrior to the main survey, the questionnaire was pilot tested among a small group of tertiary students to assess clarity, comprehension, and cultural relevance. Feedback obtained during the pilot phase was used to revise ambiguous items and improve the overall structure of the questionnaire.\u003c/p\u003e \u003cp\u003eThe internal consistency of the questionnaire scales was assessed using Cronbach\u0026rsquo;s alpha, a commonly used indicator of reliability in behavioural and social science research\u0026sup2;⁷. The pilot study indicated acceptable reliability for all retained subscales.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Data Collection Procedure\u003c/h2\u003e \u003cp\u003eData collection was conducted in participating institutions after obtaining permission from relevant academic authorities. Students who met the eligibility criteria were invited to participate. After providing informed consent, participants completed the questionnaire anonymously. This approach encouraged honest responses, particularly for questions related to stigma and emotional reactions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Data Analysis\u003c/h2\u003e \u003cp\u003eData were analysed using IBM SPSS Statistics version 26\u0026sup3;\u0026sup3;. Descriptive statistics were calculated to summarise demographic characteristics and the distribution of psychosocial variables.\u003c/p\u003e \u003cp\u003eInferential statistical analyses were then performed to examine relationships among the variables. One sample t tests were used to assess whether cancer risk perception differed significantly from the theoretical midpoint of the scale. Analysis of variance was conducted to determine whether psychosocial variables differed across districts. When statistically significant differences were observed, Tukey post hoc tests were applied to identify specific group differences.\u003c/p\u003e \u003cp\u003eMultiple linear regression analysis was performed to evaluate the predictive influence of stigma, misconceptions, and emotional avoidance on cancer risk perception while controlling for relevant demographic characteristics. Statistical significance was assessed at a probability level below 0.05. Scores for stigma, misconceptions, and emotional avoidance were derived from Likert type items. For descriptive analysis, mean item scores were calculated for each subscale to allow comparison across constructs. For group comparisons, including district level analyses, summed scale scores were used to preserve variability and enhance statistical sensitivity in multi item psychometric scales\u0026sup2;⁷.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Ethical Considerations\u003c/h2\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Desh Bhagat University. Written informed consent was obtained from all participants. Participants were informed about the purpose of the study, the voluntary nature of participation, and their right to withdraw at any time. Measures were taken to protect participant privacy and minimize potential psychological distress due to the sensitive nature of the questions.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participant Characteristics\u003c/h2\u003e \u003cp\u003eA total of \u003cb\u003e700 questionnaires were distributed\u003c/b\u003e, of which \u003cb\u003e601 were completed and suitable for analysis\u003c/b\u003e, yielding a response rate of \u003cb\u003e85.9 percent\u003c/b\u003e. The demographic characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Respondents (N\u0026thinsp;=\u0026thinsp;601)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e46.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e155\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidential Background\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly Family Income (INR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow ₹10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e₹10,001 \u0026ndash; ₹20,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove ₹20,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistrict\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGurdaspur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMansa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatiala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSangrur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarn Taran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShri Muktsar Sahib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the sample consisted of 319 male students (53.1 percent) and 282 female students (46.9 percent). Most respondents were undergraduate students (74.2 percent), while 25.8 percent were enrolled in postgraduate programmes.\u003c/p\u003e \u003cp\u003eWith respect to residential background, two thirds of the participants (67.2 percent) reported coming from rural areas, whereas 32.8 percent were from urban settings. The income distribution indicated that 41.3 percent of respondents reported a monthly family income between ₹10,001 and ₹20,000, while 38.8 percent reported an income below ₹10,000. Only 19.9 percent of participants reported family incomes above ₹20,000 per month.\u003c/p\u003e \u003cp\u003eStudents were drawn from six districts across Punjab. The largest proportion of respondents came from Patiala (19.6 percent) and Shri Muktsar Sahib (19.3 percent), followed by Mansa (17.3 percent), Sangrur (15.5 percent), Gurdaspur (15.1 percent), and Tarn Taran (13.1 percent).\u003c/p\u003e \u003cp\u003eIn addition, 45.3 percent of respondents reported that a family member, friend, or neighbour had previously been diagnosed with cancer. Exposure to cancer related information through media campaigns, institutional programmes, or other communication channels was reported by 39.8 percent of participants.\u003c/p\u003e \u003cp\u003eOverall, the sample reflects a predominantly undergraduate student population with a strong rural representation and varied socioeconomic backgrounds. The geographic distribution of participants across the six districts is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Psychosocial Barriers to Cancer Engagement\u003c/h2\u003e \u003cp\u003eDescriptive statistics for the psychosocial variables are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The analysis examined three dimensions derived from the Cancer Stigma Scale subscales: stigma, misconceptions, and emotional avoidance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics of Psychosocial Barriers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (M)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandard Deviation (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.99\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisconceptions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmotional Avoidance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e3.20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.53\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the mean score for stigma was 2.99 (SD\u0026thinsp;=\u0026thinsp;0.51). This indicates a moderate level of discomfort or distancing attitudes toward individuals affected by cancer within the student population.\u003c/p\u003e \u003cp\u003eThe mean score for misconceptions was 2.80 (SD\u0026thinsp;=\u0026thinsp;0.45), suggesting that inaccurate beliefs about cancer remain present among some students. These beliefs include misunderstandings related to cancer causation, transmission, and treatment outcomes.\u003c/p\u003e \u003cp\u003eAmong the three variables, emotional avoidance recorded the highest mean score, with an average of 3.20 (SD\u0026thinsp;=\u0026thinsp;0.53). This pattern indicates that emotional disengagement from cancer related information or discussion is relatively common among respondents The distribution of mean scores across the three psychosocial barriers is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Gender Differences in Psychosocial Barriers\u003c/h2\u003e \u003cp\u003eGender differences in stigma, misconceptions, and emotional avoidance were examined using independent samples t tests. The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGender Differences in Psychosocial Barriers (Independent Samples t-test)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (M)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003edf\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisconceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e599\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e**statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the mean stigma score among female students (M\u0026thinsp;=\u0026thinsp;3.45, SD\u0026thinsp;=\u0026thinsp;0.71) was slightly higher than that of male students (M\u0026thinsp;=\u0026thinsp;3.39, SD\u0026thinsp;=\u0026thinsp;0.67). However, the difference was not statistically significant, \u003cem\u003et\u003c/em\u003e(599)\u0026thinsp;=\u0026thinsp;1.45, \u003cem\u003ep\u003c/em\u003e = .148.\u003c/p\u003e \u003cp\u003eSimilarly, no significant gender difference was observed in misconceptions about cancer. Male students reported a mean score of 3.14 (SD\u0026thinsp;=\u0026thinsp;0.80), while female students reported 3.08 (SD\u0026thinsp;=\u0026thinsp;0.76), \u003cem\u003et\u003c/em\u003e(599)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;1.02, \u003cem\u003ep\u003c/em\u003e = .307.\u003c/p\u003e \u003cp\u003eIn contrast, a significant gender difference emerged for emotional avoidance. Female students reported higher levels of emotional avoidance (M\u0026thinsp;=\u0026thinsp;3.58, SD\u0026thinsp;=\u0026thinsp;0.65) compared with male students (M\u0026thinsp;=\u0026thinsp;3.37, SD\u0026thinsp;=\u0026thinsp;0.75). This difference was statistically significant, \u003cem\u003et\u003c/em\u003e(599)\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.52, \u003cem\u003ep\u003c/em\u003e = .001.\u003c/p\u003e \u003cp\u003eOverall, the findings indicate that gender differences were evident only in emotional avoidance, while stigma and misconceptions were comparable across male and female students.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4. District Differences in Psychosocial Barriers\u003c/h2\u003e \u003cp\u003eDifferences in psychosocial barriers across the six study districts were examined using one way analysis of variance (ANOVA). The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDifferences in Psychosocial Barriers by District (One-Way ANOVA)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003edf (Between, Within)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5, 595)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisconceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5, 595)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.045*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5, 595)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e** statistically significant\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, statistically significant differences were observed across districts for all three psychosocial variables. Stigma scores differed significantly between districts, \u003cem\u003eF\u003c/em\u003e(5, 595)\u0026thinsp;=\u0026thinsp;3.74, \u003cem\u003ep\u003c/em\u003e = .003. Misconceptions also showed significant variation across districts, \u003cem\u003eF\u003c/em\u003e(5, 595)\u0026thinsp;=\u0026thinsp;2.29, \u003cem\u003ep\u003c/em\u003e = .045.\u003c/p\u003e \u003cp\u003eSimilarly, emotional avoidance differed significantly among respondents from the six districts, \u003cem\u003eF\u003c/em\u003e(5, 595)\u0026thinsp;=\u0026thinsp;4.18, \u003cem\u003ep\u003c/em\u003e = .001.\u003c/p\u003e \u003cp\u003eThese results indicate that levels of stigma, misconceptions, and emotional avoidance were not uniform across districts. To identify the specific group differences responsible for the observed variation in stigma scores, post hoc comparisons using the Tukey HSD test were conducted. The results of these comparisons are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.5. Post Hoc Comparisons of Stigma Scores Across Districts\u003c/h2\u003e \u003cp\u003eFollowing the significant ANOVA result for stigma, \u003cb\u003eTukey HSD post hoc comparisons were conducted using summed stigma scale scores\u003c/b\u003e to determine which districts differed significantly. The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost Hoc Comparison of Stigma Scores Across Districts (Tukey HSD Test)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean Stigma Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubset 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubset 2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatiala\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMansa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTarn Taran\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSangrur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShri Muktsar Sahib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGurdaspur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e✅\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: \u003cem\u003eValues represent\u003c/em\u003e \u003cb\u003esummed stigma scale scores used for district comparisons\u003c/b\u003e.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, respondents from Patiala reported the lowest mean stigma score (M\u0026thinsp;=\u0026thinsp;79.07) among the six districts. In contrast, the highest stigma scores were observed in Gurdaspur (M\u0026thinsp;=\u0026thinsp;94.00) and Shri Muktsar Sahib (M\u0026thinsp;=\u0026thinsp;91.94).\u003c/p\u003e \u003cp\u003eThe Tukey test identified two homogeneous subsets at the 0.05 significance level. Patiala formed a separate subset with comparatively lower stigma scores, while Gurdaspur and Shri Muktsar Sahib were grouped in a subset reflecting higher stigma levels. The remaining districts, including Mansa, Tarn Taran, and Sangrur, showed intermediate scores with partial overlap between the two subsets.\u003c/p\u003e \u003cp\u003eThese results indicate that stigma levels varied across districts, with lower scores observed in Patiala and higher scores recorded in Gurdaspur and Shri Muktsar Sahib.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.6. Predictors of Cancer Risk Perception\u003c/h2\u003e \u003cp\u003eTo examine the influence of psychosocial barriers on cancer risk perception, a multiple linear regression analysis was conducted. Stigma, misconceptions, and emotional avoidance were included as predictor variables, while gender, family history of cancer, and financial status were entered as control variables. The results of the regression analysis are presented in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple Regression Analysis \u0026ndash; Predicting Cancer Risk Perception\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.001**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMisconceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-3.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.000**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional Avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.264\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-4.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.000**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.003**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily History (Yes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.039*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome (Low)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote: \u003cem\u003eB\u003c/em\u003e\u0026thinsp;=\u0026thinsp;unstandardized regression coefficient; \u003cem\u003eSE\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standard error; \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;standardized coefficient. Adjusted \u003cem\u003eR\u0026sup2;\u003c/em\u003e indicates the proportion of variance explained by the model. Significance levels: \u003cem\u003ep\u003c/em\u003e \u0026lt; .05*, \u003cem\u003ep\u003c/em\u003e \u0026lt; .01**.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the multiple linear regression analysis are shown in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The model was statistically significant, F(6, 594)\u0026thinsp;=\u0026thinsp;31.12, p \u0026lt; .001, with an adjusted R\u0026sup2; of 0.238, indicating that approximately 23.8 percent of the variance in cancer risk perception was explained by the variables included in the model.\u003c/p\u003e \u003cp\u003eAll three psychosocial variables were significant predictors of cancer risk perception. Stigma was negatively associated with perceived risk (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.213, β = \u0026minus;0.168, p = .001), and misconceptions also showed a significant negative relationship (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.187, β = \u0026minus;0.141, p \u0026lt; .001). Emotional avoidance was the strongest negative predictor (B\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.264, β = \u0026minus;0.203, p \u0026lt; .001).\u003c/p\u003e \u003cp\u003eAmong the control variables, female gender was positively associated with risk perception (B\u0026thinsp;=\u0026thinsp;0.145, β\u0026thinsp;=\u0026thinsp;0.102, p = .003), and having a family history of cancer was also positively associated (B\u0026thinsp;=\u0026thinsp;0.118, β\u0026thinsp;=\u0026thinsp;0.076, p = .039). Financial status did not reach statistical significance (p = .058).\u003c/p\u003e \u003cp\u003eThese findings indicate that psychosocial barriers, particularly emotional avoidance, stigma, and misconceptions, are linked to lower perceived cancer risk among university students.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study examined how psychosocial barriers influence cancer risk perception among tertiary students in Punjab, India. The findings show that stigma, misconceptions, and emotional avoidance are present among students and are significantly associated with lower perceived risk of cancer. These results suggest that efforts to improve cancer prevention among young adults should address not only gaps in knowledge but also the emotional and social factors that shape how students interpret cancer-related information.\u003c/p\u003e \u003cp\u003eDescriptive analyses revealed moderate levels of stigma, misconceptions, and emotional avoidance among participants. While these levels were not extreme, their presence indicates that cancer remains a topic associated with discomfort and uncertainty for many young adults. Previous research has shown that stigma can discourage open discussion and delay preventive actions, such as screening or early consultation\u0026sup1;⁰ \u0026sup1;\u0026sup1;. Among students, these attitudes may be influenced by cultural narratives that portray cancer as fatal or socially isolating. Such perceptions can lead to social distancing from individuals affected by cancer and reduce engagement with prevention messages.\u003c/p\u003e \u003cp\u003eMisconceptions about cancer were also evident. Similar findings have been reported in studies showing that inaccurate beliefs about cancer causes and treatment outcomes persist even among relatively educated populations\u0026sup2;⁹ \u0026sup3;⁰. These misconceptions may arise from incomplete health education, reliance on informal information sources, or the circulation of myths within communities. When students believe that cancer is unavoidable or always fatal, preventive behaviours may seem less meaningful, weakening perceived susceptibility and reducing motivation to adopt protective practices.\u003c/p\u003e \u003cp\u003eAmong the psychosocial factors studied, emotional avoidance had the highest average score and was the strongest negative predictor of cancer risk perception in the regression analysis. This suggests that some students cope with cancer-related anxiety by distancing themselves emotionally from the topic. Emotional avoidance is a common response to threatening health information\u0026sup3;\u0026sup3;. Individuals who feel fear or discomfort may avoid seeking information or discussing cancer, which can reduce immediate stress but also limit awareness and opportunities for early detection or preventive action.\u003c/p\u003e \u003cp\u003eGender differences were observed for emotional avoidance, with female students reporting higher levels than male students. Stigma and misconceptions did not differ significantly by gender, but the greater emotional avoidance among female students may reflect differences in emotional processing or perceived vulnerability to health threats. Research in behavioural decision making suggests that emotional responses play a key role in shaping risk perception and health-related behaviour\u0026sup3;⁴ \u0026sup3;⁵. Women may therefore experience stronger emotional reactions to cancer information, which can influence how they interpret and respond to risk.\u003c/p\u003e \u003cp\u003eThe study also found differences in psychosocial barriers across districts. These variations suggest that local social environments shape how students perceive and respond to cancer-related information. Differences in community awareness, access to health campaigns, and exposure to cancer education programmes may contribute to these patterns. Previous research has shown that social norms and community-level influences can shape attitudes toward illness and affect health behaviour\u0026sup3;⁶ \u0026sup3;⁷. Interventions aimed at reducing psychosocial barriers should therefore be sensitive to the cultural and social contexts of the target population.\u003c/p\u003e \u003cp\u003eRegression analyses provided further insight into determinants of cancer risk perception. Stigma, misconceptions, and emotional avoidance all negatively predicted perceived risk, even after accounting for demographic characteristics. These findings align with behavioural health theories that emphasize the role of cognitive and emotional processes in shaping health behaviour\u0026sup3;\u0026sup1; \u0026sup3;\u0026sup2;. Students who hold stigmatizing beliefs, misunderstand cancer, or avoid emotionally challenging information may be less likely to recognize their own vulnerability.\u003c/p\u003e \u003cp\u003eIn contrast, female gender and family history of cancer were positively associated with risk perception. Individuals with direct or indirect experience of cancer often have greater awareness and may perceive themselves to be more susceptible⁸. Previous studies have similarly shown that personal or familial exposure to illness can increase perceived risk and encourage engagement with preventive behaviours.\u003c/p\u003e \u003cp\u003eTaken together, these findings highlight the need to integrate psychosocial considerations into cancer awareness programmes targeting young adults. Many educational initiatives focus primarily on delivering factual information about risk factors and prevention. The present results indicate that knowledge alone may not be sufficient to influence risk perception. Addressing emotional responses, confronting stigma, and correcting misconceptions are essential for effective cancer prevention communication.\u003c/p\u003e \u003cp\u003eUniversities and colleges offer ideal settings for such interventions because they bring together large populations of young adults during a formative period for long-term health behaviours. Educational programmes that combine accurate information with opportunities for open discussion can help reduce fear and normalize conversations about cancer. Peer-led initiatives, awareness campaigns, and collaboration with health professionals may further create supportive environments that encourage engagement with cancer prevention strategies.\u003c/p\u003e"},{"header":"5. Policy Relevance for Cancer Prevention in India","content":"\u003cp\u003eThe findings of this study have important implications for cancer prevention strategies in India. The presence of stigma, misconceptions, and emotional avoidance among university students suggests that awareness programmes need to go beyond simply providing factual information. National initiatives, such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, focus on early detection and reducing behavioural risk factors. However, psychosocial barriers may limit the effectiveness of these initiatives if they are not addressed directly\u0026sup3;⁸.\u003c/p\u003e \u003cp\u003eYoung adults are a key population for prevention because many behaviours that increase cancer risk develop during early adulthood. Integrating psychosocial education into university health programmes, public health campaigns, and digital awareness platforms could strengthen existing prevention efforts. Evidence from previous studies indicates that culturally sensitive communication and community-based education can improve cancer awareness and encourage earlier engagement with preventive services\u0026sup3;⁹ ⁴⁰.\u003c/p\u003e"},{"header":"6. Strengths and Limitations","content":"\u003cp\u003eThis study has several strengths. First, it examined psychosocial barriers to cancer risk perception using a relatively large sample of tertiary students from multiple districts in Punjab. This geographic diversity allowed us to capture variations in attitudes and perceptions across different social contexts. Second, the study considered multiple psychosocial constructs, including stigma, misconceptions, and emotional avoidance, offering a broader understanding of how cognitive and emotional factors shape cancer risk perception among young adults. Third, the use of multivariable regression analysis allowed us to assess the independent influence of these factors while controlling for demographic characteristics.\u003c/p\u003e \u003cp\u003eSeveral limitations should also be acknowledged. The cross-sectional design prevents us from drawing conclusions about causality between psychosocial barriers and cancer risk perception. Longitudinal research would provide a better understanding of how these factors evolve over time and influence preventive behaviours. In addition, the use of convenience sampling may limit the generalisability of the findings beyond the participating institutions. Although students were recruited from several districts, the sample may not fully represent the broader population of tertiary students in Punjab or other regions of India. The study also relied on self-reported responses, which could be affected by recall bias or social desirability bias. Future research incorporating qualitative methods could provide deeper insight into how students interpret cancer-related information and how emotional responses influence engagement with prevention messages.\u003c/p\u003e"},{"header":"7. Implications for Practice and Future Research","content":"\u003cp\u003eThe results highlight several implications for cancer prevention and health promotion. Educational institutions can play a central role in improving awareness among young adults. Universities may consider integrating health literacy initiatives, awareness campaigns, and peer education programmes into student activities and campus health services. Such initiatives can create supportive environments that encourage open discussion about cancer and reduce stigma associated with the disease.\u003c/p\u003e \u003cp\u003ePublic health communication strategies should also recognise the emotional dimensions of cancer awareness. Messages that combine accurate information with empathetic and supportive communication may reduce fear-based avoidance and encourage greater engagement with health information. Research has shown that approaches which acknowledge emotional concerns while providing clear preventive guidance can improve public responses to health risks⁴\u0026sup1; \u0026sup1;\u0026sup1;.\u003c/p\u003e \u003cp\u003eFuture studies should explore additional psychosocial factors that may influence cancer risk perception among young adults, including health literacy, perceived social support, and exposure to digital health information. Longitudinal research could also examine whether improvements in awareness and reductions in stigma lead to measurable changes in preventive behaviours, such as participation in screening programmes and adoption of healthier lifestyles.\u003c/p\u003e"},{"header":"8. Conclusion","content":"\u003cp\u003eThis study examined how psychosocial barriers influence cancer risk perception among tertiary students in Punjab, India. The findings indicate that stigma, misconceptions, and emotional avoidance remain present among young adults and are associated with lower perceived susceptibility to cancer. Emotional avoidance emerged as the strongest predictor, highlighting the role of emotional responses in shaping how students interpret their personal health risks. In contrast, female gender and a family history of cancer were linked to higher perceived risk.\u003c/p\u003e \u003cp\u003eThese findings underscore the need for cancer awareness initiatives that go beyond the simple dissemination of information. Educational and public health programmes should address emotional and social barriers while correcting misconceptions about cancer. Universities and colleges provide ideal platforms for such interventions, as they offer opportunities to reach large numbers of young adults during a formative stage of health behaviour development. Strengthening psychosocial engagement in cancer education may help improve risk awareness and support the adoption of preventive health behaviours among students.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Institutional Ethics Committee of Desh Bhagat University, Mandi Gobindgarh. Written informed consent was obtained from all participants prior to data collection\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: E.K.E.\u003cbr\u003e\u0026nbsp;Methodology: E.K.E., K.S.\u003cbr\u003e\u0026nbsp;Data Curation: E.K.E., K.S.\u003cbr\u003e\u0026nbsp;Software and Validation: E.K.E.\u003cbr\u003e\u0026nbsp;Investigation and Analysis: E.K.E., K.S.\u003cbr\u003e\u0026nbsp;Visualization: E.K.E.\u003cbr\u003e\u0026nbsp;Writing – Original Draft: E.K.E.\u003cbr\u003e\u0026nbsp;Writing – Review and Editing: E.K.E., K.S.\u003cbr\u003e\u0026nbsp;Resources: K.S.\u003cbr\u003e\u0026nbsp;Supervision: K.S.\u003cbr\u003e\u0026nbsp;Project Administration: K.S.\u003cbr\u003e\u0026nbsp;Funding Acquisition: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eArtificial Intelligence Use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArtificial intelligence tools were used only to assist with language editing and improvement of clarity. All data analysis, interpretation, and scientific content were developed and verified by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Dataset\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e World Health Organization. Cancer. Geneva: World Health Organization; 2022. https://www.who.int/news-room/fact-sheets/detail/cancer\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. \u003cem\u003eCA Cancer J Clin.\u003c/em\u003e 2021;71(3):209\u0026ndash;249. doi:10.3322/caac.21660\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e International Agency for Research on Cancer. Global cancer observatory: cancer today. Lyon: IARC; 2021. https://gco.iarc.fr/today\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Kushi LH, Doyle C, McCullough M, Rock CL, Demark Wahnefried W, Bandera EV, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention. \u003cem\u003eCA Cancer J Clin.\u003c/em\u003e 2012;62(1):30\u0026ndash;67. doi:10.3322/caac.20140\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments for motivating smoking cessation. \u003cem\u003eHealth Educ Res.\u003c/em\u003e 2003;18(2):156\u0026ndash;170. doi:10.1093/her/18.2.156\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Champion VL, Skinner CS. The Health Belief Model. In: Glanz K, Rimer BK, Viswanath K, editors. \u003cem\u003eHealth behavior and health education: theory, research, and practice.\u003c/em\u003e 4th ed. San Francisco: Jossey Bass; 2008. p. 45\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Katapodi MC, Lee KA, Facione NC, Dodd MJ. Predictors of perceived breast cancer risk and the relation between perceived risk and screening. \u003cem\u003eCancer Nurs.\u003c/em\u003e 2004;27(6):409\u0026ndash;418. doi:10.1097/00002820-200411000-00003\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior. \u003cem\u003eHealth Psychol.\u003c/em\u003e 2007;26(2):136\u0026ndash;145. doi:10.1037/0278-6133.26.2.136\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Else Quest NM, LoConte NK, Schiller JH, Hyde JS. Perceived stigma and barriers to care in lung cancer patients. \u003cem\u003eOncologist.\u003c/em\u003e 2009;14(8):822\u0026ndash;829. doi:10.1634/theoncologist.2009-0050\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Marlow LAV, Wardle J. Development of a scale to assess cancer stigma in the non patient population. \u003cem\u003eBMC Cancer.\u003c/em\u003e 2014;14:285. doi:10.1186/1471-2407-14-285\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Powe BD, Finnie R. Cancer fatalism: the state of the science. \u003cem\u003eCancer Nurs.\u003c/em\u003e 2003;26(6):454\u0026ndash;465. doi:10.1097/00002820-200311000-00004\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Niederdeppe J, Levy AG. Fatalistic beliefs about cancer prevention and three prevention behaviors. \u003cem\u003eCancer Epidemiol Biomarkers Prev.\u003c/em\u003e 2007;16(5):998\u0026ndash;1003. doi:10.1158/1055-9965.EPI-06-0953\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Vrinten C, McGregor LM, Heinrich M, von Wagner C, Waller J, Wardle J, et al. What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population. \u003cem\u003ePsychooncology.\u003c/em\u003e 2017;26(8):1070\u0026ndash;1079. doi:10.1002/pon.4122\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening behavior. \u003cem\u003eCancer Epidemiol Biomarkers Prev.\u003c/em\u003e 2004;13(4):501\u0026ndash;510. doi:10.1158/1055-9965.EPI-03-0230\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Katapodi MC, Northouse LL, Milliron KJ, Liu G, Merajver SD. Individual and family characteristics associated with BRCA1/2 genetic testing in high risk families. \u003cem\u003ePsychooncology.\u003c/em\u003e 2013;22(6):1336\u0026ndash;1343. doi:10.1002/pon.3114\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Rosenstock IM. Why people use health services. \u003cem\u003eMilbank Mem Fund Q.\u003c/em\u003e 1966;44(3):94\u0026ndash;127. doi:10.2307/3348967\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Becker MH. The Health Belief Model and personal health behavior. \u003cem\u003eHealth Educ Monogr.\u003c/em\u003e 1974;2:324\u0026ndash;473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Champion VL. Instrument development for health belief model constructs. \u003cem\u003eANS Adv Nurs Sci.\u003c/em\u003e 1984;6(3):73\u0026ndash;85. doi:10.1097/00012272-198404000-00008\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Glanz K, Rimer BK, Viswanath K. \u003cem\u003eHealth behavior and health education: theory, research, and practice.\u003c/em\u003e 4th ed. San Francisco: Jossey Bass; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Link BG, Phelan JC. Conceptualizing stigma. \u003cem\u003eAnnu Rev Sociol.\u003c/em\u003e 2001;27:363\u0026ndash;385. doi:10.1146/annurev.soc.27.1.363\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Waller J, Marlow LAV, Wardle J. The association between knowledge of cancer symptoms and anticipated delay in help seeking. \u003cem\u003eBr J Cancer.\u003c/em\u003e 2014;111(12):246\u0026ndash;252. doi:10.1038/bjc.2014.472\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Vrinten C, Wardle J, Marlow LAV. Cancer fear and fatalism among ethnic minority women in the United Kingdom. \u003cem\u003eBr J Cancer.\u003c/em\u003e 2016;114(5):597\u0026ndash;604. doi:10.1038/bjc.2015.453\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mann CJ. Observational research methods. Research design II: cohort, cross sectional, and case control studies. \u003cem\u003eEmerg Med J.\u003c/em\u003e 2003;20(1):54\u0026ndash;60. doi:10.1136/emj.20.1.54\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Creswell JW. \u003cem\u003eResearch design: qualitative, quantitative, and mixed methods approaches.\u003c/em\u003e 4th ed. Thousand Oaks, CA: SAGE Publications; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sedgwick P. Convenience sampling. \u003cem\u003eBMJ.\u003c/em\u003e 2013;347:f6304. doi:10.1136/bmj.f6304\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Field A. \u003cem\u003eDiscovering statistics using IBM SPSS statistics.\u003c/em\u003e 5th ed. London: SAGE Publications; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Powe BD. Cancer fatalism among elderly African American women: predictors of the intensity of the perceptions. \u003cem\u003eJ Psychosoc Oncol.\u003c/em\u003e 1995;13(3):69\u0026ndash;85. doi:10.1300/J077v13n03_05\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Mishra SI, Luce PH, Baquet CR. Increasing Pap smear utilization among urban minority women. \u003cem\u003eJ Natl Med Assoc.\u003c/em\u003e 2009;101(2):195\u0026ndash;202. doi:10.1016/S0027-9684(15)30354-2\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Nayak S, Pradhan B, Mahapatra S. Awareness about cancer and its prevention among college students in India. \u003cem\u003eAsian Pac J Cancer Prev.\u003c/em\u003e 2017;18(6):1595\u0026ndash;1600. doi:10.22034/APJCP.2017.18.6.1595\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Janz NK, Becker MH. The Health Belief Model: a decade later. \u003cem\u003eHealth Educ Q.\u003c/em\u003e 1984;11(1):1\u0026ndash;47. doi:10.1177/109019818401100101\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Bandura A. \u003cem\u003eSelf efficacy: the exercise of control.\u003c/em\u003e New York: W.H. Freeman; 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e IBM Corp. \u003cem\u003eIBM SPSS Statistics for Windows, Version 26.0.\u003c/em\u003e Armonk, NY: IBM Corp; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ferrer RA, Klein WMP. Risk perceptions and health behavior. \u003cem\u003eCurr Opin Psychol.\u003c/em\u003e 2015;5:85\u0026ndash;89. doi:10.1016/j.copsyc.2015.03.012\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Loewenstein GF, Weber EU, Hsee CK, Welch N. Risk as feelings. \u003cem\u003ePsychol Bull.\u003c/em\u003e 2001;127(2):267\u0026ndash;286. doi:10.1037/0033-2909.127.2.267\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Link BG, Phelan JC. Social conditions as fundamental causes of disease. \u003cem\u003eJ Health Soc Behav.\u003c/em\u003e 2006;47:80\u0026ndash;94. doi:10.2307/3644316\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. \u003cem\u003eLancet.\u003c/em\u003e 2010;376(9748):1261\u0026ndash;1271. doi:10.1016/S0140-6736(10)60809-4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Ministry of Health and Family Welfare. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). New Delhi: Government of India; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Gupta A, Shridhar K, Dhillon PK. A review of breast cancer awareness among women in India. \u003cem\u003eBreast.\u003c/em\u003e 2015;24(5):663\u0026ndash;671. doi:10.1016/j.breast.2015.06.003\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Sankaranarayanan R, Ramadas K, Thara S, et al. Clinical breast examination: preliminary results from a cluster randomized controlled trial in India. \u003cem\u003eJ Natl Cancer Inst.\u003c/em\u003e 2010;102(19):1476\u0026ndash;1480. doi:10.1093/jnci/djq330\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e Peters E, McCaul KD, Stefanek M, Nelson W. A heuristics approach to understanding cancer risk perception. \u003cem\u003eCancer Epidemiol Biomarkers Prev.\u003c/em\u003e 2013;22(6):1037\u0026ndash;1043. doi:10.1158/1055-9965.EPI-12-1323\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer risk perception, cancer stigma, emotional avoidance, psychosocial barriers, tertiary students, cancer prevention","lastPublishedDoi":"10.21203/rs.3.rs-9255760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9255760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCancer incidence is rising globally, with a particularly high burden in low- and middle-income countries. Psychosocial factors, including stigma, misconceptions, and emotional avoidance, can shape how individuals perceive their risk of cancer and engage in preventive behaviours. Research on these factors among young adults in India is limited.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo examine the association between cancer-related stigma, misconceptions, emotional avoidance, and cancer risk perception among tertiary students in Punjab, India.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross sectional survey was conducted with 601 tertiary students from six districts of Punjab. Data were collected using a structured questionnaire specifically designed to measure cancer risk perception and three psychosocial constructs: stigma, misconceptions, and emotional avoidance. Sociodemographic information, including gender, financial status, and family history of cancer, was also collected. Data were analysed using descriptive statistics, independent-samples t tests, one-way analysis of variance, and multiple linear regression in IBM SPSS Statistics version 26.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe regression model was statistically significant and explained 23.8 percent of the variance in cancer risk perception (adjusted R\u0026sup2; = 0.238, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Stigma (β = \u0026minus;0.168, p\u0026thinsp;=\u0026thinsp;0.001), misconceptions (β = \u0026minus;0.141, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and emotional avoidance (β = \u0026minus;0.203, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were negatively associated with cancer risk perception. Female gender (β\u0026thinsp;=\u0026thinsp;0.102, p\u0026thinsp;=\u0026thinsp;0.003) and family history of cancer (β\u0026thinsp;=\u0026thinsp;0.076, p\u0026thinsp;=\u0026thinsp;0.039) were positively associated with perceived risk.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePsychosocial barriers significantly influence how tertiary students perceive their risk of cancer. Interventions that address stigma, misconceptions, and emotional avoidance may enhance risk awareness and support preventive behaviours among young adults.\u003c/p\u003e","manuscriptTitle":"Stigma, Misconceptions, and Emotional Avoidance as Psychosocial Barriers to Cancer Risk Perception Among Indian Tertiary Students: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 05:42:22","doi":"10.21203/rs.3.rs-9255760/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"44129637308651495509765376351724314157","date":"2026-04-29T07:59:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-24T07:31:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-03T18:23:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-03T18:17:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-03T09:27:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-04-03T09:14:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c36d315-e90c-44af-a2a6-2c7aeadca987","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T07:40:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 05:42:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9255760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9255760","identity":"rs-9255760","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}