Urban–Rural Gradient in Cervical Cancer Awareness: Comparative Evaluation of Ambassador-Led Outreach Impact Across Local Government Areas in Imo State, Nigeria

*Corresponding author: Peter O. Nwadike Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. Urban–Rural Gradient in Cervical Cancer Awareness: Comparative Evaluation of Ambassador-Led Outreach Impact Across Local Government Areas in Imo State, Nigeria Peter O. Nwadike 1, 2, *, Sylvia O. Anyadoh-Nwadike 3, Chukwunonyerem C. Ogwunga 3, Nkiru N. Nwokoye 2 and Ikechukwu N.S. Dozie 4 1 Texila American University, Guyana. 2 KNCV Nigeria, Abuja, Nigeria. 3 Department of Biotechnology, Federal University of Technology, Owerri, Imo State, Nigeria. 4 Department of Public Health, Federal University of Technology, Owerri, Imo State, Nigeria. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 Publication history: Received on 15 August 2025; revised on 28 September 2025; accepted on 01 October 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.24.1.0863 Abstract Cervical cancer remains a significant public health challenge, particularly in lowand middle-income countries, despite being largely preventable. In Nigeria, significant disparities in cervical cancer knowledge and screening uptake remain along the urban–rural gradient. This study was undertaken to comparatively evaluate the effectiveness of ambassadorled outreach interventions in improving cervical cancer knowledge and screening behaviour among women in urban, semi-urban, and rural Local Government Areas (LGAs) in Imo State, Nigeria. Employing a quasi-experimental pre–post intervention design, 139 community ambassadors were trained and deployed across 15 LGAs (urban: 3; semi-urban: 6; rural: 6). Data were collected using structured questionnaires (Cronbach’s α = 0.929; Validity Index = 0.96) and field logs. Chi-square and Pearson correlation analyses were used to assess outcomes. Findings revealed statistically significant improvements in knowledge of cervical cancer among all target populations across all gradients as reported by 100% of ambassadors in urban and rural (χ², p < 0.001), effectively bridging the urban-rural gap, while in semi-urban was 94.6%. Marked discrepancy, however, existed between screening consent and actual uptake. Ambassadors in semiurban zones notably reported the highest baseline knowledge and screening rates, as well as the highest increase in post-ambassador activity screening consent (up to 60%), as reported by 78.2% of ambassadors. This indicates a nuanced socio-geographic receptiveness to interventions. Rural areas recorded the lowest screening attendance, as only 21.59% of the consenting women ultimately presented for screening. Key barriers cited by the women reached included financial/transportation challenges (51.8%); Rural (53.5%), semi-urban areas (52.7%), and urban (46.2%). Cultural /religious barriers, though minimal/least were observed in rural areas (3.5%) and urban areas (3.8%). Ambassador recruitment rates were highest in rural LGAs (96.7%), contributing to high levels of community engagement; they also faced the most field-related challenges, peaking at 91.4% on lack of funding. In conclusion, the ambassador-led outreach initiative effectively closed the urban-rural knowledge gap in cervical cancer awareness, with rural areas having the highest relative gains. The findings confirm the scalability and cultural adaptability of the cervical cancer ambassadorled outreach model across diverse settings. However, the diverse challenges faced by ambassadors underscore the need for location/context-specific, multisectoral interventions for equitable screening uptake and sustained impacts. Keywords: Cervical cancer; Urban-rural disparities; Community ambassadors; Screening uptake; Knowledge; Imo State World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 2 1. Introduction Cervical cancer is the fourth most common cancer in women globally and ranks second among women in Nigeria (WHO, 2024; WHO, 2024; Ogwunga et al., 2020; Dozie et al., 2020; Maitanmi et al., 2020). It is primarily caused by persistent infection with oncogenic strains of human papillomavirus (HPV), particularly HPV types 16 and 18, which are sexually transmitted (Dozie et al., 2020; Neeria et al., 2018; Jedy et al., 2016; Bruni et al., 2019). In 2020, 604,000 new cases of cervical cancer were reported globally, with about 342,000 deaths. An estimated 85% of the deaths occurred in lowand middle-income countries (LMICs) (WHO, 2022). The burden increased to 660,000 new cases with 350,000 deaths, out of which about 94% were in lowand middle-income countries (LMICs) (WHO, 2024). Despite its preventability through regular screening and vaccination, uptake remains low in LMICs, including Nigeria, leading to an increase in the disease burden (Akinyemiju et al., 2015; Nwankwo et al., 2011). Cervical cancer’s disproportionate impact on LMICs is exacerbated by inequities in access to healthcare, limited infrastructure, and prevailing sociocultural attitudes (Nwadike et al., 2025; Okunowo et al., 2018; Ezechi et al., 2013), worse still in rural areas. Nigeria exemplifies these challenges, with significantly lower screening rates in rural regions compared to urban centers (Ogwunga et al., 2020). Several public health strategies, including national cancer control policies and the promotion of HPV vaccination, have been implemented in Nigeria (Beddoe, 2019), yet awareness and participation remain suboptimal (Akinyemiju et al., 2015; Bisi-Onyemaechi et al., 2018). Awareness and education play a pivotal role in increasing screening uptake (Ndikom & Ofi, 2012). However, studies have consistently shown that rural and semiurban populations exhibit lower levels of knowledge due to illiteracy, poor health communication, and restricted access to services (Makadzange et al., 2022). Community-based interventions utilizing local health ambassadors or champions have demonstrated effectiveness in various contexts. These programs benefit from the cultural alignment and trust enjoyed by community members, allowing for more effective communication and behavioural influence (Lofters et al., 2023). Ambassador outreach programs, which leverage trained local volunteers to promote health education, have shown success in domains such as HIV prevention and maternal health (Dozie et al., 2020). However, their effectiveness in cancer control in Nigeria remains nascent and underexplored. This study adapts the ambassador model through three innovations: Task-shifting to non-medical ambassadors, Integration of mobile health tracking, and contextualized behavioural nudges. Nigeria's diverse geography and population distribution create significant disparities in health outcomes and access to services. Urban areas, characterized by better healthcare infrastructure and higher educational attainment, generally report higher awareness and utilization of cervical cancer screening (Akinyemiju et al., 2015). In contrast, rural communities face numerous barriers, including limited access to healthcare facilities, lower literacy levels (Nwadike et al., 2025), and entrenched traditional beliefs (Nwankwo et al., 2011; Ndikom & Ofi, 2012). Semi-urban areas, often overlooked in research, present a unique blend of challenges and opportunities. These areas may benefit from proximity to urban centers but still face infrastructural and sociocultural constraints similar to rural settings (Oluwole et al., 2017). Health awareness programs are low in rural areas of Nigeria (Oluwole et al., 2017). Worse still, a greater number of rural dwellers are illiterate and poor, hence cannot easily access their information (Makadzange et al., 2022; Zhang et al., 2022; Zeferino & Derchain, 2006). It therefore becomes crucial to have properly trained public health ambassadors provide continuous face-to-face factual health information, especially in rural areas. By understanding the role of ambassador-led programs, policymakers and healthcare practitioners can develop scalable strategies to enhance cancer prevention efforts in similar underserved populations. The Social Cognitive Theory (Bandura, 1986) and the Health Belief Model provide theoretical foundations for the ambassador approach. These models emphasize the role of observational learning, perceived barriers, and benefits in behaviour change. When individuals observe peers engaging in health-promoting behaviour and receive consistent messaging from trusted sources, they are more likely to adopt similar practices (Waller et al., 2016). This study generally explores the comparative impact of applying the Ambassador-led outreach model to cervical cancer awareness and prevention among women in urban, semi-urban, and rural LGAs of Imo State. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 3 1.1. Objectives 1.1.1. General Objective The general objective of the study is to comparatively evaluate the effectiveness of ambassador-led outreach interventions in improving cervical cancer knowledge and screening behaviour among women in urban, semi-urban, and rural Local Government Areas (LGAs) of Imo State, Nigeria 1.1.2. Specific Objectives The specific objectives include to; • Enroll, train and deploy volunteer cervical cancer ambassadors in the fifteen selected LGAs • Assess and compare baseline knowledge and attitudes across location types. • Determine the effectiveness of ambassador-led interventions. • Analyze the impact of ambassador-led interventions on knowledge and attitude of respondents towards cervical cancer screening • Identify logistical and sociocultural challenges encountered by ambassador. 2. Methodology 2.1. Study Design and Area A quasi-experimental design was adopted, with interventions administered across 15 LGAs representing the three senatorial zones of Imo State, South-East, Nigeria. Stratified random sampling was used to ensure equitable representational diversity by LGA typology (urban, semi-urban, rural). Figure 1 Physical Map of Imo State showing the study locations / LGAs World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 4 Figure 2 Mind map of Imo State 2.2. Study Population and Sampling Ambassadors were recruited via an open call for volunteers after a cervical cancer seminar for female workers in the LGAs. Criteria included basic smartphone literacy, fluency in English and Igbo, and formal education. Ten ambassadors per LGA were targeted; however, a total of 139 women volunteered. 2.3. Further Training and Deployment Ambassadors underwent structured in-depth training on cervical cancer, HPV, screening methods, and community engagement strategies. Training materials were disseminated via WhatsApp. Field activities were monitored using structured logs and supervisor oversight. The trained ambassadors were deployed to their respective LGAs/communities for the outreach interventions. They conducted awareness outreach programs, distributed informational materials, and patiently engaged in one-on-one discussions with participants, individually (in offices and homes) and at group meetings (Community, offices, faithbased gatherings, etc). The reports were logged and monitored weekly for two months. As part of an incentive to ambassadors and in furtherance of their activities, a presumptive screening test for their cervical cancer status was conducted in all the study LGAs using the Enzyme Linked Immunosorbent Assay (ELISA) kit method. 2.4. Data Collection tool and procedure Ambassadors collected and logged their daily/weekly activities outcomes in a time book provided by the researcher for ease of comprehensive reporting at the end of the field work. This was monitored weekly by the researcher to ensure comprehensiveness and compliance with details. Data were collected from ambassadors using a structured questionnaire divided into three sections: demographics, outreach activity evaluation, and challenges faced. Reliability and validity testing yielded a Cronbach’s alpha of 0.929 and a Content Validity Index of 0.96. Cronbach’s α was calculated from pilot responses while CVI was based on expert panel ratings. 2.5. Data analysis Statistical analyses, including chi-square and Pearson correlation analyses, were performed to assess the changes in knowledge and attitudes as well. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 5 3. Results 3.1. Locational /Geographic distribution of Ambassadors From the study design, the expected number of ambassadors was 10 per LGA. However, Urban Areas had a total of 26 ambassadors, ranging from 8 to 10 per location, implying 86.7% achievement of the expected number. Rural areas had the highest total of 58 ambassadors, also ranging from 8 to 10 per location, implying 96.7% achievement of the expected number for the 6 LGAs (Table 1). Table 1 Number of Ambassadors according to Location type Location Type LGA Number of Ambassadors (Range) Urban Owerri municipal 10 Orlu 8 Okigwe 8 Total 26 (8-10) Semi-urban Owerri west 10 Mbaitoli 10 Nkwerre 10 Nwangele 10 Isiala Mbano 8 Ehime Mbano 7 Total 55 (7-10) Rural Areas Ezinihitte Mbaise 10 Ngor Okpala 10 Ohaji 10 Ideato South 10 Ihitte Uboma 8 Obowo 10 Total 58 (8-10) 3.2. Demographic Characteristics of Ambassadors Table 2 below shows the distribution of age and education-level breakdowns across the three location types, along with chi-square test results: The age group 20–30 was the least represented across all location types. There was no statistically significant difference in the age distribution between location types (p = 0.215). In urban areas, Tertiary education was most common, 17(65.4%) ambassadors, but also well-represented in semiurban, 26 (47.3%), and rural areas, 22 (37.9%). Ambassadors with just Primary education were only found in rural areas, 6 (10.3%) ambassadors. Chi-square test revealed that education level distribution across the study areas was significantly different across location types (p = 0.0133), indicating education level was associated with location type. World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 6 Table 2 Demographic Characteristics of Ambassadors Ambassador data Indicators Urban (N =26) Semi-urban (N = 55) Rural (N= 58) Chi-square (P value)* Age 20 -30 2 5 5 5.814 (0.215) 31 – 40 18 23 27 >40 6 27 26 Education Primary 0 0 6 12.62 (0.0133)** Secondary 9 29 30 Tertiary 17 26 22 3.3. Ambassadors’ field work/ outreach activities Almost all the ambassadors (97.8%) received in-depth mentoring. All (100%) participated in field work, though at varying levels, and obtained data. The ambassadors in urban areas showed the highest adherence rates, rural ambassadors showed good adherence, while less than 50% of semi-urban ambassadors adhered fully to their weekly awareness schedule (Table 3). Urban ambassadors utilized faith-based dissemination far more than others, hence reaching out to more women, with 20% addressing over 100 women. Semi-urban emphasized individual visits, with low community/faith outreach, while Rural ambassadors had the lowest engagement in structured meetings; hence, above 50% often reached fewer than 50 women. In all the LGAs, the trend seemed to be the same; many women had not heard about Cervical cancer and its screening. The rural areas seem to be the worst hit. Upon Ambassador activities, many agreed to go for screening, but generally less than 30% (the highest being from urban areas, 34.06%) did. Data analysis revealed a significant gap between consent and attendance across all studied LGAs. This was especially prominent in rural areas; while about 49% of rural women consented to screening, above 70% of those who consented to screening did not attend (Table 4), possibly due to logistical and ethical challenges. On reasons for non-consent/attendance to screening, fund /cost concerns were generally the highest (51. 8%) across the studied LGAs followed by lack of awareness. Rural areas revealed higher resistance due to lack of awareness, semiurban areas had the same concerns but at lower rates while Urban areas reported more concerns about cost, fear and privacy. Table 3 Ambassadors’ activities according to indicators Indicators Number (%) of Ambassador Respondents Urban (26) Semi-Urban (55) Rural (58) Overall (139) Training Received Received in depth Training 26 (100) 54 (98.2) 55 (94.8) 135(97.1) Method of information dissemination Individually (Homes/offices) 24 (92.3) 55 (100) 55 (94.8) 134 (96.4) Community/work meetings 18 (69.2) 35 (63.6) 30 (51.7) 83 (59.7) Faith-based meetings/fellowships 20 (76.9) 21 (38.2) 19 (32.8) 60 (43.2) Ambassador organized meetings 4 (15.4) 3 (5.5) 6 (13.8) 13 (9.4) Adherence to weekly Schedule % Fully Adherence 20 (76.9) 26 (47.3) 33 (56.9) 79 (56.8) % Partial Adherence 5(19.2) 19 (34.5) 18 (31.0) 42 (30.2) World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 7 % Non-Adherence 1 (3.9) 10 (18.2) 7(12.1) 18 (13) Total number of Women Addressed: <30 2 (7.6) 20 (36.4) 17 (29.3) 39 (28.1) 50–100 4 (15.4) 20 (36.4) 25 (43.1) 49 (35.2) 101–150 10 (38.5) 6(10.9) 10 (17.2) 26 (18.7) >150 10 (38.5) 9 (16.3) 6 (10.4) 25 (18) Number with prior knowledge of Cervical cancer None 0 (0) 3 (5.5) 5 (8.6) 8 (5.8) <10 13 (50) 40 (72.7) 41 (70.7) 94 (67.6) 10–30 9 (34.6) 8 (14.6) 6 (10.3) 23 (16.5) 31–50 0 (0) 0 (0) 1(1.7) 1 (0.7) 51 – 70 3 (11.5) 2 (3.6) 3 (5.2) 8 (5.8) >70 1 (3.9) 2 (3.6) 2 (3.5) 5 (3.6) How many had Screened for CC prior to your interactions None 2 (7.7) 9 (16.4) 12 (20.7) 23 (16.5) <10 20 (76.9) 24 (43.6) 41 (70.7) 85 (61.2) 10–30 1 (3.8) 20 (36.4) 3 (5.2) 24 (17.3) 31–50 1 (3.8) 0 (0) 1 (1.7) 2 (1.4) 51 - 70 2 (7.7) 0 (0) 1 (1.7) 3 (2.2) >70 0 (0 ) 2 (3.6) 0 (0) 2(1.4) Women Consented to Screening <10 1 (3.8) 10 (18.2) 22 (37.9) 33 (23.7) 10–50 8 (30.8) 20 (36.3) 17 (29.3) 49(32.4) 51–100 10 (38.5) 15 (27.3) 15 (25.9) 40 (28.8) >100 7 (26.9) 10 (18.2) 4 (6.9) 21 (15.1) Women Attended Screening None 0 (0) 6(10.9) 9(15.5) 15(10.8) <10 5 (19.2) 24 (43.6) 36 (62.1) 65(46.8) 10–30 13 (50) 20(36.4) 11 (19) 44 (31.7) 31–50 7(26.9) 4 (7.3) 2(3.4) 13 (9.4) 51 - 70 1 (3.9) 0 (0) 0 (0) 1 (0.7) >70 0 (0) 1 (1.8) 0 (0) 1 (0.7) Reasons for Non-attendance to screening Lack of Awareness 4(15.4) 6 (10.9) 6 (10.3) 16 (11.5) Fear of Results 7(26.9) 11 (20) 10 (17.2) 28 (20.1) Cultural/Religious Beliefs 1 (3.8) 0 (0) 2 (3.5) 3 (2.2) Privacy Concerns/indecision 2 (7.7) 9 (16.4) 9(15.5) 20 (14.4) Cost Concerns/transportation 12 (46.2) 29 (52.7) 31 (53.5) 72 (51.8) World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 8 Community Receptiveness Very Receptive 23 (18) 54 (28) 51 (23) 128 (92.1) Moderately Receptive 2(7) 0(0) 3 (23) 5 (3.6) Not Receptive 1(1) 1 (8) 4(12) 6 (4.3) 3.3.1. Baseline knowledge and attitude of women reached by Ambassadors according to Location Type Semi-urban areas show the highest average number of women who had been screened before the intervention by ambassadors, followed by urban areas. Rural areas consistently exhibit the lowest average number of women with prior screening, and the highest percentage of ambassadors reporting "None" prior screening (20.7%) Table 4 Summary of Baseline knowledge and attitude of women reached by Ambassadors according to Location Type Location Type Total Ambassadors (N) Estimated Total Women Reached Estimated Total (%) Women with baseline Knowledge Estimated Total (%) Women Screened at baseline Urban 26 3,580 505(14.1) 289 (8.1%) Semi-urban 55 4,350 640(14.7) 620 (14.3%) Rural 58 4,580 605(13.2) 365 (8.0%) Total 139 12,510 1,750 (14) 1,274 (10.2%) 3.3.2. Summary of Ambassador Reach, Consent, and Screening Attendance by Location Type Using the mid-points to get estimates of numbers, all the ambassadors reached out to about 12,510 women in all the locations, about 7,035 (56.24%) consented to screening while only an estimated 26.51% (less than 30%) attended the screening with the rural dwellers lagging behind the most in screening uptake as only 21.59% of those who consented actually presented for screening. Table 5 Summary of Ambassador Reach, Consent, and Screening Attendance by Location Type Location Type Total Ambassadors (N) Estimated Total Women Reached Estimated Total Women Consented % of women consented to screening Estimated Total Women Attended Screening Consent-to-Attendance Conversion Rate (%) Urban 26 3,580 1,835 51.28 625 34.06 Semi-urban 55 4,350 2,975 68.39 760 25.55 Rural 58 4,580 2,225 48.58 480 21.59 Total 139 12,510 7,035 56.24 1865 26.51 World Journal of Biology Pharmacy and Health Sciences, 2025, 24(01), 001-017 9 3.3.3. Observed impact of Ambassador Activities The ambassador’s activities were of good impact, as revealed by improved knowledge according to reports by 97.8% of the ambassadors. Increased cervical cancer screening rates were also reported as observed impact by 98(70.5%) of the ambassadors (Figure 3). The semi-urban ambassadors reported highest impact on screening while 100% of ambassadors who worked in urban and rural areas reported increased knowledge. The trend, however, gave a linear trendline showcasing similarities across the studied areas. Figure 3 Observed impact of outreach activities on knowledge of cervical cancer and screening uptake reported by Ambassadors 3.4. Screening Uptake Improvement Urban Areas recorded the most significant increase, with screening uptake rising from 289 women (8.1%) at baseline to 625 women (17.5%) post-intervention (116.27% increase). Rural and Semi-Urban Areas achieved a modest improvement of 32.51% and 22,58% respectively. Overall, within the 2-month ambassador-led intervention, the programme achieved a 46.39% total increase in number of women screened. Table 6 Screening uptake improvement according to Location type Location Type Baseline Screened (No, %) Post-Intervention Screened (No, %) Uptake Improvement Rate (No) % Increase Urban 289 (8.1%) 625 (17.5%) 336 116.27% Semi-Urban 620 (14.3%) 760 (17.5%) 140 22.58% Rural 365 (8.0%) 480 (10.5%) 115 31.51% Total 1,274 (10.2%) 1,865 (14.9%) 591 46.39% 3.4.1. Challenges faced by Ambassadors The ambassadors reported varying challenges in carrying out their activities. Challenges seemed to overlap in the urban, semi-urban and rural areas as shown in Figure 4 below. Generally, Lack of appropriate funding was the most prominent (86.3%) challenge of the ambassadors militating against their optimal outreach activities across all study LGAs, peaking at 91.4% in rural areas. 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