3.2 Study Design The study employed a cross-sectional descriptive design to gather data from tertiary students in Punjab, India, at a single point in time. This design was chosen because it allows for an efficient and effective assessment of the prevalence and patterns of specific variables, such as cancer awareness, stigma, and health behaviors. By collecting data at one moment, the study can identify associations and trends between these variables without needing a long-term follow-up. Cross-sectional studies are widely used in public health research, particularly when the aim is to observe the distribution of health-related knowledge, behaviors, or perceptions within a population at a given time (Creswell, 2014). The core objective of this study was to measure how well students understood cancer, including their awareness of risk factors and early warning signs, and to assess how stigma impacted their health behaviors. The design allowed for the exploration of how awareness and perception of risk relate to preventive health actions, such as regular screenings and lifestyle choices. These aspects of cancer prevention are key to answering the research questions and objectives outlined in Chapter 1. The study assessed cancer awareness, stigma, and health-promoting behaviors using validated scales that have been previously proven reliable in similar research contexts. By using this cross-sectional design, the study also enabled the simultaneous examination of these variables across various demographic groups. For example, comparisons could be made across different age groups, gender, and socioeconomic status to identify any group-specific patterns in cancer awareness and engagement with health behaviors. A significant strength of the cross-sectional design is its ability to make geographical comparisons within the Punjab region. The study divided the districts into low, medium, and high cancer incidence categories based on previously reported data. This stratification allowed for a deeper examination of how regional differences in cancer burden might influence cancer-related knowledge and behaviors. By accounting for varying levels of exposure to cancer risks and healthcare access, the study offers a nuanced understanding of cancer awareness across Punjab. 3.3 Research Approach The research employed a quantitative approach to systematically measure and analyze key variables such as cancer awareness, risk perception, stigma, and health-promoting behaviors. Quantitative research is ideal for testing hypotheses and examining the relationships between multiple variables. This approach provides a structured way of gathering numerical data, allowing for precise comparisons and the identification of trends and patterns in the population being studied (Creswell & Creswell, 2018). The study was guided by specific hypotheses that stemmed directly from the research questions and objectives. The following hypotheses were tested: 1. Hypothesis 1: A positive association exists between cancer risk perception and health-promoting behaviors among tertiary students in Punjab. 2. Hypothesis 2: Tertiary students in Punjab perceive themselves to be at a low risk of developing cancer. 3. Hypothesis 3: Female tertiary students demonstrate higher levels of cancer awareness and greater engagement in health-promoting behaviors than male students. 4. Hypothesis 4: Higher levels of cancer-related stigma are associated with lower engagement in health-promoting behaviors. These hypotheses were tested using a range of statistical tools. Techniques like correlation analysis were used to explore relationships between variables, while regression analysis and t-tests were employed to assess differences between groups. By using these methods, the study was able to identify how different factors such as gender, age, and socioeconomic status influenced cancer awareness and related health behaviors. The quantitative approach allowed for clear, objective comparisons between different demographic groups. It also provided a robust statistical framework for identifying patterns of behavior and examining the extent to which cancer-related stigma, risk perception, and awareness are interconnected. This made the study an ideal method for testing the specific hypotheses about how cancer knowledge and stigma impact health-related actions in the student population. 3.4 Study Setting: Punjab, India Punjab, a state in northern India, was selected as the setting for this study due to its unusually high cancer incidence rates, which are significantly higher than the national average. This has placed the region at the center of public health discussions around cancer prevention and intervention, making it a crucial focal point for research. Over the years, epidemiological studies have revealed a growing cancer burden in Punjab, largely attributed to environmental factors, lifestyle choices, and dietary habits prevalent in the state (Kumar et al., 2019). The historical and cultural aspects of the region further complicate the situation, as discussions about cancer are often shrouded in fear, misinformation, and social stigma. Punjab's higher-than-average cancer incidence has led to increasing concerns about the underlying causes, including environmental pollutants, such as pesticides used extensively in agriculture, as well as air pollution from industrial and vehicle emissions. The use of chemicals in farming practices, particularly in the Malwa region, has been linked to a rise in cancers like lung cancer, gastrointestinal cancers, and blood cancers (Singh et al., 2021). This elevated cancer burden, coupled with limited healthcare access in certain rural areas, highlights the need for research that can inform targeted health interventions and public health policies. The study encompassed six purposively selected districts within Punjab, each with varying levels of cancer incidence. The districts chosen represent low, medium, and high cancer-incidence areas, allowing for a geographically stratified approach to the research. This was crucial to capture the regional differences in cancer awareness, risk perceptions, stigma, and health behaviors, as these factors can vary widely depending on the local socioeconomic conditions, environmental exposure, and access to healthcare resources. To provide more insight into the cancer burden in these districts, they were categorized based on age-standardized cancer incidence rates (per 100,000 population), which were drawn from the most recent cancer registry data. The selected districts were: • Low incidence: Tarn Taran (55) and Gurdaspur (60) • Medium incidence: Patiala (82) and Sangrur (87) • High incidence: Shri Muktsar (115) and Mansa (129) This classification enabled the study to examine how the prevalence of cancer in different regions of Punjab influences cancer awareness and the engagement in preventive behaviors. It was also important to assess how these areas differed in terms of health infrastructure and educational outreach. For example, urban districts like Patiala and Sangrur often have better access to healthcare facilities and cancer screenings compared to rural districts such as Mansa and Shri Muktsar, where healthcare resources are more limited. Such disparities in healthcare access have a profound impact on students' health behaviors, including screening uptake and preventive practices. Understanding these regional variations allowed for a more nuanced examination of the factors affecting cancer awareness and behaviors across the state. Additionally, the region's cultural landscape plays a significant role in shaping how cancer is perceived. In many parts of Punjab, cancer-related stigma is pervasive, and this social barrier discourages open discussions about cancer, especially among young people. As a result, many students may not actively seek information or participate in prevention efforts due to fear of social exclusion or the negative associations with the disease. The study aimed to capture this dynamic by selecting a diverse range of districts that represent various degrees of exposure to both cancer risk factors and stigma. Overall, the selection of Punjab as the study setting provides a rich, contextual backdrop for understanding cancer awareness, risk perceptions, and health behaviors. It also underscores the importance of addressing both environmental and cultural factors when developing cancer prevention strategies, particularly in regions with high cancer incidence rates.

3.2 Study Design This research utilized a cross-sectional descriptive approach to collect information from college students across Punjab, India during a specific timeframe. Researchers selected this method because it provides an efficient way to examine how common certain variables are and identify patterns in areas like cancer knowledge, stigma, and health-related behaviors. Gathering information at one specific time allows researchers to spot connections and trends between these factors without requiring extended observation periods. Public health researchers frequently use cross-sectional studies when they want to understand how health knowledge, behaviors, or attitudes are distributed within a population at a particular moment (Creswell, 2014). The primary goal was to evaluate students' cancer understanding, including their knowledge of risk factors and early warning signs, while also examining how stigma affects their health-related choices. This approach made it possible to explore connections between awareness, risk perception, and preventive actions like regular health screenings and lifestyle decisions. These prevention elements are essential for addressing the research questions and goals presented in Chapter 1. Researchers measured cancer awareness, stigma, and health-promoting behaviors using established measurement tools that have demonstrated reliability in comparable research settings. The cross-sectional approach also enabled simultaneous evaluation of these factors across different demographic categories. This allowed for comparisons between various age ranges, genders, and economic backgrounds to detect group-specific patterns in cancer knowledge and health behavior participation. One major advantage of this design is its capacity for geographic comparisons within Punjab. Researchers categorized districts into low, medium, and high cancer occurrence groups using existing data. This classification enabled more detailed analysis of how regional differences in cancer rates might affect cancer-related knowledge and behaviors. By considering different levels of cancer risk exposure and healthcare availability, the study provides a comprehensive view of cancer awareness throughout Punjab. 3.3 Research Approach This research used a quantitative methodology to systematically measure and examine important factors including cancer awareness, risk perception, stigma, and health-promoting behaviors. Quantitative research works well for hypothesis testing and studying relationships between various factors. This method offers a systematic approach to collecting numerical information, enabling accurate comparisons and pattern identification within the studied population (Creswell & Creswell, 2018). Specific hypotheses derived from the research questions and objectives guided the study. Researchers tested these hypotheses: 1. Hypothesis 1: Cancer risk perception and health-promoting behaviors show a positive relationship among college students in Punjab. 2. Hypothesis 2: College students in Punjab view their personal cancer risk as low. 3. Hypothesis 3: Female college students show greater cancer awareness and more participation in health-promoting behaviors compared to male students. 4. Hypothesis 4: Increased cancer-related stigma connects to reduced participation in health-promoting behaviors. Various statistical methods tested these hypotheses. Correlation analysis examined relationships between factors, while regression analysis and t-tests evaluated group differences. These techniques helped identify how factors like gender, age, and economic status affected cancer awareness and related health behaviors. The quantitative method enabled clear, objective comparisons between demographic groups. It also created a solid statistical foundation for identifying behavioral patterns and examining connections between cancer-related stigma, risk perception, and awareness. This approach proved ideal for testing specific hypotheses about how cancer knowledge and stigma influence health-related decisions among students. 3.4 Study Setting: Punjab, India Researchers chose Punjab, a northern Indian state, because of its exceptionally high cancer rates that exceed national averages. This situation has made the region central to public health conversations about cancer prevention and intervention, establishing it as an important research location. Epidemiological studies over time have shown increasing cancer rates in Punjab, primarily due to environmental factors, lifestyle patterns, and dietary practices common in the state (Kumar et al., 2019). The region's historical and cultural characteristics add complexity, as cancer discussions often involve fear, incorrect information, and social stigma. Punjab's above-average cancer rates have raised concerns about root causes, including environmental pollutants like agricultural pesticides and air pollution from industrial and vehicle sources. Chemical use in farming, particularly in the Malwa region, has been connected to increased rates of lung, gastrointestinal, and blood cancers (Singh et al., 2021). This high cancer burden, combined with limited healthcare access in some rural areas, demonstrates the need for research that can guide targeted health interventions and public health policies. The study included six carefully chosen districts within Punjab, each with different cancer occurrence levels. These districts represent low, medium, and high cancer-incidence areas, creating a geographically layered research approach. This was important for capturing regional differences in cancer awareness, risk perceptions, stigma, and health behaviors, as these elements can vary significantly based on local economic conditions, environmental exposure, and healthcare resource access. To better understand cancer burden in these districts, researchers categorized them using age-standardized cancer incidence rates (per 100,000 people) from recent cancer registry information. The chosen districts were: • Low incidence: Tarn Taran (55) and Gurdaspur (60) • Medium incidence: Patiala (82) and Sangrur (87) • High incidence: Shri Muktsar (115) and Mansa (129) This grouping allowed examination of how cancer prevalence in different Punjab regions affects cancer awareness and preventive behavior participation. It was also important to evaluate how these areas differed regarding health infrastructure and educational outreach. Urban districts like Patiala and Sangrur typically have better healthcare facility access and cancer screening availability compared to rural districts such as Mansa and Shri Muktsar, where healthcare resources are more restricted. These healthcare access differences significantly impact students' health behaviors, including screening participation and preventive practices. Understanding these regional variations enabled more detailed examination of factors affecting cancer awareness and behaviors statewide. The region's cultural environment also significantly shapes cancer perceptions. Throughout much of Punjab, cancer-related stigma is widespread, creating social barriers that discourage open cancer discussions, especially among young people. Many students may avoid seeking information or participating in prevention efforts due to fears of social exclusion or negative disease associations. The study aimed to capture this dynamic by selecting diverse districts representing various levels of exposure to both cancer risk factors and stigma. Overall, selecting Punjab as the study location provides a rich contextual foundation for understanding cancer awareness, risk perceptions, and health behaviors. It also highlights the importance of addressing both environmental and cultural factors when developing cancer prevention strategies, particularly in regions with high cancer occurrence rates.