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

Cervical cancer remains a significant public health challenge, particularly in low- and 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 ambassador-led 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 semi-urban 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 ambassador-led 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.