characterized by reduced bone mass and deterioration of bone microarchitecture, leading to increased fragility and susceptibility to fractures. Globally recognized as a major public health concern, osteoporosis affects hundreds of millions of individuals—particularly postmenopausal women and the elderly—resulting in a significant burden on healthcare systems due to fracture-related morbidity and reduced quality of life. In India, the prevalence of osteoporosis is increasing at an alarming rate, driven by aging demographics, sedentary lifestyles, nutritional deficiencies, and low levels of public awareness regarding bone health.^1-4

The hilly state of Himachal Pradesh presents a unique epidemiological landscape for osteoporosis. The region's topography, climatic conditions, and occupational demands—often involving manual labor in difficult terrain—exert additional stress on the skeletal system. Compounding these factors are widespread vitamin D deficiency due to limited sun exposure in certain seasons, dietary insufficiencies, and inadequate access to specialized healthcare services in remote areas. Despite the increased risk factors, public understanding of osteoporosis, its risk factors, prevention strategies, and long-term complications remains poorly documented and likely suboptimal.^5,6

Misconceptions about bone health—such as the belief that osteoporosis is an inevitable part of aging, or that it only affects women—can lead to delayed diagnosis and poor preventive practices. The silent nature of the disease, which often remains undetected until a fracture occurs, further underscores the need for early awareness and education. Studies conducted in other regions of India have highlighted critical gaps in knowledge and perception surrounding bone health; however, limited research has focused specifically on geographically distinct, rural, and hilly populations such as that of Himachal Pradesh.^7-11

This study seeks to fill that gap by systematically assessing the level of public awareness and identifying common misconceptions related to osteoporosis and bone health among residents of Himachal Pradesh. By evaluating the influence of socio-demographic factors such as age, gender, education level, occupation, and rural-urban residence, the study aims to uncover awareness patterns that can inform targeted public health initiatives. Ultimately, the findings will contribute to developing culturally and regionally tailored interventions to promote bone health literacy, encourage preventive behaviors, and mitigate the rising burden of osteoporosis in this vulnerable population.

Study Design

A descriptive, cross-sectional study was conducted to assess the level of public awareness and prevalent misconceptions regarding osteoporosis and bone health among the general population of Himachal Pradesh. The study aimed to identify knowledge patterns and analyze the influence of socio-demographic variables on awareness levels.

Study Area and Population

The study was carried out across various districts of Himachal Pradesh, including both rural and urban settings to ensure demographic diversity. The target population comprised adult residents (aged 18 years and above) of the state, representing a broad range of educational, occupational, and socio-economic backgrounds. Healthcare professionals and students pursuing medical, pharmacy, or allied health sciences were excluded to eliminate professional bias.

Sampling Method and Sample Size

A sample size of 400 participants was determined using standard statistical methods, assuming a 50% expected awareness prevalence, 95% confidence interval, and a 5% margin of error. A non-probability convenience sampling method was used to recruit participants. The survey link was disseminated via digital platforms including WhatsApp, Facebook, Instagram, and email to maximize outreach, especially in remote and hilly areas.

Data Collection Tool

Data were collected through a structured, self-administered Google Form questionnaire developed in consultation with experts in orthopedics, community medicine, and public health. The form was made available in English, Hindi, and the local dialects to enhance accessibility and comprehension.

The questionnaire was divided into two sections:

1. Socio-Demographic Profile: Information regarding age, gender, education level, occupation, and place of residence (urban/rural) was recorded.
2. Knowledge and Misconception Assessment: Twenty multiple-choice questions were designed to assess awareness and identify misconceptions about osteoporosis. These included items on risk factors, preventive measures (e.g., calcium and vitamin D intake, weight-bearing exercise), symptoms, diagnosis, and treatment options. One correct answer was designated for each item based on current medical guidelines, while incorrect options reflected common public myths.

Pilot Testing

Prior to full-scale data collection, the questionnaire was pilot tested on a group of 30 individuals from diverse backgrounds to evaluate clarity, cultural sensitivity, and technical usability. Minor revisions were made based on the feedback received.

Scoring and Knowledge Classification

Each correct answer was awarded one point, with a maximum possible score of 20. Based on their total score, participants were categorized into four levels of awareness:

• Very Good: 17–20 points
• Good: 13–16 points
• Fair: 9–12 points
• Poor: 0–8 points

This classification helped identify gaps in knowledge and areas requiring focused educational intervention.

Ethical Considerations

Participation in the study was entirely voluntary. An informed consent statement was included at the beginning of the online questionnaire, outlining the purpose of the study, confidentiality assurance, and the right to withdraw at any time. No personal identifiers were collected. The study adhered to ethical guidelines as per the Declaration of Helsinki.

Data Management and Statistical Analysis

Data from Google Forms were exported into Microsoft Excel for preliminary cleaning and then analyzed using Epi Info Version 7. Descriptive statistics such as frequencies and percentages were used to summarize demographic variables and response patterns. Chi-square tests were applied to determine the association between knowledge levels and socio-demographic variables. A p-value < 0.05 was considered statistically significant.

Table 1 outlines the socio-demographic distribution of the 400 participants included in the study. The sample reflected a balanced age representation, with the largest group aged 26–35 years (31.0%), followed by 36–45 years (27.5%), 46 and above (23.5%), and 18–25 years (18.0%). Females constituted a slightly larger portion of the sample (54.0%) compared to males (46.0%). In terms of education, the majority had attained at least secondary school (32.0%) or undergraduate education (36.0%), while 6.0% had no formal schooling. Occupational diversity was notable, with homemakers (22.5%) and private sector employees (20.0%) forming the two largest subgroups. Notably, a higher proportion of participants resided in rural or hilly areas (58.0%) compared to urban regions (42.0%), ensuring appropriate representation of the target population in Himachal Pradesh’s geographical context.

Table 1: Socio-Demographic Characteristics of Participants (n = 400)

Table 2 summarizes responses to 20 multiple-choice questions designed to assess awareness and misconceptions related to osteoporosis and bone health. The overall findings reflect moderate-to-good awareness across most domains. Participants performed particularly well in questions concerning nutrient requirements (81.0%), calcium-rich foods (85.0%), the definition of osteoporosis (76.5%), and the role of sunlight in vitamin D production (77.0%). However, awareness was relatively lower on more nuanced topics such as the effect of high-protein diets (46.5%), family history (51.5%), and long-term steroid use (55.0%). These results suggest that while general knowledge about bone health is fair, deeper understanding of risk factors and preventive behaviors remains inconsistent, highlighting areas that require focused educational interventions.

Table 2: Awareness Questions on Osteoporosis and Bone Health (n = 400)

Table 3 categorizes participants based on their total knowledge scores out of 20. A considerable proportion of respondents demonstrated a Good (38.0%) or Very Good (28.0%) level of awareness, collectively accounting for 66.0% of the sample. Meanwhile, 22.5% fell in the Fair category and 11.5% had Poor knowledge scores (≤8), indicating that nearly one-third of the population had insufficient understanding of osteoporosis and bone health. These results underscore the presence of a foundational awareness in the population, but also reveal significant knowledge gaps that must be addressed through structured public health education, particularly for at-risk or underserved groups.

Table 3: Knowledge Score Classification Among Participants (n = 400)

Table 4 presents the statistical association between participants’ knowledge scores and key socio-demographic variables. Significant associations were observed with age (p = 0.007), education level (p < 0.001), and place of residence (p = 0.011). Participants aged 26–45 years demonstrated higher awareness, likely due to increased health-seeking behavior and digital literacy. As expected, higher educational attainment correlated strongly with better knowledge levels; those with undergraduate and postgraduate degrees had the highest proportion of Very Good and Good scores. Additionally, urban residents showed significantly better awareness than rural counterparts, emphasizing disparities in health information access and literacy. Gender and occupation did not show statistically significant differences (p = 0.425 and p = 0.213 respectively), suggesting that awareness levels were fairly consistent across these variables. These findings point to the need for targeted interventions focusing on less-educated, older, and rural populations.

Table 4: Association Between Knowledge Scores and Socio-Demographic Variables (n = 400)

This study aimed to assess the level of public awareness and identify prevailing misconceptions about osteoporosis and bone health among the hilly population of Himachal Pradesh. The findings provide critical insights into the knowledge landscape surrounding this silent yet debilitating condition, especially in geographically challenging regions where healthcare access and health literacy can be limited. The analysis also reveals key socio-demographic factors influencing awareness, which are crucial for designing targeted interventions.

The results demonstrate a moderate-to-good overall awareness, with 66.0% of participants falling under the “Very Good” or “Good” knowledge categories. This is a promising indicator and may be reflective of increasing penetration of digital health information, government health campaigns, and community-level health programs in Himachal Pradesh. However, a substantial 33.5% of participants had Fair or Poor knowledge, indicating that critical gaps persist—particularly among specific demographic segments.

Participants exhibited strong awareness in certain fundamental areas such as the role of calcium and vitamin D (81.0%), definition of osteoporosis (76.5%), and importance of sunlight in vitamin D synthesis (77.0%). These findings suggest that the population has a basic understanding of bone health fundamentals, which could be the result of public health messaging or informal health education. However, when it came to more nuanced or less publicly discussed factors—such as effects of high-protein diets (46.5%), impact of long-term steroid use (55.0%), and influence of family history (51.5%)—awareness dropped considerably. This discrepancy highlights the common public health phenomenon where superficial awareness exists, but deeper, actionable knowledge remains weak or inconsistent.

The misconception that osteoporosis predominantly affects women remains prevalent, as reflected in only 58.5% correctly identifying that men are also at risk. Similarly, the association between soda and reduced calcium absorption was correctly identified by just 64.0%, and only 55.0% recognized that long-term steroid use increases osteoporosis risk. These findings are aligned with previous studies in Indian and international settings, where osteoporosis is often misunderstood as a gender-specific or age-bound condition and not associated with modifiable lifestyle factors such as nutrition, caffeine, or medication use. This points to a pressing need for evidence-based educational content tailored to address prevalent myths and lifestyle-related misconceptions in these populations.

From a socio-demographic perspective, the association between knowledge levels and education was highly significant (p < 0.001). Participants with undergraduate and postgraduate education had the highest levels of awareness, confirming the well-documented correlation between educational attainment and health literacy. This emphasizes the importance of creating health education materials that are accessible to individuals with lower literacy levels—possibly through visual content, vernacular audio-visual media, and community health worker outreach.

Age also showed a significant association with knowledge levels (p = 0.007), with participants aged 26–45 years demonstrating the highest awareness. This could be attributed to greater digital exposure, workplace health programs, and proactive health-seeking behavior among this economically active age group. Interestingly, the elderly population (46 and above)—the group most at risk for osteoporosis—had lower awareness levels. This mismatch between vulnerability and awareness is a critical public health concern and warrants focused awareness drives for older adults, especially in rural and remote communities.

Although gender did not show a statistically significant difference in knowledge levels (p = 0.425), the overall slight edge in female participation and awareness may reflect increasing involvement of women in community health programs and self-care initiatives. However, this finding also suggests that osteoporosis education efforts should be gender-inclusive, dispelling the myth that osteoporosis is solely a “women’s disease.”

One of the most important findings was the significant difference in knowledge between urban and rural/hilly residents (p = 0.011). Rural participants had notably lower awareness, reinforcing the rural-urban divide in health knowledge and access. In the context of Himachal Pradesh—where terrain, infrastructure, and healthcare accessibility are major challenges—this underscores the necessity for mobile health education units, door-to-door awareness drives, and integration of bone health education into primary care and rural health missions.

In summary, while the study reveals a moderately encouraging level of public knowledge on osteoporosis in Himachal Pradesh, it also uncovers critical gaps that could hinder early detection, preventive behavior, and timely treatment. These findings align with literature from other regions in India, as well as global studies from countries with similar demographic and healthcare challenges.^8-13 The implications are clear: public health policies and orthopedic awareness campaigns must adopt a multi-pronged, demographically tailored approach that considers age, education, geography, and cultural health beliefs.

While this study offers valuable insights into public awareness of osteoporosis and bone health in the hilly population of Himachal Pradesh, several limitations must be acknowledged. First, the use of an online Google Form for data collection may have excluded individuals without internet access or digital literacy, particularly among older adults and those in remote, underserved areas—thus potentially introducing selection bias. Second, the reliance on self-reported data may have resulted in social desirability bias or misinterpretation of questions, affecting the accuracy of responses. Additionally, the convenience sampling method, although effective in gathering a large and diverse sample, limits the generalizability of findings to the wider population. The cross-sectional nature of the study also precludes causal inferences between socio-demographic factors and knowledge levels. Despite these limitations, the study lays a strong foundation for future research and targeted public health interventions in similar demographic and geographic settings.

This study highlights a critical yet often overlooked aspect of public health—awareness of osteoporosis and bone health—in the unique sociogeographic context of Himachal Pradesh. While two-thirds of the participants demonstrated moderate-to-good knowledge, significant gaps persist, particularly among older adults, rural residents, and individuals with lower educational attainment. Misconceptions about risk factors, prevention, and gender vulnerability continue to hinder effective health-seeking behavior and timely intervention. The findings emphasize the urgent need for culturally sensitive, demographically targeted educational programs and community outreach strategies to bridge these knowledge gaps. By enhancing bone health literacy across all population segments—especially in hilly and remote areas—healthcare systems can promote earlier diagnosis, better prevention, and improved management of osteoporosis, ultimately reducing the burden of fracture-related disability and improving quality of life in this vulnerable population

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