Road traffic accidents (RTAs) are a growing public health concern globally, with low- and middle-income countries bearing a disproportionate burden of injury and mortality. In India, RTAs represent a leading cause of trauma-related disability and death, frequently resulting in orthopedic injuries such as fractures. The hilly terrain and expanding vehicular presence in states like Himachal Pradesh further compound the risk of such incidents, where timely and appropriate first response plays a critical role in determining patient outcomes.^1-4

Fractures, if improperly handled at the scene, can lead to severe complications including nerve damage, internal bleeding, and permanent disability. While professional emergency care is ideal, the reality in most road accident scenarios is that the first responders are often untrained bystanders. Thus, their knowledge, attitudes, and immediate actions can significantly influence the prognosis of trauma victims. The concept of the "golden hour" in trauma care emphasizes the urgency of early intervention, yet public understanding of such principles remains inadequately assessed in many parts of India.^5-7

Despite the growing emphasis on emergency medical services (EMS), rural and semi-urban populations frequently experience delays in ambulance arrival and limited access to orthopedic care. In such contexts, community-level awareness and first aid knowledge become essential pillars of pre-hospital trauma management. Previous studies have explored general injury awareness, but there is a paucity of focused research on orthopedic trauma—particularly within geographically challenging and demographically diverse regions like Himachal Pradesh.^8-10

This study aims to evaluate public knowledge, attitudes, and practices related to first response for orthopedic trauma due to RTAs among residents of Himachal Pradesh. By identifying key gaps in understanding and response behaviors, this research seeks to inform targeted educational interventions and strengthen community-based trauma readiness in a state with unique topographical and infrastructural challenges.

Study Design and Setting

This was a descriptive, cross-sectional study conducted to assess the knowledge, attitudes, and first-response practices related to orthopedic trauma from road traffic accidents among the general population of Himachal Pradesh, India. Given the geographically dispersed population and logistical constraints, data were collected using a structured, self-administered Google Form-based questionnaire available in both English and Hindi.

Study Duration

The survey was conducted over a period of three months, from Feb to March, 2025.

Sample Size and Sampling Technique

A total of 400 participants were enrolled in the study. The sample size was determined using standard estimation methods for proportions with a confidence level of 95% and margin of error of 5%. A convenience sampling strategy was adopted, with the survey link disseminated through email, social media platforms (e.g., WhatsApp, Facebook), and local community groups to ensure broad demographic representation across both urban and rural regions of Himachal Pradesh.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Residents of Himachal Pradesh aged 18 years and above.
• Individuals with access to the internet and the ability to comprehend the questionnaire in English or Hindi.
• Voluntary consent to participate.

 Exclusion Criteria:

• Incomplete or duplicate submissions.
• Healthcare professionals or students in medical fields (to focus on general public awareness).

 Data Collection Tool

The questionnaire was designed and validated by a panel of public health experts and orthopedic specialists to ensure relevance and clarity. It comprised four sections:

1. Socio-demographic information (age, gender, education, occupation, residence).
2. Awareness and misconceptions related to orthopedic trauma and emergency response (20 multiple-choice questions).
3. Knowledge classification based on scoring (Very Good, Good, Fair, Poor).

Correct answers were pre-marked based on standard trauma care guidelines. Each correct response was awarded one point, with a total possible score of 20. Knowledge levels were classified as:

• Very Good (17–20),
• Good (13–16),
• Fair (9–12),
• Poor (0–8).

 Ethical Considerations

Participation was completely voluntary, anonymous, and without compensation. A clear informed consent statement was included at the beginning of the Google Form, which participants had to acknowledge before proceeding. The study adhered to the ethical principles outlined in the Declaration of Helsinki.

 Data Analysis

Collected responses were automatically recorded in Google Sheets and exported into Microsoft Excel and IBM SPSS Statistics version [Insert Version] for analysis. Descriptive statistics (frequencies, percentages) were used for categorical variables. The association between knowledge scores and socio-demographic variables was assessed using the Chi-square test, with a p-value < 0.05 considered statistically significant.

The study included 400 participants from various regions of Himachal Pradesh. The age distribution showed that the majority were aged 26–35 years (28.0%), followed by 46 years and above (30.5%), 36–45 years (24.0%), and the youngest group aged 18–25 years (17.5%). Gender representation was relatively balanced, with males comprising 53.5% (n = 214) and females 46.5% (n = 186). In terms of educational background, most participants had completed secondary school (32.0%) or held undergraduate degrees (30.5%), while a smaller proportion had postgraduate qualifications (18.0%). Notably, 5.5% had no formal education. Occupationally, the largest segments included individuals employed in the private sector (24.5%) and homemakers (19.5%), followed by students (18.0%), government employees (16.5%), self-employed individuals (13.5%), and a smaller group classified as retired or other (8.0%). Slightly more participants resided in rural areas (53.0%) compared to urban areas (47.0%).

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

The awareness assessment revealed varied levels of knowledge on first-response practices for orthopedic trauma. Most participants correctly identified that a fractured limb should be immobilized first (69.5%) and that improper handling can worsen fractures (71.5%). Awareness of the emergency medical number (108) stood at 66.0%. While 73.0% understood that roadside first aid can reduce fracture complications, only 62.8% correctly identified that a rigid object should be used to support a fractured limb. Less than two-thirds (59.5%) knew not to offer food or water to trauma victims due to potential surgical needs. High awareness was seen regarding common signs of fractures (70.5%), commonly fractured bones in RTAs (72.3%), and the importance of the golden hour (61.0%). However, only 58.0% correctly believed it is generally advisable to wait for an ambulance instead of using private transport. On issues like helmet removal, ice application, and recognizing invisible fractures or spinal injuries, correct responses ranged between 61.8% and 73.8%, indicating notable knowledge gaps and misconceptions in key areas of trauma response.

Table 2: Awareness and Misconception Questions on Orthopedic Trauma Response (n = 400)

Based on the 20-item knowledge assessment, participant scores were classified into four categories. Nearly one-third of respondents (29.8%) demonstrated a Very Good level of knowledge (17–20 correct answers), while the largest proportion (35.8%) fell into the Good category (13–16 correct). About 22.8% had Fair knowledge (9–12), and 11.8% scored in the Poor category (0–8), reflecting that while a majority showed moderate to high awareness, a significant minority still lacked essential knowledge of orthopedic trauma response.

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

Statistical analysis revealed significant associations between knowledge levels and certain socio-demographic variables. Age was significantly associated with knowledge scores (p = 0.021), with younger adults (26–35 years) more likely to demonstrate higher knowledge levels. Education was the most strongly associated factor (p < 0.001), showing a clear trend of increased knowledge with higher educational attainment; only 2.3% of those with no formal education scored in the “Very Good” category compared to 11.5% with undergraduate and 7.8% with postgraduate education. Residence was also significantly associated (p = 0.029), with urban participants exhibiting higher knowledge levels than their rural counterparts. Interestingly, no significant association was found between gender and knowledge scores (p = 0.317), indicating relatively equal awareness between males and females across the sample.

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

This study provides important insights into the level of public knowledge, awareness, and first-response attitudes toward orthopedic trauma resulting from road traffic accidents (RTAs) in Himachal Pradesh—a state with unique geographical and infrastructural challenges. The findings highlight both encouraging levels of basic understanding among many participants, as well as notable gaps and misconceptions that could significantly impact trauma outcomes if unaddressed.

The demographic profile revealed a fairly balanced distribution across age groups, gender, and urban–rural residency, making the sample reflective of the general population. Notably, more than half (53.0%) of the participants were from rural areas, where access to emergency care is often limited. This rural representation is critical, given the well-documented disparities in trauma care availability across urban and rural settings in India.

A significant proportion of participants showed adequate general knowledge regarding first-response steps for orthopedic trauma, with over two-thirds correctly identifying the importance of immobilizing a suspected fracture and acknowledging the risk of worsening the injury with improper handling. These findings align with similar studies conducted in India and other low-resource settings, which suggest that public awareness of fundamental first aid measures is increasing, albeit slowly, through both formal campaigns and informal media exposure.^5,7,9

However, the data also revealed persistent misconceptions and knowledge gaps. For instance, only 62.8% correctly identified the use of a rigid object to support a fractured limb, and just 59.5% knew that food or water should be withheld in case surgery is needed—an especially important consideration in pre-hospital care. Furthermore, the response to whether private transport should be used in lieu of waiting for an ambulance (only 58.0% correct) reflects confusion around decision-making in time-sensitive trauma situations. These gaps underscore the need for targeted community education programs, particularly in first-response principles, which could be life-saving when access to trained paramedics is delayed or unavailable.^9,10

The association between knowledge levels and socio-demographic factors was particularly telling. Education emerged as the most significant predictor of trauma knowledge (p < 0.001), consistent with findings from previous Indian and global studies that show health literacy is strongly linked to formal education. Participants with undergraduate and postgraduate degrees were significantly more likely to score in the “Very Good” category, while those with no formal education predominantly fell into the “Fair” and “Poor” categories. This underscores the role of educational empowerment in building trauma-resilient communities.

Interestingly, while gender did not significantly influence knowledge levels (p = 0.317), residence (urban vs rural) was a statistically significant factor (p = 0.029). Urban residents demonstrated better knowledge than their rural counterparts, likely due to better access to health information, more frequent exposure to emergency training initiatives, and proximity to medical infrastructure. This disparity raises a critical concern for policy-makers, especially considering that rural populations often face delayed ambulance response times and longer travel distances to reach orthopedic care facilities.

Age was also found to be significantly associated with trauma knowledge (p = 0.021), with participants aged 26–35 years performing best. This could reflect a combination of educational attainment, internet literacy, and recent exposure to digital media or safety training campaigns among younger adults. Conversely, older adults—who may be more vulnerable in accidents—showed lower awareness, pointing to a population in need of focused outreach.

Overall, the knowledge score distribution—with 29.8% “Very Good,” 35.8% “Good,” 22.8% “Fair,” and 11.8% “Poor”—indicates that while over 65% of the population demonstrated reasonably good knowledge, a considerable proportion remain unprepared to act effectively in a trauma emergency. This becomes especially critical in contexts like Himachal Pradesh, where challenging terrain, delayed medical response, and limited specialist availability can amplify the consequences of mismanaged fractures and delayed care.

Compared to previous studies from urban Indian centers and international research in developing regions, this study reinforces the global trend that bystander response is an underutilized but vital component of emergency trauma care. The widespread public misconceptions around fracture visibility, the use of private vehicles, and post-accident handling reflect a clear need for structured community-level training, including low-cost, scalable first-aid workshops and digital awareness modules in local languages.

Implications for Policy and Practice

These findings hold multiple implications for public health policy, especially in the domain of pre-hospital trauma care strengthening. Health departments, in collaboration with local panchayats and NGOs, should consider implementing community-first responder programs focusing on orthopedic trauma and other common RTA injuries. School- and college-based first aid modules, especially in rural institutions, could also bridge the awareness gap among youth and future caregivers.

Moreover, this study supports the integration of trauma awareness campaigns into road safety initiatives, leveraging digital platforms, radio, and vernacular media. Addressing rural–urban disparities will require resource mobilization for telehealth education, mobile medical units, and capacity building of community health workers in emergency response.

Strengths and Limitations

A key strength of this study lies in its use of a digital survey platform, which allowed wide dissemination and efficient data collection across diverse geographies. However, this method may have inadvertently excluded populations without internet access or digital literacy, particularly older and lower-income groups, potentially underestimating the level of knowledge gaps in these segments. Additionally, while self-reporting can introduce bias, it remains a practical tool for assessing public knowledge and attitudes at scale.

This study underscores a critical public health need for improving first-response knowledge related to orthopedic trauma from road traffic accidents among the general population in Himachal Pradesh. While a majority of respondents demonstrated moderate to good awareness, substantial gaps persist—particularly regarding proper fracture management, emergency decision-making, and misconceptions around visible symptoms and pre-hospital interventions. Education level, age, and place of residence were significantly associated with knowledge, highlighting the need for targeted interventions among rural, less-educated, and older populations. Given the state's challenging terrain and limited emergency infrastructure in many areas, enhancing community-level preparedness through structured awareness campaigns, localized training programs, and school-based modules could significantly reduce trauma complications and improve patient outcomes. This research advocates for a proactive, inclusive approach to trauma literacy as an essential component of road safety and public health resilience in geographically vulnerable regions.

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