Tuberculosis (TB) remains one of the world’s most persistent infectious diseases, posing a significant public health challenge despite decades of control efforts. Caused primarily by Mycobacterium tuberculosis, TB is an airborne disease that spreads through inhalation of droplet nuclei expelled when an infected person coughs, sneezes, speaks, or sings. According to the World Health Organization (WHO) Global Tuberculosis Report 2024, an estimated 10.6 million people fell ill with TB in 2023, with 1.3 million TB-related deaths globally—making it the second leading infectious killer after COVID-19. India bears the highest global TB burden, accounting for approximately 28% of cases worldwide, translating to nearly 2.9 million new cases annually [1-4].

In India, TB disproportionately affects socio-economically disadvantaged populations, individuals living in overcrowded conditions, and those with co-morbidities such as HIV, malnutrition, and diabetes. Although the Revised National Tuberculosis Control Programme (RNTCP), now rebranded as the National TB Elimination Programme (NTEP), has expanded diagnostic and treatment services nationwide, the country continues to face gaps in early case detection, timely treatment initiation, and treatment adherence. A critical barrier to TB control is the persistence of community-level misconceptions about its transmission, prevention, and cure—misconceptions that can perpetuate stigma, delay health-seeking behavior, and hinder public health interventions [5-9].

Evidence from multiple Indian states indicates that many people still wrongly attribute TB transmission to sharing utensils, contaminated food or water, or exposure to cold weather, while underestimating the role of airborne spread. These false beliefs, combined with stigma and fear of social exclusion, often drive patients to conceal their illness, thereby increasing the risk of continued community transmission. Studies in both rural and urban settings have revealed considerable variation in TB knowledge, often shaped by education level, socio-economic status, and access to health information [10-14].

Shimla district, the capital of Himachal Pradesh, presents a unique setting for TB epidemiology. The district encompasses both densely populated urban wards and scattered rural villages situated in hilly terrain, where healthcare access is influenced by geography, seasonal road connectivity, and health infrastructure distribution. The mixed economy—ranging from government service to agriculture and tourism—creates diverse social networks that may influence disease awareness and transmission patterns. While Himachal Pradesh has achieved relatively high literacy rates, there is limited empirical evidence on how well residents understand TB transmission and prevention, and whether misconceptions remain prevalent in this high-altitude population.

Understanding the community’s knowledge and misconceptions is vital for tailoring effective information, education, and communication (IEC) campaigns under NTEP. Identifying socio-demographic determinants of TB awareness can help public health authorities focus resources on the most at-risk groups, bridge knowledge gaps, and reduce both stigma and disease spread. Against this background, the present study was undertaken to assess public knowledge, awareness, and misconceptions regarding TB transmission among adults in the urban and rural communities of Shimla district. The study also examines associations between knowledge scores and socio-demographic factors, providing evidence to guide targeted TB health education and elimination strategies in this Himalayan region.

Study Design and Setting

This descriptive, cross-sectional study was conducted to assess knowledge, awareness, and misconceptions regarding tuberculosis (TB) transmission among adults in the urban and rural communities of Shimla district, Himachal Pradesh, India. Given the district’s challenging mountainous terrain, seasonal access issues, and dispersed population, a conventional household survey was logistically impractical. Therefore, data collection was carried out using a structured, bilingual (English and Hindi) self-administered questionnaire created on Google Forms. This online approach allowed broad geographic reach, cost efficiency, and convenience for participants, while enabling real-time data capture from both urban wards and remote rural villages.

Study Duration

The survey was conducted over a three-month period, from Jan to March, 2025. This timeframe allowed for wide dissemination of the questionnaire, reminders to potential participants, and collection of a sufficiently large and diverse sample.

Study Population and Sampling Technique

The target population included adults aged 18 years and above who were permanent residents of Shimla district. Eligibility criteria required the ability to read and understand Hindi or English and willingness to provide informed consent. No exclusions were made based on gender, education level, or occupation to ensure inclusivity and representation across socio-demographic strata.

A convenience sampling strategy was adopted. The survey link was distributed via social media platforms (WhatsApp, Facebook, Instagram), community WhatsApp groups, email lists, and through professional and personal networks of local healthcare workers, Accredited Social Health Activists (ASHAs), and community leaders. Additionally, outreach was facilitated through local NGOs and municipal offices to ensure participation from both urban and rural areas. A total of 400 completed responses were received; after excluding incomplete or duplicate entries, all were included in the final analysis.

Survey Instrument

The questionnaire was developed following a review of existing literature on TB knowledge and misconceptions, WHO guidelines, and National TB Elimination Programme (NTEP) communication materials. Content validity was ensured through expert review by two public health specialists and one pulmonologist.

The survey was structured into two main sections:

Socio-Demographic Information

Age, gender, marital status, educational level, occupation, monthly household income, and place of residence (urban or rural).

Knowledge and Misconceptions Regarding TB Transmission

Twenty multiple-choice questions, each with one correct answer, covering:

• Causative organism and main transmission route

• Organs most commonly affected

• Role of airborne spread vs. non-airborne myths (e.g., sharing utensils, touching)

• High-risk groups for TB

• Typical symptoms and duration before diagnosis

• Preventive measures and vaccination

• Importance of early detection and adherence to treatment

• Misconceptions related to diet, weather, and stigma

• Recurrence risk and community-level prevention practices

A pilot test was carried out on 25 adults from diverse backgrounds within Shimla district to assess question clarity, language suitability, and time to completion. Feedback resulted in minor wording modifications for improved comprehension and cultural appropriateness.

Scoring and Knowledge Classification

Each correct answer was awarded 1 point; incorrect or “not sure” responses were scored as 0. Total possible scores ranged from 0 to 20. Knowledge levels were classified as:

• Very Good: 16–20

• Good: 12–15

• Fair: 8–11

• Poor: 0–7

This classification enabled stratified analysis of knowledge distribution across socio-demographic groups.

Ethical Considerations

The study complied with the ethical principles outlined in the Declaration of Helsinki. The first page of the Google Form contained a digital informed consent statement, explaining study objectives, voluntary participation, anonymity, and absence of personal identifiers. Participants could withdraw at any stage without penalty. 

Data Management and Statistical Analysis

Responses were exported from Google Forms into Microsoft Excel for cleaning and verification. Statistical analyses were performed using SPSS software (Version 25.0).

• Descriptive statistics (frequencies, percentages) were used to summarize socio-demographic variables and question-wise response patterns.

• Chi-square (χ²) tests assessed associations between knowledge categories and socio-demographic factors.

• Multivariate logistic regression identified independent predictors of good knowledge (score ≥12), adjusting for potential confounders.

• A p-value of <0.05 was considered statistically significant.

This methodological approach ensured systematic data collection, minimized recall and interviewer bias, and facilitated robust analysis of TB awareness patterns and misconceptions across urban and rural settings of Shimla district.

The socio-demographic profile of the 400 participants revealed a fairly balanced representation across age groups, with the largest proportion (32.5%) aged ≥50 years, followed by 30–39 years (24.0%), 40–49 years (23.0%), and 18–29 years (20.5%). Males constituted a slight majority (52.5%) compared to females (47.5%). Most respondents were married (77.0%), while 18.0% were single and 5.0% widowed or divorced. In terms of education, 36.0% had completed secondary school, 30.5% were graduates or above, 21.5% had primary education, and 12.0% reported no formal education. Occupationally, service or professional roles were most common (37.5%), followed by skilled workers (25.5%), unskilled laborers (23.0%), and unemployed individuals (14.0%). The monthly household income distribution indicated that 34.5% earned INR 10,000–20,000, 26.5% earned less than INR 10,000, 22.5% earned INR 20,001–30,000, and 16.5% earned above INR 30,000. The sample was evenly split between rural and urban residents (50% each), ensuring comparable representation from both settings.

Assessment of awareness and misconceptions on TB transmission revealed substantial knowledge in several domains but also persistent gaps. While 71.5% correctly identified Mycobacterium tuberculosis as the causative organism, 78.0% knew the primary route of transmission was via airborne droplets from coughing or sneezing, and 74.5% recognized the lungs as the most commonly affected organ. Misconceptions persisted, as only 67.5% correctly stated that TB does not spread through handshakes, and 65.5% knew it is not transmitted by sharing food or utensils. Encouragingly, 85.5% acknowledged TB is curable with proper treatment, 81.0% were aware that treatment requires at least six months, and 87.0% knew patients should complete the full treatment course. Preventive and control measures such as covering the mouth when coughing (77.0%), early detection and treatment (83.0%), and seeking medical care upon symptom onset (85.0%) were well recognized. However, some domains, such as understanding the possibility of recurrence (64.5%) and rare sexual transmission (47.5%), indicated areas needing targeted health education.

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

Table 2: Awareness and Misconception Questions on Tuberculosis Transmission Among Participants (n = 400)

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

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

Table 5: Multivariate Logistic Regression Analysis of Factors Associated with Good Knowledge of Tuberculosis Transmission (n = 400) (Good knowledge = score ≥12; Reference group = Poor/Fair knowledge <12)

When classified according to overall knowledge scores, 29.5% of participants demonstrated a very good level of knowledge (scores 16–20), 40.5% had good knowledge (scores 12–15), 21.0% had fair knowledge (scores 8–11), and 9.0% fell into the poor knowledge category (scores 0–7). This distribution shows that while over two-thirds of the population achieved good or very good knowledge levels, nearly one-third still had fair or poor knowledge, highlighting a need for intensified educational interventions to bridge these knowledge gaps.

Bivariate analysis between knowledge level and socio-demographic variables revealed significant associations for educational level (p<0.001) and monthly household income (p<0.001), but not for age, gender, marital status, occupation, or residence type. Participants with higher education, especially graduates and above, were more likely to have very good knowledge compared to those with no formal education. Similarly, individuals from higher income brackets demonstrated markedly better knowledge compared to those earning below INR 10,000. Although not statistically significant, there was a trend towards better knowledge among urban residents and service/professional workers.

Multivariate logistic regression identified educational level and monthly household income as independent predictors of good knowledge (score ≥12). Graduates and above had over four times the odds of having good knowledge (AOR=4.62, 95% CI: 2.31–9.23, p<0.001), and those with secondary education had more than double the odds compared to those with no formal education (AOR=2.45, 95% CI: 1.29–4.66, p=0.006). Higher income levels were also strong predictors; earning above INR 30,000 was associated with nearly four times higher odds of good knowledge (AOR=3.92, 95% CI: 1.87–8.21, p<0.001), while earning INR 20,001–30,000 doubled the odds (AOR=2.11, p=0.033). Occupation in the service/professional category was another significant factor (AOR=2.38, p=0.012). Age, gender, marital status, and residence type did not show independent associations in the adjusted model.

This study offers a nuanced understanding of community-level knowledge and misconceptions regarding tuberculosis (TB) transmission in both urban and rural settings of Shimla district, Himachal Pradesh. The findings indicate that while the majority of participants demonstrated a commendable grasp of the causative agent, principal mode of transmission, hallmark symptoms, curability, and preventive measures, significant misconceptions persist that could undermine the effectiveness of TB control efforts. Notably, beliefs that TB can spread via sharing food or utensils, casual physical contact such as handshakes, or environmental factors such as cold weather, continue to exist alongside accurate knowledge of airborne droplet transmission. Such co-existence of correct and incorrect beliefs has been documented in multiple settings and reflects the complexity of translating biomedical knowledge into culturally embedded understanding.

The overall distribution of knowledge levels—where nearly 70% of respondents achieved good or very good scores—suggests that TB-related health promotion activities in Himachal Pradesh have achieved a relatively broad reach. However, the presence of nearly one-third of participants in the fair or poor knowledge categories underscores the need for targeted, equity-focused interventions. This pattern mirrors findings from states, where structural determinants such as education and socio-economic status shape TB literacy [4,6,7]. In the present study, educational attainment emerged as the strongest independent predictor of knowledge, with graduates being over four times more likely to have good knowledge than those without formal education. This reinforces global evidence, including WHO’s own analyses, that education enhances the uptake of disease-related information, improves recall, and strengthens the capacity to challenge misinformation [6,9,12]

Household income was another powerful determinant, with higher-income participants significantly more likely to possess accurate knowledge. This is consistent with socio-behavioural models that link income to better access to healthcare services, broader information sources (including digital media), and greater interaction with formal health systems. The significant association between service/professional occupations and higher knowledge scores may reflect workplace exposure to health information, mandatory health screenings, or peer networks that promote correct health-seeking behaviour [10,12].

Interestingly, after adjusting for confounders, age, gender, marital status, and place of residence did not significantly predict knowledge levels. This contrasts with  previous, where rural residence and female gender have sometimes been associated with lower TB knowledge.^9,11,13 One plausible explanation is Himachal Pradesh’s relatively high literacy rate (above 82% according to the 2011 Census) and the operational reach of the National TB Elimination Programme (NTEP), which employs Accredited Social Health Activists (ASHAs) and multi-channel health education campaigns to penetrate both urban and rural populations. This parity between rural and urban knowledge levels suggests that geographic isolation alone is no longer a major barrier to TB information dissemination in the district.

Nevertheless, certain knowledge gaps revealed in this study are of public health concern. Less than half the participants were aware that TB can, in rare cases, be sexually transmitted in the context of genital TB, and over one-third did not recognise the potential for recurrence after treatment completion. Such gaps could lead to complacency, inadequate follow-up, and delayed care-seeking in cases of relapse. Furthermore, the persistence of food- and utensil-based misconceptions, while lower than in older Indian studies, still poses a risk of perpetuating stigma and social exclusion of TB patients—factors known to delay diagnosis and reduce treatment adherence [12,14].

From a policy and programmatic standpoint, the findings highlight the need for IEC (Information, Education, and Communication) materials to evolve from broad awareness messaging toward precision health communication that actively dispels prevalent myths. In the context of Shimla’s mixed socio-economic profile, interventions could include community-based myth-busting workshops, school curriculum integration of TB education, and workplace health sessions for service and professional sectors. Importantly, messaging should not only convey correct information but also address stigma and promote empathy toward TB patients, as psychosocial barriers remain a critical challenge to the NTEP’s 2025 elimination goal.

Overall, this study adds to the growing body of Indian evidence demonstrating that while basic awareness of TB transmission is improving, the persistence of specific misconceptions—especially among lower education and income groups—remains a significant barrier. By identifying socio-demographic determinants of knowledge, the study provides a robust evidence base for designing more targeted, culturally sensitive, and socially inclusive TB education strategies in the Himalayan context. These tailored interventions, if implemented alongside existing biomedical and programmatic efforts, could meaningfully accelerate progress toward interrupting TB transmission and achieving national elimination targets.

This study reveals that while a substantial proportion of adults in Shimla district possess good to very good knowledge of tuberculosis transmission, important misconceptions—particularly regarding non-airborne routes such as sharing food or utensils and physical contact—persist across both urban and rural communities. Education level and household income emerged as strong, independent predictors of accurate knowledge, underscoring the role of socio-economic determinants in shaping public health literacy. The findings highlight the need for precision-focused health communication under the National TB Elimination Programme, shifting from general awareness to targeted myth-busting strategies that address entrenched cultural beliefs and stigma. Leveraging Shimla’s high literacy rates, community networks, and digital access, future interventions should prioritize low-education and low-income groups through school-based education, workplace sensitization, and culturally tailored IEC campaigns. Strengthening such efforts, alongside robust case detection and treatment adherence support, is essential to bridging knowledge gaps, reducing stigma, and accelerating progress toward India’s 2025 TB elimination goal in this Himalayan context.

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