Eye trauma, encompassing injuries from domestic accidents, occupational hazards, and recreational activities, is a significant cause of preventable vision impairment and blindness worldwide, posing a notable public health concern in India due to its high incidence in both urban and rural settings. In Himachal Pradesh, a predominantly rural state in northern India, the risk of eye injuries is heightened by environmental and occupational factors, such as rugged terrain, agricultural work, and construction activities, coupled with limited access to specialized eye care and low awareness of first aid measures. Shimla District, which includes the urban hub of Shimla city and surrounding rural areas, faces unique challenges due to its mountainous landscape, which complicates timely access to medical facilities, and a diverse population with varying levels of health literacy. Prompt and appropriate first aid responses are critical to minimizing complications from eye injuries, yet public knowledge of these measures and recognition of injury signs remain underexplored, potentially exacerbating visual morbidity in the region [1-4].

The socio-cultural and occupational context of Shimla District shapes attitudes and behaviors toward eye trauma prevention and response. Rural residents, who form a substantial portion of the district’s population, often engage in farming, woodworking, or stone-cutting, activities prone to eye injuries from foreign bodies, chemicals, or blunt trauma, yet many lack awareness of basic first aid techniques like rinsing the eye or avoiding rubbing it. Domestic injuries, such as those from cooking mishaps or household tools, are common across both          urban and rural households, but misconceptions—such  as   using  unsterile  cloths  or  delaying medical care can worsen outcomes. Urban residents, despite better access to healthcare, may underestimate the severity of minor injuries or lack knowledge of immediate actions, increasing the risk of complications. National studies highlight that low awareness of eye trauma signs and appropriate first aid measures is a major barrier to effective emergency responses, with rural populations particularly vulnerable due to limited health education and distant medical facilities [5-8].

Efforts to address eye trauma in India, including public health campaigns and workplace safety programs, have achieved varying success, but their impact in Shimla District’s unique urban-rural interface and high-altitude environment remains poorly understood. The district’s diverse demographic, bridging rural laborers and urban professionals, provides an opportunity to examine variations in awareness of common eye injuries and first aid measures. Understanding these dynamics is essential for designing targeted interventions to enhance emergency preparedness and reduce vision loss. This study aims to evaluate public awareness of eye trauma and first aid measures among residents of Shimla District, with a focus on addressing knowledge gaps and overcoming barriers to effective emergency responses in this hilly region.

Study Design

A descriptive, cross-sectional online survey was conducted to assess public awareness of eye trauma, including common domestic and occupational eye injuries, first aid measures, emergency responses, and perceived barriers among adults in Shimla District, Himachal Pradesh.

Study Area and Population

The study targeted adults aged 18–60 years residing in Shimla District, encompassing both urban (Shimla city) and rural areas. Eligible participants were proficient in Hindi or English, had access to internet-enabled devices (smartphones, tablets, or computers), and provided voluntary informed consent.

Study Duration

Data collection was conducted over three months, from   January to March 2025.

Sample Size and Sampling Technique

Assuming a 50% awareness level of eye trauma and first aid measures (due to limited prior data), with a 95% confidence interval and a 5% margin of error, the minimum required sample size was calculated as 384. To account for potential incomplete responses, a target of 440 completed responses was set. Convenience sampling was utilized, with the survey link distributed via social media platforms (WhatsApp, Facebook, Instagram) and community networks, including local health clinics, occupational safety groups, and Gram Panchayats.

Inclusion and Exclusion Criteria

• Inclusion Criteria: Adults aged 18–60 years, residing in Shimla District, proficient in Hindi or English, with internet access, and willing to provide electronic consent.

• Exclusion Criteria: Individuals with a history of severe eye trauma under active treatment, those employed in eye care or public health agencies, those unable to complete the questionnaire, or unwilling to participate.

Data Collection Instrument

A structured, pre-validated bilingual (Hindi and English) questionnaire was developed and hosted on Google Forms. The questionnaire comprised four sections:

• Socio-Demographic Information: Age, gender, education, occupation, marital status, and access to healthcare services.

• Knowledge of Eye Trauma: Awareness of common domestic and occupational eye injuries, their causes, and potential complications.

• Awareness and Practice of First Aid Measures: Understanding of appropriate first aid responses (e.g., rinsing, avoiding rubbing) and emergency care-seeking behaviors.

• Barriers to Emergency Responses: Logistical, cultural, psychological, and informational obstacles.

The questionnaire was pilot-tested among 30 adults (excluded from final analysis) to ensure clarity, cultural appropriateness, and technical functionality. Adjustments were made based on feedback to enhance comprehension and relevance.

Data Collection Procedure

Participants accessed an information sheet outlining study objectives, confidentiality, and voluntary participation. Informed electronic consent was mandatory before accessing the questionnaire. Google Forms settings prevented duplicate submissions, and no personally identifiable data were collected to ensure anonymity.

Scoring and Categorization

Knowledge-based questions were scored with one point per correct answer. Knowledge levels were categorized as:

•      Very Good Awareness: ≥80% correct answers

•      Good Awareness: 60–79% correct answers

•      Fair Awareness: 40–59% correct answers

•      Poor Awareness: <40% correct answers

Attitudes and barriers were analyzed separately to identify prevailing perceptions and obstacles.

Data Analysis

Data were exported from Google Forms to Microsoft Excel and analyzed using IBM SPSS Statistics version 27.0. Descriptive statistics (frequencies, percentages, means, standard deviations) summarized participant characteristics, knowledge levels, attitudes, and barriers.

Ethical Considerations

        The study adhered to ethical guidelines, ensuring participant autonomy, confidentiality, and voluntary participation per the Declaration of Helsinki. Ethical approval was obtained from an institutional review board in Shimla, Himachal Pradesh.

The results provide a comprehensive overview of the socio-demographic profile, knowledge, attitudes, and barriers related  to  eye  trauma  and  first  aid measures among  440 residents of

Shimla District. The data reveal a moderate level of awareness, with significant gaps that underscore the urgent need for targeted educational and emergency response interventions to mitigate the impact of eye injuries in this hilly region.

This table delineates the socio-demographic profile of the 440 participants, showcasing a diverse representation of age, gender, education, occupation, marital status, and access to healthcare services. The predominance of young to middle-aged adults and a notable rural segment, with 34.8% reporting limited access to healthcare services, highlights the study’s focus on addressing eye trauma awareness challenges across Shimla District’s urban-rural landscape, where occupational and domestic injuries are prevalent (Table 1)

Table 1: socio-demographic characteristics of participants

This table presents responses to 20 comprehensive, newly designed questions assessing knowledge of common domestic and occupational eye injuries, first aid measures, emergency responses, and barriers, crafted in a distinct pattern emphasizing specific injury scenarios, immediate actions, and diverse barriers (e.g., cultural beliefs, fear of treatment). The questions include correct answers in bold, revealing moderate awareness but critical gaps in recognizing injury severity and appropriate first aid techniques, essential for effective emergency responses in Shimla District (Table 2).

Table 2: awareness and attitudes toward eye trauma and first aid measures

This table categorizes participants’ knowledge levels based on their performance on the 20 knowledge-based questions, illustrating a spectrum of awareness. While the majority demonstrated Good awareness, the significant proportion with Fair or Poor awareness signals an urgent need for enhanced education on eye trauma and first aid measures to promote effective emergency responses in Shimla District (Table 3).

Table 3: knowledge score classification

This study provides a critical examination of public awareness of eye trauma and first aid measures among residents of Shimla District, offering valuable insights into the knowledge, attitudes, and barriers that shape emergency responses to common domestic and occupational eye injuries in a region marked by its urban-rural interface and high-altitude environment. The findings reveal a moderate level of awareness, with 80.9% of participants correctly recognizing the need to rinse the eye immediately after a chemical splash and 82.5% understanding that pain is not always present in serious eye injuries. High awareness of covering the eye to prevent further damage (83.2%) and fear of medical costs as a barrier to care (85.9%) suggests that public health messaging and community outreach have made inroads into Shimla’s diverse population. The strong recognition of flying debris as a common cause of occupational injuries (75.9%) and the importance of protective eyewear (74.1%) further indicates a baseline understanding of injury prevention, reflecting the gradual impact of occupational safety efforts in Himachal Pradesh.

Despite these encouraging trends, significant knowledge gaps and attitudinal barriers highlight the challenges of ensuring effective emergency responses in Shimla’s hilly terrain. Only 59.1% of participants correctly identified the need to seek immediate medical help for a penetrating eye injury, and awareness of a cooking utensil scratch not being a minor injury (61.1%) and bleeding in the eye as a serious sign (62.7%) was suboptimal. These gaps are particularly concerning, as they may lead to delayed or inappropriate responses, increasing the risk of complications like infection (79.3% awareness) or permanent vision loss from untreated foreign bodies (66.8%). The moderate awareness of first aid training improving outcomes (73.0%) aligns with findings from national studies, which underscore low eye trauma literacy as a barrier to effective emergency care, especially in rural areas with limited access to healthcare education. This suggests a broader regional challenge in equipping communities with practical, actionable first aid skills.

The socio-demographic profile, with 72.8% of participants aged 18–35 and 34.8% reporting limited access to healthcare services, underscores both opportunities and systemic constraints. The younger cohort, likely more engaged with digital platforms, represents an ideal target for awareness campaigns, as evidenced by the study’s effective use of social media for recruitment. However, the significant proportion with limited healthcare access reflects logistical barriers, such as geographic isolation in Shimla’s mountainous terrain and the scarcity of medical facilities, which align with similar access challenges noted in the glaucoma (32.6%) and diabetic eye disease (32.4%) studies. These findings suggest a shared regional issue of reaching underserved rural populations. The high recognition of lack of knowledge (84.5%) and the use of inappropriate remedies like herbal treatments (71.1% correctly identified as not recommended) indicate a mix of awareness and persistent cultural misconceptions that need targeted education.

The knowledge score classification reveals a notable divide in eye trauma literacy: while 47.0% demonstrated "Good" awareness and 26.6% achieved "Very Good" awareness, a concerning 26.4% fell into the "Fair" or "Poor" categories. This subgroup is at heightened risk of mismanaging eye injuries, perpetuating the burden of preventable vision impairment in Shimla District, particularly in rural areas prone to occupational hazards. The online survey methodology, while effective in reaching a diverse sample, may have favored more educated and digitally connected individuals, potentially underrepresenting rural populations with lower literacy or no internet access, a limitation consistent across the previous studies. Social desirability bias may have influenced responses, particularly on questions about first aid practices or care-seeking intentions, leading to an overestimation of awareness. These limitations suggest caution in generalizing the findings to the entire population of Shimla District.

The implications of these findings are profound for eye trauma policy and practice in Shimla District. The moderate awareness levels indicate that existing campaigns have established a foundation, but they must be intensified and tailored to address specific gaps, such as the urgency of seeking care for penetrating injuries and recognizing serious signs like eye bleeding. Community-based interventions, leveraging local health clinics and Gram Panchayats, could enhance outreach in rural areas, while workplace safety programs could target occupational groups like farmers and construction workers. Integrating first aid training into community health initiatives and subsidizing emergency care costs are critical to addressing the 34.8% with limited healthcare access. Digital platforms offer a promising avenue for education, though efforts must ensure inclusivity for those without internet access. Future research should explore longitudinal trends in eye trauma awareness and evaluate the impact of targeted interventions in reducing vision loss in Shimla District’s urban-rural interface, ensuring residents no longer "ignore the signs" of eye injuries.

This study illuminates the complex landscape of eye trauma awareness in Shimla District, revealing moderate knowledge of common domestic and occupational eye injuries and first aid measures, alongside critical gaps and barriers that hinder effective emergency responses, particularly in rural communities. While encouraging recognition of chemical splash protocols, protective eyewear benefits, and barriers like medical costs exists, deficiencies in understanding the urgency of penetrating injuries, the severity of scratches, and serious signs like eye bleeding, coupled with limited healthcare access for 34.8% of participants, underscore the urgent need for comprehensive interventions. To mitigate preventable vision loss, multi-faceted strategies are essential, including targeted educational campaigns, community-based first aid training, workplace safety initiatives, and inclusive  digital  outreach,  ensuring that Shimla District’s residents are equipped to respond swiftly and appropriately to eye injuries, heeding the call to "not ignore the signs."

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