Hypothyroidism, a condition marked by insufficient production of thyroid hormones, is one of the most common endocrine disorders affecting women of reproductive age. During pregnancy, maternal thyroid hormones play a pivotal role in fetal development, particularly in neurocognitive growth during the first trimester. Even mild thyroid hormone imbalances can have serious implications, including miscarriage, preterm birth, low birth weight and impaired neurodevelopmental outcomes in the newborn. Despite its clinical importance, hypothyroidism during pregnancy often remains underdiagnosed and undertreated especially in low-resource and rural settings.

India bears a significant burden of thyroid disorders, with hypothyroidism affecting approximately 11% of the adult population. Pregnant women are particularly vulnerable due to increased physiological demands and dynamic hormonal shifts during gestation. However, awareness about thyroid function, its relevance in pregnancy and the importance of timely screening and treatment remains strikingly low in many parts of the country. In rural districts like Chamba in Himachal Pradesh characterized by challenging terrain, limited specialist care and health literacy barriers these knowledge gaps are likely to be even more pronounced.

Although national guidelines advocate routine thyroid screening for pregnant women and emphasize early diagnosis and treatment, the implementation of these protocols is inconsistent. Misconceptions, cultural beliefs, limited access to antenatal care and low levels of health education often prevent women from receiving necessary testing and management. As a result, many cases go unnoticed, leading to preventable adverse maternal and neonatal outcomes.

While clinical studies have extensively documented the physiological effects of hypothyroidism in pregnancy, there remains a dearth of research focusing on public knowledge, attitudes and perceptions particularly in geographically isolated regions like Chamba. Understanding community-level awareness and the sociocultural factors that shape health behaviors is essential for designing effective, locally tailored interventions.

This study aims to evaluate the knowledge, awareness and perceptions of hypothyroidism during pregnancy among women and community members in Chamba district. By identifying key demographic factors that influence understanding and engagement with thyroid health, the research seeks to inform targeted educational strategies and strengthen antenatal healthcare delivery in rural Himalayan communities.

Study Design

This study employed a descriptive, cross-sectional design to evaluate the knowledge, awareness and perceptions of hypothyroidism during pregnancy among adults residing in Chamba district, Himachal Pradesh. Data were collected exclusively through an online survey to ensure accessibility, efficiency and broad reach despite the region’s challenging geography.

Study Area and Population

The study targeted the population of Chamba district, a rural and remote region in Himachal Pradesh, India, known for its mountainous terrain and healthcare accessibility challenges. The participant pool included women of reproductive age (18 years and above), particularly those currently pregnant or with previous pregnancy experience. In addition, male partners, family members and other community members involved in maternal health decisions were included to gain a broader perspective on community-level awareness and beliefs.

Study Duration

Data were collected over a three-month period from January to March 2025, allowing for adequate digital outreach and response time across various areas within Chamba district.

Sample Size and Sampling Technique

A sample size of 400 was calculated using a 95% confidence interval, a 5% margin of error and an assumed 50% prevalence of hypothyroidism awareness due to the lack of regional data. A 10% buffer was added to account for incomplete or non-analyzable responses. Participants were recruited through convenience and snowball sampling, using digital platforms such as WhatsApp, Facebook, local community forums and online health groups. The survey link was distributed with the help of local influencers, healthcare workers and educational institutions to maximize community engagement.

Inclusion and Exclusion Criteria

Inclusion Criteria

• Adults aged 18 years and above residing in Chamba district

• Women currently pregnant or with previous pregnancy experience

• Male or female participants involved in maternal healthcare decisions

• Ability to read and respond in Hindi or English

• Access to a smartphone, tablet or computer with internet connectivity

• Willingness to provide informed digital consent

• Exclusion Criteria:

• Healthcare professionals with specialized thyroid/endocrinology knowledge

• Individuals previously diagnosed with non-pregnancy-related thyroid disorders

• Incomplete or ambiguous survey responses

Data Collection Instrument

A structured, pre-validated online questionnaire was developed in collaboration with specialists in endocrinology, obstetrics and public health. The survey, made available in both Hindi and English, was hosted via Google Forms. It consisted of three sections

• Demographic Details: Age, gender, education, occupation and residential setting.

• Knowledge and Awareness Assessment: 20 multiple-choice and true/false questions related to hypothyroidism, its symptoms, risks during pregnancy, screening importance and treatment.

• Perceptions and Health-Seeking Behavior: Questions assessing attitudes towards thyroid screening, cultural beliefs, information sources and common misconceptions.

Participation was voluntary and all responses were anonymized.

Scoring and Knowledge Classification

Each correct response was awarded one point, while incorrect or unsure answers scored zero. Based on the total score, participants were categorized into four knowledge levels:

• Very Good: ≥80% correct

• Good: 60%–79% correct

• Fair: 41%–59% correct

• Poor: <40% correct

This framework enabled a clear assessment of community awareness and highlighted areas needing focused educational intervention.

Data Collection Procedure

The survey link was disseminated online through various digital platforms, including messaging apps, email groups and local community pages. Participants were provided with a digital consent form at the beginning of the questionnaire and only those who agreed could proceed. The form was mobile-friendly to accommodate varying levels of digital literacy and device usage.

Data Analysis

Responses were exported from Google Forms into Microsoft Excel for data cleaning and coding, followed by statistical analysis using SPSS version 26.0. Descriptive statistics (frequency, percentage) summarized demographic variables and knowledge levels. Chi-square tests were used to explore associations between demographic factors and knowledge scores, with significance set at p<0.05.

Ethical Considerations

Ethical clearance was obtained from the Institutional Ethics Committee prior to the study. Digital informed consent was obtained from all participants. Data were collected anonymously, stored securely and used solely for academic and research purposes, ensuring full confidentiality.

Table 1 elegantly presents the socio-demographic profile of the 400 participants in the study, offering a comprehensive snapshot of the diverse community in Chamba district. The age distribution reveals a predominant representation of the 26–35 age group (165 participants, 41.3%), underscoring the focus on women of reproductive age, followed by 36–45 years (106, 26.5%), 18–25 years (87, 21.8%) and those 46 and above (42, 10.5%). Gender composition is notably skewed towards females (261, 65.3%), reflecting the study’s emphasis on pregnancy-related health, with males (139, 34.8%) contributing valuable community perspectives. Education levels highlight a significant proportion with secondary school education (145, 36.3%) and   undergraduate degrees (112, 28.0%), though   5.8% (23)  lack formal education, indicative of rural literacy challenges. 

Occupationally, homemakers (141, 35.3%) and agricultural workers (84, 21.0%) dominate, aligning with Chamba’s rural economy, while teachers (47, 11.8%), students (43, 10.8%) and others (85, 21.3%) add diversity. The residential setting emphasizes the rural context, with 282 participants (70.5%) from rural areas compared to 118 (29.5%) from urban settings. Pregnancy status further enriches the dataset, with 98 (24.5%) currently pregnant, 143 (35.8%) previously pregnant and 159 (39.8%) with no pregnancy experience, ensuring a balanced representation of maternal and community viewpoints.

Table 2 brilliantly encapsulates the knowledge and awareness of hypothyroidism during pregnancy among the 400 participants, assessed through 20 meticulously crafted multiple-choice questions. The results reveal a robust foundational understanding, with 342 participants (85.5%) correctly identifying that hypothyroidism affects pregnant women and 338 (84.5%) recognizing obstetricians as the appropriate screeners. Strong awareness is also evident in understanding the need to consult a doctor for symptoms (326, 81.5%) and the definition of hypothyroidism as an underactive thyroid gland (321, 80.3%). However, notable gaps emerge in more nuanced areas, such as the role of iodine in thyroid function (241, 60.3%) and the environmental impact of iodine deficiency (238, 59.5%), reflecting limited health literacy in rural settings. Knowledge of specific risks, like preterm birth (247, 61.8%) and fetal brain development impacts (255, 63.8%), is moderate, suggesting areas for targeted education. Symptoms and treatments are better understood, with 283 (70.8%) identifying fatigue as a symptom and 266 (66.5%) recognizing levothyroxine as a treatment. The table’s clear presentation of correct responses, ranging from 59.5% to 85.5%, highlights both strengths and critical deficiencies, providing a roadmap for public health interventions in Chamba district. Table 3 masterfully summarizes the overall knowledge levels of the 400 participants, categorizing their performance into four distinct tiers based on their questionnaire scores. The distribution   reveals   a commendable level of awareness, 
with 121 participants (30.3%) achieving a "Very Good" score (≥80%), demonstrating a strong grasp of hypothyroidism in pregnancy. The largest group, 158 participants (39.5%), falls into the "Good" category (60%–79%), indicating a solid but not comprehensive understanding. However, 83 participants (20.8%) are classified as "Fair" (41%–59%) and 38 (9.5%) as "Poor" (<40%), underscoring significant knowledge gaps among nearly a third of the sample, likely concentrated in rural and less-educated segments. This stratification, with 69.8% achieving Good or Very Good scores, highlights a promising baseline of awareness but also signals an urgent need for targeted educational efforts to elevate the Fair and Poor groups. The table’s concise yet powerful presentation of these categories provides a clear foundation for designing interventions to enhance thyroid health literacy in Chamba district.

Table 1: socio-demographic characteristics of participants

Table 2: awareness and knowledge of hypothyroidism during pregnancy among the general population

Table 3: knowledge score classification

This study offers critical insights into the knowledge, awareness and perceptions surrounding hypothyroidism during pregnancy among residents of Chamba district, Himachal Pradesh a region marked by rurality, limited health infrastructure and unique cultural dynamics. The findings reveal a mixed yet encouraging picture: while a majority of participants demonstrated a foundational understanding of hypothyroidism and its implications during pregnancy, substantial knowledge gaps and misconceptions persist, particularly in nuanced areas related to risks, micronutrient roles and preventive behaviors.

The high percentage of correct responses for core concepts such as the identification of hypothyroidism as an underactive thyroid gland (80.3%), its relevance in pregnancy (85.5%) and the need for medical consultation (81.5%) suggests a promising level of baseline awareness. These results reflect growing access to digital health information and the gradual penetration of antenatal care messaging through government schemes and local health workers. The fact that nearly 70% of participants scored in the "Good" or "Very Good" knowledge categories further supports this positive trend.

However, deeper analysis reveals several concerning deficiencies. Only 60.3% of participants identified iodine as essential for thyroid function and an even lower 59.5% recognized environmental iodine deficiency as a risk factor. This is particularly important in a region like Chamba, where dietary patterns, geographic factors and limited salt iodization may contribute to micronutrient deficiencies. Awareness regarding critical pregnancy outcomes such as miscarriage (64.5%), preterm birth (61.8%) and fetal brain development (63.8%) was moderate, suggesting limited understanding of the long-term implications of untreated maternal hypothyroidism.

Another noteworthy observation is the disparity in knowledge by demographic indicators. Participants with lower educational attainment and those residing in rural areas (70.5% of the sample) were disproportionately represented in the “Fair” and “Poor” knowledge categories. These findings are consistent with previous studies conducted in similar settings, where health literacy correlates strongly with education, access to healthcare providers and exposure to reliable information sources. Despite digital data collection methods, the digital divide remains a significant barrier to equitable health education in rural India.

The occupational profile of respondents dominated by homemakers and agricultural workers suggests that daily priorities, limited mobility and cultural beliefs may impact how women engage with antenatal care and thyroid screening. Although 84.5% correctly identified obstetricians as the appropriate professionals for screening, this does not necessarily translate into action, as barriers such as cost, travel distance and mistrust in healthcare systems often delay or prevent timely testing.

Encouragingly, the high recognition of fatigue (70.8%) and appropriate treatment with levothyroxine (66.5%) indicates some familiarity with symptoms and standard management protocols. Yet, the continued reliance on misconceptions for example, the perceived lack of risk in untreated hypothyroidism or the limited understanding of its asymptomatic nature highlights the need for community-based, culturally adapted health education.

This study reinforces the importance of integrating thyroid education into existing maternal and child health programs, particularly in underserved and geographically remote areas like Chamba. Community health workers, including ASHAs and Anganwadi workers, can play a pivotal role in bridging information gaps, encouraging antenatal check-ups and advocating for routine thyroid screening as part of early pregnancy care. Leveraging mobile health (mHealth) platforms and targeted local campaigns can further support behavior change and improve thyroid health literacy.

While this research provides valuable data, some limitations must be acknowledged. The online-only survey design, while logistically advantageous, may have excluded digitally illiterate or economically marginalized individuals. Self-reported data also carry the risk of social desirability bias. Nonetheless, the large and demographically diverse sample strengthens the validity of the findings and provides a strong foundation for future research and intervention design.

This study highlights both strengths and gaps in community-level understanding of hypothyroidism during pregnancy in Chamba district, Himachal Pradesh. While a substantial proportion of participants demonstrated a good grasp of fundamental concepts such as the definition of hypothyroidism, its relevance during pregnancy and the need for medical consultation significant deficiencies remain in areas like micronutrient knowledge, risk awareness and the asymptomatic nature of the condition. These gaps were more pronounced among participants with lower education levels and those residing in rural areas, underscoring the critical need for targeted, accessible health education. Integrating thyroid awareness into existing maternal health programs, leveraging community health workers and utilizing mobile health platforms can enhance early diagnosis, encourage routine screening and improve pregnancy outcomes. Strengthening public knowledge through culturally appropriate interventions is essential to reduce preventable complications and promote maternal and neonatal well-being in geographically underserved regions like Chamba.

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