Non-communicable diseases (NCDs), such as hypertension, diabetes and obesity, represent a growing public health crisis globally, accounting for a significant proportion of morbidity and mortality in India. In Himachal Pradesh, a predominantly rural state in northern India, the rising prevalence of NCDs is particularly concerning due to its unique high-altitude environment, which may exacerbate cardiovascular and metabolic risks. Lifestyle factors, including poor diet, physical inactivity and tobacco use, coupled with low awareness and limited screening, drive the NCD burden, especially in rural areas where healthcare access is constrained. Despite national efforts like the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), public perception and understanding of NCD risks and preventive behaviors in Himachal Pradesh remain underexplored, hindering effective intervention strategies [1-4].

The socio-cultural and environmental context of Himachal Pradesh shapes attitudes toward NCD prevention and management. Rural communities, forming a substantial portion of the state’s population, often face challenges such as reliance on high-calorie diets suited to cold climates, limited opportunities for physical activity due to terrain and cultural acceptance of habits like tobacco chewing. High-altitude living, with its associated physiological stresses like lower oxygen levels, may amplify risks for hypertension and other cardiovascular conditions, yet awareness of these environmental influences is often low. Misconceptions, such as equating obesity with health or underestimating the need for regular screening, further exacerbate vulnerabilities. National studies highlight that low awareness of NCD risk factors and screening practices is a major barrier to prevention, with rural populations particularly affected due to limited access to healthcare facilities and health education [5-8].

Efforts to address NCDs in India, including community-based screening programs and awareness campaigns, have achieved varying success, but their impact in Himachal Pradesh’s unique high-altitude and rural context remains poorly understood. The state’s diverse demographic, spanning rural and semi-urban populations, offers an opportunity to examine variations in awareness of hypertension, diabetes and obesity risks, as well as behaviors and screening practices. Understanding these dynamics is crucial for designing targeted interventions that promote healthier lifestyles and reduce NCD burden. This study aims to evaluate public perception and awareness of NCD risks in Himachal Pradesh, with a focus on rural communities, to identify knowledge gaps and barriers and inform strategies for enhancing preventive behaviors and screening uptake in the region’s hilly terrain.

Study Design 

A descriptive, cross-sectional online survey was conducted to assess public perception and awareness of non-communicable disease risks (hypertension, diabetes, obesity), associated behaviors, screening practices and perceived barriers among adults in Himachal Pradesh.

Study Area and Population

The study targeted adults aged 18–60 years residing in rural and semi-urban areas of Himachal Pradesh. 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 NCD risks (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 and ensure flexibility in frequency distribution, a target of 540 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 workers, self-help groups and Gram Panchayats.

Inclusion and Exclusion Criteria

Inclusion Criteria

Adults aged 18–60 years, residents of Himachal Pradesh, proficient in Hindi or English, with internet access and willing to provide electronic consent.

Exclusion Criteria

Individuals diagnosed with NCDs under active treatment, 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.

• Knowledge of NCD Risks: Awareness of hypertension, diabetes and obesity risk factors, symptoms and prevention methods.

• Awareness and Practice of Behaviors and Screening: Understanding of lifestyle modifications and screening frequency for NCDs.

• Barriers to NCD Prevention: Logistical, cultural, psychological and informational obstacles.

The questionnaire was pilot-tested among 35 adults (excluded from final analysis) to ensure clarity, cultural appropriateness and technical functionality. Adjustments were made based on feedback.

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. 

The results provide a comprehensive overview of the socio-demographic profile, knowledge, attitudes and barriers related to non-communicable disease risks, behaviors, and screening practices among 540 participants in Himachal Pradesh. The data highlight moderate awareness levels but reveal significant gaps, underscoring the need for targeted educational and screening interventions to mitigate NCD risks in the region’s hilly terrain.

Table 1 summarizes the socio-demographic profile of the 540 participants, reflecting a diverse representation of age, gender, education, occupation, marital status and access to healthcare. The majority were young to middle-aged adults, with a significant rural segment, as 31.9% reported limited access to healthcare, emphasizing the study’s focus on addressing NCD challenges in rural Himachal Pradesh.

Table 1: Socio-Demographic Characteristics of Participants

Table 2 presents responses to 20 comprehensive questions assessing knowledge of hypertension, diabetes and obesity risks, associated behaviors, screening practices and perceived barriers. Designed to capture a broad spectrum of NCD literacy, the questions include correct answers in bold, revealing moderate awareness but critical gaps in understanding screening frequency and lifestyle risk factors, essential for effective prevention.

Table 2: Awareness and Attitudes Toward Non-Communicable Disease Risks, Behaviors and Screening

Table 2 categorizes participants’ knowledge levels based on their performance on the 20 knowledge-based questions, illustrating a spectrum of awareness. While the majority exhibited good awareness, the notable proportion with Fair or Poor awareness signals a pressing need for enhanced NCD education to empower communities in Himachal Pradesh.

Table 3: Knowledge Score Classification

This study provides a critical examination of public perception and awareness of non-communicable disease (NCD) risks in Himachal Pradesh, offering valuable insights into the interplay of knowledge, behavior and barriers in a high-altitude, predominantly rural region. The findings reveal a moderate level of NCD literacy, with 80.0% of participants correctly recognizing that regular screening detects diabetes early and 81.9% understanding that NCDs are not always fatal. High awareness of lifestyle changes reducing hypertension risk (83.5%) and lack of awareness as a barrier to screening (85.0%) suggests that national initiatives, such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), have made inroads into rural and semi-urban communities. The strong recognition of tobacco use (74.4%) and high blood pressure (76.3%) as NCD risk factors further indicates a baseline understanding of preventable risk factors, reflecting the gradual impact of health education efforts in Himachal Pradesh.

Despite these encouraging trends, significant knowledge gaps and attitudinal barriers underscore the challenges of addressing NCDs in a region with unique environmental and socio-cultural dynamics. Only 60.0% of participants correctly identified the recommended diabetes screening frequency (every 1–2 years) and awareness of the asymptomatic nature of obesity (63.7%) and the non-visible aspects of obesity (61.9%) was suboptimal. These gaps are particularly concerning, as they may delay early detection and intervention, increasing the risk of complications from hypertension, diabetes and obesity, which are exacerbated by high-altitude physiological stresses like lower oxygen levels. The moderate awareness of family history as an NCD risk factor (65.9%) and high sugar intake increasing diabetes risk (67.8%) aligns with findings from national studies, which highlight low NCD literacy as a barrier to prevention, particularly in rural areas with limited access to healthcare education. This suggests a broader regional challenge in translating general awareness into specific, actionable knowledge.

The socio-demographic profile, with 73.2% of participants aged 18–35 and 31.9% reporting limited healthcare access, highlights 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 Himachal Pradesh’s hilly terrain and scarcity of screening facilities, which align with similar access challenges noted in the food safety (31.8%) and water safety (32.6%) studies. These findings suggest a shared regional issue of reaching underserved rural populations. The high awareness of diet control (73.7%) and weight loss (73.7%) as preventive measures indicates some understanding of lifestyle modifications, but their adoption may be hindered by cultural factors, such as reliance on high-calorie diets suited to cold climates and environmental constraints, like limited spaces for physical activity.

The knowledge score classification reveals a notable divide in NCD literacy: while 45.7% demonstrated "Good" awareness and 28.0% achieved "Very Good" awareness, a concerning 26.3% fell into the "Fair" or "Poor" categories. This subgroup is at heightened risk of undiagnosed or unmanaged NCDs, perpetuating the disease burden in Himachal Pradesh, particularly in high-altitude areas where cardiovascular risks are amplified. 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 screening practices or lifestyle behaviors, leading to an overestimation of awareness. These limitations suggest caution in generalizing the findings to the entire population of Himachal Pradesh.

The implications of these findings are profound for NCD policy and practice in Himachal Pradesh. The moderate awareness levels indicate that existing campaigns, such as those under NPCDCS, have established a foundation, but they must be intensified and tailored to address specific gaps, such as screening frequency and asymptomatic NCD risks. Community-based interventions, leveraging local health workers and Gram Panchayats, could enhance outreach in rural areas, while school-based health programs could target younger populations. Expanding mobile screening units and integrating NCD services into primary healthcare are critical to addressing the 31.9% 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 NCD awareness and evaluate the impact of targeted interventions in reducing disease incidence in Himachal Pradesh’s high-altitude communities [8-10].

This study illuminates the complex landscape of NCD awareness in Himachal Pradesh, revealing moderate knowledge of hypertension, diabetes and obesity risks, alongside significant gaps and barriers that hinder preventive behaviors and screening uptake, particularly in rural, high-altitude communities. While encouraging recognition of screening benefits, lifestyle modifications and awareness barriers exists, deficiencies in understanding screening frequency, asymptomatic conditions and specific risk factors, coupled with limited healthcare access for 31.9% of participants, underscore the urgent need for comprehensive interventions. To mitigate the NCD burden, multi-faceted strategies are essential, including targeted educational campaigns, expanded screening infrastructure, community-based outreach and inclusive digital initiatives, ensuring that healthier lifestyles become attainable for all in Himachal Pradesh’s hilly regions, truly transforming “lifestyle at altitude.”

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