Skin cancer, one of the most prevalent types of cancer worldwide, continues to be a growing public health concern, especially with the increasing intensity of ultraviolet (UV) radiation exposure due to climate change and ozone layer depletion. While awareness of more common internal cancers such as breast, lung, or prostate cancer has grown substantially over the years, skin cancer often remains underestimated-particularly in regions where fair skin tones are less common and public health messaging has not prioritized dermatological risks. Contrary to popular belief, individuals with darker skin are not immune to skin cancer; though the incidence may be lower, diagnosis is often delayed and prognosis worse due to a lack of awareness and late presentation [1-3].

In the Indian context, skin cancer is often overlooked in public discourse, largely perceived as a rarity or a cosmetic concern rather than a serious health issue. Misconceptions abound: many believe that skin cancer only   affects   Western   populations  or  those  with   light

Complexions, while others fail to recognize the importance of sun protection in everyday life. Common risk factors-including prolonged sun exposure, use of tanning products, genetic predisposition, and occupational hazards-are frequently ignored due to inadequate public health campaigns and cultural attitudes that downplay sun damage [4-6].

Shimla, the capital city of Himachal Pradesh, presents a unique geographical and climatic backdrop for examining public knowledge of skin cancer. As a high-altitude region, Shimla experiences significantly greater UV radiation exposure compared to lower-altitude locations, increasing residents’ vulnerability to skin damage and carcinogenesis [7,8].             

Moreover, the population’s engagement in outdoor occupations, tourism-driven lifestyles, and low use of sun-protective measures further heighten potential risk. However, awareness regarding skin cancer, its symptoms, and preventive strategies in such areas remains underexplored and poorly documented.

This study, therefore, seeks to assess the level of public awareness, knowledge, and perceptions related to skin cancer among the adult population of Shimla. By exploring how demographic factors such as age, education, occupation, and residential setting influence awareness, the research aims to identify critical knowledge gaps and misconceptions. The insights gained will support the development of culturally appropriate, evidence-based health education initiatives that encourage sun-safe behaviors and promote early detection-ultimately reducing the burden of skin cancer in high-risk, high-altitude regions like Shimla.

This study employed a descriptive, cross-sectional research design to evaluate the level of public awareness, understanding, and perceptions concerning skin cancer risks among residents of Shimla, Himachal Pradesh. The primary aim was to assess knowledge related to the causes, symptoms, risk factors, preventive strategies, and early detection of skin cancer, while also examining prevailing attitudes toward sun exposure and dermatological health.

Study Area and Population

The research was conducted in Shimla, a hill district in northern India, known for its high altitude, variable climate, and significant exposure to ultraviolet (UV) radiation. The district comprises both urban centers and rural settlements, providing a diverse demographic mix ideal for capturing a wide spectrum of public health awareness levels. The study population included adult residents aged 18 years and above, encompassing individuals from various educational, occupational, and socio-economic backgrounds to ensure representativeness.

Study Duration

Data collection was carried out over a period of three months, from January to March 2025. This timeframe allowed for the inclusion of participants during both peak tourist and non-tourist seasons, which may influence sun exposure behaviors and awareness levels.

Sample Size and Sampling Technique

A total of 400 participants were included in the study. The sample size was determined using standard statistical formulas with a 95% confidence level, 5% margin of error, and an assumed 50% prevalence of skin cancer awareness in the absence of prior regional data. Convenience sampling to recruit participants through community centers, public places, healthcare settings, and digital platforms.

Inclusion Criteria

• Adults aged 18 years and above

• Permanent residents of Shimla district

• Individuals who could comprehend and respond in Hindi or English

• Participants who voluntarily provided informed consent

Exclusion Criteria

• Individuals with a history of diagnosed skin cancer

• Incomplete or inconsistent responses in the survey

• Respondents who declined participation

Research Instrument

Data were collected using a structured, bilingual questionnaire developed in consultation with dermatologists, oncologists, and public health experts. The tool was pilot-tested for clarity and relevance and comprised three key sections:

• Socio-Demographic Profile – Age, gender, education level, occupation, and residential location

• Knowledge and Awareness Assessment – 20 multiple-choice questions measuring understanding of skin cancer risk factors (e.g., UV exposure, fair skin, family history), early symptoms (e.g., unusual moles, non-healing wounds), and preventive behaviors (e.g., use of sunscreen, protective clothing)

• Attitudes and Practices – Questions exploring personal beliefs about skin health, frequency of sun protection use, willingness to undergo skin checks, and perceived risk of developing skin cancer

Scoring and Classification

Each correct response in the knowledge section was awarded one point. Total scores were used to categorize participants into four levels of awareness:

• Very Good Knowledge (≥80%)

• Good Knowledge (60–79%)

• Fair Knowledge (41–59%)

• Poor Knowledge (<40%)

   This classification supported subgroup analysis based on demographic variables

Data Collection Procedure

The questionnaire was disseminated both online (via Google Forms, WhatsApp, and social media groups) and offline through printed forms distributed in community gatherings, outpatient clinics, and local market areas. An introduction to the study was provided at the beginning of the survey, and informed consent was obtained digitally or in written form before participation.

Data Analysis

Collected data were cleaned, coded, and analyzed using Microsoft Excel and SPSS software. Descriptive statistics such as frequency, percentages, and mean scores were used to summarize demographic characteristics and awareness levels

Ethical Considerations

The study adhered to ethical standards in human research. Participation was entirely voluntary, with informed consent obtained from each respondent. Anonymity and confidentiality were strictly maintained, and no personal identifiers were recorded.

The study engaged 400 participants from Shimla, offering a well-distributed representation across multiple  demographic  variables. The  age composition

showed that a significant majority (61%) were between 18 and 35 years, with 29.0% in the 18–25 group and 32.0% in the 26–35 range, followed by 25.0% aged 36–45, and only 14.0% aged 46 and above. Gender distribution was perfectly balanced, with 200 male and 200 female participants (50% each), enhancing the inclusiveness of the data. Educational attainment ranged from no formal education (15.0%) to postgraduate degrees (14.0%), with the highest proportions of respondents having secondary (26.0%) and undergraduate (28.0%) education. Occupational diversity was also well-reflected-office workers and students each accounted for 22.0%, homemakers 21.0%, teachers 20.0%, healthcare professionals 9.0%, and other professions 6.0%. Geographically, the participant base leaned slightly rural, with 60.0% residing in rural areas compared to 40.0% from urban settings. This distribution ensured that the study captured a broad spectrum of perspectives across educational, professional, and geographic contexts.

The knowledge assessment revealed varying levels of public understanding regarding skin cancer among the Shimla population. A promising 72.0% of respondents correctly identified skin cancer as uncontrolled growth of skin cells, and 70.0% recognized UV exposure as a primary risk factor. Symptom awareness was relatively strong, with 74.0% acknowledging unusual skin growths or moles as indicators. The protective role of sunscreen was affirmed by 69.0%, while 71.0% correctly identified surgery as a common treatment for early-stage cases.

Table 1: Socio-Demographic Characteristics of Participants (Shimla)

Table 2: Public Knowledge and Awareness of Skin Cancer and Its Risks

Table 3: Knowledge Score Classification on Skin Cancer and Its Risks

Diagnostic awareness was also satisfactory, with 72.0% understanding what a biopsy entails. However, recognition of early detection’s importance dropped slightly to 67.0%, and only 65.0% knew that the disease could be asymptomatic initially. Risk behavior awareness was mixed-73.0% agreed that sun exposure history should be reported, 70.0% recognized metastasis as a risk of neglect, and 66.0% acknowledged the importance of dermatology visits. Although 72.0% were aware of necessary preoperative precautions, only 62.0% identified skin discoloration as a potential sign. Furthermore, 68.0% linked fair skin and 69.0% linked tanning beds with increased risk, showing room for growth in understanding risk demographics. Notably, just over half (52.0%) were aware that skin cancer can recur after treatment-a key knowledge gap that highlights the need for ongoing education regarding long-term disease management.

When categorized by knowledge score, the data revealed a generally positive yet incomplete awareness pattern among the population. A notable 28.0% of participants fell into the “Very Good Knowledge” category, scoring above 80% on the questionnaire. The largest group, 36.0%, achieved a “Good Knowledge” score (60–79%), suggesting a satisfactory baseline understanding of skin cancer risks and prevention. However, 26.0% demonstrated only “Fair Knowledge” (41–59%), and 10.0% fell into the “Poor Knowledge” category, scoring below 40%. These results underscore the presence of significant informational gaps in nearly one-third of the population-particularly regarding early asymptomatic signs, recurrence, and specific preventive strategies. The findings stress the importance of tailored awareness campaigns, particularly targeting those with lower education levels and rural residency, to bridge these critical gaps in understanding and promote proactive skin health behavior.

This study presents a timely and comprehensive analysis of public awareness regarding skin cancer among residents of Shimla, a region uniquely susceptible to ultraviolet (UV) radiation due to its high-altitude geography. With increasing global temperatures and thinning ozone layers, skin cancer risk is becoming a serious but often underestimated public health issue-even in populations traditionally considered less vulnerable. The findings of this study reveal a mixed picture: while a majority of Shimla's adult population demonstrates moderate to good awareness of skin cancer, critical knowledge gaps and misconceptions remain, particularly concerning early detection, recurrence, and long-term preventive behaviors.

The socio-demographic distribution of the sample reflects a balanced and diverse population, thereby enhancing the generalizability of the findings. Nearly two-thirds (61%) of respondents were aged 18–35 years, an age group likely to be more digitally connected and health-aware-factors that may have contributed to higher knowledge scores. Equal gender participation (50% male, 50% female) further strengthens the analysis by providing insights into gender-specific awareness trends. Education-wise, a majority held at least a secondary or undergraduate qualification, but 32% still fell under the category of no formal or only primary education, which correlates with some of the awareness disparities observed in the results.

Encouragingly, the study found that 72% of participants correctly identified skin cancer as the uncontrolled growth of skin cells, and 70% were aware of UV radiation as a major risk factor. This foundational understanding is essential for public health strategies and suggests that general messaging about sun-related risks has penetrated the population to some extent. Similarly, 74% recognized unusual skin growths or moles as a warning sign, and 71% understood that early-stage skin cancer is often treated surgically. Awareness of diagnostic tools such as biopsy (72%) and the importance of sunscreen (69%) and protective clothing (68%) also reflect promising levels of knowledge.

Despite this solid baseline, the study uncovered several concerning gaps. Only 65% of respondents knew that skin cancer can be asymptomatic in its early stages, which is critical for early detection and treatment. Moreover, just over half (52%) were aware that skin cancer can recur after treatment-a statistic that underscores the need for long-term patient education and follow-up care. Awareness regarding subtler symptoms like skin discoloration (62%) and the role of dermatologist visits (66%) was also suboptimal, indicating a limited understanding of non-obvious clinical indicators and professional screening benefits.

The categorization of knowledge scores further illustrates the uneven landscape of awareness. While 28% of respondents exhibited “very good” knowledge (≥80%), and 36% demonstrated “good” knowledge (60–79%), a combined 36% fell into the “fair” or “poor” categories. These findings highlight that over one-third of the population lacks adequate comprehension of skin cancer risks-most likely individuals with limited educational exposure or residing in rural areas, which accounted for 60% of the sample. This urban-rural divide in awareness is particularly significant in Shimla, where outdoor occupations and prolonged sun exposure are common among rural dwellers who may not have easy access to dermatological care or preventive information. Cultural beliefs and social perceptions also play a role in shaping skin cancer awareness. In India, where fair skin is often linked to aesthetic preference but not necessarily to medical vulnerability, the link between skin tone and skin cancer risk is poorly understood. While 68% of participants correctly acknowledged fair skin as a risk factor, this number should ideally be higher, given the context of increasing UV exposure in mountainous regions like Shimla. Similarly, myths about tanning beds being safe or sun damage being cosmetic rather than carcinogenic may persist due to insufficient or misdirected health communication.

From a public health standpoint, these findings call for urgent action to design and implement localized awareness campaigns that address the specific risks posed by Shimla’s geographic and socio-cultural environment. Interventions should focus on educating individuals about the invisible nature of early-stage skin cancer, its recurrence potential, and the role of regular skin checks. Campaigns must be culturally sensitive, using visual media and local languages to reach non-literate populations and dispel myths around sun exposure and skin color. Community health workers and local leaders can be empowered as outreach agents to promote sun-safe practices, including the daily use of sunscreen, protective clothing, and routine dermatologist consultations [9,10].

Moreover, integrating skin cancer awareness into broader non-communicable disease (NCD) frameworks, such as the NPCDCS, could ensure sustainability and reach. School-based programs, workplace health drives, and tourism-related outreach could further enhance impact, given Shimla’s mix of local and transient populations frequently exposed to the sun.

In summary, while this study presents a cautiously optimistic view of skin cancer awareness in Shimla, it simultaneously highlights the pressing need for structured, inclusive, and region-specific interventions. Addressing informational voids-particularly among rural residents and less educated individuals-will be key to reducing the burden of preventable skin cancer cases. By fostering a culture of proactive skin health, early detection, and sun-conscious behavior, Shimla can take vital steps toward mitigating the long-term public health threat posed by increasing UV exposure in high-altitude regions.

This study reveals a moderately strong yet incomplete level of public awareness about skin cancer among residents of Shimla, a high-altitude region uniquely vulnerable to elevated ultraviolet (UV) radiation exposure. While a majority of participants demonstrated a solid understanding of basic risk factors, symptoms, and early treatment options, critical gaps persist-particularly concerning asymptomatic onset, recurrence, and nuanced prevention strategies. These knowledge deficiencies, especially prevalent among rural and less-educated individuals, underscore the need for context-specific, culturally sensitive health education campaigns. Empowering communities through localized outreach, incorporating skin cancer literacy into existing public health frameworks, and promoting routine dermatological care can significantly improve early detection and sun-safe behaviors. As climate change continues to amplify UV-related health risks, proactive awareness interventions in regions like Shimla are not only timely but essential for reducing the future burden of skin cancer.

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