Chronic respiratory diseases (CRDs), notably chronic obstructive pulmonary disease (COPD) and asthma, represent a significant global public health challenge, contributing substantially to morbidity, mortality and healthcare burden. Characterized by persistent respiratory symptoms and airflow limitations, these conditions can severely compromise quality of life and functional capacity. The World Health Organization estimates that millions worldwide are affected by CRDs, with the majority of deaths occurring in low- and middle-income countries, where diagnosis, treatment and public awareness remain limited. Environmental factors such as air pollution, occupational dust exposure, tobacco smoke and biomass fuel usage are well-documented contributors to the development and exacerbation of respiratory diseases, making environmental awareness and prevention    strategies   critically    important [1-4].

India, facing rapid urbanization, industrial growth and a heavy reliance on solid fuels for cooking and heating, carries a disproportionate burden of CRDs. Despite the high prevalence of COPD and asthma, community-level knowledge about these diseases including their risk factors, early warning signs and prevention strategies remains fragmented, especially in semi-urban and rural populations. Limited health literacy, under-recognition of environmental triggers and delayed health-seeking behaviors continue to hamper effective disease management and contribute to the preventable progression of respiratory illnesses [5,6].

Shimla district of Himachal Pradesh, with its unique mix of rural, semi-urban and urban settlements, presents a compelling backdrop to explore community awareness and risk perceptions related to chronic respiratory diseases. Traditional lifestyles are increasingly intersecting with modern environmental hazards such as vehicular pollution, industrial emissions and changing household energy practices. However, localized data evaluating public understanding of COPD, asthma and environmental health risks remain scarce.

This study aims to assess the awareness of COPD and asthma among adults in Shimla district, investigate knowledge regarding environmental and behavioral risk factors and identify prevailing misconceptions that may impede early detection and prevention efforts. By highlighting community-level knowledge gaps and risk perceptions, the findings will provide valuable insights for designing targeted educational campaigns and public health interventions to reduce the burden of chronic respiratory diseases in the region.

Study Design

This study employed a descriptive, cross-sectional survey design to evaluate public awareness, knowledge and perceptions related to chronic respiratory diseases (CRDs) specifically COPD and asthma among adults in Shimla district, Himachal Pradesh. A cross-sectional approach was selected to capture a real-time assessment of community-level understanding of respiratory health and associated environmental risk factors.

Study Area and Population

The survey was conducted among adult residents of Shimla district, covering a range of rural, semi-urban and urban settings to ensure a representative demographic distribution. The target population included individuals aged 18 years and above, irrespective of prior diagnosis of respiratory illnesses. Healthcare professionals were excluded from participation to maintain focus on the general public’s awareness and risk perceptions.

Study Duration

Data collection was carried out over a three-month period, from January to March 2025, utilizing online survey methods exclusively to maximize reach while ensuring safety, accessibility and convenience for participants.

Sample Size and Sampling Technique

A total sample size of 400 participants was determined using a 95% confidence level, a 5% margin of error and an anticipated 50% awareness rate for CRDs, based on the absence of prior localized studies. Participants were recruited through purposive and snowball sampling techniques using digital platforms, including WhatsApp groups, Facebook communities and local online forums. Initial participants were encouraged to share the survey link within their networks to achieve diverse representation.

Inclusion and Exclusion Criteria

Inclusion Criteria

• Adults aged 18 years and above residing in Shimla district

• Ability to read and respond to the survey in Hindi or English

• Access to an internet-enabled device (smartphone, tablet or computer)

• Willingness to provide informed online consent prior to participation

Exclusion Criteria

• Practicing healthcare professionals (doctors, nurses, respiratory therapists)

• Incomplete or partially filled survey responses

Data Collection Tool

A structured, pre-validated, bilingual (Hindi and English) online questionnaire was developed based on expert consultations with pulmonologists and public health specialists. Hosted via Google Forms, the survey was mobile-friendly and accessible across digital devices. The questionnaire was divided into four sections:

• Demographic Information: Age, gender, educational level, occupation and residential setting

• Knowledge Assessment: Awareness of COPD and asthma, symptoms, causes and prevention strategies

• Environmental Risk Factors: Knowledge of triggers such as air pollution, biomass smoke, occupational dust and tobacco use

• Beliefs and Misconceptions: Identification of myths and incorrect beliefs surrounding chronic respiratory diseases

Data Collection Procedure

The survey link, along with a brief explanation of the study objectives and confidentiality assurances, was disseminated via WhatsApp groups, Facebook pages, emails and other local online networks. Participation was voluntary and responses were included only if the survey was fully completed to maintain data quality and integrity.

Scoring and Data Classification

Each correct response in the knowledge section was awarded one point, while incorrect or "don’t know" responses received zero points. Total knowledge scores were classified into four categories:

• Very Good Knowledge (≥80% correct responses)

• Good Knowledge (60%–79% correct responses)

• Fair Knowledge (41%–59% correct responses)

• Poor Knowledge (<40% correct responses)

Participants’ understanding of environmental triggers and common misconceptions were analyzed descriptively.

Data Analysis

Data were exported from Google Forms to Microsoft Excel for cleaning and preparation. Statistical analysis was conducted using SPSS version 26.0. Descriptive statistics, including frequencies, percentages and means, were used to summarize demographic characteristics, awareness levels and environmental risk factor knowledge.

Ethical Considerations

Online informed consent was obtained from all participants before survey initiation. Participation was entirely voluntary, with assurances of anonymity and confidentiality. No personally identifiable information was collected and participants were informed of their right to withdraw at any point without providing justification.

The study included 400 adult participants from Shimla district, with a predominance of young to middle-aged individuals; 38.0% were aged between 26–35 years, 25.8% were 36–45 years and 24.5% belonged to the 18–25 years age group. A slight female predominance was noted, with females accounting for 52.5% and males for 47.5% of the total participants. In terms of education, 36.8% had completed secondary schooling, 28.5% held undergraduate degrees, 19.8% had primary education and only 6.8% reported no formal education. 

Occupationally, homemakers formed the largest group at 35.0%, followed by self-employed individuals 
(21.0%) and students or unemployed persons (21.5%). A smaller proportion were employed in the government (12.0%) or private sector (10.5%). Geographically, a majority of respondents (64.5%) resided in rural areas, while 35.5% came from urban settings, ensuring a wide demographic spread that captured the diverse socio-economic landscape of the district.

The awareness assessment revealed encouraging levels of knowledge about chronic respiratory diseases among participants. A majority (76.8%) correctly identified COPD as a chronic lung condition and 79.8% recognized allergens as asthma triggers. Smoking was widely acknowledged as a major COPD risk factor by 82.8% and 81.0% understood the role of air pollution in worsening asthma symptoms. Symptoms like breathlessness (74.5%) and wheezing (76.5%) were also well recognized. However, misconceptions persisted: only 65.5% knew that CRDs cannot be completely cured and 64.5% were aware of the genetic predisposition of CRDs. Participants showed good awareness regarding the harmful effects of biomass fuel smoke (69.5%), occupational dust exposure (70.8%) and indoor air pollution (72.3%). Preventive aspects such as tobacco avoidance (84.3%), regular exercise (73.5%), vaccination for flu (75.3%) and the role of inhalers for asthma (79.0%) were reasonably well understood. Furthermore, 83.5% correctly identified pulmonologists or general practitioners as the appropriate specialists for CRD diagnosis, indicating a positive inclination towards seeking professional healthcare advice.

Based on the cumulative scoring, 31.3% of participants demonstrated "Very Good" knowledge (≥80% correct responses) and 42.8% exhibited "Good" knowledge (60%–79%), collectively indicating that nearly three-fourths of the surveyed population had a strong grasp of CRD-related facts. Nevertheless, 19.3% of respondents were classified under "Fair" knowledge (41%–59%) and 6.8% fell into the "Poor" knowledge category (<40%), highlighting that around one-fourth of participants still lacked adequate understanding. These findings underscore the necessity for targeted awareness initiatives to bridge the remaining knowledge 

Table 1: socio-demographic characteristics of participants

Table 2: awareness and knowledge of chronic respiratory diseases among participants                                                                                             

Table 3: knowledge score classification

gaps, particularly focusing on environmental risk factors, disease progression and long-term management strategies.

This community-based cross-sectional study provides crucial insights into the current levels of awareness, knowledge and perceptions related to chronic respiratory diseases (CRDs) specifically COPD and asthma among adults in Shimla district, Himachal Pradesh. Overall, the findings present a cautiously optimistic outlook, with a significant proportion of participants demonstrating sound basic knowledge about CRDs, yet they simultaneously reveal notable gaps in understanding environmental risk factors, disease management and long-term health impacts that warrant urgent public health attention.

A key strength of the study was the high level of recognition of major CRD-related facts among participants. Notably, 76.8% correctly identified COPD as a chronic lung condition, while 79.8% recognized allergens as important asthma triggers. The strong association of tobacco smoking with COPD (acknowledged by 82.8% of participants) and the link between air pollution and asthma exacerbations (recognized by 81.0%) reflect positive trends in public understanding of some major risk factors. Furthermore, symptom awareness appeared reasonably robust, with breathlessness (74.5%) and wheezing (76.5%) being well recognized. The role of preventive strategies such as tobacco smoke avoidance (84.3%), vaccination against influenza (75.3%) and the importance of lifestyle changes (82.0%) were also widely acknowledged, suggesting that a substantial segment of the community is aware of basic preventive and management measures.

However, despite these encouraging trends, the study also revealed persistent misconceptions and critical knowledge deficiencies that could hinder early detection, appropriate disease management and prevention efforts. Only 65.5% of participants were aware that CRDs cannot be completely cured, a gap that could lead to unrealistic treatment expectations and potential non-adherence to long-term management plans. Similarly, awareness of the genetic predisposition to CRDs was limited (64.5%) and only 69.5% recognized the significant role of biomass fuel smoke exposure, which is particularly concerning in a rural-majority district like Shimla where traditional cooking practices involving biomass fuels remain common. Knowledge regarding occupational dust exposure (70.8%) and indoor air pollution (72.3%) was moderate but still leaves room for improvement, considering the rising burden of environmental health hazards   in   both    rural    and    semi-urban   settings.

The cumulative knowledge classification further underscores the dichotomy observed: while 74.1% of participants fell into the "Very Good" or "Good" knowledge categories, a notable 26.1% demonstrated only "Fair" or "Poor" understanding. Given that the survey was administered online and likely attracted more digitally literate and health-aware individuals, it is reasonable to infer that awareness levels in the broader, digitally disconnected population especially in rural regions might be even lower. This raises serious public health concerns, as lower awareness levels are often associated with delayed disease recognition, underutilization of healthcare services, poor adherence to treatment protocols and avoidable exacerbations of respiratory diseases.

Moreover, the demographic profile revealed that the majority of participants belonged to younger to middle-aged groups, with a relatively high proportion having secondary or undergraduate education. However, significant representation from homemakers, self-employed individuals and rural residents suggests that respiratory health awareness efforts must be diversified and tailored to accommodate varied educational, occupational and cultural backgrounds. Strategies focusing exclusively on urban or highly educated populations will be insufficient to address the widespread burden of CRDs across Shimla district.

To bridge the existing knowledge gaps and foster better respiratory health outcomes, a multi-pronged public health strategy is imperative. Community education initiatives must emphasize the importance of reducing exposure to tobacco smoke, promoting the use of clean cooking fuels, improving indoor air quality and recognizing early warning signs of CRDs. Health communication campaigns should be culturally sensitive, delivered in local languages and utilize trusted media channels such as radio, local TV and community gatherings. Engagement of Accredited Social Health Activists (ASHAs) and local healthcare workers in respiratory health promotion could further extend the reach of educational interventions into hard-to-reach areas. School-based health education programs focusing on environmental health literacy could also play a transformative role in long-term prevention [4-6].

In addition to educational efforts, systemic integration of respiratory health services into primary healthcare facilities is essential. Routine screening for CRDs, especially among individuals with known risk exposures (e.g., smokers, biomass users, industrial workers), coupled with early referrals to pulmonologists or trained general practitioners, could significantly 
improve early diagnosis and intervention outcomes. Furthermore, enhancing access to affordable diagnostic tools such as spirometry and expanding vaccination coverage for influenza and pneumococcal infections among CRD patients would strengthen community resilience against respiratory disease progression.

This study underscores that while a substantial proportion of adults in Shimla district possess encouraging levels of awareness and knowledge regarding chronic respiratory diseases, notably COPD and asthma, critical gaps persist in understanding key environmental risk factors, disease progression and long-term management strategies. Although participants demonstrated strong recognition of smoking, air pollution and allergens as major contributors to CRDs, limited awareness surrounding the incurability of CRDs, genetic predisposition and the health impacts of biomass fuel exposure highlights areas needing urgent educational reinforcement. Given the predominance of rural residents and diverse socio-economic backgrounds in the study population, targeted, culturally tailored public health interventions are essential to bridge these knowledge gaps. Community-driven education programs, integration of CRD screening into primary healthcare, promotion of clean energy practices and strengthening health communication through trusted local channels will be pivotal in advancing early detection, improving treatment adherence and ultimately reducing the growing burden of chronic respiratory diseases across Shimla district.

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