Spine health forms the cornerstone of functional mobility, postural alignment, and overall quality of life. Disorders of the spine—such as chronic back pain, disc degeneration, postural imbalances, and spinal injuries—are increasingly prevalent across the globe, often resulting in long-term disability, reduced productivity, and significant healthcare expenditure. In India, these conditions are frequently under-recognized and underreported, with individuals often attributing symptoms to aging or lifestyle stress without seeking timely medical advice. The lack of awareness regarding preventive practices, early symptoms, and risk factors for spinal disorders contributes to delayed intervention and avoidable deterioration in spinal health [1-4].

The importance of spinal health is particularly crucial in physically demanding and geographically challenging environments such as Himachal Pradesh, a mountainous state in northern India. The unique topography, rugged terrain, and physically intensive occupations—such as agriculture, construction, and load-bearing—expose residents to heightened mechanical stress on the spine. Moreover, traditional practices, limited access to specialized spine care, and  cultural  beliefs  may influence how individuals perceive and manage spine-related symptoms. While modernization and lifestyle changes have led to an increase in sedentary behavior and screen time, contributing to spinal issues like cervical spondylosis and poor posture, awareness of preventive practices such as ergonomic correction, stretching, core strengthening, and early physiotherapeutic consultation remains limited [5-9].

Public health research has shown that educational level, occupation, age, and rural-urban residence play a substantial role in shaping health behaviors and perceptions. However, spine health as a specific focus remains underexplored, especially in regional and rural Indian populations. Existing studies assessing musculoskeletal awareness often address general orthopaedic conditions or bone health but seldom isolate spinal health as a distinct and critical concern. Considering that spine-related conditions are among the leading causes of work absenteeism and disability-adjusted life years (DALYs), enhancing public understanding is imperative for preventive healthcare [8-12].

This study aims to assess the current level of awareness, perceptions, and preventive behaviors related to spine health among adults in various communities across Himachal Pradesh. By identifying knowledge gaps, misconceptions, and demographic disparities, the findings will help inform future community health programs, educational campaigns, and policy efforts to promote spinal well-being. In doing so, the study seeks to encourage a shift from reactive treatment-seeking behavior toward a more proactive, preventive approach to spine care in the hilly regions of India.

Study Design and Objectives

This descriptive, cross-sectional study was designed to evaluate the level of public awareness, perceptions, and preventive practices related to spine health among adults residing in the mountainous regions of Himachal Pradesh. The primary objective was to assess knowledge regarding spinal anatomy, risk factors for spine-related disorders, and awareness of preventive strategies such as posture correction, physical activity, ergonomic practices, and early physiotherapeutic consultation.

Study Area and Population

The study was conducted across multiple districts of Himachal Pradesh, encompassing both rural and urban communities to capture the geographic and socio-cultural diversity of the region. The target population included adults aged 18 years and above who were permanent residents of Himachal Pradesh. Individuals with formal medical, physiotherapy, or spine-related training were excluded to ensure that the data reflected general public understanding rather than professional expertise.

Sample Size and Sampling Technique

A total of 400 participants were included in the study. The sample size was determined using a 95% confidence interval, 5% margin of error, and an assumed 50% awareness prevalence for maximum sample variability. A combination of purposive and convenience samplingmethods was adopted due to logistical considerations and the need to ensure wide digital reach across varied demographic groups.

Data Collection Instrument

Data were collected using a structured, pre-validated questionnaire developed in both English and Hindi through Google Forms. The questionnaire was reviewed by subject-matter experts including orthopedic specialists, physiotherapists, and public health researchers to ensure content validity and cultural appropriateness. The tool was distributed online through social media platforms, email, and WhatsApp, allowing participation from remote and diverse parts of the state.

The questionnaire was divided into the following sections:

• Socio-demographic Information: Including age, gender, education level, occupation, residence (urban/rural), and marital status

• Spine Health Awareness: Containing 20 multiple-choice questions covering topics such as causes of back pain, effects of poor posture, lifting techniques, ergonomics, benefits of physical activity, and early signs of spinal issues

• Preventive Practices: Assessing participants’ reported behaviors including exercise routines, ergonomic use of furniture, screen time habits, and willingness to seek professional care for spine discomfort

Pilot Testing

A pilot test was conducted with 30 individuals to assess the clarity, flow, and accessibility of the questionnaire. Feedback was used to refine the language, remove ambiguous items, and optimize digital usability before rolling out the full survey.

Scoring and Classification

Each correct answer in the awareness section was awarded 1 point, with a maximum possible score of 20. Based on total scores, participants were classified into four categories:

• Very Good Awareness: 17–20

• Good Awareness: 13–16

• Fair Awareness: 9–12

• Poor Awareness: 0–8

This scoring system allowed for stratified analysis of spine health knowledge across different socio-demographic groups.

Ethical Considerations

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Participants were informed of the purpose of the study and gave informed electronic consent prior to participation. Responses were anonymous, and data confidentiality was strictly maintained throughout the study.

Data Analysis

All responses were compiled from Google Forms and exported to Microsoft Excel. Data analysis was conducted using Epi Info version 7. Descriptive statistics (frequencies, percentages) were used to summarize the data. The Chi-square test was applied to assess associations between awareness levels and socio-demographic variables, with a p-value <0.05 considered statistically significant.

Table 1 illustrates the socio-demographic profile of the 400 participants included in the study on spine health awareness in Himachal Pradesh. The age distribution was fairly balanced, with the highest representation in the 26–35 age group (30.3%), followed closely by individuals aged 46 and above (29.8%) and 36–45 years (25.5%), indicating good coverage across middle-aged and older adults—groups commonly affected by spinal issues. Gender distribution showed a slight male predominance (53.3% male vs. 46.8% female). Educational attainment varied significantly, with the majority having completed secondary (34.5%) or undergraduate (27.8%) education; however, 24.3% had only primary or no formal education, reflecting potential disparities in health literacy. In terms of occupation, the highest proportion came from the private sector (21.3%) and homemakers (20.8%), followed by self-employed individuals and government employees. The majority of respondents (56.5%) lived in rural areas, underlining the study’s relevance for remote populations. Marital status showed that nearly two-thirds (64.5%) were married, which may influence health behavior and decision-making dynamics within households.

Table 2 presents participants’ responses to 20 structured questions assessing knowledge related to spine anatomy, risk factors, preventive measures, and ergonomics. Awareness levels were moderate to high across most items, with the highest correct response rate (74.0%) for the question identifying the spine as the key structure supporting posture. Knowledge was also strong for the impact of poor posture (68.0%), the role of physical activity in preventing spinal problems (69.0%), and appropriate lifting techniques (72.3%). However, understanding of specific concepts such as ergonomic practices (64.0%), the nature of sciatica (61.3%), and the effect of stress on spine health (65.3%) was relatively lower. A substantial number (63.5%) correctly noted that people should stretch or move every 30–60 minutes during prolonged sitting, though this leaves room for improvement. These results indicate a foundational awareness of spine health but highlight the need for more detailed education on posture management, occupational risks, and daily spine-friendly habits.

Table 3 classifies participants based on their total awareness scores, offering a clear picture of the population’s spine health literacy. Nearly   one-third (30.3%) achieved a “Very Good” score (17–20), while the largest proportion (34.8%) fell under the “Good” category (13–16). About 23.3% demonstrated only “Fair” knowledge (9–12), and 11.8% had “Poor” awareness, indicating notable gaps in understanding. Overall, more than 65% of the participants exhibited good to very good knowledge, reflecting a promising baseline. However, the remaining one-third with limited awareness underscores the need for focused interventions, particularly in populations with lower education or limited access to health information. These findings emphasize that while general awareness of spine health exists, there is a critical need to enhance specific, actionable knowledge through community-level education.

Table 1: Socio-Demographic Characteristics of Participants (n = 400)

Table 4 highlights statistically significant associations between spine health awareness and several socio-demographic factors. Age was significantly associated with awareness (p = 0.032); younger age groups (26–35 years) had higher scores, while older adults (46 and above) had the greatest proportion of fair and poor scores, pointing to the need for age-targeted education. Education level was the most influential factor (p<0.001), with postgraduate and undergraduate participants showing significantly better awareness than those with only  primary  or  no  education.  Occupation also played a role (p = 0.039), with government employees and students performing better than homemakers and retirees. Residence was another significant variable (p = 0.027), as urban residents had better awareness scores than rural ones—highlighting the information gap in remote communities. Interestingly, gender was not statistically significant (p = 0.194), indicating relatively equal dissemination of spine health information across male and female participants. These patterns suggest that spine health literacy is strongly tied to education, occupation, and geographic accessibility, reinforcing the need for localized, inclusive awareness programs.

Table 2: Awareness Questions on Spine Health and Preventive Practices (n = 400)

Table 3: Knowledge Score Classification Among Participants (n = 400)

This study offers a valuable insight into the public understanding of spine health and preventive practices among adults residing in the mountainous communities of Himachal Pradesh. The findings reveal that while there is a moderately high level of general awareness regarding spine health in the population, significant knowledge gaps persist—especially in the understanding of practical preventive behaviors, ergonomic practices, and early recognition of spine-related issues.

The demographic profile of the participants underscores the inclusive nature of the study. The population sample comprised individuals across a broad age range, with a balanced gender representation and a mix of rural (56.5%) and urban (43.5%) residents. Importantly, the diverse educational and occupational backgrounds added depth to the analysis of how socio-demographic variables influence spine health awareness. The highest number of participants fell within the 26–35 and 36–45 year age brackets—groups that are typically in their most physically active or professionally engaged years and thus at risk of lifestyle-related spinal issues, such as low back pain from desk jobs or improper lifting techniques in manual labor roles. 

Table 4: Association Between Knowledge Score and Socio-Demographic Variables (n = 400)

The awareness-based questionnaire responses (Table 2) reflected a commendable level of basic knowledge in certain areas. Participants demonstrated strong awareness that the spine is a crucial structure for body support (74.0%), that poor posture and prolonged sitting are major contributors to back problems (68–71%), and that proper lifting techniques and physical activity can play a preventive role (69.0–72.3%). These figures suggest that the foundational concepts surrounding spinal anatomy and common risk factors are increasingly understood by the public—likely due to broader digital exposure and general health messaging available through mobile technology and media.

Despite this, some key areas of spine health knowledge were relatively underrepresented. For instance, only 61.3% correctly identified sciatica as nerve pain radiating from the lower back to the leg, and just 64.0% recognized the role of lumbar back support in desk ergonomics. Additionally, only 63.5% were aware that individuals should move or stretch every 30–60 minutes when sitting for extended periods—an essential strategy for preventing occupational spine stress. These gaps reveal that while people are aware of general spine care principles, there remains a need for specific and actionable knowledge that can translate into daily practice.

The scoring data Table 3 offers a more nuanced view of knowledge distribution. While more than 65% of the participants scored within the “Very Good” and “Good” categories, indicating a promising baseline, the remaining 35% fell into “Fair” or “Poor” levels. This segment represents a vulnerable group that may not be taking adequate preventive measures, due either to limited access to health information, low health literacy, or cultural misconceptions. These findings are critical in guiding future public health interventions, which must be tailored to bridge these gaps.

A deeper look into the associations between awareness scores and socio-demographic variables (Table 4) reveals multiple statistically significant trends. Age was notably associated with awareness levels (p = 0.032), with younger participants (particularly those aged 26–35 years) achieving higher scores, while older adults (46 and above) were disproportionately represented in the Fair and Poor categories. This pattern likely reflects generational differences in education access, digital literacy, and adaptability to modern health advice. It also raises concerns because spinal degeneration and chronic back issues are more prevalent with advancing age, making this group particularly important for targeted educational outreach.

Education level emerged as the strongest predictor of spine health knowledge (p<0.001). Participants with undergraduate and postgraduate education overwhelmingly outperformed those with primary or no formal education. This aligns with global literature linking educational attainment with improved health literacy, critical thinking, and better engagement with preventive care. Similarly, occupational status had a significant influence (p = 0.039). Students, government employees, and those in the private sector displayed better awareness than homemakers, retirees, or self-employed individuals—populations that may have limited exposure to structured health information or workplace wellness programs.

The urban–rural divide (p = 0.027) further accentuates disparities in health awareness. Urban residents had a significantly higher awareness of spine health than their rural counterparts, likely due to better access to healthcare facilities, health promotion campaigns, and digital media. However, it is notable that a majority of the study population came from rural areas, reinforcing the urgent need for community-driven educational efforts in these regions. Notably, gender did not emerge as a significant factor (p = 0.194), indicating that awareness campaigns, when well-designed, can be equally effective across both sexes.

An important implication of this study is the identification of misconceptions still prevalent in the population. Misunderstandings about back pain always being serious, uncertainty around conditions like sciatica, and confusion regarding ergonomic practices suggest that spine health awareness needs to go beyond anatomical basics and engage with real-life preventive strategies. There is also a need to debunk harmful myths—such as the belief that spinal pain necessitates complete rest or that only older adults are at risk.

Overall, the findings from this study suggest that while public awareness of spine health is on an upward trajectory in Himachal Pradesh, it remains uneven and incomplete. Efforts to improve spine health literacy should include targeted health education programs, school-based ergonomics training, community physiotherapy workshops, and the integration of spine wellness into primary healthcare systems. Priority should be given to rural populations, older adults, and individuals with limited education, who consistently demonstrated lower awareness in this study. Moreover, public health authorities should leverage digital platforms, local languages, and culturally relevant messaging to maximize outreach and behavioral change [9-12].

Limitations

While this study provides meaningful insights into spine health awareness in Himachal Pradesh, it is not without limitations. Firstly, the reliance on an online survey using Google Forms may have excluded individuals without internet access or digital literacy, especially among older adults and lower socio-economic groups in remote rural areas. This could have led to a selection bias, skewing results toward younger, more educated, and urban populations. Secondly, the use of self-reported data may introduce social desirability or recall bias, as participants might overestimate their knowledge or engagement in preventive practices. Additionally, the cross-sectional design captures awareness at a single point in time and does not evaluate long-term behavior change or clinical outcomes. Future studies should consider mixed-method approaches, larger sample sizes, and in-person outreach to ensure broader inclusivity and deeper understanding.

This study highlights a moderately high level of general awareness about spine health among adults in Himachal Pradesh, yet it uncovers critical knowledge gaps in specific preventive practices, ergonomics, and symptom recognition. Awareness levels were significantly influenced by education, occupation, residence, and age, with rural, older, and less-educated groups demonstrating lower spine health literacy. Although the public shows a foundational understanding of spinal health concepts, there is a pressing need for structured interventions to enhance depth of knowledge and practical implementation. These findings underscore the importance of transitioning from reactive, symptom-driven approaches to a more proactive, preventive spine care culture, particularly in geographically challenging and resource-limited settings like Himachal Pradesh.

Recommendations

To bridge the knowledge gaps identified, it is recommended that local health departments and community organizations implement targeted spine health education campaigns tailored to rural populations, older adults, and those with low literacy. These initiatives should focus on practical, culturally relevant content—such as safe lifting techniques, posture correction, and the benefits of regular movement—delivered through accessible platforms including community health workers, radio programs, vernacular pamphlets, and school curricula. Additionally, integrating spine health promotion into existing primary care services and encouraging partnerships between physiotherapists, educators, and local leaders can amplify outreach. Leveraging digital tools for interactive learning and ergonomic demonstrations could further engage younger audiences, promoting sustainable behavioral change toward spinal wellness across the region.

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