Emergency health services are a critical component of public health systems, ensuring timely intervention to save lives during medical crises such as accidents, heart attacks, or severe injuries. In India, initiatives like the 108-ambulance service have significantly improved access to emergency care, yet challenges such as low public awareness, inadequate first-aid knowledge, and delays in seeking care persist, particularly in rural regions. Himachal Pradesh, a predominantly rural state in northern India, faces unique barriers to emergency care due to its mountainous terrain, scattered settlements, and seasonal road blockages, which complicate timely access to healthcare facilities. Despite the widespread availability of the 108-ambulance service, public understanding of its utilization and basic first-aid practices remains underexplored, potentially exacerbating preventable morbidity and mortality in the region [1-3].

The socio-cultural and geographic context of Himachal Pradesh profoundly influences emergency health behaviors. Rural communities, comprising a significant portion of the state’s population, often rely on informal care or traditional remedies during emergencies due to limited awareness of formal services like the 108 ambulances. Misconceptions, such as underestimating the urgency of symptoms or fearing hospital costs, contribute to delays in seeking care, while poor first-aid knowledge hinders effective initial responses to emergencies. Seasonal factors, such as heavy snowfall or monsoon-related road disruptions, further amplify delays, increasing the risk of adverse outcomes. National studies highlight that low awareness of emergency services and first-aid practices is a major barrier to timely care, with rural populations particularly affected due to constrained access to health education and infrastructure [4-7].

Efforts to enhance emergency health services in India, including awareness campaigns and the expansion of the 108-ambulance network, have achieved varying success, but their impact in Himachal Pradesh’s challenging terrain 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 emergency health services, first-aid knowledge, and factors contributing to care delays. Understanding these dynamics is crucial for designing targeted interventions that improve service utilization and reduce preventable deaths. This study aims to evaluate public awareness and utilization of emergency health services in Himachal Pradesh, with a focus on rural communities, to identify knowledge gaps and barriers and inform strategies for enhancing timely access to life-saving care.

Study Design

A descriptive, cross-sectional online survey was conducted to assess public awareness and utilization of emergency health services, including the 108-ambulance service, first-aid knowledge, delays in seeking care, 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 February 2025.

Sample Size and Sampling Technique

Assuming a 50% awareness level of emergency health services (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 550 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 volunteers, 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 employed in emergency health services or public health agencies, 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 emergency services.

• Knowledge of Emergency Health Services: Awareness of the 108-ambulance service, its purpose, and emergency contact protocols.

• Awareness and Practice of First-Aid and Care-Seeking: Understanding of first-aid techniques, recognition of emergency symptoms, and timeliness of care-seeking.

• Barriers to Emergency Care: Logistical, cultural, psychological, and informational obstacles.

The questionnaire was pilot-tested among 30 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 offer a detailed snapshot of the socio-demographic profile, knowledge, attitudes, and barriers related to emergency health services, first-aid practices, and care-seeking behaviors among 550 participants in HP. The data reveal a moderate level of awareness, with significant gaps that highlight the urgent need for targeted educational and infrastructural interventions to enhance timely access to emergency care.

Table 1 outlines the socio-demographic profile of the 550 participants, reflecting a diverse representation of age, gender, education, occupation, marital status, and access to emergency services. The predominance of young to middle-aged adults and a significant rural segment, with 32.7% reporting limited access to emergency services, underscores the study’s focus on addressing emergency care challenges in rural Himachal Pradesh.

Table 1: Socio-Demographic Characteristics of Participants

Table 2 presents responses to 20 comprehensive questions evaluating knowledge of the 108-ambulance service, first-aid practices, recognition of emergency symptoms, delays in seeking care, and perceived barriers. Designed to capture a broad spectrum of emergency health literacy, the questions include correct answers in bold, revealing moderate awareness but critical gaps in first-aid techniques and timely care-seeking, essential for effective emergency response.

Table 2: Awareness and Attitudes Toward Emergency Health Services, First-Aid, and Care-Seeking

Table 3 categorizes participants’ knowledge levels based on their performance on the 20 knowledge-based questions, illustrating a range of awareness. While the majority demonstrated good awareness, the significant proportion with Fair or Poor awareness signals an urgent need for enhanced education on emergency health services to empower communities in Himachal Pradesh.

Table 3: Knowledge Score Classification

This study offers a critical examination of public awareness and utilization of emergency health services in Himachal Pradesh, providing valuable insights into the knowledge, attitudes, and barriers that shape timely access to life-saving care in a predominantly rural, mountainous region. The findings reveal a moderate level of emergency health literacy, with 80.0% of participants correctly identifying the free transport provided by the 108-ambulance service and 82.0% recognizing that not all emergencies are life-threatening. High awareness of the 108 service’s on-site medical care capability (83.1%) and lack of awareness as a barrier to its use (85.1%) suggests that national and state-level initiatives, such as the expansion of the 108-ambulance network, have made significant inroads into rural and semi-urban communities. The strong recognition of symptoms like chest pain (73.5%) and the need to call 108 for suspected heart attacks (76.0%) further indicates a baseline understanding of emergency protocols, reflecting the gradual impact of public health campaigns in Himachal Pradesh.

Despite these encouraging trends, significant knowledge gaps and attitudinal barriers highlight the complexity of ensuring effective emergency care in a region with unique geographic and socio-cultural challenges. Only 60.0% of participants correctly identified the need to call 108 immediately for severe injuries, and awareness of unconsciousness not always being an emergency (61.1%) and the risks of delaying care (63.5%) was suboptimal. These gaps are particularly concerning, as they may lead to delayed or inappropriate responses, increasing the risk of adverse outcomes in emergencies like heart attacks or severe injuries, which are critical in Himachal Pradesh’s high-altitude terrain where delays are exacerbated by road blockages (74.2% awareness). The moderate awareness of first-aid techniques, such as stopping severe bleeding (67.6%) and CPR’s purpose (71.6%), aligns with findings from national studies, which highlight inadequate first-aid knowledge as a barrier to effective emergency response, particularly in rural areas with limited access to training. This suggests a broader regional challenge in equipping communities with practical emergency skills.

The socio-demographic profile, with 72.9% of participants aged 18–35 and 32.7% reporting limited access to emergency services, underscores 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 successful use of social media for recruitment. However, the significant proportion with limited access reflects logistical barriers, such as geographic isolation, seasonal road disruptions, and sparse healthcare infrastructure, which align with similar access challenges noted in the water safety (32.6%) and NCD (31.9%) studies. These findings suggest a shared regional issue of reaching underserved rural populations. The high recognition of fear of cost (76.0%) and lack of awareness (85.1%) as barriers indicates that psychological and informational factors, alongside physical constraints, significantly impede timely care-seeking, particularly in rural areas where reliance on traditional remedies is common.

The knowledge score classification reveals a notable divide in emergency health literacy: while 45.8% demonstrated "Good" awareness and 28.0% achieved "Very Good" awareness, a concerning 26.2% fell into the "Fair" or "Poor" categories. This subgroup is at heightened risk of delayed or ineffective emergency responses, perpetuating preventable morbidity and mortality in Himachal Pradesh, especially during seasons with road blockages. 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 calling 108 or first-aid knowledge, 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 emergency health policy and practice in Himachal Pradesh. The moderate awareness levels indicate that existing campaigns, such as those promoting the 108 service, have established a foundation, but they must be intensified and tailored to address specific gaps, such as the urgency of calling 108 and first-aid skills. Community-based interventions, leveraging local health volunteers and Gram Panchayats, could enhance outreach in rural areas, while school-based first-aid training could target younger populations. Improving road infrastructure and expanding 108 service coverage are critical to addressing the 32.7% with limited access, particularly in areas prone to seasonal disruptions. 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 emergency health literacy and evaluate the impact of targeted interventions in reducing care delays and improving outcomes in Himachal Pradesh’s challenging terrain.

This study unveils a nuanced landscape of emergency health awareness in Himachal Pradesh, revealing moderate knowledge of the 108-ambulance service and first-aid practices alongside critical gaps and barriers that hinder timely care-seeking, particularly in rural communities. While encouraging recognition of the 108 service’s capabilities, emergency symptoms, and awareness barriers exists, deficiencies in understanding the urgency of immediate action, first-aid techniques, and the non-emergency nature of some conditions, coupled with limited access to emergency services for 32.7% of participants, underscore the urgent need for comprehensive interventions. To enhance life-saving emergency responses, multi-faceted strategies are essential, including targeted educational campaigns, community-based first-aid training, improved infrastructure, and inclusive digital initiatives, ensuring that in Himachal Pradesh, the answer to “Emergency? Call Whom?” is a confident and effective call to 108.

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