Background: Skin cancer, while highly preventable and treatable when detected early, continues to be underestimated in India, particularly in high-altitude regions like Himachal Pradesh. The state’s increased ultraviolet (UV) exposure due to its elevation, outdoor lifestyle, and climatic conditions places its population at heightened risk. However, public awareness regarding skin cancer risks, prevention, and early detection remains largely undocumented and under-addressed. Materials and Methods: A descriptive, cross-sectional study was conducted using a bilingual (English and Hindi) Google Form questionnaire to assess skin cancer awareness among the general population of Himachal Pradesh. The online survey, disseminated via social media and community networks, collected data from 400 residents aged 18 years and above across both rural and urban areas. The questionnaire comprised socio-demographic variables and 20 knowledge-based multiple-choice items on skin cancer risk factors, symptoms, prevention, and misconceptions. Responses were scored (0–20) and categorized into four knowledge levels. Statistical analysis was performed using SPSS, with chi-square tests applied to explore associations between knowledge levels and demographic variables. Results: Among 400 participants, 66.8% demonstrated good to very good knowledge of skin cancer, while 11% scored poorly. High awareness was observed on UV-related risks (71.5%), protective clothing (73%), and biopsy-based diagnosis (73.8%). However, significant misconceptions persisted, including beliefs in herbal remedies (46.5%) and underestimation of risk in cloudy or cold climates. Knowledge levels were significantly associated with age (p = 0.021), education (p< 0.001), and residence (p = 0.037), with younger, urban, and more educated individuals showing higher awareness. Gender was not a significant factor (p = 0.301). Conclusion: The study reveals a moderately encouraging level of skin cancer awareness among Himachal Pradesh's residents, but also highlights critical knowledge gaps, especially in older, rural, and less-educated subgroups. The findings underscore the need for localized, demographically sensitive public health interventions that prioritize UV protection and debunk prevalent myths, particularly in underserved high-risk populations. Integrating skin cancer education into primary care and leveraging digital outreach in rural areas will be key to mitigating future disease burden in this Himalayan state.
Skin cancer, a group of malignancies arising from the uncontrolled growth of abnormal skin cells, is one of the most common forms of cancer worldwide. Despite its high preventability and treatability when detected early, awareness and understanding of skin cancer remain strikingly low in many parts of the world, especially in developing regions. Among the three primary types—basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and malignant melanoma—excessive exposure to ultraviolet (UV) radiation is the most significant and modifiable risk factor. Cumulative sun exposure, frequent sunburns, use of tanning beds, and inadequate skin protection practices are widely recognized contributors to its pathogenesis. The burden of skin cancer is expected to rise with increasing climate variability, changing environmental behaviors, and growing outdoor occupational exposure, particularly in geographically vulnerable regions [1-5].
India has traditionally been perceived to be at lower risk for skin cancer due to the generally higher melanin content in the population’s skin, which offers some degree of natural UV protection. However, this assumption has led to a widespread underestimation of the disease's threat, resulting in limited public discourse, poor preventive behavior, and delayed diagnosis. Moreover, recent trends suggest a gradual rise in skin cancer incidence in India, particularly in high-altitude states such as Himachal Pradesh, where atmospheric thinning and snow reflectance amplify UV exposure. Despite this, skin cancer is rarely prioritized in the public health agenda or included in mainstream awareness campaigns across the country [6-11].
Himachal Pradesh, nestled in the Western Himalayas, is characterized by its elevated terrain, extensive outdoor workforce, and increasing tourism—all factors that contribute to elevated UV exposure. The state’s unique geographical and occupational profile, coupled with seasonal variations and a predominantly rural population, increases the vulnerability of its residents to UV-induced skin conditions. However, empirical data on the awareness, perception, and preventive practices related to skin cancer among the general population of Himachal Pradesh is sparse. Myths and misinformation—such as the belief that skin cancer only affects fair-skinned individuals, or that sunscreen is unnecessary in colder or cloudy climates—continue to prevail, especially in underserved rural areas.
Previous studies in other regions have underscored the influence of socio-demographic variables—such as education, age, gender, and urban-rural residence—on public awareness and health-seeking behavior concerning skin cancer [7-10]. In a state like Himachal Pradesh, where over half the population resides in rural settings with limited access to dermatological care and health education, these determinants may significantly affect disease outcomes. Addressing these knowledge gaps is crucial for fostering early detection, encouraging protective behaviors, and reducing long-term morbidity and mortality.
Against this backdrop, the present study aims to evaluate the level of awareness, misconceptions, and knowledge related to skin cancer and UV protection among the general population of Himachal Pradesh. Using a structured, bilingual online questionnaire, the study investigates the role of socio-demographic factors in shaping public understanding of skin cancer and identifies specific misconceptions that hinder prevention. The findings are intended to inform localized, evidence-based health promotion strategies that can better equip communities to protect themselves against this largely preventable disease.
Study Design and Setting
This was a descriptive, cross-sectional study conducted to assess the level of awareness, knowledge, and misconceptions related to skin cancer and ultraviolet (UV) exposure among the general population of Himachal Pradesh, India. Recognizing the increasing digital penetration and the logistical challenges of physical data collection in the state's mountainous terrain, the study employed a structured, self-administered online survey using Google Forms to ensure wide reach and timely data collection across diverse demographic segments.
Study Duration
The study was conducted over a three-month period, from Feb to March, 2025, allowing ample time for questionnaire distribution, participant response, and subsequent analysis.
Study Population and Sampling Technique
The study targeted individuals aged 18 years and above, residing in both urban and rural areas of Himachal Pradesh. No restrictions were placed on gender, occupation, or educational background to ensure inclusive participation. A convenience sampling approach was used, with the survey link disseminated through social media platforms (WhatsApp, Facebook, Instagram), community WhatsApp groups, email lists, and networks of healthcare professionals and volunteers. A total of 400 respondents were included, with efforts made to ensure equitable geographic and demographic representation from various districts of the state.
Survey Instrument
A bilingual (English and Hindi) Google Form questionnaire was developed specifically for this study after reviewing existing literature and validated tools used in similar awareness assessments. The questionnaire was divided into two major sections:
Socio-Demographic Profile: This section gathered information on age, gender, education level, occupation, and place of residence (urban or rural).
Skin Cancer Awareness and Knowledge: This core section comprised 20 multiple-choice questions, focused on:
Basic understanding of skin cancer and its preventability
Early signs and symptoms
Role of UV exposure, altitude, and environmental factors
Protective behaviors (e.g., sunscreen use, clothing)
Awareness of risk factors (e.g., skin tone, family history)
Misconceptions (e.g., sunburn risk in winter, effect of Vitamin D, role of herbal remedies)
The questionnaire was pre-tested on a pilot group of 25 individuals to assess clarity, language suitability, and internal consistency. Feedback from the pilot led to minor modifications for improved readability and comprehension. Content validity was further ensured by consultation with public health experts and dermatologists.
Scoring and Knowledge Classification
Each correct response was awarded 1 point, while incorrect or “not sure” responses were scored 0. The cumulative knowledge score for each participant could range from 0 to 20. Based on these scores, participants were categorized into the following knowledge levels:
Very Good Knowledge: 17–20
Good Knowledge: 13–16
Fair Knowledge: 9–12
Poor Knowledge: 0–8
This classification enabled stratification of awareness levels across different population groups and facilitated targeted analysis of knowledge disparities.
Ethical Considerations
The study adhered to ethical standards for online, voluntary participation. Informed digital consent was obtained at the beginning of the Google Form, which explained the study’s purpose, assured anonymity, and clarified that no personally identifiable information would be collected. Participants were informed of their right to withdraw at any stage without penalty.
Data Management and Statistical Analysis
Responses were automatically compiled via Google Forms and exported into Microsoft Excel for initial sorting. Data analysis was conducted using SPSS software Version 25.
Descriptive statistics (frequencies and percentages) were used to summarize demographic characteristics and response distributions.
Chi-square (χ²) tests were employed to determine associations between knowledge levels and socio-demographic variables (age, gender, education, occupation, and residence).
A p-value of <0.05 was considered statistically significant.
This analytical framework enabled the identification of specific knowledge gaps and demographic determinants that influence awareness of skin cancer in Himachal Pradesh.
The study comprised 400 participants with a diverse distribution across age, gender, education, occupation, and place of residence. The largest age group was individuals aged 46 years and above (31.5%), followed by those in the 26–35 age group (27%), 36–45 (24%), and 18–25 (17.5%). Females slightly outnumbered males, accounting for 52.5% of the sample. In terms of education, the majority of participants had completed undergraduate (33.8%) or secondary education (30.3%), while only 5.5% had no formal schooling. Occupationally, the sample included private sector employees (22.5%), homemakers (18%), government employees (17%), and students (15%), with remaining participants spread across self-employment and retired/other categories. A notable aspect of the sample was the predominance of rural participants (54.5%) over urban dwellers (45.5%), reflecting a well-balanced inclusion of diverse population segments from across Himachal Pradesh (Table 1).
Table 1: Socio-Demographic Characteristics of Participants (n = 400)
| Variable | Category | Frequency (n) | Percentage |
| Age Group (Years) | 18–25 | 70 | 17.5% |
| 26–35 | 108 | 27.0% | |
| 36–45 | 96 | 24.0% | |
| 46 and above | 126 | 31.5% | |
| Gender | Male | 190 | 47.5% |
| Female | 210 | 52.5% | |
| Education Level | No formal education | 22 | 5.5% |
| Primary school | 48 | 12.0% | |
| Secondary school | 121 | 30.3% | |
| Undergraduate | 135 | 33.8% | |
| Postgraduate | 74 | 18.5% | |
| Occupation | Student | 60 | 15.0% |
| Homemaker | 72 | 18.0% | |
| Government Employee | 68 | 17.0% | |
| Private Sector | 90 | 22.5% | |
| Self-Employed | 65 | 16.3% | |
| Retired/Other | 45 | 11.3% | |
| Residence | Urban | 182 | 45.5% |
| Rural | 218 | 54.5% |
Participants’ responses to the 20 knowledge-based questions revealed a mixed but moderately positive awareness level regarding skin cancer and its preventability. High levels of correct responses were observed on questions related to UV exposure as the most common cause (71.5%), the importance of hats and protective clothing (73%), and the utility of skin biopsy in diagnosis (73.8%). Encouragingly, over two-thirds recognized that skin cancer can occur even in cooler climates like Himachal Pradesh (66.8%) and that it can affect all skin tones (60.8%). However, certain misconceptions persisted—only 56.5% knew that sunscreen is necessary even on cloudy days, and just 53.5% rejected the notion that herbal remedies are effective treatments. Misunderstandings were also seen in gender-based risk perceptions (54%) and the role of SPF 15 sunscreen (57.3%). Overall, the data underscore a commendable base-level knowledge but also point to persistent gaps in specific areas of prevention, risk behavior, and myth-busting, especially in relation to environmental and seasonal factors specific to high-altitude regions (Table 2).
Table 2: Awareness and Misconception Questions on Skin Cancer and UV Exposure (n = 400)
| Q. No. | Question | Options (Correct in Bold) | Correct (n) | Correct (%) |
| 1 | What is the most common cause of skin cancer? | a) Smoking b) UV exposure d) Hormonal imbalance c) Pollution | 286 | 71.5% |
| 2 | Can skin cancer occur even in cooler climates like Himachal? | a) No b) Yes d) Rarely c) Only in summers | 267 | 66.8% |
| 3 | What is a common early sign of skin cancer? | a) Fever b) Changing mole d) Muscle weakness c) Body pain | 258 | 64.5% |
| 4 | Does higher altitude increase UV exposure? | a) No b)Yes d) Not sure c) Only in snow | 278 | 69.5% |
| 5 | Can skin cancer affect all skin tones? | a) No b) Yesd) Rare cases c) Only fair skin | 243 | 60.8% |
| 6 | Is sunscreen necessary on cloudy days? | a) Yes d) Only at noon c) Only in summer b) No | 226 | 56.5% |
| 7 | Is skin cancer preventable? | a) No b) Yesd) Only in youth c) Only with surgery | 281 | 70.3% |
| 8 | Can wearing hats and protective clothing help prevent skin cancer? | a) Yes d) Not always c) Only UV glasses work b) No | 292 | 73.0% |
| 9 | Does snow reflect UV rays and increase exposure? | a) No b) Yes d) Slightly c) Only at noon | 254 | 63.5% |
| 10 | Do tanning beds or sunlamps cause skin damage? | a) No b) Yes d) Rarely c) Only for fair skin | 245 | 61.3% |
| 11 | Are regular skin check-ups important for early detection? | a) No b) Yes d) Only for elderly c) Only if mole is present | 266 | 66.5% |
| 12 | Can skin cancer spread to other parts of the body? | a) No b) Yes d) Only internally c) Rarely | 248 | 62.0% |
| 13 | Can sunscreen with SPF 15 provide basic protection? | a) No b) Yes d) Only creams c) Only SPF 50 | 229 | 57.3% |
| 14 | Is Vitamin D production affected by sunscreen use? | a) No b) Yes d) Never c) Only in winters | 237 | 59.3% |
| 15 | Can changes in existing moles be a sign of cancer? | a) No b) Yes d) Not sure c) Only red moles | 274 | 68.5% |
| 16 | Do men and women have equal risk for skin cancer? | a) No b) Yes d) Women only c) Only elderly men | 216 | 54.0% |
| 17 | Can overexposure to sun during childhood increase skin cancer risk later? | a) No b) Yes d) Slightly c) Only in teens | 252 | 63.0% |
| 18 | Is skin cancer more common in people with family history of the disease? | a) No b) Yes d) Not linked c) Only identical twins | 241 | 60.3% |
| 19 | Are herbal remedies effective in curing skin cancer? | a) No d) Sometimes c) Only early stages b) Yes | 214 | 53.5% |
| 20 | Can skin cancer be diagnosed with a skin biopsy? | a) No b) Yes d) Only if severe c) Only X-ray | 295 | 73.8% |
Based on the cumulative scores from the knowledge assessment, participants were categorized into four levels of awareness. A majority—66.8%—of respondents fell into the “good” (37.3%) or “very good” (29.5%) knowledge brackets, reflecting a generally favorable understanding of skin cancer causes, symptoms, and prevention (Table 3). Another 22.3% demonstrated “fair” knowledge, suggesting awareness with room for improvement. Notably, 11% of participants scored in the “poor” category, indicating a critical need for targeted educational outreach among this segment. These findings are encouraging in terms of general public awareness but also point toward the need for continuous education to uplift the fair-to-poor knowledge segments, particularly regarding subtle risk factors and preventive behaviors.
Table 3: Knowledge Score Classification Among Participants (n = 400)
Knowledge Level | Score Range (out of 20) | Frequency (n) | Percentage (%) |
Very Good | 17–20 | 118 | 29.5% |
Good | 13–16 | 149 | 37.3% |
Fair | 9–12 | 89 | 22.3% |
Poor | 0–8 | 44 | 11.0% |
Statistical analysis revealed significant associations between participants’ knowledge levels and their age, education, and residential background. Age-wise, younger participants (particularly those aged 18–35) showed significantly higher awareness scores compared to older adults (p = 0.021), with the 46-and-above group displaying the highest proportion of poor scores. Education was strongly associated with knowledge (p< 0.001), where those with undergraduate and postgraduate degrees dominated the “very good” category, and individuals with little or no formal education mostly fell in the “poor” bracket. Residence also played a role (p = 0.037), with urban residents exhibiting higher awareness levels than their rural counterparts. Interestingly, gender did not show a statistically significant difference (p = 0.301), although females marginally outperformed males. These trends highlight the influence of educational attainment and environmental access on skin cancer knowledge, emphasizing the importance of inclusive health education, especially targeting older, rural, and less-educated groups (Table 4).
Table 4: Association Between Knowledge Score and Socio-Demographic Variables (n = 400)
| Variable | Category | Very Good | Good | Fair | Poor | p-value |
| Age Group | 18–25 | 21 (5.3%) | 32 (8.0%) | 7 (1.8%) | 4 (1.0%) | 0.021 |
| 26–35 | 45 (11.3%) | 41 (10.3%) | 10 (2.5%) | 6 (1.5%) | ||
| 36–45 | 29 (7.3%) | 40 (10.0%) | 18 (4.5%) | 9 (2.3%) | ||
| 46 and above | 23 (5.8%) | 36 (9.0%) | 54 (13.5%) | 25 (6.3%) | ||
| Gender | Male | 58 (14.5%) | 74 (18.5%) | 34 (8.5%) | 22 (5.5%) | 0.301 |
| Female | 60 (15.0%) | 75 (18.8%) | 55 (13.8%) | 22 (5.5%) | ||
| Education | No formal education | 2 (0.5%) | 3 (0.8%) | 10 (2.5%) | 14 (3.5%) | <0.001 |
| Primary school | 6 (1.5%) | 11 (2.8%) | 19 (4.8%) | 15 (3.8%) | ||
| Secondary school | 34 (8.5%) | 47 (11.8%) | 30 (7.5%) | 12 (3.0%) | ||
| Undergraduate | 44 (11.0%) | 55 (13.8%) | 22 (5.5%) | 6 (1.5%) | ||
| Postgraduate | 32 (8.0%) | 33 (8.3%) | 8 (2.0%) | 3 (0.8%) | ||
| Residence | Urban | 68 (17.0%) | 81 (20.3%) | 19 (4.8%) | 8 (2.0%) | 0.037 |
| Rural | 50 (12.5%) | 68 (17.0%) | 70 (17.5%) | 36 (9.0%) |
The present study provides a comprehensive assessment of the awareness, knowledge, and misconceptions regarding skin cancer and ultraviolet (UV) exposure among the general population of Himachal Pradesh, a high-altitude state uniquely predisposed to elevated UV radiation. The findings highlight a moderately encouraging level of knowledge among participants, with nearly two-thirds (66.8%) demonstrating good to very good awareness, yet simultaneously expose persistent misconceptions and significant disparities based on age, education, and place of residence.
A key strength observed was the general recognition of UV radiation as the most common causative factor for skin cancer (71.5%) and the widespread acknowledgment of preventive strategies, such as the use of protective clothing (73%) and sunscreen (56.5%). This reflects an emerging shift in public understanding, potentially driven by increased internet access, health messaging through digital media, and broader exposure to national and international awareness campaigns. However, the relatively lower awareness of subtler aspects—such as the necessity of sunscreen use on cloudy days or the ineffectiveness of herbal remedies—underscores lingering gaps that require targeted health literacy interventions. The fact that 53.5% of respondents believed in the effectiveness of herbal treatments points to the urgent need for culturally sensitive myth-busting education, particularly in rural and traditional communities.
Importantly, the study reveals that despite Himachal Pradesh’s cooler climate and hilly terrain, a significant proportion (66.8%) of participants correctly identified that skin cancer can occur even in such regions. This contradicts the common public misbelief that skin cancer is predominantly a problem of hotter, low-altitude climates. Participants also showed an appreciable understanding of other clinical and behavioral aspects, such as the role of altitude in UV exposure (69.5%), the impact of childhood sunburns (63%), and the early warning signs like changing moles (64.5%). These findings are promising and suggest that health communication is reaching key population segments—but not uniformly.
Analysis of knowledge scores against socio-demographic variables revealed stark disparities. Younger individuals, particularly those aged 18–35, had significantly higher knowledge levels compared to older adults (p = 0.021), indicating generational differences in health awareness—possibly influenced by digital literacy and information access. Similarly, educational attainment emerged as a strong predictor of awareness (p< 0.001), affirming that those with higher education (undergraduate and postgraduate levels) were more likely to demonstrate accurate understanding and fewer misconceptions. This trend is consistent with prior studies conducted in other parts of India and globally, which link higher education with greater health-seeking behavior, disease awareness, and preventive practices.
The urban-rural divide also played a crucial role in shaping awareness levels (p = 0.037). Urban residents demonstrated a greater proportion of very good knowledge scores, while rural participants were overrepresented in the fair and poor categories. This divide is particularly relevant for a state like Himachal Pradesh, where over half the population resides in rural areas with limited access to specialized dermatological services and health education campaigns. The finding emphasizes the need for decentralized, community-based interventions and mobile health outreach programs to penetrate underserved regions.
Interestingly, gender did not show a statistically significant difference in knowledge levels (p = 0.301), although female participants marginally outperformed males. This result deviates slightly from conventional trends, where males often report higher awareness in public health surveys, and may reflect changing dynamics in health engagement among women in Himachal Pradesh—a positive indicator for future outreach.
The classification of knowledge scores—where 11% of participants demonstrated poor understanding—highlights a vulnerable subgroup that may be at increased risk due to limited knowledge of skin cancer’s causes, symptoms, and prevention. Targeted efforts to reach this segment, particularly older, less-educated rural residents, will be vital in ensuring equity in health education and reducing long-term morbidity. Overall, the study fills a critical gap in the literature by providing region-specific insights into public awareness of skin cancer in a high-altitude, predominantly rural Indian state. While the findings are encouraging in many respects, they also bring into focus the urgent need for culturally tailored health campaigns, integration of skin cancer awareness into routine primary care, and policy-driven efforts to include skin protection in occupational health and public education curriculums.
This study highlights a moderately favorable level of awareness regarding skin cancer among the general population of Himachal Pradesh, with a substantial proportion demonstrating good to very good knowledge about UV-related risk factors, preventive measures, and early warning signs. However, notable gaps persist—particularly among older adults, rural residents, and those with limited formal education—alongside prevalent misconceptions about climate-specific risks and alternative treatments. The findings emphasize the critical need for regionally tailored, demographically inclusive health education initiatives that address environmental realities unique to high-altitude populations. Strengthening community outreach, integrating dermatological education into primary healthcare, and dispelling myths through culturally resonant campaigns will be essential in fostering informed, proactive public behavior toward the prevention and early detection of skin cancer in this vulnerable Himalayan state.
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