Low back pain (LBP) is one of the most prevalent musculoskeletal conditions globally, affecting individuals across all age groups and significantly impairing quality of life, productivity, and functional independence. According to the Global Burden of Disease Study, LBP ranks among the leading causes of disability worldwide, with a particularly high burden in low- and middle-income countries due to limited access to preventive care and rehabilitation services.1-4 In India, the rising prevalence of LBP is attributed to rapid urbanization, sedentary lifestyles, poor ergonomic practices, and increasing physical strain in labor-intensive occupations. Despite its growing impact, public awareness of the risk factors and preventive strategies for LBP remains insufficient, particularly in rural and geographically challenging regions like Himachal Pradesh.

Himachal Pradesh presents a unique interplay of occupational diversity and terrain-induced physical demands. Rural residents frequently engage in strenuous agricultural tasks, manual load-bearing, and prolonged bending on uneven slopes—activities that, if performed incorrectly or repetitively, contribute significantly to the development of LBP. Conversely, urban dwellers are increasingly exposed to sedentary behaviors, prolonged screen time, poor sitting posture, and inadequate physical activity—modern lifestyle patterns equally implicated in LBP etiology.5-9 This dual burden of physical overexertion and sedentary risk factors across the rural-urban spectrum makes Himachal Pradesh an important setting for evaluating public knowledge and awareness related to LBP.

Despite widespread clinical evidence associating improper posture, poor lifting techniques, obesity, lack of exercise, and psychosocial stress with low back pain, there is limited community-level research assessing the extent to which the general population understands these risks. Early recognition and behavioral modifications are critical for LBP prevention, yet misconceptions and cultural normalization of back pain often delay appropriate management. Furthermore, awareness disparities may exist between urban and rural populations due to differences in education, access to healthcare, and exposure to ergonomic information.9-13

This study aims to evaluate and compare the awareness of risk factors contributing to low back pain among urban and rural residents of Himachal Pradesh. By identifying knowledge gaps and socio-demographic influences on LBP awareness, the findings will inform region-specific educational interventions, preventive strategies, and policy decisions to reduce the burden of back-related disability in both urbanized centers and remote communities.

Study Design

This study employed a descriptive, cross-sectional survey design to evaluate the level of awareness regarding risk factors for low back pain (LBP) among the general population of Himachal Pradesh. The primary objective was to assess and compare awareness levels across rural and urban residents and to analyze associations with key socio-demographic factors.

Study Area and Population

The study was conducted across multiple districts in Himachal Pradesh, representing both rural and urban regions to ensure geographic and demographic diversity. The target population included individuals aged 18 years and above, from various educational, occupational, and socioeconomic backgrounds. Participants with professional healthcare or physiotherapy training were excluded to avoid bias from prior clinical knowledge and to ensure the focus remained on general public awareness.

Sample Size and Sampling Technique

A total of 400 participants were included in the study, selected using a purposive and convenience sampling method. The sample size was calculated based on a 95% confidence level, 5% margin of error, and an anticipated awareness rate of 50%, which is commonly used in exploratory community-based knowledge studies. Participation was encouraged through community outreach, local influencers, and dissemination of the digital survey link via WhatsApp, email, and social media platforms.

Data Collection Tool

Data were gathered using a structured, self-administered Google Form questionnaire. The tool was developed with expert input from orthopedic specialists, physiotherapists, and public health professionals to ensure content validity. It was bilingual (English and Hindi) to enhance clarity and accessibility across different literacy levels. The questionnaire comprised three main sections:

1. Socio-demographic Profile – including age, gender, education, occupation, and place of residence.
2. Knowledge-Based Questions – 20 multiple-choice questions focusing on recognized risk factors for LBP, such as poor posture, improper lifting, prolonged sitting, obesity, stress, lack of exercise, and sedentary lifestyle.
3. Awareness and Practice Items – exploring everyday behaviors related to physical activity, posture, and early response to back pain symptoms.

Pilot Testing

The questionnaire was pre-tested on a small group of 30 individuals from different districts in Himachal Pradesh to evaluate the clarity, reliability, and digital accessibility of the survey. Based on feedback, revisions were made to improve question phrasing and eliminate ambiguity.

Scoring and Knowledge Categorization

Each correct response in the knowledge section was assigned one point, with a maximum achievable score of 20. Based on total scores, knowledge levels were classified into four categories:

• Very Good: 17–20
• Good: 13–16
• Fair: 9–12
• Poor: 0–8

This classification facilitated the analysis of population-level knowledge trends and demographic disparities.

Ethical Considerations

Participants provided informed electronic consent prior to accessing the questionnaire. The consent form detailed the study’s purpose, voluntary nature, anonymity, confidentiality, and the right to withdraw at any point without consequence. The study followed the ethical standards of the Declaration of Helsinki and did not collect any personally identifiable information.

Data Analysis

Data were exported from Google Forms to Microsoft Excel and analyzed using Epi Info Version 7. Descriptive statistics, including frequencies and percentages, were used to summarize socio-demographic characteristics and response patterns. Chi-square tests were conducted to evaluate associations between knowledge levels and socio-demographic variables, with a p-value < 0.05 considered statistically significant.

The study sample consisted of 400 participants with diverse socio-demographic backgrounds. The age distribution revealed that the largest group (31.3%) was aged 46 years and above, followed by those aged 26–35 (29.3%) and 36–45 (24.8%), with the youngest age group (18–25) comprising 14.8% of the respondents. There was a slight female predominance (54.5%) compared to males (45.5%). Educational attainment varied, with the majority having completed secondary education (34.0%) or undergraduate studies (28.5%). A smaller percentage (7.0%) had no formal education. Occupation-wise, the cohort included homemakers (22.3%), private sector employees (21.8%), students (15.3%), and government employees (17.3%), reflecting occupational diversity. Rural residents made up a larger portion of the sample (56.2%) compared to urban dwellers (43.8%), enabling the study to meaningfully assess urban–rural variations in awareness.

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

The awareness assessment indicated relatively high recognition of low back pain (LBP) risk factors among participants. Most respondents correctly identified the lower spine as the primary area affected by LBP (72.0%), acknowledged poor posture (73.5%) and prolonged sitting (74.0%) as major contributors, and understood the role of physical inactivity (75.5%) and sedentary lifestyle (74.8%) in exacerbating back pain. Other well-understood risk factors included improper lifting (74.5%), obesity (70.8%), and heavy school bags in children (72.8%). However, awareness was comparatively lower for less obvious contributors such as mental stress (62.0%), smoking (59.8%), and unnecessary imaging like routine X-rays/MRIs (58.0%). These findings reveal both strength in general understanding and specific gaps in nuanced or lesser-known risk domains, especially those involving lifestyle and psychological dimensions.

Table 2: Awareness Questions on Risk Factors for Low Back Pain (n = 400)

Participants’ cumulative knowledge scores on LBP risk factors were categorized into four levels. A majority demonstrated either Very Good (31.5%) or Good (34.8%) knowledge, indicating a promising level of public understanding. Nonetheless, 22.3% of respondents fell into the Fair category, and 11.5% showed Poor knowledge, reflecting a knowledge gap in nearly one-third of the population. These results suggest that while awareness is generally satisfactory, a substantial proportion of individuals—especially those in educationally or geographically disadvantaged groups—may be insufficiently informed about LBP risk mitigation strategies. This calls for expanded public education and targeted awareness interventions, particularly among vulnerable groups.

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

Chi-square analysis revealed significant associations between knowledge scores and variables such as age (p = 0.017), education level (p < 0.001), and place of residence (p = 0.041). Participants aged 26–45 years were most likely to score Very Good or Good, possibly due to greater engagement with health resources through work or digital media. Education emerged as a strong determinant, with postgraduate and undergraduate participants achieving higher knowledge scores than those with lower or no formal education. Urban respondents demonstrated better awareness than rural ones, reflecting disparities in information access and healthcare exposure. Interestingly, gender was not significantly associated with knowledge (p = 0.264), suggesting that both men and women had comparable awareness levels. These findings highlight the critical need for inclusive and accessible health education, particularly targeting rural and less-educated populations.

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

This study provides a comprehensive evaluation of public awareness regarding the risk factors associated with low back pain (LBP) among urban and rural populations in Himachal Pradesh. The findings highlight a generally good level of awareness across several domains, yet reveal substantial gaps in knowledge and notable disparities influenced by socio-demographic variables such as age, education level, and place of residence.

The demographic distribution of the study population was diverse and inclusive, allowing for meaningful comparisons across different groups. With a slight female predominance and a majority of participants from rural areas, the sample adequately reflects the demographic structure of Himachal Pradesh, where physical labor-intensive occupations and limited healthcare infrastructure are more common in rural settings. The broad representation across age groups and educational backgrounds strengthens the validity and applicability of the findings.

Awareness levels were encouraging overall, with most participants correctly identifying key risk factors such as poor posture, prolonged sitting, sedentary behavior, obesity, and improper lifting techniques. These findings align with global literature that attributes much of the LBP burden to modifiable lifestyle factors. Particularly high recognition of physical inactivity (75.5%) and sedentary lifestyle (74.8%) as contributors to back pain reflects increasing public exposure to health information through digital media and government campaigns. However, awareness of less visible risk factors—such as mental stress (62.0%), smoking (59.8%), and inappropriate imaging practices (58.0%)—was comparatively lower. This indicates a need to expand health education beyond physical causes and integrate psychosocial and systemic contributors to musculoskeletal health.

The study’s scoring and classification system further revealed that while 66.3% of respondents fell within the Very Good or Good knowledge categories, a significant proportion (33.8%) demonstrated only Fair or Poor knowledge. This knowledge disparity is particularly concerning in regions like Himachal Pradesh, where individuals are regularly exposed to physical demands due to the mountainous terrain, and where delayed healthcare access can exacerbate minor musculoskeletal issues into chronic conditions.

Crucially, statistical analysis underscored that education level was a significant predictor of knowledge (p < 0.001), with those holding undergraduate and postgraduate qualifications outperforming participants with lower or no formal education. This finding is consistent with previous research that links health literacy to formal education, suggesting that community-based interventions must be tailored for individuals with limited educational exposure, potentially using audio-visual aids, vernacular language, and culturally relevant illustrations.

Another significant finding was the association between age and awareness (p = 0.017). Adults aged 26–45 demonstrated the highest awareness levels, which could be attributed to their active participation in the workforce and greater interaction with digital health platforms. Older adults, particularly those over 46 years, were more likely to score in the Fair or Poor categories. This age-related gap indicates a critical need for outreach initiatives targeting elderly populations, who may rely more on traditional practices and be less familiar with modern ergonomic guidelines.

Urban residents showed higher levels of awareness than rural counterparts (p = 0.041), which can be attributed to better access to health education, ergonomic infrastructure, and healthcare professionals in urban settings. However, considering that rural participants comprised over half of the sample, and given their high-risk physical routines, this urban–rural divide presents a serious public health concern. Bridging this gap requires targeted health literacy campaigns, possibly through mobile health units, village health workers, and local governance bodies.

Interestingly, gender did not significantly influence awareness (p = 0.264), indicating that both males and females had similar levels of understanding regarding LBP risk factors. This is an important finding as it suggests that future awareness programs do not need to be gender-specific but should rather focus on other stratifying variables such as residence, education, and age.

The study's strengths lie in its comprehensive design, inclusion of both urban and rural populations, and the use of a validated and bilingual questionnaire tailored to regional needs. However, its reliance on self-reported digital forms could introduce response biases, particularly underrepresentation of individuals with limited digital literacy. Moreover, being a cross-sectional study, it does not capture behavioral changes or longitudinal outcomes related to knowledge levels.

In summary, while there is a moderately strong baseline understanding of LBP risk factors among the population, the persistence of key knowledge gaps—particularly in rural, elderly, and less-educated segments—underscores the urgent need for region-specific health promotion strategies. Integrating ergonomics education into public health initiatives, workplace wellness programs, and school curricula may substantially improve early recognition, prevention, and self-management of LBP in Himachal Pradesh.9-13

Limitations

This study, while insightful, is subject to several limitations. The use of a self-administered digital Google Form may have introduced a selection bias by favoring participants with internet access and basic digital literacy, potentially excluding older adults or individuals from remote areas with limited connectivity. The convenience sampling method, although practical, may limit the generalizability of findings to the broader Himachali population. Additionally, the cross-sectional design captures awareness at a single point in time and does not account for changes in knowledge or behavior over time. Self-reported responses also carry the risk of social desirability bias, where participants may overstate their knowledge or practices related to low back pain.

The study reveals a generally promising level of awareness regarding low back pain risk factors among the residents of Himachal Pradesh, with notable strengths in recognizing common physical contributors such as poor posture, prolonged sitting, and sedentary lifestyles. However, significant knowledge gaps remain—particularly in understanding psychosocial and lifestyle-related factors like mental stress and smoking. Education level, age, and place of residence emerged as key determinants of awareness, highlighting disparities that must be addressed. The findings underscore the importance of expanding community health literacy and ergonomic education, particularly for rural, elderly, and less-educated populations, to reduce the burden of low back pain across both urban and rural settings.

Recommendations

To effectively address the burden of low back pain in Himachal Pradesh, targeted health education initiatives must be developed and delivered through accessible and culturally appropriate channels. Community-based awareness programs should prioritize ergonomic training, proper lifting techniques, and posture correction, especially for rural laborers and sedentary urban workers. School curricula should include modules on spine health and preventive practices from an early age. Additionally, mobile health units and local health workers can play a vital role in disseminating information to underserved rural areas. Strengthening primary healthcare systems to provide early screening and rehabilitation for back pain, along with leveraging digital platforms for widespread dissemination of ergonomic awareness, can further support long-term prevention and behavioral change.

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