European Journal of Cardiovascular Medicine

Rheumatologic joint disorders, particularly inflammatory and autoimmune conditions such as rheumatoid arthritis (RA), ankylosing spondylitis, and systemic lupus erythematosus, represent a growing public health concern across both developed and developing nations. These diseases are often insidious in onset, beginning with non-specific symptoms like joint stiffness, mild swelling, or fatigue, which are frequently misinterpreted as age-related discomfort, overuse, or seasonal aches—especially in resource-constrained and low-awareness settings. Early recognition and intervention in rheumatologic conditions are critical, as delayed diagnosis can lead to irreversible joint damage, disability, reduced quality of life, and even multi-organ involvement in systemic cases.^1-3

In India, the burden of rheumatic diseases is often underreported and under-addressed, with national surveys and health policies traditionally focusing on infectious diseases, maternal-child health, and non-communicable diseases like diabetes and hypertension. Despite increasing urbanization and medical outreach, rheumatologic awareness remains significantly low, particularly in rural and hilly states such as Himachal Pradesh, where healthcare access, literacy levels, and cultural perceptions play pivotal roles in shaping health behavior.^4,5

The geography of Himachal Pradesh—with its cold winters, high-altitude villages, and limited tertiary care centers—presents unique challenges for early detection and sustained management of chronic joint disorders. Joint stiffness or pain is often dismissed as a normal consequence of cold weather, physical labor, or aging. Misconceptions, such as arthritis being an inevitable part of aging or the belief that painkillers or home remedies suffice, further delay medical consultations. Compounding these issues is the lack of community-level education on autoimmune conditions, the absence of rheumatology-trained specialists at the primary care level, and the underutilization of screening tools such as blood markers and imaging.^5-7

Furthermore, while musculoskeletal pain is one of the most common reasons for outpatient visits globally, its rheumatologic etiology is rarely explored at early stages unless significant deformity or disability emerges. This diagnostic inertia is especially concerning among young adults and women, who often delay care due to household responsibilities, stigma, or financial constraints. Additionally, early signs such as morning stiffness, symmetrical joint swelling, or fatigue are subtle and can mimic orthopedic or even psychological issues—resulting in further misdirection.^2,6,7

Given these challenges, understanding the level of public awareness regarding early rheumatologic symptoms, their causes, consequences, and management is crucial. Few studies in India have evaluated community perceptions of autoimmune joint disorders in hilly regions. The knowledge gaps and misbeliefs prevalent in such populations not only impede timely diagnosis but also result in increased long-term costs, both personal and systemic.

This study, therefore, aims to assess public awareness, beliefs, and misconceptions about early rheumatologic joint disorders among residents of Himachal Pradesh. By analyzing awareness patterns across socio-demographic variables—such as age, gender, education, occupation, and rural–urban residence—this research seeks to generate actionable evidence for community education, early screening initiatives, and policy integration into regional primary care strategies. Such data are imperative for designing terrain-sensitive, culturally aligned interventions that can curb preventable disability, improve quality of life, and strengthen rheumatologic health systems in underserved, high-risk populations.

Study Design and Setting

This study employed a descriptive, cross-sectional survey design aimed at evaluating public awareness, knowledge gaps, and prevalent misconceptions regarding early rheumatologic joint disorders in the hilly state of Himachal Pradesh, India. Given the geographically dispersed and topographically challenging nature of the region, the survey was conducted digitally using a structured Google Form. This method enabled broader reach across both urban and rural areas, accommodating participants from varying educational and socioeconomic backgrounds.

Study Period

Data collection was conducted over a period of three months, from May to June 2025.

This timeline ensured the inclusion of participants across different weather conditions—an important consideration in a study addressing musculoskeletal health, which may be perceived to fluctuate with climate and seasonal variation.

Sample Size and Sampling Technique

A total of 400 participants were included in the final analysis. The sample size was determined using Cochran’s formula for cross-sectional studies, assuming a 50% baseline awareness rate for maximum variability, a 5% margin of error, and a 95% confidence level. A non-probability, convenience sampling method was used. The survey link was disseminated through digital platforms such as WhatsApp, Facebook, and local community groups, and was supported by outreach from local influencers, healthcare volunteers, and educational institutions to enhance regional representation.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Residents of Himachal Pradesh aged 18 years and above.
• Individuals able to read and respond in Hindi or English.
• Respondents who provided informed digital consent prior to participation.

Exclusion Criteria:

• Healthcare professionals including doctors, physiotherapists, or medical students, to avoid knowledge bias.
• Incomplete, inconsistent, or duplicate responses.
• Participants with cognitive impairments or disabilities that prevented independent comprehension and response.

Survey Instrument and Validation

The survey questionnaire was designed following an extensive literature review on rheumatologic conditions, early diagnostic criteria, public health awareness studies, and WHO musculoskeletal health frameworks. It was reviewed by a panel of experts including rheumatologists, physiotherapists, and public health professionals to ensure clinical accuracy, cultural relevance, and linguistic clarity.

The final version of the questionnaire, available in both English and Hindi, was pilot-tested on a sample of 20 individuals for comprehensibility, timing, and technical issues. Necessary modifications were made based on the pilot feedback before rolling out the main survey.

Questionnaire Structure

The survey was composed of four main sections:

1. Socio-Demographic Data – including age, gender, education, occupation, and residence (urban or rural).
2. Awareness and Misconception Assessment – comprising 20 multiple-choice questions addressing:
   • Common symptoms (e.g., morning stiffness, joint swelling),
   • Risk factors (e.g., autoimmune causes, gender bias),
   • Diagnostic knowledge (e.g., role of blood tests),
   • Treatment misconceptions (e.g., sufficiency of painkillers, role of diet),
   • Long-term consequences of delayed intervention.
3. Knowledge Scoring – Based on the number of correct responses:
   • Very Good (17–20),
   • Good (13–16),
   • Fair (9–12),
   • Poor (0–8).

The correct answers were determined based on validated rheumatologic guidelines, early diagnostic criteria (e.g., ACR/EULAR), and evidence-based practices.

Ethical Considerations

The study adhered to the ethical standards of the Declaration of Helsinki. Participation was entirely voluntary, anonymous, and non-remunerative. A digital informed consent statement was embedded at the beginning of the Google Form, and only consenting participants were allowed to proceed with the survey.

Data Management and Statistical Analysis

Responses were automatically collected through Google Forms and securely stored in a password-protected Google Sheet. The dataset was then exported to Microsoft Excel for cleaning and subsequently analyzed using IBM SPSS Statistics version 25.

Descriptive statistics (frequencies and percentages) were used to summarize socio-demographic characteristics and response patterns. To determine the association between knowledge levels and socio-demographic variables, Chi-square tests were applied. A p-value of less than 0.05 was considered statistically significant in all analyses.

The study included a total of 400 respondents from diverse socio-demographic backgrounds. Age-wise, the largest segment (34.5%) of participants was in the 46 years and above group, followed by 26–35 years (26.0%), 36–45 years (24.5%), and 18–25 years (15.0%). Female participants comprised the majority (56.0%), while males made up 44.0% of the sample. Educational attainment varied across the group, with most respondents having completed secondary education (32.0%) or an undergraduate degree (30.0%). A smaller proportion had postgraduate qualifications (14.5%), while 7.5% reported having no formal education. In terms of occupation, homemakers formed the largest group (23.0%), followed by private sector employees (21.5%), students (18.5%), self-employed individuals (14.0%), government employees (12.0%), and retired or other professions (11.0%). Regarding place of residence, a larger proportion (59.0%) belonged to rural areas, while 41.0% were from urban localities—reflecting the study’s focus on region-wide inclusion across Himachal Pradesh’s mixed terrain.

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

The awareness assessment revealed moderately high knowledge levels among participants concerning early signs and implications of rheumatologic joint disorders. The majority (71.8%) correctly recognized early morning stiffness as a key symptom, and 71.5% understood that untreated joint disorders can lead to permanent deformity. Similarly, 66.5% identified autoimmune conditions as the primary cause of such disorders, while 69.5% acknowledged that joint pain in young individuals may be indicative of an early rheumatologic issue. However, misconceptions remained: only 58.0% knew that joint disorders could affect internal organs, and 57.3% correctly understood that joint noise (clicking) is not always pathological. Encouragingly, 74.3% were aware that these diseases are not contagious, and 73.8% agreed on the need for early consultation with a rheumatologist in cases of recurrent joint stiffness. Awareness regarding the diagnostic role of blood tests (69.0%) and dietary influence on inflammation (67.3%) was also substantial. Yet, knowledge remained inconsistent regarding treatment aspects, as only 60.8% correctly denied that steroids are always needed in early treatment. Overall, responses suggest that while basic awareness exists, targeted efforts are required to address nuanced misconceptions, particularly around diagnosis, treatment modalities, and systemic involvement.

Table 2: Awareness and Misconception Questions on Early Rheumatologic Joint Disorders (n = 400)

Participants' overall knowledge levels regarding early rheumatologic joint disorders were classified based on the number of correct responses out of 20 awareness questions. The majority demonstrated moderate to strong awareness, with 35.5% falling into the "Good" category (13–16 correct answers), and 30.0% achieving a "Very Good" score (17–20 correct answers). Meanwhile, 22.5% were classified under the "Fair" knowledge level (9–12 correct answers), and 12.0% scored in the "Poor" category (0–8 correct answers). These findings indicate that although approximately two-thirds of participants possessed a commendable level of awareness, there remains a significant knowledge gap among the rest of the population—underscoring the necessity for intensified health education and early screening advocacy, especially in rural and older populations.

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

Chi-square analysis revealed significant associations between knowledge levels and specific socio-demographic factors. Age was notably linked with awareness levels (p = 0.020), with younger age groups (18–35 years) more likely to score in the “Very Good” and “Good” categories, while participants aged 46 and above disproportionately represented the “Fair” and “Poor” categories. Education emerged as the strongest determinant (p < 0.001); respondents with undergraduate or postgraduate degrees had the highest proportions of “Very Good” scores, whereas those with only primary education or no formal schooling showed lower awareness. Residence also showed a statistically significant relationship with knowledge levels (p = 0.027), as urban participants had considerably higher scores compared to their rural counterparts. Interestingly, gender did not demonstrate a significant correlation (p = 0.244), indicating comparable levels of awareness across both sexes. These findings emphasize the need for targeted educational interventions aimed particularly at older adults, rural communities, and individuals with lower levels of formal education.

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

This cross-sectional survey, conducted among 400 residents of Himachal Pradesh, offers significant insights into the public's awareness and understanding of early rheumatologic joint disorders. The findings underscore both promising awareness in some domains and deeply rooted misconceptions in others—particularly within rural and less-educated populations—highlighting the urgent need for context-sensitive, terrain-appropriate health interventions.

The socio-demographic profile of participants indicated a relatively balanced and inclusive representation, with a slight female predominance and strong participation from rural areas (59%). This is reflective of the state’s predominantly rural demography and suggests that digital tools like Google Forms, when paired with community mobilization strategies, can effectively reach underrepresented populations. The high proportion of participants aged over 45 years (34.5%) further strengthened the study's relevance, as this age group is particularly vulnerable to rheumatologic morbidity yet often delays formal healthcare engagement.

The awareness assessment revealed moderately strong knowledge in certain areas—most notably regarding hallmark symptoms such as morning stiffness (71.8%) and the potential for permanent deformity from untreated disease (71.5%). These findings suggest that broad messages about joint damage and disease progression have permeated public consciousness to a degree. Encouragingly, 74.3% of respondents accurately denied that rheumatologic conditions are contagious, indicating relatively low stigma and a scientifically informed perception on disease etiology. Similarly, 69.0% were aware that blood tests could be instrumental in early diagnosis, pointing toward a baseline familiarity with diagnostic protocols.

However, despite these strengths, several critical misconceptions persist. For instance, only 58.0% were aware that rheumatologic joint disorders can affect internal organs—an alarming gap given the systemic nature of many autoimmune diseases such as lupus or psoriatic arthritis. Additionally, just 57.3% understood that joint clicking sounds are not always pathological, reflecting a tendency to conflate normal musculoskeletal variations with disease. Treatment misconceptions were also notable; only 60.8% knew that steroids are not always required, and a significant portion remained unsure about the long-term adequacy of painkillers. These gaps can lead to inappropriate self-medication or delayed medical engagement, which in turn can worsen prognosis.

The knowledge score classification adds further granularity to these findings. While 65.5% of participants were categorized under “Good” or “Very Good” knowledge levels, a non-negligible 12.0% scored “Poor”—a group likely at high risk for delayed diagnosis or reliance on non-evidence-based practices. These results align with previous studies conducted in low-literacy regions of India, which consistently report underappreciation of autoimmune causes, limited use of rheumatology services, and over-reliance on analgesics or traditional remedies.

Importantly, the association between socio-demographic variables and knowledge scores revealed statistically significant disparities. Age and education emerged as key determinants. Participants aged 46 and above were significantly more likely to fall into the “Fair” and “Poor” knowledge categories (p = 0.020), suggesting generational barriers to new medical knowledge or reduced exposure to digital health content. In contrast, younger adults—particularly those aged 26–35 years—demonstrated higher knowledge scores, potentially due to better digital literacy and more recent exposure to formal education.

Education level, unsurprisingly, showed a robust correlation with awareness (p < 0.001). Respondents with undergraduate or postgraduate education had substantially higher “Very Good” scores compared to those with only primary education or no schooling. This reinforces the need for non-text-based, vernacular, and visual health communication strategies to address the needs of low-literacy populations.

Residence also played a significant role (p = 0.027), with urban participants displaying higher knowledge scores across all categories. This urban–rural divide reflects disparities in healthcare access, exposure to specialist consultations, and proximity to diagnostic services. Given that most tertiary-level rheumatologic care is urban-centric in India, rural populations remain underserved and underinformed—despite being potentially more vulnerable due to physical labor, colder climates, and limited mobility.

Gender, interestingly, did not show a significant association with knowledge levels (p = 0.244), indicating that both males and females in this setting possess comparable levels of awareness. This could be interpreted as a positive sign of gender parity in health information dissemination, although further qualitative studies would be useful to assess gender-specific help-seeking behavior and symptom reporting.

Collectively, these findings illuminate a complex interplay of knowledge, misperception, and systemic barriers. The cold climate and mountainous terrain of Himachal Pradesh may contribute to a cultural normalization of joint discomfort, particularly among older adults and manual laborers, who often attribute stiffness and pain to aging or weather. Furthermore, the low presence of rheumatologists and limited community-level educational programs specific to autoimmune joint disorders perpetuate diagnostic inertia.^5-7

In light of these findings, public health strategies should prioritize:

• Community-based awareness campaigns using culturally appropriate media and language,
• Training of frontline health workers to recognize early red flags of rheumatologic disease,
• Integration of rheumatologic screening into existing non-communicable disease programs,
• Mobile diagnostic camps in remote and rural areas,
• And promotion of early consultation with rheumatologists or trained general physicians, especially for populations above 40 years of age.

Ultimately, this study emphasizes that early detection and education are the most cost-effective tools to prevent long-term disability and organ involvement in rheumatologic conditions. The data underscore the need for terrain-specific, demographically targeted interventions and highlight the feasibility of digital tools in epidemiological assessments, even in geographically challenging regions like Himachal Pradesh.

This cross-sectional survey, conducted among 400 residents of Himachal Pradesh, offers significant insights into the public's awareness and understanding of early rheumatologic joint disorders. The findings underscore both promising awareness in some domains and deeply rooted misconceptions in others—particularly within rural and less-educated populations—highlighting the urgent need for context-sensitive, terrain-appropriate health interventions.

The socio-demographic profile of participants indicated a relatively balanced and inclusive representation, with a slight female predominance and strong participation from rural areas (59%). This is reflective of the state’s predominantly rural demography and suggests that digital tools like Google Forms, when paired with community mobilization strategies, can effectively reach underrepresented populations. The high proportion of participants aged over 45 years (34.5%) further strengthened the study's relevance, as this age group is particularly vulnerable to rheumatologic morbidity yet often delays formal healthcare engagement.

The awareness assessment revealed moderately strong knowledge in certain areas—most notably regarding hallmark symptoms such as morning stiffness (71.8%) and the potential for permanent deformity from untreated disease (71.5%). These findings suggest that broad messages about joint damage and disease progression have permeated public consciousness to a degree. Encouragingly, 74.3% of respondents accurately denied that rheumatologic conditions are contagious, indicating relatively low stigma and a scientifically informed perception on disease etiology. Similarly, 69.0% were aware that blood tests could be instrumental in early diagnosis, pointing toward a baseline familiarity with diagnostic protocols.

However, despite these strengths, several critical misconceptions persist. For instance, only 58.0% were aware that rheumatologic joint disorders can affect internal organs—an alarming gap given the systemic nature of many autoimmune diseases such as lupus or psoriatic arthritis. Additionally, just 57.3% understood that joint clicking sounds are not always pathological, reflecting a tendency to conflate normal musculoskeletal variations with disease. Treatment misconceptions were also notable; only 60.8% knew that steroids are not always required, and a significant portion remained unsure about the long-term adequacy of painkillers. These gaps can lead to inappropriate self-medication or delayed medical engagement, which in turn can worsen prognosis.

The knowledge score classification adds further granularity to these findings. While 65.5% of participants were categorized under “Good” or “Very Good” knowledge levels, a non-negligible 12.0% scored “Poor”—a group likely at high risk for delayed diagnosis or reliance on non-evidence-based practices. These results align with previous studies conducted in low-literacy regions of India, which consistently report underappreciation of autoimmune causes, limited use of rheumatology services, and over-reliance on analgesics or traditional remedies.

Importantly, the association between socio-demographic variables and knowledge scores revealed statistically significant disparities. Age and education emerged as key determinants. Participants aged 46 and above were significantly more likely to fall into the “Fair” and “Poor” knowledge categories (p = 0.020), suggesting generational barriers to new medical knowledge or reduced exposure to digital health content. In contrast, younger adults—particularly those aged 26–35 years—demonstrated higher knowledge scores, potentially due to better digital literacy and more recent exposure to formal education.

Education level, unsurprisingly, showed a robust correlation with awareness (p < 0.001). Respondents with undergraduate or postgraduate education had substantially higher “Very Good” scores compared to those with only primary education or no schooling. This reinforces the need for non-text-based, vernacular, and visual health communication strategies to address the needs of low-literacy populations.

Residence also played a significant role (p = 0.027), with urban participants displaying higher knowledge scores across all categories. This urban–rural divide reflects disparities in healthcare access, exposure to specialist consultations, and proximity to diagnostic services. Given that most tertiary-level rheumatologic care is urban-centric in India, rural populations remain underserved and underinformed—despite being potentially more vulnerable due to physical labor, colder climates, and limited mobility.

Gender, interestingly, did not show a significant association with knowledge levels (p = 0.244), indicating that both males and females in this setting possess comparable levels of awareness. This could be interpreted as a positive sign of gender parity in health information dissemination, although further qualitative studies would be useful to assess gender-specific help-seeking behavior and symptom reporting.

Collectively, these findings illuminate a complex interplay of knowledge, misperception, and systemic barriers. The cold climate and mountainous terrain of Himachal Pradesh may contribute to a cultural normalization of joint discomfort, particularly among older adults and manual laborers, who often attribute stiffness and pain to aging or weather. Furthermore, the low presence of rheumatologists and limited community-level educational programs specific to autoimmune joint disorders perpetuate diagnostic inertia.^5-7

In light of these findings, public health strategies should prioritize:

• Community-based awareness campaigns using culturally appropriate media and language,
• Training of frontline health workers to recognize early red flags of rheumatologic disease,
• Integration of rheumatologic screening into existing non-communicable disease programs,
• Mobile diagnostic camps in remote and rural areas,
• And promotion of early consultation with rheumatologists or trained general physicians, especially for populations above 40 years of age.

Ultimately, this study emphasizes that early detection and education are the most cost-effective tools to prevent long-term disability and organ involvement in rheumatologic conditions. The data underscore the need for terrain-specific, demographically targeted interventions and highlight the feasibility of digital tools in epidemiological assessments, even in geographically challenging regions like Himachal Pradesh.

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