Bone cancer, though relatively rare compared to other malignancies, poses a significant health threat due to its aggressive nature, diagnostic delays, and high treatment burden. Early detection of bone cancer drastically improves prognosis, reduces the extent of surgical intervention, and enhances quality of life. However, public knowledge about the early warning signs—such as persistent bone pain, unexplained swelling, fatigue, pathological fractures, and weight loss—remains limited, especially in resource-constrained and geographically isolated regions. In India, where healthcare literacy varies widely and cancer awareness campaigns often focus on more prevalent cancers (like breast, cervical, or oral cancer), bone cancer remains a poorly understood condition among the general population.^1-5

Himachal Pradesh, with its unique topography, rural dominance, and limited access to specialized oncology services, represents a population at risk of delayed cancer recognition. Cultural beliefs, reliance on traditional healers, and limited exposure to formal health education further hinder timely medical consultation. While musculoskeletal pain is often dismissed as age-related or due to physical labor, the lack of awareness about when such symptoms warrant investigation for serious conditions like malignancy can lead to late-stage diagnoses. Understanding the population’s baseline knowledge about bone cancer is therefore critical to designing effective public health interventions.^6-8

Existing literature has addressed general cancer awareness in India, but region-specific studies focusing on bone cancer are scarce.^7-10 Moreover, no prior research has comprehensively assessed public knowledge of bone cancer warning signs in Himachal Pradesh. Given the importance of community-level awareness in promoting early diagnosis and improving treatment outcomes, this study aims to evaluate the current level of understanding among adults in Himachal Pradesh regarding bone cancer symptoms and risk factors. The findings will serve as a foundation for developing targeted educational programs and outreach strategies to promote early health-seeking behavior and reduce diagnostic delays in this vulnerable population.

Study Design and Objective

This study employed a descriptive, cross-sectional design to assess public awareness regarding the warning signs and early symptoms of bone cancer among adults residing in Himachal Pradesh. The primary objective was to evaluate the population’s knowledge related to common clinical presentations of bone cancer and identify socio-demographic factors influencing awareness levels.

Study Population and Setting

The study was conducted among adults aged 18 years and above across various districts of Himachal Pradesh, encompassing both rural and urban settings. Participants were eligible if they were permanent residents of the state and had no professional background in healthcare, oncology, or related fields. The aim was to capture the general public's understanding rather than expert or clinical knowledge.

Sampling Method and Sample Size

A total of 400 participants were selected using a combination of convenience and purposive sampling to ensure adequate coverage across diverse age groups, education levels, occupations, and geographic locations. The sample size was calculated using a 95% confidence interval, 5% margin of error, and an assumed awareness prevalence of 50%, which provides maximum variability.

Data Collection Tool

Data were collected using a structured, pre-validated questionnaire designed in both English and Hindi. The questionnaire was hosted on Google Forms to allow for wide digital distribution through social media platforms such as WhatsApp, Facebook, and email. The questionnaire was reviewed by oncology experts, orthopedic surgeons, and public health professionals to ensure content validity, cultural appropriateness, and clarity.

The tool included three main sections:

1. Socio-demographic details (age, gender, education, occupation, residence, marital status)
2. Bone cancer awareness questions – covering early warning signs (persistent pain, swelling, fractures, fatigue), risk perception, and awareness of the need for early medical consultation
3. Health-seeking behavior – to explore attitudes toward symptoms, common sources of health information, and preferred healthcare pathways

Pilot Testing

The questionnaire underwent pilot testing with 30 individuals to evaluate clarity, language accessibility, and digital functionality. Minor modifications were made based on participant feedback to improve the questionnaire’s effectiveness before rolling it out to the full study sample.

Scoring and Knowledge Classification

Participants received 1 point for each correct response in the awareness section. The total score out of 20 was used to categorize knowledge into four levels:

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

This allowed for stratified analysis across socio-demographic groups.

Ethical Considerations

This study adhered to the principles outlined in the Declaration of Helsinki. Electronic informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were strictly maintained throughout the study, and no personally identifiable information was recorded.

Data Analysis

All responses were exported from Google Forms into Microsoft Excel and analyzed using Epi Info version 7. Descriptive statistics (frequencies and percentages) were used to summarize categorical variables. The Chi-square test was used to determine associations between knowledge scores and socio-demographic characteristics. A p-value < 0.05 was considered statistically significant.

Table 1 presents the socio-demographic distribution of the 400 respondents who participated in the study on bone cancer awareness in Himachal Pradesh. The participants were well-distributed across various age groups, with the largest proportion (30.3%) aged 46 years and above, followed by 26–35 years (29.3%), indicating inclusion of both younger and older populations. Gender representation was nearly balanced, with males (52.3%) slightly outnumbering females (47.8%). Educational attainment showed that a substantial proportion had completed secondary education (34.8%) or were undergraduates (28.8%), though a significant minority (23.3%) had only primary or no formal education—highlighting potential disparities in health literacy. Occupationally, participants ranged from homemakers (20.3%) and private sector employees (21.0%) to government employees and self-employed individuals, reflecting occupational diversity. A rural majority (55.5%) was observed, reinforcing the study’s focus on underrepresented populations. The marital status breakdown revealed that most respondents were married (65.3%), a factor that may influence healthcare decision-making and symptom reporting.

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

Table 2 summarizes responses to 20 structured multiple-choice questions assessing knowledge about bone cancer symptoms and warning signs. Awareness was moderate to high across most questions, with the highest correct response rate (73.0%) related to the importance of early detection for better outcomes. Participants also showed good understanding that imaging techniques (72.3%), persistent bone pain (70.8%), and immediate medical consultation (71.0%) are key in managing suspected bone cancer cases. However, there were areas of relative knowledge deficit—for example, only 59.5% correctly recognized that bone cancer may not initially present with pain, indicating a gap in understanding of atypical symptom progression. Similarly, awareness regarding the age distribution of bone cancer, risk of metastasis, and early diagnostic indicators like fatigue and swelling hovered around 64–69%, suggesting that while the population has foundational knowledge, there is room for improvement in understanding nuanced and early-stage presentations of bone malignancies.

Table 2: Awareness Questions on Bone Cancer Warning Signs (n = 400)

Table 3 categorizes participants based on their overall awareness scores. A promising 66.1% of participants fell into the “Very Good” (30.8%) or “Good” (35.3%) awareness categories, indicating a relatively strong baseline understanding of bone cancer signs among the general population. However, nearly one-third of the sample showed suboptimal awareness, with 22.5% categorized as having “Fair” knowledge and 11.5% as “Poor.” These findings highlight the need for targeted awareness campaigns to bridge the knowledge gap in this segment. While the general public appears to be familiar with key signs of bone cancer, these numbers underline that a significant portion may still miss or misinterpret early symptoms, potentially leading to delayed diagnosis and poorer clinical outcomes.

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

Table 4 explores the relationship between awareness scores and socio-demographic factors, revealing several statistically significant associations. Age was significantly linked to knowledge levels (p = 0.027), with younger participants (especially those aged 26–35 years) scoring higher, while individuals over 46 years of age were more likely to have “Fair” or “Poor” scores. Education level emerged as the strongest predictor of awareness (p < 0.001), with higher education levels correlating with better scores—underscoring the impact of formal education on health literacy. Occupational differences were also significant (p = 0.041); students and government employees exhibited better awareness than retirees and homemakers. Rural participants showed lower awareness levels compared to urban counterparts (p = 0.038), likely reflecting disparities in access to health information and medical services. Interestingly, gender was not a statistically significant factor (p = 0.185), suggesting that both men and women had comparable levels of awareness when other variables were controlled.

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

This study provides valuable insight into the current level of public awareness regarding bone cancer warning signs among adults in Himachal Pradesh—a region characterized by its rural majority, limited healthcare accessibility, and cultural nuances that influence health-seeking behavior. While bone cancer is a relatively rare malignancy, its aggressive progression and poor prognosis in advanced stages underscore the importance of early detection, which is heavily reliant on public knowledge and timely consultation. The findings of this study reveal a moderate to high baseline awareness among the population, with significant variations across socio-demographic lines that demand attention from public health planners and policymakers.

The overall awareness scores indicated that approximately two-thirds (66.1%) of participants fell into the "Very Good" or "Good" categories. This suggests that general awareness of bone cancer's clinical warning signs—such as persistent localized pain, swelling, and fatigue—is reasonably well established among the general population. These findings are encouraging, particularly given the geographical and infrastructural challenges prevalent in Himachal Pradesh. The highest awareness was noted for questions related to early detection benefits (73.0%), the importance of imaging (72.3%), and the need for immediate consultation upon suspecting bone cancer (71.0%). This trend may reflect the growing penetration of digital health information, national cancer awareness drives, and improved access to online educational resources in the state.

However, deeper analysis uncovers persistent gaps and misconceptions. For instance, only 59.5% correctly recognized that bone cancer may not initially present with pain, highlighting a critical misunderstanding of early-stage symptomatology. Similarly, awareness of differential diagnoses, such as the potential for bone cancer to mimic arthritis, was lacking among nearly 37% of respondents. This limited understanding may contribute to misinterpretation of early warning signs, particularly in older adults who often attribute musculoskeletal pain to aging or lifestyle factors. The belief that cancer must always cause immediate or severe pain could delay medical consultation and contribute to diagnosis at more advanced, less treatable stages.

Socio-demographic associations in this study illuminate the disparities in knowledge distribution. Age was a statistically significant determinant (p = 0.027), with younger adults (26–35 years) scoring higher, possibly due to greater exposure to health information via digital platforms and formal education. Conversely, participants aged 46 and above were more likely to score in the “Fair” and “Poor” categories, despite being in an age group where early detection is crucial for improved outcomes. This age-related disparity in knowledge poses a public health concern and suggests the need for age-targeted educational interventions.

Education level was the most influential factor in awareness (p < 0.001). Participants with undergraduate and postgraduate qualifications were significantly more knowledgeable compared to those with only primary or no formal education. This aligns with existing literature linking higher educational attainment to greater health literacy, awareness of disease symptoms, and utilization of healthcare services. Occupational differences further support this trend, with students and government employees exhibiting better scores than homemakers, retirees, or those in informal employment. This reflects differences in exposure to structured health education, workplace wellness programs, and access to reliable health resources.

The urban-rural divide was another noteworthy finding. Urban residents demonstrated significantly better awareness than their rural counterparts (p = 0.038), which may be attributed to better connectivity, more frequent interactions with health services, and higher literacy rates in urban areas. This rural knowledge gap is particularly concerning in the context of Himachal Pradesh, where a majority of the population resides in remote or underserved areas. These disparities emphasize the urgent need for rural outreach programs tailored to local languages and cultural contexts, using trusted community health workers as delivery agents.

Interestingly, gender was not significantly associated with awareness levels (p = 0.185), indicating that both males and females had similar levels of understanding. This suggests that bone cancer awareness messages, when disseminated, reach both sexes equally—an encouraging sign for equitable health promotion.

The implications of these findings are multifold. Firstly, while basic awareness exists, there is a need for more nuanced and symptom-specific education that focuses on early-stage warning signs and risk perception. Secondly, awareness programs must be tailored to target older adults, less-educated individuals, and rural populations—groups consistently found to have lower awareness levels in this study. Thirdly, leveraging local media, school-based interventions, and community health centers can enhance the reach of health education campaigns. Finally, collaboration with orthopedic and oncology specialists in organizing screening camps and awareness drives can reinforce the importance of timely diagnosis and specialized care.^7-10

Overall, this study serves as a foundational assessment of bone cancer knowledge in Himachal Pradesh and highlights both progress and gaps. The findings provide direction for future public health interventions aimed at reducing diagnostic delays and improving bone cancer outcomes through informed community engagement.

While this study offers critical insights into the public awareness of bone cancer warning signs in Himachal Pradesh, several limitations must be acknowledged. First, the use of a digital survey (Google Forms) may have excluded individuals with limited internet access or digital literacy, particularly affecting responses from older adults and lower-income rural residents. Second, the cross-sectional design captures awareness at a single point in time and cannot assess changes in knowledge or behavior over time. Third, the reliance on self-reported data introduces the possibility of response bias, where participants may overestimate their knowledge or provide socially desirable answers. Finally, although efforts were made to ensure a diverse sample, the non-random sampling method may limit the generalizability of the findings to the broader population of Himachal Pradesh or other regions.

This study highlights a moderate to high level of public awareness regarding the warning signs of bone cancer among adults in Himachal Pradesh, with over two-thirds of respondents demonstrating good to very good knowledge. However, significant gaps persist—particularly among older adults, individuals with lower educational attainment, and rural populations. The findings underscore the importance of targeted educational interventions to improve early recognition of symptoms such as persistent bone pain, fatigue, unexplained swelling, and the importance of timely medical consultation. Enhanced awareness can play a pivotal role in reducing diagnostic delays, improving survival rates, and reducing the burden of advanced-stage bone cancer in this geographically and socio-culturally diverse region.

To bridge the identified knowledge gaps, a multi-tiered public health strategy is essential. Community-level education campaigns should be launched in collaboration with local health workers, focusing on high-risk and underserved populations, particularly in rural areas. Health education materials should be developed in local languages and disseminated through accessible media channels such

as radio, local television, and community meetings. Integration of bone cancer awareness into existing primary healthcare programs and school health curriculums can ensure early sensitization. Additionally, regular screening camps and workshops led by orthopedic oncologists and public health officials should be organized to reinforce early detection and encourage proactive health-seeking behavior. Empowering communities with knowledge is crucial to transforming cancer care outcomes in Himachal Pradesh.

1. Ramaswamy A, Rekhi B, Bakhshi S, Hingmire S, Agarwal M. Indian data on bone and soft tissue sarcomas: a summary of published study results. South Asian J Cancer. 2016 Jul–Sep;5(3):138–145.
2. Surveillance, Epidemiology, and End Results (SEER) Program. Cancer Stat Facts: Bone and Joint Cancer [Internet]. Bethesda (MD): National Cancer Institute; [cited 2025 Jul 10]. Available from: https://seer.cancer.gov/statfacts/html/bones.html
3. Alkheraiji AF, Almjlad RB, Alanzan AS, Almutairi RN, Alqadhibi MA, Alharbi AK, et al. Knowledge of malignant bone tumors in children among parents in Majmaah Region. J Pharm Bioallied Sci. 2025 May;17(Suppl 1):S873–S877.
4. Sahu DP, Subba SH, Giri PP. Cancer awareness and its predictors among the rural population of eastern India: a cross-sectional study. Indian J Community Med. 2025 Mar–Apr;50(2):324–330.
5. Sharma S, Singh Thakur A. The cancer conversation: assessing public awareness of cancer warning signs and screening in Shimla. IAR J Health Care Prev. 2025 Jan;5(1):1–6.
6. Bari YA, Mahyudin F, Edward M, Ardana FN, et al. Enhancing knowledge and education of bone cancer for adolescents in Indonesia. J Layanan Masyarakat. 2025 Mar;9(1):19–25.
7. Vemuri NV, Songa R, Azzopardi C, Thaker S, Gupta H, Botchu R. Bone tumors management survey in India – radiologist perspective. Indian J Musculoskelet Radiol. 2020;2(2):108–114.
8. Kumar D, Bhasker N, Kumar D, Srivastava S, Kumar S, Kumar A, Sharma AC. An epidemiological study of bone tumour patients with the role of needle biopsy in North Indian population. Int J Health Clin Res. 2021;4(17):137–142.
9. Chetia NP, Ahmed F, Gogoi S, Joseph A. Benign bone tumors in North East Indian population – a hospital-based study. Asian J Med Sci. 2024 Aug;15(8):115–121.
10. Priadarsini T. Awareness of bone tumor in middle aged population. Int J Curr Adv Res. 2017;6(4):3026–3028.