In modern healthcare, diagnostic pathology services form the backbone of timely disease detection, effective treatment planning, and public health surveillance. From simple blood tests and organ function profiles to advanced molecular diagnostics, these tools are vital for identifying disease at asymptomatic stages and preventing complications. However, despite the increasing availability and medical importance of such tests, public understanding of their purpose, accessibility, and implications remains uneven—particularly in geographically diverse and socioeconomically varied regions such as Himachal Pradesh, India.1-4

Himachal Pradesh, a predominantly hilly state, presents unique healthcare challenges owing to its scattered population, limited diagnostic infrastructure in rural belts, and varied educational exposure. These disparities are further compounded by cultural misconceptions, cost concerns, and fear or distrust related to medical testing. In many cases, individuals delay seeking diagnostics due to lack of awareness, perceived stigma, or reliance on self-medication. Studies from other Indian states have indicated that even when individuals have physical access to laboratories, psychological and informational barriers significantly impact their willingness to undergo routine or preventive tests.5-8

Additionally, the rise of lifestyle diseases such as diabetes, hypertension, and thyroid disorders—often silent in their early stages—demands regular screening and early intervention. The recent global emphasis on infection surveillance (e.g., during the COVID-19 pandemic) has further highlighted the need for public familiarity with tests like RT-PCR, CBC, and serological assays. However, if knowledge about the function, interpretation, and importance of these diagnostic tools is lacking, the broader goals of preventive medicine and health system efficiency remain unfulfilled.9-12

Despite the critical role of diagnostics in shaping health outcomes, limited research exists on public awareness and utilization patterns in the context of Himachal Pradesh. It becomes imperative to explore not only what people know about diagnostic tests but also how this knowledge is influenced by factors like age, gender, education, and place of residence. Such insights are essential for designing inclusive health communication strategies and ensuring that both rural and urban populations can make informed decisions about their health.

This study, therefore, aims to assess the level of awareness, prevailing misconceptions, and sociodemographic determinants influencing the public's understanding and use of diagnostic pathology services in Himachal Pradesh. By analyzing knowledge scores across various strata, the study seeks to highlight critical gaps and propose data-driven recommendations for strengthening diagnostic literacy and utilization, ultimately supporting a more proactive and preventive public health framework in the region.

Study Design and Setting

This study employed a descriptive, cross-sectional design to assess public awareness, understanding, and misconceptions related to diagnostic pathology services in Himachal Pradesh, India. The study leveraged an online survey format using Google Forms to reach a wide population across both urban and rural areas. Given the geographical challenges of Himachal Pradesh’s terrain and the post-pandemic shift toward digital tools, this approach ensured cost-effective, contactless, and scalable data collection, especially in areas with limited access to physical health infrastructure.

Study Duration

The data collection was conducted over a three-month period, from Feb to March 2025. This timeline was selected to ensure comprehensive outreach across varying occupational schedules and seasonal accessibility, and to allow for digital dissemination and snowball participation via social networks and institutional channels.

Study Population and Sampling Method

The target population consisted of adults aged 18 years and above, residing in Himachal Pradesh, regardless of gender, occupation, or educational background. A non-probability, convenience sampling method was adopted due to the online nature of the study. The survey link was shared widely through social media platforms (e.g., WhatsApp, Facebook, Instagram), local community groups, educational institutions, and via email lists. To encourage participation across diverse demographics, local volunteers and community health advocates were involved in promoting the survey in both rural and urban settings.

Sample Size Determination

A total of 400 participants were included in the final analysis. The sample size was calculated using Cochran’s formula for a population proportion with a 95% confidence interval and a 5% margin of error, assuming a 50% expected awareness rate to maximize representativeness. This sample allowed for subgroup analysis across various socio-demographic parameters.

Inclusion and Exclusion Criteria

Inclusion Criteria:

• Residents of Himachal Pradesh aged 18 years and above
• Individuals who provided informed digital consent
• Participants able to read and understand either Hindi or English
• Respondents with access to the internet or digital devices

Exclusion Criteria:

• Individuals working professionally in diagnostic laboratories or medical fields (to avoid bias)
• Incomplete or duplicate responses (automatically filtered via Google Form settings)
• Participants residing outside of Himachal Pradesh

Survey Instrument and Validation

The survey tool was a structured, self-administered questionnaire developed in both English and Hindi to ensure linguistic inclusivity. The questionnaire was based on widely accepted public health literature, WHO guidelines, and national health program objectives related to diagnostics. It was reviewed and validated by a multidisciplinary panel comprising public health experts, pathologists, general physicians, and epidemiologists. A pilot test was conducted among 30 respondents to assess clarity, technical functionality, and average completion time. Based on pilot feedback, minor modifications were made for ease of comprehension and digital compatibility.

Questionnaire Structure

The final questionnaire consisted of four key sections:

1. Socio-Demographic Details: Age, gender, education level, occupation, and area of residence (urban/rural)
2. Awareness and Misconception Assessment: 20 multiple-choice questions evaluating knowledge of common diagnostic tests (e.g., CBC, LFT, KFT, HbA1c), their purpose, importance, safety, and barriers to utilization
3. Knowledge Scoring: Each correct response was scored as 1 point. Cumulative scores (out of 20) were categorized into:

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

4. Voluntary Comments (Optional): This section allowed respondents to share personal opinions or experiences related to diagnostic services.

Ethical Considerations

The study adhered to the principles outlined in the Declaration of Helsinki. The first page of the Google Form included an informed consent statement, assuring participants of the anonymity, confidentiality, and voluntary nature of their participation. No personal identifiers (such as names, phone numbers, or IP addresses) were collected.

Data Management and Statistical Analysis

All survey responses were automatically captured and stored in a secure, password-protected Google Sheet. The data was then exported to Microsoft Excel and analyzed using IBM SPSS version 25.

• Descriptive statistics (frequencies, percentages) were used to summarize socio-demographic variables and awareness levels.
• Chi-square tests were applied to examine the association between knowledge scores and demographic variables such as age, gender, education, occupation, and residence.
• A p-value < 0.05 was considered statistically significant in all analyses.

The study included a total of 400 participants from Himachal Pradesh, with a fairly balanced representation across age groups. The majority were in the 26–35 age bracket (27.0%), followed closely by those aged 36–45 (25.5%) and 46 years and above (29.5%), while the youngest group (18–25 years) accounted for 18.0% of the sample. Gender distribution was relatively even, with females slightly outnumbering males (54.5% vs. 45.5%). In terms of education, 33.0% of respondents had completed undergraduate studies, followed by 29.5% with secondary school education, and 20.0% holding postgraduate degrees. A smaller portion had only primary education (11.0%) or no formal education (6.5%). The occupational status of participants reflected diverse roles, with the largest groups working in the private sector (23.5%), homemakers (19.0%), and students (16.0%). Government employees (16.5%), self-employed individuals (14.0%), and retired or other occupations (11.0%) were also represented. Notably, more than half of the participants (53.5%) hailed from rural areas, underscoring the inclusion of geographically dispersed populations in the study.

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

The awareness assessment revealed mixed levels of knowledge across 20 key diagnostic-related questions. High awareness was observed for tests such as RT-PCR (78.0%), LFTs (73.0%), and the role of diagnostics in disease prevention (75.3%). Over 70% of participants correctly identified the use of CBC (69.0%), the need for regular screening in adults over 40 (71.0%), and the importance of family history in choosing screenings (71.8%). However, awareness dropped in areas such as cancer marker interpretation (53.0%), pricing regulation across labs (54.8%), and NABL accreditation (58.8%), highlighting key misconceptions. A significant number of participants were unaware that improper sample handling could alter results (only 64.3% correct), and many incorrectly believed self-diagnostic kits were reliable for major decisions (56.5% correct). These results underscore a concerning gap in knowledge, particularly around test reliability, regulation, and pre-test precautions, despite reasonable awareness of common test names and purposes.

Table 2: Awareness and Misconception Questions on Diagnostic Pathology Services (n = 400)

Participants' total knowledge scores, calculated out of a maximum of 20, were classified into four categories. A commendable 29.5% of respondents demonstrated "Very Good" knowledge (17–20 correct responses), and the largest group (36.8%) fell into the "Good" category (13–16 correct answers). However, 22.3% of participants had "Fair" knowledge (9–12 correct), and a notable 11.5% scored in the "Poor" category (0–8 correct). While the overall awareness level appears moderate to good, the data also reveal that nearly one-third of the population may lack sufficient understanding to make informed decisions about diagnostic health practices, emphasizing the need for targeted educational interventions.

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

Statistically significant associations were observed between knowledge levels and several socio-demographic factors. Age was notably significant (p = 0.011), with younger groups (18–35 years) showing higher knowledge scores, while participants aged 46 and above had a higher proportion in the “Fair” and “Poor” categories. Education level was a strong determinant (p < 0.001); those with postgraduate and undergraduate degrees overwhelmingly fell into the “Very Good” and “Good” categories, whereas participants with no or only primary education were more often in the “Fair” or “Poor” groups. Residence also showed a significant correlation (p = 0.026), with urban residents displaying considerably better knowledge than their rural counterparts. Gender did not show a statistically significant difference (p = 0.089), although females had slightly higher proportions in the “Good” and “Very Good” categories. These findings highlight the critical influence of education and urban access on diagnostic awareness and underline the need for rural outreach and health literacy campaigns.

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

The findings of this study provide a comprehensive insight into the current state of public awareness, understanding, and misconceptions regarding diagnostic pathology services in Himachal Pradesh. The results reveal a moderately encouraging awareness landscape, but one that is significantly influenced by socio-demographic disparities, including age, education level, and place of residence.

A key highlight from the data is that over two-thirds of the participants demonstrated a good to very good level of knowledge about commonly used diagnostic tests such as CBC, LFTs, KFTs, thyroid screening (TSH), and HbA1c. High levels of awareness about the role of RT-PCR testing (78%) and the preventive potential of early diagnostic screening (75.3%) reflect the public's increased exposure to health information during the COVID-19 pandemic, which may have contributed to greater recognition of diagnostic importance. However, despite this general awareness, significant misconceptions persist, particularly regarding the reliability of self-diagnostic kits, the interpretation of abnormal reports, and the need for NABL accreditation of laboratories. Only 53% of respondents understood that cancer markers alone are insufficient for conclusive diagnosis, while just 58.8% recognized the importance of accreditation in ensuring lab reliability. These gaps suggest a concerning reliance on partial knowledge and an underestimation of critical safety and quality parameters.

The stratified analysis highlights how knowledge levels are not evenly distributed across the population. Participants with higher education levels, especially postgraduates, demonstrated significantly greater awareness and fewer misconceptions. In contrast, individuals with no formal or only primary education scored poorly, indicating a strong educational gradient in health literacy. Similarly, urban respondents were significantly more informed than their rural counterparts. This urban–rural divide is reflective of unequal access to health information, digital literacy, and exposure to formal healthcare systems. Age also emerged as a significant factor, with younger respondents (18–35 years) showing higher knowledge scores compared to older age groups, which may be attributed to better digital engagement and educational attainment among youth. Interestingly, while female participants slightly outperformed males in awareness scores, the gender difference was not statistically significant, indicating relatively equal engagement across sexes.

These findings are consistent with previous literature that identifies education and residence as pivotal determinants of health awareness. Studies conducted in other Indian states and LMIC settings have similarly reported that rural populations and individuals with lower educational status tend to have limited understanding of diagnostic services, often leading to delayed healthcare seeking, inappropriate test utilization, or over-reliance on informal sources. Furthermore, this study reinforces the idea that fear of diagnosis, lack of trust in private labs, and cost misperceptions continue to hinder timely diagnostic testing—barriers that are often exacerbated by misinformation and lack of public engagement campaigns.7.10,11

The public’s mixed perception of whether a doctor's prescription is mandatory for all tests (with only 63.3% answering correctly), and the relatively low awareness of regulated pricing and standardized test quality, also point to the need for clearer health communication. These gaps underscore the importance of regulatory transparency, health education in schools and communities, and improved collaboration between public health authorities and local stakeholders.8.9

In sum, while the study paints a hopeful picture in terms of general test awareness, it also reveals critical weaknesses in interpretative knowledge, procedural understanding, and trust in diagnostic infrastructure. Addressing these issues requires not only health system reforms but also community-centered health literacy initiatives that are inclusive, culturally sensitive, and accessible across socio-economic strata. Integration of diagnostic literacy into primary healthcare outreach, digital health tools, and school curricula could be instrumental in bridging the knowledge divide and promoting rational, timely use of pathology services across the state.9-14

Limitations

Despite offering valuable insights, this study has several limitations that warrant consideration. Firstly, as the data was collected via a self-administered online Google Form, the sample may be biased toward individuals with internet access and digital literacy, potentially underrepresenting rural and technologically underserved populations. Secondly, the reliance on self-reported knowledge and practices may introduce response and social desirability bias, with participants possibly overstating their understanding or engagement with diagnostic services. Thirdly, the cross-sectional nature of the study limits causal inference, preventing us from establishing whether low awareness directly leads to underutilization of diagnostic services. Additionally, while the questionnaire was reviewed for content validity, it did not undergo formal psychometric testing, which may affect the precision of knowledge classification. Finally, regional generalizability is limited, as findings are specific to Himachal Pradesh and may not reflect trends in other Indian states with differing healthcare infrastructures and health literacy profiles.

This study sheds light on the current state of public awareness and utilization of diagnostic pathology services in Himachal Pradesh, revealing both encouraging trends and pressing gaps. While a significant proportion of the population demonstrated good knowledge of basic diagnostic tests and their role in disease prevention, critical misconceptions persist regarding test reliability, laboratory accreditation, and the necessity of professional consultation. The findings underscore the strong influence of socio-demographic factors—particularly education level, age, and urban-rural residence—on diagnostic health literacy. With rural residents and less-educated groups consistently exhibiting lower awareness levels, it becomes evident that equitable access to diagnostic information remains a public health challenge. To foster more informed health-seeking behavior, there is an urgent need for targeted awareness campaigns, integration of diagnostic education into community health programs, and improved outreach in underserved areas. Strengthening public understanding of pathology services is not just a matter of knowledge, but a crucial step toward promoting early detection, timely treatment, and overall health system efficiency in the region.

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