Oral cancer continues to pose a serious threat to public health, especially in low- and middle-income countries where tobacco use is widespread and preventive healthcare is often underutilized. In India, oral cancer ranks among the most common cancers, accounting for a significant proportion of cancer-related deaths, particularly among adult males [1,2]. Its high incidence is largely linked to the use of tobacco in both smoking and smokeless forms-such as gutkha, khaini and betel quid-as well as contributing factors like alcohol consumption, poor dental hygiene and prolonged exposure to harmful irritants [3,4]. Although early detection can drastically improve treatment outcomes, late-stage diagnosis remains common, primarily due to inadequate awareness and the normalization of harmful habits [5,6].

Shimla, a hilly district in the northern state of Himachal Pradesh, presents a distinct epidemiological context. The region's terrain, colder climate and sociocultural practices have encouraged unique forms of tobacco use, often seen as tradition rather than threat. In many rural parts of Shimla, signs such as mouth ulcers, difficulty chewing, or persistent oral discomfort are frequently overlooked or self-managed with local remedies, delaying medical attention. Moreover, accessibility to oral cancer screening facilities is limited and health education campaigns often fail to reach remote populations with consistency or cultural relevance [7-9].

While national frameworks like the National Tobacco Control Programme (NTCP) aim to reduce tobacco use and spread awareness, their implementation at the grassroots level-especially in semi-urban and rural settings like Shimla-is still a work in progress. Misconceptions about oral cancer, low health literacy and societal stigma around the disease continue to hinder early recognition and timely treatment. Alarmingly, many individuals remain unaware of early symptoms such as red or white patches in the mouth, persistent sores, or unexplained bleeding-factors that are critical to prompt diagnosis.

This study seeks to investigate the current state of public knowledge, attitudes and perception regarding oral cancer in Shimla. By exploring how factors such as age, gender, education and place of residence influence awareness levels, the research aims to uncover existing gaps and challenges in oral cancer literacy. The findings will support the development of tailored health communication strategies that resonate with the local population and encourage informed, preventive health behaviors within the community.

Study Design

This research was conducted as a descriptive, cross-sectional study aimed at assessing the awareness, perceptions and understanding of oral cancer among the general population of Shimla district, Himachal Pradesh. The main objective was to evaluate public knowledge of oral cancer symptoms, risk factors (especially tobacco use) and early detection strategies.

Study Area and Target Population

The study was carried out in Shimla, a high-altitude region in northern India characterized by a blend of urban and rural settlements. The district’s unique environmental and sociocultural conditions, particularly in relation to tobacco habits, made it an ideal location for assessing public health literacy on oral cancer. Adults aged 18 years and above residing in Shimla, irrespective of gender, education level, or occupation, formed the target population.

Study Duration

Data collection was conducted over a three-month period, from January to March 2025. This timeline facilitated consistent digital engagement and allowed for responses from a broad demographic spectrum within the region.

Sample Size and Sampling Technique

A total of 400 participants were enrolled in the study. The sample size was determined using a 95% confidence interval, a 5% margin of error and an estimated awareness prevalence of 50%, ensuring statistical reliability and representation. A combination of purposive and convenience sampling was employed. The survey link was disseminated through widely used digital platforms such as WhatsApp, Facebook and local community networks to optimize participation.

Inclusion Criteria

• Individuals aged 18 years or older

• Permanent residents of Shimla district

• Ability to comprehend and respond in either Hindi or English

• Willingness to provide informed digital consent

Exclusion Criteria

• Prior diagnosis of oral cancer

• Incomplete or inconsistent survey responses

• Respondents who did not consent to participate

Study Tool – Structured Questionnaire

Data were collected through a structured, pre-validated questionnaire developed in collaboration with dental health professionals and public health experts. The tool was bilingual (Hindi and English) to enhance accessibility and comprised three primary sections:

• Socio-demographic details: Capturing information such as age, gender, education level, occupation and residence

• Knowledge and awareness: Containing 20 multiple-choice questions evaluating respondents’ understanding of oral cancer symptoms, tobacco-related risks, other contributing factors and preventive measures

• Attitudes and perceptions: Exploring beliefs regarding oral health, stigma, willingness to seek early diagnosis and perceived barriers to accessing healthcare

Scoring and Knowledge Classification

Each correct response in the awareness section was assigned one point. Based on their total scores, participants were categorized into four levels:

• Very Good Knowledge (≥80% correct)

• Good Knowledge (60–79%)

• Fair Knowledge (41–59%)

• Poor Knowledge (<40%)

This stratification was used to identify knowledge disparities across demographic groups and inform targeted health communication efforts.

Data Collection Procedure

The survey was administered exclusively online using Google Forms. A secure link was circulated digitally and participants were required to provide informed digital consent before proceeding. All responses were anonymous and no personal identifiers were collected to ensure confidentiality and ethical compliance.

Data Analysis

Collected data were downloaded and organized using Microsoft Excel. Descriptive statistics such as frequencies and percentages were used to summarize socio-demographic characteristics and levels of awareness. Cross-tabulations were also performed to observe patterns and differences across age, education, occupation and urban-rural residence.

Ethical Considerations

The study strictly adhered to ethical standards applicable to online public health surveys. Participation was entirely voluntary, informed digital consent was obtained from each respondent and all data were handled with full confidentiality.d aspects of oral cancer (Table 3).

The study encompassed a total of 400 participants from Shimla district, exhibiting a diverse socio-demographic profile. The majority of respondents (33.0%) were in the 26–35 years age group, followed by those aged 36–45 years (28.0%), 18–25 years (26.0%) and 13.0% aged 46 years and above. In terms of gender distribution, males constituted a slightly higher proportion (53.0%) compared to females (47.0%). Educational attainment among participants was varied, with the largest segments having completed undergraduate degrees (31.0%) or secondary education (29.0%), followed by postgraduate qualifications (15.0%), primary schooling (15.0%) and no formal education (10.0%). Occupation-wise, homemakers (25.0%), teachers (19.0%), students (19.0%) and office workers (19.0%) formed the bulk of respondents, alongside healthcare professionals (11.0%) and others (7.0%). Notably, 55.0% of respondents resided in rural areas, indicating significant rural representation, while 45.0% hailed from urban settings-ensuring a well-rounded perspective on community awareness levels across geographic locations (Table 1). The assessment of public knowledge on oral cancer yielded promising results, with high levels of awareness observed across several key domains. A substantial 81.0% correctly identified oral cancer as a malignancy of the mouth or throat and 80.0% acknowledged smoking as a major risk factor. Furthermore, 84.0% recognized non-healing mouth ulcers as a primary symptom, while 77.0% were aware that alcohol consumption also increases oral cancer risk. Regarding treatment knowledge, 78.0% correctly chose surgical removal for early-stage oral cancer and 79.0% understood the purpose of an oral biopsy. While 75.0% acknowledged the importance of early detection, slightly fewer (72.0%) were aware that oral cancer can be asymptomatic in early stages. Notably, 80.0% believed tobacco history should be reported during screenings and 77.0% identified metastasis as a risk of untreated disease. Dental check-ups as a detection tool were recognized by 73.0%, while understanding of HPV and betel quid as risk factors stood at 75.0% and 76.0% respectively. However, knowledge gaps emerged in less visible aspects, such as voice changes (68.0%) and recurrence after treatment (65.0%). Overall, the data reflect a sound foundational awareness, with specific areas needing further emphasis in public health messaging (Table 2). Knowledge scores were categorized into four levels to assess the depth of public understanding. Of the total participants, 37.5% demonstrated very good knowledge (scoring 80% or above), while the largest group (39.5%) fell into the good knowledge range (60–79%), indicating that over three-quarters of the respondents possessed a relatively strong awareness of oral cancer. Meanwhile, 15.5% were classified as having fair knowledge (41–59%) and 7.5% showed poor awareness, having scored below 40%. These figures reveal a largely informed population, but also point to critical gaps in knowledge among a minority-particularly those likely influenced by lower educational levels or limited healthcare access. This distribution highlights the importance of targeted awareness initiatives that not only reinforce general knowledge but also address nuanced and underrecognized aspects of oral cancer (Table 3).

This cross-sectional study presents an in-depth exploration of public awareness, perceptions and knowledge levels related to oral cancer among the residents of Shimla, a high-altitude district where cultural

Table 1: Socio-Demographic Characteristics of Participants (Shimla)

Table 2: Public Knowledge and Awareness of Oral Cancer and Its Risk Factors

Table 3: Knowledge Score Classification on Oral Cancer and Its Risk Factors

norms, environmental exposure and healthcare accessibility uniquely intersect. The findings offer crucial insights into the current state of oral cancer literacy, revealing both strengths in general awareness and notable gaps that warrant strategic public health interventions.

The demographic distribution of the study population underscores the representativeness of the sample. The age group of 26–35 years accounted for the largest segment (33.0%), followed closely by the 36–45 and 18–25 brackets, suggesting that the majority of participants belonged to the economically productive and socially active demographic. Gender representation was nearly balanced, with a slight male predominance (53.0%), which aligns with national patterns where males show higher prevalence of tobacco-related behaviors-a critical risk factor for oral cancer. Educationally, the majority had at least secondary or undergraduate-level qualifications, providing a reasonable foundation for health education initiatives to be received and comprehended. However, the presence of individuals with no formal education (10.0%) and only primary schooling (15.0%) signifies the necessity of customizing awareness programs for varying literacy levels. The significant rural representation (55.0%) highlights the value of including populations often underserved in cancer prevention efforts, especially those more prone to traditional tobacco use and less likely to access timely medical care.

The knowledge assessment revealed encouraging overall awareness, particularly on primary risk factors and visible symptoms of oral cancer. Over 80% of respondents correctly identified smoking as a major cause and understood that oral cancer affects the mouth and throat. Moreover, 84.0% recognized non-healing ulcers as a key symptom, indicating that classic clinical signs are generally understood by the public. This could be attributed to national-level tobacco awareness campaigns and pictorial warnings on tobacco products, which emphasize these aspects. However, deeper examination revealed notable limitations in the recognition of less overt or systemic indicators of the disease. For example, only 68.0% were aware that voice changes could be a symptom and just 65.0% acknowledged the possibility of recurrence after treatment-highlighting a gap in understanding of the full disease trajectory and long-term management. Additionally, only 72.0% recognized that early-stage oral cancer can be asymptomatic, suggesting a dangerous reliance on visible symptoms before seeking care.

Importantly, awareness extended beyond traditional risk factors. A considerable 77.0% acknowledged alcohol consumption as a contributor to oral cancer and 75.0% correctly identified HPV infection as a risk factor—showing improved understanding of multifactorial etiology. Furthermore, 76.0% linked betel quid chewing to increased cancer risk, reflecting growing public recognition of culturally ingrained habits as hazardous. Encouragingly, 73.0% saw value in regular dental visits for early detection, which points to the potential of integrating oral cancer screening into routine dental check-ups, especially in rural health infrastructure where dentists may be among the first points of contact.

When analyzed by knowledge categories, over three-quarters (77.0%) of respondents fell into the good to very good knowledge tiers, indicating a strong foundational understanding of oral cancer. However, the remaining 23.0%-split between fair (15.5%) and poor (7.5%) knowledge-should not be overlooked. These groups may represent communities with lower educational attainment, poorer health literacy, or greater geographic isolation and are consequently at higher risk for late diagnosis and poorer outcomes. The disparities observed reinforce the need for targeted, inclusive health communication strategies tailored to cultural and linguistic contexts.

Digital data collection through online platforms proved effective in capturing a wide demographic, especially among younger and digitally literate individuals. However, this methodology may have inadvertently excluded older adults, technologically disconnected populations and those residing in remote hamlets-groups often more vulnerable to undiagnosed oral cancers due to lack of awareness or healthcare access. Future studies may benefit from hybrid data collection models that include on-ground surveys and focus group discussions to capture the perspectives of these underrepresented segments.

From a public health standpoint, this study underscores the pressing need to enhance grassroots-level awareness of oral cancer in Shimla. While the foundational knowledge is commendable, the lack of familiarity with early asymptomatic presentation, disease recurrence and subtle symptoms suggests that current awareness programs are insufficiently comprehensive. Health promotion efforts must evolve from simply identifying tobacco as a threat to educating people on the full clinical spectrum of oral cancer, the importance of regular screening and the long-term consequences of neglect. This is particularly relevant in Shimla, where cultural normalization of tobacco chewing and reliance on home remedies delay early diagnosis. Collaboration with Accredited Social Health Activists (ASHAs), school health educators, local dental practitioners and community leaders can amplify message penetration and drive behavior change in a relatable and sustained manner [10-12].

The findings of this study highlight a commendable level of public awareness regarding oral cancer among residents of Shimla, with over 75% of participants demonstrating good to very good knowledge of its symptoms, risk factors and early detection strategies. While awareness of smoking, alcohol use and classic symptoms such as non-healing mouth ulcers was strong, notable gaps persist in recognizing subtler indicators like voice changes, asymptomatic progression and the possibility of recurrence after treatment. These deficiencies, more prevalent among individuals with lower educational backgrounds and rural dwellers, emphasize the urgent need for more inclusive and nuanced health education initiatives. Tailored awareness campaigns that address cultural perceptions, promote regular dental screening and demystify the early stages of the disease are essential. Strengthening grassroots outreach through schools, community health workers and local influencers will be pivotal in bridging the knowledge divide and fostering a proactive, informed approach to oral cancer prevention and timely care in high-risk populations such as Shimla.

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