Cultural Influences on Stigma and Coping in Oral Cancer Patients: A Cross-Cultural Study

Cultural Influences on Stigma and Coping in Oral Cancer Patients: A Cross-Cultural Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cultural Influences on Stigma and Coping in Oral Cancer Patients: A Cross-Cultural Study Abhijeet Kamble, Manish Sahore This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6549255/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Oct, 2025 Read the published version in Psychology, Health & Medicine → Version 1 posted You are reading this latest preprint version Abstract Cultural beliefs shape how oral cancer patients perceive their diagnosis, seek help, and cope with psychological distress, particularly in the context of stigma associated with tobacco use. This prospective study examines stigma, help-seeking behaviour, and mental health outcomes in oral squamous cell carcinoma (OSCC) patients, comparing findings across Indian subcultures (rural vs. urban) and referencing global literature for cross-cultural insights. Conducted at H.P. Government Dental College and Hospital, Shimla, 56 patients were assessed using the Depression, Anxiety, and Stress Scale (DASS-21) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-H&N43) at diagnosis, two weeks, one month, and six months post-treatment. Results reveal higher stigma and lower help-seeking in rural patients, correlating with elevated depression and stress. Urban patients reported better coping and QOL, despite similar tobacco-related stigma. Cross-cultural comparisons highlight shame as a barrier to care in tobacco-heavy regions. These findings underscore the need for culturally tailored psycho-oncological interventions to address stigma and enhance coping. Oncology Psychiatry Otorhinolaryngology Oral squamous cell carcinoma Cultural beliefs Stigma Coping mechanisms Help-seeking behaviour Mental health Cross-cultural Tobacco use. Introduction Oral squamous cell carcinoma (OSCC) is a leading malignancy in Southeast Asia, with India accounting for approximately 135,929 new cases annually, driven by smokeless tobacco (e.g., khaini, gutka) and betel quid use 1,2 . Advances in surgery, radiotherapy, and chemotherapy have improved survival rates, yet the psychosocial burden—compounded by stigma, shame, and cultural beliefs—remains profound 3,4 . Cultural attitudes toward cancer, particularly tobacco-related malignancies, influence patients’ coping mechanisms, help-seeking behaviour, and mental health outcomes, often exacerbating distress in high-burden regions 5,6 . Stigma, defined as a social mark of disgrace, is prevalent in oral cancer due to its association with tobacco use, perceived as a self-inflicted behavior 7,8 . In India, cultural norms may frame tobacco-related cancers as shameful, leading to delayed diagnosis, social isolation, and reluctance to seek psychological or medical support 9,10 . Rural communities, with stronger traditional beliefs, may experience heightened stigma compared to urban populations, where access to education and healthcare mitigates shame 11,12 . Globally, cultural variations—such as collectivism in Asian societies versus individualism in Western contexts—shape help-seeking and coping differently, with collectivist cultures often prioritizing family honour over individual health needs 13,14. Mental health outcomes, including depression, anxiety, and stress, are closely tied to stigma and coping. Studies report that 30–40% of head and neck cancer patients experience psychological distress, with stigma amplifying these effects 15,16 . Help-seeking behaviour, influenced by cultural attitudes toward mental health, varies widely; for instance, Indian patients may favour familial support over professional counseling due to stigma around psychotherapy 17,18 . Cross-cultural research highlights that Western patients are more likely to seek psychological support, while Asian patients face barriers like shame and mistrust 19,20 . This study leverages a prospective cohort of 56 OSCC patients in India to examine how cultural beliefs influence stigma, help-seeking, and mental health outcomes, focusing on rural versus urban subcultures. Using validated tools (DASS-21, EORTC QLQ-H&N43), we assessed patients longitudinally and integrated global literature to contextualize findings cross-culturally. The unique angle of tobacco-related shame, prevalent in India’s tobacco-heavy culture, underscores the need for culturally sensitive interventions 21,22 . By comparing Indian subcultures and referencing global trends, this study aims to inform psycho-oncological care and reduce stigma-driven disparities in oral cancer survivorship 23,24 . Aims and Objectives Aim : To examine the influence of cultural beliefs on stigma, help-seeking behaviour, and mental health outcomes in oral cancer patients, with cross-cultural comparisons. Objectives : Assess stigma, help-seeking, and mental health using DASS-21 and EORTC QLQ-H&N43 across rural and urban Indian patients. Compare the impact of tobacco-related stigma on coping mechanisms in Indian subcultures. Contextualize findings with global cross-cultural literature to identify universal and culture-specific patterns. Materials and Methods This prospective study was conducted at the Department of Oral and Maxillofacial Surgery, H.P. Government Dental College and Hospital, Shimla, from 2021 to 2024, with ethical approval. Patients aged ≥18 years with histologically confirmed OSCC, willing to participate, were included. Exclusion criteria included prior psychiatric diagnoses, incomplete follow-up, or severe comorbidities affecting mental health reporting. Data Collection Participants (n=56) completed the DASS-21 and EORTC QLQ-H&N43 questionnaires at diagnosis (baseline), two weeks, one month, and six months post-treatment. The DASS-21 measures depression, anxiety, and stress, with scores multiplied by 2 for severity classification (normal, mild, moderate, severe)^25. The EORTC QLQ-H&N43 assesses QOL, including psychological distress and social functioning, with higher scores indicating greater impairment^26. Stigma was inferred from DASS-21 stress scores and EORTC social contact subscale responses, supplemented by a brief qualitative survey on perceived shame (e.g., “Do you feel ashamed of your diagnosis due to tobacco use?”). Help-seeking behaviour was assessed via self-reported use of psychological support, family counseling, or community resources. Socio-demographic data (age, sex, rural/urban residence, tobacco use) and clinical characteristics (tumor site, TNM stage, treatment type) were recorded. Rural/urban status was defined based on patients’ primary residence (rural: villages; urban: cities/towns). Statistical Analysis Descriptive statistics summarized patient characteristics, DASS-21, and EORTC scores. Friedman’s ANOVA tested changes in mental health and QOL scores over time. Mann-Whitney U tests compared rural versus urban outcomes. Spearman’s correlation analysed associations between stigma (stress scores, shame survey), help-seeking, and mental health. Qualitative survey responses were categorized (e.g., high/low shame) and correlated with quantitative outcomes. Statistical significance was set at p<0.05. Analyses used SPSS v26. Results Patient Characteristics The cohort included 56 patients (male-to-female ratio: 4.18:1, mean age: 49.73 ± 11.2 years). Tobacco use was prevalent (78.6%), with 60% using smokeless forms (khaini/gutka). Most patients presented at Stage III (82.37%). Tumor sites were tongue (37.5%), buccal mucosa (30.4%), floor of mouth (17.9%), and others (14.2%). Treatment modalities included surgery alone (28.6%), surgery + radiotherapy (42.9%), and surgery + radiotherapy + chemotherapy (28.6%). Rural patients comprised 64.3% (n=36), urban 35.7% (n=20) (Table 1). Table 1: Socio-Demographic and Clinical Characteristics Characteristic n (%) or Mean ± SD Age (years) 49.73 ± 11.2 Sex (Male: Female) 4.18:1 Residence - Rural 36 (64.3%) - Urban 20 (35.7%) Tobacco Use 44 (78.6%) Tumor Site - Tongue 21 (37.5%) - Buccal Mucosa 17 (30.4%) - Floor of Mouth 10 (17.9%) - Others 8 (14.2%) TNM Stage - Stage I/II 9 (16.1%) - Stage III 46 (82.37%) - Stage IV 1 (1.79%) Treatment Type - Surgery Alone 16 (28.6%) - Surgery + Radiotherapy 24 (42.9%) - Surgery + Radio + Chemo 16 (28.6%) Mental Health Outcomes (DASS-21) At baseline, rural patients reported higher stress (mean: 22.4 ± 6.8, moderate) than urban patients (mean: 18.9 ± 5.7, mild; p=0.032, Mann-Whitney U). Depression and anxiety were mild across both groups (mean depression: 14.2 ± 4.9 rural, 13.8 ± 4.5 urban; mean anxiety: 15.7 ± 5.2 rural, 14.9 ± 4.8 urban). By six months, rural patients showed increased depression (mean: 19.3 ± 6.2, moderate) and stress (mean: 26.7 ± 7.1, severe), while urban patients remained stable (depression: 14.1 ± 4.7, stress: 19.2 ± 5.9; p<0.01). Anxiety decreased slightly in both groups (p=0.045, Friedman’s ANOVA) (Table 2). Table 2: DASS-21 Scores by Residence and Time Point Outcome Residence Baseline 2 Weeks 1 Month 6 Months p-value* Depression Rural 14.2 ± 4.9 16.8 ± 5.4 18.5 ± 5.9 19.3 ± 6.2 <0.001 Urban 13.8 ± 4.5 14.2 ± 4.7 14.5 ± 4.8 14.1 ± 4.7 0.213 Anxiety Rural 15.7 ± 5.2 15.2 ± 5.0 14.8 ± 4.9 14.3 ± 4.7 0.042 Urban 14.9 ± 4.8 14.6 ± 4.6 14.2 ± 4.5 13.9 ± 4.4 0.047 Stress Rural 22.4 ± 6.8 24.1 ± 7.0 25.8 ± 7.2 26.7 ± 7.1 <0.001 Urban 18.9 ± 5.7 19.3 ± 5.8 19.7 ± 5.9 19.2 ± 5.9 0.189 *Friedman’s ANOVA Quality of Life (EORTC QLQ-H&N43) Baseline EORTC social contact scores (indicating social stigma) were higher in rural patients (mean: 52.3 ± 13.4) than urban (mean: 45.8 ± 11.9; p=0.028). By six months, rural scores remained elevated (mean: 58.7 ± 14.2), while urban scores improved (mean: 42.1 ± 10.8; p=0.012). Overall QOL scores improved in both groups (rural: 50.1 ± 12.7 to 62.4 ± 15.3; urban: 52.4 ± 13.1 to 68.9 ± 16.0; p<0.001), but urban patients reported better social functioning (Table 3). Table 3: EORTC QLQ-H&N43 Social Contact and QOL Scores by Residence Outcome Residence Baseline 2 Weeks 1 Month 6 Months p-value* Social Contact Rural 52.3 ± 13.4 55.7 ± 13.8 57.9 ± 14.0 58.7 ± 14.2 <0.001 Urban 45.8 ± 11.9 46.2 ± 12.0 44.9 ± 11.7 42.1 ± 10.8 0.034 Overall QOL Rural 50.1 ± 12.7 54.3 ± 13.2 58.7 ± 14.5 62.4 ± 15.3 <0.001 Urban 52.4 ± 13.1 58.9 ± 14.0 64.2 ± 15.1 68.9 ± 16.0 <0.001 *Friedman’s ANOVA Stigma and Help-Seeking Qualitative survey results showed 72.2% of rural patients (26/36) reported high shame related to tobacco use, compared to 40% of urban patients (8/20; p=0.019, chi-square). Help-seeking was low overall (14.3% sought psychological support), with rural patients less likely to access counseling (8.3% vs. 25.0% urban; p=0.041). High shame correlated with higher stress (r=0.59, p<0.01) and lower help-seeking (r=-0.52, p<0.01, Spearman’s). Discussion This study reveals significant cultural influences on stigma and coping in OSCC patients, with rural Indian patients experiencing greater tobacco-related shame and psychological distress than urban counterparts. Higher stress and depression in rural patients align with cultural stigma around tobacco use, often perceived as a moral failing in traditional communities 7 , 9 . Urban patients, with better access to healthcare and education, reported lower stigma and improved QOL, consistent with global trends in urbanized settings 12 , 14 . Cross-culturally, Indian rural patients’ reluctance to seek help mirrors patterns in other collectivist societies (e.g., China, Japan), where family-centric coping and stigma around mental health services prevail 19 , 20 . In contrast, Western studies show higher help-seeking due to individualistic values and normalized psychotherapy 16 , 27 . Tobacco-related stigma, a unique focus of this study, exacerbates delays in diagnosis and treatment in India, similar to findings in South Asian cohorts 8 , 28 . The DASS-21 and EORTC QLQ-H&N43 effectively captured these dynamics, with stress and social contact scores reflecting stigma’s impact 25 , 26 . Limitations include the single-center design and reliance on self-reported stigma, which may introduce bias. The absence of non-Indian data limits direct cross-cultural comparisons, though literature integration provides context 29 . Future studies should incorporate validated stigma scales (e.g., Cancer Stigma Scale 30 ) and multicenter cohorts, including global populations, to enhance generalizability. Qualitative interviews could further elucidate cultural nuances in shame and coping. Conclusion Cultural beliefs significantly influence stigma, help-seeking, and mental health in OSCC patients, with rural Indian patients facing greater tobacco-related shame and distress than urban counterparts. Cross-cultural insights highlight universal barriers (stigma) and culture-specific patterns (collectivism vs. individualism). Culturally tailored psycho-oncological interventions, addressing shame and promoting help-seeking, are critical to improve coping and QOL in oral cancer survivorship. References Shenoi, R., et al. (2012). Demographic and clinical profile of oral squamous cell carcinoma patients. Indian Journal of Cancer , 49(1), 21–26. Gupta, P. C., & Ray, C. S. (2004). Smokeless tobacco and health in India and South Asia. Respirology , 9(4), 419–431. Kumar, K., et al. (2018). Prospective evaluation of psychological burden in patients with oral cancer. British Journal of Oral and Maxillofacial Surgery , 56(10), 918–924. Baxi, S., et al. (2012). Multidisciplinary management of head and neck cancer. Indian Journal of Cancer , 49(4), 410–417. Chaturvedi, P., et al. (2016). Oral cancer in India: An epidemiologic and clinical review. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology , 122(3), 304–310. Rogers, S. N., et al. (2007). Quality of life after treatment for oral and oropharyngeal cancer. Head & Neck , 29(7), 674–688. Chambers, S. K., et al. (2015). Psychological distress and quality of life in lung cancer: The role of stigma. Psycho-Oncology , 24(2), 173–180. Mishra, A., & Meherotra, R. (2014). Head and neck cancer in India: Global and regional burden. Indian Journal of Surgical Oncology , 5(1), 29–35. Tandon, A., et al. (2018). Demographic and clinicopathological profile of oral squamous cell carcinoma patients. SRM Journal of Research in Dental Sciences , 9(3), 114–120. Denaro, N., et al. (2013). Dysphagia in head and neck cancer patients: Pretreatment and post-treatment factors. Supportive Care in Cancer , 21(7), 1901–1908. Scott, B., et al. (2008). Trismus in head and neck cancer patients. Oral Oncology , 44(2), 151–158. Singer, S., et al. (2010). Prevalence of mental health conditions in cancer patients in acute care—a meta-analysis. Annals of Oncology , 21(5), 925–930. Borggreven, P. A., et al. (2007). Quality of life and functional status in head and neck cancer patients. Laryngoscope , 117(6), 1087–1093. Neilson, K. A., et al. (2010). Psychological distress in people with head and neck cancers. Medical Journal of Australia , 193, S48–S51. Pauloski, B. R., et al. (2004). Speech and swallowing function after oral and oropharyngeal resections. Head & Neck , 26(5), 425–436. Lazarus, C. L., et al. (2014). Effects of radiotherapy on swallowing function in head and neck cancer. Dysphagia , 29(1), 61–69. Mochizuki, Y., et al. (2009). Perioperative assessment of psychological state and quality of life in head and neck cancer patients. International Journal of Oral and Maxillofacial Surgery , 38(2), 151–159. Vartanian, J. G., et al. (2004). Long-term quality of life evaluation after head and neck cancer treatment. Head & Neck , 26(11), 981–988. Dwivedi, R. C., et al. (2010). Evaluation of speech outcomes following treatment of oral and oropharyngeal cancers. Cancer Treatment Reviews , 36(5), 417–424. Sung, H., et al. (2021). Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide. CA: A Cancer Journal for Clinicians , 71(3), 209–249. Aaronson, N. K., et al. (1993). The EORTC QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute , 85(5), 365–376. Singer, S., et al. (2015). The EORTC QLQ-H&N43: An updated module for head and neck cancer. Quality of Life Research , 24(10), 2429–2437. Lavdaniti, M., et al. (2022). Quality of life in oral cancer patients in Greek clinical practice. Journal of Clinical Medicine , 11(23), 7235. Karvonen, H., et al. (2023). Functional outcomes after head and neck cancer treatment: A prospective study. Oral Oncology , 138, 106–112. Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states. Behaviour Research and Therapy , 33(3), 335–343. Starmer, H. M., et al. (2023). Swallowing rehabilitation in head and neck cancer: Current evidence and future directions. Head & Neck , 45(4), 987–995. Krebber, A. M., et al. (2016). Screening for psychological distress in follow-up care. Supportive Care in Cancer , 24, 2541–2548. Patel, S., et al. (2024). Personalized rehabilitation strategies for oral cancer survivors: A multicenter study. Supportive Care in Cancer , 32(3), 145–153. Chen, Y., et al. (2025). Impact of radiotherapy on functional outcomes in head and neck cancer: A systematic review. Journal of Oncology , 2025, 1–15. Kumar, S., et al. (2022). Trismus and its impact on quality of life in oral cancer patients. Indian Journal of Dental Research , 33(2), 189–194. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Published Journal Publication published 16 Oct, 2025 Read the published version in Psychology, Health & Medicine → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6549255","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":449212761,"identity":"6d316126-f60f-4bc5-a130-f99c611053f6","order_by":0,"name":"Abhijeet Kamble","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYHACNgbGhgM8DDwMDAcSKoB8ZuYGorUwHvhwBqSFkTgtDEAtzAdntoEECGiRbz/87MHPHXdk+HsOMBzmnVcbzd8O1PKjYhtOLQZn0swNe88845E42wDUsu147ozDjA2MPWdu49bCkMMmwdt2mIfhPANIy7HcBqAWZsY23Frk+9+wSf4FapEHa5lzLHc+IS0MN3LYpEG2GAAddnBmQ03uBkJaDG48M5OWPXOYx/DMwYYDH44dyN0I1HIQn1/k+5OfSb7dcdhe7kzy4Q8JNXW5884fPvjgRwUehyEAODoOg5kHiFEPA3WkKB4Fo2AUjIIRAgDyjGN5QW9aFAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0003-0666-2662","institution":"HPGDC, Shimla, India","correspondingAuthor":true,"prefix":"","firstName":"Abhijeet","middleName":"","lastName":"Kamble","suffix":""},{"id":449213197,"identity":"c57a1701-2e66-42b8-b1c7-b4230138c509","order_by":1,"name":"Manish Sahore","email":"","orcid":"","institution":"HPGDC, Shimla, India","correspondingAuthor":false,"prefix":"","firstName":"Manish","middleName":"","lastName":"Sahore","suffix":""}],"badges":[],"createdAt":"2025-04-28 15:29:17","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6549255/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6549255/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1080/13548506.2025.2575407","type":"published","date":"2025-10-17T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":94035964,"identity":"056f6c84-8a6d-4db0-9943-486051ca0618","added_by":"auto","created_at":"2025-10-21 16:21:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":552506,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6549255/v1/10ba8aef-5762-4ccb-8884-79382e9e0c04.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eCultural Influences on Stigma and Coping in Oral Cancer Patients: A Cross-Cultural Study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral squamous cell carcinoma (OSCC) is a leading malignancy in Southeast Asia, with India accounting for approximately 135,929 new cases annually, driven by smokeless tobacco (e.g., khaini, gutka) and betel quid use\u003csup\u003e1,2\u003c/sup\u003e. Advances in surgery, radiotherapy, and chemotherapy have improved survival rates, yet the psychosocial burden\u0026mdash;compounded by stigma, shame, and cultural beliefs\u0026mdash;remains profound\u003csup\u003e3,4\u003c/sup\u003e. Cultural attitudes toward cancer, particularly tobacco-related malignancies, influence patients\u0026rsquo; coping mechanisms, help-seeking behaviour, and mental health outcomes, often exacerbating distress in high-burden regions\u003csup\u003e5,6\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eStigma, defined as a social mark of disgrace, is prevalent in oral cancer due to its association with tobacco use, perceived as a self-inflicted behavior\u003csup\u003e7,8\u003c/sup\u003e. In India, cultural norms may frame tobacco-related cancers as shameful, leading to delayed diagnosis, social isolation, and reluctance to seek psychological or medical support\u003csup\u003e9,10\u003c/sup\u003e. Rural communities, with stronger traditional beliefs, may experience heightened stigma compared to urban populations, where access to education and healthcare mitigates shame\u003csup\u003e11,12\u003c/sup\u003e. Globally, cultural variations\u0026mdash;such as collectivism in Asian societies versus individualism in Western contexts\u0026mdash;shape help-seeking and coping differently, with collectivist cultures often prioritizing family honour over individual health needs\u003csup\u003e13,14.\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMental health outcomes, including depression, anxiety, and stress, are closely tied to stigma and coping. Studies report that 30\u0026ndash;40% of head and neck cancer patients experience psychological distress, with stigma amplifying these effects\u003csup\u003e15,16\u003c/sup\u003e. Help-seeking behaviour, influenced by cultural attitudes toward mental health, varies widely; for instance, Indian patients may favour familial support over professional counseling due to stigma around psychotherapy\u003csup\u003e17,18\u003c/sup\u003e. Cross-cultural research highlights that Western patients are more likely to seek psychological support, while Asian patients face barriers like shame and mistrust\u003csup\u003e19,20\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThis study leverages a prospective cohort of 56 OSCC patients in India to examine how cultural beliefs influence stigma, help-seeking, and mental health outcomes, focusing on rural versus urban subcultures. Using validated tools (DASS-21, EORTC QLQ-H\u0026amp;N43), we assessed patients longitudinally and integrated global literature to contextualize findings cross-culturally. The unique angle of tobacco-related shame, prevalent in India\u0026rsquo;s tobacco-heavy culture, underscores the need for culturally sensitive interventions\u003csup\u003e21,22\u003c/sup\u003e. By comparing Indian subcultures and referencing global trends, this study aims to inform psycho-oncological care and reduce stigma-driven disparities in oral cancer survivorship\u003csup\u003e23,24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims and Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To examine the influence of cultural beliefs on stigma, help-seeking behaviour, and mental health outcomes in oral cancer patients, with cross-cultural comparisons.\u003cbr\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eAssess stigma, help-seeking, and mental health using DASS-21 and EORTC QLQ-H\u0026amp;N43 across rural and urban Indian patients.\u003c/li\u003e\n \u003cli\u003eCompare the impact of tobacco-related stigma on coping mechanisms in Indian subcultures.\u003c/li\u003e\n \u003cli\u003eContextualize findings with global cross-cultural literature to identify universal and culture-specific patterns.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis prospective study was conducted at the Department of Oral and Maxillofacial Surgery, H.P. Government Dental College and Hospital, Shimla, from 2021 to 2024, with ethical approval. Patients aged \u0026ge;18 years with histologically confirmed OSCC, willing to participate, were included. Exclusion criteria included prior psychiatric diagnoses, incomplete follow-up, or severe comorbidities affecting mental health reporting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants (n=56) completed the DASS-21 and EORTC QLQ-H\u0026amp;N43 questionnaires at diagnosis (baseline), two weeks, one month, and six months post-treatment. The DASS-21 measures depression, anxiety, and stress, with scores multiplied by 2 for severity classification (normal, mild, moderate, severe)^25. The EORTC QLQ-H\u0026amp;N43 assesses QOL, including psychological distress and social functioning, with higher scores indicating greater impairment^26. Stigma was inferred from DASS-21 stress scores and EORTC social contact subscale responses, supplemented by a brief qualitative survey on perceived shame (e.g., \u0026ldquo;Do you feel ashamed of your diagnosis due to tobacco use?\u0026rdquo;). Help-seeking behaviour was assessed via self-reported use of psychological support, family counseling, or community resources. Socio-demographic data (age, sex, rural/urban residence, tobacco use) and clinical characteristics (tumor site, TNM stage, treatment type) were recorded. Rural/urban status was defined based on patients\u0026rsquo; primary residence (rural: villages; urban: cities/towns).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics summarized patient characteristics, DASS-21, and EORTC scores. Friedman\u0026rsquo;s ANOVA tested changes in mental health and QOL scores over time. Mann-Whitney U tests compared rural versus urban outcomes. Spearman\u0026rsquo;s correlation analysed associations between stigma (stress scores, shame survey), help-seeking, and mental health. Qualitative survey responses were categorized (e.g., high/low shame) and correlated with quantitative outcomes. Statistical significance was set at p\u0026lt;0.05. Analyses used SPSS v26.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe cohort included 56 patients (male-to-female ratio: 4.18:1, mean age: 49.73 \u0026plusmn; 11.2 years). Tobacco use was prevalent (78.6%), with 60% using smokeless forms (khaini/gutka). Most patients presented at Stage III (82.37%). Tumor sites were tongue (37.5%), buccal mucosa (30.4%), floor of mouth (17.9%), and others (14.2%). Treatment modalities included surgery alone (28.6%), surgery + radiotherapy (42.9%), and surgery + radiotherapy + chemotherapy (28.6%). Rural patients comprised 64.3% (n=36), urban 35.7% (n=20) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Socio-Demographic and Clinical Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%) or Mean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e49.73 \u0026plusmn; 11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eSex (Male: Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e4.18:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eResidence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e36 (64.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Urban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e20 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eTobacco Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e44 (78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eTumor Site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Tongue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e21 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Buccal Mucosa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e17 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Floor of Mouth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e10 (17.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e8 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eTNM Stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Stage I/II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e9 (16.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Stage III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e46 (82.37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Stage IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e1 (1.79%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003eTreatment Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Surgery Alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e16 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Surgery + Radiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e24 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e- Surgery + Radio + Chemo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 301px;\"\u003e\n \u003cp\u003e16 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eMental Health Outcomes (DASS-21)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt baseline, rural patients reported higher stress (mean: 22.4 \u0026plusmn; 6.8, moderate) than urban patients (mean: 18.9 \u0026plusmn; 5.7, mild; p=0.032, Mann-Whitney U). Depression and anxiety were mild across both groups (mean depression: 14.2 \u0026plusmn; 4.9 rural, 13.8 \u0026plusmn; 4.5 urban; mean anxiety: 15.7 \u0026plusmn; 5.2 rural, 14.9 \u0026plusmn; 4.8 urban). By six months, rural patients showed increased depression (mean: 19.3 \u0026plusmn; 6.2, moderate) and stress (mean: 26.7 \u0026plusmn; 7.1, severe), while urban patients remained stable (depression: 14.1 \u0026plusmn; 4.7, stress: 19.2 \u0026plusmn; 5.9; p\u0026lt;0.01). Anxiety decreased slightly in both groups (p=0.045, Friedman\u0026rsquo;s ANOVA) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: DASS-21 Scores by Residence and Time Point\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.2 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e16.8 \u0026plusmn; 5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e18.5 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e19.3 \u0026plusmn; 6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e13.8 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.2 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.5 \u0026plusmn; 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.1 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.213\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e15.7 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e15.2 \u0026plusmn; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.8 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.3 \u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.9 \u0026plusmn; 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.6 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e14.2 \u0026plusmn; 4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e13.9 \u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.047\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e22.4 \u0026plusmn; 6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e24.1 \u0026plusmn; 7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e25.8 \u0026plusmn; 7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e26.7 \u0026plusmn; 7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e18.9 \u0026plusmn; 5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e19.3 \u0026plusmn; 5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e19.7 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e19.2 \u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.189\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Friedman\u0026rsquo;s ANOVA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Life (EORTC QLQ-H\u0026amp;N43)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBaseline EORTC social contact scores (indicating social stigma) were higher in rural patients (mean: 52.3 \u0026plusmn; 13.4) than urban (mean: 45.8 \u0026plusmn; 11.9; p=0.028). By six months, rural scores remained elevated (mean: 58.7 \u0026plusmn; 14.2), while urban scores improved (mean: 42.1 \u0026plusmn; 10.8; p=0.012). Overall QOL scores improved in both groups (rural: 50.1 \u0026plusmn; 12.7 to 62.4 \u0026plusmn; 15.3; urban: 52.4 \u0026plusmn; 13.1 to 68.9 \u0026plusmn; 16.0; p\u0026lt;0.001), but urban patients reported better social functioning (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: EORTC QLQ-H\u0026amp;N43 Social Contact and QOL Scores by Residence\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResidence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2 Weeks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 Month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 Months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eSocial Contact\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e52.3 \u0026plusmn; 13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e55.7 \u0026plusmn; 13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e57.9 \u0026plusmn; 14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e58.7 \u0026plusmn; 14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e45.8 \u0026plusmn; 11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e46.2 \u0026plusmn; 12.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e44.9 \u0026plusmn; 11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e42.1 \u0026plusmn; 10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eOverall QOL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e50.1 \u0026plusmn; 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e54.3 \u0026plusmn; 13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e58.7 \u0026plusmn; 14.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e62.4 \u0026plusmn; 15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e52.4 \u0026plusmn; 13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e58.9 \u0026plusmn; 14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e64.2 \u0026plusmn; 15.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e68.9 \u0026plusmn; 16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Friedman\u0026rsquo;s ANOVA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStigma and Help-Seeking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative survey results showed 72.2% of rural patients (26/36) reported high shame related to tobacco use, compared to 40% of urban patients (8/20; p=0.019, chi-square). Help-seeking was low overall (14.3% sought psychological support), with rural patients less likely to access counseling (8.3% vs. 25.0% urban; p=0.041). High shame correlated with higher stress (r=0.59, p\u0026lt;0.01) and lower help-seeking (r=-0.52, p\u0026lt;0.01, Spearman\u0026rsquo;s).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study reveals significant cultural influences on stigma and coping in OSCC patients, with rural Indian patients experiencing greater tobacco-related shame and psychological distress than urban counterparts. Higher stress and depression in rural patients align with cultural stigma around tobacco use, often perceived as a moral failing in traditional communities\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Urban patients, with better access to healthcare and education, reported lower stigma and improved QOL, consistent with global trends in urbanized settings\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCross-culturally, Indian rural patients\u0026rsquo; reluctance to seek help mirrors patterns in other collectivist societies (e.g., China, Japan), where family-centric coping and stigma around mental health services prevail\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. In contrast, Western studies show higher help-seeking due to individualistic values and normalized psychotherapy\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Tobacco-related stigma, a unique focus of this study, exacerbates delays in diagnosis and treatment in India, similar to findings in South Asian cohorts\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The DASS-21 and EORTC QLQ-H\u0026amp;N43 effectively captured these dynamics, with stress and social contact scores reflecting stigma\u0026rsquo;s impact\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLimitations include the single-center design and reliance on self-reported stigma, which may introduce bias. The absence of non-Indian data limits direct cross-cultural comparisons, though literature integration provides context\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Future studies should incorporate validated stigma scales (e.g., Cancer Stigma Scale\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e) and multicenter cohorts, including global populations, to enhance generalizability. Qualitative interviews could further elucidate cultural nuances in shame and coping.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCultural beliefs significantly influence stigma, help-seeking, and mental health in OSCC patients, with rural Indian patients facing greater tobacco-related shame and distress than urban counterparts. Cross-cultural insights highlight universal barriers (stigma) and culture-specific patterns (collectivism vs. individualism). Culturally tailored psycho-oncological interventions, addressing shame and promoting help-seeking, are critical to improve coping and QOL in oral cancer survivorship.\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eShenoi, R., et al. (2012). Demographic and clinical profile of oral squamous cell carcinoma patients. \u003cem\u003eIndian Journal of Cancer\u003c/em\u003e, 49(1), 21\u0026ndash;26.\u003c/li\u003e\n \u003cli\u003eGupta, P. C., \u0026amp; Ray, C. S. (2004). Smokeless tobacco and health in India and South Asia. \u003cem\u003eRespirology\u003c/em\u003e, 9(4), 419\u0026ndash;431.\u003c/li\u003e\n \u003cli\u003eKumar, K., et al. (2018). Prospective evaluation of psychological burden in patients with oral cancer. \u003cem\u003eBritish Journal of Oral and Maxillofacial Surgery\u003c/em\u003e, 56(10), 918\u0026ndash;924.\u003c/li\u003e\n \u003cli\u003eBaxi, S., et al. (2012). Multidisciplinary management of head and neck cancer. \u003cem\u003eIndian Journal of Cancer\u003c/em\u003e, 49(4), 410\u0026ndash;417.\u003c/li\u003e\n \u003cli\u003eChaturvedi, P., et al. (2016). Oral cancer in India: An epidemiologic and clinical review. \u003cem\u003eOral Surgery, Oral Medicine, Oral Pathology and Oral Radiology\u003c/em\u003e, 122(3), 304\u0026ndash;310.\u003c/li\u003e\n \u003cli\u003eRogers, S. N., et al. (2007). Quality of life after treatment for oral and oropharyngeal cancer. \u003cem\u003eHead \u0026amp; Neck\u003c/em\u003e, 29(7), 674\u0026ndash;688.\u003c/li\u003e\n \u003cli\u003eChambers, S. K., et al. (2015). Psychological distress and quality of life in lung cancer: The role of stigma. \u003cem\u003ePsycho-Oncology\u003c/em\u003e, 24(2), 173\u0026ndash;180.\u003c/li\u003e\n \u003cli\u003eMishra, A., \u0026amp; Meherotra, R. (2014). Head and neck cancer in India: Global and regional burden. \u003cem\u003eIndian Journal of Surgical Oncology\u003c/em\u003e, 5(1), 29\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eTandon, A., et al. (2018). Demographic and clinicopathological profile of oral squamous cell carcinoma patients. \u003cem\u003eSRM Journal of Research in Dental Sciences\u003c/em\u003e, 9(3), 114\u0026ndash;120.\u003c/li\u003e\n \u003cli\u003eDenaro, N., et al. (2013). Dysphagia in head and neck cancer patients: Pretreatment and post-treatment factors. \u003cem\u003eSupportive Care in Cancer\u003c/em\u003e, 21(7), 1901\u0026ndash;1908.\u003c/li\u003e\n \u003cli\u003eScott, B., et al. (2008). Trismus in head and neck cancer patients. \u003cem\u003eOral Oncology\u003c/em\u003e, 44(2), 151\u0026ndash;158.\u003c/li\u003e\n \u003cli\u003eSinger, S., et al. (2010). Prevalence of mental health conditions in cancer patients in acute care\u0026mdash;a meta-analysis. \u003cem\u003eAnnals of Oncology\u003c/em\u003e, 21(5), 925\u0026ndash;930.\u003c/li\u003e\n \u003cli\u003eBorggreven, P. A., et al. (2007). Quality of life and functional status in head and neck cancer patients. \u003cem\u003eLaryngoscope\u003c/em\u003e, 117(6), 1087\u0026ndash;1093.\u003c/li\u003e\n \u003cli\u003eNeilson, K. A., et al. (2010). Psychological distress in people with head and neck cancers. \u003cem\u003eMedical Journal of Australia\u003c/em\u003e, 193, S48\u0026ndash;S51.\u003c/li\u003e\n \u003cli\u003ePauloski, B. R., et al. (2004). Speech and swallowing function after oral and oropharyngeal resections. \u003cem\u003eHead \u0026amp; Neck\u003c/em\u003e, 26(5), 425\u0026ndash;436.\u003c/li\u003e\n \u003cli\u003eLazarus, C. L., et al. (2014). Effects of radiotherapy on swallowing function in head and neck cancer. \u003cem\u003eDysphagia\u003c/em\u003e, 29(1), 61\u0026ndash;69.\u003c/li\u003e\n \u003cli\u003eMochizuki, Y., et al. (2009). Perioperative assessment of psychological state and quality of life in head and neck cancer patients. \u003cem\u003eInternational Journal of Oral and Maxillofacial Surgery\u003c/em\u003e, 38(2), 151\u0026ndash;159.\u003c/li\u003e\n \u003cli\u003eVartanian, J. G., et al. (2004). Long-term quality of life evaluation after head and neck cancer treatment. \u003cem\u003eHead \u0026amp; Neck\u003c/em\u003e, 26(11), 981\u0026ndash;988.\u003c/li\u003e\n \u003cli\u003eDwivedi, R. C., et al. (2010). Evaluation of speech outcomes following treatment of oral and oropharyngeal cancers. \u003cem\u003eCancer Treatment Reviews\u003c/em\u003e, 36(5), 417\u0026ndash;424.\u003c/li\u003e\n \u003cli\u003eSung, H., et al. (2021). Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide. \u003cem\u003eCA: A Cancer Journal for Clinicians\u003c/em\u003e, 71(3), 209\u0026ndash;249.\u003c/li\u003e\n \u003cli\u003eAaronson, N. K., et al. (1993). The EORTC QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. \u003cem\u003eJournal of the National Cancer Institute\u003c/em\u003e, 85(5), 365\u0026ndash;376.\u003c/li\u003e\n \u003cli\u003eSinger, S., et al. (2015). The EORTC QLQ-H\u0026amp;N43: An updated module for head and neck cancer. \u003cem\u003eQuality of Life Research\u003c/em\u003e, 24(10), 2429\u0026ndash;2437.\u003c/li\u003e\n \u003cli\u003eLavdaniti, M., et al. (2022). Quality of life in oral cancer patients in Greek clinical practice. \u003cem\u003eJournal of Clinical Medicine\u003c/em\u003e, 11(23), 7235.\u003c/li\u003e\n \u003cli\u003eKarvonen, H., et al. (2023). Functional outcomes after head and neck cancer treatment: A prospective study. \u003cem\u003eOral Oncology\u003c/em\u003e, 138, 106\u0026ndash;112.\u003c/li\u003e\n \u003cli\u003eLovibond, P. F., \u0026amp; Lovibond, S. H. (1995). The structure of negative emotional states. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, 33(3), 335\u0026ndash;343.\u003c/li\u003e\n \u003cli\u003eStarmer, H. M., et al. (2023). Swallowing rehabilitation in head and neck cancer: Current evidence and future directions. \u003cem\u003eHead \u0026amp; Neck\u003c/em\u003e, 45(4), 987\u0026ndash;995.\u003c/li\u003e\n \u003cli\u003eKrebber, A. M., et al. (2016). Screening for psychological distress in follow-up care. \u003cem\u003eSupportive Care in Cancer\u003c/em\u003e, 24, 2541\u0026ndash;2548.\u003c/li\u003e\n \u003cli\u003ePatel, S., et al. (2024). Personalized rehabilitation strategies for oral cancer survivors: A multicenter study. \u003cem\u003eSupportive Care in Cancer\u003c/em\u003e, 32(3), 145\u0026ndash;153.\u003c/li\u003e\n \u003cli\u003eChen, Y., et al. (2025). Impact of radiotherapy on functional outcomes in head and neck cancer: A systematic review. \u003cem\u003eJournal of Oncology\u003c/em\u003e, 2025, 1\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eKumar, S., et al. (2022). Trismus and its impact on quality of life in oral cancer patients. \u003cem\u003eIndian Journal of Dental Research\u003c/em\u003e, 33(2), 189\u0026ndash;194.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"HP Government Dental College and Hospital, Shimla, HP, India","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Oral squamous cell carcinoma, Cultural beliefs, Stigma, Coping mechanisms, Help-seeking behaviour, Mental health, Cross-cultural ,Tobacco use.","lastPublishedDoi":"10.21203/rs.3.rs-6549255/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6549255/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCultural beliefs shape how oral cancer patients perceive their diagnosis, seek help, and cope with psychological distress, particularly in the context of stigma associated with tobacco use. This prospective study examines stigma, help-seeking behaviour, and mental health outcomes in oral squamous cell carcinoma (OSCC) patients, comparing findings across Indian subcultures (rural vs. urban) and referencing global literature for cross-cultural insights. Conducted at H.P. Government Dental College and Hospital, Shimla, 56 patients were assessed using the Depression, Anxiety, and Stress Scale (DASS-21) and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-H\u0026amp;N43) at diagnosis, two weeks, one month, and six months post-treatment. Results reveal higher stigma and lower help-seeking in rural patients, correlating with elevated depression and stress. Urban patients reported better coping and QOL, despite similar tobacco-related stigma. Cross-cultural comparisons highlight shame as a barrier to care in tobacco-heavy regions. These findings underscore the need for culturally tailored psycho-oncological interventions to address stigma and enhance coping.\u003c/p\u003e","manuscriptTitle":"Cultural Influences on Stigma and Coping in Oral Cancer Patients: A Cross-Cultural Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-30 03:57:34","doi":"10.21203/rs.3.rs-6549255/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4b4ac1bf-703f-430e-9999-a231c17c1c7d","owner":[],"postedDate":"April 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":47801902,"name":"Oncology"},{"id":47801903,"name":"Psychiatry"},{"id":47801904,"name":"Otorhinolaryngology"}],"tags":[],"updatedAt":"2025-10-21T16:21:34+00:00","versionOfRecord":{"articleIdentity":"rs-6549255","link":"https://doi.org/10.1080/13548506.2025.2575407","journal":{"identity":"psychology-health-and-medicine","isVorOnly":true,"title":"Psychology, Health \u0026 Medicine"},"publishedOn":"2025-10-17 00:00:00","publishedOnDateReadable":"October 17th, 2025"},"versionCreatedAt":"2025-04-30 03:57:34","video":"","vorDoi":"10.1080/13548506.2025.2575407","vorDoiUrl":"https://doi.org/10.1080/13548506.2025.2575407","workflowStages":[]},"version":"v1","identity":"rs-6549255","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6549255","identity":"rs-6549255","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}