Knowledge, Attitudes, and Practices Regarding Ethnomedicinal Therapies in Oral Cancer Care: Insights from Healthcare Professionals with Reference to Thuja occidentalis

INTRODUCTION

Oral cancer arising from the oral mucosal epithelium represents a significant global public health challenge, particularly in populations with high prevalence of tobacco use, alcohol consumption, and betel quid chewing. The disease is associated with substantial functional and aesthetic impairments, including altered speech, swallowing difficulties, and loss of taste, which collectively contribute to a markedly reduced oral health-related quality of life (Tan et al., 2023). OSCC constitutes the most common histological subtype and may occur across multiple anatomical sites within the oral cavity. Despite advancements in diagnostic and therapeutic modalities, survival rates remain unsatisfactory, largely due to delayed diagnosis and the aggressive biological behavior of the disease (Bugshan and Farooq, 2020).

Conventional management of oral cancer primarily involves surgery, chemotherapy, and radiotherapy. Chemotherapy plays a crucial role in reducing the risk of recurrence and metastasis, thereby improving survival outcomes (Liu et al., 2015). However, these treatment modalities are frequently associated with considerable physical, psychological, and functional burdens (Khurshid et al., 2023). Adverse effects such as mucositis, xerostomia, pain, dysphagia, and immunosuppression often negatively impact patient well-being, prompting many individuals to explore CAM approaches. Consequently, there is growing interest in integrative strategies that incorporate traditional and ethnomedicinal practices alongside standard oncologic care (Lopes et al., 2023).

CAM have been utilized for centuries to prevent and manage various chronic diseases, including cancer (Reyaz et al., 2025). CAM typically adopts a holistic approach, employing whole plants or herbal combinations for therapeutic purposes. Numerous plant-derived compounds exhibit antioxidant, anti-inflammatory, immunomodulatory, and antineoplastic properties, rendering them potential candidates for adjunctive cancer therapy (Imtiaz et al., 2024). In the context of oral cancer, several medicinal plants have been investigated for their potential roles in symptom management, enhancing host immune responses and modulating carcinogenic pathways (Imtiaz et al., 2024; Reyaz et al., 2025).

In India, ethnomedicinal and traditional healthcare products are regulated under the framework of the Ministry of AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy), which oversees their education, research, manufacturing, and clinical application. The regulatory framework emphasizes quality assurance, standardization, safety monitoring, and the promotion of evidence-based practices for traditional medicinal products. Recent initiatives have focused on strengthening pharmacovigilance systems, improving manufacturing standards, and encouraging scientific validation of traditional therapies to facilitate their safe integration into contemporary healthcare. Despite these efforts, challenges related to clinical evidence, healthcare professional awareness, and standardized therapeutic guidelines continue to influence the acceptance and utilization of ethnomedicinal products in oncology care.

T. occidentalis, a plant widely used in CAM and homeopathy, has attracted attention due to its reported antimicrobial, antioxidant, anti-inflammatory, antidiabetic, antipyretic, and anticancer properties (Ramsridhar et al., 2024). Experimental studies have suggested that extracts of T. occidentalis may influence immune regulation and apoptosis, however, evidence supporting its clinical effectiveness in cancer management remains limited. In addition to T. occidentalis, various CAM therapies are commonly employed across traditional healthcare systems. However, their scientific validation, clinical indications, and safety profiles remain insufficiently characterized (Hakobjanyan et al., 2025).

Healthcare professionals play a pivotal role in guiding patients toward evidence-based treatment decisions and ensuring the safe use of complementary therapies (Alzahrani et al., 2024). Their knowledge, attitudes, and clinical practices substantially influence patient counseling, acceptance of integrative approaches, and the prevention of potential drug-herb interactions. Nevertheless, limited evidence exists regarding healthcare professionals' awareness and perceptions of T. occidentalis and other CAM application in oral cancer management (Hernandez-Fuentes et al., 2025).

T. occidentalis was selected as the representative ethnomedicinal plant in this study because of its documented medicinal properties, including antioxidant, immunomodulatory, and anticancer activities, and its emerging therapeutic relevance in OSCC (Hakobjanyan et al., 2025; Ramsridhar et al., 2024). Despite its growing scientific interest, evidence regarding its clinical applicability remains limited, and little is known about healthcare professionals' awareness and perceptions of its use. As healthcare professionals play a critical role in guiding evidence-based decisions regarding complementary therapies, understanding their knowledge, attitudes, and practices is essential. Therefore, the present study aimed to evaluate healthcare professionals' knowledge, attitudes, and practices regarding ethnomedicinal therapies in oral cancer care, using T. occidentalis as a representative example of a plant with emerging therapeutic potential.

MATERIALS AND METHODS

Study Design and Setting

A cross-sectional study was conducted among healthcare practitioners in Chennai, Tamil Nadu, India, to assess Knowledge, Attitudes, and Practices (KAP) regarding T. occidentalis and other CAM in the management of oral cancer. The study was conducted over a period of 6 months.

Ethical Considerations

Ethical approval was obtained from the appropriate Institutional Ethics Committee prior to commencement of the study. All participants were informed about the study objectives and procedures before participation, and written or implied informed consent was obtained.

Study Population and Eligibility Criteria

The study population included healthcare professionals, including dentists, medical practitioners, Ayurvedic physicians, and homeopathic practitioners, with at least 1 year of clinical experience. Interns, students, non-clinical professionals, and individuals who submitted incomplete questionnaires were excluded from the study.

Sample Size Determination

The sample size was calculated using the single population proportion formula (n=4pq/d²), assuming a 95% confidence level (Z=1.96), a margin of error of 5%, and an estimated prevalence of 48% derived from pilot study findings. The minimum required sample size was 384. To account for potential non-response and incomplete data, the final sample size was increased to 400 participants. All eligible participants completed the questionnaire, and no responses were excluded from the analysis, resulting in a response rate of 100%.

Sampling Technique and Data Collection

Participants were recruited using a non-probability convenience sampling method. Healthcare practitioners were approached from government and private hospitals, academic institutions, and private clinics across Chennai. Additionally, practitioners attending professional meetings and continuing medical education programs were invited to participate. Where feasible, the questionnaire was also distributed electronically through professional networks.

Data were collected using a structured, self-administered questionnaire developed through an extensive literature review and expert consultation (see Supplementary File). The instrument comprised five sections: sociodemographic characteristics; knowledge; attitudes; practices; and perceived barriers to the use of CAM in oral cancer management.

Questionnaire Validation and Reliability

Content validity was established through expert panel evaluation by specialists in public health dentistry, oral medicine, oncology, and CAM, including Ayurvedic practitioners. Each item was assessed for relevance, clarity, representativeness, and appropriateness. Minor revisions were made based on expert feedback to improve clarity and comprehensiveness.

Face validity was assessed through a pilot test with 10 healthcare practitioners to evaluate readability and comprehensibility. Feedback indicated that the questionnaire was clear and well-structured, and necessary refinements were incorporated. Data from the pilot study were excluded from the final analysis.

Internal consistency reliability was assessed using Cronbach's alpha, which demonstrated acceptable reliability (α ≥ 0.7).

Scoring System

The KAP domains were scored as follows:

• Knowledge: Comprised 9 items, with each correct response scored as 1 and incorrect or "not sure" responses scored as 0 (total score range: 0-9).
• Attitude: Included 9 items measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a total score range of 9-45.
• Practice: Consisted of eight items scored as "Yes" (2), "Occasionally" (1), and "No" (0), yielding a total score range of 0-16. Although the validated questionnaire included all three response options, no participant selected "Occasionally" during data collection; therefore, only the observed response categories ("Yes" and "No") are presented in the results table.
• Scores in each domain were categorized as good (>75%), moderate (50-75%), and poor (<50%).

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize participants' demographic characteristics and KAP scores. Continuous variables were expressed as mean±Standard Deviation (SD), while categorical variables were presented as frequencies and percentages.

Ordinal logistic regression analysis (proportional odds model) was employed to identify factors associated with practice levels. Independent variables included knowledge score, attitude score, profession, years of clinical experience, gender, and qualification. The proportional odds assumption was assessed before model interpretation.

Adjusted Odds Ratios (AORs) with 95% Confidence Intervals (CIs) were reported. A p-value of <0.05 was considered statistically significant.

RESULTS

Participant Characteristics

A total of 400 healthcare practitioners participated in the study. The majority were medical practitioners (n=180, 45.0%), followed by dentists (n=140, 35.0%), Ayurvedic practitioners (n=60, 15.0%), and homeopathic practitioners (n=20, 5.0%).

Most participants belonged to the 30-45-year age group (n=260, 65.0%), followed by 46-60 years (n=90, 22.5%) and 25-29 years (n=50, 12.5%). Female participants accounted for 60.0% (n=240) of the sample, whereas males constituted 40.0% (n=160).

Regarding professional experience, 38.0% (n=152) had <5 years of clinical experience, 35.0% (n=140) had 5-10 years, and 27.0% (n=108) had >10 years of experience. More than half of the participants held postgraduate qualifications (n=220, 55.0%), followed by undergraduate degrees (n=140, 35.0%) and doctoral qualifications (n=40, 10.0%).

In terms of practice setting, private practitioners represented the largest group (n=180, 45.0%), followed by mixed practice (n=90, 22.5%), academic practice (n=80, 20.0%), and government service (n=50, 12.5%). Nearly half of the respondents (n=190, 47.5%) reported prior experience in managing oral cancer patients (Figure 1).

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The mean knowledge score among the participants was approximately 3.16±2.00 (range: 0-9), indicating an overall low level of knowledge regarding CAM and T. occidentalis in oral cancer management. The mean attitude score was approximately 32.33±6.00 (range: 9-45), reflecting a generally positive attitude toward the integration of ethnomedicinal therapies into oral cancer care. In contrast, the mean practice score was approximately 3.20±2.50 (range: 0-16), suggesting limited implementation of CAM-related practices in routine clinical settings despite favorable attitudes.

Knowledge Regarding CAM and T. occidentalis

Overall awareness of CAM for oral cancer management was high, with 85.0% (n=340) of participants reporting familiarity with these therapies. However, specific knowledge regarding T. occidentalis was comparatively limited.

Only 39.0% (n=156) had heard of T. occidentalis as a medicinal plant, while 35.0% (n=140) were aware of its use in CAM. Awareness of its potential anticancer or immunomodulatory properties was reported by 34.0% (n=136).

Knowledge related to safety and evidence-based use was notably inadequate. Only 24.0% (n=96) were aware of potential adverse effects associated with T. occidentalis, and merely 13.0% (n=52) recognized possible herb-drug interactions. Although 36.0% (n=144) believed ethnomedicinal plant use should be evidence-based, only 12.0% (n=48) had received formal education or training in ethnomedicinal or complementary therapies (Table 1).

Values are expressed as frequency (n) and percentage (%). "No/Not sure" responses were combined for analysis.

Attitudes Toward CAM in Oral Cancer Care

Participants generally demonstrated a favorable attitude toward integrating CAM into oral cancer management.

Approximately one-third agreed that CAM could complement conventional oral cancer treatment (34.0%, n=136), while 33.0% (n=132) believed T. occidentalis may offer therapeutic benefits in oral cancer care.

A majority agreed that healthcare professionals should possess knowledge regarding ethnomedicinal therapies (63.0%, n=252), and 56.0% (n=224) supported regulation and standardization of ethnomedicinal practices.

Notably, 78.0% (n=312) agreed that further research on T. occidentalis in oral cancer is required, indicating strong interest in validating its therapeutic potential through scientific research (Table 2).

Values are expressed as frequency (n) and percentage (%). Percentages are calculated row-wise.

Practices Related to Ethnomedicinal Plant Use

Despite moderate awareness and generally positive attitudes, the clinical application of CAM was limited.

Only 10.0% (n=40) reported recommending CAM to patients, and just 6.0% (n=24) had specifically recommended T. occidentalis in clinical practice. Additionally, only 29.0% (n=116) routinely enquired about ethnomedicinal plant use during patient history taking.

15% (n=60) reported observing patients concurrently using CAM alongside conventional cancer therapies, while only 11.0% (n=44) counseled patients regarding potential adverse effects.

Encouragingly, 57.0% (n=228) expressed willingness to undergo formal training on CAM in oral cancer management, indicating interest in improving competency in this area (Table 3).

Perceived Barriers to Ethnomedicinal Plant Use

The most frequently reported barrier to integrating CAM into oral cancer management was a lack of training (35.0%, n=140), followed by safety concerns (30.0%, n=120) and insufficient scientific evidence (20.0%, n=80).

Legal and ethical concerns (10.0%, n=40) and patient noncompliance (5.0%, n=20) were less frequently reported (Figure 2).

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Factors Associated with Practice Levels

Ordinal logistic regression analysis was performed to identify predictors of practice levels among healthcare practitioners. The overall model was statistically significant (χ²=196.664, p<0.001), demonstrating acceptable model fit (Deviance p=0.998) and moderate explanatory power (Nagelkerke R²=0.465).

Knowledge, attitude, and profession were identified as significant predictors of practice levels.

Participants with poor knowledge demonstrated significantly lower odds of good practice than those with good knowledge (OR=0.23, 95% CI: 0.08-0.67, p=0.007). Similarly, participants with moderate knowledge also had reduced odds of good practice (OR=0.31, 95% CI: 0.17-0.58, p<0.001).

Regression analysis identified attitude as the strongest independent predictor of practice. Compared with participants with a positive attitude, those with a negative attitude had significantly lower odds of good practice (OR=0.07, 95% CI: 0.01-0.32, p=0.001), while those with a neutral attitude also demonstrated significantly lower odds (OR = 0.53, 95% CI: 0.29-0.95, p=0.035).

Among professions, dentists had significantly lower odds of good practice than homeopathic practitioners (OR=0.08, 95% CI: 0.03-0.21, p<0.001). No statistically significant associations were observed for years of experience, gender, or qualification (p>0.05).

Age was excluded from interpretation due to instability arising from sparse observations in higher age categories (Table 4).

Model Summary: Chi-square- 196.664; p value<0.001; Nagelkerke R²-0.465; Deviance p value- 0.998.

DISCUSSION

The present study demonstrated that knowledge, attitude, and profession were significant predictors of practice, highlighting the important role of cognitive and perceptual factors in the adoption of ethnomedicine in oral cancer care. These findings are consistent with previous studies showing that knowledge and perceptions significantly influence the integration of Complementary and Alternative Medicine (CAM) into clinical practice (Ammar et al., 2023; Barikani et al., 2015).

A significant association was observed between knowledge and practice, with participants possessing lower levels of knowledge being less likely to engage in appropriate clinical practices related to ethnomedicinal therapies. Similar findings have been reported among healthcare professionals, where awareness of CAM did not necessarily translate into its clinical recommendation or use (Bahall and Legall, 2017; Kong et al., 2013). Previous studies have suggested that insufficient understanding of the safety, efficacy, and clinical applications of CAM remains a major barrier to its integration into routine healthcare practice (Jafari et al., 2021; Liu et al., 2021; Sundaramurthy et al., 2016).

Attitude emerged as the strongest predictor of practice, influencing healthcare professionals’ willingness to discuss and recommend CAM therapies. This observation is consistent with findings indicating that practitioners’ perceptions of efficacy, safety, and scientific validity strongly shape their readiness to incorporate CAM into patient care (Hyodo et al., 2003; Shashikumar et al., Sont et al., 2023; Trimborn et al., 2013).

Significant differences were also identified across professional groups, with dentists demonstrating lower levels of practice compared with homeopathy practitioners. This finding aligns with previous reports suggesting that conventional healthcare professionals tend to be more cautious regarding CAM integration than practitioners from traditional systems of medicine (Liu et al., 2021; Stub et al., 2016). Although ethnomedicinal therapies are widely accepted in India because of their cultural relevance, accessibility, and longstanding traditional use, their incorporation into formal healthcare settings remains limited (Gawde et al., 2013; Khapre and Saxena, 2018; Kshirsagar et al., 2020).

No significant association was observed between demographic variables and practice, indicating that clinical behaviour is influenced more by knowledge and professional attitudes than by age, gender, or years of experience. Collectively, these findings underscore the need to strengthen evidence-based education and foster positive professional attitudes to support the safe and effective integration of ethnomedicinal therapies into oral cancer care.

STRENGTHS AND LIMITATIONS OF THE STUDY

This study has several notable strengths. To the best of our knowledge, few studies have specifically evaluated knowledge, attitudes, and practices related to T. occidentalis and other CAM techniques within a multidisciplinary cohort of healthcare professionals, encompassing both conventional and traditional systems of medicine. The inclusion of diverse professional groups and practice settings enhances the external relevance and contextual applicability of the findings. Additionally, the relatively large sample size, structured recruitment approach, and use of a validated questionnaire with acceptable internal consistency contribute to the methodological rigor and reliability of the study outcomes.

However, certain limitations should be acknowledged. The cross-sectional design restricts the ability to establish causal relationships or assess temporal changes in knowledge and practice. The use of non-probability convenience sampling may introduce selection bias and limit the generalisability of the findings. Furthermore, reliance on self-reported data may be subject to recall and social desirability biases, particularly regarding reported clinical practices. Future studies employing longitudinal designs, probability-based sampling, and objective assessment methods are warranted to strengthen the evidence base.

CONCLUSION

This study identified a significant knowledge-practice gap regarding T. occidentalis and CAM among healthcare professionals involved in oral cancer care. Despite generally positive attitudes toward CAM, limited knowledge, inadequate training, and safety concerns restricted its clinical application. Knowledge, attitude, and profession emerged as significant predictors of practice. These findings underscore the need for evidence-based education and targeted training initiatives to improve healthcare professionals' understanding of CAM and facilitate informed clinical discussions regarding its use in oral cancer care.

ACKNOWLEDGEMENT

The authors would like to thank all healthcare practitioners who participated in this study for their valuable time and responses. The authors also express their gratitude to the faculty members and experts who contributed to the validation of the questionnaire and provided constructive suggestions during the study.

ABBREVIATIONS

AOR

Adjusted Odds Ratio

CAM

Complementary and Alternative Medicine

CI

Confidence Interval

KAP

Knowledge, Attitudes, and Practices

OR

Odds Ratio

OSCC

Oral Squamous Cell Carcinoma

PG

Postgraduate

SD

Standard Deviation

SPSS

Statistical Package for the Social Sciences

UG

Undergraduate.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

AUTHORS CONTRIBUTION

S.R. conceptualized and designed the study, performed formal analysis, and wrote the original manuscript draft; C.R. and V.P.V. contributed to methodology development, data collection, and manuscript review; K.M. and M.A.H. participated in investigation, validation, and data interpretation; M.B. supervised the study, contributed to methodology and critical revision of the manuscript. All authors reviewed and approved the final manuscript.

SUMMARY

This cross-sectional study evaluated the knowledge, attitudes, and practices of 400 healthcare practitioners in Chennai, India, regarding the use of and other CAM practice in oral cancer care. While overall awareness and attitudes toward integrating these therapies were positive, specific clinical knowledge and practical implementation remained highly limited due to a lack of formal training and safety concerns. The findings highlight the critical need to bridge this knowledge-practice gap by integrating evidence-based education on complementary therapies into standard oncology and medical curricula.