A Study on the Current Status and Correlations of Knowledge, Beliefs, and Practices Regarding Oral Health among College Students Based on Structural Equation Modeling

Abstract

Objective: To investigate the current status of college students’ oral health knowledge, attitudes, and behaviors, and to explore the association pathways among these three factors and the mediating effect of attitudes using structural equation modeling, thereby providing empirical evidence for optimizing oral health education strategies in higher education institutions. Methods: A single-time-point cross-sectional questionnaire survey was conducted from October 2024 to October 2025 using convenience sampling, involving 927 students from a university. Students were invited to complete the survey once during their scheduled class periods to ensure a high response rate. The survey tool comprised four sections: general demographic characteristics, oral health knowledge (25 items), oral health attitudes (5 items), and oral health behaviors (10 items). The overall Cronbach’s α coefficient was 0.907, with a KMO value of 0.929. Bartlett’s sphericity test ( P < 0.001) indicated suitability for factor analysis. Descriptive statistics, correlation analysis, and reliability/validity testing were performed using R Studio software. A structural equation model was constructed using the Diagonally Weighted Least Squares (DWLS) estimator to account for mixed item types (dichotomous and Likert-scale), and the significance of the mediating effect was tested using the bias-corrected Bootstrap method (5000 repeated samples). Results: A total of 927 valid questionnaires were collected. College students’ oral health knowledge, attitude, and behavior scores were 12.62 ± 3.06, 16.55 ± 4.45, and 33.82 ± 8.26, respectively. Correlation analysis revealed significant positive correlations between knowledge, attitude, and behavior (r = 0.453 - 0.551, all P < 0.001). The structural equation model demonstrated good fit (χ 2 / df = 2.501, CFI = 0.982, TLI = 0.979, RMSEA = 0.040, SRMR = 0.025). Path analysis revealed significant positive associations of knowledge on attitude (β = 0.521, P < 0.001), attitude on behavior (β = 0.279, P < 0.001), and knowledge on behavior (β = 0.426, P < 0.001). Mediation analysis indicated that attitude partially mediated the relationship between knowledge and behavior, with an indirect effect size of 0.038 (95% CI : 0.025 - 0.053). The mediating effect accounted for 25.5% of the total effect. Conclusion: Oral health knowledge is significantly associated with behavior both directly and indirectly through partial mediation by attitude. Oral health education in higher education institutions should prioritize both knowledge dissemination and attitude internalization, while strengthening environmental support and behavioral skill training to promote effective knowledge-to-behavior conversion.