Relationship between periodontal health-related knowledge, belief, and behaviors: a structural equation modeling approach

Abstract

Background: Periodontal diseases remain a global health concern despite being largely preventable. University students represent a key population for targeted interventions, given their transitional life stage and potential for adopting long-term oral health behaviors. This study utilized Structural Equation Modeling (SEM) to elucidate associations among periodontal health knowledge, beliefs, and behaviors, using a validated periodontal health literacy questionnaire (ALPHABET) based on the Health Belief Model.

Methods: A cross-sectional study was conducted among 2,335 Thai undergraduate students at Chulalongkorn University. Participants completed a structured questionnaire assessing demographic characteristics, periodontal health knowledge, and beliefs. Exploratory Factor Analysis identified underlying constructs, while Confirmatory Factor Analysis validated latent variables. SEM with path analysis examined relationships between periodontal knowledge, beliefs, and oral hygiene behaviors, including brushing and flossing frequency.

Results: SEM analysis demonstrated suboptimal model fit but supported theory-driven associations among knowledge, beliefs, and oral hygiene behaviors. Self-efficacy (EFF) strongly predicted flossing (β = 0.439, p < 0.001) and brushing frequency (β = 0.194, p < 0.001). Perceived benefits (BEN) also positively influenced both behaviors, while cues to action (CUE) and perceived susceptibility (SUS) negatively predicted flossing. Perceived severity (SEV) showed a dual effect positively associated with brushing frequency (β = 0.088, p = 0.005) but negatively with brushing technique (β = -0.063, p = 0.017). SEM revealed that perceived benefits, barriers, self-efficacy, and perceived severity significantly predicted brushing behaviors, while flossing frequency was positively associated with self-efficacy and perceived benefits, and negatively associated with perceived susceptibility, cues to action, and symptom knowledge.

Conclusion: This study provides empirical evidence on the associations between periodontal health knowledge, beliefs, and behaviors among university students. Self-efficacy and perceived benefits were key facilitators, while perceived susceptibility, perceived barriers, and cues to action acted as deterrents to preventive oral hygiene behaviors. These findings support tailored interventions to enhance periodontal health literacy and promote sustained adherence to recommended oral hygiene practices.

Keywords: HBM; Health care access; Periodontal health belief; Periodontal health knowledge; Questionnaire; SEM.

Fig. 1

Theoretical framework based on the health belief model (HBM). This diagram illustrates the hypothesized structural pathways linking periodontal health knowledge constructs to HBM construct, which in turn influences oral hygiene behaviors through indirect effects. Latent variables, represented as ellipses, include periodontal health knowledge constructs (ALPHA-K): General Knowledge (GEN), Prevention and Treatment (PnT), Oral Health Care (OHC), Signs and Symptoms (SnS); and periodontal health belief constructs (ALPHA-B): Perceived Severity (SEV), Perceived Susceptibility (SUS), Perceived Barriers (BAR), Cues to Action (CUE), Perceived Benefits (BEN), and Self-Efficacy (EFF). Observed outcome variables, represented as rectangles, include oral hygiene behaviors: “How do you usually brush your teeth?” (Brushing Technique: BTech), “How many times a day do you usually brush your teeth?” (Brushing Frequency: Brush), “How long do you typically spend brushing your teeth?” (Brushing Duration: BTime), and “How often do you floss your teeth?” (Flossing Frequency: Floss)

Fig. 2

Theory-driven structural equation model illustrating standardized path coefficients among periodontal knowledge, beliefs, and oral hygiene behaviors. This figure presents a theory-driven Structural Equation Model (SEM) based on the Health Belief Model (HBM), illustrating standardized path coefficients among periodontal health knowledge construct (ALPHA-K), periodontal health belief construct (ALPHA-B), and oral hygiene behaviors. All directional paths were specified a priori, with periodontal health knowledge constructs including General Knowledge (GEN), Prevention and Treatment (PnT), Oral Health Care (OHC), and Signs and Symptoms (SnS), predicting periodontal health belief construct including Perceived Severity (SEV), Perceived Susceptibility (SUS), Perceived Barriers (BAR), Cues to Action (CUE), Perceived Benefits (BEN), and Self-Efficacy (EFF), which act as mediators influencing oral hygiene behaviors. The model incorporates both direct and indirect effects as theorized by HBM. Bold arrows represent significant relationships (p < 0.05), while dashed arrows indicate non-significant. Numbers labels on paths denote standardized coefficients. Oral hygiene behaviors outcomes were modeled as follows: “How many times a day do you usually brush your teeth?” (Brushing Frequency: Brush): “Less than twice a day”, “How long do you typically spend brushing your teeth?” (Brushing Duration: BTime): “Less than 1 minute”, and “How often do you floss your teeth?” (Flossing Frequency: Floss): “Never” while “How do you usually brush your teeth?” (Brushing Technique: BTech) was modeled as a nominal categorical variable