Abstract
INTRODUCTION AND AIMS: Early childhood caries (ECC) remains widespread in China. Although socioeconomic status (SES) is a recognised driver, its pathway through parental preventive beliefs (BeliefPrev) and child high-risk behaviors (BehaviorRisk) is seldom examined within a single model. This study quantified SES's direct and indirect effects on ECC in preschoolers. METHODS: A cross-sectional survey of 595 children aged 3-6 years and their caregivers was conducted in 10 Nantong kindergartens (2024). Questionnaires captured SES, a 4-item BeliefPrev subscale, BehaviourRisk, and dmft. Scale reliability and factor structure (exploratory factor analysis, EFA) were assessed. Observed-variable SEM specified SES→BeliefPrev→BehaviourRisk→dmft. Coefficients are standardised β with bias-corrected bootstrap mediation. SES was characterised by family socioeconomic index; BeliefPrev was derived from the POHBS; BehaviourRisk combined parent-reported free-sugar exposure frequency and toothbrushing frequency; dmft was recorded using WHO criteria. RESULTS: SES showed a direct inverse association with dmft after adjusting for BeliefPrev and BehaviourRisk, while indirect paths via BeliefPrev or BehaviourRisk were non-significant. The belief scale showed low reliability (α = 0.18) and 2 factors (professional prevention/misconception and outcome appearance). SES was inversely associated with BehaviourRisk (β = -0.187, p < .001) and retained a direct inverse effect on dmft after adjustment (β = -0.329, p = .044). BehaviourRisk did not predict dmft (β = 0.193, p = .233). Sensitivity analyses with extended behaviour items and sex or age-specific models produced similar patterns. CONCLUSION: SES was inversely associated with preschool ECC after accounting for behaviour and beliefs, whereas behaviour showed a modest association and parental beliefs showed none. These findings suggest that knowledge‑based interventions are unlikely to overcome the socioeconomic gradient. CLINICAL RELEVANCE: Population-level sugar-reduction policies, kindergarten fluoride schemes, and coverage for basic child dental care should be prioritised, with targeted education/behavior coaching as a complement, particularly for low-SES families (SES index Q1-Q2).