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.