Acculturation, Academic Stress, and Self-Care Disparities: A Cross-Sectional Evaluation of Oral Health Attitudes among International University Students in Iran

Acculturation, Academic Stress, and Self-Care Disparities: A Cross-Sectional Evaluation of Oral Health Attitudes among International University Students in Iran | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acculturation, Academic Stress, and Self-Care Disparities: A Cross-Sectional Evaluation of Oral Health Attitudes among International University Students in Iran Ahmad Tleis, Parham Farzam, Firouzeh Nilchian This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8507873/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Background: Oral health disorders, including dental caries and periodontal disease, represent a substantial global disease burden, often exacerbated in mobile and migrant populations due to complex socioeconomic and structural barriers. International university students constitute a vulnerable demographic experiencing compounded challenges, including high academic load and acculturation stress, which can negatively impact oral health self-care attitudes (OHAs). Objectives: This study aimed to assess the mean OHA score among international university students residing in Iranian cities and to evaluate the influence of key demographic (gender, nationality) and academic discipline factors on these attitudes. Methods: A cross-sectional study was performed during 2023–2024, enrolling N=207 international students residing in dormitories across four major Iranian university cities (Isfahan, Tehran, Mashhad, Shiraz). Data were collected using a modified, validated 33-item questionnaire focusing on self-care attitudes (Cronbach’s alpha=0.78). Statistical analysis utilized non-parametric tests, including Mann-Whitney U and Kruskal-Wallis H tests, given the confirmed non-normal distribution of the OHA scores (p=0.019). Results: The mean overall OHA score for the cohort was 19.01 \pm 3.00 (out of 33), classifying the general attitude as moderate. No significant difference in OHA score was detected based on gender (Mann-Whitney U, p=0.961). However, a highly significant difference was observed when comparing academic disciplines (Kruskal-Wallis H, p < 0.001). Counterintuitively, students in Engineering (Mean Score: 20.09) and Basic Sciences disciplines demonstrated significantly higher positive OHA ranks compared to Medical students (Mean Score: 17.92). Significant variations were also identified based on nationality and city of study. Conclusions: The moderate overall OHA score and the unexpected deficit observed specifically among Medical students suggest that academic stress and associated self-care neglect may actively undermine knowledge and intent for preventive behaviors in high-pressure fields. Targeted, culturally sensitive, and structural interventions addressing time poverty and mental health are essential to improve oral health outcomes for this vulnerable population of international students. Students International Oral Health Self-Care Attitude Academic Stress Acculturation Introduction Oral health problems significantly impact all populations throughout the lifespan, underscoring that prevention remains the most efficacious available treatment modality. Within societies, equitable access to oral health knowledge and self-care resources is lacking, with indigenous low-income populations, migrants, and ethnic and racial minorities often bearing the disproportionate burden of the poorest oral health status (1-3). Global migration, frequently observed from less economically developed to more advanced nations, has been on the rise. Globally, there were 244 million international migrants, with approximately 66% residing in developed countries and the remainder in developing nations. Furthermore, the population of international migrants increased by 50% between 1990 and 2013 (4). Sam DL et al. (2006) posited that individuals migrating to a new country encounter the phenomenon of "acculturation." Acculturation is a consequence of cultural contact, leading to modifications in one or both interacting cultures (5). The health culture of different countries varies, and migrant populations often exhibit distinct disease patterns, dietary habits, and health self-care behaviors compared to the host population. Upon entering a new country and experiencing a novel social, cultural, and psychological environment, migrants may undergo a form of "culture shock." This shock is associated with negative mental health outcomes such as depression, sadness, lack of self-confidence, identity crises, and, critically, unfavorable health behaviors (6-10). Ward-Wai et al. (2011) concluded that post-migration psychological stressors, including grief, lack of self-confidence, anxiety, sadness, financial pressures, severe depression, and personal/family crises, were among the reasons why oral health was not a priority for the migrants studied (11). Chaplin TM et al. (2008) suggested that in different cultures, men typically resort to potentially more harmful "external solutions" to achieve solace, whereas women more frequently utilize internal or comparably healthy coping mechanisms (3). Kwun SY et al. (1999) highlighted that every culture possesses its unique health beliefs. A confluence of beliefs, thoughts, and attitudes about health and illness forms the foundation for health-related behaviors. The success of disseminating health promotion programs is contingent upon discovering culturally sensitive facts and beliefs related to health. In their study on a group of Chinese adults, the researchers found that older adults believed no hygienic methods could prevent edentulism, particularly among women who were believed to lose teeth due to pregnancy. Conversely, they held the belief that certain herbal remedies could prevent dental issues. However, the younger Chinese population exhibited a more positive attitude toward hygienic behaviors (12). An individual's attitude toward a specific subject fundamentally dictates their corresponding behavior. Nematollahi et al. (2011) stated that oral health self-care behaviors, including brushing, flossing, and using mouthwash, are among the simplest methods for plaque control and removal (13). Pitts NB (2002) emphasized that maintaining oral health typically requires brushing twice daily with fluoride toothpaste containing at least 1000 PPM and that after brushing, the individual should spit out the toothpaste without rinsing with water (14). Hatta K et al. (2007) proposed that health behaviors reflect an individual's attitude regarding oral health, which is rooted in both emotional and cognitive origins (15). In many health behavior change models, as highlighted by Daly B et al. (2013), a significant emphasis is placed on attitude modification. Based on educational learning theory, learning encompasses cognitive (acquiring factual knowledge and rational comprehension of ideas), attitudinal (beliefs and attitudes), and behavioral (considering future execution of the behavior) dimensions. The opportunities and circumstances individuals encounter also influence the formation of behaviors (e.g., self-care and hygienic behaviors) (16). The Theory of Planned Behavior posits that the intention to perform a behavior is determined by three factors: attitude toward the behavior, subjective norms, and perceived behavioral control, where perceived behavioral control is itself influenced by the individual's environment, personality, and demographic characteristics (16). Furthermore, the Health Belief Model, which explores the impact of beliefs on decision-making, states that when an individual considers a behavioral change, they engage in a cost-benefit analysis regarding its potential success (16). Given the lack of suitable educational opportunities in some countries juxtaposed with the favorable academic and living conditions in others, the number of international students continues to increase. Iran, in the Middle East, hosts numerous educational migrants, particularly from neighboring countries such as Lebanon, Syria, and Iraq, due to its conducive academic and living environments. The primary destinations for these students are major cities like Tehran, Isfahan, Mashhad, and Shiraz, with university dormitories accommodating international students. The objective of this study was to investigate the attitudes toward oral health self-care behaviors among international students residing in Iran. Methodology Study Design, Setting, and Ethical Considerations This investigation employed a cross-sectional survey design. The study population consisted of international students currently enrolled in major universities across four principal Iranian cities: Isfahan, Tehran, Shiraz, and Mashhad, during the academic years 2023–2024.The study specifically targeted students residing in university dormitories, introducing a degree of control over environmental and housing factors. The study protocol received approval from the scientific and ethical committees of the School of Dentistry, Isfahan University of Medical Sciences (Project No. 340268, Ethics Code: IR.MUI.RESEARCH.REC.1402.128). Participation was voluntary, and digital informed consent was obtained electronically from all students prior to their participation, ensuring adherence to ethical guidelines. Study Population and Sampling The target population included all international students fulfilling the inclusion criteria. Inclusion and Exclusion Criteria Inclusion criteria mandated current enrollment as an international student in one of the universities located in the specified cities (Isfahan, Tehran, Shiraz, or Mashhad) and current residency in a university dormitory. Exclusion criteria included non-consent to participate and non-permanent residency in Iran Sample Size Determination and Sampling Method The required minimum sample size was calculated using a formula based on a desired confidence level of 95% (alpha=0.05), an estimated standard deviation (sigma) of 15 (derived from prior related literature), and a maximum acceptable error of 15% of the standard deviation. This calculation estimated a minimum requirement of N=170.7 participants. Accounting for a 20\% non-response rate, the required sample size was rounded up to 205. A total of N=207 students successfully completed the survey. Sampling was conducted using a convenience/snowball method. This technique was selected due to the challenges associated with accessing and surveying this specific, geographically dispersed, and sometimes hard-to-reach international student population. Data Collection Instrument Data were gathered using a structured electronic questionnaire, distributed primarily via the WhatsApp messaging platform. The core instrument utilized a modified version of the "Attitudes toward Oral Self-Care" questionnaire, originally developed and validated for adolescents by Asgari et al. (57). The instrument consisted of 33 items designed to measure various aspects of OHA, utilizing a 5-point Likert scale ranging from "Completely Disagree" to "Completely Agree". Validation and Reliability To ensure construct validity, the initial 33 items underwent expert review by four faculty members specializing in Community Dentistry and Oral Medicine. Based on Content Validity Ratio (CVR) scores, questions below 0.75 were removed, and necessary textual modifications were implemented. The final Content Validity Index (CVI) for the retained items was calculated as 0.75. Reliability (internal consistency) was assessed using Cronbach’s alpha yielding a coefficient of 0.78. This value confirms the instrument possessed adequate internal consistency for measuring the target construct within this population. Data Processing and Statistical Analysis Data analysis was performed using SPSS statistical software, version 24. Descriptive statistics, including means, standard deviations, and frequencies, were generated to characterize the demographic profile and overall attitude scores. Prior to comparative analysis, the distribution of the OHA score was assessed using the Kolmogorov-Smirnov test. The results indicated that the data violated the assumption of normality (p=0.019). Consequently, non-parametric statistical methods were employed for all comparative analyses to maintain the rigor and fidelity of the reported findings. The Mann-Whitney U test was used for comparing OHA scores between two independent groups (e.g., male vs. female, Medical vs. Engineering students).The Kruskal-Wallis H test was employed for comparisons involving three or more independent groups (e.g., nationality, city of study, multiple academic disciplines).Statistical significance was established at an alpha level of 0.05. Results A total of 207 international students participated in the study. The mean age of the participants was 25.41 years, with the majority falling within the 0 to 25 year age bracket. Demographic Characteristics Table 1 summarizes the demographic features of the study cohort. Males constituted 60.9% (n=126) of the sample, while females made up 39.1% (n=81). Geographically, the largest proportion of students were enrolled in Isfahan (42.0%), followed by Tehran (25.6%) Students from Lebanon comprised the largest single nationality group (55.1%), followed by Syria (24.2%) and Iraq (11.1%). Table 1: Socio-demographic Characteristics of International Student Participants (N=207) Variable Category N % Gender Female 81 39.1 Male 126 60.9 Age (Years) Mean (SD) 25.41 (NA) NA Nationality Lebanon 114 55.1 Syria 50 24.2 Iraq 23 11.1 Pakistan 12 5.8 India 6 2.9 City of Study Isfahan 87 42.0 Tehran 53 25.6 Shiraz 38 18.4 Mashhad 27 13.0 Descriptive Analysis of Oral Health Attitude Score The overall mean attitude score toward oral health self-care for the entire international student cohort was 19.01 pm 3.00 (on a scale up to 33). Based on the calculated threshold ranges used for classification, this score falls into the " Moderate" attitude range (13.2–19.8). Comparative Analysis of Attitude Scores by Key Variables Gender Comparison The Mann-Whitney U test was used to compare OHA scores by gender. The results indicated no statistically significant difference between male (Mean Rank: 103.88) and female (Mean Rank: 104.91) students (p=0.961). Academic Discipline Comparison Analysis using the Kruskal-Wallis H test demonstrated a highly significant difference in OHA scores across the sampled academic disciplines (p < 0.001). Post-hoc comparisons confirmed that students in Engineering disciplines (Mean Rank: 126.98) and Basic Sciences (Mean Rank: 136.27) exhibited significantly higher positive attitude ranks compared to students in Medical disciplines (Mean Rank: 80.16). While the Medical group's mean score (17.92) was classified as Moderate, the Engineering (20.09) and Basic Sciences (20.32) groups achieved an "Excellent" classification. Table 2: Non-Parametric Comparison of Oral Health Attitude Scores (Mean Ranks) by Academic Discipline and Gender Variable Group N Mean Rank Mean Score (SD) P-value Academic Discipline Medical 108 80.16 17.92 (2.76) <0.001 Engineering 58 126.98 20.09 (3.09) Basic Sciences 13 136.27 20.33 (1.60) Other 28 133.38 20.32 (2.72) Gender Female 81 104.91 19.01 (NA) 0.961 Male 126 103.88 19.00 (NA) Geographic and Nationality Comparisons The Kruskal-Wallis test also confirmed statistically significant differences across both nationality and city of study (p < 0.001 for both comparisons, based on analytical findings). Descriptively, students studying in Tehran demonstrated the highest mean score (19.75), closely approaching the 'Excellent' threshold, whereas Mashhad students reported the lowest mean OHA score (17.86). Regarding nationality, students from Iraq (20.39) and India (20.67) reported the highest mean attitude scores (Excellent classification), significantly above the large cohort of Lebanese students, who showed the lowest mean score (18.24) (Moderate classification). Table 3: Comparative Analysis of Mean Oral Health Attitude Scores by Nationality and City of Study Variable Group N Mean Score (SD) Kruskal-Wallis Mean Rank Overall P-value Nationality Lebanon 114 18.24 (3.00) 85.37 <0.001 Syria 50 19.90 (2.98) 122.44 Iraq 23 20.39 (2.34) 135.48 Pakistan 12 19.48 (1.71) 114.13 India 6 20.67 (3.76) 129.17 City of Study Isfahan 87 19.11 (3.09) 103.68 <0.001 Tehran 53 19.75 (2.64) 119.59 Mashhad 27 17.86 (3.05) 80.94 Shiraz 38 18.49 (3.09) 93.96 Item-Level Analysis of Attitude Barriers Analysis of individual questionnaire items revealed specific attitudes that may act as barriers to consistent self-care. A substantial portion of the cohort endorsed statements related to practical constraints and psychological barriers. For example, 58.4% of students agreed or completely agreed with the statement (Q12) that they "cannot brush when tired or sleepy at night," highlighting fatigue and time constraints as a critical practical barrier. In terms of psychological barriers, 51.6% agreed or completely agreed (Q4) that they "feel I will get tooth decay even if I keep my teeth clean," suggesting a high degree of fatalism or low perceived self-efficacy regarding prevention. This fatalistic worldview was further supported by the 30.9% agreement (Q8) that decay is primarily due to "bad tooth structure/genes," shifting the locus of control externally. Conversely, while only 17.8% agreed (Q10) that "brushing is unnecessary, the dentist can fix it," showing a general understanding of personal responsibility, the strong agreement (87.9%) with Q23 ("Maintain hygiene to avoid high dental costs") points to financial motivation as a powerful driver for preventive behavior in this group. Discussion The current study aimed to evaluate the mean oral health attitude score among international students residing in dormitories. Overall, the mean attitude score was 19, which indicates a moderate level of attitude among the foreign students. Impact of Study Location In terms of comparing cities of study, students residing in Tehran achieved the highest scores. This finding can be justified by the influence of a larger social environment and broader socio-economic factors on the formation of dental health habits (58). Furthermore, the higher accessibility to dental services in larger cities like Tehran could contribute to this elevated score (59). Another explanatory factor is the impact of the students' living location on their mental health status, which, in turn, can affect their oral health attitudes (60). Influence of Academic Major It is also noteworthy that the academic major emerged as an influential factor concerning oral health-related behaviors. In the present study, Engineering students obtained a higher score compared to students in other majors, which is contrary to the findings of previous studies. The results of Doshi et al. (2007) indicated higher oral health attitude scores among students in medical fields. Additionally, a comparison of attitudes among Dental, Medical, and Nursing students revealed higher attitude scores for Dental students compared to the others, along with an improvement in their attitudes over the years of study (61). Generally, the level of oral health-related education for non-dental students is significantly lower (62). The findings of the present study—the lower scores among medical students—may be attributed to the high academic pressure, lifestyle habits, and psychological status of this group in recent years, potentially manifesting as burnout syndrome. Studies have shown that the incidence of burnout syndrome can generally lead to a reduction in individuals' preventive behaviors, including those related to oral health (63). Furthermore, medical students typically spend long hours in hospitals, which can contribute to the weakening of oral hygiene behaviors in this group (64). Another contributing factor is the high academic and socio-economic pressure on this group, which can exacerbate symptoms of depression in these individuals. General Attitude Level and the Effect of Migration As mentioned, the overall attitude score for international students was 19, signifying a moderate level of attitude, knowledge, and practice in this group. The relatively lower attitude scores can be attributed to factors inherent to the migration process itself. Generally, migration is accompanied by numerous risks that can have significant psychological consequences for individuals (65). These impacts can lead to a decrease in motivation for various activities, including academic pursuits, which is evident in the academic decline observed among international students (66). Another manifestation is a reduction in personal self-care behaviors, such as brushing, exercising, and maintaining healthy lifestyle behaviors like nutrition. Therefore, it is plausible that this phenomenon results in lower performance scores for individuals (67). Differences Based on Nationality In explaining the differences among students of various nationalities, the variation in attitudes among different ethnicities regarding the type and intensity of care behaviors is relevant. Moreover, the impact of the migration experience is heterogeneous across nationalities. Different nationalities face varying conditions in the host country due to distinct customs and cultures. This disparity leads individuals to experience different psychological burdens, which, as noted, influences dental behavior and performance (68). Instrument Development and Limitations Regarding the assessment of validity and reliability, the results of the current questionnaire led to the development of a reliable tool for measuring attitudes among international students. While various instruments have been developed for this purpose, examining the role of social factors was a noteworthy focus of this study. Finally, the present study was not without limitations. The use of a questionnaire in Farsi (Persian), which is a second language for the study population, and the challenges in communication with some participants constituted a limitation. Additionally, some countries had a small number of students represented in the sample. Research Recommendations Practical Recommendations Considering the study results, it is suggested that greater attention be paid to international medical and dormitory-resident students. Therefore, providing education and emphasizing self-care behaviors will assist responsible authorities in achieving their objectives more effectively. Recommendations for Future Research Given the scarcity of necessary research on self-care behaviors, particularly those influenced by broader contextual factors, it is recommended that future studies investigate these behaviors within wider scopes. Comparing the results obtained from such research with the findings of the present study will yield a more robust conclusion in this area. Conclusion Based on the findings of the present study, the attitude of international students in Iran towards oral health self-care behaviors appears to be at a moderate level. Students in Technical and Engineering majors achieved higher scores. No significant difference was observed between the scores of male and female students. Abbreviations OHA: Oral Health Attitude; CVR: Content Validity Ratio; CVI:Content Validity Index; SPSS: Statistical Package for the Social Sciences. Declarations Ethics approval and consent to participate: The study protocol received approval from the scientific and ethical committees of the School of Dentistry, Isfahan University of Medical Sciences (Project No. 340268, Ethics Code: IR.MUI.RESEARCH.REC.1402.128). Participation was voluntary, and digital informed consent was obtained electronically from all students prior to their participation, ensuring adherence to ethical guidelines. Consent for publication: Not applicable. Availability of data and materials: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: The authors received no financial support for the research, authorship, and publication of this article. Authors' contributions: A.T. conceptualized the study and drafted the manuscript. F.N. and P.F. contributed to the literature search and critically revised the draft. All authors read and approved the final manuscript. Acknowledgments: The authors acknowledge the use of the GPT-4o large language model through the preparation of this work in order to improve the grammar and readability of the text. After the use, as needed, all authors reviewed and edited the content and take responsibility for the content References McAuliffe M, Ruhs M. World migration report 2018. Geneva: International Organization for Migration. 2017. Petersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bulletin of the world health organization. 2005;83:661-9. Health UDo, Services H. 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Oral health knowledge, attitude, and practices among dental and medical students in Eastern India–A comparative study. Journal of International Society of Preventive and Community Dentistry. 2017 Jan 1;7(1):58-63. Munz SM, Kim RY, Holley TJ, Donkersloot JN, Inglehart MR. Dental hygiene, dental, and medical students’ OMFS/hospital dentistry‐related knowledge/skills, attitudes, and behavior: an exploration. Journal of Dental Education. 2017 Feb;81(2):149-61. Chauca Bajaña LA, Campos Lascano L, Jaramillo Castellon L, Carpio Cevallos C, Cevallos-Pozo G, Velasquez Ron B, Vieira e Silva FF, Perez-Sayans M. The Prevalence of the Burnout Syndrome and Factors Associated in the Students of Dentistry in Integral Clinic: A Cross‐Sectional Study. International Journal of Dentistry. 2023;2023(1):5576835. The Pieces of the Puzzle on the Psychological Effects of Immigrating. Jung journal, (2023).;17(1-2):97-100. doi: 10.1080/19342039.2023.2171226 Laura, A., B., Elias. Immigrant status and the social returns to academic achievement in adolescence. Journal of Ethnic and Migration Studies, (2022).;48(15):3619-3640. doi: 10.1080/1369183x.2021.2020630 Sarah, E., Choi. Self-Care in Korean Immigrants with Chronic Diseases: A Concept Analysis. Western Journal of Nursing Research, (2023). doi: 10.1177/01939459231174071 Radha, Maddhesia, -. Significance of Nationality and Duration on Mental Health of Immigrants. International Journal For Multidisciplinary Research, (2023). doi: 10.36948/ijfmr.2023.v05i04.5819 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8507873","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583450486,"identity":"58aeab7e-217e-4940-87d3-867993fd8f58","order_by":0,"name":"Ahmad Tleis","email":"","orcid":"","institution":"1.\tDepartment of Community Oral Health, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran.","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Tleis","suffix":""},{"id":583450487,"identity":"130a0d2b-5fec-4555-94cc-042882d44b1d","order_by":1,"name":"Parham Farzam","email":"","orcid":"","institution":"Student Research Committee, Islamic Azad University","correspondingAuthor":false,"prefix":"","firstName":"Parham","middleName":"","lastName":"Farzam","suffix":""},{"id":583450488,"identity":"e7a423dd-5c9d-4b54-831e-a1711ac5ae4e","order_by":2,"name":"Firouzeh Nilchian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBAC+wMMDAceMBzgYWBgPiABFmIGkxI4tRgA8YEEsBa2BAmGBCK1ABUC7WLgMYBoIQQMGHgPHkiouSPDP7vn4+3CHwzRBscZGD/8YLDIx+kXBr6EAwnHnvFI3Dm72XpGAkPuhsMMzJI9DBKWDTht4TE4kNhwmIfhRu42aR6IFgZpoF8McDsMqkX+Rs4zmBbm30RpMbiRwwbTwkbYloRjh3kMb6QZW/OkSeTOPMzYZtljgFeL8YcPNYft5W4kP7zNY2OT23f+8OEbPyrqcGphkH+AwgXFIGMDNL5GwSgYBaNgFJALAObRUAG6yW9DAAAAAElFTkSuQmCC","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Firouzeh","middleName":"","lastName":"Nilchian","suffix":""}],"badges":[],"createdAt":"2026-01-03 15:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8507873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8507873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101754205,"identity":"2e996f61-7345-4b5c-8aeb-0e9da712f1ef","added_by":"auto","created_at":"2026-02-03 10:42:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":748051,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8507873/v1/6087c76d-1a9b-4e9e-b219-213d746239d8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acculturation, Academic Stress, and Self-Care Disparities: A Cross-Sectional Evaluation of Oral Health Attitudes among International University Students in Iran","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral health problems significantly impact all populations throughout the lifespan, underscoring that prevention remains the most efficacious available treatment modality. Within societies, equitable access to oral health knowledge and self-care resources is lacking, with indigenous low-income populations, migrants, and ethnic and racial minorities often bearing the disproportionate burden of the poorest oral health status (1-3).\u003c/p\u003e\n\u003cp\u003eGlobal migration, frequently observed from less economically developed to more advanced nations, has been on the rise. Globally, there were 244 million international migrants, with approximately 66% residing in developed countries and the remainder in developing nations. Furthermore, the population of international migrants increased by 50% between 1990 and 2013 (4). Sam DL et al. (2006) posited that individuals migrating to a new country encounter the phenomenon of \"acculturation.\" Acculturation is a consequence of cultural contact, leading to modifications in one or both interacting cultures (5).\u003c/p\u003e\n\u003cp\u003eThe health culture of different countries varies, and migrant populations often exhibit distinct disease patterns, dietary habits, and health self-care behaviors compared to the host population. Upon entering a new country and experiencing a novel social, cultural, and psychological environment, migrants may undergo a form of \"culture shock.\" This shock is associated with negative mental health outcomes such as depression, sadness, lack of self-confidence, identity crises, and, critically, unfavorable health behaviors (6-10). Ward-Wai et al. (2011) concluded that post-migration psychological stressors, including grief, lack of self-confidence, anxiety, sadness, financial pressures, severe depression, and personal/family crises, were among the reasons why oral health was not a priority for the migrants studied (11).\u003c/p\u003e\n\u003cp\u003eChaplin TM et al. (2008) suggested that in different cultures, men typically resort to potentially more harmful \"external solutions\" to achieve solace, whereas women more frequently utilize internal or comparably healthy coping mechanisms (3). Kwun SY et al. (1999) highlighted that every culture possesses its unique health beliefs. A confluence of beliefs, thoughts, and attitudes about health and illness forms the foundation for health-related behaviors. The success of disseminating health promotion programs is contingent upon discovering culturally sensitive facts and beliefs related to health. In their study on a group of Chinese adults, the researchers found that older adults believed no hygienic methods could prevent edentulism, particularly among women who were believed to lose teeth due to pregnancy. Conversely, they held the belief that certain herbal remedies could prevent dental issues. However, the younger Chinese population exhibited a more positive attitude toward hygienic behaviors (12).\u003c/p\u003e\n\u003cp\u003eAn individual's attitude toward a specific subject fundamentally dictates their corresponding behavior. Nematollahi et al. (2011) stated that oral health self-care behaviors, including brushing, flossing, and using mouthwash, are among the simplest methods for plaque control and removal (13). Pitts NB (2002) emphasized that maintaining oral health typically requires brushing twice daily with fluoride toothpaste containing at least 1000 PPM and that after brushing, the individual should spit out the toothpaste without rinsing with water (14). Hatta K et al. (2007) proposed that health behaviors reflect an individual's attitude regarding oral health, which is rooted in both emotional and cognitive origins (15).\u003c/p\u003e\n\u003cp\u003eIn many health behavior change models, as highlighted by Daly B et al. (2013), a significant emphasis is placed on attitude modification. Based on educational learning theory, learning encompasses cognitive (acquiring factual knowledge and rational comprehension of ideas), attitudinal (beliefs and attitudes), and behavioral (considering future execution of the behavior) dimensions. The opportunities and circumstances individuals encounter also influence the formation of behaviors (e.g., self-care and hygienic behaviors) (16).\u003c/p\u003e\n\u003cp\u003eThe Theory of Planned Behavior posits that the intention to perform a behavior is determined by three factors: attitude toward the behavior, subjective norms, and perceived behavioral control, where perceived behavioral control is itself influenced by the individual's environment, personality, and demographic characteristics (16). Furthermore, the Health Belief Model, which explores the impact of beliefs on decision-making, states that when an individual considers a behavioral change, they engage in a cost-benefit analysis regarding its potential success (16).\u003c/p\u003e\n\u003cp\u003eGiven the lack of suitable educational opportunities in some countries juxtaposed with the favorable academic and living conditions in others, the number of international students continues to increase. Iran, in the Middle East, hosts numerous educational migrants, particularly from neighboring countries such as Lebanon, Syria, and Iraq, due to its conducive academic and living environments. The primary destinations for these students are major cities like Tehran, Isfahan, Mashhad, and Shiraz, with university dormitories accommodating international students.\u003c/p\u003e\n\u003cp\u003eThe objective of this study was to investigate the attitudes toward oral health self-care behaviors among international students residing in Iran.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Design, Setting, and Ethical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis investigation employed a cross-sectional survey design. The study population consisted of international students currently enrolled in major universities across four principal Iranian cities: Isfahan, Tehran, Shiraz, and Mashhad, during the academic years 2023–2024.The study specifically targeted students residing in university dormitories, introducing a degree of control over environmental and housing factors.\u003c/p\u003e\n\u003cp\u003eThe study protocol received approval from the scientific and ethical committees of the School of Dentistry, Isfahan University of Medical Sciences (Project No. 340268, Ethics Code: IR.MUI.RESEARCH.REC.1402.128). Participation was voluntary, and digital informed consent was obtained electronically from all students prior to their participation, ensuring adherence to ethical guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population included all international students fulfilling the inclusion criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria mandated current enrollment as an international student in one of the universities located in the specified cities (Isfahan, Tehran, Shiraz, or Mashhad) and current residency in a university dormitory. Exclusion criteria included non-consent to participate and non-permanent residency in Iran\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Determination and Sampling Method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe required minimum sample size was calculated using a formula based on a desired confidence level of 95% (alpha=0.05), an estimated standard deviation (sigma) of 15 (derived from prior related literature), and a maximum acceptable error of 15% of the standard deviation. This calculation estimated a minimum requirement of N=170.7 participants. Accounting for a 20\\% non-response rate, the required sample size was rounded up to 205. A total of N=207 students successfully completed the survey.\u003c/p\u003e\n\u003cp\u003eSampling was conducted using a convenience/snowball method. This technique was selected due to the challenges associated with accessing and surveying this specific, geographically dispersed, and sometimes hard-to-reach international student population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Instrument\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were gathered using a structured electronic questionnaire, distributed primarily via the WhatsApp messaging platform. The core instrument utilized a modified version of the \"Attitudes toward Oral Self-Care\" questionnaire, originally developed and validated for adolescents by Asgari et al. (57). The instrument consisted of 33 items designed to measure various aspects of OHA, utilizing a 5-point Likert scale ranging from \"Completely Disagree\" to \"Completely Agree\".\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidation and Reliability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure construct validity, the initial 33 items underwent expert review by four faculty members specializing in Community Dentistry and Oral Medicine. Based on Content Validity Ratio (CVR) scores, questions below 0.75 were removed, and necessary textual modifications were implemented. The final Content Validity Index (CVI) for the retained items was calculated as 0.75. Reliability (internal consistency) was assessed using Cronbach’s alpha yielding a coefficient of 0.78. This value confirms the instrument possessed adequate internal consistency for measuring the target construct within this population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Processing and Statistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysis was performed using SPSS statistical software, version 24. Descriptive statistics, including means, standard deviations, and frequencies, were generated to characterize the demographic profile and overall attitude scores.\u003c/p\u003e\n\u003cp\u003ePrior to comparative analysis, the distribution of the OHA score was assessed using the Kolmogorov-Smirnov test. The results indicated that the data violated the assumption of normality (p=0.019). Consequently, non-parametric statistical methods were employed for all comparative analyses to maintain the rigor and fidelity of the reported findings.\u003c/p\u003e\n\u003cp\u003eThe Mann-Whitney U test was used for comparing OHA scores between two independent groups (e.g., male vs. female, Medical vs. Engineering students).The Kruskal-Wallis H test was employed for comparisons involving three or more independent groups (e.g., nationality, city of study, multiple academic disciplines).Statistical significance was established at an alpha level of 0.05.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 207 international students participated in the study. The mean age of the participants was 25.41 years, with the majority falling within the 0 to 25 year age bracket.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDemographic Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the demographic features of the study cohort. Males constituted 60.9% (n=126) of the sample, while females made up 39.1% (n=81).\u003csup\u003e\u0026nbsp;\u003c/sup\u003eGeographically, the largest proportion of students were enrolled in Isfahan (42.0%), followed by Tehran (25.6%) Students from Lebanon comprised the largest single nationality group (55.1%), followed by Syria (24.2%) and Iraq (11.1%).\u003c/p\u003e\n\u003cp\u003eTable 1: Socio-demographic Characteristics of International Student Participants (N=207)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge (Years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.41 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNationality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLebanon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSyria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIraq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCity of Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIsfahan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTehran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShiraz\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMashhad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eDescriptive Analysis of Oral Health Attitude Score\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall mean attitude score toward oral health self-care for the entire international student cohort was 19.01 pm 3.00 (on a scale up to 33). Based on the calculated threshold ranges used for classification, this score falls into the \u003cstrong\u003e\u0026quot;\u003c/strong\u003eModerate\u0026quot; attitude range (13.2\u0026ndash;19.8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparative Analysis of Attitude Scores by Key Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGender Comparison\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mann-Whitney U test was used to compare OHA scores by gender. The results indicated no statistically significant difference between male (Mean Rank: 103.88) and female (Mean Rank: 104.91) students (p=0.961).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcademic Discipline Comparison\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis using the Kruskal-Wallis H test demonstrated a highly significant difference in OHA scores across the sampled academic disciplines (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003ePost-hoc comparisons confirmed that students in Engineering disciplines (Mean Rank: 126.98) and Basic Sciences (Mean Rank: 136.27) exhibited significantly higher positive attitude ranks compared to students in Medical disciplines (Mean Rank: 80.16).\u003csup\u003e\u0026nbsp;\u003c/sup\u003eWhile the Medical group\u0026apos;s mean score (17.92) was classified as Moderate, the Engineering (20.09) and Basic Sciences (20.32) groups achieved an \u0026quot;Excellent\u0026quot; classification.\u003c/p\u003e\n\u003cp\u003eTable 2: Non-Parametric Comparison of Oral Health Attitude Scores (Mean Ranks) by Academic Discipline and Gender\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMean Rank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMean Score (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAcademic Discipline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMedical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.92 (2.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEngineering\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.09 (3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBasic Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e136.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.33 (1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e133.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.32 (2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.01 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.961\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.00 (NA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eGeographic and Nationality Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Kruskal-Wallis test also confirmed statistically significant differences across both nationality and city of study (p \u0026lt; 0.001 for both comparisons, based on analytical findings).\u003c/p\u003e\n\u003cp\u003eDescriptively, students studying in Tehran demonstrated the highest mean score (19.75), closely approaching the \u0026apos;Excellent\u0026apos; threshold, whereas Mashhad students reported the lowest mean OHA score (17.86). Regarding nationality, students from Iraq (20.39) and India (20.67) reported the highest mean attitude scores (Excellent classification), significantly above the large cohort of Lebanese students, who showed the lowest mean score (18.24) (Moderate classification).\u003c/p\u003e\n\u003cp\u003eTable 3: Comparative Analysis of Mean Oral Health Attitude Scores by Nationality and City of Study\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMean Score (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKruskal-Wallis Mean Rank\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOverall P-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNationality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLebanon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.24 (3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSyria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.90 (2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e122.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIraq\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.39 (2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e135.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.48 (1.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e114.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e20.67 (3.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e129.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCity of Study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIsfahan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.11 (3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTehran\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.75 (2.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e119.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMashhad\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.86 (3.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eShiraz\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.49 (3.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e93.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eItem-Level Analysis of Attitude Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of individual questionnaire items revealed specific attitudes that may act as barriers to consistent self-care. A substantial portion of the cohort endorsed statements related to practical constraints and psychological barriers. For example, 58.4% of students agreed or completely agreed with the statement (Q12) that they \u0026quot;cannot brush when tired or sleepy at night,\u0026quot; highlighting fatigue and time constraints as a critical practical barrier.\u003c/p\u003e\n\u003cp\u003eIn terms of psychological barriers, \u0026nbsp; 51.6% agreed or completely agreed (Q4) that they \u0026quot;feel I will get tooth decay even if I keep my teeth clean,\u0026quot; suggesting a high degree of fatalism or low perceived self-efficacy regarding prevention. This fatalistic worldview was further supported by the 30.9% agreement (Q8) that decay is primarily due to \u0026quot;bad tooth structure/genes,\u0026quot; shifting the locus of control externally. Conversely, while only 17.8% agreed (Q10) that \u0026quot;brushing is unnecessary, the dentist can fix it,\u0026quot; showing a general understanding of personal responsibility, the strong agreement (87.9%) with Q23 (\u0026quot;Maintain hygiene to avoid high dental costs\u0026quot;) points to financial motivation as a powerful driver for preventive behavior in this group.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study aimed to evaluate the mean oral health attitude score among international students residing in dormitories. Overall, the mean attitude score was 19, which indicates a moderate level of attitude among the foreign students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImpact of Study Location\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn terms of comparing cities of study, students residing in Tehran achieved the highest scores. This finding can be justified by the influence of a larger social environment and broader socio-economic factors on the formation of dental health habits (58). Furthermore, the higher accessibility to dental services in larger cities like Tehran could contribute to this elevated score (59). Another explanatory factor is the impact of the students' living location on their mental health status, which, in turn, can affect their oral health attitudes (60).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluence of Academic Major\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is also noteworthy that the academic major emerged as an influential factor concerning oral health-related behaviors. In the present study, Engineering students obtained a higher score compared to students in other majors, which is contrary to the findings of previous studies. The results of Doshi et al. (2007) indicated higher oral health attitude scores among students in medical fields. Additionally, a comparison of attitudes among Dental, Medical, and Nursing students revealed higher attitude scores for Dental students compared to the others, along with an improvement in their attitudes over the years of study (61). Generally, the level of oral health-related education for non-dental students is significantly lower (62).\u003c/p\u003e\n\u003cp\u003eThe findings of the present study—the lower scores among medical students—may be attributed to the high academic pressure, lifestyle habits, and psychological status of this group in recent years, potentially manifesting as burnout syndrome. Studies have shown that the incidence of burnout syndrome can generally lead to a reduction in individuals' preventive behaviors, including those related to oral health (63). Furthermore, medical students typically spend long hours in hospitals, which can contribute to the weakening of oral hygiene behaviors in this group (64). Another contributing factor is the high academic and socio-economic pressure on this group, which can exacerbate symptoms of depression in these individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Attitude Level and the Effect of Migration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs mentioned, the overall attitude score for international students was 19, signifying a moderate level of attitude, knowledge, and practice in this group. The relatively lower attitude scores can be attributed to factors inherent to the migration process itself. Generally, migration is accompanied by numerous risks that can have significant psychological consequences for individuals (65). These impacts can lead to a decrease in motivation for various activities, including academic pursuits, which is evident in the academic decline observed among international students (66). Another manifestation is a reduction in personal self-care behaviors, such as brushing, exercising, and maintaining healthy lifestyle behaviors like nutrition. Therefore, it is plausible that this phenomenon results in lower performance scores for individuals (67).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDifferences Based on Nationality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn explaining the differences among students of various nationalities, the variation in attitudes among different ethnicities regarding the type and intensity of care behaviors is relevant. Moreover, the impact of the migration experience is heterogeneous across nationalities. Different nationalities face varying conditions in the host country due to distinct customs and cultures. This disparity leads individuals to experience different psychological burdens, which, as noted, influences dental behavior and performance (68).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstrument Development and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding the assessment of validity and reliability, the results of the current questionnaire led to the development of a reliable tool for measuring attitudes among international students. While various instruments have been developed for this purpose, examining the role of social factors was a noteworthy focus of this study.\u003c/p\u003e\n\u003cp\u003eFinally, the present study was not without limitations. The use of a questionnaire in Farsi (Persian), which is a second language for the study population, and the challenges in communication with some participants constituted a limitation. Additionally, some countries had a small number of students represented in the sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePractical Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsidering the study results, it is suggested that greater attention be paid to international medical and dormitory-resident students. Therefore, providing education and emphasizing self-care behaviors will assist responsible authorities in achieving their objectives more effectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations for Future Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the scarcity of necessary research on self-care behaviors, particularly those influenced by broader contextual factors, it is recommended that future studies investigate these behaviors within wider scopes. Comparing the results obtained from such research with the findings of the present study will yield a more robust conclusion in this area.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the findings of the present study, the attitude of international students in Iran towards oral health self-care behaviors appears to be at a moderate level. Students in Technical and Engineering majors achieved higher scores. No significant difference was observed between the scores of male and female students.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOHA: Oral Health Attitude; CVR: Content Validity Ratio; CVI:Content Validity Index; SPSS: Statistical Package for the Social Sciences.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u003c/em\u003e The study protocol received approval from the scientific and ethical committees of the School of Dentistry, Isfahan University of Medical Sciences (Project No. 340268, Ethics Code: IR.MUI.RESEARCH.REC.1402.128). Participation was voluntary, and digital informed consent was obtained electronically from all students prior to their participation, ensuring adherence to ethical guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u003c/em\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u003c/em\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u003c/em\u003eThe authors received no financial support for the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions:\u003c/em\u003e A.T. conceptualized the study and drafted the manuscript. F.N. and P.F. contributed to the literature search and critically revised the draft. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgments:\u003c/em\u003eThe authors acknowledge the use of the GPT-4o large language model through the preparation of this work in order to improve the grammar and readability of the text. After the use, as needed, all authors reviewed and edited the content and take responsibility for the content\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMcAuliffe M, Ruhs M. World migration report 2018. Geneva: International Organization for Migration. 2017.\u003c/li\u003e\n\u003cli\u003ePetersen PE, Bourgeois D, Ogawa H, Estupinan-Day S, Ndiaye C. The global burden of oral diseases and risks to oral health. Bulletin of the world health organization. 2005;83:661-9.\u003c/li\u003e\n\u003cli\u003eHealth UDo, Services H. Oral health in America: a report of the Surgeon General. 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International journal of environmental research and public health. 2020 Feb;17(3):703.\u003c/li\u003e\n\u003cli\u003eAlbrecht M, Kupfer R, Reissmann DR, M\u0026uuml;hlhauser I, K\u0026ouml;pke S. Oral health educational interventions for nursing home staff and residents. Cochrane Database of Systematic Reviews. 2016(9).\u003c/li\u003e\n\u003cli\u003ePeker I, Alkurt MT. Oral health attitudes and behavior among a group of Turkish dental students. European journal of dentistry. 2009 Jan;3(01):24-31.\u003c/li\u003e\n\u003cli\u003eVujicic M, Buchmueller T, Klein R. Dental care presents the highest level of financial barriers, compared to other types of health care services. Health affairs. 2016 Dec 1;35(12):2176-82.\u003c/li\u003e\n\u003cli\u003eMofidi M, Zeldin LP, Rozier RG. Oral health of early head start children: a qualitative study of staff, parents, and pregnant women. American journal of public health. 2009 Feb;99(2):245-51.\u003c/li\u003e\n\u003cli\u003eAl‐Omiri MK, Al‐Wahadni AM, Saeed KN. Oral health attitudes, knowledge, and behavior among school children in North Jordan. Journal of dental education. 2006 Feb;70(2):179-87.\u003c/li\u003e\n\u003cli\u003eDolce MC, Parker JL, Werrlein DT. Innovations in oral health: A toolkit for interprofessional education. Journal of Interprofessional Care. 2017 May 4;31(3):413-6.\u003c/li\u003e\n\u003cli\u003eDeyhimi P, Eslamipour F, Naseri HA. DMFT and the effect of dental education on orodental health of dental students in Isfahan School of Dentistry ;JIDS,6,2010:383-89.\u003c/li\u003e\n\u003cli\u003eHoseinifar R, Shadman R, Hajizadeh R .Oral and Dental Health Knowledge, Attitude and Performance of Dental Students of Kerman University of Medical Sciences. JIDS,2002,3:20-7.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"50\"\u003e\n\u003cli\u003eIka, Yuni, Susanti. Knowledge and attitude towards oral health related behaviors of international students in Chulalongkorn University, during the pandemic of covid-19. (2024). doi: 10.58837/chula.the.2023.15\u003c/li\u003e\n\u003cli\u003eBlerina, Xhihani., Lori, Rainchuso., Dianne, Smallidge., Christine, Dominick. Oral Health Beliefs, Attitudes, and Practices of Albanian Immigrants in the United States. Journal of Community Health, (2017).;42(2):235-241. doi: 10.1007/S10900-016-0248-9\u003c/li\u003e\n\u003cli\u003eMarit, Sl\u0026aring;ttelid, Skeie., Paul, J., Riordan., Kristin, S., Klock., Ivar, Espelid. Parental risk attitudes and caries-related behaviours among immigrant and western native children in Oslo.. Community Dentistry and Oral Epidemiology, (2006).;34(2):103-113. doi: 10.1111/J.1600-0528.2006.00256.X\u003c/li\u003e\n\u003cli\u003ePranavi, Jadhav., Sardhar, Malothu., Pradeep, S., Anand., Vidyasagar, Goje., Revanth, Kumar., Sunny, Priyatham, Tirupathi., Lamea, Afnan. Oral health knowledge, attitude and practices among medical students. International Journal of Health Sciences (IJHS), (2022).1414-1423. doi: 10.53730/ijhs.v6ns6.9960\u003c/li\u003e\n\u003cli\u003eM., Gurung., Sudha, Sen, Malla., Bipul, Rajbhandari., B, Bajracharya. Knowledge, Attitude and Practice (KAP) on Oral Health among students of Nepalese Army Institute of Health Sciences. Medical Journal of Shree Birendra Hospital, (2022).;21(1):81-86. doi: 10.3126/mjsbh.v21i1.39856\u003c/li\u003e\n\u003cli\u003eCaroline, C, Okoroafor., O, E, Okobi., Oluwasayo, J, Owolabi., Jane, N, Nwafor. (2023). Dental Health Knowledge Attitude and Practice Among University of Calabar Students. Cureus, 15 doi: 10.7759/cureus.40055\u003c/li\u003e\n\u003cli\u003eBurcu, Bakir., Mustafa, Karaca. Evaluation of oral health behavior, knowledge and attitude among dental and nursing preclinical students. 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Journal of Oral Research. 2016;5(1):43-9.\u003c/li\u003e\n\u003cli\u003eDoshi D, Baldava P, Anup N, Sequeira PS. A comparative evaluation of self-reported oral hygiene practices among medical and engineering university students with access to health-promotive dental care. J Contemp Dent Pract. 2007 Jan 1;8(1):68-75.\u003c/li\u003e\n\u003cli\u003eKumar H, Behura SS, Ramachandra S, Nishat R, Dash KC, Mohiddin G. Oral health knowledge, attitude, and practices among dental and medical students in Eastern India\u0026ndash;A comparative study. Journal of International Society of Preventive and Community Dentistry. 2017 Jan 1;7(1):58-63.\u003c/li\u003e\n\u003cli\u003eMunz SM, Kim RY, Holley TJ, Donkersloot JN, Inglehart MR. Dental hygiene, dental, and medical students\u0026rsquo; OMFS/hospital dentistry‐related knowledge/skills, attitudes, and behavior: an exploration. Journal of Dental Education. 2017 Feb;81(2):149-61.\u003c/li\u003e\n\u003cli\u003eChauca Baja\u0026ntilde;a LA, Campos Lascano L, Jaramillo Castellon L, Carpio Cevallos C, Cevallos-Pozo G, Velasquez Ron B, Vieira e Silva FF, Perez-Sayans M. The Prevalence of the Burnout Syndrome and Factors Associated in the Students of Dentistry in Integral Clinic: A Cross‐Sectional Study. International Journal of Dentistry. 2023;2023(1):5576835.\u003c/li\u003e\n\u003cli\u003eThe Pieces of the Puzzle on the Psychological Effects of Immigrating. Jung journal, (2023).;17(1-2):97-100. doi: 10.1080/19342039.2023.2171226\u003c/li\u003e\n\u003cli\u003eLaura, A., B., Elias. Immigrant status and the social returns to academic achievement in adolescence. Journal of Ethnic and Migration Studies, (2022).;48(15):3619-3640. doi: 10.1080/1369183x.2021.2020630\u003c/li\u003e\n\u003cli\u003eSarah, E., Choi. Self-Care in Korean Immigrants with Chronic Diseases: A Concept Analysis. Western Journal of Nursing Research, (2023). doi: 10.1177/01939459231174071\u003c/li\u003e\n\u003cli\u003eRadha, Maddhesia, -. Significance of Nationality and Duration on Mental Health of Immigrants. International Journal For Multidisciplinary Research, (2023). doi: 10.36948/ijfmr.2023.v05i04.5819\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Students, International, Oral Health, Self-Care, Attitude, Academic Stress, Acculturation","lastPublishedDoi":"10.21203/rs.3.rs-8507873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8507873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Oral health disorders, including dental caries and periodontal disease, represent a substantial global disease burden, often exacerbated in mobile and migrant populations due to complex socioeconomic and structural barriers. International university students constitute a vulnerable demographic experiencing compounded challenges, including high academic load and acculturation stress, which can negatively impact oral health self-care attitudes (OHAs).\u003c/p\u003e\n\u003cp\u003eObjectives: This study aimed to assess the mean OHA score among international university students residing in Iranian cities and to evaluate the influence of key demographic (gender, nationality) and academic discipline factors on these attitudes.\u003c/p\u003e\n\u003cp\u003eMethods: A cross-sectional study was performed during 2023–2024, enrolling N=207 international students residing in dormitories across four major Iranian university cities (Isfahan, Tehran, Mashhad, Shiraz). Data were collected using a modified, validated 33-item questionnaire focusing on self-care attitudes (Cronbach’s alpha=0.78). Statistical analysis utilized non-parametric tests, including Mann-Whitney U and Kruskal-Wallis H tests, given the confirmed non-normal distribution of the OHA scores (p=0.019).\u003c/p\u003e\n\u003cp\u003eResults: The mean overall OHA score for the cohort was 19.01 \\pm 3.00 (out of 33), classifying the general attitude as moderate. No significant difference in OHA score was detected based on gender (Mann-Whitney U, p=0.961). However, a highly significant difference was observed when comparing academic disciplines (Kruskal-Wallis H, p \u0026lt; 0.001). Counterintuitively, students in Engineering (Mean Score: 20.09) and Basic Sciences disciplines demonstrated significantly higher positive OHA ranks compared to Medical students (Mean Score: 17.92). Significant variations were also identified based on nationality and city of study.\u003c/p\u003e\n\u003cp\u003eConclusions: The moderate overall OHA score and the unexpected deficit observed specifically among Medical students suggest that academic stress and associated self-care neglect may actively undermine knowledge and intent for preventive behaviors in high-pressure fields.\u003csup\u003e \u003c/sup\u003eTargeted, culturally sensitive, and structural interventions addressing time poverty and mental health are essential to improve oral health outcomes for this vulnerable population of international students.\u003c/p\u003e","manuscriptTitle":"Acculturation, Academic Stress, and Self-Care Disparities: A Cross-Sectional Evaluation of Oral Health Attitudes among International University Students in Iran","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 18:41:14","doi":"10.21203/rs.3.rs-8507873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-19T08:37:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-18T09:25:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T06:49:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139545799607062294796345452454434910911","date":"2026-02-10T05:42:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-07T19:29:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36813993949781094516682916092924093601","date":"2026-02-07T13:55:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309373011230127346904875065794855484611","date":"2026-02-07T09:32:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132964180756391261372600302966194986044","date":"2026-02-05T07:02:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T19:05:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"83119508178633411457425963775503062606","date":"2026-01-29T15:31:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T11:28:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-07T09:02:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-06T06:02:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-06T05:59:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-01-03T15:30:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7048166-b50a-4e3c-ac9c-79e0358b510d","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T18:41:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 18:41:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8507873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8507873","identity":"rs-8507873","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}