Psychometric analysis of a KAP questionnaire on green dentistry using PLS-SEM and EFA: a pilot study

Abstract

Background

Green dentistry promotes sustainable practices in oral healthcare. As environmental challenges intensify, integrating eco-friendly principles into dental education and practice becomes increasingly important. To advance sustainability in oral health settings, it is crucial to comprehend the knowledge, attitudes, and practices (KAP) of dental professionals and students. Despite growing interest, there is scarcity of research on green dentistry and a lack of standardized, validated tools to measure KAP makes it more difficult to compare studies. The rationale for this study was to conduct a psychometric analysis of a KAP questionnaire designed to assess eco-friendly clinical dental practices among dental school personnel and students in a dental school of Karachi.

Method

A 43-item questionnaire on green dentistry, adapted from existing green models and literature, and further validated through expert consultation and psychometric analysis, covers knowledge, attitudes, and practices. This cross-sectional pilot study involved 150 dental school personnel and students from the clinical side of an institution, using a self-administered, web-based questionnaire based on the Green Dental Model (GDM). The construct validity of ‘knowledge’ and ‘practice’ sections of the questionnaire was assessed using Partial Least Squares- Structural Equation Modeling (PLS-SEM) whereas Exploratory Factor Analysis (EFA) to uncover the latent factor structure of the ‘attitude’ section.

Results

Findings indicate that the model was identified as formative, with VIF values (< 5) indicating no multicollinearity. Through careful decision-making, almost all formative indicators were retained based on outer loads > 0.5. In EFA, factor loadings for the three extracted factors exceeded the reliability threshold. Factor 1 dealt with digital radiography and energy and water conservation; factor 2 involved waste management, recycling, and sterilization; and factor 3 represented green practices as a financial burden.

Conclusion

The instrument’s construct validity and feasibility makes it a valuable resource for sustainability focused researchers and dental professionals. This study uses advanced statistical techniques intended to address the questionnaire’s formative and reflective elements, improving the validity of assessment, a factor that was frequently overlooked in other studies on green dentistry. The distinctive contribution of this novel approach to the existing body of literature could facilitate potential research on the tool’s responsiveness to interventions on KAP change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06745-1.

Background

In the dynamic field of dentistry, the pursuit of environmentally sustainable practices has become increasingly urgent [1]. Green dentistry, aimed at reducing the ecological impact of dental care, stands as a beacon for aligning patient health with environmental responsibility [2]. However, there have been challenges in evaluating green dentistry techniques [3]. In addition to studies lacking standardized and thorough evaluation of instruments other challenges include profession’s disparities, lack of economic viability, and inadequate subject-matter knowledge that do not prioritize or evaluate sustainable practices [3]. Despite growing interest, the evaluation of knowledge, attitudes, and practices (KAP) related to green dentistry has been fragmented, with limited consensus on evaluation methods. Most studies on green dentistry measure KAP without evaluating the questionnaire’s psychometric properties [4]. The psychometric analysis of a questionnaire plays a critical role in establishing the validity, reliability, and cross-cultural applicability of measures used to assess KAP, there-by enhancing the credibility and robustness of research findings [5].

Prior studies on green dentistry have highlighted the importance of assessing KAP using adapted questionnaires [6–9]. However, comparability and reliability have been hampered by the absence of standardized constructs and validation techniques. To contribute to this discourse, the present study employs an adapted instrument, developed by incorporating validated items from foundational studies on green dentistry [6, 10, 11] and updated guides from the Eco-dentistry Association and Centre for Sustainable Healthcare [12, 13]. This blended approach ensures cultural relevance while maintaining consistency with prior research. Psychometric analysis techniques, including Partial Least Square- Structural Equation Model (PLS-SEM) and Exploratory Factor Analysis (EFA), were applied to improve the validity and reliability of questionnaire for eco-friendly dental practices. The questionnaire integrates both formative and reflective assessment models to measure knowledge, attitudes, and practices effectively. Additionally, this study emphasizes the importance of diversifying the target population to enhance the generalizability of results, a factor that was homogenous in previous studies focusing on specific practitioner groups. The present study includes a diverse sample of dental school personnel and students, ensuring a representation of viewpoints across the clinical, support and student communities. It enhances the robustness of assessment tools and standardizes evaluation methods, paving the way for sustainable dental care and promoting a holistic, evidence-based approach to environmental responsibility.

Methods

Design, setting and participants

A cross-sectional pilot study design was adopted to assess the validity and reliability of the green dentistry questionnaire. A convenience sample of 150 participants, including dental school personnel (clinical faculty and dental auxiliaries) and students (undergraduate and postgraduate) working in the clinics of the Sindh Institute of Oral Health Sciences (SIOHS) participated in this pilot study. Sample sizes between 150 and 200 are considered adequate for pilot psychometric testing when the goal is to identify preliminary factor structure and refine instruments [14]. Among the student population, undergraduate students included third and final-year clinical students, while postgraduate participants were enrolled in advanced clinical training programs. Dental auxiliaries, who participated in the study, were involved as clinical support and radiographic support staff, contributing to patient care and diagnostic services alongside clinical faculty, postgraduate trainees and house officers. Their exposure to green dentistry concepts had been informal. Currently, SIOHS, like any other dental institution in this region, does not have green dentistry in their curriculum. But awareness of some of the participants may have been facilitated through informal channels like social media, the internet, or professional circles. This lack of formal inclusion in the academic curriculum further underlines the importance of the present study and makes it a pioneering effort to assess KAP related to eco-friendly clinical dental practices.

This study was approved by the Faculty of Dentistry’s Medical Ethics Committee (FDMEC), University Malaya, and the Dean of the Faculty of Dentistry, (SIOHS), Jinnah Sindh Medical University (JSMU), Karachi, Pakistan. A sustainable digital approach was employed for data collection using online Google Forms. The self-administered survey evaluated the knowledge, attitudes, and practices of dental school personnel and students regarding eco-friendly clinical dental practices. Written informed consent was embedded into the online Google Forms. Only participants who consented via the online form proceeded to complete the survey, and 150 valid responses were received. Data collection commenced on 25 March 2023 and was completed on 5 May 2023.

Table 1 shows a summary of the target groups and sample size.

Table 1.

Target groups and sample size

Target Groups	Sample Size
Undergraduate Students	72
Clinical Faculty	30
Dental Auxiliary	20
Postgraduate Students	28

Instrument development

The KAP instrument was adapted from existing instruments assessing sustainability in dental practices and further modified through expert consultation and psychometric evaluation to fit the context of green dentistry in Pakistan.

Phase 1

The green dentistry questionnaire utilized in this study aimed to assess participants’ KAP regarding eco-friendly clinical dental practices. This questionnaire is an adapted instrument from the three pioneer studies on green dentistry using Green Dental Model (GDM) [6, 10, 15] and by combining updated practice guides from the Eco-Dentistry Association (EDA) and from the Center for Sustainable Healthcare (CSH) UK [12, 13]. The approvals from authors of original studies were obtained to ensure consistent utilization of validated and reliable items across diverse cultural settings. To ensure cross-cultural adaptation and enhance the instrument’s validity and reliability, Herdman’s framework was employed throughout the development process to obtain conceptual, item, semantic, operational and measurement equivalence without language translation, given that the questionnaire was originally in English [16].

Phase 2

The second phase involved the psychometric analysis of questionnaire which also serves as the final measurement step of Herdman’s framework ensuring thorough assessment of reliability and validity.

Preliminary 52-item KAP questionnaire with four sections- demography followed up by 3 sections of knowledge and attitude and practice was reduced to a 50 items instrument after cross cultural adaptation and content and face validity by experts from Universiti Malaya (Malaysia) and Jinnah Sindh Medical University (Pakistan). Results indicated that the instrument attained a satisfactory level of content validity, with overall content validity indices exceeding 0.95 for all four instruments. In preparation for psychometric analysis, seven items were excluded (specific to each target group) making it a 43-item questionnaire. The first section of the questionnaire is the socio-demographic section followed by sections to assess participants’ knowledge, attitudes toward green dentistry, and practices using a five-themed green dental model. (Fig. 1) summarizes the process of questionnaire development using Herdman’s framework for cross cultural adaptation and validation [16].

Fig. 1.

Steps in questionnaire development, guided by Herdman’s framework for cross-cultural adaptation [16]

This tool is based on a GDM which is a predefined model with an operational definition of domains and themes with indicators defining the construct i.e. Amalgam management, Radiographic management, Infection Control, Green procurement, Energy and Water conservation [6, 10, 15]. Since the items in each theme guide the formation of each theme and construct, these items are not interchangeable or correlated to each other indicating that these domains are formative in nature. Consequently, the three portions of the instrument follow a mixed pattern of formative and reflective constructs (Fig. 2) shows the direction and relationships between indicators and the three latent variables that correspond to them. Hence, the psychometric analysis of the questionnaire was conducted in two steps. PLS-SEM was used to establish the construct validity for the knowledge and practice sections, while EFA was used to determine the dimensionality of the attitude portion.

Fig. 2.

The direction and relationship of indicators and latent variables for the three sections of the questionnaire (Knowledge, Attitude, and Practice). This visual representation distinguishes between formative constructs (indicators forming the construct) and reflective constructs (indicators caused by the construct) [22]

Results

PLS-SEM results- formative model assessment

Validity analysis

The test of Variance Inflation Factor (VIF) in regression analysis was run to check collinearity between predictor variables. Results confirmed that the model is formative in nature (VIF values < 5) and predictor variables are not correlated with each other (Table 2). The outer weights and p-values (0.05) were assessed for the significance and relevance of the formative indicators.

Table 2.

Formative measurement model assessment for knowledge and practice subdomains

Construct	Indicator	Outer loads a	P values*	Outer weightsb	P values*	VIF*
Knowledge (General Category)	1.Term green dentistry	0.581	0.04	0.093	0.744	1.195
	2. Green responsibility	0.919	0.024	0.755	0.064	1.265
	3 Energy/water	0.73	0.019	0.353	0.137	1.333
Specific knowledge (MCQ’s)	4. Mercury Excess	0.881	0.014	0.321	0.298	1.440
	5. pre-cap AM	0.795	0.042	0.489	0.174	1.412
	6. Xray	0.838	0.031	−0.301	0.186	1.174
	7. I.C Plastics	0.712	0.041	0.614	0.097	1.056
	8.Water/energy	0.694	0.012	0.178	0.392	1.060
Practice (Amalgam)	1. Use pre-capsulated AM	0.996	0.051	−0.978	0.031	2.777
	2. AM disposal	0.599	0.041	0.040	0.895	3.169
	3. AM storage	0.656	0.036	−0.128	0.697	2.658
	4. Alternate to AM	−0.442	0.194	0.077	0.777	2.811
Practice (Radiography)	1.Digital radiography	0.551	0.022	0.083	0.758	2.271
	2.Traditional radiography	0.997	0.034	1.022	0.018	2.402
Practice (Green Procurement)	1.Recycle paper	0.533	0.487	0.273	0.038	1.528
	2.Two sided prints	0.599	0.542	0.389	0.018	2.876
	3.Computer	0.617	0.449	−0.452	0.228	2.694
	4.Recycled paper	0.694	0.611	0.335	0.049	1.457
	5.Recycling	−0.653	−0.029	0.238	0.054	3.011
Practice (Infection Control)	1.Digital Den	0.61	0.01	−0.132	0.340	2.883
	2.Rusable cups	−0.048	−0.003	0.274	0.042	3.555
	3.Metal syringe	0.798	0.041	0.257	0.157	3.828
	4. Cloth wraps	0.600	0.059	0.160	0.225	3.006
	5.Metal suction	0.755	0.669	0.248	0.034	3.041
	6.Cloth lab coat	0.721	0.034	−0.258	0.234	2.668
	7.Sterlizable trays	0.67	0.045	−0.039	0.740	2.379
	8. Reusable eyewear	0.703	0.023	−0.172	0.095	2.824
	9.Reuse Autoclave pouches	0.673	0.601	−0.135	0.042	1.463
	10.Recycle plastic	0.642	0.047	0.166	0.164	1.375
Practice (Water Conservation)	1.Taps with automatic sensor system	0.989	0.039	0.947	0.047	1.098
	2.Hand sanitizers use	0.610	0.031	0.148	0.328	2.036
	3.Turn off water taps	0.694	0.036	−0.045	0.765	1.222

^aOuter Loads: Contribution of each indicator to its construct

^bOuter Weights: Weight assigned to each indicator in the model

*VIF Variance Inflation Factor (Measure of multicollinearity among indicators)

*P Values: Statistical significance level of outer loads or weights (<0.05)

Results revealed that for outer weights most of the values were insignificant > 0.05 particularly in knowledge and practice of amalgam management. Item 4 related to ‘amalgam management’ did not achieve significant levels for both outer weights and outer loads. Despite insignificant outer weights and outer loads this item was retained because of its contribution to the conceptual domain of the construct and theoretical importance in the green dental model. While some items exhibited insignificant outer weights, they were retained because their outer loadings exceeded 0.5. Results of indicators with VIF, outer weight and our loads with their respective p-values in a formative measurement model assessment are shown in (Table 2).

(Figs. 3 and 4)show the graphical output of the formative model of latent variables knowledge and practice and sub domains with their outer weight (p-values).

Fig. 3.

This figure presents the measurement model for knowledge and practice constructs, categorized under the Green Dental Model’s domains Practice Subdomains: First-order latent variables, including PracAM (Amalgam), Pradio (Radiography), PIC (Infection Control), PGproc (Green Procurement), and Pwater (Water Conservation). Knowledge Subdomains: First-order latent variables, including Know1 (General Knowledge) and Know2 (Knowledge MCQs). Practice: Second-order latent construct

Fig. 4.

This figure presents the outer weights and p-values for knowledge and practice constructs within the measurement model. The blue latent variables represent: Practice: first-order latent variables, including: PracAM (Amalgam), Pradio (Radiography), PIC (Infection Control), PGproc (Green Procurement), Pwater (Water Conservation) Knowledge: first-order latent variables, including: Know1 (General Knowledge), Know2 (Knowledge MCQs) Practice: Second-order latent construct (centre)

EFA results- reflective model assessment

Dimensionality analysis

The Exploratory Factor Analysis (EFA) was conducted using JASP software. The Kaiser–Meyer–Olkin (KMO) was 0.734, indicating EFA was appropriate for this sample. Bartlett’s Test of Sphericity produced a Chi-Square value of 1862.233 (df = 45, p < 0.001), indicating sufficient inter-item correlations and justifying the use of factor analysis. (Table 3) presents results of factor loadings for three extracted factors.

Table 3.

Factor loadings for exploratory factor analysis (EFA)

Factor Loadings
	Factor 1	Factor 2	Factor 3	Uniqueness
R-WATER-CONS	0.953			0.063
ENERGY-MAN	0.953			0.063
DIGI-RADIO	0.853			0.371
TOOTH-COL-DM	0.551			0.685
LOWBILLS	0.509			0.675
R-RECYC-WASTE		0.897		0.137
R-DEN-PRAC		0.595		0.458
R-STER-INST		0.535		0.640
R-ENV-FRIENDLY			0.968	−0.002
R-FIN-BURDEN			0.520	0.509

Factor 1 Magnitude of factor loadings for Factor 1, Factor 2 Magnitude of factor loadings for Factor 2, Factor 3 Magnitude of factor loadings for Factor 3

Factor loadings above 0.4 indicate significant associations between items and underlying factors, providing a robust factor structure

Overall, the EFA of the attitude dataset revealed a three-factor solution with cumulative variances of 30%, 48.6%, and 63%, respectively. All factors, characterized by eigenvalues greater than 1, were retained. Factor 3, although a meaningful factor, explains a smaller amount of variance compared to Factors 1 and 2. (Table 4) shows Factor 1, representing 30% of the total variance, signifying a substantial portion of the dataset’s underlying structure, while Factor 2 and Factor 3 contribute significantly with variances of 48.6% and 63%, respectively.

Table 4.

Three-factor solution for exploratory factor analysis of the attitude

Factor Characteristics
		Unrotated solution a			Rotated solution b
	Eigenvalues	Sum Sq. Loadings	Proportion var.	Cumulative	Sum Sq. Loadings	Proportion var.	Cumulative
Factor 1	3.946	3.642	0.364	0.364	3.010	0.301	0.301
Factor 2	2.061	1.794	0.179	0.544	1.845	0.185	0.486
Factor 3	1.095	0.868	0.087	0.630	1.444	0.144	0.630

^aUnrotated Solution: Initial results of EFA without rotation, showing Eigenvalues, Sum of Squared Loadings, Proportion of Variance, and Cumulative Proportion of Variance for each factor

^bRotated Solution: Results of EFA after rotation, presenting Sum of Squared Loadings, Proportion of Variance, and Cumulative Proportion of Variance for each factor, offering a clearer factor structure

Similarly, in the scree plot the eigenvalues for each factor were examined see (Fig. 5). A clear break or ‘elbow’ was observed after the first two factors, suggesting that the first two factors capture a substantial amount of variance in the data.

Fig. 5.

Scree plot shows the eigenvalues for three factors

Discussion

The present study is one of the first studies evaluating the psychometric properties of the KAP questionnaire to refine its subscales for use in green dental practices. The adapted instrument, derived from three original studies [6, 10, 11] supplemented with the latest sustainability guidelines from the eco-dentistry association and the center for sustainable healthcare UK, necessitates psychometric analysis [12, 13]. Original studies did not provide details on prior psychometric analysis, aside from the assessment of content validity by a limited group of faculty experts on a small participant sample [6, 10, 15]. This questionnaire was developed based on a thorough analysis of the literature, consulting with experts, and conducting pilot testing followed by vigilant psychometric analysis to assess several aspects of green dentistry. The nature of this predefined GDM model with an operational definition of themes guides the format of questions to be asked. Farhani and Suchak, pioneers of green dentistry, introduced the concept of GDM [10]. Building upon their work, Al Shatrat et al. and Agrasuta conducted KAP studies in Jordan and Thailand, respectively, by adapting this concept [6, 10, 11, 15]. The content validity of the KAP questionnaire used in Jordanian study was evaluated by a group of faculty experts at Old Dominion University and Jordanian dentists at Jordan University of Science and Technology [15]. The same KAP questionnaire was adapted by a study conducted in Thailand [6]. Following the footsteps of these three pioneer studies, several studies conducted in India used almost the same KAP questionnaire with common themes to assess green dentistry with some modifications [7–9]. It is challenging to validate the results of most of these studies and produce a standardized instrument because each study used the tool without a robust construct validation approach with varying approach to validity and reliability of instruments [4]. Studies in literature [7–9, 17] have made commendable contributions to the field by adapting and applying the GDM-based questionnaire to assess KAP in green dentistry. By acknowledging valuable insights from these prior works, this study aims to set a precedent for future research in this domain.

In the current study, using PLS-SEM, the test of VIF confirmed that the nature of our knowledge and practice model is formative particularly as the nature of items were non-interchangeable and level of collinearity within each domain remained below < 5. Typically, a lower VIF is preferred as it signifies reduced multicollinearity, leading to more stable and reliable estimates for coefficients [18]. Widely accepted rules of thumb for VIF is: value of 5 or higher indicates a potential issue with collinearity problem [19]. However, the construct validity of the formative model assessment for knowledge and practice using PLS-validity test revealed the insignificant outer weights (p-values) for latent construct of knowledge and most practice items. Of the remaining five second order constructs (subdomains), the ‘amalgam practice and radiographic practice’ had only one significant outer weight with p-value of 0.031 and 0.018 respectively. The outer weights of 4 items of 5 in ‘green procurement’ were significant. ‘Infection control’ had three of 10 items, while ‘water conservation’ had one significant outer weight of three. So, we employed a decision-making process to determine whether to retain or remove formative indicators. When an indicator’s outer weight is non-significant, but its outer loading is high (i.e. above 0.50), the indicator should be interpreted as relatively important but not as absolutely important [18]. In this situation, the indicator would generally be retained [19, 20]. However, when an indicator has a non-significant weight and the outer loading is below 0.50, the researchers should decide whether to retain or delete the indicator by examining its theoretical relevance and potential content overlap with other indicators of the same construct [19]. As a rule of thumb, (Fig. 6) shows the criterion used to retain or remove indicators in formative constructive models.

Fig. 6.

This figure illustrates the systematic approach for evaluating formative indicators, where theoretical relevance and statistical significance guide the decision to retain or delete items. Caption credit: Hair Jr JF, Hult GTM, Ringle CM, Sarstedt M, Danks NP, Ray S. Partial least squares structural equation modeling (PLS-SEM) using R: A workbook. Switzerland AG: Springer Nature; 2021, Chap. 5; Pp 91–95. Decision-making process for retaining or deleting formative indicators [20]

Since the indicators define the construct in formative a model, the domain of the construct is sensitive to the number and types of indicators representing the construct. Therefore, altering or deleting an indicator might alter the construct’s conceptual scope [21]. This was one of the reasons that item 4 in the ‘amalgam management’ domain was retained despite nonsignificant p-values for both outer weight (0.777) and outer loads (−0.442). The results of construct validity using SEM for our formative model unequivocally confirm the suitability of this approach for psychometric analysis in this context. Each indicator in a formative model contributes a unique aspect to the overall construct, traditional reliability measures, including Cronbach’s alpha, are not applicable as the focus is not on internal consistency [22]. According to Hair et al. [23] when an indicator shows a non-significant weight and lacks strong outer loading, its retention should be based on theoretical relevance and potential content overlap with other indicators of the same construct. The assessment is often more qualitative and relies heavily on conceptual rationale (operational definition of domains of GDM) and expert judgment [21]. It’s essential to build a strong theoretical foundation for a formative model and provide a compelling argument for the inclusion of each [23]. Additionally, the content validity and conducting collinearity checks are crucial to ensure the validity and reliability of a formative instrument [24]. In present study, the content validity was ensured by involving expert reviewers to confirm that the indicators comprehensively captured all relevant aspects of the construct. Collinearity checks were conducted to ensure that the indicators were distinct and contributed uniquely to the overall latent construct, avoiding redundancy or overlap.

Our results of checking the dimensionality of attitude by EFA aimed to discern the underlying factor structure within the attitude section of the questionnaire, which followed a reflective construct. The suitability of EFA was confirmed by KMO (0.734) along with significant results of the Chi-Square test and Bartlett’s Test of Sphericity supported the appropriateness of factor analysis as well as the multivariate normality of the variables. Factor loadings obtained for the three extracted factors, and each item displayed loadings above the established threshold of 0.4, confirming their reliability as indicators of the respective factors [25]. The consistent presence of loadings exceeding 0.4 across all items further strengthens the confidence in the reliability and interpretability of the identified factors, thereby affirming the robustness of the factor solution. It’s noteworthy that previous KAP studies have primarily focused on a relatively homogeneous target population [6–9, 15]. The target population for study conducted in Hyderabad and Secunderabad, Telangana, India was general practitioners [8]. Similarly other studies conducted across India including Chennai and Bangalore chose dentists as their study group [7, 9]. Initial KAP studies conducted in Canada, Thailand and Jordan also targeted public and private practitioners [6, 10, 11, 15]. In cognizance of the fact that dental hygienists and assistants may also play a significant influence in the adoption of environmentally friendly dentistry practices [26], our diverse sample of dental school personnel (dental practitioners and dental auxiliaries) and students (undergraduate and postgraduate) increases the generalizability of results and guarantees a representative viewpoint from the student and academic communities.

Crucially, this study advances the methodology used in the creation and validation of evaluation instruments for green dentistry along with adding to the expanding corpus of literature on the subject. With special attention devoted to cross-cultural adaptation as part of this psychometric analysis, particularly within the context of Pakistani culture. By ensuring that every aspect of the questionnaire’s application was meticulously considered, including linguistic nuances, cultural relevance, and socio-cultural norms using Hardman’s framework, we aimed to enhance the validation process [16]. This comprehensive approach underscores the robustness of the questionnaire’s adaptation.

While our pilot study was constrained by a small sample size, the feasibility and efficacy of our methodology are evident. Although, it may limit the generalizability of findings, however, the main objective was to assess psychometric properties of the questionnaire, not to generalize findings. A larger sample would allow for more precise estimation of paths and relationships within complex structural models. Our findings offer valuable insights for academics, practitioners, and educators by advancing the psychometric validation of predefined KAP themes in sustainable dental care.

Conclusion

The psychometric analysis of the green dentistry measurement instrument demonstrates its reliability and validity for assessing KAP among dental school personnel and students. Comprehensive content validity, cross-cultural adaptability, and checking dimensionality using EFA and construct validity using PLS-SEM confirmed the instrument’s usefulness. This tool offers a helpful resource for researchers, students, and dental health care providers attempting to assess KAP of green dentistry. Further research could explore the instrument’s sensitivity to interventions and its ability to track changes in KAP levels over time.

Abbreviations

KAP

Knowledge, attitude, and practice

GDM

Green dental model

PLS-SEM

Partial least squares- structural equation modeling

EFA

Exploratory factor analysis

VIF

Variance inflation factor

SIOHS

Sindh institute of oral health sciences

FDMEC

Faculty of dentistry’s medical ethics committee

JSMU

Jinnah sindh medical university

KMO

Kaiser–Meyer–Olkin

MSA

Measure of sampling adequacy

EDA

Eco-Dentistry association

CSH

Centre for sustainable healthcare

UK

United Kingdom

Authors’ contributions

N.Z, J.G.D, J.J, M.D (Study Conceptualization and Design)M.D and N.Z (Formal analysis)M.D and N.Z (Validation)M.D and N.Z (Software Smart PLS4 and JASP)J.G.D, J.J, M.D, J.P (Supervision)N.Z (Writing– original draft)J.G.D, J.J, N.Z, J.P (Writing– review & editing) All authors reviewed the results and approved the final version.

Funding

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

All results are available in the text of the manuscript and Tables. However, they are available from the corresponding author on reasonable request under specific conditions to ensure participant confidentiality.

Declarations

Ethics approval and consent to participate

This research was approved by the Ethics Committee of Medical Ethics Committee, Faculty of Dentistry (FDMEC), University of Malaya, 50603, Kuala Lumpur (Ethics Committee/IRB; Reference Number: DF Co2205/0058 P) and Dean, Faculty of Dentistry Sindh Institute of Oral Health Sciences (SIOHS), Jinnah Sindh Medical University (JSMU), Karachi, Pakistan allow conducting the pilot testing of the questionnaire at Sindh Institute of Oral Health Sciences SIOHS on the selected participants. The study was conducted in compliance with all relevant ethical guidelines and regulations. All participants were provided with a written informed consent form embedded into the online Google Form, ensuring the confidentiality and anonymity of their data.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

All authors reviewed the results and approved the final version.