Knowledge, Attitudes, and Practices of Patients with Urolithiasis Regarding Stone Examination Methods: A Cross-Sectional Study in China

Abstract

Background

This study aims to assess the knowledge, attitudes, and practices (KAP) of patients with urolithiasis regarding stone examination methods.

Methods

A cross-sectional survey was conducted in Wuhai City, Inner Mongolia Autonomous Region, between September 16, 2023, and December 30, 2024. Data were collected using a structured questionnaire, which included demographic information and KAP-related items. KAP scores were calculated, and their variations across different demographic groups were analyzed, with structural equation modeling (SEM) used to examine the interrelationships among the KAP dimensions.

Results

A total of 457 valid responses were obtained, with 251 participants (54.92%) being male. Among the respondents, 373 (81.62%) reported experiencing pain in the lower back or abdomen. The mean knowledge, attitude, and practice scores were 11.23±2.98 (possible range: 0–18), 19.18±1.67 (possible range: 4–20), and 18.04±2.88 (possible range: 4–20), respectively. The mediation analysis showed that knowledge directly affected attitude (β = 0.462, P = 0.015) and practice (β = 0.312, P = 0.013), and attitude directly affected practice (β = 0.501, P = 0.009), as well as the knowledge indirectly affected practice (β = 0.231, P = 0.012).

Conclusion

Patients with urolithiasis demonstrated inadequate knowledge but self-reported highly positive attitudes and proactive practices, which were likely influenced by social desirability bias. Targeted educational interventions are urgently needed to translate these positive declarations into genuine clinical examination adherence.

Background

Urolithiasis is a significant global health concern with increasing prevalence rates across various populations. The disease is characterized by the formation of stones in different parts of the urinary system, including kidneys, ureters, bladder, and urethra.¹ In China and worldwide, urolithiasis has emerged as one of the most common urological disorders, with approximately 1 in 11 individuals in the United States experiencing kidney stones during their lifetime.² The recurrence rate within 10 years reaches approximately 50%, making it a chronic concern for many patients.³ Recent epidemiological data show that in 2021, China reported 19,141,120 cases of urolithiasis, representing one of the highest burdens globally alongside India and the United States.⁴ The systematic review and meta-analysis of urolithiasis in China indicates an overall prevalence of 8.1%, with kidney stones accounting for 7.8% of cases. This prevalence varies significantly across different regions of China, with higher rates observed in economically developed eastern regions compared to western regions.⁵ The burden of this disease extends beyond clinical symptoms to include substantial economic costs, which in the United States alone exceed $10 billion annually.⁴

Modern management of urolithiasis relies heavily on accurate diagnostic procedures, including various imaging techniques and metabolic evaluations. Standard diagnostic approaches include ultrasound, kidney-ureter-bladder (KUB) radiography, and non-contrast enhanced computed tomography (NCCT), each with varying sensitivity, specificity, and radiation exposure considerations.¹ Non-contrast CT has become the gold standard for diagnosing acute flank pain, with a sensitivity of 93.1% and specificity of 96.6% for detecting urolithiasis.⁶ Ultrasound, while having lower sensitivity (45% for renal stones), offers the advantage of safety without radiation exposure.⁷ Additionally, stone analysis and metabolic evaluations are recommended for first-time stone formers and recurrent cases to guide treatment and prevention strategies.¹ Despite these established guidelines, clinical practice reveals several challenges in patient engagement with stone examination methods. Patients often express confusion regarding the purpose and process of different diagnostic modalities, with concerns particularly centered on radiation exposure from imaging techniques, perceived costs, and the necessity of multiple examinations. In clinical settings, healthcare providers frequently encounter reluctance to undergo comprehensive metabolic evaluations, incomplete adherence to follow-up imaging protocols, and misunderstandings about the interpretations of results. These gaps highlight the need for better patient education about examination rationales, improved communication regarding result implications, and development of patient-centered approaches to diagnostic pathways that address concerns about safety, accessibility, and cost-effectiveness.

The Knowledge, Attitude, and Practices (KAP) survey functions as a diagnostic research tool, illuminating a group’s comprehension, beliefs, and actions on a specific subject, particularly within the realm of health literacy, where it is based on the premise that knowledge positively influences attitudes, which in turn mold behaviors.^8–10 The evaluation of KAP regarding examination methods is particularly relevant in China, where significant regional variations in healthcare resources exist and where the prevalence of urolithiasis shows distinct geographical patterns.⁵ As the country continues to experience an increasing burden of urolithiasis, with projections indicating continued growth through 2050,⁴ understanding patient perspectives becomes essential for developing effective management strategies toward improving diagnostic compliance, reducing treatment delays, optimizing resource utilization, and ultimately decreasing stone recurrence rates.

This study evaluates the knowledge, attitudes, and practices of Chinese patients with urolithiasis regarding stone examination methods. We aim to identify specific knowledge deficits and behavioral patterns to improve doctor-patient communication and develop targeted education. By examining demographic and medical factors influencing KAP scores, we seek to personalize patient education approaches. This research addresses a gap in current literature on patient perspectives of urolithiasis diagnostics in China. Specifically, the regional context of Inner Mongolia, including Wuhai City, presents unique challenges characterized by uneven healthcare resource distribution and varying patient out-of-pocket medical costs. These local socioeconomic factors are critical to consider, as they may significantly influence healthcare access and act as barriers to patient adherence regarding recommended stone examination methods.

Methods

Study Design and Participants

This cross-sectional study was conducted in Wuhai City, Inner Mongolia Autonomous Region, from September 16, 2023, to December 30, 2024. This study was reported in accordance with the STROBE guidelines (see Supplementary Material 1). The sample size was determined using the formula for cross-sectional studies. Assuming an expected adequate practice rate of 50% to yield the maximum variance, a significance level of 0.05, and a margin of error of 5%, the minimum required sample size was calculated as 384. Our final sample of 457 valid cases comfortably met this requirement. The study population comprised urolithiasis patients aged 18–70 years. Participants were recruited from both outpatient and inpatient departments of Wuhai People’s Hospital in Inner Mongolia, based on accessibility and convenience. Inclusion criteria were: (1) urolithiasis confirmed by imaging (abdominal ultrasound, CT, or X-ray) with stone diameters of 0.3–2.0 cm; (2) age 18–70 years; (3) no severe renal colic episodes at enrollment or colic relieved for >48 hours after medication, with no signs of acute infection; (4) clear consciousness, no history of psychiatric disorders or cognitive impairment; and (5) willingness to provide informed consent without plans to enroll in other urolithiasis studies within three months. Patients were excluded if they had: (1) serious cardiovascular diseases, hepatic or renal dysfunction, or respiratory diseases; (2) cystine or uric acid calculi; (3) were pregnant or breastfeeding; (4) had undergone urolithiasis treatment within the past three months or were receiving pharmacological stone dissolution therapy; or (5) had allergies to medications relevant to urolithiasis treatment. Eligible participants were identified based on predefined inclusion criteria (eg, age, disease diagnosis, disease duration) and exclusion criteria (eg, presence of severe complications, cognitive impairment). Potential participants were screened through the hospital’s electronic medical record system, hospital registration database, and outpatient/inpatient department records. Eligible individuals were then approached by researchers for face-to-face communication to confirm their voluntary participation. Upon agreement, participants scanned a QR code to complete the questionnaire. The Clinical Research Ethics Committee of Wuhai People’s Hospital approved this study (Whsrmyyky20220801), and all participants provided written informed consent. Questionnaires were completed online through the Wenjuanxing platform via QR code.

Questionnaire Introduction

The questionnaire, administered in Chinese, comprised four sections: demographic information, knowledge, attitude, and practice dimensions (see Supplementary Material 2). The knowledge dimension contained nine questions, with correct answers awarded 2 points and incorrect or “uncertain” responses receiving 0 points (range: 0–18 points). The attitude dimension included four questions using a five-point Likert scale from “strongly disagree” (1 point) to “strongly agree” (5 points) (range: 4–20 points). Similarly, the practice dimension contained four questions assessed on a five-point Likert scale from “always” (5 points) to “never” (1 point) (range: 4–20 points). Scores above 70% of the maximum in each section indicated adequate knowledge, positive attitude, and proactive practice, respectively.¹¹ While a score of 70% was established as the general threshold, an 80% threshold was specifically utilized in the logistic regression analyses to distinguish highly proactive behavior performers.

Screening Personnel

The screening process was conducted by clinical physicians and professional research assistants from the study team. All screening personnel possessed relevant medical backgrounds and research qualifications, and were thoroughly familiar with the inclusion and exclusion criteria to ensure the accuracy and consistency of participant selection.

Questionnaire Distribution and Validation

The questionnaire was administered through face-to-face interviews. Participants were instructed to scan a QR code to access the online survey platform. Trained research assistants and physicians guided participants in logging into the platform, explained the requirements for completing the questionnaire, and addressed any questions or concerns to ensure that participants fully understood the content. Written instructions and contact information were provided for participants who had further questions or required assistance. A pilot study with 40 questionnaires was conducted, excluding cases with response times under 90 seconds (n=2), anomalous monthly income values (n=1), and incorrect answers to the trap question (n=4). The 33 remaining valid questionnaires yielded an overall reliability coefficient of 0.758, with dimension-specific reliability coefficients of 0.579 (knowledge), 0.788 (attitude), and 0.689 (practice). The pilot study KMO value was 0.788. In the formal study (n=457), the overall Cronbach’s α coefficient was 0.841 with a KMO value of 0.860, indicating good internal consistency and sampling adequacy. The 33 participants from the pilot study were excluded from the final analysis of 457 patients.

Statistical Methods

Statistical analyses were performed using SPSS 27.0 (IBM, Armonk, NY, USA) and AMOS 26.0 (IBM, Armonk, NY, USA). Descriptive statistics summarized demographic characteristics and knowledge, attitude, and practice (KAP) scores. Continuous variables were presented as means and standard deviations (SD), while categorical variables were expressed as frequencies and percentages (n, %). Group differences in KAP scores were analyzed using the Mann–Whitney U-test for two groups and the Kruskal–Wallis H-test for three or more groups. Spearman’s rank correlation assessed associations among KAP dimensions. Multivariate logistic regression identified independent predictors of practice, with odds ratios (OR) and 95% confidence intervals (CI) reported. Structural equation modeling (SEM) examined the interrelationships among KAP dimensions. Model fit was evaluated using the root mean square error of approximation (RMSEA), incremental fit index (IFI), Tucker-Lewis index (TLI), and comparative fit index (CFI). Statistical significance was set at P < 0.05. A cutoff of 80% of the maximum score was selected to categorize proactive practice based on previously established criteria in KAP literature. Furthermore, an ordinal logistic regression model was constructed as a sensitivity analysis to confirm the robustness of the primary logistic regression findings.

Results

Demographic Information on Participants

Initially, a total of 566 cases of samples were collected for this study. The following cases were deleted: 1) 4 cases of disagreement with the study; 2) 32 cases of answering time less than 40 seconds; 3) 40 cases of missing values; 4) 19 cases of answering trap questions incorrectly; 5) 14 cases of less-than-18-years-old; the final valid questionnaires were 457 cases. Among them, 251 (54.92%) were males, 363 (79.43%) lived in urban areas, 201 (43.98%) had Bachelor’s degree and above, 301 (65.86%) were employed, 172 (37.64%) had monthly income per capita of less than 5000 Yuan, 282 (61.71%) suffered from ureteral calculus, and 373 (81.62%) showed symptoms of pain in the lower back or abdomen. The mean knowledge, attitude, and practice scores were 11.23±2.98, 19.18±1.67, and 18.04±2.88, respectively. Knowledge scores varied significantly by age (P < 0.001), education (P < 0.001), current employment status (P < 0.001), and monthly income per capita (P < 0.001). Attitude scores varied significantly by age (P < 0.001), residence (P = 0.029), education (P < 0.001), current employment status (P = 0.004), and monthly income per capita (P = 0.042). Practice scores varied significantly by age (P < 0.001), education (P < 0.001), and current employment status (P < 0.001) (Supplementary Table 1).

Distribution of Responses to Knowledge, Attitude, and Practice

The distribution of knowledge dimension revealed that the three knowledge items with the lowest correctness rates were as follows: “A 64-slice spiral CT scan without contrast enhancement can be used to diagnose urinary system calculus and requires the use of a contrast agent.” (K9) with 12.69%, “Urinary system ultrasound can detect calculus in all locations and of all types.” (K5) with 20.35%, and “Non-contrast CT can detect small calculus that ultrasound and X-ray may miss.” (K8) with 77.02%. In attitude dimension, around 80% of the participants were very positive towards all the items in the attitude dimension, however, there were still 10–20 individuals who showed neutral or negative attitudes, showing that there is still room for this group of people to be promoted and encouraged in their attitudes towards stone examination methods. Responses to the practice dimension showed that only 65.43% always visit the hospital for follow-up examinations to check for stone recurrence (P4), only 68.05% always actively seek information related to urinary system stone examinations, such as from TV programs or WeChat public accounts (P2), only 73.52% always actively consult the doctor about appropriate examination methods (P1) (Tables 1–3).

Table 1.

Distribution of Patient Responses in Knowledge Dimension Regarding Urolithiasis Examination Methods

Knowledge Dimension	Correctness Rate (%)
Calculus can occur in the kidneys and may also develop in the ureter, urethra, or bladder.	431 (94.31)
2.If symptoms such as flank percussion pain, difficulty urinating, or hematuria occur, urinary system calculus may be present.	430 (94.09)
3.Blood tests, such as uric acid and creatinine, can reflect kidney function and metabolic conditions related to calculus.	396 (86.65)
4.X-ray is one of the commonly used methods for detecting calculus and can identify calcified calculus.	389 (85.12)
5.Urinary system ultrasound can detect calculus in all locations and of all types.	93 (20.35)
6.Before an ultrasound examination for calculus, drinking water to fill the bladder is necessary for optimal results.	416 (91.03)
7.Non-contrast CT can detect small calculus that ultrasound and X-ray may miss.	352 (77.02)
8.A 64-slice spiral CT scan without contrast enhancement can be used to diagnose urinary system calculus and requires the use of a contrast agent.	58 (12.69)

Table 2.

Distribution of Patient Responses in Attitude Dimension Regarding Urolithiasis Examination Methods

Attitude Dimension	N (%)
	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
When symptoms of urinary system calculus appear, one should seek medical examination as soon as possible.	395 (86.43)	52 (11.38)	7 (1.53)	3 (0.66)	/
2.One should follow the doctor’s recommendations and choose an appropriate examination method for calculus.	394 (86.21)	50 (10.94)	12 (2.63)	1 (0.22)	/
3.Imaging examinations for urinary system calculus are safe.	365 (79.87)	76 (16.63)	13 (2.84)	3 (0.66)	/
4.Ultrasound examination of the urinary system is cost-effective for detecting urinary system calculus.	364 (79.65)	76 (16.63)	15 (3.28)	2 (0.44)	/

Table 3.

Distribution of Patient Responses in Practice Dimension Regarding Urolithiasis Examination Methods

Practice Dimension	N (%)
	Always	Often	Sometimes	Rarely	Never
Do you actively consult your doctor about appropriate examination methods?	336 (73.52)	67 (14.66)	39 (8.53)	14 (3.06)	1 (0.22)
2.Do you actively seek information related to urinary system stone examinations, such as from TV programs or WeChat public accounts?	311 (68.05)	60 (13.13)	53 (11.6)	28 (6.13)	5 (1.09)
3.Do you follow the doctor’s recommended examination methods for stone diagnosis?	351 (76.81)	68 (14.88)	28 (6.13)	10 (2.19)
4.Do you regularly visit the hospital for follow-up examinations to check for stone recurrence?	299 (65.43)	66 (14.44)	66 (14.44)	23 (5.03)	3 (0.66)

Correlation Analysis

In the correlation analysis, significant positive correlations were found between knowledge and attitude (r = 0.353, P < 0.001), knowledge and practice (r = 0.343, P < 0.001), and attitude and practice (r = 0.632, P < 0.001), respectively (Table 4).

Table 4.

Correlation Analysis

	Knowledge	Attitude	Practice
Knowledge	1
Attitude	0.353 (P<0.001)	1
Practice	0.343 (P<0.001)	0.632 (P<0.001)	1

Univariate and Multivariate Analysis of Practice

An 80% cutoff of the maximum score for the practice dimension was used to divide the groups based on clinical relevance and established literature, resulting in 332 participants above the cutoff value. Multivariate logistic regression showed that knowledge score (OR = 1.210, 95% CI: [1.105–1.325], P < 0.001) and attitude score (OR = 1.802, 95% CI: [1.520–2.137], P < 0.001) were independently associated with proactive practice (Table 5). Sensitivity analysis using multivariable ordinal logistic regression confirmed the robustness of these results, demonstrating that higher knowledge and attitude scores remained significant independent predictors of higher practice categories (Supplementary Table 2).

Table 5.

Univariate and Multivariate Logistic Analysis for Practice Dimension

The Total Score of Practice is 20, with 80%, ie 16 Points, as Cutoff, Greater Than 16 Points Totaling 332, and Less Than or Equal to 16 Points Totaling 125.	Univariate Logistic Regression		Multivariate Logistic Regression
	OR (95% CI)	P	OR (95% CI)	P
Knowledge total score	1.329 (1.226–1.440)	<0.001	1.210 (1.105–1.325)	<0.001
Attitude total score	2.008 (1.716–2.350)	<0.001	1.802 (1.520–2.137)	<0.001
Gender
Male	0.823 (0.543–1.248)	0.360
Female	Ref
Age
18–30	0.916 (0.566–1.483)	0.720	0.745 (0.335–1.657)	0.470
31–50	0.435 (0.255–0.744)	0.002	0.900 (0.426–1.903)	0.783
More than 50	Ref		Ref
Residence
Rural	Ref		Ref
Urban	0.892 (0.493–1.616)	0.706	0.569 (0.256–1.262)	0.165
Suburban	0.321 (0.122–0.845)	0.021	0.320 (0.096–1.061)	0.062
Education
Junior high school or below	Ref		Ref
High school/vocational school/technical school	0.867 (0.464–1.622)	0.655	1.085 (0.465–2.533)	0.850
Associate degree	2.057 (1.050–4.029)	0.036	2.089 (0.793–5.498)	0.136
Bachelor’s degree or above	2.647 (1.479–4.737)	0.001	1.519 (0.583–3.955)	0.392
Marital status
Married	1.316 (0.850–2.037)	0.218
Single	Ref
Current employment status
Employed	1.973 (1.292–3.012)	0.002	1.170 (0.638–2.146)	0.612
Unemployed	Ref		Ref
Monthly income per capita
<5000	Ref		Ref
5000–10,000	1.265 (0.777–2.061)	0.344	0.877 (0.469–1.642)	0.682
10,000–20,000	1.955 (1.078–3.546)	0.027	1.115 (0.503–2.470)	0.789
>20,000	2.713 (1.245–5.913)	0.012	1.391 (0.558–3.467)	0.479

Abbreviations: OR, odds ratio; CI, confidence interval; ref, reference.

Structural Equation Model

The SEM demonstrate a highly favorable model fit indices (CMIN/DF value: 3.780, RMSEA value: 0.078, IFI value: 0.901, TLI value: 0.881, and CFI value: 0.900), suggesting a well-fitting model (Supplementary Table 3), and the effect estimates between the various paths have been presented (Supplementary Table 4 and Figure 1). The mediation analysis showed that knowledge directly affected attitude (β = 0.462, P = 0.015) and practice (β = 0.312, P = 0.013), and attitude directly affected practice (β = 0.501, P = 0.009), as well as the knowledge indirectly affected practice (β = 0.231, P = 0.012) (Table 6).

Figure 1.

SEM model.

Table 6.

Mediation Analysis

Model Paths	Standardized Total Effects		Standardized Direct Effects		Standardized Indirect Effects
	β (95% CI)	P	β (95% CI)	P	β (95% CI)	P
Knowledge→Attitude	0.462 (0.347–0.585)	0.015	0.462 (0.347–0.585)	0.015
Knowledge→Practice	0.543 (0.404–0.655)	0.018	0.312 (0.146–0.440)	0.013	0.231 (0.164–0.331)	0.012
Attitude→Practice	0.501 (0.377–0.634)	0.009	0.501 (0.377–0.634)	0.009

Abbreviation: CI, confidence interval.

Discussion

Patients with urolithiasis exhibited inadequate knowledge yet demonstrated positive attitudes and proactive practices regarding stone examination methods. Given the significant associations among knowledge, attitude, and practice, targeted educational interventions may enhance patients’ awareness and encourage evidence-based decision-making, ultimately improving adherence to appropriate diagnostic strategies.

Previous research has suggested that knowledge plays a central role in shaping health-related attitudes and behaviors, particularly in chronic disease management and diagnostic adherence.^12–14 Our findings align with this perspective, revealing that knowledge is not only directly associated with practice but also exerts an indirect influence through attitudes. The strong associations between these dimensions highlight the need for targeted interventions that enhance patient understanding while fostering positive attitudes toward stone examination methods. From a clinical perspective, the effect sizes observed in our models translate to meaningful practical benefits. For instance, our results indicate that each 1-point increase in a patient’s knowledge score is associated with a 21.0% higher likelihood (OR = 1.210) of adopting proactive examination practices, while each 1-point increase in attitude score increases this likelihood by 80.2% (OR = 1.802). Furthermore, our structural equation modeling highlighted that knowledge directly affects practice (β = 0.312) and indirectly shapes it by improving attitudes (β = 0.462). These effect sizes demonstrate that even fundamental health education initiatives aimed at incrementally improving patient knowledge can yield substantial clinical benefits by significantly enhancing diagnostic adherence.

Patients in this study exhibited insufficient knowledge regarding urinary stone examinations, with notable differences across demographic groups. Older individuals, those with lower educational attainment, and those from socioeconomically disadvantaged backgrounds demonstrated lower levels of awareness, mirroring findings from previous research that has identified education and financial status as key determinants of health literacy.^15–17 However, despite these knowledge gaps, attitudes toward stone examinations remained largely positive. This suggests that while patients may recognize the importance of seeking medical attention, their lack of understanding regarding specific examination methods could limit their ability to make informed choices. These findings emphasize the necessity of structured patient education initiatives that address both fundamental knowledge gaps and the broader motivational factors influencing behavior. Community-based programs, hospital-led counseling sessions, and digital health resources could serve as effective channels for delivering targeted information, particularly for older adults and those with limited formal education.^18,19

To effectively bridge the knowledge gap among the most vulnerable patients, particularly those with lower income and limited formal education, we propose the implementation of a multimodal educational framework. Recognizing that traditional written materials may be inadequate for this demographic, interventions should combine accessible digital health tools, such as targeted educational pushes via WeChat official accounts, with engaging visual formats like animated videos displayed in outpatient waiting areas.²⁰ Furthermore, to overcome the persistent barrier of inadequate digital health literacy prevalent in these vulnerable groups,²¹ these technological tools must be coupled with personalized, direct verbal education delivered by specialist urology nurses. This integrated, multi-channel approach ensures that vital information regarding stone examination methods is conveyed in an accessible, easily digestible manner, empowering disadvantaged patients to actively participate in their diagnostic care.

Our structural equation modeling revealed attitude as a significant mediator between knowledge and practice in the context of urolithiasis examination, aligning with our study’s central theme of understanding patient perspectives on diagnostic methods. We observed that participants with positive attitudes toward stone examinations were substantially more likely to engage in proactive health-seeking behaviors, regardless of their knowledge levels. Particularly notable was how patients’ beliefs about examination safety and effectiveness compensated for knowledge deficits regarding specific technical aspects of ultrasound limitations and CT requirements. This mediating relationship suggests that healthcare interventions should address both cognitive and affective dimensions of patient education. When designing educational programs for urolithiasis patients, providers should focus not only on improving technical knowledge but also on fostering positive perceptions about examination benefits, addressing safety concerns, and reinforcing the value of comprehensive diagnostic approaches.^22,23

Our study explored demographic influences on examination adherence among urolithiasis patients in Wuhai City. While univariate analysis indicated that socioeconomic factors, such as lower educational attainment and income, were associated with practice, our multivariate logistic regression revealed that these demographic variables were not significant independent predictors. This indicates that the influence of socioeconomic status on examination adherence is fully mediated by patients’ knowledge and attitudes, rather than acting as a direct cause of poor adherence. Nonetheless, the underlying socioeconomic disparities observed remain relevant, reflecting specific challenges in this region of Inner Mongolia, where healthcare resource distribution is uneven, and extending beyond general barriers identified in previous research^24,25 to provide important context for urolithiasis care. For instance, our practice dimension results showed that regular follow-up visits for stone recurrence monitoring were among the least adhered-to behaviors, suggesting potential geographical or financial obstacles particular to this population. This regional perspective is crucial as China continues to address healthcare inequality across diverse provinces. For urolithiasis management specifically, our findings suggest that improving examination adherence requires targeted approaches that consider the unique healthcare landscape of Inner Mongolia, including culturally appropriate patient education materials, mobile diagnostic services for remote communities, and economic support programs tailored to local income levels.^26,27

It is critical to interpret the exceptionally high attitude and practice scores observed in our cohort (means of 19.18 and 18.04, respectively) with caution. These near-perfect scores strongly indicate the presence of a social desirability bias, wherein patients likely selected responses they deemed correct or expected by healthcare providers, rather than those accurately reflecting their actual clinical behaviors. This bias creates a pronounced discrepancy between our survey findings and the clinical reality outlined earlier, where patients frequently exhibit reluctance and non-compliance with diagnostic pathways. Consistent with previous literature, self-reported adherence is often significantly higher than objective clinical measurements.²⁸ Consequently, this false illusion of high scores may mask genuine clinical resistance and the underlying apprehensions patients hold toward comprehensive stone examinations. Recognizing this divergence is essential, as it highlights the necessity for future interventions to look beyond self-reported compliance and address the actual, undocumented barriers to diagnostic adherence.

This study has several limitations. First, as a cross-sectional design, it only captures associations rather than causal relationships, limiting the ability to determine the directionality of the observed effects. The use of convenience sampling may introduce selection bias, as the sample may not be fully representative of the broader population. Second, self-reported data may be subject to recall and social desirability biases, potentially affecting the accuracy of responses. Third, the study was conducted in a single city, which may limit the generalizability of the findings to broader populations with different healthcare access and cultural backgrounds.

Conclusions

In conclusion, patients with urolithiasis demonstrated inadequate knowledge regarding stone examination methods, with knowledge significantly influencing both attitude and practice. Although patients self-reported highly positive attitudes and proactive practices, which were likely influenced by social desirability bias, future educational interventions must focus on narrowing the gap between self-reported behavior and actual clinical adherence. These targeted interventions are essential not merely to enhance knowledge, but to translate patients’ positive declarations into genuine clinical examination compliance, ultimately aiding in the early detection and effective management of urolithiasis.

Funding Statement

This research was supported by the Project of Science and Technology Guidance of Inner Mongolia Autonomous Region: “Application of 64-Slice Spiral CT Three-dimensional Reconstruction after Non-Enhanced Ureteral Stent Placement in the Diagnosis of Urinary Calculi” (2022NKC1503004), under the direction of Professor Xiaodong Liu.

Abbreviations

KAP, knowledge, attitudes, and practices; KUB, kidney-ureter-bladder; NCCT, non-contrast enhanced computed tomography; CI, confidence intervals; OR, odds ratios; SEM, Structural equation modeling; RMSEA, root mean square error of approximation; IFI, incremental fit index; TLI, Tucker-Lewis index; CFI, comparative fit index.

Data Sharing Statement

All data generated or analysed during this study are included in this published article.

Ethics Approval and Consent to Participate

This work has been carried out in accordance with the Declaration of Helsinki (2000) of the World Medical Association. I confirm that all methods were performed in accordance with the relevant guidelines. The Clinical Research Ethics Committee of Wuhai People’s Hospital approved this study (Whsrmyyky20220801), and all participants provided written informed consent.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.