Assessment of cancer risk factors, prevention beliefs, and health behaviors among undergraduate university students: a cross-sectional study

Cancer remains a leading cause of mortality worldwide, yet awareness and preventive behavior remain understudied in conflict-affected low- and middle-income countries (LMICs). University student a strategically important target group for cancer prevention interventions at a formative stage of health behavior development. This study aimed to assess cancer risk factor knowledge, Health Belief Model (HBM) attitudinal constructs, and protective health behaviors among undergraduate male university students in Afghanistan, and to identify demographic and faculty-based predictors of knowledge level. A cross-sectional study was conducted between October 2025 and January 2026 among undergraduate male students enrolled at Helmand University, Wadie Helmand Institute, and Arakozia Institute, Helmand Province, Afghanistan. Proportional stratified sampling by faculty was used. Following data quality screening, a final sample of N = 678 participants with complete responses was retained from an initial target of 800. Data were collected via a structured self-administered questionnaire covering sociodemographic characteristics, a 12-item cancer knowledge scale, 11 HBM attitudinal items (five subscales), and behavioral indicators (tobacco use, physical activity, diet, and healthcare engagement). No students who met the inclusion criteria withdrew from the study. Key analytical approaches included internal consistency analysis (Cronbach’s α and McDonald’s ω), Confirmatory Factor Analysis (CFA) with WLSMV estimation, Structural Equation Modeling (SEM), and binary and ordinal logistic regression. The mean cancer knowledge score was 6.38 ± 1.95 out of 9 analyzable items, indicating a moderate level of awareness. Three items demonstrated severely skewed response distributions (80%, 58%, and 56% incorrect), reflecting prevalent misconceptions rather than random responding. CFA confirmed acceptable fit of the five-factor HBM structure (CFI = 0.952, RMSEA = 0.053, SRMR = 0.047). However, SEM revealed that none of the HBM constructs nor cancer knowledge significantly predicted the Protective Behavior Index (all p > 0.05; R²=0.031), indicating a pronounced knowledge-attitude-behavior gap. Ordinal logistic regression identified age (OR = 1.09, 95% CI: 1.03–1.17) and faculty of enrollment as significant predictors of knowledge level, with Health Sciences students demonstrating significantly higher knowledge than Natural Sciences (OR = 0.583) and Social Sciences (OR = 0.516) students. Moderate cancer knowledge coexists with a significant knowledge-attitude-behavior gap among Afghan male university students. The five-factor HBM measurement model demonstrated acceptable psychometric performance in this population. Structural pathways from HBM beliefs to protective behavior were non-significant, suggesting that belief modification alone is insufficient without simultaneous structural facilitation. Faculty-targeted educational programs, scalable digital health tools, and improved access to cancer screening are urgently needed in this underrepresented population.