From ambivalence to agency: parents’ conceptions of a theory-based behavioural intervention to prevent dental caries in their preschool children – a qualitative study

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Methods A qualitative interview study was carried out using phenomenographic analysis in 10 public dental clinics in Region Västra Götaland, Sweden (March 2023–July 2024). Ten parents (eight women, two men) of 3–6-year-old children at elevated caries risk completed two or more counselling sessions with university-trained health promoters. Interviews (30–60 min) were audio-recorded, transcribed verbatim and analysed inductively to capture variation in parental perceptions. Flexible delivery (digital/in-clinic) and interpreter support were made available. Results Three themes were identified: (1) an offer lined with ambivalence , (2) empowered alliance through personalised support and (3) active choices through parental agency . These themes coalesced into the overarching theme ‘from ambivalence to agency: embracing health-promoting behaviour’. Conclusions Parents conceived the health-promoter-led, theory-based behavioural intervention as non-judgemental, culturally responsive and practically useful. By fostering relational safety and providing actionable tools, the intervention appeared to strengthen parental self-efficacy and catalyse family-level behavioural change. This shift, while modest in scale, may represent a necessary step towards equitable and sustainable oral-health promotion. Trial registration Not applicable Dental caries Empowerment Family health Health promotion Public Health Dentistry Self-efficacy Qualitative research Figures Figure 1 Background Health is based on an interplay of structural and individual-level determinants, including socioeconomic status, healthcare provision and daily behaviours 1 . Dental caries stem from these determinants and remain the most common non-communicable disease among children worldwide, including in Sweden 2 , 3 . In Sweden, dental care for children is publicly funded and organised by the country’s 21 regions, which are responsible for providing preventive, restorative and emergency services, financed through taxes. Despite a strong focus on prevention, social inequalities in oral health persist – particularly among children from disadvantaged backgrounds 4 , 5 . Approximately 83% of 6-year-olds in Västra Götaland are caries-free. However, in certain geographic areas, this proportion varies from 60% to 95% stable year after year, reflecting persistent and localised disparities in oral-health outcomes related to socioeconomic factors 6 . In Region Västra Götaland, all children are offered a routine dental check-up as part of a structured risk-assessment protocol that categorises them according to their likelihood of developing caries. Those identified as being at elevated risk are subsequently offered participation in the Recommended Programme for Caries Treatment (RPCT), which is delivered by dental hygienists and dental assistants through preventive measures. The RPCT focuses on early detection, individualised follow-ups and tailored guidance aimed at reducing the need for invasive treatment. Such treatment not only imposes financial burdens on the healthcare system but also adversely affects children’s quality of life, academic performance and future oral-health trajectories 5 , 7 . Given the preventable nature of dental caries, early childhood is a key developmental period for establishing enduring oral-health behaviours that can mitigate future disease burden. In response to persistent oral-health inequalities, Region Västra Götaland initiated a 3-year project in 2021 that introduced a new occupational role known as ‘health promoter’ within the public dental-care system. As part of this initiative, a targeted behavioural intervention was implemented at eleven clinics selected for their consistently high prevalence of dental caries among 6-year-old children. Unlike traditional dental professionals, health promoters have no formal education in odontology. Instead, they hold academic degrees in areas such as behavioural science, health promotion or public health, which provide them with competencies in theory-based methods designed to support sustained changes in health behaviours. This approach is consistent with national guidelines that emphasise the importance of theory-driven interventions in preventive and promotive care 8 . The health promoters engaged with families of children aged 3–6 years who were classified as having elevated caries risk, delivering a structured theory-based behavioural intervention. The promoters received specialised training in oral-health promotion and collaborated with dental professionals closely working alongside their clinical expertise, thereby supporting an integrated model of care. The intervention was conceptually grounded in social cognitive theory 9 and informed by the principles of motivational interviewing 10 , both of which underscore the importance of self-efficacy, behavioural reinforcement and social modelling in influencing health-related behaviours. Employing an empowerment-based approach, the health promoters aimed to reshape parental attitudes and facilitate behavioural change within the family context. Given the significant role of caregiver practices in shaping children’s oral health, family-oriented interventions are recognised as essential 5 , 7 , 11 . A health economic evaluation demonstrated that a theory-based behavioural intervention, delivered by health promoters, showed a statistically significant reduction in caries prevalence and increased cost-effectiveness compared with the RPCT 12 . Yet the intervention’s acceptability, perceived usefulness and impact on family dynamics remain unexplored. The success and sustainability of such interventions depend on their resonance with the perceptions and lived experiences of the families they serve. Understanding how parents perceive these theory-based consultations is therefore essential for assessing whether the intervention meets familial needs, facilitates sustainable behavioural change and mitigates barriers to achieving good oral health for the families and their young children. Therefore, the aim of this study is to describe the different ways in which parents perceive a theory-based behavioural intervention to prevent dental caries in their preschool-aged children. Methods Study design A qualitative study design was selected to capture the variation in parental perceptions of a theory-based behavioural intervention delivered by health promoters. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. A purposive sample of 10 parents (eight women and two men) were recruited, all of whom had children aged 3–6 years that had been identified during routine dental examinations as being at increased risk of caries. The inclusion criteria required the parents to have participated in a minimum of two consultations with a health promoter. Eligible families were identified by the health promoters during the intervention period and were selected based on their perceived ability to contribute diverse perspectives to this study. To ensure representation across all participating clinics, each of the five health promoters was instructed to invite two parents from the health promoter’s assigned clinic. Two respondents spoke Swedish as their native language, seven participants spoke Swedish as a second language and one interview was facilitated by an interpreter. Setting The interviews were conducted between March 2023 and July 2024 and occurred in Region Västra Götaland, Sweden. Participants were offered a choice between digital or in-person interviews; all selected digital formats (video or telephone). Interviews were conducted by the author (SB), a dental public health researcher unaffiliated with the participants’ clinical care. Participants were informed of their right to request an interpreter for free, and one interview was conducted with professional interpreting support to ensure communication in the participant’s preferred language. Interviews lasted 30–60 minutes; they were audio-recorded after written informed consent was obtained and then transcribed verbatim by SB. A semi-structured interview guide questionnaire developed for this study (Supplementary) that began with an explanation of the study purpose. This was followed by open-ended questions exploring participants’ perceptions of the intervention’s purpose, delivery, relational dynamics and perceived impact on family health behaviours. Analytical approach The analysis took an inductive phenomenographic approach 13 , 14 , based on Alexandersson’s 15 four steps. First, the transcripts were read thoroughly several times to obtain an overall impression of the material. Next, similarities and differences in the material were noted. In the third step, statements were sorted into descriptive categories of conceptions. In the final step, the categories were reflected upon and three themes emerged; these then resulted in an overarching theme articulating how parents experienced the theory-based behavioural intervention with health promoters in the Public Dental Service. Illustrative quotes are provided alongside each thematic category to increase transparency and support the analytical findings. Ethical considerations Ethical approval was granted by the Swedish Ethical Review Authority (No. 2022-06428-01). Ethical considerations were made during the planning and implementation of the study, including requirements concerning information, consent, use and confidentiality. Participants received both oral and written information about the study and its purpose prior to the start of the interview. They were informed that participation was voluntary and that they could decline, withdraw from the study at any time or choose not to answer specific questions without providing a reason. LLM disclosure Parts of the editing and language refinement of this manuscript were supported by a large language model (ChatGPT). The model was used only for language support under the supervision of the authors and did not contribute to study design, data collection, analysis or interpretation. Results The aim of this study was to describe the different ways in which parents perceived a theory-based behavioural intervention to prevent dental caries in their preschool-aged children. The analysis resulted in three descriptive themes: an offer lined with ambivalence , empowered alliance through personalised support and active choices through parental agency . Each theme comprises several subcategories that reflect variations in how parents understood and experienced the intervention. The three themes were synthesised into an overarching theme: ‘from ambivalence to agency: embracing health-promoting behaviour’ (Fig. 1 ). Theme 1 : an offer lined with ambivalence The first theme, an offer lined with ambivalence , covers the parents’ perceptions of the intervention before meeting with the health promoters. The theme consists of three categories: ‘fear of being judged as a parent’, ‘anticipatory anxiety rooted in prior dental experiences’ and ‘feels like an offer’. Category 1.1: ‘ fear of being judged as a parent’ Parents entered the consultation with a pronounced apprehension about being judged for their caregiving practices. One parent explained, So, I was a little nervous, I felt, but it felt good at the same time; I felt like, ‘Oh, now she’s probably going to judge and criticise me’, but she didn’t. She was absolutely wonderful … (R10) This statement illustrates the parents’ initial fear of criticism, which was subsequently alleviated by the health promoter’s empathetic approach. Category 1.2: ‘anticipatory anxiety rooted in prior dental experiences’ A second category reflected parents’ concern regarding the state of their children’s oral health and their previous experiences with dentists. One parent noted, The most important thing when we go to the health centre is that he doesn’t cry and starts to feel safe. That he starts to take fluoride. It makes a big difference for me and his dad. Before [when we had a dentist appointment], we would start thinking and worrying for 10 days, thinking, ‘What can we do? What should we do about that place?’ [The intervention] makes a big difference. It has changed his situation so much. (R6) Category 1.3: ‘feels like an offer’ The third category pertains to the parents’ conception of the invitation to participate in the intervention. One parent stated, Yes. It happened in such a way that my son had caries or had cavities on some teeth. And it was more like an offer that I received … (R3) Here, the parent explained that the intervention was an offer received after a routine examination where multiple dental caries were detected. Theme 2 : empowered alliance through personalised support The second theme, empowered alliance through personalised support , includes the parents’ conceptions of the theory-based behavioural intervention itself. This theme consists of four categories: ‘a feeling of being understood’, ‘creating an treatment alliance with the counsellor’, ‘being provided with guidance, knowledge and useful tools’ and ‘flexible solutions based on the family’s needs were success factor’. Category 2.1: ‘a feeling of being understood’ During the consultation, many parents reported a sense of being understood by the health promoter. One parent remarked, ‘But yeah, but that was the thing about it, that I didn’t feel like she was judging me, but she was more understanding, and that’s what I actually liked about her.’ (R10) Here, the parent highlights the significance of an empathetic, non-judgmental dialogue. Category 2.2: ‘creating an treatment alliance with the counsellor’ Parents also emphasised the establishment of a collaborative relationship with the health promoter. As one parent explained, ‘It was great, and it felt like there was, there was someone who was on my side and kind of supporting me.’ (R5) This parent felt a sense of alliance that contributed to a supportive consultation environment, facilitating open communication. Category 2.3: ‘being provided with guidance, knowledge and useful tools’ The consultation provided concrete guidance and practical tools, enabling parents to make informed decisions regarding their children’s oral health. One participant observed, ‘The second tip was about bread that contains sugar, and she told me about the Keyhole [ nyckelhålet ] label on products [a Nordic nutrition label marking healthier products]. I started buying products with a Keyhole label.' (R5) This category reflects how the participants described the practical guidance and tools offered during the consultation as helpful in supporting decisions related to their children’s oral health. Category 2.4: ‘flexible solutions based on the family’s needs were success factor’ This category shows how participants described the flexibility of the consultation format as a positive aspect of the intervention that enabled adaptation to the needs and circumstances of individual families. One parent commented, ‘[During the] digital meeting, it was exactly as if I were there [in person] … It was the same quality … I don’t think it was strange, it was great, I think so.’ (R2) This parent’s comment emphasises that the adaptability of the intervention (i.e. whether it was delivered in person or digitally) was experienced as a strength. Theme 3 : active choices through parental agency The third theme, active choices through parental agency , contains perceptions the parents’ had after the theory-based behavioural intervention with health promotor. This theme consists of four categories: ‘strengthened parenthood’,‘active choices based on new knowledge’, ‘inspiration for lifestyle changes for the whole family’ and ‘ambassadorship - spreading knowledge further’. Category 3.1: ‘strengthened parenthood’ Following the consultation, parents reported an enhanced sense of self-efficacy and empowerment in their caregiving roles. One parent remarked, ‘Now we stop it; even if she cries in the store, we don’t listen. At first, that was our response. But she also started to accept that it was every other Friday that she gets candy. Even if we go to the store now, there’s less screaming. Now she doesn’t act like before, when she screamed that she had to have candy. Even when she says no, if she cries all day, she gets it every other Friday.’ (R9) In this quotation, the parents explain how the intervention helped reinforce their parental role, fostering both personal and familial well-being. Category 3.2: ‘active choices based on new knowledge’ Acquiring new, practical insights prompted the parents to adopt more proactive measures in their daily routines. One parent stated, ‘… And so we talked about such a multivitamin without sugar that would be best for my child, and something else. What was it? A jam. Because my child craves jam a lot.’(R2) The parents described how the actionable recommendations they were given encouraged them to make deliberate and healthier choices. Category 3.3: ‘inspiration for lifestyle changes for the whole family’ The parents described how the consultations acted as a catalyst for broader changes in habits that extended beyond the immediate focus on oral health and affected the whole family. One participant noted, ‘The meeting was just about my daughter, but it affected the whole family.’ (R9) As in this example, the knowledge the parents gained led them to re-evaluate their family’s daily habits. Category 3.4: ‘ambassadorship - spreading knowledge further’ The parents described how they took on an ambassador role, enthusiastically sharing the new insights and practical tips they had gained with their friends, relatives and community: ‘I’ve told many of my friends [about the things] I didn’t know – like, I’ve been brushing my teeth, little things like that, wrong my whole life. And I was lucky that I haven’t lost many teeth.’ (R2) Discussion The parents’ conceptions of the theory-based behavioural intervention to prevent dental caries were framed into three descriptive themes: (1) ‘an offer lined with ambivalence’, (2) ‘empowered alliance through personalised support’ and (3) ‘active choices through parental agency’. Taken together, the findings suggest that a health-promoter-led approach, grounded in social cognitive theory and motivational interviewing, was able to foster a non-judgmental atmosphere and empower families with targeted practical guidance. The fear of judgment and uncertainty reported by the parents prior to their visit is consistent with prior research showing that stigma or apprehension about parental practices can inhibit health-seeking behaviours 16 . However, the encounters with the health promoters were perceived as non-judgemental, personalised and flexible – qualities associated with successful motivational interviewing 10 . The parents’ accounts described a transition from ambivalence to agency, with the intervention facilitating deliberate health-related decisions and broader lifestyle shifts, including practices such as limiting sugary snacks and adopting more nutrient-dense, low-sugar dietary choices. These changes indicate a generalisation of behaviour beyond oral hygiene – an outcome congruent with social cognitive theory’s emphasis on reinforcement and modelling in diverse contexts 9 . Perceptions such as ‘feeling understood’ and ‘acting as ambassadors’ reflect not only increased self-efficacy but also the emergence of a relational context that enables the internalisation of new caregiving norms. This result is consistent with the findings of Alvenfors et al. 17 , which emphasise the importance of alliance-building between dental professionals and caregivers as a prerequisite for translating knowledge into sustained behavioural change. The current study extends this work by demonstrating that combining culturally responsive communication with theory-based behavioural strategies supports parents in transforming specific oral-health advice into broader, proactive family behaviours. Theoretical frameworks such as relational autonomy can help interpret these findings. This concept suggests that individual agency is co-constructed through supportive, trust-based social relationships 18 . In this study, the non-judgemental stance of the health promoters appeared to create a ‘safe relational space’ in which parents could reflect on and recalibrate their caregiving practices in achievable ways while feeling respected. This finding complements social cognitive theory’s focus on self-efficacy by highlighting the social conditions that enable individuals to act on health-related intentions 9 . An intersectional perspective based on Antonovsky’s sense of coherence 19 can further inform our understanding of the findings. Several parents described navigating language barriers and cultural differences when accessing public services. Intersectionality theory helps explain why a culturally tailored intervention may better support engagement among diverse families, how generic caries prevention often under-serves marginalised groups, and why culturally responsive dialogue proved critical in the present case 20 . Furthermore, the parents’ positive reception to practical guidance and flexible solutions resonates with literature emphasising the necessity of culturally and contextually adapted interventions for families from diverse backgrounds 21 . This study’s findings are also compatible with the salutogenic model: parents described how the intervention helped make oral-health tasks more comprehensible, manageable and meaningful – dimensions central to a sense of coherence 19 . At the micro level, the theme active choices through parental agency showed how parents reported tangible shifts such as adopting Keyhole-labelled foods and enforcing ‘candy only on Saturdays’, signalling a recalibration of day-to-day routines. These examples illustrate the enactment of the overarching theme, ‘from ambivalence to agency’, as families translated abstract guidance into tangible routines. These changes were enabled by meso-level dynamics, as captured in the theme empowered alliance through personalised support , where trust-based rapport with culturally responsive health promoters and the option of digital visits lowered logistical and communicative barriers. However, some accounts covered in Theme 1 reflected enduring concerns related to past healthcare experiences, which may continue to shape how preventive and promotive efforts are received and acted upon. Importantly, the interpreter-facilitated session was described as effective, suggesting that a relational alliance can be achieved across linguistic boundaries when delivery is culturally sensitive. Thus, the findings from this study suggest that an integrated approach that reinforces micro-level behavioural shifts, optimises meso-level service delivery and addresses macro-structural inequities may lead to durable reductions in childhood caries risk. Dental caries shares dietary, socioeconomic and behavioural determinants with obesity, type-2 diabetes and cardiovascular disease. The observed reductions in sugary-snack frequency suggest potential collateral benefits across multiple non-communicable diseases consistent with the common risk-factor approach 22 . Framing the intervention within a syndemic paradigm, where oral disease co-occurs and interacts biologically and socially with other conditions, may increase its relevance for inter-sectoral collaboration and resource allocation 23 . The ambassadorial role described by several parents may reflect peer-led social modelling, potentially amplifying the intervention’s reach beyond the immediate family and reinforcing social-cognitive-theory-based mechanisms of influence. Overall, these findings suggest that culturally attuned, theory-based consultations can support parents in moving from externally motivated compliance to internally anchored agency. This shift, while modest in scale, may represent a necessary step towards equitable and sustainable oral-health promotion. This study has certain limitations that should be noted. This phenomenographic enquiry was based on a region-specific sample of 10 families, which was appropriate for depth but inevitably restricted the range of parental conception that could be captured. Self-selection and awareness that the interviewer was linked to the dental service may have introduced social-desirability bias. Interviews were conducted in Swedish, with interpreter support where needed; subtle meanings may therefore have been attenuated during translation and transcription. Credibility was bolstered by the purposive recruitment of linguistically and culturally diverse participants, independent double-coding, member checking and an auditable analytic trail; still, transferability beyond similar high-risk settings must be inferred with caution. Regarding implications and future research, the findings from this study have clear implications for both practice and policy. By demonstrating how culturally responsive, theory-based behavioural intervention can enhance parental agency and foster health-promoting routines beyond toothbrushing, this research supports the scale-up of health-promoter-led interventions within child dental-care services. The alignment with social cognitive theory and salutogenic principles suggests that behavioural counselling in dental contexts should not be narrowly confined to risk communication or compliance but instead framed within a broader relational and contextual understanding of families’ lived realities. In clinical practice, these insights can inform training modules that equip health promoters and dental teams to work relationally, motivationally and with attention to intersectional determinants of health. Importantly, health promoters should be viewed as just one component within an interprofessional team, where dental hygienists, dental assistants and dentists play a pivotal role in promotive and preventive care. Dental hygienists are uniquely positioned to integrate behavioural conversation into routine practice, bridging clinical prevention with person-centred communication. A collaborative approach in which health promoters, dental hygienists and other team members contribute complementary skills can maximise the impact of preventive and promotive strategies and ensure that interventions resonate with families’ daily realities. At the policy level, the findings argue for stronger structural integration between oral-health services and broader child health or family support systems. This includes revisiting commissioning models to ensure that preventive and promotive services are not only reimbursed adequately but also designed in ways that allow for flexible, tailored and culturally sensitive encounters. Moreover, applying a syndemic perspective may enable oral-health interventions to be strategically embedded within cross-sectoral public-health strategies targeting diet, equity and early child development. Given the disproportionate burden of dental caries among socioeconomically and culturally marginalised groups, this approach could increase both efficiency and equity in resource allocation. Further research is warranted to build on these findings. Interviews with clinical personnel involved in the delivery of such interventions could provide a more complete picture of implementation dynamics, role clarity and perceived enablers or barriers within everyday practice. A complementary retrospective epidemiological analysis of children’s dental records, comparing those exposed to the health-promoter intervention with controls, could help assess whether the reported behavioural shifts translate into measurable clinical outcomes over time. Such mixed-method triangulation would strengthen the evidence base and inform future guidelines for scalable, equity-oriented caries-prevention programmes. Conclusions This study contributes new insights into how parents perceived the value and delivery of a theory-based behavioural intervention delivered by health promoters. This intervention was perceived as non-judgemental, flexible and practically useful, supporting parental self-efficacy and encouraging broader family-level change. Abbreviations COREQ Consolidated Criteria for Reporting Qualitative Research MI Motivational interviewing RPCT Recommended Programme for Caries Treatment SCT Social cognitive theory SKaPa Swedish Quality Register for Caries and Periodontitis Declarations Author contributions: SB: Conceptualisation, data collection, analysis, drafting; MM: Methodology, supervision, critical revision; PL: Supervision, critical revision; E-KB: Methodology, supervision, critical revision. All authors approved the final manuscript. Acknowledgements: We are grateful to the families who shared their experiences, the Public Dental Service, the health promoters who assisted with recruitment and the project manager, Stina Bertling. Ethical considerations: This study was approved by the Swedish Ethical Review Authority (No. 2022-06428-01) and adhere to the Declaration of Helsinki both in regard of ethics approval and consent to participate. Consent to participate: Written informed consent was obtained from all participants. Consent for publication: Written informed consent was obtained from all participants. Declaration of conflicting interest: The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding: This research was funded by Health Promotion Research Funding (VGFOUREG-982910 and VGFOUREG-991628), Region Västra Götaland, Sweden. 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Supplementary Files 25.12.03Interviewguide.docx Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2026 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 09 Jan, 2026 Reviews received at journal 05 Jan, 2026 Reviews received at journal 31 Dec, 2025 Reviewers agreed at journal 15 Dec, 2025 Reviews received at journal 13 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviewers agreed at journal 12 Dec, 2025 Reviewers invited by journal 04 Dec, 2025 Editor assigned by journal 04 Dec, 2025 Editor invited by journal 03 Dec, 2025 Submission checks completed at journal 03 Dec, 2025 First submitted to journal 03 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":84266,"visible":true,"origin":"","legend":"\u003cp\u003eThemes and categories framing parents’ conceptions of the value and delivery of an intervention designed to reduce caries risk among children aged 3–6 years.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8221127/v1/1ffb4e05c203db8b5ae64493.png"},{"id":102785527,"identity":"dc7625e3-bac2-4d08-819c-3345daf04d89","added_by":"auto","created_at":"2026-02-16 16:07:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":955395,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8221127/v1/6e7aae35-19cf-4c3e-bca1-b988252177fb.pdf"},{"id":97704503,"identity":"4e5e119d-772d-44b4-abe0-b01d3708ca1a","added_by":"auto","created_at":"2025-12-08 12:48:53","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18410,"visible":true,"origin":"","legend":"","description":"","filename":"25.12.03Interviewguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-8221127/v1/7794dcbfa88a447ea768df28.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From ambivalence to agency: parents’ conceptions of a theory-based behavioural intervention to prevent dental caries in their preschool children – a qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eHealth is based on an interplay of structural and individual-level determinants, including socioeconomic status, healthcare provision and daily behaviours\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Dental caries stem from these determinants and remain the most common non-communicable disease among children worldwide, including in Sweden\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In Sweden, dental care for children is publicly funded and organised by the country\u0026rsquo;s 21 regions, which are responsible for providing preventive, restorative and emergency services, financed through taxes. Despite a strong focus on prevention, social inequalities in oral health persist \u0026ndash; particularly among children from disadvantaged backgrounds\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Approximately 83% of 6-year-olds in V\u0026auml;stra G\u0026ouml;taland are caries-free. However, in certain geographic areas, this proportion varies from 60% to 95% stable year after year, reflecting persistent and localised disparities in oral-health outcomes related to socioeconomic factors\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn Region V\u0026auml;stra G\u0026ouml;taland, all children are offered a routine dental check-up as part of a structured risk-assessment protocol that categorises them according to their likelihood of developing caries. Those identified as being at elevated risk are subsequently offered participation in the Recommended Programme for Caries Treatment (RPCT), which is delivered by dental hygienists and dental assistants through preventive measures. The RPCT focuses on early detection, individualised follow-ups and tailored guidance aimed at reducing the need for invasive treatment. Such treatment not only imposes financial burdens on the healthcare system but also adversely affects children\u0026rsquo;s quality of life, academic performance and future oral-health trajectories\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Given the preventable nature of dental caries, early childhood is a key developmental period for establishing enduring oral-health behaviours that can mitigate future disease burden.\u003c/p\u003e\u003cp\u003eIn response to persistent oral-health inequalities, Region V\u0026auml;stra G\u0026ouml;taland initiated a 3-year project in 2021 that introduced a new occupational role known as \u0026lsquo;health promoter\u0026rsquo; within the public dental-care system. As part of this initiative, a targeted behavioural intervention was implemented at eleven clinics selected for their consistently high prevalence of dental caries among 6-year-old children. Unlike traditional dental professionals, health promoters have no formal education in odontology. Instead, they hold academic degrees in areas such as behavioural science, health promotion or public health, which provide them with competencies in theory-based methods designed to support sustained changes in health behaviours. This approach is consistent with national guidelines that emphasise the importance of theory-driven interventions in preventive and promotive care\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. The health promoters engaged with families of children aged 3\u0026ndash;6 years who were classified as having elevated caries risk, delivering a structured theory-based behavioural intervention. The promoters received specialised training in oral-health promotion and collaborated with dental professionals closely working alongside their clinical expertise, thereby supporting an integrated model of care. The intervention was conceptually grounded in social cognitive theory\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e and informed by the principles of motivational interviewing\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, both of which underscore the importance of self-efficacy, behavioural reinforcement and social modelling in influencing health-related behaviours. Employing an empowerment-based approach, the health promoters aimed to reshape parental attitudes and facilitate behavioural change within the family context. Given the significant role of caregiver practices in shaping children\u0026rsquo;s oral health, family-oriented interventions are recognised as essential\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA health economic evaluation demonstrated that a theory-based behavioural intervention, delivered by health promoters, showed a statistically significant reduction in caries prevalence and increased cost-effectiveness compared with the RPCT\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Yet the intervention\u0026rsquo;s acceptability, perceived usefulness and impact on family dynamics remain unexplored. The success and sustainability of such interventions depend on their resonance with the perceptions and lived experiences of the families they serve. Understanding how parents perceive these theory-based consultations is therefore essential for assessing whether the intervention meets familial needs, facilitates sustainable behavioural change and mitigates barriers to achieving good oral health for the families and their young children. Therefore, the aim of this study is to describe the different ways in which parents perceive a theory-based behavioural intervention to prevent dental caries in their preschool-aged children.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003eA qualitative study design was selected to capture the variation in parental perceptions of a theory-based behavioural intervention delivered by health promoters. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. A purposive sample of 10 parents (eight women and two men) were recruited, all of whom had children aged 3\u0026ndash;6 years that had been identified during routine dental examinations as being at increased risk of caries. The inclusion criteria required the parents to have participated in a minimum of two consultations with a health promoter. Eligible families were identified by the health promoters during the intervention period and were selected based on their perceived ability to contribute diverse perspectives to this study. To ensure representation across all participating clinics, each of the five health promoters was instructed to invite two parents from the health promoter\u0026rsquo;s assigned clinic. Two respondents spoke Swedish as their native language, seven participants spoke Swedish as a second language and one interview was facilitated by an interpreter.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThe interviews were conducted between March 2023 and July 2024 and occurred in Region V\u0026auml;stra G\u0026ouml;taland, Sweden. Participants were offered a choice between digital or in-person interviews; all selected digital formats (video or telephone). Interviews were conducted by the author (SB), a dental public health researcher unaffiliated with the participants\u0026rsquo; clinical care. Participants were informed of their right to request an interpreter for free, and one interview was conducted with professional interpreting support to ensure communication in the participant\u0026rsquo;s preferred language. Interviews lasted 30\u0026ndash;60 minutes; they were audio-recorded after written informed consent was obtained and then transcribed verbatim by SB. A semi-structured interview guide questionnaire developed for this study (Supplementary) that began with an explanation of the study purpose. This was followed by open-ended questions exploring participants\u0026rsquo; perceptions of the intervention\u0026rsquo;s purpose, delivery, relational dynamics and perceived impact on family health behaviours.\u003c/p\u003e\n\u003ch3\u003eAnalytical approach\u003c/h3\u003e\n\u003cp\u003eThe analysis took an inductive phenomenographic approach\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, based on Alexandersson\u0026rsquo;s\u003csup\u003e15\u003c/sup\u003e four steps. First, the transcripts were read thoroughly several times to obtain an overall impression of the material. Next, similarities and differences in the material were noted. In the third step, statements were sorted into descriptive categories of conceptions. In the final step, the categories were reflected upon and three themes emerged; these then resulted in an overarching theme articulating how parents experienced the theory-based behavioural intervention with health promoters in the Public Dental Service. Illustrative quotes are provided alongside each thematic category to increase transparency and support the analytical findings.\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003ewas granted by the Swedish Ethical Review Authority (No. 2022-06428-01). Ethical considerations were made during the planning and implementation of the study, including requirements concerning information, consent, use and confidentiality. Participants received both oral and written information about the study and its purpose prior to the start of the interview. They were informed that participation was voluntary and that they could decline, withdraw from the study at any time or choose not to answer specific questions without providing a reason.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eLLM disclosure\u003c/h3\u003e\n\u003cp\u003eParts of the editing and language refinement of this manuscript were supported by a large language model (ChatGPT). The model was used only for language support under the supervision of the authors and did not contribute to study design, data collection, analysis or interpretation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe aim of this study was to describe the different ways in which parents perceived a theory-based behavioural intervention to prevent dental caries in their preschool-aged children. The analysis resulted in three descriptive themes: \u003cem\u003ean offer lined with ambivalence\u003c/em\u003e, \u003cem\u003eempowered alliance through personalised support\u003c/em\u003e and \u003cem\u003eactive choices through parental agency\u003c/em\u003e. Each theme comprises several subcategories that reflect variations in how parents understood and experienced the intervention. The three themes were synthesised into an overarching theme: \u0026lsquo;from ambivalence to agency: embracing health-promoting behaviour\u0026rsquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1\u003c/b\u003e: \u003cb\u003ean offer lined with ambivalence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe first theme, \u003cem\u003ean offer lined with ambivalence\u003c/em\u003e, covers the parents\u0026rsquo; perceptions of the intervention before meeting with the health promoters. The theme consists of three categories: \u0026lsquo;fear of being judged as a parent\u0026rsquo;, \u0026lsquo;anticipatory anxiety rooted in prior dental experiences\u0026rsquo; and \u0026lsquo;feels like an offer\u0026rsquo;.\u003c/p\u003e\u003cp\u003e\u003cem\u003eCategory 1.1: \u0026lsquo;\u003c/em\u003efear of being judged as a parent\u0026rsquo;\u003c/p\u003e\u003cp\u003eParents entered the consultation with a pronounced apprehension about being judged for their caregiving practices. One parent explained,\u003c/p\u003e\u003cp\u003eSo, I was a little nervous, I felt, but it felt good at the same time; I felt like, \u0026lsquo;Oh, now she\u0026rsquo;s probably going to judge and criticise me\u0026rsquo;, but she didn\u0026rsquo;t. She was absolutely wonderful \u0026hellip; (R10)\u003c/p\u003e\u003cp\u003eThis statement illustrates the parents\u0026rsquo; initial fear of criticism, which was subsequently alleviated by the health promoter\u0026rsquo;s empathetic approach.\u003c/p\u003e\n\u003ch3\u003eCategory 1.2: ‘anticipatory anxiety rooted in prior dental experiences’\u003c/h3\u003e\n\u003cp\u003eA second category reflected parents\u0026rsquo; concern regarding the state of their children\u0026rsquo;s oral health and their previous experiences with dentists. One parent noted,\u003c/p\u003e\u003cp\u003eThe most important thing when we go to the health centre is that he doesn\u0026rsquo;t cry and starts to feel safe. That he starts to take fluoride. It makes a big difference for me and his dad. Before [when we had a dentist appointment], we would start thinking and worrying for 10 days, thinking, \u0026lsquo;What can we do? What should we do about that place?\u0026rsquo; [The intervention] makes a big difference. It has changed his situation so much. (R6)\u003c/p\u003e\n\u003ch3\u003eCategory 1.3: ‘feels like an offer’\u003c/h3\u003e\n\u003cp\u003e The third category pertains to the parents\u0026rsquo; conception of the invitation to participate in the intervention. One parent stated,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eYes. It happened in such a way that my son had caries or had cavities on some teeth. And it was more like an offer that I received \u0026hellip; (R3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eHere, the parent explained that the intervention was an offer received after a routine examination where multiple dental caries were detected.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2\u003c/b\u003e: \u003cb\u003eempowered alliance through personalised support\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe second theme, \u003cem\u003eempowered alliance through personalised support\u003c/em\u003e, includes the parents\u0026rsquo; conceptions of the theory-based behavioural intervention itself. This theme consists of four categories: \u0026lsquo;a feeling of being understood\u0026rsquo;, \u0026lsquo;creating an treatment alliance with the counsellor\u0026rsquo;, \u0026lsquo;being provided with guidance, knowledge and useful tools\u0026rsquo; and \u0026lsquo;flexible solutions based on the family\u0026rsquo;s needs were success factor\u0026rsquo;.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCategory 2.1: \u0026lsquo;a feeling of being understood\u0026rsquo;\u003c/h2\u003e\u003cp\u003eDuring the consultation, many parents reported a sense of being understood by the health promoter. One parent remarked,\u003c/p\u003e\u003cp\u003e\u0026lsquo;But yeah, but that was the thing about it, that I didn\u0026rsquo;t feel like she was judging me, but she was more understanding, and that\u0026rsquo;s what I actually liked about her.\u0026rsquo; (R10)\u003c/p\u003e\u003cp\u003eHere, the parent highlights the significance of an empathetic, non-judgmental dialogue.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCategory 2.2: \u0026lsquo;creating an treatment alliance with the counsellor\u0026rsquo;\u003c/h2\u003e\u003cp\u003e Parents also emphasised the establishment of a collaborative relationship with the health promoter. As one parent explained,\u003c/p\u003e\u003cp\u003e\u0026lsquo;It was great, and it felt like there was, there was someone who was on my side and kind of supporting me.\u0026rsquo; (R5)\u003c/p\u003e\u003cp\u003eThis parent felt a sense of alliance that contributed to a supportive consultation environment, facilitating open communication.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCategory 2.3: \u0026lsquo;being provided with guidance, knowledge and useful tools\u0026rsquo;\u003c/h2\u003e\u003cp\u003eThe consultation provided concrete guidance and practical tools, enabling parents to make informed decisions regarding their children\u0026rsquo;s oral health. One participant observed,\u003c/p\u003e\u003cp\u003e\u0026lsquo;The second tip was about bread that contains sugar, and she told me about the Keyhole [\u003cem\u003enyckelh\u0026aring;let\u003c/em\u003e] label on products [a Nordic nutrition label marking healthier products]. I started buying products with a Keyhole label.' (R5)\u003c/p\u003e\u003cp\u003eThis category reflects how the participants described the practical guidance and tools offered during the consultation as helpful in supporting decisions related to their children\u0026rsquo;s oral health.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCategory 2.4: \u0026lsquo;flexible solutions based on the family\u0026rsquo;s needs were success factor\u0026rsquo;\u003c/h2\u003e\u003cp\u003eThis category shows how participants described the flexibility of the consultation format as a positive aspect of the intervention that enabled adaptation to the needs and circumstances of individual families. One parent commented,\u003c/p\u003e\u003cp\u003e\u0026lsquo;[During the] digital meeting, it was exactly as if I were there [in person] \u0026hellip; It was the same quality \u0026hellip; I don\u0026rsquo;t think it was strange, it was great, I think so.\u0026rsquo; (R2)\u003c/p\u003e\u003cp\u003eThis parent\u0026rsquo;s comment emphasises that the adaptability of the intervention (i.e. whether it was delivered in person or digitally) was experienced as a strength.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3\u003c/b\u003e: \u003cb\u003eactive choices through parental agency\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe third theme, \u003cem\u003eactive choices through parental agency\u003c/em\u003e, contains perceptions the parents\u0026rsquo; had after the theory-based behavioural intervention with health promotor. This theme consists of four categories: \u0026lsquo;strengthened parenthood\u0026rsquo;,\u0026lsquo;active choices based on new knowledge\u0026rsquo;, \u0026lsquo;inspiration for lifestyle changes for the whole family\u0026rsquo; and \u0026lsquo;ambassadorship - spreading knowledge further\u0026rsquo;.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eCategory 3.1: \u0026lsquo;strengthened parenthood\u0026rsquo;\u003c/h2\u003e\u003cp\u003e Following the consultation, parents reported an enhanced sense of self-efficacy and empowerment in their caregiving roles. One parent remarked,\u003c/p\u003e\u003cp\u003e\u0026lsquo;Now we stop it; even if she cries in the store, we don\u0026rsquo;t listen. At first, that was our response. But she also started to accept that it was every other Friday that she gets candy. Even if we go to the store now, there\u0026rsquo;s less screaming. Now she doesn\u0026rsquo;t act like before, when she screamed that she had to have candy. Even when she says no, if she cries all day, she gets it every other Friday.\u0026rsquo; (R9)\u003c/p\u003e\u003cp\u003e In this quotation, the parents explain how the intervention helped reinforce their parental role, fostering both personal and familial well-being.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eCategory 3.2: \u0026lsquo;active choices based on new knowledge\u0026rsquo;\u003c/h2\u003e\u003cp\u003eAcquiring new, practical insights prompted the parents to adopt more proactive measures in their daily routines. One parent stated,\u003c/p\u003e\u003cp\u003e\u0026lsquo;\u0026hellip; And so we talked about such a multivitamin without sugar that would be best for my child, and something else. What was it? A jam. Because my child craves jam a lot.\u0026rsquo;(R2)\u003c/p\u003e\u003cp\u003eThe parents described how the actionable recommendations they were given encouraged them to make deliberate and healthier choices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eCategory 3.3: \u0026lsquo;inspiration for lifestyle changes for the whole family\u0026rsquo;\u003c/h2\u003e\u003cp\u003eThe parents described how the consultations acted as a catalyst for broader changes in habits that extended beyond the immediate focus on oral health and affected the whole family. One participant noted,\u003c/p\u003e\u003cp\u003e\u0026lsquo;The meeting was just about my daughter, but it affected the whole family.\u0026rsquo; (R9)\u003c/p\u003e\u003cp\u003eAs in this example, the knowledge the parents gained led them to re-evaluate their family\u0026rsquo;s daily habits.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eCategory 3.4: \u0026lsquo;ambassadorship - spreading knowledge further\u0026rsquo;\u003c/h2\u003e\u003cp\u003eThe parents described how they took on an ambassador role, enthusiastically sharing the new insights and practical tips they had gained with their friends, relatives and community:\u003c/p\u003e\u003cp\u003e\u0026lsquo;I\u0026rsquo;ve told many of my friends [about the things] I didn\u0026rsquo;t know \u0026ndash; like, I\u0026rsquo;ve been brushing my teeth, little things like that, wrong my whole life. And I was lucky that I haven\u0026rsquo;t lost many teeth.\u0026rsquo; (R2)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The parents\u0026rsquo; conceptions of the theory-based behavioural intervention to prevent dental caries were framed into three descriptive themes: (1) \u0026lsquo;an offer lined with ambivalence\u0026rsquo;, (2) \u0026lsquo;empowered alliance through personalised support\u0026rsquo; and (3) \u0026lsquo;active choices through parental agency\u0026rsquo;. Taken together, the findings suggest that a health-promoter-led approach, grounded in social cognitive theory and motivational interviewing, was able to foster a non-judgmental atmosphere and empower families with targeted practical guidance.\u003c/p\u003e\u003cp\u003eThe fear of judgment and uncertainty reported by the parents prior to their visit is consistent with prior research showing that stigma or apprehension about parental practices can inhibit health-seeking behaviours\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. However, the encounters with the health promoters were perceived as non-judgemental, personalised and flexible \u0026ndash; qualities associated with successful motivational interviewing\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The parents\u0026rsquo; accounts described a transition from ambivalence to agency, with the intervention facilitating deliberate health-related decisions and broader lifestyle shifts, including practices such as limiting sugary snacks and adopting more nutrient-dense, low-sugar dietary choices. These changes indicate a generalisation of behaviour beyond oral hygiene \u0026ndash; an outcome congruent with social cognitive theory\u0026rsquo;s emphasis on reinforcement and modelling in diverse contexts\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Perceptions such as \u0026lsquo;feeling understood\u0026rsquo; and \u0026lsquo;acting as ambassadors\u0026rsquo; reflect not only increased self-efficacy but also the emergence of a relational context that enables the internalisation of new caregiving norms. This result is consistent with the findings of Alvenfors et al.\u003csup\u003e17\u003c/sup\u003e, which emphasise the importance of alliance-building between dental professionals and caregivers as a prerequisite for translating knowledge into sustained behavioural change. The current study extends this work by demonstrating that combining culturally responsive communication with theory-based behavioural strategies supports parents in transforming specific oral-health advice into broader, proactive family behaviours.\u003c/p\u003e\u003cp\u003eTheoretical frameworks such as relational autonomy can help interpret these findings. This concept suggests that individual agency is co-constructed through supportive, trust-based social relationships\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In this study, the non-judgemental stance of the health promoters appeared to create a \u0026lsquo;safe relational space\u0026rsquo; in which parents could reflect on and recalibrate their caregiving practices in achievable ways while feeling respected. This finding complements social cognitive theory\u0026rsquo;s focus on self-efficacy by highlighting the social conditions that enable individuals to act on health-related intentions\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAn intersectional perspective based on Antonovsky\u0026rsquo;s sense of coherence\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e can further inform our understanding of the findings. Several parents described navigating language barriers and cultural differences when accessing public services. Intersectionality theory helps explain why a culturally tailored intervention may better support engagement among diverse families, how generic caries prevention often under-serves marginalised groups, and why culturally responsive dialogue proved critical in the present case\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Furthermore, the parents\u0026rsquo; positive reception to practical guidance and flexible solutions resonates with literature emphasising the necessity of culturally and contextually adapted interventions for families from diverse backgrounds\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. This study\u0026rsquo;s findings are also compatible with the salutogenic model: parents described how the intervention helped make oral-health tasks more comprehensible, manageable and meaningful \u0026ndash; dimensions central to a sense of coherence\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAt the micro level, the theme \u003cem\u003eactive choices through parental agency\u003c/em\u003e showed how parents reported tangible shifts such as adopting Keyhole-labelled foods and enforcing \u0026lsquo;candy only on Saturdays\u0026rsquo;, signalling a recalibration of day-to-day routines. These examples illustrate the enactment of the overarching theme, \u0026lsquo;from ambivalence to agency\u0026rsquo;, as families translated abstract guidance into tangible routines. These changes were enabled by meso-level dynamics, as captured in the theme \u003cem\u003eempowered alliance through personalised support\u003c/em\u003e, where trust-based rapport with culturally responsive health promoters and the option of digital visits lowered logistical and communicative barriers. However, some accounts covered in Theme 1 reflected enduring concerns related to past healthcare experiences, which may continue to shape how preventive and promotive efforts are received and acted upon. Importantly, the interpreter-facilitated session was described as effective, suggesting that a relational alliance can be achieved across linguistic boundaries when delivery is culturally sensitive. Thus, the findings from this study suggest that an integrated approach that reinforces micro-level behavioural shifts, optimises meso-level service delivery and addresses macro-structural inequities may lead to durable reductions in childhood caries risk.\u003c/p\u003e\u003cp\u003eDental caries shares dietary, socioeconomic and behavioural determinants with obesity, type-2 diabetes and cardiovascular disease. The observed reductions in sugary-snack frequency suggest potential collateral benefits across multiple non-communicable diseases consistent with the common risk-factor approach\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Framing the intervention within a syndemic paradigm, where oral disease co-occurs and interacts biologically and socially with other conditions, may increase its relevance for inter-sectoral collaboration and resource allocation\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The ambassadorial role described by several parents may reflect peer-led social modelling, potentially amplifying the intervention\u0026rsquo;s reach beyond the immediate family and reinforcing social-cognitive-theory-based mechanisms of influence.\u003c/p\u003e\u003cp\u003e Overall, these findings suggest that culturally attuned, theory-based consultations can support parents in moving from externally motivated compliance to internally anchored agency. This shift, while modest in scale, may represent a necessary step towards equitable and sustainable oral-health promotion.\u003c/p\u003e\u003cp\u003eThis study has certain limitations that should be noted. This phenomenographic enquiry was based on a region-specific sample of 10 families, which was appropriate for depth but inevitably restricted the range of parental conception that could be captured. Self-selection and awareness that the interviewer was linked to the dental service may have introduced social-desirability bias. Interviews were conducted in Swedish, with interpreter support where needed; subtle meanings may therefore have been attenuated during translation and transcription. Credibility was bolstered by the purposive recruitment of linguistically and culturally diverse participants, independent double-coding, member checking and an auditable analytic trail; still, transferability beyond similar high-risk settings must be inferred with caution.\u003c/p\u003e\u003cp\u003eRegarding implications and future research, the findings from this study have clear implications for both practice and policy. By demonstrating how culturally responsive, theory-based behavioural intervention can enhance parental agency and foster health-promoting routines beyond toothbrushing, this research supports the scale-up of health-promoter-led interventions within child dental-care services. The alignment with social cognitive theory and salutogenic principles suggests that behavioural counselling in dental contexts should not be narrowly confined to risk communication or compliance but instead framed within a broader relational and contextual understanding of families\u0026rsquo; lived realities. In clinical practice, these insights can inform training modules that equip health promoters and dental teams to work relationally, motivationally and with attention to intersectional determinants of health.\u003c/p\u003e\u003cp\u003eImportantly, health promoters should be viewed as just one component within an interprofessional team, where dental hygienists, dental assistants and dentists play a pivotal role in promotive and preventive care. Dental hygienists are uniquely positioned to integrate behavioural conversation into routine practice, bridging clinical prevention with person-centred communication. A collaborative approach in which health promoters, dental hygienists and other team members contribute complementary skills can maximise the impact of preventive and promotive strategies and ensure that interventions resonate with families\u0026rsquo; daily realities.\u003c/p\u003e\u003cp\u003e At the policy level, the findings argue for stronger structural integration between oral-health services and broader child health or family support systems. This includes revisiting commissioning models to ensure that preventive and promotive services are not only reimbursed adequately but also designed in ways that allow for flexible, tailored and culturally sensitive encounters. Moreover, applying a syndemic perspective may enable oral-health interventions to be strategically embedded within cross-sectoral public-health strategies targeting diet, equity and early child development. Given the disproportionate burden of dental caries among socioeconomically and culturally marginalised groups, this approach could increase both efficiency and equity in resource allocation.\u003c/p\u003e\u003cp\u003eFurther research is warranted to build on these findings. Interviews with clinical personnel involved in the delivery of such interventions could provide a more complete picture of implementation dynamics, role clarity and perceived enablers or barriers within everyday practice. A complementary retrospective epidemiological analysis of children\u0026rsquo;s dental records, comparing those exposed to the health-promoter intervention with controls, could help assess whether the reported behavioural shifts translate into measurable clinical outcomes over time. Such mixed-method triangulation would strengthen the evidence base and inform future guidelines for scalable, equity-oriented caries-prevention programmes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study contributes new insights into how parents perceived the value and delivery of a theory-based behavioural intervention delivered by health promoters. This intervention was perceived as non-judgemental, flexible and practically useful, supporting parental self-efficacy and encouraging broader family-level change.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCOREQ\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConsolidated Criteria for Reporting Qualitative Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eMI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMotivational interviewing\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eRPCT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRecommended Programme for Caries Treatment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSCT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSocial cognitive theory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSKaPa\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSwedish Quality Register for Caries and Periodontitis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSB:\u0026nbsp;\u003c/strong\u003eConceptualisation, data collection, analysis, drafting;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMM:\u0026nbsp;\u003c/strong\u003eMethodology, supervision, critical revision;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePL:\u0026nbsp;\u003c/strong\u003eSupervision, critical revision;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE-KB:\u0026nbsp;\u003c/strong\u003eMethodology, supervision, critical revision.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eWe are grateful to the families who shared their experiences, the Public Dental Service, the health promoters who assisted with recruitment and the project manager, Stina Bertling.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Swedish Ethical Review Authority (No. 2022-06428-01) and adhere to the Declaration of Helsinki both in regard of ethics approval and consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was funded by Health Promotion Research Funding (VGFOUREG-982910 and VGFOUREG-991628), Region Västra Götaland, Sweden.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eDe-identified interview transcripts are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDyar OJ, Haglund BJA, Melder C, Skillington T, Kristenson M, Sarkadi A. Rainbows over the world's public health: determinants of health models in the past, present, and future. Scand J Public Health. 2022;50:1047\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. Global oral health status report: towards universal health coverage for oral health by 2030. Geneva: WHO; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organisation. Bangkok declaration on oral health. Geneva: WHO; 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAndr\u0026eacute; Kramer AC, Petzold M, Hakeberg M, \u0026Ouml;stberg AL. Multiple socioeconomic factors and dental caries in Swedish children and adolescents. Caries Res. 2018;52:42\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlm A, Wendt LK, Koch G, Birkhed D, Nilsson M. Caries in adolescence \u0026ndash; influence from early childhood. Community Dent Oral Epidemiol. 2012;40:125\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwedish Quality Register. for Caries and Periodontitis (SKaPa). \u003cem\u003eSKaPa annual report\u003c/em\u003e. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWendt LK, Hallonsten AL, Koch G, Birkhed D. Analysis of caries-related factors in infants and toddlers living in Sweden. Acta Odontol Scand. 1996;54:131\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Board of Health and Welfare. \u003cem\u003eNational guidelines for dental care\u003c/em\u003e. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBandura A. Health promotion by social cognitive means. Health Educ Behav. 2004;31:143\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiller WR, Rollnick S. Meeting in the middle: motivational interviewing and self-determination theory. Int J Behav Nutr Phys Act. 2012;9:25.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCastilho AR, Mialhe FL, Barbosa TDE, Puppin-Rontani RM. Influence of family environment on children's oral health: a systematic review. J Pediatr (Rio J). 2013;89:116\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBj\u0026ouml;rns S, Bergstr\u0026ouml;m E-K, Lingstr\u0026ouml;m P, Wretlind K, Makenzius M. Treatment and prevention of dental caries in children via a theory-based behavioural intervention led by health promoters: a health economic evaluation. Accepted, not yet published Caries Research.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSj\u0026ouml;str\u0026ouml;m B, Dahlgren LO. Applying phenomenography in nursing research. J Adv Nurs. 2002;40:339\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWenestam C-G. \u003cem\u003eQualitative research methods in the service of health\u003c/em\u003e. Studentlitteratur; 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlexandersson M. \u003cem\u003eDen fenomenografiska forskningsansatsens fokus\u003c/em\u003e [The phenomenographic research approach in focus]. Lund: Studentlitteratur; 1994.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNewton JT, Asimakopoulou K. Stigma and parental help-seeking in child oral health. Community Dent Health. 2015;32:150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlvenfors A, Lingstr\u0026ouml;m P, Oskarsson E, Milton C, Bernson J. Finding the person behind caries disease: the dental caregivers' experiences of empowering patients to implement beneficial behavioral changes. J Dent. 2024;145:104990.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMackenzie C, Stoljar N. Relational autonomy: feminist perspectives on autonomy, agency, and the social self. New York: Oxford University Press; 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAntonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996;11:11\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHankivsky O. Women\u0026rsquo;s health, men\u0026rsquo;s health, and gender and health: implications of intersectionality. Soc Sci Med. 2012;74(11):1712\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReda M, Sen A, \u0026Aring;str\u0026oslash;m AN, Mustafa M. Effects of an intervention on immigrant parents' knowledge and attitudes toward their children's oral health: a cluster randomised trial in Norway. Eur J Oral Sci. 2025;133:e13037.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheiham A, Watt RG. The common risk factor approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol. 2000;28(6):399\u0026ndash;406. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1034/j.1600-0528.2000.028006399.x\u003c/span\u003e\u003cspan address=\"10.1034/j.1600-0528.2000.028006399.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSinger M. Syndemics and the biosocial conception of health. Lancet. 2017;389(10072):941\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Dental caries, Empowerment, Family health, Health promotion, Public Health Dentistry, Self-efficacy, Qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8221127/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8221127/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eTo describe the different ways in which parents perceive a theory-based behavioural intervention to prevent dental caries in their preschool-aged children.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA qualitative interview study was carried out using phenomenographic analysis in 10 public dental clinics in Region V\u0026auml;stra G\u0026ouml;taland, Sweden (March 2023\u0026ndash;July 2024). Ten parents (eight women, two men) of 3\u0026ndash;6-year-old children at elevated caries risk completed two or more counselling sessions with university-trained health promoters. Interviews (30\u0026ndash;60 min) were audio-recorded, transcribed verbatim and analysed inductively to capture variation in parental perceptions. Flexible delivery (digital/in-clinic) and interpreter support were made available.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThree themes were identified: (1) \u003cem\u003ean offer lined with ambivalence\u003c/em\u003e, (2) \u003cem\u003eempowered alliance through personalised support\u003c/em\u003e and (3) \u003cem\u003eactive choices through parental agency\u003c/em\u003e. These themes coalesced into the overarching theme \u0026lsquo;from ambivalence to agency: embracing health-promoting behaviour\u0026rsquo;.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eParents conceived the health-promoter-led, theory-based behavioural intervention as non-judgemental, culturally responsive and practically useful. By fostering relational safety and providing actionable tools, the intervention appeared to strengthen parental self-efficacy and catalyse family-level behavioural change. This shift, while modest in scale, may represent a necessary step towards equitable and sustainable oral-health promotion.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"From ambivalence to agency: parents’ conceptions of a theory-based behavioural intervention to prevent dental caries in their preschool children – a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 12:48:48","doi":"10.21203/rs.3.rs-8221127/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-09T06:38:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-06T02:18:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-31T10:55:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"655556245259604458637482622668436797","date":"2025-12-15T05:33:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-14T04:07:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182780208956621138392536156516750643796","date":"2025-12-14T01:05:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312141950478723599186126668936973455145","date":"2025-12-13T01:11:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-04T09:35:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-04T09:31:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-03T14:24:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-03T10:46:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-12-03T10:35:33+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":"4ae990cb-7a9c-44ba-be88-eb59ae3b31df","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:04:54+00:00","versionOfRecord":{"articleIdentity":"rs-8221127","link":"https://doi.org/10.1186/s12903-026-07864-z","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2026-02-11 15:58:06","publishedOnDateReadable":"February 11th, 2026"},"versionCreatedAt":"2025-12-08 12:48:48","video":"","vorDoi":"10.1186/s12903-026-07864-z","vorDoiUrl":"https://doi.org/10.1186/s12903-026-07864-z","workflowStages":[]},"version":"v1","identity":"rs-8221127","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8221127","identity":"rs-8221127","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}