Health is based on an interplay of structural and individual-level determinants, including socioeconomic status, healthcare provision and daily behaviours¹. 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 factors⁶.

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 care⁸. 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 theory⁹ and informed by the principles of motivational interviewing¹⁰, 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 RPCT¹². 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.

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.

The analysis took an inductive phenomenographic approach^13,14, based on Alexandersson’s¹⁵ 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.

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.

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.

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)

The third category pertains to the parents’ conception of the invitation to participate in the intervention. One parent stated,

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’.

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 behaviours¹⁶. However, the encounters with the health promoters were perceived as non-judgemental, personalised and flexible – qualities associated with successful motivational interviewing¹⁰. 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 contexts⁹. 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 relationships¹⁸. 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 intentions⁹.

An intersectional perspective based on Antonovsky’s sense of coherence¹⁹ 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 case²⁰. 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 backgrounds²¹. 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 coherence¹⁹.

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 approach²². 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 allocation²³. 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.

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.