Parental Social Support and Preschoolers' Oral Health Behaviours: The Mediating Role of Parental Stress and Self-Efficacy

Abstract

Introduction and aims

Oral health behaviours (OHBs) of preschoolers are crucial for preventing early childhood caries (ECC); however, the relationship between parental/caregivers' factors and the OHBs of Chinese preschoolers has not been clearly defined. This study aimed to explore the relationship between parental/caregivers' social support and the OHBs of Chinese preschoolers, and whether parental stress and self-efficacy mediate this relationship serially.

Methods

This cross-sectional study was conducted in Minhang District, Shanghai, from December 2023 to March 2024, among 2393 participants recruited from parents or caregivers of preschoolers from 46 kindergartens. All data were collected using a self-reported structured questionnaire, including questions about sociodemographic characteristics, children's OHBs, self-efficacy, perceived social support (MSPSS), and parental stress (PSS-18). Ordinary least-squares regression and the bootstrap method were used to test the significance of the serial multiple mediation model.

Results

The multiple mediations of parental stress and self-efficacy were found significant in the relationship of children's OHBs with all three dimensions of parental/caregivers' social support. When considered as individual mediators, only self-efficacy showed significant mediations across all three dimensions, while the mediation of parental stress alone was not significant.

Conclusion

This study revealed a pathway of association between parental/caregivers' social support and their children's OHBs, in which parental stress and self-efficacy had indirect effects. These insights provide a theoretical basis for understanding the mechanism of oral health promotion interventions to improve children's OHBs and help develop effective early childhood caries (ECC) prevention strategies and interventions at family and community levels.

Clinical Relevance

Enhancing parental social support and self-efficacy while reducing stress may improve preschoolers' oral health behaviours, offering a targeted family-cantered strategy for early childhood caries prevention in clinical and community settings.

Introduction

Early childhood caries (ECC) is the most common chronic disease among preschoolers,¹ with a prevalence of 52% in Asia, significantly higher than in the Americas (48%) and Europe (43%). Furthermore, the prevalence of dental caries among 5-year-old children in China is even higher, reaching over 70%.^2,3 Children with ECC are more likely to experience additional caries throughout childhood.⁴ The consequences of ECC extend beyond oral health, as severely advanced ECC can impair children's ability to chew and eat, delaying their growth and development, including height and weight gain.⁵ ECC can lead to increased sleep disturbances, loss of school time, and days of restricted activity,⁶ and can reduce a child's ability to learn.⁷

Evidence shows that adopting appropriate oral health/hygiene behaviours (OHBs), such as brushing teeth correctly and regularly, using dental floss, rinsing the mouth after meals or after consuming sweets, fluoridated toothpaste use and undergoing regular oral examinations, can help prevent early childhood caries and promote children's oral and general health.8, 9, 10 Additionally, broader factors, including dietary habits and access to oral healthcare, play crucial roles in determining their oral hygiene practices and the prevalence of non-communicable oral diseases.^11,12 However, according to a survey from China, less than 20% of preschoolers have had an oral examination over the period of 2015 to 2016,¹³ and only 50.9% of children brush their teeth twice a day, with just 9.5% using dental floss.¹⁴ The OHBs of preschoolers urgently need improvement.

Preschoolers often struggle to form and maintain their OHBs due to their limited awareness and capability to independently care for their oral health.¹⁵ At this stage, parents and caregivers play a critical role in developing and maintaining these behaviours. Recent studies have focused on parental and caregiver-level social cognitive factors related to parental/caregivers' OHBs for their children,¹⁶ including knowledge, health beliefs, attitudes, stress, self-efficacy, social network strength, and cultural adaptation status.¹⁷

It is crucial to understand on parents' psychosocial, social and behavioural cognition mechanisms during the parenting process, especially in the management of children's health. Commonly used theories in this field cover attachment theory,^18,19 social learning theory,20, 21, 22, 23 family systems theory,^24,25 and stress and coping theory, etc.26, 27, 28, 29 Various stress issues faced by Chinese parents, including parental stress, affect their management of children's behaviour by their different coping processes.^30,31 Stress and coping theory, as a psychological framework of stress, regards coping processes as moderators of critical stressful person-environment relationships and their immediate and long-term outcomes.²⁷ According to this theory, high levels of perceived parenting-related stress and a lack of effective coping skills can act as barriers to achieving the challenges of the parenting process, thus affecting the health outcomes of their children.^32,33 Positive coping styles, such as seeking support, are often associated with healthier parenting behaviours. Specifically, social support may promote better children's health behaviours by affecting parental/caregivers' perceived stress and regulating parenting behaviors.^34,35 and help them better cope with parenting challenges,^36,37 including managing children's oral health. Meanwhile, parental self-efficacy in guiding and supervising children's OHBs, is a cognitive mechanism for generating positive coping behaviour as well as a key psychosocial gain reflecting how parents/caregivers adapt to stress.^38,39 By increasing self-efficacy, specifically parents/caregivers’ confidence in performing difficult or resource-demanding behaviours (eg, a parent supervising a child's daily tooth brushing),³⁸ they can improve ability to actively manage their children's OHBs.¹⁶ Parents/caregivers who receive more social support than their peers have higher parenting self-efficacy and are better able to cope with various child-rearing situations, which has a positive impact on children's health behaviours, including oral hygiene.^40,41

Most existing literature suggests that there is an interrelationship among stress, social support, and self-efficacy,42, 43, 44 although the exact relationship among them is inconclusive.45, 46, 47 Yet, in the context of oral health in preschoolers, there has few explorations of the mechanisms by which parent/caregiver parenting-related stress and coping ways affect children's OHBs. Therefore, our study integrated a theoretical model based on the pathways proposed by Hong and Liu (2021),⁴⁵ and Stephenson et al (2023),⁴⁷ which posits that parental stress and self-efficacy may serially mediate the effects of social support on OHBs (Figure 1). Specifically, this study proposes the following three hypotheses.

Fig. 1.

Theoretical pathways linking parental social support to children's oral health behaviours: a sequential mediation model. Theoretical pathways include: (1) direct effects of parental social support on children's oral health behaviours (Path a); (2) indirect effects mediated sequentially by parental stress (Path b₁); (3) indirect effects mediated sequentially by self-efficacy (Path b₂); (4) indirect effects mediated sequentially by parental stress and self-efficacy (Path c). Arrow directions reflect hypothesized causal priority.

H1

Parental stress mediates the relationship between parental/caregivers' social support and children's OHBs.

H2

Self-efficacy mediates the relationship between parental/caregivers' social support and children's OHBs.

H3

Parental stress and self-efficacy play serial multiple mediating roles in the relationship between parental/caregivers' social support and children's OHBs.

Through a deeper understanding of these relationships, this study will provide a theoretical basis for developing children's lifelong oral hygiene behaviours along with effective ECC prevention strategies and provide recommendations for interventions at the family and community levels.

Methods

Setting and participants

All participants were parents or caregivers of preschoolers recruited from 46 kindergartens in Minhang District, Shanghai. Currently, there are 180 kindergartens with 54,233 children aged 3 to 6 years enrolled in the Minhang District of Shanghai. Before recruiting subjects, we estimated the sample size required for the mediation effect analysis. The empirical efficacy tables indicate that the sample size required for 0.8 power in the bias-corrected bootstrap test of the mediation is largest when both effects (mediator regressed on main predictor and outcome regressed on mediator) are deemed to be the smallest.⁴⁸ Also, as model complexity increases, the sample size required for accurate and stable estimation is expected to increase. To ensure that the sample size required to satisfy mediation is met, we assumed that both effects are minimal and chose the maximum sample size of 1090 in the table as the lower bound for this study.⁴⁹ If measurement error exists, a larger sample will be required.

Cluster sampling was used in this study, and recruitment invitations were sent to parents/caregivers of 46 kindergartens in Minhang District, Shanghai. A web-based survey questionnaire was created using the online survey platform Questionnaire Star (https://www.wjx.cn/). On December 4, 2023, the questionnaire was posted in each kindergarten's WeChat group via WeChat, a popular social media platform in China. Kindergarten teachers forwarded the link to the questionnaire to parents/caregivers in their respective class WeChat groups with a brief description of the purpose of the study. Parents/caregivers then completed the questionnaire online. By March 7, 2024, a total of 3196 questionnaires were received. To ensure the quality of responses, three quality control questions were included, and only questionnaires that correctly answered these three questions were considered valid. Finally, after screening, 2393 valid questionnaires were obtained. The questionnaire was designed to allow submission only after answering all the questions, and only one submission was allowed per account.

An electronic version of the informed consent document was provided to all participants before the start of the survey. The document described the purpose and significance of the study and informed participants that they would be providing data for scientific research, assuring them of the confidentiality and anonymity of all data, and emphasizing that the information would be used for the study only. Parents/caregivers had the autonomy to decide whether or not to participate in the survey. Consent was obtained from the participants for their answers to the questionnaire. The study was approved by the Ethics Committee of Minhang District Central Hospital (K2024-062). All methods were performed in line with the relevant guidelines and regulations.

Measurement

All data were collected using a self-reported structured questionnaire, which included questions about sociodemographic characteristics (child's age, sex, grade, parent's age, sex, education level), family status (number of children in the household, family structure.), parental/caregivers' perceived social support, parental stress, self-efficacy, and oral health behaviours (OHBs) for their child.

Children's oral health behaviour (Children's OHB)

Referring to the 4th National Oral Health Epidemiology Questionnaire⁵⁰ and relevant literature, we developed a questionnaire to measure the oral health behaviours (OHBs) of preschoolers. The questionnaire consists of 9 items covering various aspects such as brushing activity, rinsing habits, flossing, and eating habits. Examples of items include: “How many times does your child brush his/her teeth every day?”, “How long does your child brush his/her teeth each time?”, and “How often does your child rinse his/her mouth after meals?”. These items were discussed within the research team, which included experts in paediatric dentistry, public health, and behavioural science, and selected based on previous literature51, 52, 53 and their relevance to preschool oral health, cultural adaptability, and their ability to reflect daily behaviours. Each item was assigned a score from 0 to 1 based on the responses, and the final score is calculated by summing the scores of the 9 questions, with a possible range of 0 to 9 points. Higher scores reflect better levels of OHBs among preschoolers.

Perceived social support (PSS)

Perceived social support (PSS) was measured using the Multidimensional Scale of Perceived Social Support (MSPSS), a self-report questionnaire developed by Zimet et al, which has a high internal consistency of 0.88.⁵⁴ The 12-item MSPSS assesses participants' perceived social support from three informal sources: Family (PSS-Fa), Friends (PSS-Fr), and Significant Others (PSS-O). Participants rated each item on a 7-point Likert scale ranging from 1 (“strongly disagree”) to 7 (“strongly agree”). Items included statements such as, “I get the emotional help and support I need from my family.” Scores were used as a continuous variable, and the mean scores (ranging from 1 to 7 points) were calculated to assess the levels of perceived social support, with higher scores indicating greater total perceived social support across all three sources.

Parental self-efficacy (for children's OHB engagement)

Parental self-efficacy in this study refers to parents'/caregivers’ confidence in their ability to help their children engage in oral health behaviours (OHBs). Following previous studies,^17,41,55,56 a self-developed questionnaire was used to measure parental/caregivers' self-efficacy in this area, which consisting of 6 items. The research team mentioned above evaluated these items and their applicability to parents' daily management of their children's oral health. Participants rated their confidence on a 5-point Likert scale ranging from 1 (“not at all confident”) to 5 (“very confident”) Items included statements such as: “I can help/guide my child(ren) to brush his/her (their) teeth in the right way,” “I can help/supervise my child(ren) to rinse his/her (their) mouths after every meal,” and “I can insist on taking my child(ren) for regular dental checkups.” The mean scores (ranging from 1 to 5 points) were calculated and higher scores indicated higher parental self-efficacy in helping their children engage in OHBs.

Parental stress

Parental stress was measured using the Parental Stress Scale (PSS-18), a self-report questionnaire developed by Berry and Jones (1995) that has a high internal consistency of 0.83.⁵⁷ The PSS-18 consists of 18 items and is easy to administer, assessing individuals' perceptions of parental stress, defined as subjective feelings of strain, difficulty, and dissatisfaction as a parent, rather than specific stressful events and behaviours. Participants rated the items on a 5-point Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). A composite score was obtained by summing the items after reversing the scores of appropriate items, with higher scores indicating higher levels of parental stress.

There is no official Chinese version of the PSS-18 for use with Chinese parents on the mainland. Therefore, after obtaining permission to translate and use the questionnaire, the research team followed these steps to translate it:

• 1.Two native Chinese-speaking experts independently translated the original PSS-18 into simplified Chinese. A third native Chinese-speaking expert reconciled their translations to create a hybrid version.
• 2.The hybrid Chinese version was back-translated into English by a native English-speaking expert who was not familiar with the original English version of the questionnaire.
• 3.Three more experts (native Chinese speakers) reviewed the translated and back-translated versions to select the most appropriate translation for each item or provide alternate translations if necessary. One item, “If I had to do it over again, I might decide not to have children,” was deemed unsuitable for the Chinese context and was deleted.
• 4.Consequently, the translated version showed acceptable model-fit (χ2 (112) = 1647.454, P < .001; RMSEA = 0.076 [90% CI 0.072, 0.079], CFI = 0.930/TLI = 0.915, SRMR = 0.053).

Statistical methods

Descriptive analyses of background characteristics, parental/caregiver’s perceived level of social support, parental stress, self-efficacy, and children's OHBs were first conducted. Numbers and percentages were calculated for categorical variables. Baseline characteristics of the child's OHBs were compared using the F test for multi-categorical variables and the T test for dichotomous variables. Pearson correlation analyses were performed to assess correlations among the six variables (PSS-Fr, PSS-Fa, PSS-O, parental stress, self-efficacy, and children's OHBs). Multiple linear regression analyses were then used to examine the effect of the independent variables on children's OHBs. Variables that were significant in the univariate analyses were included as covariates in the multiple regression analyses. The PROCESS macro model 6 provided by Hayes was used to test the significance of the mediator model in this study.⁵⁸ This method is based on ordinary least squares regression and bootstrapping. In this study, 5000 bootstrap bias-corrected 95% confidence intervals (BC CI) were used to test the mediation analyses of the Serial-multiple Mediation Model 6, and mediation was considered significant if BC CI did not contain zero. Non-standardized Beta coefficients were calculated in this study to reduce Type 1 errors due to distribution. All effects are presented as unstandardized regression coefficients (B), with bootstrapped 95% confidence intervals (BC CI). The proportion of mediated effect is expressed as the percentage of total effect. Moreover, variables that were significant in the univariate analysis were treated as covariates in this mediation analysis.

All statistical analyses were performed using R version 4.3.3 and SPSS version 25.0.

Results

The data in this study were obtained from subjects' self-reports, which may lead to significant biases. To ensure the scientific accuracy of the findings, the Harman one-way test was conducted to test for possible common methodological bias before data analysis.⁵⁹ All items of the questionnaire were integrated for exploratory factor analysis. The results showed that there were 12 factors with an eigenvalue greater than 1, and the first common factor explained 22.94%, which is much less than 40%. Therefore, there is no significant common methodological bias in this study.⁶⁰

Table 1 demonstrates the characteristics of the distribution of sociodemographic information and the OHBs of the participants' children. A total of 2393 parents of preschoolers were included in this study, most of whom (59.76%) were studying in the senior class. The vast majority (99.71%) of the respondents were parents of their children, with more than half being female caregivers, and most of them (76.14%) had received an undergraduate education or above. More than half of these participants' families were raising only one child (56.08%); 48.02% were nuclear families. There were significant differences in the level of children's OHBs depending on children's grade (F = 19.34, P < .001), number of children in the family (F = 4.81, P = .008), and family structure (F = 2.95, P = .019).

Table 1.

Average score of children's oral health behaviour among various basic characteristics (n = 2393).

Characteristics	N (%) or mean (SD)	Mean (SD) of children's oral health behaviour	t/F	P
Children's age (years)	5.44 (1.37)
grade			19.34	<.001
Toddler class	19 (0.79)	3.58 (0.97)
Primary class	287 (11.99)	4.10 (0.94)
Junior class	657 (27.46)	4.34 (1.03)
Senior class	1430 (59.76)	4.47 (0.96)
Children's sex			−1.87	.061
Male	1271 (53.11)	4.35 (0.98)
Female	1122 (46.89)	4.42 (1.00)
Parents'age (years)	36.4 (4.39)
parents' sex			−1.85	.064
Male	747 (31.22)	4.34 (1.05)
Female	1646 (68.78)	4.40 (0.96)
Parents' education			0.30	.767
College or below	571 (23.86)	4.44 (0.95)
Undergraduate or above	1822 (76.14)	4.36 (1.00)
Parents' role			0.07	.941
Parents	2386 (99.71)	4.38 (0.99)
Grandparents or Others	7 (0.29)	4.24 (0.66)
Number of children in the family			4.81	.008
1	1342 (56.08)	4.43 (1.00)
2	997 (41.66)	4.32 (0.97)
≥3	54 (2.26)	4.38 (0.99)
Family structure			2.95	.019
Nuclear family	1149 (48.02)	4.46 (1.03)
Multigenerational family	1180 (49.31)	4.31 (0.94)
Single-parent family	23 (0.96)	4.05 (1.15)
Skipped-generation/grandparent family	39 (1.63)	4.32 (1.09)
Other types	2 (0.08)	3.86 (1.11)

Table 2 shows the Cronbach alpha coefficients, means, and standard deviations of the variables and the relationships between them. The Cronbach alpha coefficients for several variables of the study ranged from 0.62 to 0.94. Children's OHBs, parental stress, self-efficacy, and all three dimensions of PSS were significantly correlated. The correlation coefficients ranged from -0.42 to 0.82.

Table 2.

Descriptive statistics of various variables and correlations between the variables (n = 2393).

	Cronbach alpha	Mean (SD)	1	2	3	4	5	6
1 PSS-Fa	0.94	5.85 (1.16)	1
2 PSS-Fr	0.94	5.45 (1.31)	.70⁎⁎	1
3 PSS-O	0.93	5.41 (1.32)	.71⁎⁎	.82⁎⁎	1
4 Self-efficacy	0.92	3.93 (0.64)	.37⁎⁎	.33⁎⁎	.32⁎⁎	1
5 Parental stress	0.85	4.56 (0.90)	-.42⁎⁎	-.34⁎⁎	-.35⁎⁎	-.36⁎⁎	1
6 Children's oral health behaviour	0.62	4.38 (0.99)	.16⁎⁎	.14⁎⁎	.14⁎⁎	.37⁎⁎	-.17⁎⁎	1

PSS-Fa, perceived social support from family; PSS-Fr, perceived social support from friends; PSS-O, perceived social support from significant others.

*P < .05.

^⁎⁎P < .01.

Taking each of the three dimensions of the PSS as independent variables respectively, serial multiple mediation analyses of parental stress and self-efficacy in the relationship between these independent variables and children's OHBs based on ordinary least squares regression analyses and bootstrapping were analysed as follows.

PSS-Fa was taken as the independent variable. Results regarding the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-Fa and children's OHBs, based on ordinary least-squares regression analysis, are shown in Figure 2. The results showed that the pathway through both mediators was significant. On the other hand, the pathway through self-efficacy alone was also significant, while the pathway through parental stress alone was not significant.

Fig. 2.

Serial multiple mediations of parental stress and Self-efficacy in the relationship between the subscale of perceived social support (PSS-Fa) and children's oral health behaviour with non-standardized beta values. Controls: Children's age; Grade; Number of Children in the family; Family Structure; C is the total effect of PSS-Fa (perceived social support from family) on children's oral health behaviour. C’ is the direct effect of PSS-Fa on children's oral health behaviour, represented by a dotted line. The other values in the figure are regression coefficients in the model. *P < .05, **P < .01, ***P < .001.

Results regarding the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-Fa and children's OHBs, based on the bootstrap method, are presented in Table 3. The total indirect effect (the difference between total and direct effects/c–c') of PSS-Fa through parental stress and self-efficacy on children's OHBs was statistically significant (B = 0.1246; 95% BC CI [0.1034, 0.1467]). When considering mediating variables individually and together, the single mediation of self-efficacy (B= 0.0827; 95% BC CI [0.0677, 0.0992]) and the serial-multiple mediation of parental stress and self-efficacy (B = 0.0317; 95% BC CI [0.0252, 0.0395]) were found to be statistically significant, whereas the single mediation of parental stress (B = 0.0101; 95% BC CI [-0.0053, 0.0255]) was found to be insignificant. Overall, parental stress and self-efficacy mediated 83.40% of the pathway from PSS-Fa to children's OHBs.

Table 3.

The indirect effects of 3 dimensions of perceived social support (PSS) (X) on children's oral health behaviour (Y) through parental stress (M1) and self-efficacy (M2) with non-standardized values.

Model pathways		Mediating effect value	SE	Bootstrapping 95% BC CI		Proportion mediated
				LL	UL
X1→Y	Total indirect effect	0.1246*	0.0112	0.1034	0.1467	83.40%
	Path1	0.0101	0.0079	−0.0053	0.0255	6.76%
	Path2	0.0827*	0.0081	0.0677	0.0992	55.35%
	Path3	0.0317*	0.0037	0.0252	0.0395	21.22%
X2→Y	Total indirect effect	0.0959*	0.0088	0.0788	0.1134	81.34%
	Path1	0.0077	0.0055	−0.0029	0.0184	6.53%
	Path2	0.0623*	0.0068	0.0494	0.0765	52.84%
	Path3	0.0259*	0.0029	0.0206	0.0321	21.97%
X3→Y	Total indirect effect	0.0954*	0.0087	0.0791	0.1129	82.10%
	Path1	0.0078	0.0055	−0.0029	0.0186	6.71%
	Path2	0.0615*	0.0067	0.0491	0.0751	52.93%
	Path3	0.0260*	0.0030	0.0206	0.0323	22.38%

Number of bootstrap samples = 5000. X1: PSS-Fa (perceived social support from family); X2: PSS-Fr (perceived social support from friends) X3: PSS-O (perceived social support from significant others). Path1: X → M1→Y; Path 2: X→ M2→Y; Path 3: X → M1 → M2→Y; BC CI, bias-corrected confidence interval.

^⁎BC CI did not contain zero, the mediation was considered significant, P < .05.

**The percentage of the total effect that is explained by indirect (mediation) effect.

PSS-Fr was taken as the independent variable. Results about the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-Fr and children's OHBs, based on ordinary least-squares regression analysis, are presented in Figure 3. The results indicated that the pathway through both mediators was significant. On the other hand, the pathway through self-efficacy alone was also significant, while the path through parental stress alone was not significant.

Fig. 3.

Serial multiple mediations of parental stress and Self-efficacy in the relationship between the subscale of perceived social support (PSS-Fr) and children's oral health behaviour with non-standardized beta values. Controls: Children's age; Grade; Number of Children in the family; Family Structure; C is the total effect of PSS-Fr (perceived social support from friends) on children's oral health behaviour. C’ is the direct effect of PSS-Fr on children's oral health behaviour, represented by a dotted line. The other values in the figure are regression coefficients in the model. *P < .05, **P < .01, ***P < .001.

Results regarding the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-Fr and children's OHBs, based on the bootstrap method, are presented in Table 3. The total indirect effect (the difference between total and direct effects/c–c') of PSS-Fr through parental stress and self-efficacy on children's OHBs was statistically significant (B = 0.0959; 95% BC CI [0.0788, 0.1134]). When considering the mediating variables separately and together, the single mediation of self-efficacy (B = 0.0623; 95% BC CI [0.0494, 0.0765]) and the serial-multiple mediation of parental stress and self-efficacy (B = 0.0259; 95% BC CI [0.0206, 0.0321]) were found statistically significant, whereas the single mediation of parental stress (B = 0.0077; 95% BC CI [-0.0029, 0.0184]) was found to be insignificant. Overall, parental stress and self-efficacy mediated 81.34% of the pathway from PSS-Fr to children's OHBs.

PSS-O was taken as the independent variable. Results regarding the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-O and children's OHBs, based on ordinary least-squares regression analysis, are presented in Figure 4. The results indicated that the pathway through both mediators was significant. On the other hand, the pathway through self-efficacy alone was also significant, while the pathway through parental stress alone was not significant.

Fig. 4.

Serial multiple mediations of parental stress and Self-efficacy in the relationship between the subscale of perceived social support (PSS-O) and children's oral health behaviour with non-standardized beta values. Controls: children's age; Grade; Number of children in the family; Family Structure; C is the total effect of PSS-O (perceived social support from significant others) on children's oral health behaviour. C’ is the direct effect of PSS-O on children's oral health behaviour, represented by a dotted line. The other values in the figure are regression coefficients in the model. *P < .05, **P < .01, ***P < .001.

Results regarding the serial-multiple mediation of parental stress and self-efficacy in the relationship between PSS-O and children's OHBs, based on the bootstrap method, are presented in Table 3. The total indirect effect (the difference between total and direct effects/c–c') of PSS-O through parental stress and self-efficacy on children's OHBs was statistically significant (B = 0.0954; 95% BC CI [0.0791, 0.1129]). When considering the mediating variables singly and together, the single mediation of self-efficacy (B = 0.0615; 95% BC CI [0.0491, 0.0751]) and the serial-multiple mediation of parental stress and self-efficacy (B = 0.0260; 95% BC CI [0.0206, 0.0323]) were found statistically significant, whereas the single mediation of parental stress (B = 0.0078; 95% BC CI [-0.0029, 0.0186]) was found to be insignificant. Overall, parental stress and self-efficacy mediated 82.10% of the pathway from PSS-O to children's OHBs.

Discussion

This study aimed to examine the indirect effects of parental/caregivers’ social support on their children's oral health behaviours (OHBs). The results indicated that self-efficacy mediated the relationship between parental/caregivers' social support and their children's OHBs, but not parental stress. Additionally, parental stress and self-efficacy played serial multiple mediating roles in the relationship between parents' social support and their children's OHBs. Our findings partially supported the proposed H2 and H3 regarding the relationship between parental social support and children's oral health behaviours, rather than H1.

Our research found significant differences in children's OHB scores based on their grades, the number of children in the family, and family structure. The results suggest that as children grow older, their OHBs tend to improve, consistent with prior research.⁶¹ The study also implies that having fewer children might allow parents/caregivers to focus more on children's oral health,⁶² and children living in more stable and supportive family structures tend to have better OHBs.^33,63 Since fluoride application has been widely used among preschool children in Shanghai which is provided free of charge by dental disease prevention and treatment institutions, this study did not investigate this factor.

We found a significant positive correlation between parental social support and children's OHBs, consistent with previous studies.^64,65 This may be because parents/caregivers with more social support can obtain more information about children's oral health from their family members or friends and are more focused on improving OHBs in their young children.⁶⁴ Additionally, parents/caregivers who feel more social support tend to have better psychological well-being and parent-child relationships, contributing to early childhood behavioural development.

Our study revealed that parental/caregivers' social support indirectly influenced children's OHBs, fully mediated through parental stress and self-efficacy. Parents/caregivers who perceived more social support had lower parental stress, but this was not directly associated with promoting good OHBs in their children. One possible reason for this is that the high level of parental stress perceived by parents/caregivers may be more likely to affect psychological states rather than their actual oral parenting practices with their children.

The results suggest that parental social support influences young children's OHBs through the independent mediating role of self-efficacy. Higher levels of social support are associated with increased self-efficacy, thereby aiding preschoolers' OHB development. This is consistent with previous studies that social support contributes to self-efficacy and promotes beliefs about one's ability to make changes, including parental/caregivers' beliefs about changing children's behavior.^65,66 Parents/caregivers with more social support have richer supportive resources to gain more knowledge and practical experience of children's dentistry from their surroundings, thus increasing their confidence in raising their children's healthy behaviors.^45,67 In parallel, parents/caregivers with high self-efficacy not only create a favourable psychological environment for children's behavioural development through positive emotions and sensitive responses⁴⁷ but also tend to engage in effective parenting activities that provide good role models for preschoolers.⁴⁵

Most notably, this study confirmed that higher levels of parent/caregiver social support will promote OHBs in preschoolers by reducing parental stress and increasing self-efficacy. Previous research has shown that higher levels of stress during parenting are likely to decrease the parenting confidence and self-efficacy of parents/caregivers.⁴² Parents/caregivers under higher levels of parental stress are more likely to have negative attitudes toward their children, which may cause more problems in fostering children's oral behaviours, further exacerbating their negative attitudes, lowering their confidence, and forming lower self-efficacy. Conversely, parents/caregivers under lower levels of parental stress with greater confidence in their parenting are more likely to have positive attitudes toward their children, creating a conducive environment to improve children's behavior.³⁷ Importantly, external social support, such as family resources, can reduce parental stress and improve self-efficacy.⁶⁸ Parents with more social support are more likely to seek help when facing difficulties, receive material assistance (eg, to help them with their parenting duties), and cope with stress positively, leading to more active parenting strategies that support preschoolers' development of good psychological and behavioural abilities.

Furthermore, in our study, family support exhibited a significantly greater indirect effect through the mediating pathway of parental stress and self-efficacy (and thus promoting children's OHBs) than the other two mediating pathways (friend support and significant others support). This suggests that parental stress and self-efficacy may have a greater mediating role in the family system for cultivating healthy behaviours in children. In many cultures, including China, the family is viewed as the most critical support system, and parents/caregivers have higher expectations and reliance on family support.⁶⁹ Family support is enduring and stable relative to support from a wider range of social networks such as friends and significant others.⁵⁴ Family members are usually the closest ones who can provide deeper emotional support and practical help, such as taking care of the child's daily affairs and providing parenting advice. It helps parents/caregivers maintain confidence and positive attitudes when facing parenting challenges, thus managing children's OHBs more effectively.

In this study, we developed several measurement tools. The self-developed parental self-efficacy questionnaire demonstrated excellent internal consistency comparable to established scales in other cultural contexts,^41,55,67 while the internal consistency of the children's OHB questionnaire was moderate. Since the impact of only single behaviour requires long-term observation and evidence-based results, both of their item weights determination needs further research. Although the results of this study showed a certain correlation, the external validity of the questionaries used in the study still needs to be confirmed by more observational studies and further experimental research. On a further note, the validation processes for both questionnaires must be acknowledged as critical limitations. The lack of validation could significantly impact the results, as it may lead to measurement errors, unreliable or inconsistent findings, and misinterpretation of the data. Without proper validation, the scores may not accurately reflect the constructs being measured, potentially skewing the conclusions and undermining the study's credibility. Additionally, the results may not be generalizable across different populations or time points, making meaningful comparisons with validated studies impossible. This could ultimately weaken the overall impact and reliability of the research. In addition, compared to Structural Equation Modeling (SEM) which focus on overall model fit, this study with a relatively small number of latent variables employed Bootstrap-based mediation analysis to provide more precise estimates of specific indirect effects in sequential mediation paths, allowing for a more direct examination of hypotheses.^58,70

Our study has several other limitations. First, we collected data through an online survey, which may have affected the quality of the data, even though we used quality control questions to ensure the validity of the questionnaire. Second, data were collected through parent/caregiver self-reports. Although Harman's one-way test was conducted and verified that there was no significant common method bias in this study, it is plausible that the correlations between variables may have been exaggerated. As the most prevalent chronic disease among preschool children, ECC impacts not only oral health but also overall health status, making it crucial to understand its clinical variables for effective prevention and intervention. However, it is also difficult to obtain accurate data on children's dental caries through subjective reports from parents despite the importance of this clinical variable. Third, although the findings provide the mediating mechanism which aligns with existing theoretical framework,^31,71,72 the nature of cross-sectional study limits our ability to establish true causal relationships. Cross-sectional mediation analyses can substantially over or underestimate longitudinal effects, as they cannot capture the temporal sequence necessary for assessing a cause-effect relationship.⁷³ Longitudinal or experimental studies will be needed in the future to more accurately investigate these variables. Finally, the participants in this study were all from Shanghai, one of the most developed cities in China, which may jeopardize the representativeness of the study sample as it does not represent the overall situation of Chinese parents. Given the accessibility of the study, only a limited set of variables was collected, and cluster sampling was employed. However, this hierarchical structure was not accounted for in our statistical model, which may impact the validity of the findings. In future research, we plan to adopt more appropriate methods to enhance the accuracy of the results, and further studies in other regions are needed to assess these variables.

Conclusion

This study found that parental stress and self-efficacy play serial multiple mediating roles in the relationship between social support and children's oral health behaviours. This finding suggests that to ensure the effectiveness of social support interventions for children's oral health, oral health care workers should pay more attention to providing parents/caregivers with children's oral parenting skills based on direct assessment and orientation to parenting resources/stresses. Enhancing parental self-efficacy may be a more effective intervention strategy.

Contribution details

All co-authors have participated sufficiently in the intellectual content, conception and design of this work or the analysis and interpretation of the data (when applicable), as well as the writing of the manuscript, to take public responsibility for it.

	Contributor 1	Contributor 2	Contributor 3	Contributor 4	Contributor 5	Contributor 6	Contributor 7
Concepts		✓					✓
Design		✓					✓
Definition of intellectual content	✓						✓
Literature search	✓
Clinical studies
Experimental studies
Data acquisition		✓	✓	✓
Data analysis	✓
Statistical analysis	✓
Manuscript preparation	✓
Manuscript editing	✓
Manuscript review					✓	✓	✓

Conflict of interest

None disclosed.