Mother’s story of struggle and hope: barriers and enablers of Early Childhood Caries (ECC) preventive behaviours among mothers and caregivers in urban underserved settlements in Colombo, Sri Lanka

Abstract

Background

Early Childhood Caries (ECC) is a highly prevalent chronic condition that disproportionately affects children from low-income and marginalised communities. Globally, approximately 500 million children have untreated caries in their primary teeth. ECC affects approximately 49% of the global population and up to 90% of the population in some Low- and Middle-Income countries (LMICs), compared with 30–50% in high-income countries. Behavioural science frameworks offer structured approaches to diagnosing behavioural determinants. This study aimed to explore the determinants, barriers, and facilitators of ECC-preventive behaviours among mothers and caregivers of 1-3-year-old children in urban underserved settlements (USS).

Methods

A qualitative study with five focus group discussions (FGDs) with mothers and caregivers of children aged 1–3 years with ECC and 11 key informant interviews (KIIs) with health professionals and community stakeholders was conducted in the USS of Colombo City. Reporting was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Audio-recorded data were transcribed, translated, and analysed using a framework analysis. The coding was primarily deductive. Behavioural diagnosis was guided by the Behaviour Change Wheel (BCW), with the COM-B model and the Theoretical Domains Framework (TDF) used to map the determinants.

Results

Thirty-four caregivers and 11 professionals participated. The caregivers’ mean age was 29.3 years and the informants’ mean age was 43.7 years. Twelve themes from FGDs and 18 from KIIs were mapped to the COM-B components. Capability barriers included limited tooth brushing skills, inadequate ECC knowledge, and low prioritisation of oral health. Opportunity barriers included social norms, intergenerational practices, restricted or constrained services and economic hardship. The motivational factors included beliefs, fear, guilt, low perceived severity, competing priorities, and unsupported intentions to improve child oral health. Nevertheless, the participants exhibited clear motivation, readiness, and intention to enhance their oral health practices.

Conclusion

The BCW, COM-B, and TDF frameworks identified key deficits in capability, opportunity, and motivation that sustain ECC risk despite mother or caregiver concerns, informing targeted, context-specific interventions to improve early childhood oral health and reduce urban inequities.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12903-026-09241-2.

Introduction

ECC is one of the most common chronic conditions in early childhood and a major cause of preventable pain, infection, and impaired quality of life [1, 2]. The global estimated random-effect pooled prevalence of ECC is 49% [3], with substantially higher levels in many low- and middle-income settings [4, 5]. Socioeconomic gradients in ECC are well-documented. Poor households and marginalised groups often face a double burden of higher disease risk and lower access to timely preventive and restorative care [6–8]. In Colombo, nearly half of the population lives in urban underserved settlements, with 379,909 residents in 1,360 settlements [9]. These settlements are characterised by overcrowding, precarious housing, poor sanitation, and constrained access to primary health care and dental services [10, 11]. Prior studies in Sri Lanka have documented high ECC prevalence and oral health inequities among preschool children, linked to poverty, low parental education, and limited service access [12–14]. ECC is strongly linked to health-related behaviours, including tooth brushing frequency, fluoride exposure, sugar intake, nocturnal feeding, and patterns of dental attendance [2, 15–17]. However, changing these behaviours is complex, especially in contexts where daily life is shaped by poverty, crowding, and precarious work [18, 19]. Traditional oral health education tends to focus on knowledge transfer and individual advice, with limited attention to the wider social and structural conditions that shape realistic expectations of caregivers [18, 20].

The Behaviour Change Wheel (BCW) was developed to provide a systematic way to design behaviour change interventions across public health domains [20, 21]. At its core, the COM-B model proposes that behaviour arises from the interaction of Capability, Opportunity, and Motivation. The Theoretical Domains Framework (TDF) groups a range of psychological and contextual constructs into 14 domains that fall under these three components [20, 22, 23].

Several oral health studies have used the COM-B and TDF to design interventions that seek to change oral hygiene and dental attendance behaviours [23–25]. In Canada, Kaur et al. used the BCW, COM-B, and TDF to develop a culturally tailored oral health intervention for Punjabi immigrants, which improved knowledge, self-care, and clinical outcomes, including reduced plaque and gingivitis [26]. Holloway used the BCW and COM-B to address barriers to regular dental attendance in the United Kingdom and reported improved preventive attendance among vulnerable adults [27]. Acceptance and commitment therapy-based behavioural interventions have shown promise in promoting oral hygiene among young adults [28]. These studies show that behavioural science can inform structured oral health interventions. However, much of the existing work is from high-income countries, and relatively little is known about how COM-B and TDF operate in low-income urban informal settlements, where systemic constraints and social norms may be different and more severe [23].

Three main gaps motivated this research. First, there is limited qualitative research that applies the BCW, COM-B, and TDF to understand ECC-preventive behaviours among caregivers of very young children in low- and middle-income urban informal settlements. Existing work in Sri Lanka has described ECC prevalence and some socio-behavioural correlates [5, 12, 14]; however, few studies have used explicit behavioural models to diagnose the determinants of caregiver behaviour in underserved settlements. Second, little is known about how caregivers and frontline workers in such settings perceive the feasibility of recommended behaviours, such as twice-daily brushing with fluoride toothpaste, early dental attendance, and early cessation of nocturnal feeding, when households face structural constraints such as lack of running water, high costs of oral hygiene products, and a local food environment dominated by cheap sugary snacks [13, 19]. Third, there is a lack of detailed behavioural diagnoses that can be directly translated into candidate intervention functions and policy categories within the BCW, such as education, training, environmental restructuring, service provision, and fiscal measures [20, 21, 29]. Without such diagnoses, oral health promotion strategies risk remaining generic and poorly matched to the lived realities of caregivers in high-risk populations. Therefore, this study sought to explore how mothers, caregivers, and key informants in Colombo’s underserved settlements understand and experience ECC-preventive behaviours, and to map these perceptions onto the COM-B model and TDF.

Methods

We used a qualitative design that combined FGDs with mothers and caregivers and KIIs with professionals and community stakeholders. This design enabled the exploration of both individual and shared experiences, as well as the wider service and community context. The study used the BCW, COM-B, and TDF to guide the topic guides and analysis. Reporting follows the COREQ 32-item checklist for interviews and focus groups, covering the research team and reflexivity, study design, and analysis and findings [30].

The study was conducted in urban underserved settlements within the Colombo District, Sri Lanka. According to the 2023 Colombo Settlements Survey, 379,909 individuals reside in 1,360 settlements across six municipal districts, with 55,866 housing units and 87,119 families [9]. These settlements are characterised by high population density, small dwellings, shared water and sanitation facilities, and limited access to public services.

Research team and reflexivity

The research team included public health and oral health professionals employed in the Sri Lankan health system with experience in maternal and child health, oral health promotion, and qualitative research. FGDs and KIIs were conducted by the principal investigator, with a trained moderator assisting during the group discussions. The team was familiar with the study communities through ongoing public health work, which facilitated the establishment of rapport. Simultaneously, the team remained aware that their professional roles could influence participants’ responses. Neutral probes, open questions, and an emphasis on non-judgmental listening were used to minimise social desirability bias. The team reflected on their assumptions during regular analytical meetings.

Participant selection and sampling

Two participant groups were included in this study: FGD participants, comprising mothers or primary caregivers of children aged 1–3 years, and KII participants, comprising health professionals and community leaders.

Mothers and primary caregivers of children aged 1–3 years diagnosed with ECC and living in urban underserved settlements were recruited using purposive sampling with the assistance of public health staff, including Public Health Midwives, Health Instructors and other field-level health workers who were familiar with the study communities. These personnel facilitated the identification and initial approach to eligible participants within the selected underserved urban settlements. Eligibility criteria included being a primary caregiver of a child aged 1–3 years, residing in the selected study areas, and willingness to participate in the study. Caregivers included mothers as well as caregivers primarily responsible for the child’s daily care. Efforts were made to ensure variation in participant characteristics, including ethnicity (Sinhala, Tamil, Muslim and other races), household composition and caregiving contexts, in order to capture a broad range of experiences relevant to early childhood oral health practices. Each FGD included 6–8 participants with heterogenous in nature with regards to ethnicity and was conducted in a community setting familiar to the participants. Data collection continued until no new themes appeared, and the team judged that thematic saturation had been reached.

Key informants were purposively selected based on their roles in child oral health and public health promotion and those who served in the area for more than 6 months. The sample included Medical Officers of Maternal and Child Health (n = 2), Dental Surgeons (n = 2), Public Health Midwives (n = 2), a Health Education Officer (n = 1), Health Instructors (n = 2), and community leaders (n = 2). This combination of clinical, public health, and community perspectives allowed for triangulation and captured system-level determinants.

Data collection

Separate semi-structured guides were developed for the FGDs and KIIs. Guide development drew on the BCW, COM-B, and TDF literature and on previous oral health behaviour studies [23, 26, 29]. The guides covered the four target behaviours (tooth brushing, dietary practices, oral health care seeking, and child mouth examination by mother/caregiver) and probed capability, opportunity, and motivation related to each.

A multidisciplinary expert panel reviewed the guides for face, content, and consensual validity using a five-point Likert scale. Items with a mean rating of 4.0 or higher were retained, and lower-rated items were revised for clarity and relevance. The guides were translated into Sinhala and Tamil using forward and backward translations by bilingual experts. Pretesting was conducted in the Gampaha District with mothers and caregivers who were similar to, but outside, the target population. Feedback on clarity, cultural appropriateness, and flow was used to refine the FGDs guides.

FGDs and KIIs were conducted between September and November 2023. Sessions took place in calm, convenient community locations for mothers and caregivers and workplaces or other suitable venues for key informants. At each session, the facilitator explained the study’s purpose, the voluntary nature of participation, confidentiality, and the right to withdraw. Written informed consent was obtained from all the participants. Each FGD session was conducted between 60 and 90 min. With permission, the discussions were audio recorded. KII session duration was from 30 to 60 min.

The principal investigator facilitated all sessions in Sinhala language. All these sessions were supported by an assistant who was an expert in both Sinhala and Tamil languages. During the FGDs, she managed group dynamics, ensured that quieter participants were invited to speak, and noted nonverbal cues, translating some terms into Tamil Language. All participants were able to understand and speak Sinhala language as they live in a mixed culture society from childhood. The guides were used flexibly to encourage open discussions. Probing questions explored specific COM-B and TDF domains, such as knowledge, skills, social influences, environmental constraints, beliefs about consequences, and emotional responses. At the end of each session, key points were summarised back to participants for clarification and confirmation.

Data collection and analysis were conducted concurrently. No predefined sample size was established for FGDs; instead, recruitment continued until thematic saturation was achieved, defined as the point at which no new themes emerged from successive interviews and discussions. Saturation was reached after conducting five FGDs, resulting in a sample of 34 participants and 11 KIIs, facilitated by the relative homogeneity of participants in terms of socioeconomic and cultural context.

Transcription and translation

Audio recordings from the FGDs were transcribed verbatim in Sinhala and then translated into English. KIIs conducted in Sinhala followed the same process. The transcripts were checked against the recordings for accuracy. Field notes were integrated into the dataset to preserve contextual information.

Analytic approach and deductive mapping

Data were analysed using framework analysis which is applied in public health qualitative studies [31, 32]. The analysis combined deductive and inductive elements, with primary emphasis on deductive mapping to the COM-B and TDF.

The analytic steps were familiarisation (through repeated reading of transcripts and listening to selected audio recordings), development of an initial analytic matrix using COM-B components and related TDF domains as a priori categories, indexing, where segments of text were coded into the relevant COM-B and TDF domains (coding was led by the principal investigator, with at least one other team member independently coding a subset of transcripts), charting, where coded data were summarised within a matrix organised by participant group, target behaviour, and COM-B/TDF domain, and mapping and interpretation (where the team compared patterns across FGDs and KIIs, identified convergent and divergent perspectives, and developed higher order themes within each COM-B component). Codes that did not fit the a priori COM-B or TDF domains were retained and grouped into emergent categories, which helped refine the understanding of contextual influences. The analysis remained anchored in the four target behaviours, allowing for clear links between behavioural determinants and potential intervention strategies.

Rigour and trustworthiness

Several strategies were used to enhance the rigour of the study. Triangulation across data sources was achieved by comparing caregiver accounts with the perspectives of key informants in different professional roles. Within each group, themes were examined for variations by ethnicity and settlement context. As the study involved participants from Sinhala-, Tamil-, and Muslim-Sinhala-speaking backgrounds, the research team remained attentive to the possibility that culturally embedded sentiments and locally nuanced terminology may not have been fully conveyed during fieldwork or subsequent translation. Although Tamil-speaking participants were conversant in Sinhala and a bilingual assistant supported real-time clarification of Tamil terms, expressing emotionally and culturally laden experiences such as maternal guilt, affection conveyed through the giving of sweets, or beliefs surrounding “milk teeth” (kiri dath) as transient and lesser in importance in a second language may have led to some flattening of affective register and cultural specificity. During transcription and translation from Sinhala into English, undertaken by bilingual members of the research team and cross-checked against the original audio recordings, every effort was made to preserve contextual and idiomatic meaning; where culturally specific terms had no direct English equivalent, the original word was retained with a brief contextual gloss. Nevertheless, certain sociocultural nuances including kinship-based authority dynamics, religiously framed notions of caregiving, and idiomatic expressions of fatigue or resignation may have been partially diluted in the translated transcripts. The team addressed this through reflexive discussions that explicitly explored alternative interpretations of culturally loaded terms and through retention of selected source-language words alongside English in the analytic matrix. Regular analytic meetings were held to discuss coding decisions, resolve discrepancies, and reflect on the influence of the researchers’ assumptions. Member checking occurred informally at the end of the FGDs and KIIs when facilitators summarised key messages and invited corrections. A transparent audit trail was maintained, documenting the coding frameworks, analytic matrices, and decisions.

Ethical considerations

Ethical approval was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Colombo. Local authorities and local health authorities granted permission to conduct the study in selected communities. Written informed consent was obtained from all participants. Identifiers were removed from the transcripts, and quotes used in publications were anonymised. Audio files and transcripts were securely stored with access limited to the research team.

Results

Sociodemographic characteristics of participants of FGD

A total of 34 mothers/caregivers, including mothers (n = 32) and other primary caregivers (n = 2) (all were females) participated in five focus group discussions (FGDs), each comprising 6–8 participants. The mothers’/ caregivers’ ages ranged from 20 to 41 years (mean 29.3 ± 5.2 years). Both caregivers were close family members directly involved in the child’s daily care. All mothers were married and living with their spouses, reflecting typical family structures within the study setting.Participants represented the Sinhala (44.1%), Muslim (29.4%), and Tamil (26.5%) ethnic groups, reflecting the diversity of Colombo’s underserved, urban communities. In terms of highest educational attainment, most caregivers had completed secondary education, with half reporting education up to the G.C.E. Ordinary Level (O/L) and a further proportion having passed O/L. A smaller proportion had primary education or advanced to G.C.E. Advanced Level (A/L). The majority of caregivers were not engaged in paid employment (88.2%). Based on monthly household income categories, most participants were within the lower and lower-middle income groups. The majority of households were concentrated in the income category of LKR 50,000–74,999 (38.2%), followed by the category of LKR 25,000–49,999 (29.4%). Household income was primarily derived from informal or daily wage occupations of other family members, particularly spouses of the study participants.

A smaller proportion (17.6%) was in the 75, 000–99, 999 category, while only 5.9% each were in the lowest (< 25,000) and highest (≥ 100,000) income groups. One participant (2.9%) preferred not to disclose their income.

The children were aged 16–35 months (mean age was 26.0 ± 6.1 months), and 55.9% were males (n = 19).

Most participants resided in extended family households (73.5%), whereas the remainder lived in nuclear families. Households commonly included multiple family members and more than one child, reflecting the crowded living conditions typical of the underserved urban settlements.

These sociodemographic features provide essential context for interpreting mothers’/ caregivers’ beliefs, knowledge, and practices regarding early childhood caries within low-income, multi-ethnic urban settings (Table 1).

Table 1.

Sociodemographic characteristics of caregivers who participated in FGDs (n = 34)

Characteristic	Category	n (%)	Mean ± SD / Range
Type of caregiver	Mother	32 (94.1)
	Caregiver	2 (5.9)
Age of mother/caregiver (years)			29.3 ± 5.2 (20–41)
	25–29 Years	13 (38.2)
	30–34 Years	8 (23.5)
	≥ 35 Years	7 (20.6)
Ethnicity	Sinhala	15 (44.1)
	Muslim	10 (29.4)
	Tamil	9 (26.5)
Educational level	Primary	7 (20.6)
	Up to GCE O/L (not completed)	15 (44.1)
	Passed GCE O/L	7 (20.6)
	Up to GCE A/L (not completed)	5 (14.7)
Employment status	Not employed	30 (88.2)
	Employed	4 (11.8)
Monthly household income	< 25,000	2 (5.9)
	25,000–49,999	10 (29.4)
	50,000–74,999	13 (38.2)
	75,000–99,999	6 (17.6)
	≥ 100,000	2 (5.9)
	Prefer not to say	1 (2.9)
Family structure	Extended Families	25 (73.5)
	Nuclear Families	9 (26.5)
Child’s age (months)			26.0 ± 6.1 (16–35)
Child’s gender	Male	19 (55.9)
	Female	15 (44.1)

Abbreviations: O/L Ordinary Level, A/L Advanced Level

These sociodemographic characteristics, particularly lower educational attainment, limited engagement in paid employment, and concentration within lower- and lower-middle-income households, provided important context for understanding the barriers and facilitators to early childhood caries (ECC) preventive behaviours identified in the thematic analysis.

Furthermore, the underserved settlements were broadly similar in terms of socioeconomic conditions and cultural context; this relative homogeneity of the study population facilitated the identification of recurring patterns across FGDs and supported the achievement of thematic saturation in relation to ECC-related behaviours.

Themes of FGDs mapping against the COM-B/ TDF domains

COM – B component- capability (physical and psychological)

Within the Capability component, three themes were identified, representing both physical and psychological capability, corresponding to three domains of the TDF.

Theme 1: lack of physical skills (TDF domain: skills)

Across all FGDs, mothers and caregivers consistently reported inadequate practical skills in brushing their children’s teeth. Although participants were confident in managing routine childcare activities, tooth brushing emerged as a distinct challenge because of limited hands-on instruction and uncertainty about the correct techniques. Caregivers frequently described difficulties in manoeuvring the toothbrush in a small child’s mouth, applying appropriate brushing force, and managing resistance during the task.

“I try my best to brush my son’s teeth every morning, but I am unsure whether I am doing it correctly.” (FGD3, M3)

Caregivers described the practical difficulties caused by uncooperative behaviours.

Most of them expressed that verbal advice alone was insufficient, repeatedly emphasising the need for structured demonstrations and practical guidance in the training.

“I am not confident about how to do it. Sometimes, I just let him hold the brush because I do not feel skilled enough. I wish we had some demonstration or hands-on training for parents like us.” (FGD2, M3)

These perspectives highlight a substantive gap in physical capability, indicating that effective oral health interventions should include skill-building components, such as practical demonstrations and parent-focused training, to strengthen caregivers’ confidence and competence in toothbrushing for young children.

Theme 2: limited knowledge of oral health-related behaviours (TDF domain: knowledge)

Most participants demonstrated a limited understanding of oral health-related behaviours relevant to children aged 1–3 years. Although brushing twice daily was widely mentioned, there was considerable confusion regarding when to begin brushing, the importance of nighttime brushing, and the role of fluoride. Mothers tended to associate tooth brushing with cleanliness and appearance rather than caries prevention or long-term oral health benefits.

“Is it necessary for small children to have their teeth brushed as they look white and clean?” (FDG3, M1)

“I was not sure when to start brushing my son’s teeth, so I only began recently, even though he is already two. I thought brushing was mostly to keep his breath fresh. I have seen fluoride toothpaste in the shops, but I do not know if it makes a difference for him.” (FGD3, M6)

Mothers were also unsure about identifying foods with hidden sugars. While most avoided visible sweets, many routinely offered biscuits and buns, unaware that these were cariogenic.

“I do not give my son sugary foods. But I give biscuits with savoury flavour every day at tea time.” (FGD4, M2)

Knowledge of dental visits and preventive care was minimal. Several participants believed that dental visits were only necessary when a child had visible decay or experienced pain. Preventive checkups and early interventions were rarely mentioned.

“I have never taken my daughter to the dentist because her teeth seem fine. I thought you only went to the dentist if there was a problem, like if she had a toothache or something. I did not know you were supposed to take kids for regular check-ups.” (FGD2, M5)

During the discussions, many mothers revealed that they had little or no knowledge of where to seek preventive dental care for their young children. Most had never heard of dental clinics that treat children below school age. They shared that information about free or government dental services was rarely communicated through community channels.

“In our area, no one talks about children’s dental care. We do not see any leaflets or health workers coming to tell us. I hear about vaccines and nutrition, but not about teeth.” (FGD1, M2)

Some mothers mentioned that although hospitals offered dental clinics, they were unaware of which ones provided services for young children or how to access those services. Some assumed that private dental treatment would be costly and therefore avoided seeking care.

“We do not know which hospital has a dental clinic for children. I thought it’s expensive, so I never even tried to ask.” (FGD4, M1)

“If someone came to our community and explained what services are available for small children, it would help a lot.” (FGD5, M6)

Collectively, the mothers’ narratives highlight a significant gap in awareness and outreach regarding preventive dental services, suggesting the need for better communication between health systems and underserved urban communities.

These insights indicate that mothers’ psychological capability, particularly their knowledge and understanding of preventive care, is low. Misconceptions about the importance of primary dentition, limited awareness of fluoride, and the absence of anticipatory guidance all contribute to delayed preventive behaviours and a greater risk of ECC.

Theme 3: oral health is not prioritised in daily decision-making (TDF domain: memory, attention and decision processes)

For many caregivers, children’s oral health was not considered a daily priority, amidst competing household responsibilities. Nighttime brushing was often skipped because of fatigue, forgetfulness, or children’s resistance. Some mothers rationalised this behaviour by perceiving primary teeth as temporary and unimportant.

“By the time I have finished all the housework and got dinner ready, I am exhausted. I should brush my son’s teeth at night, but I sometimes forget. It does not seem like a big deal because he will lose these baby teeth. I brush his teeth in the morning, and that feels like enough.” (FGD2, M4)

Emotional fatigue, time constraints, and lack of cooperative behaviour from children reduced the likelihood of consistent routines.

“My son does not cooperate when brushing his teeth, especially at night. He screams and does not sit still. After a long day of work and looking after the house, it is just one more fight I do not have the energy for.” (FGD 5, M4)

Preventive dental visits were rarely integrated into decision-making, as caregivers viewed them as unnecessary in the absence of pain or visible problems.

“I have never taken my daughter to a dental clinic because her teeth do not seem to have any problems. I do not think about going unless she is in pain or has a serious issue.” (FGD 5, M5)

These findings reflect a lack of prioritisation of preventive oral health due to cognitive overload, competing demands, and limited perceived importance of primary dentition, which are key features of low psychological capability that contribute to delayed or inconsistent oral health behaviours.

Overall, mothers and caregivers demonstrated limited physical capability due to a lack of practical tooth brushing skills and low psychological capability resulting from knowledge gaps, competing priorities, and underestimation of ECC risk. These constraints collectively hindered the adoption of consistent oral hygiene practices and timely preventive care-seeking behaviours among families in urban slum settings.

COM – B component- opportunity (social and physical)

Four themes were identified under the Opportunity (Social and Physical) component across four domains of the TDF.

Theme 4: social norms shaping oral health and feeding practices (TDF domain: social influences)

Social norms strongly influenced the daily oral health routines and feeding practices of mothers and caregivers in this study. Across all focus group discussions, brushing children’s teeth once daily in the morning, typically during or after the child’s bath, was an accepted routine. Nighttime brushing was rarely practised and not socially reinforced, as most mothers perceived once-daily brushing to be sufficient.

“I always brush my son’s teeth in the morning when he bathes. It is just part of our routine, and I did not think we needed to do it more than that. He gets a bath every day, so it feels like brushing once is enough.” (FGD 3, M6)

Others echoed that brushing was embedded in morning hygiene routines rather than being viewed as a preventive oral health practice. These accounts reflect how collective norms and intergenerational habits shape oral hygiene behaviours. Nighttime brushing was perceived as unnecessary, inconvenient, or culturally uncommon, underscoring the powerful role of routine-based norms over health-driven intention.

Feeding practices were also shaped by social expectations and family traditions of the mothers. Nighttime breastfeeding or bottle-feeding was common and socially accepted, with most mothers unaware of its cariogenic impact.

“I still breastfeed my daughter at night because it helps her fall asleep. We have always done this, and I did not know it could be bad for her teeth. It is also hard to stop because she is used to it.” (FGD 4, M3)

Mothers frequently described feeling powerless against social pressures from extended family members and peers who habitually offered their children sweet foods. Fathers and grandparents were identified as primary contributors to this pattern, often linking sweet treats with affection.

“Whenever family or friends visit, they bring sweets for him, and I cannot stop them. My husband also brings him candy or buns daily after work, which is difficult to control. It is just what everyone does.” (FGD 5-M2)

“I know that always giving my son sweets is not good, but it is hard to avoid. His grandparents and neighbours always bring him sugary treats, and I do not want to be rude by refusing.” (FGD 2, M3)

These findings demonstrate how social norms and familial influences shape both oral hygiene and dietary behaviours, often reinforcing practices that inadvertently increase children’s exposure to cariogenic foods. Such norms limit caregivers’ autonomy and constrain their ability to enforce healthier routines, highlighting the need for community-level, culturally sensitive interventions that engage fathers and extended family members alongside mothers.

Theme 5: intergenerational practices and peer influence (TDF domain: social influences)

Mothers and caregivers described how beliefs and habits often shaped oral health-related practices passed down through generations. Many reported following the same routines their parents or elders used when they were young, such as cleaning children’s teeth with a cloth, using herbal remedies, or delaying dental visits until problems arose. Advice from grandparents, neighbours, and other mothers in the community played a significant role in shaping daily oral care decisions. These intergenerational and peer influences often reinforce traditional practices rather than evidence-based preventive behaviours.

“We use a small piece of cloth with salt or herbal powder to clean our teeth. It is what we have always done, and it feels clean afterwards. My mother-in-law says they are better than chemical toothpaste, especially for little ones.” (FGD1, M6)

“My mother-in-law says that giving a bottle at night is essential because all her children had milk before bed and their teeth were okay. So, I didn’t think it was harmful.” (FGD2, M6)

These statements highlight how deep-rooted cultural beliefs, social learning, and community norms strongly influence mothers’ decisions, often perpetuating misconceptions regarding oral hygiene and dietary habits. Intergenerational advice, while well-intentioned, may hinder the adoption of modern preventive practices, emphasising the importance of culturally sensitive, targeted education and community-based peer support to promote behaviour change.

Theme 6: structural and resource constraints (TDF domain: environmental context and resources)

Environmental barriers were consistently described as key impediments to practising optimal oral health. The lack of basic facilities, such as access to running water, made nighttime tooth brushing impractical for many families living in urban, underserved settlement areas.

“Brushing my son’s teeth at night is hard because we do not have running water at home. I have to carry water from the tap outside, and by the end of the day, I am too tired to go through all that to brush his teeth again. We only manage to do it in the morning when we all get ready for the day.” (FGD 4, M5)

Another barrier was the limited availability and affordability of appropriate oral care products. Mothers described how non-fluoridated toothpaste, often in colourful, child-friendly packaging, was more accessible than fluoridated options.

“There are so many toothpastes for kids in the store. Usually, I buy the ones that look attractive to my daughter.” (FGD 5, M6)

Some mothers also continued using traditional cleaning methods, such as cloth wiping or herbal sticks, viewing these as familiar, affordable, and adequate alternatives to modern products.

“We have always used traditional methods to clean our children’s teeth, such as rubbing their gums with a piece of cloth or using herbal sticks. Toothbrushes and toothpaste are available, but they are expensive. Therefore, I feel like the old ways are better and cheaper, too.” (FGD 1, M5)

Environmental constraints extend to food availability and its affordability. The local food environment in urban slum areas was dominated by low-cost, sugar-rich snacks, which mothers identified as the most financially feasible option amid the economic crisis.

“In our area, the shops mostly sell sugary stuff, such as cookies, buns, and candy. It is what is available and cheap. With the prices of everything going up, I cannot buy the more expensive fruits or healthy snacks.” (FGD 5, M7)

In addition, mothers highlighted limited access to dental care facilities as a significant structural constraint. The absence of nearby clinics and transportation difficulties discouraged timely care-seeking, reinforcing the perception that dental visits should occur only when pain arises.

“There is no dental clinic nearby, and we do not have the money to take a taxi. With all the other things going on, dental care feels like something that has to wait.” (FGD 5, M2)

Theme 7: economic hardship (TDF domain: environmental context and resources)

Mothers and caregivers frequently described how economic hardship shaped their children’s oral health-related behaviours. In urban underserved settings, most families face financial constraints that limit their ability to purchase toothpaste and nutritious foods. Instead, they relied heavily on inexpensive, easily accessible, and available items in nearby small shops and street vendors.

“Toothbrushes for small children are costly, and sometimes they do not like using them. So, I use my finger.” (FGD4, M3)

“Healthy food is too expensive now. Fruits and milk cost so much, so we end up buying biscuits or buns for snacks. They are cheap and fill our stomachs.” (FGD2, M4)

These discussions revealed how poverty reinforces oral health-related behaviours, contributing to the risk of ECC.

COM – B component- motivation (reflective motivation and automatic)

There were four themes identified within the Component Motivation (Reflective Motivation and Automatic) and mapped across five domains of TDF.

Theme 8: awareness of pain and emotional regret (TDF domain: beliefs about consequences & emotion)

Mothers and caregivers frequently expressed awareness of the severe pain associated with dental caries, often drawing from their past experiences of untreated tooth decay. Many described feelings of guilt and regret for neglecting their oral health and feared that their children would endure similar suffering. Emotional reflections, particularly sadness, frustration, and worry, were powerful motivators for some mothers to adopt better oral health practices for their children. However, others expressed helplessness due to competing priorities, limited knowledge, and structural barriers, leading to emotional distress and feelings of resignation.

“I know how bad a toothache can be because I have had it many times. I don’t want my son to go through that pain. I try to make time to brush his teeth.” (FGD3, M3)

These narratives reveal how emotional experiences rooted in awareness of pain and regret serve as barriers and motivators for behaviour change. While mothers’ empathy and guilt often strengthen their intention to improve their children’s oral hygiene, persistent stress and low self-efficacy may hinder such sustained action. Therefore, emotional support, reassurance, and positive reinforcement from health professionals could play a key role in empowering caregivers in underserved urban communities.

Theme 9: lack of perceived severity of ECC (TDF domains: beliefs about consequences / emotion)

Some mothers perceived dental caries in young children as a minor or temporary issue, often assuming that “milk teeth” would eventually fall out and be replaced by stronger, permanent teeth. This belief reduced their sense of urgency to act and limited preventive behaviours, such as early brushing or dental visits. A few mothers expressed surprise upon learning that early caries could cause pain and long-term problems for their children.

“I did not think baby teeth were that important because they fall out anyway. I thought the new teeth would be fine.” (FGD2, M3)

“When my daughter’s teeth got discoloured, I thought it was just stains. I didn’t realise it could turn into holes or pain.” (FGD1, M6)

This limited perception of severity contributed to a reactive rather than a preventive approach, with most caregivers seeking care only when visible decay or pain occurred.

Theme 10: emotional conflict and satisfaction (TDF domains: emotion / reinforcement)

Caregivers described mixed emotions, ranging from guilt and frustration to satisfaction and pride, associated with their children’s oral care routines. They felt emotionally rewarded when they could brush their child’s teeth or provide healthier food, but also experienced inner conflict when they could not maintain consistency due to fatigue, financial struggles, or children’s resistance.

“When I manage to brush his teeth, I feel happy and proud, like I did something good as a mother.” (FGD4, M2)

“Sometimes, she cries and refuses to brush her teeth, and I just give up. Later, I feel bad and think I failed.” (FGD2, M5)

This emotional duality highlights how positive reinforcement can strengthen desired behaviours, whereas negative emotions may discourage long-term consistency if not adequately supported.

Theme 11: desire, readiness and intention to improve oral health practices (TDF domain: beliefs about capabilities & intentions)

Despite gaps in awareness, many mothers expressed a clear desire to improve their children’s oral health. They acknowledged the importance of developing good habits and expressed their readiness to change if they received appropriate guidance and support. Mothers frequently linked their intentions to emotional drivers, such as love, guilt, and hope for a better future for their children.

“I really want to make sure my daughter has strong teeth. I just need to know what exactly to do and how often. If someone teaches us properly, I will definitely start brushing my daughter’s teeth daily. I don’t want her to suffer” (FGD3, M5)

This intention reflects a stage of emerging motivation, suggesting that with knowledge reinforcement and accessible resources, many caregivers could transition from intention to consistent action to adopt and maintain better oral health practices for their young children.

Theme 12: need for structured support systems

Across the focus groups, the mothers emphasised the need for regular guidance, reminders, and accessible community-based support to sustain oral health practices. They valued the idea of structured interventions, such as follow-up visits, educational sessions at child health clinics, or visual aids to remind and motivate them. Mothers also highlighted the importance of receiving advice from trusted healthcare workers rather than relying on hearsay information.

“If the PHM or doctors reminded us about brushing at every visit, we would not forget.” (FGD5, M1)

“We want some follow-up or reminders, something that helps us stick to what we learn.” (FGD2, M6)

These accounts underscore the importance of structured and consistent reinforcement mechanisms, including health worker engagement, visual communication, and reminder systems, to bridge the gap between intention and sustained behavioural change.

Sociodemographic characteristics of key informants

A total of 11 key informants were included in the study, representing both healthcare providers and community stakeholders. The sample comprised predominantly females (n = 7; 63.6%), with participants’ ages ranging from 28 to 60 years old. The mean age of the participants was 43.7 ± 10.6 years. Most respondents were Sinhala (72.7%), and three (27.3%). Key informants included Medical Officers attached to Maternal and Child Health services (MOH–MCH), Dental Surgeons, Public Health Midwives (PHMs), a Health Education Officer (HEO), Health Instructors, and community leaders.

The duration of professional or community experience ranged from 2 to 20 years. Community leaders reported the longest duration of engagement (20 years), whereas most healthcare providers had between 2 and 6 years of experience, except the HEO, who reported 15 years of service. This composition ensured representation of both service delivery and community-level perspectives relevant to early childhood oral health (Table 2).

Table 2.

Sociodemographic characteristics of key informants (n = 11)

Characteristic	Category/Affiliation	n (%)	Mean±SD (Range)
Total key informants		11 (100)
Gender	Female	7 (63.6)
	Male	4 (36.4)
Age (years)	Mean ± SD (range)		43.7 ± 10.6 (28–60)
Ethnicity	Sinhala	8 (72.7)
	Muslim	3 (27.3)
Professional affiliation	MO (MOH–MCH)	2 (18.2)
	Dental Surgeon	2 (18.2)
	PHM	2 (18.2)
	Chief HEO	1 (9.1)
	Health Instructor	2 (18.2)
	Community leader	2 (18.2)

The COM-B and TDF analyses revealed multiple interconnected themes in this population.

Themes of KIIs mapping against the COM-B/ TDF domains

With 11 KIIs conducted, 18 themes were identified and mapped onto the COM-B model and the corresponding TDF domains to explain behavioural determinants.

Further, triangulation across key informant groups revealed consistent findings across sectors, with only minor variations in emphasis. The convergence of insights from multiple sources strengthened the credibility and transferability of the findings. Detailed thematic findings and supporting quotations are provided in the supplementary file 1.

Key informant interviews (n = 11) provided important contextual and explanatory insights that enriched and triangulated caregiver-reported findings across all major themes. Under Capability, informants consistently highlighted that although some caregivers were aware of recommended practices, they lacked practical skills and confidence to perform effective toothbrushing and early mouth examination, alongside persistent misconceptions regarding the importance of primary teeth and appropriate oral hygiene practices. These findings complemented caregiver narratives by explaining the observed gap between knowledge and practice, further emphasising the importance of hands-on demonstrations and repeated education (TDF: skills, knowledge, behavioural regulation).

Within Opportunity, KIIs revealed that structural barriers—including financial hardship, limited access to oral health resources, competing caregiving demands, and inadequate integration of oral health into routine maternal and child health services—substantially constrained caregivers’ ability to adopt preventive behaviours. Informants further highlighted the influence of social and cultural norms, such as the routine use of sugary foods as expressions of care and the role of family members in shaping practices, thereby deepening understanding of contextual influences identified in caregiver data (TDF: environmental context and resources; social influences). In addition, health personnel described how home visits and community-level engagement could act as practical enablers to reinforce behaviour change.

Regarding Motivation, KIIs underscored that low perceived importance of primary teeth, competing life priorities, and fear of dental care contributed to delayed care-seeking and inconsistent oral hygiene practices. Importantly, informants consistently reported that caregivers demonstrated willingness and readiness to improve when provided with clear, practical guidance and supportive follow-up, reinforcing caregiver-reported intentions and highlighting opportunities for intervention (TDF: beliefs about consequences; emotion; intentions; reinforcement).

Discussion

This qualitative study, guided by the BCW, COM-B, and TDF, identified multiple interacting determinants of ECC-preventive behaviours among mothers and caregivers of toddlers in Colombo’s underserved settlements, as well as among professionals and community leaders supporting them. Caregivers described limited practical skills in brushing and examining children’s teeth, gaps in knowledge about the importance of primary teeth and fluoride, and low prioritisation of oral health in the context of heavy household workloads and cognitive overload. These factors reflect limited physical and psychological capabilities.

Social norms, intergenerational advice, economic hardship, and constrained service access limit opportunities for optimal behaviour. Once-daily morning brushing aligned with bathing routines was widely normalised, whereas night brushing and routine dental checkups were rare. Cheap sugary snacks and sweetened drinks are omnipresent and socially accepted, often linked to affection from fathers and grandparents. Structural barriers included the lack of running water at home, the cost and availability of toothbrushes and fluoride toothpaste, transport costs, and limited coordination between oral health and maternal and child health services.

The motivational influences were complex. Many mothers expressed fear of dental pain based on their own experiences and guilt regarding their children’s oral health. Some underestimated the severity of ECC because they believed that primary teeth are temporary. Others held strong intentions to improve their children’s oral health but struggled to translate these intentions into consistent routines due to fatigue, stress, and competing priorities. Health workers perceived similar patterns and emphasised parents’ attitudes, low perceived importance of oral health, and fears about dental treatment as key influences. Simultaneously, both caregivers and key informants described a clear desire for change and responded positively to practical demonstrations and consistent encouragement.

How findings relate to COM-B, TDF, and prior literature

The results support the relevance of the COM-B model and TDF for understanding ECC-related behaviours in low-income urban settlements. Capability constraints, such as a lack of tooth brushing skills and limited knowledge about fluoride and early dental visits, echo findings from other oral health studies [23, 26]. However, this study extends prior work by showing how these capability gaps are shaped by and interact with structural and social conditions specific to informal settlements, such as shared water sources, crowded living spaces, and highly constrained household budgets [13].

Opportunity-related barriers were particularly significant. The normalisation of once-daily brushing and frequent sugary snacks within families and communities meant that recommended practices such as twice-daily brushing and restricting sugar between meals did not align with shared expectations. Similar findings have been reported in other contexts, where social influences and intergenerational habits act as powerful drivers of oral health behaviours [12, 26]. In Colombo’s underserved settlements, economic hardship made low-cost sugary snacks and non-fluoridated child toothpastes more attractive than healthier options. Informants described preventive dental visits as rare, owing to logistical hurdles and a lack of established preventive culture, which is consistent with earlier work in Sri Lanka that highlighted late presentation of untreated caries among toddlers [5, 14].

Motivational factors showed an interplay between emotions, beliefs about consequences, and intentions. Mothers’ accounts of fear, guilt, and regret resemble patterns observed in other dental behaviour research that linked negative experiences with both avoidance and motivation to protect children [25, 28]. In this study, emotional drivers were often insufficient to change behaviour in the face of practical constraints and limited self-efficacy, which underlines the importance of combined strategies that address capability and opportunity alongside motivation [20, 21].

By employing a largely deductive analysis, this study demonstrates how COM-B and TDF can structure behavioural diagnosis in a low-resource setting and generate clear, theory-informed intervention options. This responds to earlier calls to apply these models in oral health in more diverse contexts [23].

Methodological strengths and limitations

A key strength of this study lies in the systematic application of the BCW, COM-B, and TDF to guide sampling, data collection, and analysis. The combination of FGDs with mothers and caregivers and KIIs with health workers and community leaders enabled triangulation across perspectives and improved the contextual understanding. Topic guides were developed and validated through a structured process, and the analytic approach used explicit, transparent mapping between data and behavioural domains [23, 33].

This study also had some limitations. Participants were drawn from urban underserved settlements in one district, which may limit the transferability of the findings to rural settings or other cities. Fathers, grandparents, and private sector providers were not directly included, although they played a prominent role in the caregivers’ accounts of social influences. Social desirability bias is possible, especially in discussions about parenting and health behaviours in the presence of health professionals [34]. Resource constraints limited the extent of dual coding across all transcripts, although analytic meetings and a detailed audit trail helped to maintain consistency. Although the analysis was mainly deductive, relying on the COM-B and TDF, some nuances may lie beyond these domains. The study did not formally assess intercoder agreement or use software-based reliability statistics [35].

Policy and practice implications

Behavioural diagnosis suggests several concrete directions for policy and practice in Sri Lanka and similar settings. First, interventions should not focus solely on knowledge but also on building practical skills and confidence. Caregivers expressed a clear demand for demonstrations on how to brush a toddler’s teeth, hold the child, and use appropriate amounts of toothpaste. This supports the inclusion of brief, hands-on training in child health clinics, vaccination sessions, and home visits by Public Health Midwives and health instructors [14].

Second, a stronger integration of oral health into existing maternal and child health platforms is needed. Key informants described fragmented responsibilities and inconsistent messages across the providers. Embedding simple oral health assessments and counselling into growth monitoring, immunisation, and antenatal and postnatal care could normalise early preventive visits and routine mouth examinations. National guidelines for PHMs and Medical Officers of Maternal and Child Health could be updated to include standardised oral health promotion protocols, backed by practical training and supportive supervision [20].

Third, the local food and product environments in underserved settlements require attention. Policies that support affordable fluoride toothpaste, reduce the cost gap between healthier snacks and cheap sugary products, and regulate the marketing of sugar-rich foods to young children could help reshape the choice architecture facing parents [1, 16]. Collaboration with local vendors, as suggested by the participants, offers a practical entry point. Vendors can prominently display children’s toothbrushes and fluoride toothpaste, remind parents about oral care, and reduce the visibility of high-sugar snacks near payment areas.

Fourth, interventions should engage the wider family, including fathers and grandparents, who often act as gatekeepers of traditions and providers of sweet foods. Community meetings, group sessions at clinics, and targeted communication materials can address the beliefs that primary teeth are unimportant and that sweets are an essential expression of love. Peer examples and stories from local caregivers who have successfully changed their routines can serve as credible models [36].

Finally, efforts are needed to address emotional and motivational factors. Health workers can validate caregivers’ feelings of guilt and regret while emphasising that small and consistent changes can protect children from pain. Positive reinforcement, such as praising caregivers when improvements are observed at follow-up visits, was identified as a strong motivator and can be integrated into routine practice [37].

Implications for future research

Future work should build on this behavioural diagnosis to co-design and test specific intervention packages in collaboration with caregivers, health workers, community leaders, and local vendors. Cluster randomised or stepped wedge designs within urban settlements could assess the effectiveness and feasibility of combining education, skills training, and environmental changes for ECC prevention. Implementation research is needed to understand how best to train and support front-line staff to deliver brief, tailored behaviour change support within time-constrained clinics and home visits. Studies should also explore digital and low-tech reminder systems, such as mobile phone messages or visual cues in the home, that can support habit formation for twice daily brushing. Research that directly includes fathers, grandparents, and commercial actors would deepen our understanding of the social and commercial determinants of ECC in these communities. Economic evaluations could assess the costs and benefits of providing subsidised fluoride toothpaste or integrating oral health into existing child health packages, given the high human and economic costs of untreated ECC [7, 8].

Conclusion

This study used the BCW, COM-B, and TDF to examine ECC-preventive behaviours among mothers, caregivers, and key informants in Colombo’s underserved settlements. The results show that limited skills and knowledge, constrained social and physical opportunities, and complex motivational patterns combine to shape oral health behaviours for toddlers in this high-risk context. Simultaneously, caregivers expressed strong concern for their children and a clear willingness to engage in practical, supportive interventions. By providing a detailed behavioural diagnosis, this study offers a foundation for designing targeted, theory-based interventions and policy responses that are realistic for families living in urban informal settlements in Sri Lanka and similar settings.

Abbreviations

BCW

Behaviour Change Wheel

COM-B

Capability, Opportunity, Motivation, and Behaviour model

ECC

Early Childhood Caries

FGD

Focus Group Discussion

KII

Key Informant Interview

TDF

Theoretical Domain Framework

USS

Under-Served Settlements

WHO

World Health Organisation

Authors’ contributions

PLBCSK: Conceptualisation, Methodology, Investigation, Data Curation, Formal Analysis, Writing, & Original Draft Preparation. MSDW: Conceptualisation, Methodology, Formal Analysis, Review & Editing, Supervision. NCR: Conceptualisation, Methodology, Formal Analysis, Review & Editing, Supervision. All authors have read and approved the final manuscript and agree to be accountable for all aspects of the work.

Funding

This research was funded by the College of Dentistry & Stomatology of Sri Lanka- Grant number 2022/2023-01.

Data availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study proposal was submitted to the Ethics Review Committee of the Faculty of Medicine, University of Colombo, and approval was obtained (ERC No: EC 22–122). All methods were carried out in accordance with the principles of the Declaration of Helsinki. Participation in this study was completely voluntary and anonymous. After explaining the objective of the study and procedures (audio recording), written informed consent was obtained from parents and caregivers of the FGDs and key informants before data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.