Accepted for/Published in: JMIR Pediatrics and Parenting
Date Submitted: Feb 6, 2025
Date Accepted: Sep 10, 2025
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Co-designing a Short Message Service Intervention (SmilesUp) using behavioural theory to address Early Childhood Caries: A mixed methods study
ABSTRACT
Background:
Early childhood dental caries (ECC) remains a common childhood condition affecting 600 million children worldwide. Providing parents with support for oral health behaviour change can address ECC risk factors and complement preventative clinical care. Mobile Health (mHealth) text message programs that are co-designed and evaluated by parents and health professionals using behaviour theory have been shown to be effective in improving oral health outcomes.
Objective:
The objective of this study was to describe the co-design process, development and content evaluation of a text message program designed to promote oral health behaviour change among parents of children diagnosed with ECC using the Behaviour Change Wheel (BCW) framework.
Methods:
The SmilesUp mHealth program was codesigned with parents in two stages using the Behaviour Change Wheel (BCW) framework, a widely used theoretical framework to underpin miHealth programs, recommended by the WHO. Through focus groups with parents in phase 1, the BCW framework was utilised to understand parental perspectives by identifying barriers and enablers and selecting target behaviours that could be feasibly delivered within a mHealth intervention. Barriers and enablers were mapped to the relevant theoretical domains and behaviour change techniques (BCTs) of the BCW framework. Phase 2 evaluated the content acceptability measured by (understandability, usefulness and appropriateness) of the program through questionnaires with parents and health professionals. Highly rated messages were finalised into an algorithm for the SMS text message program delivery.
Results:
In Phase 1, the overall target behaviour was parental behaviour change to support good oral health including oral hygiene, dietary sugar intake and bedtime routines for their children. The five intervention functions focused on education, training, persuasion and enablement, and 16 BCTs focused on addressing the motivation enablers and knowledge gap barriers identified by the parents. 111 draft health messages were developed and mapped to the BCTs. In Phase 2, a total of 2,045 reviews of the 111 draft messages were completed by parents (n=14) and health professionals (n=17). Parents rated 86 messages and health professionals rated 68 as understandable, useful and accepted. The messages that were considered understandable, useful and appropriate by both groups were incorporated into SmilesUp 12-week semi-personalised SMS message program.
Conclusions:
The SmilesUp program, uses behavioural theory to address knowledge gaps in tooth brushing, diet and bedtime routines identified by parents. It provides parents with convenient bite-sized nudges of information to support oral health-promoting behaviours in the home context. Robust content development and evaluation is a crucial initial step before further investments are made to conduct a clinical trial to assess the effectiveness of the program. Clinical Trial: N/A
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