Barriers and challenges of mothers’ participation in fluoride varnish program for children aged 3

Abstract

Background:

Early Childhood Caries (ECC) is one of the most prevalent global dental challenges, especially in Iran. The beneficial role of fluoride as an effective agent in the prevention of ECC is scientifically approved. Thus, this study was designed to explain the barriers and challenges of mothers’ participation in the Fluoride Varnish Program (FVP) for children aged 3–6 years.

Design and methods:

The present study was conducted with a qualitative approach and Directed Content Analysis method in 2021. Semi-structured interviews were conducted with 20 mothers of preschool children. The interview questions were asked based on the constructs of the PRECEDE-PROCEED model, and then the data analysis process was carried out simultaneously and continuously with the data collection based on Graneheim and Landman method.

Results:

According to the categories of predisposing factors (awareness, attitude, perceived threat, and self-efficacy), the data regarding reinforcing factors (family, peers, and health workers), and enabling factors (facilities, resources, and skills) were extracted.

Conclusions:

The findings provide valuable insights into the barriers and challenges faced by mothers to participate in the fluoride varnish program for 3–6 year old children. It seems that by addressing these factors, it is possible to design interventions to promote the participation of mothers and ultimately improve the effectiveness of the program.

Keywords

child fluoride varnish mothers oral health qualitative research

Background

Early Childhood Caries (ECC) is a type of tooth decay in infants and children, which is one of the most common dental problems in this era.¹ Premature tooth loss can lead to several challenges, including chewing problems, altered occlusion, phonation issues, and esthetic concerns.^2–4 According to the definition of the American Academy of Pediatric Dentistry, the presence of one or more decayed, missing, or filled primary teeth in children <71 months is defined as ECC.⁵ Various critical factors like poor nutrition, genetic predisposition, inadequate dental hygiene, dietary habits, cariogenic organisms (like Streptococcus mutans), lack of fluoride and vitamin D, high sugar consumption, prolonged bottle-feeding, and other effective factors such as age, gender, and place of residence can contribute to tooth decay in children.⁶ According to the WHO reports, dental caries in childhood with a universal prevalence of 60%–90% seems a critical global issue.⁷ Its prevalence in Iranian children is reported between 19.5% and 44%.⁸ ECC treatment is a costly and time-consuming issue for the family and dentist. In most cases, due to the lack of cooperation of children, the clinical treatment requires anesthesia and sedation, along with re-treatment due to the high recurrence rate.⁹

The role of fluoride as the most effective and important factor in the prevention of dental caries is confirmed scientifically.¹⁰ In recent decades, the administration of fluoride varnish (FV) has gained attention due to the intrinsic benefits including adhesion to the tooth surface which acts as a fluoride-release source accelerating the contact time of fluoride with the tooth. This feature is reported as quick, simple, and safe; thus, it is highly preferred for use in younger children.^10–14 The key mechanisms of action of fluoride varnish are¹³:

Sustained Fluoride Release: Fluoride varnish can adhere to the tooth surfaces and slowly release fluoride over an extended period, typically several hours to several days. This sustained fluoride release is more effective than a single, short-term application.

Remineralization Enhancement: The released fluoride ions diffuse into the enamel surface and promote the formation of fluorapatite. Fluorapatite is more resistant to acid demineralization than regular hydroxyapatite, thus enhancing the remineralization process.

Bacterial Inhibition: Increasing the concentration of fluoride may inhibit the metabolism of cariogenic bacteria, reducing their ability to produce the acidic byproducts that lead to enamel demineralization.

Enamel Strengthening: Systemic fluoride ingestion during tooth development can integrate with the tooth structure, converting hydroxyapatite into more acid-resistant fluorapatite. This makes the teeth more resistant to caries formation.

Numerous studies have demonstrated the effectiveness of fluoride varnish in reducing dental caries in children and adolescents. According to a study by Arruda et al.,¹⁵ applying fluoride varnish to the teeth twice yearly results in a 46% decrease in the number of decayed, missing, and filled tooth surfaces over 1 year. This evidence highlights the significant benefits of regular fluoride varnish application as a preventive measure to improve oral health outcomes in young populations.

Research shows that topical application of fluoride does not necessarily need to be provided by a dentist and can be done well by trained individuals. Mohebbi et al.’s study confirmed the ability of mothers to use fluoride varnish for preschool children and showed that mothers can play an essential role in improving the oral health of their children.¹⁴

Since 2013, after the implementation of the health system reform plan in the country, Iran, one of the measures taken in the field of health has been the application of fluoride varnish therapy in the age group of 7–12 years old in Iranian schools, which is carried out in 6-month periods by health workers and health care workers. and about 100% of primary school students receive fluoride varnish therapy. The increase in the number of decayed baby teeth in children aged 3–6 years and the good results of fluoride therapy for 7–12 year olds have led to the implementation of a fluoride therapy varnish plan for children aged 3–6 years.¹⁶ Iran formally expanded its fluoride varnish program to include preschool children (ages 3–6) nationwide in 2014. This initiative includes implementation in regions such as Kermanshah. The program is administered periodically (every 6 months) through urban and rural health centers.

Under this scheme, mothers of children in the target age group visit healthcare centers to receive essential instruction on the correct application of fluoride varnish. The necessary materials are subsequently provided for home application to their children. Program operation relies primarily on the registration of children’s age data within the health center system, followed by proactive follow-up by health caregivers.

Parental outreach and information dissemination are conducted via in-person education sessions at health centers, health-related text messages (SMS), and occasionally through kindergartens and community health posts.¹⁶

So, the qualitative methods can study behaviors, attitudes, and living experiences of people. This method may provide an in-depth understanding of individual experiences where quantitative approach methods cannot be used or where experiences, perceptions, and beliefs cannot be measured.¹⁷ Therefore, this qualitative study was conducted to determine the obstacles and problems of participation of mothers with children aged 3–6 in the FV program of Kermanshah City, Iran.

Methods

Type of study and approval of ethics committee

This qualitative research was conducted using the Directed Content Analysis method involving interpreting and analyzing the data content through a systematic classification of codes for the identification of patterns or themes.¹⁸ The prominent feature of Directed research is the initial coding based on previous findings or theories, but the concepts or themes are derived during the analysis process of data.

The study utilized the PRECEDE-PROCEED model (Phase 3: Educational and Ecological Diagnosis) as a theoretical framework to systematically identify barriers to maternal participation in the Fluoride Varnish Program. This model categorizes determinants of health behaviors into: (a) predisposing factors, (b) reinforcing factors, and (c) enabling factors, providing a structured basis for data analysis.¹⁹

Ethical consideration approval was obtained from the Kermanshah University of Medical Sciences, Iran. Also, verbal and written informed consent and introduction letter were obtained during the research process (introducing and stating the purpose of the study, data collection, and recording methods, and the role of the researcher and participants in the study).

Sampling, data collection, and inclusion criteria

Inclusion criteria were mothers of children aged 3–6 years who had either never participated in the Fluoride Varnish Program (FVP) or had participated initially but discontinued subsequent applications. After purposeful sampling (maximum variation sampling in terms of economic classes, education, occupation, and age), 20 mothers (12 never participated, 8 discontinued after initial use) participated in the study. The sampling process was applied until data saturation (no new data was obtained later).²⁰ During recruitment, 3 eligible mothers declined participation due to Lack of time, No participants dropped out after providing consent.

Data was collected in 2021 using semi-structured interviews (30–45 min per interview). Interviews using basic questions “Do you know what fluoride varnish is?” and “Do you know the use of fluoride varnish?” Was formed. During the interview, exploratory questions such as “Can you explain more?” It was used to provide details and reduce ambiguity.²¹ The questions were the same for each participant and the interview was conducted by the researcher. The interview was conducted by recording audio conversations of the interviewees in Persian language. The interview questions were designed based on the PRECEDE-PROCEED model and the researcher’s effort in interview guidance was applied using two main questions; (1) “What obstacles and problems cause you to not participate in the FVP?” and (2) “What factors can increase your participation in FVP?”. The goal of asking these questions was to determine the predisposing, reinforcing, and enabling factors for maternal participation, as well as to evaluate the management of the healthcare centers and ulti0mately design educational interventions based on the PRECEDE-PROCEED model to increase maternal participation in the fluoride varnish therapy program.

The researcher maintained observational field notes during interviews to document contextual details and non-verbal cues. Interviews were conducted in private rooms at comprehensive health service center of Kermanshah Pardis, Iran affiliated with Kermanshah University of Medical Sciences. This setting ensured participant confidentiality and aligned with the program’s implementation sites. Only the participant and researcher were present during all interviews to prevent third-party influence.

Interviews were conducted face-to-face by a trained female qualitative researcher (PH, NH; with a Master of Science in Public Health, experienced in qualitative methods including semi-structured interviews and directed content analysis, motivated by addressing gaps in maternal participation in preventive oral health programs, employed as a university researcher and unaffiliated with the FV program, and with no prior relationship with participants). Although data saturation (when new data no longer introduces new themes or codes) was achieved in interview NO 17, for more certainty, three more interviews were also conducted, but no new data was obtained, so a total of 20 mothers of 3–6 year old children were interviewed. No repeat interviews with the same participants were performed. Participants were informed that the interviewer was a university researcher not involved in the FV program delivery, ensuring neutrality and minimizing social desirability bias.

Quotations underwent English translation via a rigorous multi-step protocol. Initial translation was performed by a bilingual researcher (fluent in Persian and English). Subsequently, an independent translator conducted blind back-translation into Persian to verify conceptual equivalence. Ambiguous expressions were resolved through consensus discussions between translators and the research team. Translated quotations preserved original semantic content, emotional resonance, and colloquial expressions through contextual fidelity measures.

Analysis method

Data were analyzed simultaneously and continuously based on the Graneheim and Landman method.²² Two trained qualitative researchers independently coded the data using Graniham and Lundman’s framework.²² Inter-coder discrepancies were resolved through consensus discussions, with unresolved disagreements arbitrated by a third qualitative expert. Although coding commenced within the PRECEDE-PROCEED framework, the analysis remained open to emergent themes beyond the model. No novel overarching categories emerged. All data organization, coding, and thematic analysis were performed manually using physical documentation (transcripts, field notes, coding matrices). No qualitative data analysis software was employed. The five-stage of data analyses included; the first immediate interview implementation, the second reading of the provided text for a general understanding of the associated content, third determination of semantic units and primary codes, fourth classification of similar primary codes in more comprehensive classes, and fifth identification of the main topics for each class.

Study implementation process

Each recorded interview was implemented immediately after listening several times. In order to obtain an overall understanding of interview content, the implemented text was read, semantic units were determined and primary codes were extracted. Similar primary codes were classified into more general classes with main themes. To ensure the accuracy and the strength of data, four criteria proposed by Goba and Lincoln (1982) were used; the reliability index as a criterion instead of validity and reliability in qualitative research including Credibility, Transferability, Verifiability, and Reliability.²³ In order to increase the credibility of the data, the process of simultaneous analysis during data collection along with the sampling with maximum diversity (economic, social, education, age, and other categories) was considered until theoretical saturation. The credibility of the data was obtained through note reviewing by participants, the long-term involvement of the researchers, and their communication with the participants. Confirmability was obtained by not applying the personal opinions of researchers and assessment of the text of interviews, codes, and classes/subclasses extracted by the authors. In order to ensure the stability of the findings (Dependability), the interviews were implemented immediately and Experienced qualitative researchers were invited to review data analysis and conclusions (External Check) as well as the re-reading of the data were applied for this purpose. In order to assess the transferability, the participants with maximum diversity along with direct quotes (for better data expression) were used.

Results

The study included 20 mothers who met the inclusion criteria, with a mean age of 32.5 ± 4.35 years (min:23, max:41). Among participants, 12 had never participated in FVP, and 8 discontinued after initial use. 35% of the samples had an academic degree, 50% with the diploma, and 15% of the mothers had school education. 85% of the mothers were housewives and 70% had middle economic status. Three main categories of predisposing, strengthening, and enabling factors of promotion of mothers’ participation in FVP were formed based on the PRECEDE-PROCEED model (Table 1).

Table 1.

The categorization process.

Main category	Semantic unit	Code	Semantic unit
Predisposing	Awareness	Lack of information about fluoride varnish	“I don’t know what varnish is, I don’t know exactly, I understand from the word “fluoride” that it must be related to teeth.”
		Varnish is not necessary for this age	“I think it is not necessary for my child’s age.”
		Lack of confidence regarding the effectiveness of varnish	“I’m not sure about its effectiveness as I haven’t heard much about it.”
	Attitude	Ineffectiveness of varnish to prevent decay	“I am not sure if it is effective to prevent tooth decay.”
		Tooth discoloration following the use of fluoride varnish	“I think it will change the color of my child’s teeth.”
		Toxicity of fluoride varnish	“I feel that this substance is poisonous.”
	Perceived threat	Correlation of caries with tooth type	“In my opinion, everything depends on the type of teeth, for example, I don’t brush my teeth much and they are mostly healthy.”
		Permanent lack of milk teeth	“Baby teeth fall out, they are not permanent, why should I use chemicals for my child.”
	Efficacy	Not enough self-confidence to perform fluoride varnish therapy	“I don’t think I can do this and get away with it.”
		Fear of an accident during administration	“I am afraid that something will happen to my child while I am using.”
		lack of experience	“Even if they explain it to me, I still can’t use it for my child because I have no experience.”
Reinforcing	Family and peers	Wife’s opposition to use fluoride varnish for the child	“My wife does not allow to use it.”
		Child’s non-cooperation during fluoride varnish therapy	“My child does not cooperate at all and I cannot use it for her.”
		Not using acquaintances and the effect on individuals	“They gave it to my sister-in-law, but she didn’t use it either.”
		Not recommending the use of this method by the person’s relatives	“My mother says that these substances are harmful for my child.”
	Health workers	Failure to encourage the person by health workers	“Health workers did not talk to me about the benefits and harms, and I was not convinced.”
Enabling	Facilities and resources	Non-availability of fluoride varnish in medical centers	“When I visited the centers, there were no available centers.”
		Lack of practical guidance	“They did not show me a practical guide so that I can master this work.”
	Skill	Lack of familiarity with the way of application	“I don’t know how to use it, I received the varnish, but honestly, I didn’t know how to use it, so I threw it away.”

Predisposing factors increasing mothers’ participation in FVP

The main category of predisposing factors was extracted from four sub-categories of awareness, attitude, perceived threat, and self-efficacy:

A) Awareness: The extent of an individual’s knowledge and understanding regarding the nature, purpose, benefits, and procedures of Fluoride Varnish (FV) application. The present study represented that most of the participants contained no adequate knowledge and understanding regarding the FVP. For a better understanding, some direct quotes were presented as follows: “I don’t even know what varnish is!” (P4, diploma, never participated), “I don’t know exactly. I understand that the fluoride may be related to teeth.” (P9, diploma, never participated), “I think it is not necessary for my child’s age.” (P19, academic degree, discontinued after initial use). “I am not sure about its effectiveness; I did not hear so much about it.” (P13, diploma, never participated).

B) Attitude: The attitude is a personal belief regarding a subject. The present study showed that most mothers had no positive attitude toward children’s FV therapy. They also believed that the FV causes permanent discoloration of teeth and poisoning in children with no necessary efficiency. In this regard, some direct quotes were presented as; “I am not sure if it is effective to prevent tooth decay.” (P12, school education, never participated), “I think it will change the color of my child’s teeth.” (P6, academic degree, discontinued after initial use) and “I feel that this substance is poisonous.” (P2, diploma, never participated).

C) Perceived threat: The perceived threat is a combination of sensitivity and perceived intensity. In perceived susceptibility, a person feels the risk of contracting a disease. Perceived severity also indicates a person’s belief in the severity of a disease. Based on the findings of the present study and due to the temporary nature of primary teeth, the mothers were not able to detect the teeth decay as a serious threat to the health of future child’s teeth. Some direct quotes extracted from the interviews were presented as; “I think everything depends on the type of teeth, for example, I don’t brush my teeth very much, my teeth are mostly healthy.” (P19, academic degree, discontinued after initial use), and “My baby’s teeth are falling out permanently, so why should I use chemicals for my child.” (P5, academic degree, discontinued after initial use).

D) self-efficacy: The self-efficacy is a feeling of confidence regarding the implementation of an activity. In the present study, the mothers often had not enough confidence or self-confidence to perform the FV therapy for children. Some direct quotes were; “I don’t think I can do this and get over it.” (P20, diploma, never participated), and “I still can’t use it for my child because I have no experience.” (P4, diploma, never participated).

Reinforcing factors increasing mothers’ participation in FVP

The main category of reinforcing factors was extracted from the sub-category of the family role, peers, and health workers, as follows:

A) The role of family, peers, and health workers:

In the present study, the lack of encouragement and support of mothers by family and peers and the incomplete information of health workers regarding the Varnish Fluoride Therapy program were identified as an obstacle for mothers to participate in this program. Some direct quotes were; “My wife doesn’t allow me to use it.” (P17, academic degree, discontinued after initial use), “They gave it to my sister-in-law, but she didn’t use it either.” (P3, school education, never participated), “My mother says that these substances are harmful to my child.” (P5, academic degree, discontinued after initial use), and “I was not really convinced and sure that the health workers did not talk to me about the benefits and harms.” (P11, diploma, never participated).

Enabling factors increasing mothers’ participation in FVP

The main category of enabling factors was extracted from the two sub-categories of the availability of facilities, resources and skills:

A): Resources/Facilities:

In the current study, some mothers complained about not receiving fluoride varnish in health centers and insufficient education regarding the necessity and how to use fluoride varnish, which was identified as an obstacle to their participation in the fluoride varnish therapy program. An important direct quote was; “I went to the centers but it was not available.” (P14, academic degree, discontinued after initial use).

B): Skill:

The skill is the ability to perform a task with minimum errors and maximum quality. In the present study, some mothers had no application of FV therapy for their children due to their inability to perform this procedure. An important direct quote was; “I don’t know how to use it.” (P15, diploma, never participated), and “I received the varnish, but I honestly didn’t know how to use it, so I threw it away.” (P13, diploma, never participated).

Discussion

This qualitative study aimed to identify barriers and challenges to maternal participation in the Fluoride Varnish Program (FVP) for children aged 3–6 years in Kermanshah, Iran. Findings revealed that maternal participation is influenced by three key categories of factors based on the PRECEDE model: predisposing factors (including insufficient awareness of program benefits, negative attitudes toward tooth discoloration or fluoride toxicity, low perceived threat of primary tooth decay due to their temporary nature, and inadequate self-efficacy in varnish application); reinforcing factors (such as lack of family/peer support and insufficient guidance from healthcare staff); and enabling factors (limited access to equipment and technical skills). These challenges highlight the necessity of designing comprehensive interventions to enhance awareness, correct negative attitudes and threat perceptions, strengthen maternal self-efficacy, mobilize social support, and facilitate access to resources and skill development in FVP application. Such measures are essential to improve maternal participation and program effectiveness in preventing Early Childhood Caries (ECC).

The level of information and awareness of mothers in the field of oral and dental health seems a critical factor including the importance of primary teeth, tooth decay, and the methods of prevention of caries and observation of oral/dental hygiene. In this regard, knowledge has an important effect on the type of attitude leading to the critical basis of appropriate health behavior.²⁴ According to the conducted interviews, it seems that mothers do not have much knowledge about the fluoride therapy varnish program. In this regard, Rahaei et al. stated in their study that mothers’ awareness of the role of fluoride in preventing tooth decay and fluoride varnish therapy programs had been inadequate, attributing this to insufficient parental education by dentists and schools as well as lack of adequate attention by mothers to the fluoride varnish program.²⁵ Other studies, including the study by Far et al. and Faezi et al., showed that most mothers had moderate to poor knowledge about the oral and dental health of preschool children.^26,27 In the study of Alkhtib and Morawala, a total of 48% of mothers believed that children should brush their teeth from the age of 3, and 42% stated the age <2 years as the starting age for teeth brushing. More than half (54%) of mothers believed that there was no necessary need for children to use dental floss. The results of this study detected an important need for oral health promotion programs to fill the knowledge gaps of mothers regarding oral/dental health care for young children.²⁸

In addition to the presence of correct and sufficient information, a positive attitude is essential for the formation of health-promoting behaviors. In this research, according to the interviews conducted, it seems that most mothers do not have a positive attitude toward fluoride varnish therapy for children, and they believed that fluoride varnish causes permanent changes in the color of teeth, causes poisoning in children and does not have the necessary efficiency. In this regard, Jafari and Naseri conducted a study with the aim of investigating the beliefs and ambiguous points that hindered the favorable cooperation of families to participate in the Fluoride Varnish Therapy program, and the results of the study showed false beliefs such as irreversible discoloration of teeth, Decreased intelligence, carcinogenicity, poisoning and sensitivity prevent the optimal participation of mothers in the fluoride varnish therapy program, which requires the education of mothers by health workers and dentists.²⁹ Other studies, including the study of Hendaus et al. and Rahmatzadeh et al., showed that most parents expressed concerns about the safety of fluoride varnish, the main concern of parents was swallowing fluoride by the child.^30,31

Ignoring the possibility of children suffering from early tooth decay by mothers will have serious consequences. According to the interviews conducted, it seems that mothers did not see caries in the primary teeth as a serious threat to the health of the child’s teeth in the future due to the temporary nature of the primary teeth, This finding was also confirmed by Sahrayi et al. Therefore, in the interventions, sufficient attention should be paid to arousing parents by sensitizing them to children’s oral and dental health in order to understand the serious threat caused by this issue.³²

Self-efficacy is generally a person’s belief in his ability to successfully perform a specific behavior, which can affect a person’s thoughts, feelings, motivation, and actions.³³ According to the conducted interviews, it seems that most mothers do not have enough self-efficacy to perform oral and dental health care for children, including fluoride varnish therapy. Self-efficacy is one of the behavioral barriers of mothers to protect children’s oral and dental health. In this regard, studies have shown that there are various barriers to maintaining oral and dental hygiene in preschool children, such as high costs, low self-efficacy, fear, misconceptions about restoring primary teeth, not cooperating and not having time for dental care.^34,35 Wilson et al. stated that mothers’ self-efficacy is an important predictor for children’s oral health care.³⁶ This barrier can prevent mothers from taking preventive steps for oral health care. By addressing this barrier, health care providers and policy makers can empower mothers to take a more active role in their child’s oral health.

It seems that people around a person can play an important role in improving oral and dental hygiene behaviors. According to the conducted interviews, lack of encouragement and support of mothers from families, insufficient provision of information by health workers as a reliable source and not sharing the experiences of peers with each other were raised as an obstacle for mothers to participate in the Varnish Fluoride program. In this regard, studies have found the role and effect of families and the support of social groups to be effective in adopting oral and dental health behavior.^37–39 Also, according to the findings of Mazaheri et al.,⁴⁰ Solhi et al.,⁴¹ and Mazloomi Mahmoodabad and Roohani Tanekaboni,⁴² Healthcare workers are recognized as a pivotal conduit for health information dissemination. However, their current performance necessitates improvement. To enhance effectiveness, it is imperative to implement more innovative training methodologies specifically targeting vulnerable populations. Furthermore, strengthening cross-sectoral collaboration—encompassing health, education, and family systems—is essential for sustainable health behavior modification.

It appears that insufficient resources and facilities constitute a significant barrier to adopting preventive oral health behaviors. In our study, some mothers reported inadequate provision of fluoride varnish at healthcare centers, coupled with insufficient education regarding its necessity and proper application. Similar to Montazeri et al.’s study on barriers to accessing pediatric dental services in Tehran, when it comes to accessing fluoridation and fissure sealing services, these are received by less than half (45.38%) of children. Also, because of a lack of infrastructure for imparting health education to parents, very often, oral hygiene of the children is overlooked. Preventive services curtail the need for future treatments and emergency visits, and such barriers will have to be addressed to bring behavioral change in oral health.^43,44 In addition to receiving facilities and material resources, it is also necessary to receive information from reliable sources. Burgette et al. stated that mothers receive information about fluoride from different sources including family, community members, friends, and dentists, which causes them confusion, so it is necessary that mothers get information sources from dentists and health workers who are reliable sources in this regard.⁴⁵

Lack of skills appears to be a barrier to mothers’ participation in the children’s therapeutic fluoride varnish program. In the present study, the results of the interviews showed that some mothers do not use fluoride varnish therapy for their children, even if they receive fluoride varnish, due to their inability to do it. In this regard, Faezi et al. stated in their study that the performance of mothers regarding the care of children’s mouth and teeth is insufficient and the reason for this is lack of information and insufficient training.²⁷ Therefore, by conducting educational interventions, parents should be made aware of their influential role in the child’s oral and dental health and his health behaviors. These interventions should empower parents’ abilities to improve health behaviors.

Strengths, limitations, and suggestions

Among the strengths of the current study, we can mention things like the use of face-to-face interviews to collect data, which resulted in receiving spontaneous and sincere answers from parents. In addition, there was no relationship between the interviewer and the participants. They were asked to speak frankly and express their problems openly. The interviewer did not comment on the behavior of the participants during the interviews so that they could talk freely. Despite the small number of participants, the sample size was appropriate given the qualitative methodological approach, emphasizing the purposive selection of information-rich cases that provided in-depth data.

This study also had some limitations, such as the fact that the current research was conducted only in one region of Kermanshah city, Iran and since there are cultural and social differences among the regions of the country, one should be careful to generalize the results of the research to other regions. Therefore, it is suggested that in future researches, the obstacles and problems of participation of mothers in Fluoride Varnish Therapy program who live in other regions should be investigated in order to obtain more comprehensive results.

According to the findings of the present study, in order to promote the participation of mothers in fluoride varnish therapy program, comprehensive programs with the approach of empowering mothers in health planning should be considered. Also, in order to remove the identified obstacles, in addition to revising the current programs, it is recommended to implement support and training programs for all the people involved, including mothers, families, peers and health workers.

Conclusion

This qualitative study aimed at the identification of barriers or challenges faced by mothers in engaging in the fluoride varnish program for children in the age range of 3–6. The barriers identified were categorized according to the PRECEDE theory: predisposing factors (awareness, attitude, perceived threat, and self-efficacy), reinforcing factors (family, peers, and health workers), and enabling factors (resources and skills). Knowledge about the type of barriers would help policymakers, health-care providers, and program developers to actively develop programs and implement strategies to solve the identified challenges, thereby increasing participation rates of mothers with 3- to 6-year-old children in the fluoride varnish program.

Footnotes

Acknowledgements

The cooperation and participation of the Department of Health Education and Promotion, School of Health, Kermanshah University of Medical Sciences is gratefully acknowledged.

Abbreviations

ECC: Early Childhood Caries

FVP: Fluoride Varnish Program

FV: Fluoride varnish

ORCID iD

Masoud Mohammadi

Ethical considerations

The Ethics Committee of Kermanshah University of Medical Sciences (IR.KUMS.REC.1401.014) approved the study. All procedures performed in this study were performed in accordance with the ethical standards contained in the Declaration of Helsinki and its subsequent amendments or comparable ethical standards.

Author contributions

PH, SS, and NH contributed to the design, MM, NS, and AA prepared the manuscript. SS, NH, PH, and MM assisted in designing the study, and helped in the, interpretation of the study. All authors have read and approved the content of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: By Deputy for Research and Technology, Kermanshah University of Medical Sciences (IR; 4010093). This deputy has no role in the study process.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Datasets are available through the corresponding author upon reasonable request.

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