Exploring schoolchildren’s perspectives on oral health in a disadvantaged neighbourhood in The Hague - a participatory action research project

Abstract

Background and aim

Dental caries is the most common childhood disease worldwide, including the Netherlands. Children from low socioeconomic backgrounds and migrant communities are at high risk. This study aimed to explore the perspectives of schoolchildren (9–13 years), from a low socioeconomic neighbourhood in The Hague with a high immigrant population, on oral health, oral health behaviours, oral health professionals and dental care, as well as the root causes and the outcomes of oral health problems. A secondary aim was to co-create suitable oral health interventions with the children.

Methodology

The study used a Participatory Action Research (PAR) approach involving 9 focus group discussions (FGDs) with 45 children, semi-structured in-depth interviews with 4 children, 3 informal conversations with adult stakeholders (the school’s principal, a teacher, and a women’s group ‘SW mothers’ consisting of 24 women), participant observation in the neighbourhood, and food diaries from 7 children. The research team immersed themselves in the community for 8 months. The study comprised three phases with the children: 1) exploring children’s perspectives on oral health, 2) identifying root causes and outcomes of oral health problems constructing a ‘problem tree’, and 3) co-creating solutions. In phase 4 data were analysed using thematic analysis, and findings were structured according to the Fisher-Owens model, highlighting child-level, family-level, and community-level influences on children's oral health.

Results

Children demonstrated oral health knowledge, understanding links between diet, oral health, and social status. They reported conflicting perspectives towards dental professionals, who were seen as kind, but also scary, leading to low dental care utilisation. Poverty in the neighbourhood contributed to ‘parentification’. Children were often responsible for their own and their siblings’ diet and oral health. Although health initiatives existed, cultural traditions and the local unhealthy food environment influenced dietary habits.

Conclusion

While children understood the importance of oral health, socioeconomic and cultural factors hindered their ability to act upon their knowledge. Poverty and the local food environment were identified as key challenges. This PAR project raised awareness, empowering children to drive positive change and share knowledge with their community through a self-made YouTube video and folder on toothbrushing, regular dental visits and healthy eating.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-025-06347-x.

Introduction

Dental caries is the most prevalent chronic disease globally and the most common childhood disease [1]. Worldwide, 486 million children suffer from dental caries, also known as tooth decay [2]; and 5% of children do not have access to a toothbrush [3]. Untreated dental caries often results in toothache, making it difficult for children to eat and sleep. This affects their growth, and contributes significantly to school absenteeism, which can harm their future [1].

Dental caries disproportionately impacts children with low socioeconomic position (SEP), emphasizing the urgent need for targeted oral health interventions in underserved communities lacking sufficient access to education and dental care [2]. In deprived areas in the UK, up to 50% of five-year-olds suffer from dental caries, impacting their diet, speech, sleep, quality of life, and school attendance. A new report proposes measures such as banning energy drink sales to under-16 s, expanding sugar taxes, and implementing school toothbrushing programmes to address England’s childhood ‘oral health crisis’[4]. In the Netherlands, children from low socioeconomic positions (SEP) exhibit high rates of dental caries too. Moreover, the mother’s migration background impacts the caries risk significantly [5]. In 2018, in a low SEP group, 22% of 5-year-olds had dental caries if their mother was born in the Netherlands and this percentage increased to 74% if their mother had a migrant background [5].

In The Netherlands, the Schilderswijk (SW) in The Hague is one such a low SEP neighbourhood. Home to approximately 31,300 residents, 91% of whom have migrant backgrounds. It is a highly multicultural area, with 149 nationalities or cultures, and a mix of second and third generation migrants [6, 7]. 54.5% of its inhabitants have a low education level [8]. It is one of the poorest neighbourhoods in The Netherlands [9], whose inhabitants are daily facing various problems, such as poverty, financial stress and debts, language barriers, and domestic violence [10]. A significant proportion (65%) of the population lives on a minimum income [7]. Additionally, the neighbourhood has limited outdoor spaces for children to play or practice sports, few trees, and mainly concrete housing. Dangerous traffic and littered streets pose additional challenges. Children in the SW-neighbourhood face significant oral health challenges, with dental caries being particularly prevalent. In The Hague, over 24% of children (0—17 years) do not visit a dentist, and this percentage is 34% in young children (0—4 years). Additionally, 25% of the young children (0—4 years) already have or had cavities, with rates in some areas of the city, like the SW-neighbourhood, reaching 52% [11]. Access to dental care in this neighbourhood is also limited, with only four general dental practices available in addition to youth dental care services. Numerous barriers hinder children in low socioeconomic regions from accessing dental care and maintaining optimal oral health. Additionally, cultural practices and beliefs can adversely impact oral health and dental conditions, further contributing to challenges in seeking professional dental services [12, 13].

In the past, research on children’s oral health has primarily been conducted through the perspectives and voices of adults, such as parents and dental professionals. Nonetheless, studies focusing on children's own experiences and viewpoints remain scarce. This exclusion risks shaping policies and practices that fail to accurately address their needs, experiences, and priorities [14]. Marshman et al. state children’s voices are often under-represented in dental research [15]. In other words, most research on children’s oral health has been conducted on them rather than with them. Although the volume of research involving children has increased significantly between 2006 and 2014, there remains a critical need for studies that actively incorporate children’s perspectives [15]. Integrating their voices into the evaluation of dental treatments can lead to better treatment outcomes tailored to their needs. Consequently, a significant gap persists in the literature regarding a comprehensive understanding of children’s oral health from their own point of view.

Since the adoption of the United Nations Convention on the Rights of the Child, children have been regarded as active agents with the capacity to act, shape their own lives, and influence others [16]. Fortunately, pioneering studies increasingly acknowledge children’s agency, integrating their experiences and perspectives into dental research. Bhatti et al. [17] emphasize that comprehending the context and triangulating the perspectives of various stakeholders—such as children, parents, and dental teams—engaged in preventive oral health discussions for young children is crucial. This process is a critical step in the co-creation of a complex oral health intervention. Gaining insights into the experiences and context of those involved, as well as identifying their specific needs, forms a vital foundation for initiating discussions on oral health behaviour change [17]. Parmar et al. conducted an evaluation of the Bright Smiles Bright Futures (BSBF) programme with children in Australia, obtaining insights into their perspectives on the intervention [18]. They emphasized the importance of actively engaging children in oral health promotion initiatives, as this involvement offers valuable insights that can inform more effective strategies and policies.

A Participatory Action Research (PAR) approach is ideally suited for conducting research with children, because PAR assumes that communities or stakeholders affected by a certain problem should be engaged in defining, developing solutions and making decisions [19, 20]. PAR proves especially effective in empowering marginalized and hard-to-reach populations [21]. PAR adopts a participatory and democratic approach to produce knowledge [22] through an evolving process undertaken in a spirit of collaboration and co-inquiry, in which research is done with people rather than on them or for them [23]; with its dual objectives to address real life issues and to contribute to science [24]. Lems et al. highlight how adolescent participation in PAR in disadvantaged neighbourhoods fostered the co-creation of health promotion materials, enhancing awareness and promoted personal empowerment for healthy living [21]. PAR can also incorporate creative activities, making it suitable for younger children. Activities such as drawing, writing, walking and playing help children express themselves and share personal or sensitive topics effectively [25]. Moreover, a participatory approach recognizes children as ‘experts in their own lives’, highlighting the significance of their perspectives and experiences as valuable sources of knowledge [14].

By using a Participatory Action Research (PAR) approach this study aimed to explore the perspectives of SW schoolchildren’s (9–13 years) on oral health, oral health behaviours, oral health professionals and dental care, as well as the root causes and the outcomes of oral health problems. A secondary aim was to co-create suitable oral health interventions with the children.

Methods

Ethical permission

Ethical approval was granted by the Academic Centre for Dentistry Amsterdam (ACTA-ETC, protocol number 2021–49543). The study was promoted via school-distributed information letters. Written informed consent was obtained prior to participation for all participants and parental written informed consent was obtained for all children under the age of 16. All children gave verbal consent. Participants were reminded of their right to withdraw anytime without consequences. This study was executed according to the WMA Declaration of Helsinki 2013. Participants received oral health products, including bamboo toothbrushes, fluoridated toothpaste, comprehensive toothbrushing instructions, and oral health education. Healthy snacks and drinks were provided during activities.

Participant recruitment and eligibility

Participants were selected using purposive sampling. The main location was a primary school with 200 children in the Schilderswijk (SW-neighbourhood), The Hague, where the oral health interventions were also implemented. Children in grades 4–6 (ages 9–13) were invited to participate through information letters. Participants, who lived locally and attended the school, were Dutch children and children of first-generation migrant parents from diverse cultural backgrounds: Ghanaian, Eritrean, Ethiopian, Somali, Sudanese, Moroccan, Turkish, Tunisian, Egyptian, Syrian, Pakistani, Antillean, Surinamese, Chinese, Spanish, Bulgarian, Ukrainian, Polish. The research team also visited a nearby community centre, a supportive space for the neighbourhood. The research team engaged with adult stakeholders—including the principal, a teacher, and a women’s group (‘SW mothers')—through informal conversations held at the primary school and the community centre.

Approach

The study used a PAR approach involving 9 focus group discussions (FGDs) with 45 children, semi-structured in-depth interviews with 4 children, 3 informal conversations with adult stakeholders (the school’s principal, a teacher, and a women’s group ‘SW mothers’ consisting of 24 women), participant observation in the neighbourhood, and food diaries from 7 children to verify and confirm the information received from the children. The COnsolidated criteria for REporting Qualitative research (COREQ) checklist [26] was used when writing down the results of this study. This checklist can be found in supplementary file 1.

The research team, trained and guided by the project supervisor (AEG) on PAR methodologies and ethical responsibilities, comprised six female researchers: one supervisor who is a dental hygienist, medical anthropologist, and action researcher (AEG), two dental hygiene students, and three dental students. Over 8 months, the research team actively engaged with the SW-neighbourhood, immersing themselves in its context and the children’s living environment through participant observation and involvement in local activities at both the primary school and the community centre. Engaging with children's living environments offers deep understanding of their daily lives, living conditions, and interactions with their parents and cultural context [25]. Connecting with children’s living environment also means connecting to their community.

There were three phases of research with the children: Phase 1—The children’s perspectives on oral health, oral health behaviours, oral health professionals and dental care were explored (FGDs 1–3); Phase 2—After an interim analysis, together with the children, the root causes and the outcomes of oral health problems were identified, rated on the basis of importance, and organised in a problem tree (FGDs 4–7); and Phase 3—Possible solutions were explored and oral health interventions were co-created (FGDs 8–9), see Fig. 1.

Fig. 1.

flowchart of the four phases of data collection and analysis

Four children were interviewed in-depth to provide more detailed insights into the topics mentioned above (Phase 1; interview guide see supplementary file 2). FGDs and interviews were conducted until data saturation was achieved. FGDs lasted approximately one hour and interviews 30–45 min.

In addition, 3 informal conversations were held with adult stakeholders: one with the SW mothers, consisting of 24 women, one with the school’s principal, and one with a teacher, to verify and confirm information from the children (Phase 1). The SW mothers is a women’s group at the community centre and are the ‘eyes and ears’ of the SW-neighbourhood, supporting up to 600 women with advice on domestic violence, dental care, children’s addictions, and healthy eating [27].

The socioeconomic factors and living conditions were studied by participant observation throughout the presence of the researchers at school and in the SW-neighbourhood (Phase 1). Participant observation (PO) is a research methodology, typically used in fields such as anthropology, sociology, and other social sciences, in which the researcher is immersed in the day-to-day activities of the participants; differing from naturalistic observation as the latter does not involve interaction between the researcher and participants [28].

Finally, two-day food diaries completed by seven children provided insights into their daily eating and drinking patterns, including the types, quantities, and healthiness of their food intake (Phase 1).

Research activities during focus group discussions

During the focus group discussions (FGDs), the research team collaborated with the children, actively engaging them in the research process. At the beginning of each FGD participants were asked to respect one another’s opinions and to maintain confidentiality. The FGDs were held in a familiar school room used for parent-teacher meetings (Fig. 2a). To foster engagement and maintain eye contact, participants were arranged in a circle around a big table [18]. By doing creative activities or exercises together with the children, we hoped that they could express themselves freely. Engaging in activities with children reduces barriers to self-expression and fosters opportunities for them to share personal or sensitive topics of their choice [25]. Water and healthy snacks, including tomatoes, cucumbers, popcorn, and grapes, were provided to help the children feel at ease before starting the exercises. The sessions began with introductions, where participants shared their cultural background, heritage, and age.

Fig. 2.

a-f focus group activities: children's oral health perspectives (a, b), food choices (c), problem tree (d), toothbrushing (e), and discussion results (f)

Focus group discussions: exploring children’s perspectives on oral health, oral health behaviours, oral health professionals and dental care (Phase 1)

In the first three focus group discussions (FGDs 1–3), the research team and children explored their perspectives on oral health (OH), oral health behaviours, oral health professionals and dental care through various meaning-making exercises.

• The perspectives on OH professionals and dental care: Using laminated plates showing oral health professionals, children wrote their associations and perspectives on sticky notes (Fig. 2a, b and f). The research team asked them to elaborate, recorded their answers and gained insight into their thoughts, feelings and perspectives. The children were invited to organise their sticky notes into themes. Finally, the research team summarized and verified their understanding of the responses.

• The perspectives on oral health & OH behaviours: In groups of three, children were asked to care for a"toothbrush animal", demonstrating proper care, including toothbrushing, oral health materials, toothpaste use, and creating a healthy diet. The research team prompted them to explain their choices.

• Healthy and unhealthy dietary habits in relation to OH: Laminated pictures of healthy and unhealthy food from municipal healthcare services (Fig. 2c) were used for health education. The children categorized the images into healthy and unhealthy sections to demonstrate their knowledge of a healthy diet, followed by discussions on healthy eating.

• Toothbrushing instructions: The focus group ended with a demonstration of the ‘Bass method’ of toothbrushing using a large teeth model (Fig. 2e), with two children practicing the technique on the teeth model afterwards. All participating children received bamboo toothbrushes and fluoridated toothpaste as a token of appreciation.

The last two interactive activities raised awareness about food and oral health in an engaging way.

Focus group discussions: identifying the root causes and the outcomes of oral health problems and co-creating a ‘problem tree’ (Phase 2)

Four focus group discussions (FGDs 4–7) were held to examine children's views on the root causes and outcomes of oral health problems. Subsequently, the children engaged in a participatory analysis, where they rated and thematically categorized the root causes and outcomes, collaborating with the research team to co-create a ‘problem tree’.

• Associations with healthy or unhealthy teeth: Using laminated plates of a well-known figure with healthy teeth (e.g. Barack Obama) and an unknown individual with unhealthy teeth, children noted five associations for each image on sticky notes, elaborated on their reasoning and rated the associations from 1 (not important) to 10 (very important). The sticky notes were then grouped on flipcharts, and the team summarized and verified their understanding.

• Root causes of oral health problems: Children participated in an exercise to identify the root causes and outcomes of oral health problems in the SW-neighbourhood. They grouped root causes and outcomes on a large flipchart sheet, rated their importance (1–10), and discussed their views on the causes and consequences of dental caries (Fig. 2d). By thematically organising and rating the root causes and outcomes the children actively participated in the analysis and hence co-created research outcomes.

• Problem tree: Using the root causes and outcomes of dental caries identified by the children, we co-created a ‘problem tree’ (Fig. 2d). The research team then summarized the children’s responses to verify understanding and extracted the main causes for oral health problems (Fig. 2f).

• Toothbrushing demonstration: same as described in Phase 1.

Focus group discussions: defining solutions and co-creating oral health interventions (Phase 3)

With twelve 5th graders, we co-created two oral health interventions, which was the secondary aim of this research. Over two sessions (FGD 8–9 in Phase 3), revisiting exercises 1–3 from Phase 2, children proposed creative and actionable solutions to reduce oral health problems and to raise oral health awareness in the SW-neighbourhood. They were encouraged to propose realistic initiatives that they could implement themselves, with the aim of extending their influence on their families and other community members, including those at school and the community centre. Based on their input, we co-developed a YouTube video on oral health and a folder on toothbrushing, dental visits, and healthy eating.

Final analysis (Phase 4)

Focus group discussions and interviews were recorded and transcribed verbatim, with field notes taken after informal conversations and participant observation. The research outcomes stemming from children’s interactive engagement in meaning-making activities (Phase 1, 2 & 3) and the participatory analysis resulting in a ‘problem tree’ (Phase 2) served as primary data. During the final analysis (Phase 4) the research team analysed transcripts from focus groups and interviews (participant-generated data), field notes from informal conversation and PO (researcher-collected data), and food diaries, using thematic analysis, as outlined by Braun and Clarke [29]. This analysis followed five steps: (1) familiarizing with the data; (2) generating relevant codes; (3) generating themes and sub-themes; (4) assessing the themes; and (5) defining and naming the key themes. Thematic analysis is a valuable qualitative approach for applied or health research and studies conducted outside academia, such as in policy or practice [30]. Data was organised, analysed and managed using Atlas t.i. version 22.2.4. The research team cross-checked the themes from the ‘problem tree’ with themes from their thematic analysis of transcripts and fieldnotes. Consistent results among 6 coders provided triangulation. An inductive and iterative approach derived theory from the data, with final themes structured according to the Fisher-Owens model: child-level, family-level, and community-level influences on children’s oral health [31].

Results

Between October 2021 and June 2022, we conducted 9 FGDs with 45 children, 4 semi-structured interviews with children, 3 informal conversations with adult stakeholders, participant observation, and the collection of food diaries from 7 children. Findings highlighted various factors at the child-, family-, and community-level that influence children’s oral health. Accordingly, we organized the primary themes based on the framework of the Fisher Owens Model.

Children’s problem tree

Children actively participated in meaning-making activities during the FGDs, where a ‘problem tree’ was co-created through a participatory analysis (Fig. 3). Data from these interactive exercises largely aligned with thematic analysis of transcripts and fieldnotes, uncovering neighbourhood issues unintentionally recognized by the children.

Fig. 3.

Problem tree, co-created with the children

Children attributed poor oral health to root causes such as genetic susceptibility to cavities, poverty limiting access to oral health products, and challenges faced by migrants, including limited healthcare knowledge, and language barriers. They mentioned cultural practices like toothbrushing with a miswak. Parents often avoided dental visits, and access to dental care in the area was poor. Dental fear, linked to intergenerational trauma, was common. An unhealthy lifestyle, including high sugar consumption, particularly through sweets and soft drinks, skipping toothbrushing, and teenage habits of smoking and alcohol use, exacerbated the problem.

Children identified the outcomes of poor oral health as cavities, pain, bad breath, rotten or broken teeth requiring extractions, and difficulty eating, which impacted overall health. Shame and reluctance to smile due to poor oral health also hindered social interactions. When children visited dentists, it was often too late for effective treatment.

Final analysis revealed greater depth and richness in children’s responses than initially perceived. Some themes were confirmed, while others proved less significant through thematic analysis of transcripts and fieldnotes. Below, themes are elaborated and supported by quotes.

Children’s oral health knowledge

Children from the SW-neighbourhood demonstrated sufficient knowledge of oral health practices, including the importance of brushing twice daily with fluoridated toothpaste and the reasons behind it. They expressed this understanding through their responses: “Because taking care of your teeth prevents you from having dirty teeth and cavities.” “In toothpaste there is fluoride, it makes your teeth white and that protects against plaque.” and “You also must brush your tongue…. Because if you don’t (brush it), your breath smells in the morning.” (FGDs).

In general, children preferred to brush manually: I have two toothbrushes, the one that you gave me (manual toothbrush) and an electric one. I prefer (to use) the one you gave me. I really don’t like the electric one.” Although they possess oral health knowledge, this does not consistently translate into improved oral hygiene behaviors, as children mention they did not always brush a day and many children in the area were observed to have dental caries.‬‬‬‬‬ “They don’t manage to brush twice a day, because they are lazy, and I am often not in the mood too. If I am sleepy, I don’t brush my teeth. I am going straight to bed.” (FGDs).‬‬‬‬‬‬‬‬‬‬‬‬

Importance of healthy teeth

Children recognized the connection between good oral health and social status. During the FGD, when shown images of a well-known figure with healthy teeth (e.g., Barack Obama) and an unknown individual with unhealthy teeth, they shared their thoughts:”A president needs to have good teeth, just like a nice house and a nice car.” and “And they (famous people) have a lot of money so they can go to the dentist, bleach their teeth, buy an electric toothbrush and toothpaste.” Another child said: “I have to take care of my teeth, so they can stay clean, so when I’m a professional footballer my teeth are nice and clean, I don’t want my teeth to rot like this person (unknown person with unhealthy teeth).” (FGDs).

Experience with oral health professionals

Children recognized the importance of biannual check-ups by oral health professionals to maintain healthy teeth. While they referred to all oral health professionals as dentists, they could distinguish between dentists and dental hygienists: “The dentist looks at your teeth (to fix or fill) them, but if it needs cleaning then you get an appointment for the dental hygienist. Then they look at your teeth and what you can do about it to get your teeth clean.” (FGDs).

Many children experienced dental anxiety, often rooted in uncertainty about what to expect during appointments. One child voiced this concern: “A friend of mine wrote down “I don’t feel safe.” He wrote it a bit for fun, but he used to go to the dentist and usually when he was there, people grabbed him hard, and put him right on the chair, and he screamed in pain, but they went right on anyway. With me, they had pulled out a molar too and then I had to cry because it hurt… I was also scared one time because ‘the gun’ used to fill a cavity is very big. The dentist said: don't get scared, but it looked very scary.” (FGDs). Another child described the dentist as ‘a monster’ and explained why when prompted: “Because the dentist is not nice, he is annoying." His friend said: “That spinning thing (the drill)…it tickles…. It’s scary…. Because they are either going to look or…if you have a hole, they are going to fill it.” and “I think the sharp instruments are scary.” (FGDs). We learned that dentists in this area are often not very child-friendly, except those at the youth dental service. Some children have been traumatized by unpleasant past dental experiences.

In contrast, some children viewed dentists positively, describing them as “pretty girls” and “lovely people” and enjoyed visits, often mentioning gifts like toys. One girl was inspired by the project and expressed her desire to become a dentist. Other children shared similar positive statements: “I go to the youth dental care. Yes, I just have a safe feeling there.” and “I think they (oral health professionals) are funny; they say funny things.” and “Yes, sometimes I get a gift I like (after treatment)… And then I’m happy, with what I get.” (FGDs). However, sometimes they have just mixed feelings: “Yes, because it’s also scary at the same time, and it’s also fun afterwards because then you see your teeth and your teeth are all beautiful. And you see those doctors all around you and that's why it's both scary and fun.” (FGDs).

Poor oral health, pain & dietary habits

The children understand that poor oral health can result in pain: “Imagine your teeth are broken and that hurts, and then you go to eat then that also hurts.” and: “Sometimes when I press too hard (on my gums), it starts to bleed.” (FGDs).

They recognize individuals with poor oral health in their surroundings: “When I go outside to play then uh…I do see a lot of people with holes and bad teeth…Not looking fresh…Yellow with black.” (FGDs). When shown a laminated picture of periodontitis, a child reacted: “These gums are inflamed, just like my grandfather’s gums!” (FGDs).

Most children reported receiving toothbrushing assistance from their mothers only until age five or six. Many admitted laziness or described parents as too lenient, often ignoring reminders, while some stated parents provided no reminders: “From an early age, parents should already help and tell their children to brush and then that child will learn. But if those parents don’t do that, then the child doesn't know to brush his teeth.” (FGDs).

The children seemed to understand the link between their diet and oral health: “When I was little, I used to eat a lot of sweets and my mother always said if you don’t brush well, you will get a lot of cavities and in the end, I got 3 cavities…. But now I brush well.” When asked how to prevent bad teeth, they responded: “Brush every day, don’t eat too many sweets, eat less sweets, don’t drink energy drinks, like AA.” and “Good food, healthy food…. keeps your teeth healthy.” (FGDs).

While children linked unhealthy food to poor oral health, this awareness did not lead to healthier eating habits. One child stated that eating in the bedroom was permitted at home: “I don’t eat food in my bed, but my brother does. He does brush, but he then brings chips to his room and eats it in his bed.” (FGDs). An obese boy in the focus groups proudly claimed he could eat anything he wanted. Food diaries revealed insufficient nutritious intake among children, with most skipping breakfast, leading to later snacking. Sweets and snack consumption increased further on weekends (Food diaries).

Household: poverty level

Inhabitants of the SW-neighbourhood face poverty-related challenges, leading to chronic stress. Children acknowledged that financial difficulties could hinder dental visits and the purchase of oral health products. One child observed: “When someone is poor…then he doesn’t have enough money to buy a toothbrush or go to the dentist.” Another child said: “If you don’t earn anything you still get money from the Dutch government and child benefit.” and “Sometimes I must use old and dirty toothbrushes, if I don’t have money to buy a new one. To my dad I say, dad this is old, but he says no, just brush with that.” (FGDs).

Low utilisation of dental care

In the SW-neighbourhood, many parents refrain from dental visits due to fear or financial challenges. Although children’s dental care is covered by basic insurance in the Netherlands, adult care is not, discouraging parents from seeking treatment and, in turn, reducing their children's visits. Additionally, some migrant parents come from countries where biannual preventive check-ups are uncommon and only seek dental care during emergencies. A child stated: “No, my parents don’t go to the dentist.” Another boy recounted a story of his grandfather hitting the dentist during a painful treatment: “Last time my grandpa went to hit dentist. Really…My grandpa was scared. He’s lying in that chair, mouth open. He hits him like just that. My grandma said (to me) grandpa hit the doctor, hit the dentist….” (FGDs). This indicates intergenerational influence on the development of dental anxiety.

Children bear significant responsibilities

Children in the SW-neighbourhood bear significant responsibilities. An oral health professional from the youth dental service noted that some children as young as four visit the dentist alone. One child mentioned: “No, sometimes go myself and sometimes they (the youth dental service) pick me up.” and another child added “No some parents don’t feel like it (going to the dentist with their children) or have to work.” (FGDs). Additionally, many children must act as translators for their parents during healthcare visits due to language barriers.

Furthermore, older children often take care of their younger siblings by walking them to school, helping with homework, feeding them, and ensuring they brush their teeth. “First, my sister would help me but now she is in secondary school and has a lot of homework. I’m not allowed to use my phone either because the 5th grade is an important year, so it’s kind of boring at home so I do my chores and homework alone then.” (Interview). Or they must buy and prepare their own food: "Yes, but sometimes I make my own food. Then I usually choose something unhealthy. But today my mother had made a healthy sandwich, and I’m going to ask her to make that from now on. That's quite tasty." (Interview). These responsibilities partly arise from parents working long hours to make ends meet. Moreover, during the COVID-19 pandemic, when parents were not allowed in schools, children’s responsibilities increased even further.

Social structure: extended family

The extended family played a pivotal role in shaping children’s oral health. Grandparents, particularly grandmothers, often served as caregivers while parents worked, spending considerable time with the children. They frequently accompanied their grandchildren to dental appointments but also indulged them with sweets and unhealthy foods, enjoying the opportunity to spoil them (Informal conversation). A child mentioned: “… we went to the city centre and then we went to my grandmother’s, and my grandmother had made a feast meal….” (Interview).

Culture and religion

The SW-neighbourhood is a multicultural area, with children from 38 nationalities attending the primary school where this study took place, including Turkish, Moroccan, Syrian, Egyptian, Chinese, Spanish, Polish, Surinamese, Indian, Pakistani, Armenian, Bulgarian, Russian, Ghanaian, Eritrean, Ethiopian, Somali, Sudanese, Antillean, and Dutch backgrounds (Informal conversation). Cultural and religious practices significantly influenced dietary and oral hygiene habits, shaping oral health. For instance, during Ramadan, some Muslim children, who represented half the school, refrained from brushing their teeth during fasting hours to avoid swallowing anything. A girl explained: “Yes but you must make sure you don’t swallow the toothpaste while brushing. My mother used to do it when she was little, when she didn’t know what Ramadan was, then she would go and drink water in the toilet because she was thirsty.” (Interview). During the Sugar Festival (Eid Mubarak), everyone visits family and friends. Togetherness is important, and people share sweet, sugary foods and exchange gifts. A child: “…with Sugar Festival we do go to people, but then they don’t hand out cake, but you get to choose a sweet…Sometimes they just make cakes too. And at our home, food is important too.” (Interview).‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬

Many children drank Arabic tea at home: “Yes on weekends, my mother makes Arabic tea then. Not with a lot of sugar, I put a little bit in it myself.”‬‬‬‬‬‬‬‬‬‬‬‬‬‬ (FGDs).

Some children practiced oral health traditions from their parents’ place of origin: “I use a special twig (to brush my teeth). My mother bought that, and you can put it on your teeth. We brush our teeth with that at home…you can brush like that. …I do it half-half (with the toothbrush and twig).” (FGDs). This twig, known as a Miswak, is often used in Arabic countries.

Initiatives from municipal and neighbourhood organizations

The school participated in the ‘Healthy School Programme’ by the Municipal Health Service, promoting a healthy lifestyle. Children could bring only healthy food, like savoury sandwiches, fruit, and water. The school had a water pump providing fresh water and students received fruit and vegetables from the school garden. Healthy cooking classes were also integrated into the curriculum (Participant observation and informal conversation). A child remarked: “I learned at school about nutrition that you should eat enough (to not get hungry and start snacking) and how your parents should raise you. There are some children who bring sweets to school and because this is a healthy school if the teacher sees you with unhealthy food, then you must put it in your bag.” (FGDs).

The school actively encouraged children to visit youth dental care. The principal mentioned that teachers motivated parents to take their children to the youth dental service, similar to a ‘school dentist.’ Oral health professionals visited the school for check-ups, and with parental authorization, children needing treatment were taken by van to the dental clinic. The principal also explained his reasons for allowing this PAR at the school: “The children from this neighbourhood get limited opportunities in life. Therefore, I want to give them as many opportunities as possible through school. So, it is either education through school or NOT. This (good oral health, healthy teeth) is part of the basics like healthy food and lifestyle.” (Informal conversation).

The community centre played a crucial role in the neighbourhood, with children in our study attending for afterschool activities (Participant observation). Known as the ‘house of the neighbourhood,’ it fosters connections among people from different cultural backgrounds and religions. The centre offered various activities for mothers and children in participation, sports, health, and art. It positively impacted over 2,000 residents weekly. The centre also housed the SW mothers, who gathered every Wednesday morning, fostering a sense of sisterhood. One mother said: “The beauty of this neighbourhood is that there is connection between people, many different cultures live together peacefully. Also, the communication network is good. Important messages are passed on from mouth to mouth, things sing around in the neighbourhood. So, we should also get the ball rolling about oral hygiene.” (Informal conversation).

Multicultural neighbourhood

According to the children, many inhabitants of the SW-neighbourhood are migrants. In some countries, visiting the dentist is considered a luxury, with preventive check-ups uncommon (FGDs). People typically sought dental care only when in severe pain, which may lead them to believe the same applies here. Furthermore, there was a lack of understanding about the healthcare system, with many thinking it was expensive and difficult to access (dental) care. A child explained: “Some people are poor and…some countries too and then you can’t just go to the dentist. For example, I have only €100 for the dentist. Here in the Netherlands the dentist is free but in some countries it's not free. Then they must pay for it themselves. Maybe they don't know that it's free here?” Another child added: “No, my parents don’t go to the dentist.” (FGDs). A SW mother stated: “There are many undocumented people in the area. These people do not dare to go to doctors and dentists unless they perish in pain. They are afraid of being deported or because they do not know the language.” (Informal conversation).

Living environment

In the SW-neighbourhood, the unhealthy food environment contributed to poor lifestyle choices. A supermarket, candy shop, and snack bar next to the school featured advertisements for sweets, sugary drinks, and junk food (Participant observation), making it tempting for children to buy sweets after school. Many children reported receiving pocket money from their parents for snacks like sweets, chips, and sweet drinks. A boy admitted: “Yeah, after school I buy sweets and sour mats and Taki’s, those are spicy crisps.” (FGDs). An overview of the unhealthy living environment is presented in Fig. 4a-f.

Fig. 4.

a-f rat infestation warnings (a), littered streets (b), unhealthy food availability, and advertisements dominate the SW neighbourhood (c, d, e, f)

The principal noted that many children struggled with obesity, often skipping breakfast or arriving with a croissant or crisps at school (Informal conversation). During focus group discussions, half the children mentioned buying their own breakfast. A boy: “Yes, I ate crisps this morning, yummy!” Another child added: "Parents give money to children to buy something, buy sweets. Always when I go to the park with my friend, she takes money for sweets, every day!" (FGDs). A SW mother explained the obesity issue, stating: “The area now has no outdoor facilities to play, there are no football pitches or sports courts. This is the reason many children are overweight. It is also dangerous to cycle. The Zuiderpark is unfortunately too far to walk.” (Informal conversation).

During our observational walk, we noticed a pamphlet on avoiding a rat plague and observed garbage littering the streets (Fig. 4a and b). Additionally, the SW is considered unsafe at night or early morning due to crime. A Salvation Army facility next to the school housed homeless people, many of whom struggled with alcohol or drug dependency (Participant observation). A boy said: “The Schilderswijk is a ghetto neighbourhood.” Another child shared fears about visiting the oral health professional alone: “There are many children who go to the dentist alone (without their parents), but it’s scary. Yes, you just go out on the street, and you don’t know who you will meet. Often my dental appointment is in the morning, and then you have all these junkies on the street, and you don’t know what they are going to do…I have a junkie next to my house.” (FGDs).

Children’s solutions

During FGDs 8–9 of Phase 3, twelve 5th grade children actively collaborated with the research team to brainstorm actionable solutions for promoting oral health awareness within their community. Children cannot transform the entire system, but we asked them what actions are within their capacity. They were encouraged to propose realistic initiatives that they could implement themselves, with the aim of extending their influence on their families and other community members, including those at school and the community centre. The children identified toothbrushing, regular dental visits and healthy eating as key behaviours for maintaining oral health, which they recognized as both crucial and achievable.

One child proposed door-to-door outreach, but another suggested creating a YouTube video about oral health, which the group agreed to. The next day, the children developed the script and acted in a video on toothbrushing, dental visits, and healthy eating; filmed and edited by the research team. The video was member-checked by the children and, after their approval, shared with parents via WhatsApp, published on PARRO (the school’s internal site), and uploaded on YouTube (https://youtu.be/olN6R8zOVDA). The video was also presented to the SW mothers at the community centre.

Additionally, they proposed and co-designed a folder on toothbrushing, dental visits, and healthy eating (Fig. 5). The folder featured colourful drawings and essential oral care information. Each child took one home, and they were also distributed to parents at the community centre.

Fig. 5.

folder designed by schoolchildren that promotes toothbrushing, regular dental visits, and healthy eating habits

The self-made YouTube video and folder constituted the oral health interventions, the secondary aim of this research. Moreover, the children suggested various other ideas to improve community oral health. They suggested parents stop giving pocket money for sweets and urged local shops to raise prices on sugary treats. To make dental treatments more enjoyable, they recommended decorating dental instruments with bright colours and glitter. They emphasized the importance of continuing to provide incentives such as free gifts after dental treatment. Another suggestion was for dentists to approach children slowly and explain procedures. Lastly, they recommended always giving children sunglasses during treatments to protect them from the bright light (FGDs).

Discussion

This study addresses a gap in the literature by focusing on schoolchildren’s perspectives regarding oral health, oral health behaviours, oral health professionals, dental care, and root causes and outcomes of oral health problems. To the authors’ knowledge, this is one of the few studies in this area. A distinctive aspect of this PAR is that children actively contributed by proposing solutions to enhance their oral health, underscoring the necessity for further dental research that incorporates children’s perspectives on dental treatments and experiences [15].

Although participant children recognised the importance of healthy teeth for social status and future opportunities, their oral health and dietary behaviours were often incongruent. Knowledge alone was insufficient to change behaviour [32]. Many children consumed excessive sugar, influenced by their socio-cultural food environment. In the SW-neighbourhood, for example, pocket money was often spent on sweets after school, driven by peer pressure and the desire to fit in. Food choices did not always align with cultural preferences, as not everyone favours options like oatmeal or stew daily [33]. While affordable and healthy, these options are often either unavailable or culturally unaccepted in neighbourhoods like the SW.

In the SW-neighbourhood, an unhealthy food environment promoted poor lifestyle choices, with soft-drink displays in supermarkets, nearby candy shops, and a snack bar next to the school. The main shopping street amplified temptations with snack bars, doner kebab stores, and candy shops featuring prominent advertisements, diminishing the appeal of healthier choices like fruits and vegetables.

For families on a minimum income, maintaining a healthy and varied diet is nearly impossible [33]. Healthier foods, particularly fruits and vegetables, tend to be more expensive, and scientific consensus confirms that unhealthy food is cheaper and more accessible than healthy food. Over 80% of the food available in supermarkets and a typical shopping street is unhealthy [33]. Limited access to nutritious food, such as fruits and vegetables, and dental care supplies were also identified as barriers for parents in indigenous communities in Canada, hindering their ability to maintain their children’s oral health [34].

A supporting food environment is crucial in combating lifestyle diseases such as obesity, type 2 diabetes, and cardiovascular disease. According to de Ruijter, “The Netherlands is increasingly taking the shape of a food swamp’” [35], where unhealthy food and drinks are readily available. Dijkstra notes that “The food environment has a negative impact on food choices and possibly on residents health” [35], suggesting that municipalities should regulate the food landscape by controlling the establishment of new unhealthy food outlets in specific areas.

People living in poverty face daily stress in meeting basic needs such as food, shelter, and clothing [36]. In the SW-neighbourhood, parents striving to make ends meet often lead children to assume significant responsibilities, such as buying their own breakfast and caring for younger siblings—feeding them, taking them to school, assisting with homework, and putting them to bed. This phenomenon is known as ‘parentification’, where children assume adult roles, which can impact children’s physical, mental, and social-emotional well-being in both the short and long term [37].

Parentification is prevalent among vulnerable populations with low SEP. Barriers like inadequate insurance, transportation issues, and language or cultural challenges often overlap, contributing to parentification. This difficult environment also affects dental care, as children taking on adult responsibilities may struggle to arrange or attend appointments [37]. In the SW-neighbourhood, it was common for children, sometimes as young as four, to visit the oral health professional alone, and older siblings frequently accompanied their younger brothers and sisters to their dental appointments.

Parentification is commonly seen in migrant families, arising from an ‘adolescent-parent acculturation gap,’ where children or adolescents adapt to the language and culture of their new environment more quickly than their parents [38]. Children from the SW often acted as translators for their parents during healthcare visits, including to oral health professionals, due to their parents’ limited Dutch fluency. Migration can disrupt family hierarchies, causing parents to depend on their children for navigating the new environment. As children are exposed to the language daily at school, they frequently assume the role of ‘language brokers’, further intensifying their parentification [38].

This study was conducted during the COVID-19 pandemic, a global crisis that caused sudden loss of essential resources like childcare, schooling, and employment. Many faced financial hardship, including job and health insurance loss. Education was disrupted for over 1.6 billion children worldwide. Overall, COVID-19 intensified factors contributing to parentification, such as caregiver loss, unemployment, reduced income, and educational interruptions [39].

In the SW-neighbourhood, grandparents, especially grandmothers, often care for children while parents work, significantly shaping children’s oral health. Cultural beliefs influence grandmothers’ tendency to indulge grandchildren with food. For example, in Turkish culture, a preference for ‘chubbier’ babies symbolizes health and proper care, a view similarly observed in Amsterdam New-West, home to a large Turkish community [40]. Bhatti et al. found that while some parents viewed their child as responsible for their own oral health habits, others faced challenges due to differing beliefs among family members about maintaining optimal habits, making it difficult to change family norms and convey oral health messages effectively [17].

Dental anxiety remains a significant barrier to dental care for children in the SW-neighbourhood. Despite perceiving oral health professionals as kind, particularly when incentives such as small gifts were offered post-treatment, fear persisted due to prior experiences. In children, dental anxiety is associated with higher rates of dental caries, extractions, frequent episodes of toothache, symptomatic visits, and diminished oral health-related quality of life [41]. Moreover, dental anxiety can be passed down through generations [42]. In addition to dental anxiety, many migrant parents from the SW avoid dental visits due to financial barriers, fear, or unfamiliarity with preventive check-ups in their country of origin. Consequently, their children are less likely to access dental care.

Limitations & strengths

Limitations

This research faced certain limitations. The COVID-19 pandemic prevented planned FGDs with adult stakeholders, such as parents, which were part of the initial design and could have enriched the co-creation and implementation of oral health interventions. While a holistic approach integrating insights from children, adults, and professionals would have added depth, the study remains valuable for enhancing understanding of children's oral health from their perspective and emphasizing the importance of their active role in developing and implementing interventions. This lays the groundwork for more inclusive future research. Another potential limitation was that the oral health interventions were co-created with twelve 5th grade children, chosen by the principal as the most motivated class. This selection may have introduced bias, as the children had a strong grasp of the topic, supported by their teacher who incorporated oral health education into their school schedule.

Strengths

This study actively engaged children over 8 months, empowering them to share their experiences and collaborate with the research team, emphasizing research conducted with children, not on them. It uniquely highlighted children’s perspectives on oral health, oral health professionals, dental care and root causes of oral health problems like diet, lifestyle, environment, poverty, and culture. The co-creation of two oral health interventions with schoolchildren stood out as an impactful approach and fostered a strong sense of ownership.

This project fostered lasting collaboration on oral health between the research supervisor (AEG) and neighbourhood stakeholders, including school and community centre staff. Post-study, AEG and her team were invited to provide oral health education and organize holiday activities for mothers and children, fostering trust and integrating into the SW community—key elements of PAR. This collaboration yielded valuable community insights and lasting advancements in prevention and oral health literacy.

At the conclusion of this study, the collaboration did not come to an end. The children achieved meaningful outcomes, raising awareness about oral health. Due to COVID-19, the research team worked exclusively with the children, which led to changes initiated by them. These results allowed the oral health interventions to continue. The video and the folder created a positive impact in the neighbourhood. The children advocated for stricter policies, emphasizing that adults should listen to children rather than the other way around. They successfully persuaded adults to set a good example, demonstrating the influence of the children's efforts.

Recommendations

The study’s participatory approach empowered children to take ownership of their oral health, demonstrating the value of involving them in research and co-creation of interventions. Policymakers and public health professionals should adopt similar co-creation strategies to develop child-tailored oral health policies that truly reflect children’s lived experiences and needs. Acknowledging children as ‘experts in their own lives’ [15] empowers them to contribute meaningful insights to research and initiatives designed to improve their well-being. Their firsthand experiences are invaluable in shaping interventions that truly reflect their needs and perspectives. Excluding children risks shaping policies and practices that fail to accurately address their needs, experiences, and priorities [14]. Incorporating children’s perspectives, rooted in their lived experiences, is essential for understanding the impact of paediatric obesity on their lives and for designing interventions and policies that better align with their individual needs and living environments [25]. The same applies to oral health.

Although this study effectively captured children’s perspectives, future research should engage parents and adult stakeholders for a more comprehensive understanding of children’s oral health challenges and solutions. Parent–child meetings and collaboration with healthcare professionals can strengthen parental knowledge and improve children's oral health behaviours. Indeed, authentic partnerships with parents, teachers, and community leaders (adult stakeholders) are essential for culturally appropriate solutions regarding oral health [34]. The importance of establishing a trusting relationship between the healthcare professionals and parents was also highlighted in the Food4Smiles study in Amsterdam New-West [43]. Moreover, parent–child meetings can contribute to enhancing parental knowledge, skills, and practices regarding children’s healthy behaviours [44].

The study highlighted root causes of oral health problems, including diet, lifestyle, environment, poverty, and culture. Future interventions should consider targeted strategies to address these barriers, such as culturally tailored health education programs, accessible dental care initiatives, and community-driven advocacy efforts. Researchers must consider community context, including socioeconomic status, traditional practices, and their impact on oral health behaviour before co-creating solutions [45].

Given the success of the child-tailored interventions, integrating oral health education into school curricula could be a powerful step forward. Schools can serve as key stakeholders for promoting preventive oral health behaviours and fostering long-term positive habits among children. School-based oral health programs aim to overcome access barriers for high-risk children, preventing dental caries while promoting health and academic achievement [46] and includes measures such as oral health education for pupils, parents, and school staff; promoting healthy school nutrition; oral health screening and referrals as needed.

Conclusion

In conclusion, despite understanding the importance of oral health, children in the SW-neighbourhood faced systemic barriers that limited their ability to act on this knowledge. Poverty worsened these challenges, causing ‘parentification’ and unhealthy dietary habits shaped by cultural norms and the local food environment. Effective oral health interventions must address these socio-cultural complexities. This PAR project raised awareness, empowering children to drive positive change and share knowledge with their community through a self-made YouTube video and folder on toothbrushing, regular dental visits and healthy eating.

Abbreviations

SW

Schilderswijk, a disadvantaged neighbourhood in The Hague, the Netherlands

SEP

Socioeconomic position

FGDs

Focus Group Discussions

COREQ

COnsolidated criteria for REporting Qualitative research

PAR

Participatory Action Research

OH

Oral Health

THTF

The Healthy Teeth Foundation

ACTA

Academic Centre for Dentistry Amsterdam

Authors’ contributions

AEG, a PhD student and founder of The Healthy Teeth Foundation, served as the principal investigator and facilitator of this research. She conducted the study, trained and guided co-researchers, led the analysis (overseen by MHV and CCB), and developed the codebook (verified by MHV and CCB). AEG authored the manuscript under the supervision of MHV and CCB, prepared Figures 1, 2, 3, 4 and 5, and, along with CCB and MHV, reviewed, provided feedback, and approved the final manuscript for publication.

Funding

This PAR on oral health was funded by the Amsterdam University Fund (AUF), VU Association (VUvereniging), and Dutch Association for Paediatric Dentistry (NVvK). Colgate Netherlands and Bamboovement | B Corp donated materials, including fluoridated toothpaste and bamboo toothbrushes. Participants were informed that The Healthy Teeth Foundation (THTF), founded by AEG, supported the study through labour and manpower. Funding and support had no influence on the research design, data, or outcomes.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by the Academic Centre for Dentistry Amsterdam (ACTA-ETC, protocol number 2021–49543). The study was promoted via school-distributed information letters. Written informed consent was obtained prior to participation for all participants and parental written informed consent was obtained for all children under the age of 16. All children gave verbal consent. Participants were reminded of their right to withdraw anytime without consequences. This study was executed according to the WMA Declaration of Helsinki 2013.

Consent for publication

Parents of participating children have been informed in writing that photos and videos were being made during the project and provided written informed consent. Consent for publication was obtained from the parents or legal guardians of the children participating in this study.

Competing interests

The authors declare no competing interests.