Evaluation of children’s needs for creating a child-friendly environment in dental hospitals and strategy study

Abstract

Objective

This study aims to provide inputs for creating a child-friendly dental hospital by investigating the satisfaction and needs of children and their parents regarding the current environment of dental hospitals.

Study design

Firstly, the KJ method was used to construct evaluation indicators. Secondly, need indicators were classified with the Kano model. Thirdly, the weight of need indicators was evaluated using the Analytic Hierarchy Process (AHP) from both expert and user perspectives, thereby determining indicator priorities. Finally, the Kano-AHP model was used to fit indicator weights, and targeted optimization schemes were proposed.

Results

A total of 484 children aged 6–14 and their parents, along with 10 experts, participated in this study. (1) The Kano model shows that 9 Must-be needs are prioritized; 6 Attractive needs can significantly improve satisfaction; 12 One-dimensional needs call for continuous improvement; and 1 Indifferent needs can be postponed. (2) Based on AHP analysis, both experts and users prioritize needs for facilities and physical environment. After the improvement of weight, user needs shifted to equal emphasis on facilities and activities, indicating that the existing environment design can partially meet the must-be needs, with expectations for interactive experiences and emotional design significantly increasing. (3) A design priority sequence has been formed: “construct visual environment and interactive experiences - configure facilities and innovate treatment forms - enhance environmental safety and comfort - sustain advantageous projects”. (4) Five design strategies have been proposed.

Conclusion

For dental hospitals, it is essential to strike a balance between the renovation of child-friendly environment and the integration of humanized services. The study findings may help designers and clinicians create child-friendly environments in dental hospitals, and provide references for similar dental hospitals to enhance children’s visiting experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24989-y.

Introduction

Children’s oral health is a critical issue in public health [1]. It not only affects children growth and development but also correlates with their long-term quality of life [2]. Dental medical institutions, as key venues for maintaining oral health, must effectively address the expectations and needs of their service populations through environmental design and service provision [3]. Compared with adults, children are a vulnerable group with diverse health needs and differ significantly from adults in psychological and physiological aspects [4]. This makes them more sensitive to dental hospital environments. Children often struggle to express themselves, require guardian accompaniment during medical visits, and have unique needs for facilities, However, in the decision-making process of dental environment design, the perspectives of children are frequently overlooked.

During dental treatments, children may experience fear, distress, struggle, anxiety and even defiant behaviors [5], which are often triggered by environmental factors such as loud noises, distinct odors, and bright lights in hospitals [6][7]. Furthermore, the current dominant environmental planning, facility configuration, and treatment forms in dental hospitals are predominantly centered on adult needs, but fail to fully align with physical and psychological characteristics and usage preferences of children [8]. This phenomenon reveals that existing dental hospitals suffer from a “developmental mismatch” caused by an “adult-centric” design paradigm [9], a contradiction between the adult-centered environmental design logic and the developmental needs and behavioral characteristics of children. This mismatch increases the possibility of children experiencing stress and negative emotions during dental treatments, thereby potentially compromising their treatment experience, reducing compliance, and negatively impacting the long-term development of their oral health behavior[10]. To improve the quality of children’s oral treatment and promote the formation of good oral hygiene habits, it is essential to consider their knowledge, attitudes, intentions, and behavioral characteristics when designing and implementing effective health-related behavior change interventions. This approach enables them to better accept care.

Current research regarding satisfaction with and needs for dental hospitals primarily focuses on adult satisfaction regarding oral health, such as the outcomes of prosthetics and implants [11][12], or specific service quality aspects such as rehabilitation, nursing, and postoperative satisfaction [13]. Some research also focuses on parents’ satisfaction with and expectations for hospital environments [14], concerns [15], perceptions [16], and satisfaction [17] of child guardians, as well as evaluations of specific services such as child care quality [18] and postoperative treatment [19]. Such research often relies on reports from parents, but neglects children’s experiences, perceptions, and right to express their needs. This results in severely insufficient participation of children in environmental evaluations, thereby undermining the validity of research conclusions. Most research mainly focuses on satisfaction or needs of users, merely captures their opinions or needs, and fails to simultaneously identify design factors to be optimized and their priority order. Moreover, existing research specifically explores how environmental features of dental hospitals, such as space and facilities affect children treatment experiences. As a result, the design guidance proposed based on existing research remains relatively scarce.

In contemporary society, parents pay unprecedented attention to children oral health and show close concern for the medical environment during dental visits. This concern stems not only from profound care for children’s growth environments but also reflects the positive vision of families as fundamental social units for constructing child-friendly developmental environments. Moreover, growing evidence suggests that improving patient (including children and their families) satisfaction with the medical environment and services can effectively enhance treatment compliance, thereby improving health outcomes [20]. Against this backdrop, transforming dental medical institutions into “child-friendly” models has become a critical pathway to improving the quality of children oral health services.

Rooted in the UN Convention on the Rights of the Child, the “child-friendly” concept emphasizes children’s equal spatial rights and fulfillment of their must-be needs [21]. Child-friendly healthcare aims to provide safe, comfortable, and supportive physical and humanistic environments through improved medical facility design, service process and humanistic care, so as to fully respect children’s rights and needs [22]. Integrating child-friendly principles into the environmental design of dental hospitals is a rational choice to alleviate pediatric dental anxiety and improve treatment experiences and outcomes for children. This study focuses on the children-friendly features of dental hospital environments. Taking Hospital of Stomatology Xi’an Jiaotong University, one of China’s leading dental hospitals, as a case, this study employed a questionnaire survey to systematically collect satisfactions and expectations from children aged 6–14 and their parents regarding the existing environment and services. Using the Kano-AHP model, this study conducted in-depth data analysis to scientifically determine different need attributes and their priority order, thereby proposing optimized design strategies for child-friendly dental hospitals. This study aims to establish evaluation and optimization method for child-friendly environment design in modern dental hospitals, integrating need fulfillment and priority ranking, based on the real experiences and needs of users (children and their parents). This will provide decision-makers with specific optimization suggestions and design models. Ultimately, this study will enhance the treatment satisfaction and experience of child patients and their families, promote treatment cooperation, and contribute to the long-term establishment of children oral health behaviors and overall well-being.

Methodology

Study objects

Due to the limited number of specialized children dental hospitals in China, most children and parents prefer pediatric departments in stomatological hospitals [23]. By taking the Hospital of Stomatology Xi’an Jiaotong University as the case, this study investigated the child-friendly environments in dental hospitals. The Hospital of Stomatology Xi’an Jiaotong University is located in Xi’an, Shaanxi Province. It is a Grade A tertiary stomatological hospitals directly affiliated with the National Health Commission. It integrates medical treatment, teaching, scientific research, and preventive care. Founded in 1950, the hospital has now become the only large-scale Grade A tertiary specialized dental hospital in Northwest China directly affiliated with the National Health Commission. Notably, it pioneered the “Special Needs Ward for Pediatric Dentofacial Disease Diagnosis and Treatment” in China, dedicated to comfortable pediatric oral treatment. As a representative in this field, it was selected as the case for this study.

Method

Compared to the intuitiveness of functional needs, the design needs of children and their parents for medical environments are abstract, dynamic, variable, and diversified. Also, some design needs are implicit while some others remain explicit. Therefore, it is difficult for traditional single-method approaches to systematically identify the attribute differences of these needs and their priority order in design.

In the need-driven design, the Kano model is used as a methodology for systematically understanding user needs and expectations [24]. This model categorizes user needs into five typical types: Must-be Quality (M), One-dimensional Quality (O), Attractive Quality (A), Indifferent Quality (I), and Reverse Quality (R). This model allows for a reasonable classification of needs in design. However, the Kano model cannot further prioritize user needs, making it difficult to compare the importance of need factors across different levels or at the same level.

The AHP model is a quantitative method combined with multi-criteria decision-making [25]. Its advantage lies in its ability to break down the final decision (goal level) into criteria and sub-criteria levels, then calculate the weight of each influencing factor through a judgment matrix, thereby providing scientific decision-making support for the goal level [26]. However, the initial indicators may deviate from actual user needs in some cases.

Therefore, this study employs the Kano-AHP integrated model to establish a user need-driven decision-making model. This approach combines the need classification ability of the Kano model with the multi-dimensional weight quantification ability of AHP. It compensates for the limitations of the Kano model in quantifying need priority importance and the difficulty of AHP in identifying need attributes. The integration of the two methods follows an overall analysis of “need classification → weight assignment → priority fitting”, so as to precisely identify need categories and attributes, quantify need importance dynamically through weight analysis, and provide a clear priority order for design optimization through quantified numerical results, thereby improving decision-making accuracy.

Process

Need data collection and index system based on KJ method

To tackle the environmental design challenges for child-friendly dental hospitals, the KJ method was employed in this study to identify preliminary needs. Data were collected through literature reviews, user interviews, and expert consultations [27]. Specifically [1], 35 interviewees were carefully selected, including medical professionals from various departments at the Hospital of Stomatology Xi’an Jiaotong University, pediatric patients along with their guardians, and environmental design experts from universities. Semi-structured interviews were then conducted to systematically explore their needs regarding child-friendly environments in dental hospitals [2]. After screening and categorizing the data, 28 indicators were extracted [3]. Following the hierarchical structure of “goal level → criteria level → factor level”, need dimensions were formed and divided into five major categories, finally forming a survey indicator system (Table 1).

Table 1.

Questionnaire evaluation indicators

Need ID		Need factor	Description
Physical environment needs PH	PH1	Spatial distribution rationality	Provision of adequate and well-divided functional spaces
	PH2	Reasonable spatial dimensions	Space dimensions designed to meet children’s needs
	PH3	Lighting environment comfort	Comfort of indoor brightness and light intensity
	PH4	Acoustic environment comfort	Comfort of indoor sound intensity and type
	PH5	Temperature and humidity comfort	Indoor temperature and humidity comfort
	PH6	Odor comfort	Indoor odor comfort
	PH7	Ventilation comfort	Indoor ventilation comfort
	PH8	Environmental cleanliness	Overall space cleanliness
Facility needs FA	FA1	Safety and protective facilities	Safety protection facilities for children
	FA2	Hygiene and cleaning facilities	Hygiene and cleaning facilities suitable for children
	FA3	Children activity facilities	Play facilities that enable interactive or intelligent experiences
	FA4	Child-appropriate facilities	Furniture and barrier-free facilities adapted to children’s needs
	FA5	Child-appropriate signage and guidance facilities	Guidance via voice prompts, screen instructions, and signage
	FA6	Infrastructure	Trash bins and water dispensers
Activity needs AC	AC1	Personalized activity design	Customizable activity content
	AC2	Diversified special activities for children	Reading, painting, climbing, or parent-child interactions
	AC3	Expression of child participation	Strengthening the sense of belonging
	AC4	Science education activities	Fun and educational activities on children’s oral health
Services and management needs SM	SM1	Medical staff intervention in diagnosis and treatment	Emotional support and intervention by medical staff in diagnosis and treatment
	SM2	Treatment forms	Encouragement-based, game-based, or scenario-simulated approach
	SM3	Auxiliary treatment forms for children	Animal-assisted therapy and other complementary therapeutic approaches
	SM4	Auxiliary treatment equipment for children	Child-friendly imaging devices, multimedia systems, and other auxiliary equipment
	SM5	Data privacy and security	Encrypted user diagnostic data
	SM6	Health management	Pediatric oral health assessment and management
Environmental decoration needs ED	ED1	Playful and engaging spatial atmosphere	Story-based environmental design for children
	ED2	Vibrant and colorful design	Child-aesthetic-oriented color design
	ED3	Comfort and safety of materials	Eco-friendly and high-quality materials
	ED4	Healing-oriented environmental decoration	Decorations such as plants and posters that improve space and relieve anxiety

Questionnaire distribution and collection

To ensure data accuracy and reliability, the study team conducted a systematic survey at Hospital of Stomatology Xi’an Jiaotong University from May 2024 to May 2025, the study participants included pediatric patients aged 6 to 14 (with parental consent required for participation) who visited the Hospital of Stomatology Xi’an Jiaotong University during the research period, as well as their parents. Informed consent was obtained from all the research participants and the parents or legal guardians of any participants under the age of 16. Data of user needs were collected through questionnaire survey at the study site. The survey was conducted daily from 9:00–11:00 AM and 2:00–5:00 PM, covering both weekdays and weekends, to ensure sample diversity and representativeness. A total of 500 questionnaires were distributed, with 484 valid responses collected, yielding a response rate of 96.8%.

Quantitative analysis was adopted in the questionnaire survey, and respondents were required to indicate their perceptions of the listed items. The questionnaire consisted of three sections: The first section involved demographic information of the respondents, such as age, gender, and other basic characteristics; the second section was the model-based questionnaire, comprising 28 indicator items, each designed with both positive and negative questions, accompanied by illustrative images to assess respondents’ needs for a “child-friendly dental hospital”. The third section focused on satisfaction evaluation. This part included two types of surveys: one was used to collect experts’ ratings on each indicator; the other one was used to collect users’ evaluation on qualitative indicators based on the current environment, including their actual satisfaction level and expected satisfaction level. All data and information collected through the questionnaire survey were anonymous. All research methods and procedures in this study complied with ethical principles and regulations.

Kano method analysis

The Kano model-based need questionnaire in this study set paired positive and negative questions for each need factor to assess users’ expectations for child-friendly design in dental hospitals (Table 2). Respondents answered using a 5-point Likert scale. Simple language and smiley face stickers representing the 5-point Likert scale were used to help child respondents understand.

Table 2.

Kano Model-based need questionnaire scoring table

Function/service		Negative question
		Dislike	Reluctantly accept	Indifferent	Expected	Like
Positive question	Dislike	Q	A	A	A	A
	Reluctantly accept	R	I	I	I	M
	Indifferent	R	I	I	I	M
	Expected	R	I	I	I	M
	Like	R	R	R	R	Q

To more accurately quantify the potential impact intensity of each need on user satisfaction, we calculated the “requirement sensitivity value (R-value)”[28]. This value was derived by comprehensively measuring the satisfaction (Better) and dissatisfaction (Worse) levels for each need, ultimately computing the R-value. A higher R-value indicated a greater potential impact on user satisfaction (whether met or unmet), providing a key metric for subsequent priority ranking.

1

AHP method analysis

(1) Expert weight evaluation.

This study employed the AHP to analyze the need characteristics of child-friendly environments of dental hospitals. 10 experts from fields of dentistry, environmental design, and architecture were invited to participate in the evaluation. A 1–5 scale was introduced to construct a judgment matrix by pairwise comparison of indicators and taking the mean score. After consistency test, the relative importance weight of each need indicator from the expert perspective was calculated, providing a scientific basis for subsequent analysis and decision-making [29].

(2) User weight evaluation and Kano adjustment.

To more accurately reflect the user perspective and incorporate their perception of the gap between the current state and expectations, this study combined questionnaire survey data from both parents and children to determine the evaluation indicator weights [30]. Based on user ratings of the importance of each indicator (Sect. 3 of the questionnaire), the preliminary user weights was calculated using AHP method.

To more clearly identify the gap between the current status and user expectations for each indicator, satisfaction cores from the Kano model were used for improvement [31][32]. The adjusted improvement rate was then calculated based on the gap between the user expectations and the current status:

2

Where, represents the users’ expected satisfaction scores, is the actual satisfaction score for each indicator. A higher value indicates that users perceive a larger gap between the current state and the exceptions for that indicator, reflecting a more urgent need for improvement.

Subsequently, the user weights were adjusted by combining the original user importance weights with the improvement rate adjustment, resulting in weights that better reflect users’ actual improvement needs, denoted as:

3

The adjusted weights were normalized to obtain the final weights for each indicator.

The difference between weights after improvement and before improvement was used to determine users’ actual satisfaction with each indicator in the current dental hospital, thus further enhancing the objectivity and reference value of the survey results.

Fitting weight of indicators using Kano-AHP model

To integrate the expert weights, user weights, and the inherent impact potential of the needs, a weight fitting process was conducted to generate a comprehensive priority score for design optimization  

For each need indicator, its final comprehensive priority score  consists of following two components:

The need impact potential coefficient evaluated by the Kano model  .

The need importance evaluated by the AHP model  :

4

Where, is the mean satisfaction evaluation weight from children and parents, and is the mean evaluation weight from experts.

Given the equal importance of the Kano and AHP models in evaluation, a mean weight allocation method was employed to calculate the comprehensive score [32]:

5

The final weight values were used to determine the ultimate optimization priority order. A higher value indicates a higher priority for that need in optimizing the design of child-friendly environments of dental hospitals.

Results

Socio-demographic characteristics

A total of 484 respondents participated in this study, including 251 children and 233 parents. Among the child respondents, 51 were aged 6–8, 73 aged 9–11, and 127 aged 12–14. There were 132 girls and 119 boys. 89 children were first-time hospital visitors, 141 had visited 2–5 times, and 21 had visited more than 5 times. 144 used outpatient services, 53 used inpatient medical services, and 54 used inpatient surgical services. Among the parent respondents, 139 were mothers, 78 were fathers, and 16 were grandparents. 14 parents were aged 20–29, 132 aged 30–39, 61 aged 40–49, and 26 aged 50 and above.

KANO model based user need analysis

The KANO model analysis (Table 3) showed the following results. 9 items were identified as Must-be Quality (M), including PH5, PH7, FA1, FA2, FA6, SM1, SM2, SM5, SM6. These 9 items mainly relate to the physical environment of temperature, humidity and ventilation comfort, safety and protective facilities, hygiene and cleaning facilities as well as basic infrastructure provision such as trash bins, along with medical staff intervention in diagnosis and treatment services, diverse treatment forms, children data privacy and security, and health management. These indicators represent needs users expect to be fulfilled. Fulfilling these needs may not notably elevate user satisfaction, but non-fulfillment can indeed result in substantial dissatisfaction. 6 items were identified as Attractive Quality (A), including PH2, PH3, FA3, AC4, SM3, ED1, covering the creation of reasonable spatial dimensions and comfortable lighting environments, provision of children activity facilities, implementation of science education activities, diverse forms of auxiliary treatment for children, and the creation of fun spatial atmospheres. These indicators exceeded user expectations. Fulfilling these needs can significantly enhance satisfaction, while non-fulfillment will not trigger negative emotions. 12 items were identified as One-dimensional Quality (O), including PH1, PH4, PH6, PH8, FA4, FA5, AC2, AC3, SM4, ED2, ED3, ED4, focusing on the rationality of spatial functional zoning, acoustic environment, odor comfort, environmental hygiene, child-appropriate facilities and signage establishment, design of diverse characteristic activities and participatory expression for children, use of auxiliary treatment equipment for children, as well as environmental color richness, material comfort and safety, and decorative effects. These needs show a positive correlation with satisfaction - the more they are fulfilled, the higher the user satisfaction, and vice versa. Indifferent Quality (I) involves AC1, which has no impact on user satisfaction. It indicates very low user interest in customized activities, and suggests poor cost-effectiveness for resource investment.

Table 3.

Kano model analysis results

Indicator factor	Better-Worse Classification	R Value
PH1	O	0.744
PH2	A	0.637
PH3	A	0.702
PH4	O	0.891
PH5	M	0.565
PH6	O	0.868
PH7	M	0.672
PH8	O	0.750
FA1	M	0.648
FA2	M	0.616
FA3	A	0.737
FA4	O	0.714
FA5	O	1.012
FA6	M	0.718
AC1	I	0.155
AC2	O	0.844
AC3	O	0.903
AC4	A	0.599
SM1	M	0.624
SM2	M	0.662
SM3	A	0.871
SM4	O	0.718
SM5	M	0.725
SM6	M	0.581
ED1	A	0.747
ED2	O	0.956
ED3	O	0.773
ED4	O	0.896

Weight comparison of evaluation indicators and satisfaction analysis based on AHP model

Overall, in terms of criteria level, the expert evaluation weight ranking is: facility needs (FA, 0.2892) > physical environment needs (PH, 0.2736) > service management needs (SM, 0.1810) > environmental decoration needs (ED, 0.1446) > activity needs (AC, 0.1116), reflecting the priority concern for facility safety and environmental function accessibility. From the user perspective, initial weights show physical environment needs (PH, 0.2133) as the highest priority. After weight adjustment, user weights evolve to: facility needs (FA, 0.2483) > activity needs (AC, 0.2220) > environmental decoration needs (ED, 0.2164) > physical environment needs (PH, 0.2133) > service management needs (SM, 0.1000). User need weights for FA, AC, PH, ED increase, while attention to SM relatively decreases, indicating that current services and management at Hospital of Stomatology Xi’an Jiaotong University have partially met needs, while improvements in physical environment, facility diversity and interactive activity design remain users’ main concerns (Table 4).

Table 4.

AHP evaluation results at the criteria level

Indicator factor	Expert Evaluation Weight	Kano-Adjusted User Evaluation Weight	Change in User Evaluation Weight
PH	0.2736	0.2133	0.0005↑
FA	0.2892	0.2483	0.0377↑
AC	0.1116	0.2220	0.0351↑
SM	0.1810	0.1000	−0.0992↓
ED	0.1446	0.2164	0.0258↑

Specifically, 9 indicators including PH5, PH7, FA6, AC1, AC4, SM4, SM5, SM6, ED4 show weight decreases after adjustment. Infrastructure (FA6), ventilation comfort (PH7), temperature-humidity comfort (PH5), health management (SM6), and auxiliary treatment equipment for children (SM4) all show decreases exceeding 0.098, suggesting Hospital of Stomatology Xi’an Jiaotong University perform well in these aspects at current stage, and priority can be given to other aspects. Among these, the expected satisfaction scores regarding the children’s personalized activity design indicator (AC1) is the lowest. It also falls under indifferent quality. This indicates that users had little concern about it, making it non-urgent in current hospital improvement plans (Table 5).

Table 5.

AHP evaluation results at the criteria level

Indicator factor	Expert Evaluation Weight	Kano-Adjusted User Evaluation Weight	Change in User Evaluation Weight
PH1	0.1732	0.2202	0.0876↑
PH2	0.1510	0.1641	0.0370↑
PH3	0.1105	0.1481	0.0230↑
PH4	0.1112	0.1332	0.0130↑
PH5	0.0939	0.0216	−0.0988↓
PH6	0.1049	0.1598	0.0338↑
PH7	0.0913	0.0175	−0.1034↓
PH8	0.1641	0.1356	0.0079↑
FA1	0.1961	0.1879	0.0198↑
FA2	0.2285	0.1766	0.0034↑
FA3	0.1427	0.1963	0.0297↑
FA4	0.1391	0.2252	0.0641↑
FA5	0.1257	0.1635	0.0016↑
FA6	0.1679	0.0505	−0.1185↓
AC1	0.1724	0.1936	−0.0267↓
AC2	0.3254	0.3150	0.0460↑
AC3	0.2076	0.2986	0.0455↑
AC4	0.2946	0.1928	−0.0648↓
SM1	0.1246	0.2640	0.0947↑
SM2	0.1697	0.2180	0.0741↑
SM3	0.0831	0.3294	0.1557↑
SM4	0.1860	0.0268	−0.1351↓
SM5	0.2917	0.1099	−0.0723↓
SM6	0.1449	0.0519	−0.1171↓
ED1	0.1733	0.2633	0.0138↑
ED2	0.2742	0.2898	0.0356↑
ED3	0.3434	0.2481	0.0047↑
ED4	0.2091	0.1989	−0.0541↓

The remaining 19 indicators show increased weights, and represent factors causing user dissatisfaction and user needs in the current dental hospital environment. These indicators can service as more targeted references for environmental improvement. Among them, auxiliary treatment forms for children (SM3), medical staff intervention in diagnosis and treatment (SM1), child-appropriate facilities (FA4), reasonable spatial layout (PH1), and expression of child participation (AC3) are the 5 indicators with most significant weight increases, all exceeding 0.045, representing indicators with highest user dissatisfaction that require special attention. Indicators such as odor comfort (PH6), acoustic environment comfort (PH4), child-appropriate signage system (FA5), and vibrant and colorful design (ED2) also show significant increases, indicating user dissatisfaction that needs improvement.

Priority order for Child-friendly environmental design needs in dental hospitals

Through the Kano-AHP model, the priority order for improving various indicator levels in the dental hospital is fitted (Table 6). Design optimization should follow a three-tiered priority scale: High priority (Z ≥ 0.5), medium priority (0.4 ≤ Z < 0.5), low priority (Z < 0.4). 9 high-priority indicators involve visual environment, interactive experience and facility configuration and treatment forms (ED2, AC2, FA5, AC3, ED4, SM3, ED3, PH4, PH6). 14 medium-priority indicators mainly relate to environmental safety and comfort (ED1, PH1, SM5, FA3, PH8, FA4, SM2, AC4, FA1, PH3, FA6, SM4, FA2, SM1). 5 low-priority indicators (PH2, PH7, SM6, PH5, AC1), can be temporarily deferred in design due to low user need sensitivity. As a result, the recommended design priority order is as follows: “construct visual environment and interactive experiences - configure facilities and innovate treatment forms - enhance environmental safety and comfort - sustain advantageous projects”. This priority order aims to effectively increase user satisfaction with child-friendly dental hospital.

Table 6.

Priority order for design needs of Child-friendly environments of dental hospitals

Priority	Indicator factor	Z	Ranking
High priority	ED2	0.6190	1
	AC2	0.5821	2
	FA5	0.5783	3
	AC3	0.578	4
	ED4	0.5500	5
	SM3	0.5386	6
	ED3	0.5344	7
	PH4	0.5066	8
	PH6	0.5002	9
Medium priority	ED1	0.4826	10
	PH1	0.4704	11
	SM5	0.4629	12
	FA3	0.4532	13
	PH8	0.4499	14
	FA4	0.4481	15
	SM2	0.4279	16
	AC4	0.4214	17
	FA1	0.4200	18
	PH3	0.4156	19
	FA6	0.4136	20
	SM4	0.4122	21
	FA2	0.4093	22
	SM1	0.4091	23
Low priority	PH2	0.3973	24
	PH7	0.3632	25
	SM6	0.3397	26
	PH5	0.3114	27
	AC1	0.1690	28

Discussion

Influencing factors and design strategies

In this section, we comprehensively discuss the factors influencing the current findings based on questionnaire results and field investigations:

1. s In terms of physical environment, acoustic environment comfort (PH4) and odor comfort (PH6) are two high-priority design needs. A Chinese study supports this finding, demonstrating that scent sprays and musical environments foster positive emotions of comfort and relaxation, while unpleasant odors and noisy environments lead to negative emotions [33]. At the Hospital of Stomatology Xi’an Jiaotong University, disinfectant odors are pungent, and diagnostic equipment noise is not effectively isolated. During busy periods, children’s crying and parents’ conversations further intensify emotional stress in children patients. Pediatric environment design is shifting toward multi-sensory experiences beyond visual elements [34], which integrates olfactory and auditory sensations, thereby transforming research on “treatment environments”. Spatial distribution rationality (PH1) is a medium-priority need. A Qatari study highlights that children’s first impressions of hospitals are crucial, and diverse and comfortable spatial functions significantly impact overall satisfaction [35]. Play areas, indoor/outdoor green spaces, recreational activities, and dining spaces strongly attract children and help alleviate anxiety [36]. While the current dental hospital has relatively rich spatial functions, it lacks features specifically serving children. Environmental cleanliness (PH8) is a medium-priority need. Trash such as tissues, receipts, and plastic bags is occasionally seen on the floor, which severely impacts environmental hygiene and increases health risks for children and directly impacts medical experience of patients [37]. Lighting environment comfort (PH3) is a medium-priority need. Light is crucial for creating a positive and therapeutic environment. Currently, the dental hospital primarily uses cold light sources with excessive illumination intensity. The hospital needs to utilize various lighting environments combining natural and artificial light to create a soft and comfortable treatment environment for children [38]. PH2, PH7, and PH5 are low-priority needs. As these needs have been partially met, the optimization can be deferred.

2. In terms of facility configuration, child-appropriate signage and guidance facilities (FA5) are high-priority needs. The wayfinding system can help children and their parents better understand and navigate the medical treatment process. This personalized healthcare navigation service can reduce children anxiety and stress during visits, thus serving as an important element of child-friendly design [39]. The children’s dedicated wayfinding systems are insufficient. The existing signage uses complex text and lacks cartoon or visual elements, making it difficult for children to understand. Safety and protective facilities (FA1) and hygiene and cleaning facilities (FA2) are medium-priority needs. Ensuring children safety and health is the primary design principle [38]. Inadequate safety facilities, such as missing anti-collision padding and accessible facilities, pose collision risks for children. Most hygiene and disinfection facilities are designed for adults, with limited consideration for children needs, items such as child-friendly hand sanitizers and wet wipes are notably absent. These facilities need to be optimized based on physical and behavioral characteristics of children. Child-appropriate facilities (FA4) and infrastructure (FA6) are also medium-priority needs. A Chinese study confirms that supporting facilities and details show significant positive correlation with overall environmental satisfaction [38]. However, children needs are not fully considered in facilities, such as excessively high waiting area seats and oversized diagnostic tables, causing inconvenience to children. Children activity facilities (FA3) are medium-priority needs. The lack of children activity facilities has been proven to affect children satisfaction with medical visits and is not conducive to reducing children tension during treatment [41].

3. In terms of children activity design, diversified special activities for children (AC2) rank as the second highest-priority need. A Swedish study report indicates children needs for painting, various animals, interesting activities, puzzles and riddles [42]. The lack of recreational facilities and activities leads to decreased satisfaction and increased treatment stress among children [43]. Children prefer hospital environments that provide entertainment facilities. Currently, the dental hospital lacks sufficient child-specific activities, so most children patients play with mobile phones during waiting time. Expression of child participation (AC3) is a high-priority need, indicating the need to focus on child participation. Patient surveys in dental hospitals revealed that current institutions pay little attention to children treatment satisfaction, with less child participation making their preferences and feedback difficult to value. Science education activities (AC4) are a priority needs. Introducing edutainment into hospital environments not only helps children better cope with treatment stress but also enhances their satisfaction [44]. AC1 is the only Type I need and belongs to low-priority needs, so it can be deferred in design.

4. In terms of service and management, auxiliary treatment forms for children (SM3) are high-priority needs. Animal-assisted therapy, art therapy and music therapy have been proven significantly effective in alleviating pain and anxiety [45]. Currently, the Hospital of Stomatology Xi’an Jiaotong University has not yet introduced the relevant auxiliary treatment forms, creating demand among children for such services. Treatment forms (SM2) and child-friendly medical interventions (SM1) are medium-priority needs. In medical environments, working attitude and humanistic care of medical staff and diversified treatment forms play crucial roles in improving quality and outcomes [46]. For instance, play therapy can significantly enhance the quality of pediatric healthcare [40]. The current dental hospital employs monotonous psychological interventions and treatment methods where medical staff predominantly use traditional directive communication approaches instead of child-friendly treatment methods. This negatively impacts children treatment experience and need to be improved. Data privacy and security (SM5) are also medium-priority needs. Protecting children privacy is paramount and represents a universal requirement for hospital environments [47]. Current practices of parental proxy access to medical records and extensive use of mobile data have elevated the need for children data privacy protection. Meanwhile, auxiliary treatment equipment for children (SM4) is a medium-priority need. Digital technologies and interactive media displays (e.g., televisions) have been proven to enhance healthcare experiences [48][49]. The current absence of these auxiliary treatment methods and technologies in the dental hospital has generated significant demand among users. SM6 is a low-priority need with satisfactory performance that should be maintained.

5. In spatial decoration, vibrant and colorful design (ED2) is the most urgently needed improvement among all 28 indicators. This aligns with previous research suggesting the need for playful and colorful design for children, and represents one of the most significant concerns for most children [50]. Vibrant colors typically attract children attention, thereby reducing their fear of medical treatment [51]. The current spatial decoration of dental hospital relies heavily on white and gray hues, with limited integration of vibrant colors or child-oriented design features, leading to a monotonous visual experience that lacks appeal for young patients. Monochromatic environmental colors constitute a major factor causing user dissatisfaction. Material comfort and safety (ED3) is also a high-priority need. To enhance safety, eco-friendly materials harmless to children should be employed [33]. Current construction and decorative materials predominantly consist of plastics, synthetic polymers, and metals, exhibiting insufficient environmental sustainability. These materials may release hazardous substances, posing health risks to children. Moreover, these materials often have cold textures that contradict the comfortable and safe environmental design concept of child-friendly dental hospitals. Healing-oriented environmental decoration (ED4) and playful and engaging spatial atmosphere (ED1) are high-priority and medium-priority design needs respectively. This finding is consistent with the study of Sara Nourmusavi Nasab [52]. Children prefer hospital environments that combine recreational facilities with distinctive design features, including colorful decorations. Environmental decorations and amusing settings can distract children’s patients, so it is recommended to create positive imagery through artworks [53]. Notably, the adjusted user weight for ED4 has decreased, indicating that current decorations partially meet requirements. However, final weight reaches 0.1989, and as a One-dimensional Quality (O) where fulfillment level positively correlates with satisfaction, it needs to be further optimized.

Based on these findings, we propose the following recommendations:

1. Optimize spatial functions and enhance environmental comfort. In the spatial function design of dental hospitals, establish independent children activity areas and parent-child interaction areas, and provide interactive functions such as independent play for children, parent-child games, temporary dining, and rest. Reconsider the layout of medical staff pathways and patient pathways to optimize circulation separation and reduce congestion. Pay attention to adjusting spatial scale in children activity areas, and adopt a “one-meter height” perspective to enhance approachability. Use soundproofing materials and play soft background music to control noise. Adopt environmentally friendly disinfectants to improve odors, and install air purification equipment to create a fresh environment. Set treatment areas with dynamic lighting devices, such as using warm-color LED lights with adjustable color temperature to optimize lighting. Introduce natural light in public areas such as waiting areas and corridors. Increase cleaning frequency, and set up visual or audio prompts to encourage both staff and visitors to maintain hygiene together.

2. Increase child-appropriate facilities configurations: It is recommended to strengthen safety protection in terms of collision prevention and slip resistance to reduce the possibility of child injuries. Add barrier-free facilities and child-friendly sanitary facilities, such as low-position, sensor-activated devices. Adopt adjustable child-appropriate furniture and equipment with cartoon elements, such as dental chairs equipped with cartoon-patterned child-specific headrests and armrests. Improve wayfinding systems by designing visualized, simple and understandable design to facilitate children’s independent navigation.

3. Interactive Activities and Child-participatory Design Enrich diversified static and dynamic interactive activities, incorporate digital technologies such as VR simulation experiences and role-playing games, thus transforming treatment spaces into exploratory learning environments. Make full use of available space to set up fun science education devices and story-based scenarios for health education, thereby guiding children to learn dental care knowledge. Establish children feedback mechanisms through workshops, smiley-face ratings, etc., to provide real-time feedback on treatment experiences and help hospitals optimize services and environmental design.

4. Service and Management Optimization Medical staff should wear approachable cloth with soft colors and textures to reduce the oppressive feeling caused by white coats. Design gamified treatment processes by using storytelling language, encouraging communication, pre-treatment simulation operations, and digital technology-assisted psychological interventions and emotional management to innovate service models. Simultaneously strengthen database construction and data information security.

5. Strengthen environmental atmosphere creation. In color selection, use bright and warm colors such as light blue, pale yellow, and pink, or natural/cartoon themes to create a relaxed atmosphere. Prioritize environmentally friendly and tactilely comfortable materials, such as natural rubber flooring, fabrics, and temperature-sensitive silicone materials, to help children relax in the environment. Add healing elements such as greenery, water features, and positive art decorations to create a soothing environment. Focus on environmental fun, construct an overall story theme narrative, integrate functional areas into coherent story scenarios, enhance immersion and exploration, and build a narrative treatment experience for children active exploration.

To evaluate whether the design solutions in this study meet user needs, we compared the design solutions with current photos of the Hospital of Stomatology Xi’an Jiaotong University, using a five-point Likert scale-based questionnaire to assess user satisfaction with the design solutions based on indicators such as physical space, spatial decoration, facility application, treatment forms, and interactive activities. A total of 300 questionnaires were distributed to children and their parents, with 297 valid responses collected. The results show that the average score for the original design sample is 2.51, while the satisfaction score for the optimized design of child-friendly dental hospitals based on user needs is 3.92. This indicates that the optimized design of child-friendly dental hospitals guided by the methodology of this study can effectively improve the satisfaction of children and their parents, thus offering valuable guidance for child-friendly design of medical environments.

Innovations

Child-friendly environmental design in dental hospitals involves multiple complex factors, and the children’s perspective is often overlooked in current researches. Current researches on hospital satisfaction and needs mainly focus on parents rather than environment analysis. As children’s feelings and needs are often overlooked, directly involving them in the survey of satisfaction and needs is essential for capturing their unique perspectives and advancing the design of child-friendly dental hospitals.

Compared with previous researches, this study proposes a more systematic design evaluation process and a more comprehensive user needs analysis method by combining the Kano model with the AHP, an integrated framework of “need classification-weight evaluation-priority fitting” has been constructed. The Kano-AHP integrated model effectively overcomes the limitations of a single method. The Kano model accurately distinguishes need attributes, while the AHP dynamically reflects actual improvement needs of users in combination with user satisfaction gap weight modification. The fitting of the two methods ultimately determines a clear design priority order through the quantitative scores, thus providing a scientific basis for resource allocation. The priority order derived from the weight fitting using Kano-AHP model integrates diverse perspectives from children, parents, and experts. This not only ensures the inclusion and expression of children needs but also enables a multidimensional analysis of stakeholder opinions, significantly enhancing the scientific rigor and rationality of design decisions regarding child-friendly environmental design in dental hospitals.

Limitations

Despite providing a systematic approach for collecting user needs and satisfaction data, the study has certain limitations. In terms of participants, this study did not categorize children by age groups. Children at different developmental stages perceive the environment differently. For example, preschool and lower-grade children (6–8 years old) may rely more on sensory experiences and direct interactive activities to alleviate anxiety; while upper-grade and adolescent children (9–14 years old) may pay more attention to privacy, autonomy, social space and sense of environmental control [8]. The current broad age grouping may obscure these developmental stage-specific needs, and limit the precise applicability of design strategies for different age groups. Future research will consider more detailed analyses of children at various stages, such as referring to Piaget’s cognitive development stages, to reveal more age-specific environmental design needs.

In terms of research methods, this study used traditional questionnaire forms to collect data. Although visual symbols and contextualized questions were adopted to simplify understanding, children’s cognitive limitations regarding abstract concepts such as “privacy” and “therapeutic quality” and scales may still lead to response bias. Meanwhile, parental presence may introduce social desirability pressure, suppress children’s negative feedback, and parents’ satisfaction may influence how they guide children’s responses, resulting in limitations in research results. Future research could consider more objective and diverse research methods to collect children needs, and develop child-friendly mixed research methods. For example, embed small-sample participatory design, story creation, digital games, etc., to explore the non-verbalized needs of young children, making the research data richer and the result analysis more accurate and comprehensive.

As for the study case, due to time and funding constraints, this study focuses on a Grade A tertiary dental hospital, without covering institutions in regions with varying levels of economic development or primary healthcare settings. The single-source samples may limit the generalizability of the research results. Values, perceptions of environmental symbols, socioeconomic levels, accessibility of medical resources, and parenting concepts vary across regions. For example, preferences for color symbolism may have cultural specificity in different cultural backgrounds. These cultural factors may influence children and their parents’ cognition, expectations and evaluation criteria regarding friendly environment. Future research needs to explore cross-cultural adaptability and conduct multi-center studies across different regions to verify the generalizability and effectiveness of survey tools and design strategies in different regions. At the same time, future research needs to strengthen the culturally adaptable design framework. This means that core principles may be universal, but specific spatial expressions, interactive activities, decorative schemes and even service methods need to be localized according to the local cultural background.

This study adopted a cross-sectional design, which only captured the needs of children and their parents at a specific time point. Therefore the data cannot reflect how children needs dynamically evolve with increased visits, improved familiarity with the hospital environment, and their growth. As children grow older, changes in their cognitive abilities and preferences will also lead to shifts in need focus. Neglecting this temporal change may result in design optimization solutions lacking foresight and difficulty in meeting children’s continuous needs throughout the entire medical treatment process. Future research should introduce longitudinal tracking designs and conduct multiple follow-ups with the same group of children to depict the trajectory of need evolution and provide more dynamically adaptive strategies for design.

Conclusion

The construction of child-friendly environments of dental hospitals is not only a matter of physical space transformation but also a practical response to the protection of children’s rights and the pursuit of human-centered care. This study aims to enhance dental visit experiences of children by focusing on satisfaction evaluation and needs analysis of child-friendly environments of dental hospitals. Taking the Hospital of Stomatology Xi’an Jiaotong University as an example, we quantified 28 environmental needs from 484 children and their parents using the Kano-AHP integrated model. This study reveals the diversified attributes and satisfaction levels of children needs, has established a design priority sequence of “construct visual environment and interactive experiences - configure facilities and innovate treatment forms - enhance environmental safety and comfort - sustain advantageous projects”. Future design optimizations from five aspects “spatial optimization, Child-friendly facilities, interactive activities, service management, and environmental decoration”, can effectively enhance child-friendly environments of dental hospitals.

This study has broken through the limitations of traditional parent proxy reports by directly incorporating children’s perspectives for needs classification and verification. Simultaneously, the Kano-AHP integrated model effectively combines the need attribute classification advantages of the Kano model with AHP’s capability in cross-dimensional importance weighting, which can promote the development of child-centered research methods and provide references for alleviating medical anxiety of children and improving healthcare service quality. Looking forward, we need to continuously deepen multidisciplinary collaboration, conduct more age-specific research for children from different cultural backgrounds and regions, and encourage greater international research efforts to advance the quality of pediatric oral healthcare, thereby fostering the sustainable development of child-centered dental services.

Abbreviations

AHP

Analytic hierarchy proces

Kano

Kano mode

KJ

Kawakita jiro method (Affinity Diagram)

R-value

Requirement sensitivity value

M

Must-be quality

O

One-dimensional quality

A

Attractive quality

I

Indifferent quality

R

Reverse quality

PH

Physical environment needs

FA

Facility needs

AC

Activity needs

SM

Services and management needs

ED

Environmental Decoration Needs

VR

Virtual reality

LED

Light emitting diode

Authors’ contributions

Mengting Li, Jiabin Xu, Zhiyuan Ma and Yulei Guan drafted the first version and revision of the article, editing, investigation and statistical analysis, which was critically reviewed by Xiao Sun and Kexin Wei.

Funding

This study was conducted without any funding.

Data availability

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

Declarations

Ethics approval and consent to participate

Confirm that all experiments were performed in compliance with the Helsinki Declaration.

Informed consent was obtained from all the research participants and the parents or legal guardians of any participants under the age of 16.

1. Name of the institutional approval committee: Ethical approval was obtained from the Ethics Committee of School of Stomatology, Xi’an Jiaotong University.

2. The approval number: IEC-AF/17 − 2.1.

3. Date of approval:2023.06.13.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical number

Not applicable.