Children's voices in health promotion: Co-creating healthy lifestyle in primary schools

Abstract Background Healthy lifestyle promotion is fundamental for reducing the risk of noncommunicable diseases and fostering well-being from an early age. While much research focuses on adults’ perspectives, the active engagement of children in shaping health promotion strategies remains limited. Recognizing children as competent social actors, this study explored their perceptions of healthy lifestyles to inform more participatory and contextually grounded interventions. Methods A qualitative, exploratory, and descriptive study was conducted through a focus group with seven children aged 7-11 years from primary schools in vulnerable communities in Northern Portugal. A semi-structured guide, complemented by drawing activities, was used to facilitate child-friendly communication. Thematic analysis, following Braun and Clarke's reflexive approach, was employed to interpret the data. Results Children identified six key determinants of healthy lifestyles: nutrition, physical activity, personal care, interpersonal relationships, leisure activities, and well-being. Nutrition and social relationships emerged most frequently. Children highlighted the importance of family, peers, school, and the broader community in supporting healthy behaviors. Their narratives emphasized autonomy, enjoyment, and feeling good as central to their health perceptions, offering rich insights for health promotion design. Conclusions Co-creating health interventions with children provides a nuanced understanding of health determinants and fosters greater relevance and impact. Actively involving children can strengthen school health promotion efforts, making them more responsive to children's real needs and experiences, and supporting long-term health equity.