Exploring factors influencing oral hygiene behavior among 11- to 14-year-old adolescents: a qualitative study based on the PRECEDE-PROCEED

Oral hygiene behavior is essential for preventing tooth decay in adolescents, yet there is often a considerable disconnect between what they know about oral health and what they actually do. Most studies conducted in Iran have taken a quantitative approach and therefore have not been able to shed light on the contextual and experiential factors that shape adolescent behaviors. To address this gap, this qualitative study uses the PRECEDE-PROCEED model to explore the factors influensing from the perspective of adolescents’ own lived experiences. The results aim to inform the design of oral health programs that are tailored to the local context and aligned with cultural values. Methods This study employed a qualitative descriptive design utilizing directed content analysis, anchored in the PRECEDE-PROCEED model. Semi-structured, in-depth interviews were conducted with 28 participants (12 adolescents aged 11–14, 10 mothers, 5 dental specialists and one oral health hygienist) who were recruited through purposeful and snowball sampling until data saturation was achieved. Participants were accessed and recruited via the two primary settings mentioned earlier—Comprehensive Health Centers and pediatric dental clinics—with the assistance of clinic staff and coordinators. Data trustworthiness was ensured using Lincoln and Guba’s criteria (member checking, peer debriefing, and an audit trail), and ethical standards were strictly maintained throughout. The interviews were conducted between February and June 2024 at the respective health centers and dental clinics, in private rooms to ensure comfort and privacy. Results A total of 547 initial codes, 65 refined codes, and 19 sub-categories emerged, all of which were consistent with the PRECEDE-PROCEED model. Predisposing factors centered on superficial knowledge, dental myths (e.g., heredity bias), dental fear, and a knowledge-action gap. Enabling factors involved economic constraints, inadequate brushing skills, smartphone distraction, biological barriers (gum bleeding/gag reflex), and environmental limitations. Although these factors appear negative, they are classified as enabling factors within the PRECEDE-PROCEED framework, as they represent structural barriers that hinder rather than facilitate proper oral hygiene behaviors. Reinforcing factors included parental modeling, aesthetic-focused peer feedback, social media influence, material rewards, and past experiences of dental pain. Conclusion Achieving sustainable behavioral change requires shifting from clinical messaging to holistic, multi-level interventions. Public health authorities must prioritize supportive school environments, digital tools, equitable access to hygiene products, and family empowerment. Future quantitative trials should evaluate the long-term impact of these PRECEDE-PROCEED-guided strategies across broader adolescent populations.