The aim of this study was to investigate the perceptions of health among school-aged children from socially vulnerable areas.

The study has an explorative mixed-method design with a participatory and inductive approach (31–33) at the MaCs in three of the vulnerable areas in Malmö Municipality. Data is based on focus group interviews, about health and activities, including interviews with school-aged children and youth leaders. The focus was on the children’s own descriptions of health. Data from the MaCs’ own questionnaire is also included.

In this study, there were a purposive sampling of participants from three groups, involving either youth leaders or schoolchildren, from each MaC in the three areas.

The first interview group consisted of children and the second interview group consisted of youth leaders. The inclusion criteria were understanding and speaking Swedish and being interested in sharing their experiences of health and activities.

The third questionnaire group of participants consisted of children of all age groups from the three schools involved in the study.

The questionnaires were distributed to children in the schools (N = 1,473), by their teachers.

The data collection is based on three datasets: (1) the focus group interviews with children, (2) the focus group interviews with leaders, and (3) the MaCs’ own questionnaire.

Focus groups are an interview form where a small group of committed people talk about a predetermined topic (32). The group participants have something in common (age, gender, experience, etc.) and the question time is led by interviewers/moderators. With the help of the conversation taking place in the group, the perspective on the subject being talked about is broadened, in that the participants can express their opinions while the others listen and complement with their own experiences. The group leaders have an interview guide to help the participants focus on the subject (32). At the end of the meeting, one of the researchers summarizes the conversations and conclusions.

The first dataset, about children’s perceptions of health, consists of focus group interviews with schoolchildren accompanied by leaders. After an introduction round, the participants were asked, in pairs, to discuss and write down their conception of health on Post-it^® notes. Thereafter, each pair posted their notes on a flipchart and presented their thoughts about health. After each pair had presented their notes and perceptions, the children were asked to group the Post-it^® notes into categories making sense of their perception of health. In all three interviews, the children described health in terms of well-being, activity, and participation. Therefore, the rest of the data collection was based on those three themes. Besides being audio recorded, the interviews were documented by the Post-it^® notes and by field notes taken by the participating researchers.

The second dataset consists of three focus group interviews with leaders at the MaCs. The interviews were scheduled as face-to-face interviews, but because of the Covid-19 pandemic, they were re-scheduled and carried out digitally on Zoom. After an introduction round, the participants were asked to present their experiences about how activities at MaCs can contribute to children’s health, operationalized as well-being, activity, and participation. The interviews were audio recorded and field notes were taken by the participating researcher.

The third dataset consists of the MaCs’ own questionnaire about children’s perceptions on activities. The questionnaire contains 15 questions in total and was developed and used by the MaCs to plan their activities for the next semester, and to evaluate the children’s satisfaction with the activities. In the questionnaire, the children reported background data (5 questions) and participation in activities, as well as writing their free comments on the value of different activities and on health, operationalized as well-being, activity, and participation (5 questions). The last five questions are about what the children want to do the next semester (this was not analyzed in this study).

The first data analysis was carried out based on the data from Post-it^® notes, recorded interviews, and field notes from focus group interviews with children about health. The analysis used was an inductive content and text analysis (32, 35) to answer the question of children’s perceptions of health. This analysis showed three aspects of health: well-being, activity, and participation.

Thereafter, a second analysis was carried out, based on the children’s understanding of the concept of health. In this analysis, data from the first analysis, together with transcribed focus group interviews with leaders as well as the children’s free comments in the questionnaire, were included. This qualitative content analysis was carried out as a deductive content analysis (32) to explore children’s perceptions of health operationalized as well-being, activity, and participation. In this analysis, those three aspects of health, were closely scrutinized and resulted in themes with subthemes.

Ethical research with children and young people is facilitated by a multistep procedure for ensuring that both the research design and protocols are suitable and secure for child participants.

The research group honor the ethical standards set by the Helsinki Committee (36), with respect to autonomy, beneficence, nonmaleficence, and justice (37). On December 1, 2010, the Swedish Parliament approved the government bill “Strategy to strengthen the child’s rights in Sweden” (38). Children should be given the opportunity to express their views on issues that concern them.

All children, parents, and leaders have given their written consent to participate in all research activities in this study.

The study is part of a larger initiative for developing and studying health-promoting activities informed by community-based participatory research in a socially disadvantaged district in the city of Malmö. Ethical approval was granted (Reg.no. 2018/384).

The result of the analysis shows that participating in activities increases the child’s sense of well-being. The children and leaders described health and well-being as being recognized and feeling good and safe, and having a healthy body.

The result of the analysis shows that children describe participating in activities and having fun as an important agent for health, when doing things together with friends and leaders.

In the interviews and in the questionnaire, the children saw health as being related to different activities. The most frequent activities the children participated in were divided groups for boys and girls, different kinds of crafts, sports activities, such as football, and sports combined with cooking or baking.

Children and leaders stressed the importance of giving children the possibility of doing the activities together with others, such as friends and adults. The children commented that activities at the MaCs gave them opportunities to meet their friends. Moreover, participating in activities gave the children a chance to make new friends.

Participating in activities also created a good base for good relationships. Both children and leaders stated the importance of a good atmosphere and of trustful relationships between children and leaders. The activities were especially valued by children with few friends.

Furthermore, the leaders emphasized the value of being present and available for establishing a trustful relationship and of spending time with the children.

The result of the analysis shows that participating in activities was described by children and leaders as not just being present but having a feeling of involvement, by being able to have an influence and to participate on one’s own terms.

The result of the analysis shows that children and leaders describe participating in activities as a way for the child to gain faith in the future and to learn by trying new things, thus positively influencing the child’s development, and resulting in increased self-confidence and a positive behavior.

Conducting focus groups is a method for reducing the power imbalance between researcher and children (39, 40). The children in the present study thought that taking part in focus group interviews was fun, which suggests that the children’s perspective on health was represented. However, the children’s perceptions of health may have been influenced by interviews being undertaken at the MaCs, and by having a few leaders present at the interviews. The Post-it^® notes were used as a starting point for the focus group discussions, and the children could present an unlimited number of notes and then sort and discuss the ones of their choice in the focus groups. This gave the children freedom to experiment through play, which they pointed out at the end of the study. Moreover, the Post-it^® notes opened for reflections on aspects that were not always obvious to an adult. The smaller number of participating children as well as leaders, in some of the focus groups, is a possible limitation. But it might be easier for children in a focus group to stay focused and be heard when there are only few participants in the group (40, 41).

Another possible limitation is the questionnaire, which were developed for use by the MaCs themselves. The questions did not pass through a scientific screening before being used. Therefore only a few questions were analyzed, such as frequencies of participation, together with the free comments written by children. The authors had no control over how many children were in fact reached by the questionnaire, and no knowledge of other reasons for not participating. Also, the actual response rate of the questionnaire is not known to the authors, and there is no data on those who did not respond, hence the interpretation of data needs to be done cautiously. Short comments and short answers in interviews are not uncommon in studies with children (42) but can be a problem in the analysis. Still, a short comment from a child could contain valuable information on the subject under study (40, 41, 43).

Finally, the transferability of the results may be questioned because this study is limited to immigrant children from vulnerable areas in Sweden.

The result of this study shows that for the children health could be described in terms of different dimensions, such as well-being, activity, and participation. This could be related to the findings of Natapoff (42) and Almquist et al. (12). When they interviewed young children about their concept of health, they concluded that overall health seems to be an abstract concept that is multi-dimensional and hard to define for children and that children’s perception of health involves both physical and mental dimensions.

An important finding in this study was that the children related health to participation, in a supportive environment, where they could perform activities based upon their own choices. This is consistent with other studies that connect health and well-being for children to participating in activities (13, 44). Participation in activities also seems to influence increased self-rated health, life satisfaction, and happiness (45) Moreover, Lloyd and Emerson (46) found a correlation between children’s subjective well-being and their perceptions that their participation rights are respected.

The children and leaders in this study described health and well-being as, among other things, having a healthy body. However, the cost may restrict families’ possibilities to adopt healthy behaviors such as eating fruit and vegetables (47–49). Unhealthy behavior regarding nutrition can affect school results negatively and be a risk for children’s physical and mental well-being, so regular lunches in school are very important (50). The children who participated in this study pointed out the value of free meals, when participating in the Breakfast club and in Baking and Cooking activities.

Moreover, in the present study, children pinpointed participating in activities as an important means for health and enjoying oneself. They argued that activities are highly related to being able to do things together with friends and young leaders. Positive social interactions with friends and adults give children social skills that will be important for them later in life (51), as well as happiness and self-esteem (52, 53), and may also have a long-term effect on social adjustment (54). It is well known that social support and activities are important for a child’s development and for how they experience and understand their own self (55). School-aged children have described leisure activities as joint and meaningful activities (14) and having fun and feeling good have been shown to be children’s reasons for participation in activities (56).

Another aspect that the children and leaders in this study particularly pointed out was the importance of creating a good and trustful relationship between the children and the leaders, to promote children’s engagement in activities. This process of trust requires recognizing and respecting the child and paying attention to the child as an individual as well as being familiar with the child’s family (57, 58). In this study, the most frequent activities the children were involved in were single-sex group activities, that is, girls’ and boys’ groups. Possibly the main reason for choosing those groups was the content of the activity and the close relation to the leaders. But the single-sex approach also attracted the children. Single-sex school programs are under discussion, regarding both advantages and disadvantages [see, e.g., Debating Europe, 2021 (59)], but after-school activity has not been evaluated as frequently. In this study, the high number of girls participating in the activities might be a result of non-gender-mixed activities, since gender-mixed activities sometimes prevent children from migrant families from participating (60). Hence, the first goal is to get children to participate, the next goal is to counteract discrimination.

Furthermore, the children gave examples of activities they enjoyed and found fun, and such activities have several positive effects on children’s development (13). Among other activities in this study, the children engaged in physical activities, such as football and dance, which was, by the children, mentioned as joyful and important for healthy living. It is well known that reducing a child’s possibilities to have an active lifestyle may in the future lead to an increase in chronic diseases (61) and health-related quality of life (62).

Yet, children’s needs are not met by simply having playgrounds for football and a schoolyard; children need to explore and discover different spaces, such as their neighborhood, the city, and the surrounding landscape (3, 61). This was illustrated in the present study by the fact that the children wished for more outdoor activities and excursions. Research has shown that exploring the physical environment is important for children’s development of self (63), and that nature activities could benefit children’s mental well-being (64). In our earlier study on children’s perception of their outdoor environment in a socially vulnerable area (65), the children pointed out places where they must not go, adults having warned them about the risks. In this way the adults restricted the children’s freedom to move around in the local environment. The local environment, as part of the ecological systems (66, 67), is important for the children’s lives in terms of socialization, health, and development. Eriksson and Dahlblom (44) show a close link between social activities and physical environment. They argue that children’s access to places for health promotion, such as outdoor arenas for activities, constitutes an important social capital reducing inequalities between different neighborhoods.

Furthermore, children living in vulnerable areas have been shown to be less engaged in organized activities (19). Not taking part in organized activities might result in lower achievement in school work and affect mental health (50). Results of an evaluation from an adult’s perspective in 2015 (68) show that most children think it is fun to come to the MaC, that children feel seen and listened to, and that they feel very proud of their work. Another result shows that the school staff describe the school environment as more positive since the start of the MaCs, in that the atmosphere at the school becomes calmer, and the children feel safer and can concentrate better. This can be measured by the calmness during the lessons, less noise, fewer false fire alarms, and reduced destruction costs, as well as lower stress for the school staff. Yet another clear result is that, in one of the areas, the grades of the students in school year nine have risen by 11 percent after the start of the MaC (68).The result of this study shows that participating in activities was described by children and leaders as not just being present but having a feeling of involvement, by being able to have an influence and to participate on one’s own terms in organizing the activities. The WHO’s (51) definition of participation as “an individual’s engagement in his or her life situation” considers both the social and functional aspects of health, with the individual as an active participant in their own development. Eriksson and Granlund (69) define participation as “a feeling of belonging and engagement experienced by the individual in relation to being active in a certain context,” divided into two dimensions: presence (i.e., physically being there) and engagement (i.e., expressions of involvement) (70), which is in line with what the children in this study have described.

In the present study, the children and the leaders pointed out the importance of involving children in all decision-making regarding both the choice and the outline of activities at the MaC. Many documents about human rights have drawn attention to the right for children to participate in decision-making processes. However, the implementation of this right through meaningful participation has been a challenge (71, 72), even if it is now accepted in research and policy making (72).

The children in this study were somewhat disappointed at not being part of the decision-making regarding the choice of all activities. Some suggestions for activities were related to a need to travel or were expensive. As most children in this study come from disadvantaged families, the leaders stated that those families might not be able to offer such activities themselves. Thus, despite the wish for children to be able to participate on equal terms in activities, independently of family economy, cost may restrict families’ opportunities to participate in fee-based activities (73, 74).

Another important result of this study shows that children and leaders describe participating in activities as a way for the child to gain faith in the future and to learn by trying new things, thus positively influencing the child’s development, and resulting in increased self-confidence and a positive behavior. Health inequalities can also arise because children living in disadvantaged families are exposed to psychosocial stress (75). But positive development and positive behaviors can be gained by relationships and activities fostering knowledge, competence, confidence, character, and a feeling of contributing. Children’s participation and behaviors are important for the direction of their future development (55). Today children can be seen as active citizens. Their possibility for participating in activities allows them to actively understand what promotes their health and well-being. When children participate in organizing meaningful activities together, this also contributes to their understanding of both self and the society.