A Health Promoting School (HPS) is a school that systematically is strengthening its capacity as a healthy setting for living, learning and working, implementing policies and practices to enhance the health and well-being of its students, staff, and the wider community (World Health Organization & UNESCO, 2021). This concept, initiated by the World Health Organization (WHO), adopts a holistic, whole-school and comprehensive health promotion approach, integrating health into all aspects of school life, that capitalizes on the organizational potential of schools to foster the physical, social and psychological conditions for health (World Health Organization, 2025). This involves not only health education in the classroom but also creating a supportive environment, establishing health-promoting policies, and engaging with the community to support health and well-being (Vilaça, Darlington, Velasco, Martinis, & Masson, 2019). The Schools for Health in Europe (SHE) network defines a health promoting school as “a ‘learning’ and ‘growing’ community, where students develop their capabilities and attributes and improve their knowledge, skills and competences both in the classroom and in everyday school life. Also, school is an important setting for staff development and their health and wellbeing (Paakkari, Simovska, Pedersen, & Schulz, 2019, p.6). This definition underscores the importance of a coordinated and comprehensive approach to health promotion within the school setting. Developing health-promoting habits in children is critical to public health, as childhood and adolescence are key years of biological, social and emotional change that lay the foundation for their health and well-being as adults. Sawyer (2012) argue that promoting health during adolescence is key to many public health agendas, as of non-communicable diseases, mental disorders, and injuries in adults arise from a focus on risk processes that begin in or before adolescence. In summary, a Health Promoting School is characterized by its commitment to integrating health into all facets of school life, thereby fostering a supportive environment that enhances the health and educational outcomes of students and the broader school community contributes to provide a response to The Green Paper on Aging (European Commission, 2021), which argues that living a healthy childhood and adolescence shapes our future prospects, our health status and our well-being in old age.

This research was developed within the scope of a partnership representing the Schools for Health in Europe Network (SHE) created to carry out the three-year School for Health in Europe for Active and Healthy Aging Project (SHE4AHA), an ERASMUS⁺ Project (2021-1-DK01-KA220-SCH-000032766), involving Denmark, France, Iceland, Portugal and Slovenia. SHE has a set of materials that policy makers, school board and teachers can use to make each school a Health Promoting School. These SHE material includes the SHE School Manual 2.0 (Vilaça, Darlington, Miranda, Martinis, & Masson, 2019), the SHE Rapid Assessment Tool (Safarjan, Buijs, & Ruiter, 2013), which is an assessment of the current situation and priorities of schools regarding health promotion and education, a set of European Standards and Indicators for Health Promoting Schools version 2.0 (Darlington, Bada, Masson, & Santos, 2021) and a pixie version of the SHE School Manual 2.0 co-created by the SHE4AHA team. The main aim of the SHE4AHA project was to develop teaching material to help schools around Europe to use and implement the SHE material.

Against this background, this research aims to contribute to the evidence base on the potentials and barriers of using SHE materials in developing students' action competence and promoting health in schools.

In this context, this multiple case study, included teachers from the multidisciplinary team for health of two rural school clusters, one urban preparatory school and one semi-urban preparatory and secondary school in Portugal. The rural school cluster A includes a set of schools from pre-school education to the 9th grade with over 700 students aged 6-14 years old and about 300 children from 3 to 5 years old. This network of schools has several leisure clubs and projects, such as school sports, gardening club, science and sexuality education club. The rural preparatory school B, has around 440 students from the 5th to 9th grades, however only one class participated in the project. In this school there are several national and international projects, such as ERASMUS+ Projects the Eco-schools Program, the Cultural Project of the National Arts Plan. The urban preparatory school C has around 700 students from the 5th to the 9th grade. This school currently has the Healthy School seal and the Eco-Schools seal. The school has several clubs and projects. The semi-urban preparatory and secondary school D has about 700 students from the 5th to the 12th grade. This school has participated in several ERASMUS+ and eTwinning projects and has several clubs, such as the arts, sports, robotics and “living science”. The SHE4AHA project started with a b-learning in-service teacher training course (25 hours) and 25 hours at school context. The first 10 hours took place online. In this component, the concepts of health, health determinants, health promotion and ethics (SHE values), the whole school approach, and the SHE Pillars were co-constructed. The SHE website was explored and participants were invited to explore the Material for Teachers on Health Promotion at home in more depth. At this stage, these teachers wanted to expand the group and involve more teachers and some technicians from the school. The second phase of the training (15hours) at the University aimed to present the SHE materials. Subsequently, a co-created project was design, implemented and co-assessed. Data were collected through: i) a focus group in each school at the beginning and at the end of the training and also two years after training, which included the teachers and technicians (n=15) who carried out the training; ii) the analysis of the documents produced by the participants during the SHE4AHA project; iii) and the analysis of collaborative logbooks constructed by each school group after each session.

At the beginning of the project, the assessment of the current situation and priorities of schools in relation to health promotion, using The SHE rapid assessment tool, by the SHE4AHA school team (A, B) or by the SH4AHA facilitator (C, D). The school cluster A at the beginning of the project scored moderately its priorities for action in the areas of orientation, school health policies, physical school environment, community connections, and health of teaching and non-teaching staff. However, had lower scores in the areas of health competencies and the school's social environment. Therefore, there was an urgent need to focus efforts to improve the health and well-being of students and staff. In this sense, teachers developed class-based projects from 1st to 9th grades to promote mental health and the quality of relationships between members of the school community, as well as stimulate creativity, "outside the box" thinking and projects with students and adults that students felt are appropriate to get involved to solve the health problems they initially identify. Similar results were found in schools C and D At the school B, the SHE4AHA team concluded at the beginning that most of the dimensions of the health promoting school are already being implemented. However, there are weaknesses in terms of links to the community. As it was only possible to involve one class, whose selected problem by students was dating violence, they worked on this priority by involving several members of the community in the action-oriented project developed. All teachers preferred to use the pixie version of the SHE Manual to organize their action strategy at school, however, they identify as main barriers/difficulties in its use the time to meet with colleagues to discuss the concepts and develop health promotion projects, and the large number of citizenship education activities.

Darlington, E., Bada, E., Masson, J., & Santos, R. (2021). European Standards and Indicators for Health Promoting Schools version 2.0. Schools for Health in Europe Network Foundation (SHE) Ed.. https://www.schoolsforhealth.org/sites/default/files/editor/standards_and_indicators_2.pdf Paakkari, L., Simovska, V., Pedersen, U., & Schulz, S. (2019). Materials for Teachers (version 1.2.). Learning about health and health promotion in schools: Key concepts and activities. Schools for Health in Europe Network Foundation. Safarjan, E., Buijs, G., & Ruiter,S. (2013). The SHE Rapid Assessment Tool. Schools for Health in Europe Network Foundation (SHE) Ed. https://www.schoolsforhealth.org/resources/materials-and-tools/health-promoting-school-manuals/english Sawyer, S.M., Afifi, R.A., Bearinger, L.H., Blakemore, S-J, Dick, B., Ezeh, A.C., et al. (2012). Adolescence: a foundation for future health. Lancet, 379(9826), 1630–40. doi: 10.1016/S0140-6736(12)60072-5. Epub 2012 Apr 25. Vilaça, T., Darlington, E., Velasco, M.J.M, Martinis, O., & Masson, J (2019). SHE School Manual 2.0. A Methodological Guidebook to become a health promoting school. Schools for Health in Europe Network Foundation (SHE) Ed.. https://www.schoolsforhealth.org/resources/materials-and-tools/how-be-health-promoting-school World Health Organization (2025). Implementation guidance for school health services. World Health Organization. World Health Organization & UNESCO. (‎2021)‎. WHO guideline on school health services. World Health Organization.