Childhood obesity represents one of the most pressing public health challenges in Europe, requiring integrated, sustainable, and equity-oriented solutions. Understanding and intervening in health promotion must consider an ecological perspective and use a participatory methodology in order to encompass the complexity of the phenomenon and promote greater sustainability.1,2

In Portugal, approximately one-third of children aged 6–9 present overweight or obesity.3 Addressing these trends demands coordinated action across education, health, and local governance sectors. The Health4EUKids Joint Action aims to reduce inequalities in child health through evidence-based interventions and cross-country learning. The Portuguese pilot operationalized this approach in the district of Portalegre in Alentejo region, emphasizing co-creation, participatory governance, and ecological health promotion. The study explores how local participatory processes can inform and strengthen national and European child health policies.

This study included 202 primary school students, 52.6% (n=100) boys and 47.4% (n=90) girls, aged 6 to 10. It should be noted that 12 students did not answer the gender question. Regarding geographical distribution, 52.5% reside in the municipality of Portalegre and 47.5% in Alter do Chão. Concerning school years, the largest percentage of students are in the 1st and 2nd years of schooling.

Regarding socioeconomic status (ASE), among the beneficiary students 45.8% (n=49) reports having social action level A, indicating that a significant part of the sample is from a context of greater economic vulnerability (Table 1).

The biopsychosocial assessment identified the coexistence of protective and risk factors in the individual, behavioral, and contextual domains. Regarding mental and emotional health, a moderate prevalence of irritability (57%) and nervousness (46.7%) was reported, coexisting with overall positive perceptions of quality of life and peer relationships. Gender differences were observed, with girls showing higher levels of emotional well-being and boys’ greater involvement in physical activity. Regarding physical health, most children had a body mass index within the normal range (66%), with cases of overweight (11%) and obesity (4%) also identified. Although indicators of consistent eating routines were observed, such as daily breakfast and frequent family meals, reported by 90% of participants, more than a third of the sample did not meet the World Health Organization's recommendations for daily physical activity.

Analysis of lifestyle patterns revealed moderate to high screen dependence in about half of the sample, particularly in urban settings, while children from rural areas reported healthier leisure routines and greater community involvement (Tables 2 and 3).

At the community level, the Living Healthy Tool showed more favorable perceptions in rural areas regarding access to safe outdoor spaces, social cohesion, and health-promoting food environments, while urban participants highlighted barriers associated with safety and access to sports facilities. Across the board, satisfaction levels with the activities carried out were high among students and professionals, who reported greater awareness, strengthened intersectoral collaboration, and increased community empowerment.

Overall, the results of this pilot study highlight the added value of participatory approaches and mixed methods in understanding the multidimensional determinants of child health and in strengthening local ownership and sustainability of health promotion actions, particularly in differentiated territorial contexts.

At the policy level, the Health4EUKids project demonstrated strategic relevance by fostering intersectoral governance and informing future public health planning. The development of Policy Brief and locally implemented actions aligned with national health priorities, reinforcing sustainability and institutional commitment. A major methodological advancement was the adaptation of the HBSC protocol to younger age groups (6–10 years), expanding its scope beyond the traditional adolescent cohort. This innovation enhanced the capacity to monitor early health determinants and will inform future iterations of the National Health in Schools Program. The implementation in Alter do Chão and Portalegre, two small municipalities sharing institutional frameworks but differing in their urban–rural profiles, provided valuable comparative insights and strengthened the transferability of lessons learned to other Portuguese contexts.

The study reveals a complex biopsychosocial profile among school-aged children. In terms of physical health, most children presented a body mass index within the normal range (66%), although a moderate prevalence of overweight (11%) and obesity (4%) was also observed. This profile reflects the coexistence of both protective and risk factors, which is particularly relevant in the context of early childhood obesity prevention. The presence of structured family routines was highlighted by the fact that 90% of children consumed breakfast daily and shared frequent family meals, both of which are behaviors recognized as key drivers of healthy development and building long-term health resilience.4–7 However, more than one-third of the sample did not meet the WHO's recommendations for daily physical activity, and a high dependence on screens was observed, especially in urban contexts. These findings underscore the need for integrated interventions that promote active lifestyles and healthy behaviors from early childhood, particularly in urban environments.4,5

Regarding mental and emotional health, the results indicate a complex interplay between risk and protective factors. A significant proportion of children reported moderate levels of irritability and nervousness, yet these psychological symptoms coexisted with generally positive perceptions of quality of life and peer relationships. This duality highlights the complexity of psychosocial development in childhood and aligns with evidence suggesting that supportive relationships can mitigate the negative effects of stress on well-being.6–8

The application of the Living Healthy Tool allowed for a deeper analysis of the contextual determinants of health, highlighting relevant territorial differences. The more favorable perceptions in rural areas regarding community cohesion, social trust, and access to safe outdoor spaces are consistent with studies that emphasize the role of social capital and the built environment in promoting healthy lifestyles. In contrast, the barriers identified in the urban context reinforce previous evidence on inequalities in access to infrastructure and safe environments for physical activity.

Taken together, these results support the importance of holistic approaches that address both physical and psychosocial dimensions of child health, emphasizing the value of participatory and context-sensitive strategies to enhance well-being and prevent obesity from an early age.5–9

Moreover, the co-creation process promoted intersectoral dialogue between health and education systems, often fragmented in practice. This participatory governance model aligns with the WHO Health in All Policies framework and the EU's 2024–2030 Strategy for Childhood Obesity Prevention, illustrating how community engagement can operationalize these high-level goals at the municipal level.10

Despite the contributions of the study, some limitations should be noted. The small sample size, particularly regarding the instruments applied to the community and professionals, limits the generalizability of the results. The short duration of the study prevents the evaluation of medium- and long-term effects of the interventions. Additionally, the use of self-report-based instruments may induce response biases. However, the triangulation of methods and information collected support the ecological validity of the results, as advocated by the methodological literature in community health research.11

The Portuguese Health4EUKids pilot show the added value of participatory and multi-level governance models in translating evidence into action for childhood obesity prevention. By aligning local knowledge, scientific evidence, and policy priorities, the approach strengthened intersectoral collaboration, promoted health literacy, and supported more equitable and context-sensitive health promotion strategies. The findings suggest that embedding co-creation processes within local governance structures enhances sustainability and community ownership, particularly in diverse urban and rural settings. Scaling this model nationally and across European contexts could meaningfully contribute to the implementation of the National Health in Schools Program, the Portuguese National Health Plan 2030, and the achievement of the United Nations Sustainable Development Goals related to health and equity (SDG 3 and SDG 10).

Based on the study results, implications for the formulation of public policies in the field of child health can be identified, anchored in the evidence produced by the study:

Integration of participatory processes at the local level: the high acceptance of the activities carried out by children and professionals suggests that the inclusion of co-creation mechanisms in municipal health and education planning processes can strengthen local ownership of interventions.

Strengthening intersectoral coordination at a municipal level: the observed collaboration between schools, municipalities, and health services shows that permanent intersectoral partnerships can facilitate the implementation of consistent actions to promote children's health.

Use of community assessment tools: the application of the Living Healthy Tool proved useful in identifying contextual assets and barriers to the promotion of healthy lifestyles, suggesting its potential as a tool to support decision-making at the local level.

Adaptation of interventions to the territorial context: the differences identified between urban and rural contexts highlight the need for policies tailored to local characteristics, particularly regarding access to safe spaces, infrastructure, and community networks.

Contribution to European collaborative initiatives: the experience of the Portuguese pilot study provides empirical evidence on the applicability of participatory approaches and mixed methods in local contexts and may inform future collaborative actions within the framework of European initiatives to promote child health.

José Manuel Jiménez Rodríguez.

The corresponding author, on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

T. Gaspar conceptualized the study design, conducted the analyses, original draft preparation and critically reviewed the final manuscript, supervision, discussion and conclusions, methodology and formal analysis, investigation. M.R. Nóbrega: data collection, data analysis, result description, writing, review and editing, investigation. F. Botelho Guedes: data analysis, result description, writing, review and editing. A. Cerqueira: writing, review and editing, investigation. L. Quelhas Pinto: project administration, supervision, writing, review and editing. M. Telo de Arriaga: project administration, contributed to the study conceptualization and critically reviewed the manuscript and the results, writing, review and funding acquisition. All authors have read and agreed to the published version of the manuscript.

The authors thank the municipalities of Portalegre and Alter do Chão, the Local Health Unit of Alto Alentejo, the participating schools, educators, families, and children.

Health4EUKids Joint Action is funded by the European Union under the grant agreement No. 101079944.

None.