School as ideal setting to promote health and wellbeing among young people

Background: Nowadays, young people face several health challenges. As children and teenagers spend most of their time in the classroom, schools may have the opportunity to positively influence students’ quality of life, playing a crucial role in fostering their health. The aim of this review was to analyze evidence that demonstrated why school is the ideal setting for thepromotion of young generations’ wellbeing. Methods: We have reviewed the available literature about health promotion in school setting, searching for articles and books published from 1977 to 2020. A total of 74 articles and 17books were selected and assessed. Results: The promotion of students’ wellbeing could reduce the prevalence of measurable unhealthy outcomes and improve their academic achievements. At least 80% of all cases of heart diseases, strokes, type 2 diabetes and one third of all cancers can be prevented through health education. In this perspective, primary prevention and health promotion should start as early as possible, finding in the school the ideal setting of action. Effective school-based preventive approaches should raise students’ motivation towards a personal interiorization of health knowledge and develop in young people a critical thinking about harmful consequences of the most common risky behaviours. Educators should receive adequate training concerning health topics and become expert in the most innovative approaches to effectively engage students in adopting healthy lifestyles. Conclusion: As primary educational institution, school should integrate students’ health promotion in its ordinary teaching and learning practices in the perspective of "better health through better schools".


Introduction
In the 21st century, young people face several health challenges. On one hand, a high intake of total fat, free sugars, and salt, along with the lack of physical activity, have contributed to increase chidren's obesity at alarming rates; on the other hand, adolescents' lives are threatened by addictive and risky behaviours (e.g. tobacco smoking, alcohol, substance abuse, unprotected sex, inter-personal violence, intentional self-harm, extreme "deadly selfies"). 1 In this context, the United Nations (UN) recognize education as essential for children's global growth and key factor for improving young people health. The UN agency UNESCO is focused on turning into actions the educational commitments set by the United Nations "2030 Agenda for Sustainable Development", 2 while our Unesco Chair on Educational Health and Sustainable Development is specifically aimed at addressing the Sustainable Development Goals (SDGs), paying particular attention to the SDG3 concerning the promotion of "good health and wellbeing" and SDG4 to "ensure inclusive and equitable quality education and promote lifelong learning opportunities for all" (Figure 1). The schoolbased activities of our Unesco Chair are targeted to the prevention of harmful habits and promotion of wellbeing among schoolchildren living in Southern Italy, an area characterized by a widespread presence of vulnerable social groups at higher risk of developing unhealthy behaviours, due to socio-economic disadvantages. 3 In the view of the holistic individual development, the primary commitment of school systems -along with students' academic achievements -should be the improvement of children's physical, mental and social wellbeing. 4 In our vision, school may represent the optimal setting to display educational health-related interventions, [5][6][7][8] as educators can have the opportunity to positively influence -day by day -students' life-long learning and work to reduce health inequalities among young people. 3 Our first systematic review examined a number of studies concerning the effectiveness of multicomponent narrative-based strategies to improve healthy eating habits and decrease risk factors for overweight and obesity in schoolchildren. 9 More broadly, beyond the specific topic of healthy nutrition, children's global wellbeing might be systematically promoted at school by adopting innovative active approaches, where young people are not considered passive or simple audience, but are engaged in practical actions about healthy lifestyles (i.e. balanced nutrition and physical exercise, no smoking, no alcohol, no drugs etc). 10,11 The World Health Organization (WHO) suggests that health literacy should be incorporated in the core curriculum as children enter school, supported by a healthpromoting school environment. [12][13][14] A comprehensive school commitment towards students' global wellbeing is expected to positively impact both children's behaviours and their families. 15 For that reason, we question why scholastic institutions are not widely and systematically engaged in a proper path -according to specific keypoints set by WHO -to become "health-promoting schools" (Table 1), able to prevent students' risky behaviours. 16,17 This review is specifically aimed at providing evidencebased justification to consider school as ideal setting for the promotion of young generations' wellbeing.

Information sources, search strategies and study selection
In this short narrative review, we have explored the available literature concerning the rationale for promoting children's wellbeing in school setting. The review has been carried out by PhD candidates and academic experts in Human Sciences together with Medical Doctors according to the main items reported in the PRISMA checklist 2009. 18 We searched on Web of Science and Google Scholar for original articles and books published from 1977 to 2020 by using a search strategy based on the following keywords: Table 1. Keypoints identified by WHO to set up "health promoting schools" A health promoting school is one that constantly strengthens its capacity as a healthy setting for living, learning and working A health promoting school: Fosters health and learning with all the measures at its disposal.

•
Engages health and education officials, teachers, teachers' unions, students, parents, health providers and community leaders in efforts to make the school a healthy place.
• Strives to provide a healthy environment, school health education, and school health services along with school/community projects and outreach, health promotion programmes for staff, nutrition and food safety programmes, opportunities for physical education and recreation, and programmes for counselling, social support and mental health promotion.
• Implements policies and practices that respect an individual's wellbeing and dignity, provide multiple opportunities for success, and acknowledge good efforts and intentions as well as personal achievements.

•
Strives to improve the health of school personnel, families and community members as well as pupils; and works with community leaders to help them understand how the community contributes to, or undermines, health and education.
Health promoting schools focus on: • Caring for oneself and others.
• Making healthy decisions and taking control over life's circumstances.
• Creating conditions that are conducive to health (through policies, services, physical/social conditions).
• Building capacities for peace, shelter, education, food, income, a stable ecosystem, equity, social justice, sustainable development. "health promotion" OR "primary prevention" OR "wellbeing" AND "students" OR "school". Data extraction was performed by a PhD candidate and separately confirmed by a medical doctor. Additionally, we used citation tracking to detect other papers concerning health promotion in school setting. Exploration of heterogeneity of the studies was performed by assessing their quality (i.e. level of evidence). Interpretation of the findings has been conducted in the frame of current knowledge. 19

Exclusion criteria
We have excluded studies concerning psychopathology, psychiatric disorders, drug/alcohol addiction or eating disorders, and therapeutical applications. We have also left out articles regarding clinical topics such as autism spectrum conditions, specific learning difficulties, cognitive or sensory/physical deficits. Moreover, we removed all the articles presented in language other than English and Italian.

Synthesis of search results and summary measures
A total of 74 articles and 17 books' chapters were selected for the review. We have briefly summarized definitions of health, healthy lifestyles, health promotion, primary prevention, protective and risk factors, considering wellbeing (in its three dimensions of physical, emotional/ mental and social health) as the main goal of every educational practice, and school system as the ideal setting to perform educational health-related interventions.

Students' wellbeing promotion and academic achievements: a virtuous circle
Since education and wellbeing are intertwined dimensions, an important "mission" of any educational system is to ensure that students are healthy and able to learn. 1 Children spend most of their lifetime in classroom and that's why school can be the natural setting for promoting their health. By working everyday with pupils, teachers have a crucial role in positively influencing their global development and equipping them with the knowledge, attitudes, and skills needed to protect and maintain their healthy habits for the entire life. 20,21 In the socio-cognitive perspective, school should educate young people to take responsibility for their own health since the early childhood. 22 A correct approach towards health in daily life encourages the development of children's self-efficacy, which represents the ability to maintain healthy lifestyles during the life and enjoy the benefits of behavioural changes acquired. This emerging interest towards students' positive dimensions (such as self-esteem, happiness and resilience) should represent a new priority for school staff and families, to be addressed in a synergic effort. 23,24 It is clear that school system is a strategic social environment that can impact children's wellbeing, although in the last decades school has mainly focused on cognitive and academic achievements rather than adopting a comprehensive children's care model. 4 However, as documented in various studies, the wellbeing of the students has also an undoubtable impact on their learning outcomes and should be considered by teachers as a crucial dimension to work on. 25 Therefore, health promotion can't remain a marginal aspect of teacher work, as it has the potential to create a 'virtuous circle' that makes students able to reach better academic attainments and to improve health outcomes ( Figure 2). 26 Children with social and emotional problems usually show negative results at school, but at the same time those pupils who are experiencing academic difficulties might present increased social and emotional complications. 27,28 On the other hand, children who perform well at school seem to enjoy better health and have access to more opportunities during their lives. 29 WHO has started in 2014 a specific "Health Promoting Schools framework" (HPS) to integrate health educational goals in a holistic perspective at school. This programme has shown to positively influence students' behaviours at least for those interventions having the following endpoints: body mass index, physical activity, fruit and vegetables consumption, prevention of tobacco use and being bullied. 30 Despite this evidence regarding the potential benefits of school-based health interventions, nationwide structured and well planned health promotion strategies are still lacking. To achieve this goal, healthrelated contents may be embedded in the school curricula as core discipline, or could be integrated in a healthcarrier discipline such as science, or even delivered as extracurricular programme. 14 The complexity of nowadays requires a deep change in teaching and learning practices, shifting the focus from the mere transmission of notions to active and motivational approaches, able to equip students with a fruitful knowledge and a wide range of life skills. This aspect is also relevant in the field of health education: teachers need  to master an array of participatory activities such as class discussions, debates, case analysis, brainstorming, small working groups, peer teaching, co-writing, co-creating projects, educational games and simulations, storytelling, audio and visual laboratories (e.g. arts, music, theatre, dance etc.), in order to enhance students' health learning outcomes. 31,32 Moreover, the accomplishment of multifaceted and authentic tasks over a long period of time, along with providing opportunities to reflect on the health-based learning experiences from different points of view, allow students to acquire those transversal skills they need in the real life. These innovative approaches are helpful in involving pupils in the control of the learning environment 33,34 and can be also useful to generate a respectful climate in the classroom, where pupils can freely practice social skills and lower anxiety due to competition or pressure of success. 35 Furthermore, researches on anti-bullying programmes have proved that structures, conditions, and learning settings (school environment) are at least as significant as individual factors. 36,37 Finally, school-based health promotion is more successful if a "whole-school approach" (based on comprehensive school policies) is adopted, paying also attention to school physical environment (appeal and sustainability of buildings, grounds and surroundings). Community links are an additional relevant dimension, because working together with families or communities (in collaboration with available health professionals) help schools in more effectively spreading a "culture of prevention". 38

Primary prevention and education: a scientific justification for school-based interventions
According to the World Health Organization, health is a human right defined as "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity" 39 and it is influenced by culture, which plays an important role in shaping quality of life perception, both for individuals and communities. Thus, health can be considered as a universal dimension of human culture, reflecting socio-cultural values, traditions, and beliefs shared by a community of people. [40][41][42][43] In light of this wide-ranging concepts of health, also healthy lifestyles could be regarded as complex cultural schemes, involving different aspects such as nutrition, physical activity, work/leisure time, and environmental protection. 44,45 The efficacy of health education at school can only be evaluated if taking into account multidimensional factors within a comprehensive view of health.
As pointed out by positive psychology, it is fundamental to foster physical, mental/emotional and social wellbeing of individuals since the early childhood, shifting from being focused on diseases prevention to wellbeing promotion, namely from risk factors to protective factors. 46 Both primary prevention and health promotion approaches are focused on proactively maintaining people healthy, ensuring this change of views. 47 According to the medical paradigm, three levels of preventive interventions are possible. Primary prevention (universal provision of information about healthy lifestyles) corresponds to health promotion and can be managed at school or community level, while secondary (early diagnosis of risky behaviours in selected population), and tertiary prevention (rehabilitative/ dedicated interventions) concern medical field and require professional operators. 48 The knowledge about protective and risk factors (that belongs to the domain of primary prevention) is useful to plan psycho-socio-pedagogical interventions in school setting that might increase the benefits of protective factors (i.e. resilience, empathy and other soft skills, useful as personal resources or coping strategies to deal more effectively with stressful events). [49][50][51] On the other hand, risk factors are described as individual or environmental characteristics that predispose to the early onset of problems (including school dropouts, substance abuse, delinquency, violence, and early pregnancies), usually overlapping in vulnerable social groups. 52 At the present time, the prevention of emotional problems among young people, leading to possible social deviations, has become one of the most urgent educational emergencies so that primary prevention represents an important educational commitment. 53 Educational institutions face also the challenge of reducing health inequalities among students and their exsposure to risk factors associated to a higher probability of future problematic behaviours. 54,55 In particular, school system and teachers are asked to reinforce the points of strength (emotional and social skills) of the students, spreading "a warm blanket of prevention", instead of adopting a regulatory and stigmatizing style towards already marginalized children or teenagers. 56 This means encouraging young people to make healthy choices, in order to reduce the risk of developing emotional/social difficulties and future chronic diseases.
Indeed, the World Health Organization has demonstrated that many early deaths are avoidable: at least 80% of all cases of heart diseases, strokes, type 2 diabetes and one third of all cancers can be prevented through health education. 3 In this perspective, as children's health is a valuable resource for communities, primary prevention represents a necessary investment for our present and future. 57 A society that wants to live better should ask each stakeholder to take a piece of responsibility and invest in promoting healthy lifestyles since childhood (Figure 3). Going beyond the mere academic achievements that students are expected to acquire, every educational practice should provide children with the basis for personal self-realization, helping them to grow up as confident learners and responsible citizens for individual and collective health. 58,59 The attention to students' wellbeing (physical, social and mental condition) should become part of any pedagogical design that wants to be effective in preventing socio-emotional difficulties and risky behaviours (i.e. addictions to alcohol, tobacco, and drugs). Educators must encourage the adoption of healthy lifestyles and foster the development of critical thinking towards unhealthy behaviours and their physical, psychological and social consequences. 60 From a pedagogical point of view, the principle of prevention is one of the fundamental concepts of education, in the perspective of life-long learning and people empowerment. Empowered students can be able to trigger processes of social progress in their communities, moving from a passive state to an agency asset and expressing a transformative potential on their communities. 61 The promotion of children's health is not only a matter of preventive medicine, but it involves educational and ethical dimensions of social responsibility aimed at increasing young people consciousness and responsibility for their own and other people's health. Therefore, while working on students' motivation towards healthy lifestyles, school can raise their awareness about sustainable development topics, as health and environment are strictly interconnected. The adoption of healthy lifestyles -which turns into responsible consumers' choices (ethical consumption) -is linked to the concepts of ecological, social and economic sustainability, as well as to those of solidarity, peace, equity and legality. 62,63 Finally, promoting students' health at school has been found to engage in healthy habits also families and communities (a kind of multiplier effect): children can become health trainers of their parents, relatives and friends, impacting positively the entire society. 15 Due to its social commitment, school needs the support of all the private and public social actors, in order to overcome the obstacles that arise in the educational path, and build up a comprehensive "preventive system", able to foster healthy protagonism of the "youngest part of the society". 64

Discussion
Everybody has the right to reach a state of wellbeing in which his or her own talents are fully accomplished, providing a personal contribution to the society. 65 Since

Health & Wellbeing Promotion
School Family Community Entire Society Figure 3. Stakeholders involved in Health and Wellbeing Promotion education and health are interrelated, educational system can be considered among the most committed institutions for the promotion of young people's wellbeing, together with families and communities. 66,67 However, the changes in social relationships occurred in the last decades (increase in the number of divorces, births outside marriage and family mobility), along with the difficulties due to recent economical crises, make even more crucial the comprehensive educational role of the school. [68][69][70] Working for prevention and bringing health information to students represents an intrinsic ethical duty for any scholastic institution, so that teachers -who are already recognized as "promoters of culture" -should become also "health promoters" and "emotional trainers" of their students. 71 Health education should inform the ordinary teaching activities, becoming part of the daily work of school staff, who have the responsibility to guide students towards the adoption of healthy lifestyles, developing all their cognitive, affective, spiritual and social aspects, especially in a context characterized by an increasing absence of parental support at home. [72][73][74] Indeed, effective school-based preventive approaches are those that raise students' motivation towards healthy habits and foster their critical thinking about harmful consequences of the most common risky behaviours. In this perspective, teachers should boost students' problem solving and judgment attitudes necessary for protecting their health, working on skills such as communication, assertiveness, self-management, rejection of influences, conflict resolution and negotiation with peers and adults. 75 The adoption of meaningful contents, methods and tools can ensure a deep and "transformative" learning process, and generates a personal interiorization of knowledge in young people. 76 Furthermore, a classroom climate of mutual trust and support -where each pupil is an equal participant -encourage students to find by themselves own life projects, following their personal interests and inclinations. 77,78 The modern educational challenges call for reviewing and updating teaching/learning practices, in order to implement promotional and motivating strategies -with a long-wide-deep learning perspective -thus addressing the limitations of traditional education that does not always satisfy the needs of the new generations. 79,80 At the same time, invasive or regulatory style should be avoided to reduce the risk of stigmatizing already vulnerable children. 81 It is possible to overcome the vertical transmission of knowledge based on passive acquisition of information by adopting experiential and participatory approaches such as role playing, debates, tasks of reality, artistic laboratories, 31 that help students' to develop transversal competences and personal re-construction of knowledge, stimulating their agency. Active, motivational and participatory teaching/learning methodologies are also useful to set a healthy supportive school environment, where positive values are shared by the students, growing up as socially skilled citizens, able to select and build up their own learning, manage properly their time and apply in real life the knowledge acquired. 82 Health educational interventions should start as early as possible, addressing all areas of children's growth (physical, emotional, social and cognitive development) 83 and should be planned at different levels of operation (with a structured and continuous monitoring of the processes and outcomes): universal programmes for the whole school or targeted preventive actions focused on most vulnerable groups. Health promotion impacts on the whole school population, while preventive interventions are more effective in those groups at higher risk. Healthpromoting interventions implemented for disadvantaged children since early stage of life have been proved to be effective in coping with several forms of social marginalization and inequalities. 84 For this reason, subpopulations of children suffering from socio-emotional problems should be identified in advance (paying special attention to those pupils belonging to socio-economically disadvantaged families), by detecting the presence of 'warning signs", such as disturbing behaviours, school refusal, or unusual deviations in their academic profile. 85 The urgency of putting more efforts on health literacy at school is also triggered by the COVID-19 pandemic and other possible challenges arising from the altered ecosystems balance due to human activities. 86 Indeed, health promotion is strictly related to education for sustainable development, and the entire school system should deal also with the unavoidable task of environmental protection throughout a systemic strategy. The goal is to stimulate students' citizenship skills, in particular their sense of responsibility towards personal and collective health, thus empowering young people to take action for a more healthy and sustainable society and to claim -as informed citizens -for policies that positively impact their health and the environment. 87,88 However, even though there is a strong evidence for implementing health education in school setting, the effects of this kind of interventions are variable and there is no guarantee of success, unless a full commitment of teachers and school staff is displayed. It must be also considered that every organization, including school system, has to deal with the low propensity of teachers to make full use of all the new training opportunities and accept to modify their current educational practices. 89,90 Moreover, schools have to cope with the lack of financial resources and expert staff (e.g. PhD candidates, professional health services, pedagogical and psychological consultants potentially useful for specific targeted interventions), that could be possibly provided to the school system by a stable cooperation with private and public stakeholders. 91,92 Conclusion Scientific evidence demonstrates that school can be the ideal setting to implement health-related interventions aimed at fostering young people global growth. 93 Health promotion at school could be effective in improving both students' wellbeing and their academic achievements, thus generating a virtuos circle. As primary educational institution, school might integrate children's health promotion in its ordinary teaching and learning practices through a specific revision of the curricula. Educators should be adequately trained on how to raise students' motivation towards healthy/sustainable lifestyles and display the most innovative participatory methodologies, in order to effectively convey health knowledge to young people, fostering at the same time their critical thinking about harmful consequences of risky behaviours. As Unesco Chair, we highlight that primary prevention should start as early as possible by carrying out well-structured health educational interventions, finding in teachers the most committed social actors, in the perspective of "better health through better schools". 94