School Health Promotion Through UNESCO's Four Pillars of Education and NICE Participation Frameworks: A Systematic Review.

Abstract

School health promotion is a central component of Life-Course Health Development (LCHD); however, limited evidence has examined how the governance of intervention processes relates to pedagogical depth. This systematic review aimed to analyze and classify school health promotion programs through a cross-analysis based on UNESCO's Four Pillars of Education and the community participation levels outlined in the NICE NG44 guideline. Following PRISMA 2020 guidelines, a systematic search was conducted in MEDLINE, PsycINFO, and ERIC for studies published between January 2014 and December 2024, yielding 1,643 records. After screening and eligibility assessment, 35 studies were included and evaluated using deductive coding. The findings revealed an uneven descriptive and inferential pattern rather than a balanced alignment between pedagogical depth and participatory intensity. Learning to Be reached transformative levels in 77.1% of the studies, whereas Learning to Know remained predominantly instrumental (51.4%). Participation patterns were mostly directive, with 51.4% of programs classified at low participation levels ("Inform" and "Consult"), and only 17.1% reaching shared governance levels ("Collaborate" and "Empower"). Exact inferential testing showed that transformative depth in social and community-oriented learning (Learning to Live Together) was significantly associated with participation intensity (p = .001), whereas no statistically significant associations were observed for Learning to Know, Learning to Do, or Learning to Be (p > .05). To our knowledge, this is the first systematic review to cross-analyze pedagogical architectures and power-transfer dynamics in universal school health promotion, offering an evidence-informed roadmap to strengthen collective agency in school health design.