Health actions in schools must be comprehensive and intersectoral, involving families and communities as a shared construction among professionals, services, and schools [1]. In Brazil, the School Health Program (Programa Saúde na Escola—PSE) strengthens promotion, prevention, and care initiatives within Primary Health Care and the Unified Health System through vaccination, oral health, and educational activities [2,3]. In Portugal, the National School Health Program (PNSE) follows the World Health Organization (WHO) health-promoting schools model, integrating health and education through a holistic approach with nurses, psychologists, and community health professionals [4]. In Brazil, actions are mainly carried out through Basic Health Units in a punctual manner, whereas, in Portugal, there is a consolidated structure with school nurses and continuous school health surveillance [5].

Brazil also has the National School Feeding Program (Programa Nacional de Alimentação Escolar), which guarantees daily meals for students and promotes healthy, sustainable eating. In Portugal, schools follow national nutritional guidelines, with menus designed by nutritionists and initiatives to reduce sugar and ultraprocessed food consumption [6]. Physical education is mandatory in both countries: in Brazil, it is reinforced through extracurricular activities and educational campaigns, whereas, in Portugal, it is fully integrated into the pedagogical project, emphasizing active mobility [7].

A comparison shows that, despite structural differences, both countries share a commitment to school health promotion—through programs articulated with the Primary Health Care and the Unified Health System in Brazil and through the consolidation of healthy environments aligned with WHO guidelines in Portugal [8]. However, the Portuguese model stands out for its greater cohesion, advances in mental health, intersectoral coordination, and the prominent role of school nurses [9].

School health promotion has evolved from a biomedical and assistentialist model toward a socioecological approach, which recognizes the school as a complex system and a determinant of children’s and adolescents’ well-being [8]. A review on health-promoting schools in Latin America, however, highlights the scarcity of interventions evaluated with robust methodologies, the absence of large-scale impact indicators, and the need for stronger articulation between science and public policy [10].

These experiences indicate that effective policies depend on intersectoral cooperation, community involvement, and consistent investments in health and education. In this context, it becomes necessary to critically analyze school environments in Brazil and Portugal in light of international guidelines [11,12].

This study describes the protocol of a mixed methods study adopting a complex explanatory sequential design, detailing the planning, data collection, and analysis of school health policies and practices, including the Global School Health Policies and Practices Survey (G-SHPPS) as the central instrument. The synthesis will be conducted collaboratively by Brazilian and Portuguese researchers.

The WHO advocates for salutogenic and health-promoting approaches within the school environment, recognizing the interdependence between health and education as essential to sustainable human development [4]. In this regard, the health-promoting school is conceived as an ecosystem of learning and citizenship, grounded in the values of equity, inclusion, sustainability, democracy, and empowerment, which guide actions toward equal access, appreciation of diversity, and community participation [8].

This model is structured around 6 components: healthy school policies; physical and social environment; individual skills; engagement with the community and school health services; as well as accreditation, continuous evaluation, intersectoral coordination, and qualified professional training [8,13]. The health-promoting school perspective is based on the premise that the quality of education is directly linked to the well-being of the entire school community. WHO and UNESCO (United Nations Educational, Scientific and Cultural Organization) emphasize that no educational system can be effective without promoting the health of students, staff, and families, highlighting key pillars, such as active participation, safe environments, inclusion of health competencies in the curriculum, collaboration with families and communities, and access to school health services [14].

The operationalization of this model requires sustainable intersectoral policies, evidence-based practices, continuous professional development, and a commitment to equity and inclusion. Recognizing the school as a strategic setting for health promotion from early childhood underscores its transformative role, in alignment with the Sustainable Development Goals of the 2030 Agenda [15].

Although most countries have some form of school health services, the WHO guideline on school health services identifies limitations, such as a lack of evidence-based foundations, weaknesses in implementation, underfunding, and limited reach [4], reinforcing the urgency of more robust, integrated, and equitable models.

The G-SHPPS is an international tool designed to assess school health policies and practices across 5 main components: healthy and safe school environment, health services, nutrition, health education, and physical education [16]. Its purpose is to support countries in defining priorities, implementing programs, allocating resources, and monitoring trends, thereby enabling comparisons across different contexts.

The global version of the G-SHPPS is derived from the School Health Policies and Practices Study, developed by the Centers for Disease Control and Prevention in the United States since the 1990s [17]. Based on this foundation, the WHO and Centers for Disease Control and Prevention conducted methodological revisions that led to the current global format.

In Brazil, the G-SHPPS was cross-culturally adapted by the researchers of this project to ensure its suitability for the national context. The process included translation, cross-cultural adaptation, and expert committee review, addressing semantic, idiomatic, conceptual, and cultural equivalence. The instrument achieved a total content validity index of 0.99 and demonstrated strong semantic validation among the target audience (school administrators), indicating high agreement among evaluators regarding the relevance and adequacy of the Brazilian version [18].

In Portugal, the cross-cultural adaptation of the G-SHPPS is planned and will be conducted following approval by the relevant ethics committee, using methodological steps equivalent to those adopted in Brazil. These steps will include independent forward translation by bilingual translators familiar with the educational and health contexts, synthesis of translations, and review by an expert committee composed of researchers with expertise in school health, public health, nursing, education, and survey methodology from both countries. Decision rules will be based on predefined equivalence criteria, with items retained, revised, or excluded according to expert consensus and content validity index thresholds.

The original version of the questionnaire is publicly available [16] and represents a valuable tool to support diagnostics, international comparisons, and the strengthening of educational and health policies in both countries.

This project was conceived through a partnership between Brazilian and Portuguese researchers, with the overarching goal of evaluating and comparing school health policies and practices in both countries. Based on the data generated through the application of the G-SHPPS instrument with school administrators, sequential interviews by the principal or head teacher (or the person acting in that capacity) and school nurses, interviews with adolescents using the photovoice technique, and the integration of quantitative and qualitative data, the study seeks to address the following research questions: (1) what is the profile of the principal or head teacher of the participating schools? (quantitative); (2) what are the characteristics of school health policies and practices in both contexts, considering school health services, physical environment, food and nutrition services, health education, physical education, school governance and leadership, and school policies and resources? (quantitative); (3) do school health policies and practices differ between schools that have adhered to the Brazilian PSE and those that have not? (quantitative); (4) what are the perceptions of administrators and school nurses in Brazil and Portugal regarding school health policies and practices? (qualitative); (5) what are adolescents’ perceptions of school health policies and practices? (qualitative); (6) to what extent do adolescents participate in the design, implementation, and monitoring of these policies and practices? (qualitative); (7) how do the quantitative results on the characteristics of school health policies and practices converge or diverge from the qualitative perceptions of school administrators and nurses? (mixed methods); (8) which aspects of school health policies and practices, identified quantitatively, are corroborated or complemented by adolescents’ qualitative reports? (mixed methods); and (9) how do quantitative and qualitative data complement each other to identify priorities for investment in school health? (mixed methods).

The specific objectives of this project are: (1) to describe the profile of the principal or head teacher of elementary and secondary schools (quantitative); (2) to characterize existing school health policies and practices in both contexts, considering the domains of school health services, physical environment, food and nutrition services, health education, physical education, school governance and leadership, and school policies and resources (quantitative); (3) to compare school health policies and practices implemented in schools that have adhered to the Brazilian PSE with those that have not (quantitative); (4) to analyze the perceptions of administrators and nurses regarding school health policies and practices (qualitative); (5) to understand adolescents’ critical awareness of school health policies and practices (qualitative); (6) to identify the extent to which adolescents have participated in the design, implementation, and monitoring of school health practices in each country (qualitative); (7) to examine how the quantitative results on the characteristics of school health policies and practices converge or diverge from the qualitative perceptions of school administrators and nurses (mixed methods); (8) to analyze which quantitative aspects of school health policies and practices are corroborated or complemented by adolescents’ qualitative reports (mixed methods); and (9) to develop a list of priorities for investments in school health policies and practices in both countries, based on the integration of quantitative and qualitative findings (mixed methods).

This is a mixed methods study adopting a complex explanatory sequential design (QUAN → qual → [qual] → [qual]), as outlined by Creswell and Creswell [19] (2021). This approach was chosen because it allows for an in-depth and contextualized exploration of a phenomenon initially described through quantitative data.

In the quantitative phase (QUAN), a cross-sectional study will be conducted with school administrators using the G-SHPPS instrument (phase I). Subsequently, in the qualitative phases (qual), the initial findings will be further explored through semistructured interviews by the principal or head teacher (or the person acting in that capacity) (phase II) and school nurses (phase III), employing an exploratory-descriptive approach. Phase IV will consist of a participatory study, applying the photovoice technique with adolescent students.

The phases are organized sequentially, and the data will be connected and integrated at the end of the study, with the aim of producing meta-inferences on school health policies and practices, as well as proposing investment priorities for both the Brazilian and Portuguese contexts. For better visualization, the study design diagram is presented in Figure 1.

The study will be conducted in elementary and secondary schools, as well as in health services linked to the school territory, located in different cities across Brazil and Portugal. The selection of these settings aimed to represent the diversity of institutional, regional, and intersectoral contexts involved in the implementation of school health policies and practices.

The study settings were selected to reflect the geographical and administrative complexities of both nations:

Brazil: Being a continental-sized country, Brazil presents significant regional, socioeconomic, and cultural heterogeneities. To capture this diversity, the research will take place in 8 cities across different regions: Brasília (DF), Campo Grande (MS), Cuiabá (MT), Curitiba (PR), Goiânia (GO), Recife (PE), Manaus (AM), and Santa Maria (RS). This selection ensures a representative overview of the PNSE implementation across its decentralized territory. Portugal: Although the geographical scale is smaller, the selection of Cascais and Leiria supports the transferability of findings by representing diverse territorial models within Portugal’s centralized system.

Cascais, part of the Lisbon Metropolitan Area, provides insights into school health management in high-density urban environments with well-established intersectoral networks. Leiria represents a vital regional hub that encompasses both urban and semiurban characteristics, a common profile among medium-sized Portuguese cities. Both municipalities feature high maturity in the PNSE, offering a robust basis for comparison against the Brazilian reality.

Data collection activities will take place in school environments and health services where nurses work in connection with the participating schools. The specific sites will be defined collaboratively with school management teams to ensure privacy and comfort for participants, appropriate conditions for conducting interviews and administering questionnaires, and adequate space for holding participatory workshops.

The study population consists of 3 main groups of participants: principals or head teachers (or the person acting in that capacity), nurses working in the participating schools, and adolescents enrolled in the selected schools. These groups were defined according to the specific objectives of the study and the multiactor perspective that guides the analysis of school health policies and practices.

The quantitative results from the G-SHPPS will inform the development of qualitative interview guides with school administrators (phase II), school nurses (phase III), and adolescents (phase IV). Upon completion of all phases, data integration will occur through sequential connection and comparison, consistent with the explanatory design. This process will use joint displays [24] to articulate quantitative and qualitative findings across the main axes of analysis—domains of school health policies and practices, differences between schools with and without adherence to the PSE, and levels of adolescent participation. Joint displays will be structured as integrative matrices in which quantitative indicators derived from the G-SHPPS (eg, presence, absence, or frequency of specific policies and practices across domains) are presented alongside corresponding qualitative themes generated from interviews and photovoice narratives.

For example, a joint display may juxtapose quantitative findings, indicating limited implementation of student participation practices with qualitative excerpts from administrators, nurses, and adolescents, which explain institutional constraints, professional challenges, or lived experiences related to participation. Another display may contrast schools with and without PSE adherence, combining quantitative differences in reported policies and practices with qualitative explanations of contextual facilitators or barriers.

Meta-inferences will be developed through integrated interpretation of these displays, systematically examining convergence (corroborating findings), divergence (discordant findings), and complementarity (findings that elaborate or expand the quantitative indicators). The generation of meta-inferences will be iterative and theory-informed, aiming to produce integrated explanations and identify priorities for the improvement of school health policies and practices. The specific structure of joint displays and final meta-inferences will be refined according to the empirical results generated in each phase.

Methodological rigor will be ensured through specific strategies aligned with the mixed methods appraisal tool [25] and the recommendations of Lorenzini et al [26] (2024). In the quantitative phase, rigor will rely on probability sampling, the use of a validated and transculturally adapted instrument, clear eligibility criteria, and appropriate statistical analysis. In the qualitative phase, it will be supported by credibility, transferability, dependability, and confirmability criteria through verbatim transcription, independent coding, participant validation, and researcher triangulation. Overall, rigor will be safeguarded by ensuring the quality and legitimation of inferences, maintaining coherence among objectives, study design, integrated analysis, and meta-inferences, with data integration performed through joint displays to reveal convergences, divergences, and complementarities across findings.

ChatGPT (OpenAI, version 5.2, professional plan) was used solely to support translation, grammatical revision, and linguistic refinement of the manuscript, including narrative sections of the text. No empirical study data, sensitive information, identifiable participant data, adolescent data, or original research results were entered into the tool at any stage.

All outputs generated by the tool were critically reviewed and validated by the authors, who assessed linguistic accuracy, scientific coherence, and methodological appropriateness prior to incorporation into the paper. Full responsibility for the scientific content, interpretations, and conclusions rests entirely with the research team.

The study was approved by the Research Ethics Committee of the Federal University of Mato Grosso (UFMT), the coordinating institution of the project, on April 15, 2025 (approval number 7.509.968; Certificate of Presentation for Ethical Review: 77984223.0.1001.8124). Subprojects at participating centers will be submitted to local ethics committees when required, prior to data collection.

Participation will be voluntary and based on informed consent. School principals, head teachers, coordinators, and school nurses will provide written informed consent. For adolescents, written informed assent will be obtained together with consent from parents or legal guardians.

Quantitative data will be collected using Google Forms configured with restricted access and disabled public sharing. Limited identifiable information (school name, participant role, and institutional email address) will be collected solely to identify participating schools and enable recruitment for subsequent qualitative phases. Access to identifiable data will be restricted to the project coordinator and stored separately from analytical datasets. All identifiers will be removed prior to data analysis and dissemination. After the quantitative data collection phase, datasets will be downloaded to secure institutional storage and permanently deleted from the online platform. Participant confidentiality will be preserved throughout the study.

All qualitative data, including interview transcripts and photovoice narratives, will be anonymized prior to analysis. Identifiable information will be removed during transcription, and participants will be identified using role-based alphanumeric codes. The linkage key between identifiers and codes will be stored separately with restricted access and destroyed after completion of data integration.

For the photovoice phase, additional ethical safeguards will be implemented due to the potential inclusion of identifiable visual content. Images will be reviewed by the research team prior to analysis, and photographs containing identifiable individuals will be digitally modified (eg, through face blurring) or excluded, as appropriate, to ensure confidentiality. All images will be stored in secure, password-protected institutional repositories and anonymized prior to analysis and dissemination. All data collected during this phase will be handled with strict confidentiality and used exclusively for research purposes, with access restricted to authorized members of the research team. No identifiable information will be disclosed in any publications or reports. Participants will not receive any financial or material compensation for their participation in this study. Participation will be entirely voluntary, and participants may withdraw at any time without any consequences.

This protocol outlines a mixed methods study to evaluate school health policies and practices in Brazil and Portugal. The integration of quantitative and qualitative data will enable a comprehensive and comparable assessment across contexts. Findings are expected to inform policy and support future research in child and adolescent health.

This protocol is expected to generate robust and comparative evidence on school health policies and practices in Brazil and Portugal, anticipating the identification of both shared patterns and context-specific gaps across different educational and health system settings. The central hypothesis underpinning this study is that variations in governance, intersectoral coordination, resource allocation, and adolescent participation will be observed between and within countries, influencing the organization, implementation, and perceived effectiveness of school health policies. By integrating quantitative findings from the G-SHPPS with qualitative insights from school administrators, nurses, and adolescents, the study is designed to produce a comprehensive and nuanced understanding of how school health policies are operationalized in real-world contexts.

This protocol is aligned with the international guidelines of the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016‐2030) and the AA-HA! (Global Accelerated Action for the Health of Adolescents) guide [11,12], which emphasize adolescence as a critical life stage and schools as strategic settings for health promotion. Considering that schools play a central role in fostering holistic development, the use of robust, standardized, and contextually adapted instruments is essential for monitoring and evaluating health-promoting environments [4]. In this regard, the articulation between global frameworks and locally contextualized evidence generated through the G-SHPPS reinforces the importance of public policies grounded in empirical data and tailored to specific national and local contexts [16]. Applying the G-SHPPS in both Brazil and Portugal addresses a significant gap in the literature by enabling, for the first time, a standardized and comparative assessment of school health policies across these 2 countries.

From a methodological perspective, the study advances the field by adopting an explanatory sequential multiphase mixed methods design, which allows quantitative results to guide successive qualitative inquiry. This approach strengthens interpretation by integrating structural data on policies and practices with the lived experiences and perceptions of key stakeholders, including school administrators, nurses, and adolescents [27]. The inclusion of photovoice further enhances methodological innovation by foregrounding adolescents’ voices through participatory visual methods, capturing dimensions of school health that are often overlooked in traditional survey-based research [27]. This participatory component is expected to generate actionable insights regarding adolescents’ needs, expectations, and priorities in relation to healthier, safer, and more inclusive school environments.

Despite its strengths, this study may face limitations related to sociocultural, educational, and socioeconomic differences between Brazil and Portugal, which may influence how policies are implemented and perceived. Additionally, contextual heterogeneity within countries may affect comparability across regions and school types. To mitigate these limitations, the study employs a standardized instrument adapted through rigorous cross-cultural procedures, harmonized inclusion criteria, and analytic strategies that consider contextual and socioeconomic variability. The mixed methods design itself enhances analytical robustness by allowing convergence and complementarity across data sources.

Looking ahead, this protocol establishes a foundation for future comparative and longitudinal research on school health policies, including potential expansion to other countries and educational contexts. The findings are expected to inform evidence-based decision-making, support intersectoral collaboration between health and education systems, and guide strategic investment priorities. Dissemination plans include scientific publications, technical reports, presentations at national and international conferences, and knowledge translation products tailored to policymakers, educators, health professionals, and school communities. Collectively, the study aims to contribute to the advancement of health-promoting schools and to the development of more equitable and effective school health policies in both Brazil and Portugal.

This protocol defines a comprehensive and methodologically robust framework for a binational mixed methods study on school health policies and practices in Brazil and Portugal. By adopting a comparative and integrative approach, the study is positioned to generate evidence capable of identifying strengths, gaps, and context-specific challenges in school health systems, while supporting collaboration between the health and education sectors. The findings derived from this protocol are expected to inform the development, monitoring, and refinement of school health policies in both countries. In addition, the methodological framework proposed here may support future research and interventions in school health and serve as a reference for comparative studies in other national and international contexts.