# Life skills, self-efficacy, life satisfaction and health literacy evolution from primary school to middle school: a 3-year longitudinal interventional study of the Explo'Santé cohort

Corélie Salque, Adeline Darlington-Bernard, Florence Carrouel, Emily Darlington

► To cite this version:

Corélie Salque, Adeline Darlington-Bernard, Florence Carrouel, Emily Darlington. Life skills, self-efficacy, life satisfaction and health literacy evolution from primary school to middle school: a 3-year longitudinal interventional study of the Explo'Santé cohort. Frontiers in Public Health, 2026, 14, pp.1720265. 10.3389/fpubh.2026.1720265. [hal-05478968]

HAL Id: hal-05478968

https://hal.science/hal-05478968v1

Submitted on 27 Jan 2026

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons CC BY 4.0 - Attribution - International License
<figure><img src="image_2.png" /></figure>

Check for updates

OPEN ACCESS

EDITED BY
Mohan Bairwa,
All India Institute of Medical Sciences, India

REVIEWED BY
Joanna Teresa Mazur,
University of Zielona Góra, Poland
Leonidas Gavrilas,
University of Ioannina, Greece

*CORRESPONDENCE
Corélie Salque
✉ corelie.salque@univ-lyon1.fr

RECEIVED 07 October 2025
REVISED 09 December 2025
ACCEPTED 05 January 2026
PUBLISHED 27 January 2026

CITATION
Salque C, Darlington-Bernard A,
Carrouel F and Darlington E (2026) Life skills,
self-efficacy, life satisfaction and health
literacy evolution from primary school to
middle school: a 3-year longitudinal
interventional study of the Explo'Santé
cohort.
Front. Public Health 14:1720265.
doi: 10.3389/fpubh.2026.1720265

COPYRIGHT
© 2026 Salque, Darlington-Bernard, Carrouel
and Darlington. This is an open-access article
distributed under the terms of the Creative
Commons Attribution License (CC BY). The
use, distribution or reproduction in other
forums is permitted, provided the original
author(s) and the copyright owner(s) are
credited and that the original publication in
this journal is cited, in accordance with
accepted academic practice. No use,
distribution or reproduction is permitted
which does not comply with these terms.

# Life skills, self-efficacy, life satisfaction and health literacy evolution from primary school to middle school: a 3-year longitudinal interventional study of the Explo'Santé cohort

Corélie Salque*, Adeline Darlington-Bernard, Florence Carrouel and Emily Darlington

Laboratory Health Systemic Process (P2S) UR4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France

**Introduction:** Childhood and adolescence are decisive life stages during which social and health inequalities emerge and widen. Schools represent a privileged setting for health promotion, particularly through the development of psychosocial resources such as life skills (LS), self-efficacy (SE), life satisfaction (LSa), and health literacy (HL). The Explo'Santé program is a French school-based health promotion intervention that combines structured health education sessions with supportive environments.

**Methods:** This longitudinal cohort study followed 744 pupils from 4th grade in primary school to the first year of middle school. LS, SE, LSa, and HL were assessed at six time points across three annual intervention cycles, each including ten weekly school-based health education sessions.

**Results:** Linear mixed models showed short-term gains in LS, SE, and LSa during primary school, followed by a marked decline after the transition to middle school, whereas HL increased steadily throughout the 3 years. Girls consistently scored higher than boys but also showed sharper decreases once in 6th grade. Territorial disparities were observed, with some districts showing strong improvements while others consistently lagged.

**Discussion:** These findings suggest that the Explo'Santé program supports the development of key psychosocial competencies, but that the transition to middle school represents a critical turning point which challenges their sustainability. By highlighting gendered vulnerabilities and contextual inequalities, this work contributes to understanding how school-based health promotion can foster more equitable developmental trajectories.

KEYWORDS

evaluation, health education, health literacy, health promotion, life satisfaction, life skills, self-efficacy

1 Introduction

Childhood and adolescence are decisive developmental periods during which social, emotional, and health inequalities emerge and often widen (1, 2). From the first years of primary school, disparities can already be observed in well-being, coping resources, and access to health-promoting environments. Recent data confirm these early gaps: in Europe, about
13% of schoolchildren aged 6–11 have a “probable” mental health problem (3). In the Organisation for Economic Cooperation and Development (OECD) countries, nearly 18% adolescents reported low life satisfaction in 2022, compared to 12% in 2015 (4). These early differences tend to persist in adolescence, shaping both educational attainment and long-term health trajectories. Evidence shows, for instance, that health-related behaviors established before age 14 strongly predict risks of obesity, cardiovascular disease, and mental health disorders later in life (5).

This interdependence between education and health has led to a growing recognition that schools are not only places of academic instruction but also privileged settings for reducing inequalities and fostering holistic development (6). Since almost all children spend a large part of their daily lives in school, the educational environment offers a unique and universal entry point for promoting health in an equitable and sustainable way (7). With over 95% of children in Europe enrolled in school (8), and with two-thirds identifying school pressure as a major source of stress (9), schools represent both a challenge and an opportunity for mental and physical health promotion.

In this perspective, health education is increasingly conceived not as the mere transmission of knowledge about risk behaviors or healthy lifestyles. It is understood as the development of psychosocial and cognitive resources that empower children to navigate daily challenges, transitions and uncertainties. The World Health Organization defines life skills (LS) as “abilities for adaptive and positive behavior that enable individuals to deal effectively with the demands and challenges of everyday life.” Closely related constructs further highlight their multidimensional nature Firstly, self-efficacy (SE) was conceptualized in Bandura’s social cognitive theory as the belief in one’s ability to organize and execute courses of action required to manage prospective situations (10). In the school context, SE is defined as a transversal perception of one’s capacity to understand and respond to the expectations of the school environment across disciplines (11). Secondly, health literacy (HL) is defined as “people’s knowledge, motivation and competencies to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life” (12). Finally, life satisfaction (LSa) is framed as the cognitive evaluation of one’s overall quality of life (13). Large-scale international surveys such as the Health Behavior in School-aged Children (HBSC) and the Programme for International Student Assessment (PISA) have repeatedly shown that these psychosocial indicators are socially patterned and linked both to educational outcomes and to long-term health inequalities (14, 15).

Together, these psychosocial indicators —interlinked and mutually reinforcing—have been shown to support both academic success and health outcomes (16–18). This positions them at the crossroads of education and public health and underlines their potential as levers for reducing social and health inequalities from an early age (1, 19).

Nevertheless, evaluating the effectiveness of school-based health promotion programs is complex. Interventions are implemented in diverse contexts, shaped by school resources, socioeconomic environments, and local dynamics that can strongly influence outcomes (20, 21). Program impacts may also vary over time, particularly as children move up from primary to middle school, a period marked by profound developmental, social, and institutional changes (22, 23). This primary–secondary school transition is understood as a complex and multidimensional process involving

shifts in relationships, identity, school environments, and academic expectations, often overlapping with broader developmental changes (24). This raises key methodological challenges: assessing not only short-term effects but also long-term developmental trajectories, while accounting for both individual factors (e.g., gender, socioeconomic context) and contextual ones (e.g., school, district) (6, 21). Despite a growing literature on school health promotion, relatively few studies have followed large cohorts of children longitudinally, with designs capable of disentangling program effects from contextual influences across critical educational transitions (25–27).

The Explo'Santé program was developed in this perspective, as a universal school-based health education initiative grounded in LS development. Its pedagogical framework integrates health promotion principles with educational objectives, aiming to strengthen pupils' psychosocial resources and to support more equitable educational pathways (28). In doing so, it aligns with the WHO Health Promoting Schools framework, which emphasizes the integration of health into the core mission, culture, and environment of schools (6). By embedding health promotion within the ordinary functioning of schools, the program seeks not only to improve individual skills but also create learning environments that are more supportive, inclusive, and conducive to health and learning (6, 29). In the French education system, health education is not delivered as a standalone subject. It is proposed within the scope of the *Parcours Éducatif de Santé* (Health Education Pathway (HEP)) (30). This scheme covers screening and vaccination campaigns, and prevention and health promotion intervention, including health education interventions, for all pupils from nursery school to the end of high school. Its objective is to accompany pupils to develop their knowledge and competences, to make their own choices and to behave responsibly towards themselves and others (31). Although its design is specific to each school and defined by the teachers, the school nurse and the school district doctor. In primary school, health is addressed either through cross-disciplinary competencies and prevention-related themes integrated across subjects. At the beginning of lower secondary school (Grade 6), this remains the case. In addition, the activities of the school board includes the *Comité d'Éducation à la Santé et la Citoyenneté* (School Health and Citizenship Committee (SHCC)). It gathers representatives from the school community to implement health-related projects and interventions. Against this backdrop, Explo'Santé falls within the scope of both the French HEP and SHCC. It is proposed by the French League against Cancer as a structured LS-based program. It is delivered within regular school hours, either within standard lessons in primary school, or, in 6th grade, during class meetings or slots freed from other subjects. It offers a coherent and operational framework that extends and strengthens the existing health education mandate. Evaluating such a program offers a valuable opportunity to explore the potential of school health promotion to mitigate inequalities, while at the same time fostering psychosocial development and encouraging healthier pathways across educational transitions (5).

This study aims to evaluate the Explo'Santé intervention through a three-year longitudinal follow-up of pupils from primary to middle school. Specifically, it seeks to (1) describe the overall trajectories of LS, SE, LSa and HL across the six measurement points; (2) examine whether these trajectories differ by gender and district; and (3) assess individual and contextual variability using mixed-effects models. Together, these aims provide a comprehensive understanding of how pupils' psychosocial resources evolve over time and how the program's effects may vary across
whole-data analyses. Thirdly, hierarchical mixed models accounted for clustering at class and institutional levels.

## 2.8 Study size

The study size was determined a priori using Cochran's formula, assuming a 50% prevalence of satisfactory LS to maximize statistical variance in the absence of prior data. With a 95% confidence level and a ± 5% margin of error, the minimum required sample size was estimated at 385 pupils. In practice, 744 pupils aged 8–10 at baseline (44) participated in the study, which provided sufficient power for the planned analyses. Among them, 254 pupils completed all questionnaires across the follow-up period; this complete-case subset was used exclusively for sensitivity analyses to assess the robustness of the findings.

## 2.9 Quantitative variables

Quantitative variables were analyzed as continuous measures to preserve statistical power and variability. Scores from the four scales and their subscales were normalized to a uniform range of 0–100 to facilitate comparability across instruments. The SSI was used as a continuous proxy for socioeconomic background; no arbitrary cut-offs were applied to avoid loss of information. Time was operationalized both as repeated measures at pupil level and at school stage (primary vs. middle school) to capture potential contextual effects. No additional categorization or grouping was performed beyond these theoretically justified distinctions.

## 2.10 Statistical methods

All statistical analyses were performed in RStudio. Descriptives were first used to summarize participant characteristics by time point, gender, and district. Repeated-measures ANOVA were conducted to examine overall time effects on LS, SE, LSa, and HL scores, followed by Bonferroni-adjusted post-hoc pairwise comparisons. To account for individual and contextual variability, mixed-effects linear regression models with random intercepts for pupils were performed. Models sequentially included gender, district, and school level, with and without adjustment for the Socioeconomic Status Index (SSI), to disentangle contextual from socioeconomic effects. Subscale analyses were conducted for LS (cognitive, emotional, social), LSa (family, school, friends, living environment, self), and SE (general, French, mathematics). Missing data were imputed by the mean at scale level for mixed models on the full dataset. As loss to follow-up could not be avoided in this longitudinal design, sensitivity analyses were performed by comparing complete-case (n = 254) and full datasets (n = 744) to assess robustness of findings. Statistical significance was set at *p* < 0.05, with borderline significances noted for 0.05 ≤ *p* < 0.10.

## 2.11 Ethics

The protocol was approved by the University of Lyon's ethics committee (France) on March 1, 2023 (n°2023-01-12-004). CNIL reference: 2226244 v 0.

Anonymity was ensured during data collection, data handling and data analysis. No risk was identified from participating in the study.

# 3 Results

## 3.1 Participants

At baseline, 662 pupils completed the questionnaires. Participation remained steady at T1 (659) and slightly increased at T2 (705), before declining to 472 at T4, and 443 at T5. Attrition was mainly due to pupil absence, school transfer, or withdrawal of consent. Despite this, 726 pupils contributed repeated measures, enabling longitudinal analyses. Flow diagram is provided in Figure 1.

Table 1 summarizes the distribution of participants by gender and district at each time point, while the gender distribution and mean SSI across the six districts are addressed in Supplementary Table 2. Gender distribution was relatively balanced across time points, with a slight predominance of girls (52–55%). District representation varied: District A consistently accounted for about one quarter of participants (~25%), whereas Districts B and C contributed less than 10% each. Socioeconomic context, assessed using the SSI, showed moderate variability across schools, with higher average scores in District A and lower ones in District E.

## 3.2 Life skills, self efficacy, life satisfaction and health literacy scores evolution

### 3.2.1 Overall score evolution

Descriptive statistics for all four scales at each measurement point (mean, n) for the full sample are presented in Supplementary Table 3. As shown in Figure 2 and Table 2, LS, SE, and LSa scores increased significantly from T0 to T4 before declining at T5. Post-hoc tests confirmed significant improvements at T4 compared with earlier time points, followed by significant decreases at T5. HL displayed a different trajectory, with steady but modest improvements from baseline to T3 and T5.

### 3.2.2 Scores evolution according to gender

Figure 3 illustrates LS, SE, LSa, and HL scores evolution by gender, with corresponding means and standard deviations reported in Supplementary Table 3. Across all outcomes and time points, girls tended to score higher than boys, although these differences gradually narrowed by T5. For LS, SE, and LSa, all genders showed an overall increase from T0 to T4 (e.g., +2.7, +4.3, +2.7 for boys, and +3.3, +4.0, +1.9 for girls, on average), marked by gains between T1–T2 and T3–T4, followed by a decline from T4 to T5 (e.g., -1.8, -4.1, -2.5 for boys, and -4.5, -3.8, -3.2 for girls, on average). Boys experienced an initial decrease in LS and LSa between T0 and T1, while all genders declined between T2 and T3. For HL, all genders peaked at T1, dropped between T1 and T2, and then rose steadily up to T4. At T4–T5, girls showed a slight decrease in HL, whereas boys continued to improve. By T5, girls had lost an average of 1.2 points in LS and 1.5 points in LSa compared to T0, while boys still exhibited a net increase from baseline across all outcomes.
<figure><img src="image_3.png" /><figcaption>FIGURE 1
Flowchart of the study.</figcaption></figure>

### 3.2.3 Scores evolution according to districts

District effects are shown in Figure 4 and Supplementary Table 4. Districts A and E started with the highest scores and improved up to T4, both experienced steep declines at

T5. District E, which had the highest LS scores at baseline (63.3), ended with the lowest LS scores at T5 (58.2). By contrast, District C, which started from relatively low baseline scores, showed the most favorable trajectory, gaining +7.7 in LS, +5.2 in SE, +4.2 in
<table><caption>TABLE 1 Population distribution according to gender and district.</caption><thead><tr><th>Time</th><th>T0</th><th>T1</th><th>T2</th><th>T3</th><th>T4</th><th>T5</th><th>All times</th></tr><tr><th>Variables</th><th>N (%)</th><th>N (%)</th><th>N (%)</th><th>N (%)</th><th>N (%)</th><th>N (%)</th><th>N (%)</th></tr></thead><tbody><tr><td>Overall</td><td>662 (100)</td><td>659 (100)</td><td>705 (100)</td><td>675 (100)</td><td>472 (100)</td><td>443 (100)</td><td>744 (100)</td></tr><tr><td>Missing</td><td>82 (11.02)</td><td>85 (11.42)</td><td>39 (5.24)</td><td>69 (9.27)</td><td>272 (36.56)</td><td>301 (40.46)</td><td>-</td></tr><tr><td>Gender</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Girls</td><td>344 (51.96)</td><td>347 (52.66)</td><td>368 (52.20)</td><td>361 (53.48)</td><td>259 (54.87)</td><td>242 (54.63)</td><td>390 (52.42)</td></tr><tr><td>Boys</td><td>318 (48.04)</td><td>312 (47.34)</td><td>337 (47.80)</td><td>314 (46.52)</td><td>213 (45.13)</td><td>201 (45.37)</td><td>354 (47.58)</td></tr><tr><td>District</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>A</td><td>159 (24.02)</td><td>165 (25.04)</td><td>177 (25.11)</td><td>168 (24.89)</td><td>144 (30.51)</td><td>127 (28.67)</td><td>186 (25.00)</td></tr><tr><td>B</td><td>64 (9.67)</td><td>53 (8.04)</td><td>65 (9.22)</td><td>68 (10.07)</td><td>48 (10.17)</td><td>47 (10.61)</td><td>69 (9.14)</td></tr><tr><td>C</td><td>52 (7.85)</td><td>53 (8.04)</td><td>65 (9.22)</td><td>67 (9.93)</td><td>52 (11.02)</td><td>45 (10.16)</td><td>66 (8.87)</td></tr><tr><td>D</td><td>169 (25.53)</td><td>171 (25.95)</td><td>175 (24.82)</td><td>139 (20.59)</td><td>77 (16.31)</td><td>83 (18.74)</td><td>179 (24.06)</td></tr><tr><td>E</td><td>127 (19.18)</td><td>126 (19.12)</td><td>130 (18.44)</td><td>141 (20.89)</td><td>84 (17.80)</td><td>79 (17.83)</td><td>150 (20.16)</td></tr><tr><td>F</td><td>91 (13.75)</td><td>91 (13.81)</td><td>93 (13.19)</td><td>92 (13.63)</td><td>67 (14.19)</td><td>62 (14.00)</td><td>95 (12.77)</td></tr></tbody></table>

<figure><img src="image_4.png" /></figure>

LSa, and +11.1 in HL, despite temporary declines in LS, SE, and LSa between T2-T3, and in HL from T0 to T5, and was the only district to increase LS and SE between T4 and T5. District B also

showed overall improvement, despite very low baseline scores. In contrast, District F declined steadily after T4 and was the only district to finish below baseline across all outcomes.
<table><caption>TABLE 2 Life skills, self efficacy, life satisfaction, and health literacy scores evolution with time: ANOVA and pairwise post-hoc tests.</caption><thead><tr><th>Outcome</th><th>Time comparison<sup>a</sup></th><th>Pairwise comparisons<sup>b</sup> (β, p)</th><th>Overall time effect<sup>c</sup></th></tr></thead><tbody><tr><td rowspan="5">Life skills</td><td>T4 vs. T0</td><td>2.76, p &lt; 0.001</td><td rowspan="5">p &lt; 0.001</td></tr><tr><td>T4 vs. T1</td><td>3.38, p &lt; 0.001</td></tr><tr><td>T4 vs. T2</td><td>2.56, p &lt; 0.001</td></tr><tr><td>T4 vs. T3</td><td>2.17, p = 0.010</td></tr><tr><td>T5 vs. T4</td><td>-3.44, p &lt; 0.001</td></tr><tr><td rowspan="5">Self-efficacy</td><td>T2 vs. T0</td><td>2.06, p = 0.014</td><td rowspan="5">p &lt; 0.001</td></tr><tr><td>T3 vs. T0</td><td>2.12, p = 0.013</td></tr><tr><td>T4 vs. T0</td><td>3.76, p &lt; 0.001</td></tr><tr><td>T4 vs. T1</td><td>2.70, p = 0.002</td></tr><tr><td>T5 vs. T2</td><td>-2.35, p = 0.015</td></tr><tr><td rowspan="5">Life satisfaction</td><td>T5 vs. T3</td><td>-2.41, p = 0.012</td><td rowspan="5">p &lt; 0.001</td></tr><tr><td>T5 vs. T4</td><td>-4.04, p &lt; 0.001</td></tr><tr><td>T2 vs. T0</td><td>1.97, p = 0.002</td></tr><tr><td>T2 vs. T1</td><td>2.03, p &lt; 0.001</td></tr><tr><td>T4 vs. T0</td><td>1.72, p = 0.041</td></tr><tr><td rowspan="5">Health literacy</td><td>T4 vs. T1</td><td>1.78, p = 0.029</td><td rowspan="5">p = 0.004</td></tr><tr><td>T5 vs. T2</td><td>-3.57, p &lt; 0.001</td></tr><tr><td>T5 vs. T3</td><td>-2.17, p = 0.003</td></tr><tr><td>T5 vs. T4</td><td>-3.32, p &lt; 0.001</td></tr><tr><td>T3 vs. T0</td><td>2.31, p = 0.032</td></tr><tr><td>T5 vs. T0</td><td>2.71, p = 0.021</td><td></td></tr></tbody></table>

## 3.3 Contextual and individual factors impacting life skills, self efficacy, life satisfaction and health literacy scores evolution

### 3.3.1 Gender effect on life skills, self efficacy, life satisfaction and health literacy scores over time

Girls scored higher than boys on several outcomes (LS: +3.69, *p* < 0.001; LSa: +2.13, *p* < 0.01; HL: +2.09, *p* < 0.05; Table 3), which confirms the previous results. After accounting for SSI, the difference in HL was no longer significant, suggesting that SSI partly explained this gap.

At the subscale level, the LS girls' advantage was mainly due to cognitive LS (+3.13, *p* < 0.001) and social LS (+5.63, *p* < 0.001) (Table 4).

For LSa, the higher scores among girls were largely attributable to the school-related satisfaction subscale (+8.69, *p* < 0.001) (Table 5).

In SE, overall gender differences were not significant, but girls scored higher on French SE (+5.85, *p* < 0.001) and lower on Maths SE (−2.81, *p* < 0.05) (Table 6).

No gender-specific effects were observed in primary school. In middle school, girls showed smaller increases in LS and LSa

than boys (−2.28, *p* < 0.1 for LS; −2.07, *p* ≈ 0.06 for LSa), indicating a tendency toward less pronounced improvements (Table 7).

### 3.3.2 District effect on life skills, self efficacy, life satisfaction and health literacy scores over time

Compared to District A, District B scored significantly lower on all scales. This difference was maintained and even reinforced after accounting for SSI, indicating socioeconomic context did not fully explain this gap. Districts D and F also showed less favorable results in SE, LSa and HL. District C scored lower in LSa and HL overall but displayed more pronounced gains in middle school, significant for LS (+5.76, *p* < 0.05) and marginal for LSa (+4.46, *p* < 0.1). District E showed slightly higher scores in LS and a small advantage in LSa (+2.46, *p* < 0.1), but this effect was strongly reduced when SSI was included (LSa: −0.45), suggesting that the apparent benefit was largely due to socioeconomic context. In terms of trajectories, District D exhibited a significantly less pronounced increase in SE during primary school (−1.65, *p* < 0.05), while District F showed smaller gains in LSa (−1.40, *p* < 0.05) and HL (−8.30, *p* < 0.05) during middle school (Table 8).

## 3.4 Sensitivity analyses

Fixed effects such as the negative association of time in middle school with LS and LSa, and the positive association of female gender with LS, remained significant and of similar magnitude in both complete-case and full datasets. However, most district effects were attenuated or reduced to statistical borderline significances, and the positive effect of female gender on SE, LSa, and HL no longer reached significance. District F remained robustly associated with lower HL in both datasets.

# 4 Discussion

## 4.1 Key findings

This quantitative longitudinal evaluation of the Explo'Santé program provides new evidence on the evolution of psychosocial and cognitive resources among pupils transitioning from primary to middle school. Three main findings stand out. First, LS, SE, and LSa increased significantly throughout primary school and into early middle school (up to T4), before experiencing a sharp decline at T5. This suggests that initial program benefits and developmental gains were not sustained during the transition to middle school. In contrast, HL followed a steadier, incremental growth over the entire period, with no collapse at T5. Secondly, gender differences were evident: girls consistently outperformed boys across all indicators. However, the gender gap narrowed at T5 due to sharper declines among girls, suggesting differential vulnerabilities during early adolescence. Thirdly, district-level disparities suggest that contextual and territorial context mediates program effects, with some districts (notably District C) showing sustained improvements, while others exhibited stagnation or even deterioration, especially during middle school.

<footnote><sup>a</sup>Only significant results are presented. <sup>b</sup>Bonferroni-adjusted test. <sup>c</sup>Repeated-measures ANOVA test. Green indicates positive regression coefficients (β > 0), while yellow indicates negative coefficients (β < 0).</footnote>
<figure><img src="image_5.png" /><figcaption>FIGURE 3
Life skills, self efficacy, life satisfaction, health literacy mean scores evolution between T0 and T5 according to gender.</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>FIGURE 4
Life skills, self efficacy, life satisfaction, health literacy mean scores evolution between T0 and T5 according to district.</figcaption></figure>
<table><caption>TABLE 3 Life skills, self efficacy, life satisfaction, and health literacy scores evolution according to gender, district, and school level, with or without the socio-economic status index (SSI): Linear mixed models results.</caption><thead><tr><th rowspan="2">Socioeconomic status index</th><th colspan="2">Life skills</th><th colspan="2">Self efficacy</th><th colspan="2">Life satisfaction</th><th colspan="2">Health literacy</th></tr><tr><th>NI</th><th>0.14</th><th>NI</th><th>0.14</th><th>NI</th><th>0.21</th><th>NI</th><th>0.44</th></tr></thead><tbody><tr><td>Gender<sup>a</sup></td><td>3.69</td><td>3.59</td><td>1.53</td><td>1.24</td><td>2.13</td><td>2.12</td><td>2.09</td><td>1.92</td></tr><tr><td>District<sup>b</sup></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>B</td><td>-4.32</td><td>-4.46</td><td>-7.05</td><td>-7.77</td><td>-3.07</td><td>-4.32</td><td>-5.73</td><td>-6.71</td></tr><tr><td>C</td><td>-0.80</td><td>-0.84</td><td>-1.76</td><td>-1.79</td><td>-1.31</td><td>-1.50</td><td>-5.01</td><td>-5.46</td></tr><tr><td>D</td><td>-1.38</td><td>-1.30</td><td>-2.80</td><td>-3.81</td><td>-2.17</td><td>-3.77</td><td>-3.31</td><td>-4.57</td></tr><tr><td>E</td><td>0.43</td><td>0.78</td><td>-0.63</td><td>-2.59</td><td>2.46</td><td>-0.45</td><td>-0.94</td><td>-3.30</td></tr><tr><td>F</td><td>-1.55</td><td>-1.43</td><td>-3.71</td><td>-5.08</td><td>-1.80</td><td>-3.59</td><td>-6.09</td><td>-7.39</td></tr><tr><td>Time in primary school</td><td>0.12</td><td>0.14</td><td>0.08</td><td>0.32</td><td>0.23</td><td>0.21</td><td>0.37</td><td>0.44</td></tr><tr><td>Time in middle school</td><td>-2.70</td><td>-2.68</td><td>0.03</td><td>-1.70</td><td>-2.45</td><td>-2.24</td><td>1.28</td><td>1.06</td></tr></tbody></table>

Significant results (*p* < 0.05) are in bold and marginally significant results (*p* < 0.1) are in italics. Reference: boys of District A at T0. NI: not included. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

<table><caption>TABLE 4 Cognitive, emotional and social life skills scores evolution according to gender, district, and school level: Linear mixed models results.</caption><thead><tr><th>Predictor</th><th>Cognitive life skills</th><th>Emotional life skills</th><th>Social life skills</th></tr></thead><tbody><tr><td>Gender</td><td>3.13</td><td>0.98</td><td>5.63</td></tr><tr><td>District<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>B</td><td>-2.85</td><td>-2.82</td><td>-6.35</td></tr><tr><td>C</td><td>-0.95</td><td>-1.28</td><td>-0.38</td></tr><tr><td>D</td><td>0.40</td><td>-0.08</td><td>-3.68</td></tr><tr><td>E</td><td>3.61</td><td>-1.88</td><td>-1.29</td></tr><tr><td>F</td><td>0.44</td><td>-1.23</td><td>-3.99</td></tr><tr><td>Time in primary school</td><td>-0.26</td><td>0.32</td><td>0.29</td></tr><tr><td>Time in middle school</td><td>-3.32</td><td>-0.54</td><td>-2.72</td></tr></tbody></table>

Significant results (*p* < 0.05) are in bold and marginally significant results (*p* < 0.1) are in italics. Reference: Boys of District A at T0. NI: Not included. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

## 4.2 Psychosocial versus health literacy trajectories

The divergent trajectories of LS, SE, and LSa compared to HL raise questions about the nature and determinants of these constructs. LS, SE, and LSa appear highly sensitive to school climate and contextual disruptions, with marked fluctuations across timepoints and an acute vulnerability during the primary-middle school transition. This pattern is supported by recent research: for example, Jarusevičiūtė et al. (2023) show that support from teachers and family significantly predict socioemotional functioning across the move to lower secondary school (45). Pedditzi et al. (46) also demonstrated that LS, SE and LSa decline more sharply around transitions, particularly among those who perceive less support (46). Longitudinal work also shows that adolescents with lower social-emotional skills and greater loneliness experience greater school burnout, implying that

relational and peer climate are key predictors (47). By contrast, HL followed a steadier upward trajectory, suggesting that it depends more on cumulative cognitive exposure, structured educational input, and mediated information access. Recent studies confirm that HL scales remain stable and valid across adolescence (39), and longitudinal evidence highlights how family and educational mediation gradually strengthen HL development (48).

## 4.3 Gendered patterns

Gendered trajectories revealed both persistent advantages for girls and critical vulnerabilities. Girls scored higher in overall LS, particularly in their cognitive and social dimensions, as well as in LSa at school and SE in French. This is consistent with evidence of girls' greater social orientation and verbal abilities (49). Boys, however, reported higher SE in mathematics, reflecting both academic gender stereotypes and differential feedback in science-related domains (50, 51). Importantly, although girls started with these advantages, their score declines at T5 were sharper, particularly in LS and LSa, suggesting a greater susceptibility to the stressors associated with the transition to middle school. This aligns with studies showing that in more gender-egalitarian contexts, girls' satisfaction of life can decline due to heightened fear of failure or competitiveness (52). Evidence consistently shows that adolescent girls report higher levels of stress than boys, with school emerging as one of the most salient sources. Data from the HELENA study demonstrated that girls systematically perceived more stress related to school and future uncertainty than boys (53). More recently, a large mixed-method study confirmed these gender differences in school stress and identified underlying factors such as heavier school workload, emotional vulnerability, gender stereotypes, social expectations, and differential teacher treatment (54). Gendered socialization may amplify these vulnerabilities: girls may feel more pressure to maintain social bonds and academic performance, while boys may be comparatively buffered by lower socio-emotional expectations. Recent data from WHO/Europe (2024) show that school pressure has increased notably among girls, and that declines in family and peer support during adolescence are steeper for girls than for boys, suggesting that the support structures that buffer stress may erode more rapidly for girls (55).
<table><caption>TABLE 5 Life satisfaction with family, school, friends, living environment, and self scores evolution according to gender, district, and school level: Linear mixed models results.</caption><thead><tr><th>Predictor</th><th>Family</th><th>School</th><th>Friends</th><th>Living environment</th><th>Self</th></tr></thead><tbody><tr><td>Gender</td><td>0.28</td><td>8.69</td><td>0.05</td><td>1.04</td><td>-1.37</td></tr><tr><td>District<sup>b</sup></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>B</td><td>-4.27</td><td>-0.60</td><td>-2.53</td><td>-1.18</td><td>-4.55</td></tr><tr><td>C</td><td>-0.88</td><td>1.80</td><td>-0.43</td><td>3.32</td><td>-8.87</td></tr><tr><td>D</td><td>-2.63</td><td>0.22</td><td>-1.68</td><td>-2.16</td><td>-4.90</td></tr><tr><td>E</td><td>4.94</td><td>3.94</td><td>2.95</td><td>-7.17</td><td>3.18</td></tr><tr><td>F</td><td>-2.95</td><td>1.92</td><td>-0.32</td><td>-2.44</td><td>-5.52</td></tr><tr><td>Time in primary school</td><td>0.70</td><td>-0.73</td><td>0.70</td><td>0.18</td><td>0.23</td></tr><tr><td>Time in middle school</td><td>-0.45</td><td>-7.25</td><td>-0.54</td><td>-3.21</td><td>-1.10</td></tr></tbody></table>

Significant results (p < 0.05) are in bold and marginally significant results (p < 0.1) are in italics. Reference: Boys of District A at T0. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

<table><caption>TABLE 6 General, French and maths self-efficacy scores evolution according to gender, district, and school level: linear mixed models results.</caption><thead><tr><th>Predictor</th><th>General self efficacy</th><th>French self efficacy</th><th>Maths self efficacy</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td></td></tr><tr><td>Girls vs Boys</td><td>0.90</td><td>5.85</td><td>-2.81</td></tr><tr><td>District<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>B</td><td>-6.98</td><td>-6.85</td><td>-6.55</td></tr><tr><td>C</td><td>-4.31</td><td>-0.69</td><td>0.74</td></tr><tr><td>D</td><td>-3.33</td><td>-2.44</td><td>-2.34</td></tr><tr><td>E</td><td>-1.62</td><td>0.95</td><td>-1.33</td></tr><tr><td>F</td><td>-5.28</td><td>-1.46</td><td>-4.12</td></tr><tr><td>Time in primary school</td><td>0.34</td><td>0.74</td><td>0.55</td></tr><tr><td>Time in middle school</td><td>-0.84</td><td>-1.82</td><td>-5.97</td></tr></tbody></table>

Significant results (p < 0.05) are in bold and marginally significant results (p < 0.1) are in italics. *Boys are the reference. †District A is the reference. NI: Not included. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

## 4.4 Territorial and contextual inequalities

Marked differences across districts confirm that program effects are mediated by local environments. District C, despite low baseline scores, showed the most consistent gains and even resisted the T5 decline, suggesting that supportive contexts can amplify and sustain program benefits. In contrast, District E started from a favorable position but experienced the steepest decline at T5, highlighting how even seemingly advantaged settings can be vulnerable during transitions. District F, with lower SSI and weaker school climates, consistently underperformed, pointing to persistent territorial inequalities. These observations align with recent findings in France and Europe. Indeed, a scoping review showed that educational facility structures and social inequalities significantly shape children's health and well-being outcomes, including trajectories over time (56).

<table><caption>TABLE 7 Life skills, self efficacy, life satisfaction, and health literacy scores evolution of girls compared to boys according to school level: linear mixed models results.</caption><thead><tr><th>Outcome</th><th>Primary school (β)</th><th>Middle school (β)</th></tr></thead><tbody><tr><td>Life skills</td><td>0.22</td><td>-2.28</td></tr><tr><td>Self efficacy</td><td>0.52</td><td>0.43</td></tr><tr><td>Life satisfaction</td><td>-0.14</td><td>-2.07</td></tr><tr><td>Health literacy</td><td>-0.36</td><td>-2.08</td></tr></tbody></table>

Significant results (p < 0.05) are in bold and marginally significant results (p < 0.1) are in italics. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

Similarly, the Education and Training Monitor (2024) for France documents widening socio-economic achievement gaps and stresses the importance of school climate and support in disadvantaged districts (57). In primary school settings, case study evidence shows that schools located in socially disadvantaged neighborhoods with strong local partnership and supportive leadership are better able to integrate health promotion modules effectively, suggesting that context responsiveness matters greatly for intervention success (58). These findings raise important equity concerns: without additional support, such programs risk widening existing inequalities by benefiting already favorable environments more. Addressing territorial disparities is therefore essential for ensuring the fairness and effectiveness of universal health promotion interventions.

## 4.5 The primary–middle school transition as a critical juncture

The steep decline in LS, SE, and LSa at T5 underscores the transition from primary to middle school as a period of heightened vulnerability. This transition entails not only pedagogical rupture—with greater demands for autonomy, workload, and self-regulation—but also relational discontinuity, as pupils shift from having one main teacher to multiple subject teachers, often weakening individualized socioemotional support. Evidence from recent longitudinal studies
<table><caption>TABLE 8 Life skills, self efficacy, life satisfaction, and health literacy scores evolution of all districts according to school level: Linear mixed models results.</caption><thead><tr><th>District<sup>a</sup></th><th>School level</th><th>Life skills (β)</th><th>Self efficacy (β)</th><th>Life satisfaction (β)</th><th>Health literacy (β)</th></tr></thead><tbody><tr><td rowspan="2">B</td><td>Primary</td><td>0.14</td><td>0.14</td><td>0.28</td><td>0.17</td></tr><tr><td>Middle</td><td>1.33</td><td>1.63</td><td>3.85</td><td>-2.61</td></tr><tr><td rowspan="2">C</td><td>Primary</td><td>-0.03</td><td>-1.12</td><td>-0.05</td><td>0.86</td></tr><tr><td>Middle</td><td>5.76</td><td>3.18</td><td>4.46</td><td>-0.06</td></tr><tr><td rowspan="2">D</td><td>Primary</td><td>-1.07</td><td>-1.65</td><td>-0.72</td><td>-1.06</td></tr><tr><td>Middle</td><td>0.2</td><td>-0.97</td><td>0.3</td><td>-2.17</td></tr><tr><td rowspan="2">E</td><td>Primary</td><td>-0.24</td><td>-0.24</td><td>-0.48</td><td>0.05</td></tr><tr><td>Middle</td><td>-1.57</td><td>-3.4</td><td>-1.12</td><td>-4.06</td></tr><tr><td rowspan="2">F</td><td>Primary</td><td>-0.94</td><td>-1.98</td><td>-1.4</td><td>-0.81</td></tr><tr><td>Middle</td><td>-1.41</td><td>-5.01</td><td>-3.64</td><td>-8.3</td></tr></tbody></table>

Significant results (p < 0.05) are in bold and marginally significant results (p < 0.1) are in italics<sup>a</sup> district of reference: A. The color scale reflects the sign and magnitude of the β coefficients: red denotes negative effects, green positive effects, and yellow coefficients close to zero.

supports these patterns: for example, a German study found that LSa and school satisfaction decline statistically significantly during secondary school, particularly following the end of primary school, and that school-level achievement composition moderates these declines (59). A U. S. study of teacher-student relational warmth documents a sharp drop in perceived warmth at the transition to middle school, which predicts declines in engagement, belonging and achievement (60). In France, socio-economic gradients in academic SE become more pronounced by the end of primary school, suggesting that vulnerabilities accumulate before the transition (61). Similarly, adolescents in studies of school transition report lower school satisfaction and SE tied to the shift in environment and expectations (46). Our results suggest that the Explo'Santé program, although designed to anticipate this rupture, was not sufficient to fully buffer its disruptive effects. This finding highlights a structural challenge for school-based health promotion: while programs can strengthen psychosocial resources, broader institutional transitions and relational changes may overwhelm these gains unless systemic measures are taken.

## 4.6 Implications for health promotion programs and policies

These findings carry several implications for health promotion in schools. First, interventions should explicitly anticipate the primary-middle school transition, integrating targeted supports to maintain psychosocial gains during this critical period. Systematic reviews show that such transition-focused programs can positively affect students' social-emotional outcomes, engagement, and self-concept when implemented around the time of transfer from primary to secondary school (62). Secondly, teacher training is crucial: educators require tools to adopt health-promoting pedagogical approaches that sustain socioemotional support alongside academic expectations. Evidence from vulnerable backgrounds indicates that a positive school climate—often maintained by teacher practices, leadership, and peer relationships—can moderate negative impacts on social and emotional skill development (63). Thirdly, territorial equity must be addressed,

as program effectiveness depends heavily on local school climate and socioeconomic environments. Schools in disadvantaged contexts with poor climate or leadership tend to have less benefit from health promotion programs unless these contextual barriers are identified and directly addressed (64). Without additional resources for disadvantaged districts, universal interventions risk reproducing or widening existing inequalities (21). This underscores the relevance of the Health Promoting Schools framework, which advocates for whole-school, ecological approaches integrating curriculum, environment, and community partnerships to foster health and equity (6). More recent evidence emphasizes the importance of student engagement in HPS implementation: participatory strategies and meaningful involvement of pupils are key facilitators of success, while rigid school structures often act as barriers (65). At the same time, the Explo'Santé experience illustrates the centrality of LS in health education, but also the persistent lack of a consensual definition in research, which complicates evaluation and cross-study comparison (66). Finally, gender-sensitive approaches are needed: programs must account for differential vulnerabilities of girls and boys, tailoring strategies to support girls' resilience during transitions and addressing boys' persistent gaps in relational and literacy-based domains.

## 4.7 Strengths and limitations

This study has several strengths. It involved a large cohort of pupils followed longitudinally over 3 years, providing robust insights into developmental trajectories. The use of validated instruments for LS, SE, LSa, and HL ensured comparability with prior research. Multilevel modelling accounted for clustering at class and school levels, strengthening the reliability of findings. Sensitivity analyses confirmed the robustness of main effects despite attrition. However, limitations must be acknowledged. It should be noted that many scales are available to explore LS, SE, LSa and HL, with different conceptual focuses and dimensionalities. Choosing alternative measuring tools may impact the results observed. Attrition was substantial by T5, potentially introducing selection bias. Data relied on self-administered questionnaires, which may be influenced by
social desirability and subjective interpretation. Importantly, no control group was available for ethical reasons, limiting causal inference on the program's effectiveness. Moreover, the precision of district-level estimates varied substantially across the sample. Several districts included only a small number of pupils, which increases statistical uncertainty and limits the robustness of comparisons across contexts. Therefore, findings related to these smaller sub-samples should be interpreted with caution. Finally, contextual variability across districts complicates generalization, highlighting the need for replication in other educational systems.

## 5 Conclusion

This study provides new longitudinal evidence on the potential and limitations of school-based health promotion. The Explo'Santé program contributed to strengthening pupils' psychosocial resources, confirming the relevance of embedding LS and HL into the daily functioning of schools. However, the sharp decline observed during the transition to middle school underlines the importance of reinforcing support structures at this pivotal stage of development. Gendered patterns and territorial disparities also reveal the need for context-sensitive approaches that adapt to local dynamics while ensuring equity. To better understand these differences, qualitative analyses are required, notably to identify the mechanisms, facilitators, and barriers that explain why some territories show more sustained impacts than others. Beyond its immediate outcomes, Explo'Santé illustrates how the Health Promoting Schools framework can be operationalized to address health and social inequalities from an early age, fostering environments that support both academic success and long-term well-being.

## Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

## Ethics statement

The protocol was approved by the University of Lyon's ethics committee (France) on March 1, 2023 (n°2023-01-12-004). CNIL reference: 2226244 v 0. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin.

## Author contributions

CS: Investigation, Visualization, Formal analysis, Writing - review & editing, Writing - original draft, Data curation, Methodology, Software. AD-B: Writing - review & editing, Investigation. FC: Validation, Project administration, Writing - review & editing, Supervision. ED: Project administration, Supervision, Writing - review & editing, Funding acquisition, Conceptualization, Resources.

## Funding

The author(s) declared that financial support was received for this work and/or its publication. This work was supported by the French League Against Cancer (Ligue contre le Cancer) under Grant n°AAPPVN2022.LCC/ED.

## Acknowledgments

The authors would like to thank all the children who participated in this study, as well as their parents, the teachers and the school heads involved in the project. They also would like to express their gratitude to the French League Against Cancer prevention officers on the field, Angélique Vidal (Ardèche), Johanna Laporte (Corrèze), Valentine Sarrut (Hérault), Victoria Pieteraerents (Ille-et-Vilaine), Anaïs Magnin, Christelle Rogues and Roxanne Dimier (Loire), Estelle Le Vatant and Camille Rousseau (Loire-Atlantique), as well as to their facilitators, Thierry Brulavoine, Alexandre Cobigo and Emmanuel Ricard.

## Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The author FC declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.

## Generative AI statement

The author(s) declared that Generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

## Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

## Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2026.1720265/full#supplementary-material
References

1. McNamara, CL, Balaj, M, Thomson, KH, Eikemo, TA, Solheim, EF, and Bambra, C. The socioeconomic distribution of non-communicable diseases in Europe: findings from the European social survey (2014) special module on the social determinants of health. *Eur J Pub Health.* (2017) 27:22–6. doi: 10.1093/eurpub/ckw222

2. World Health Organization. The Ottawa charter for health promotion. First international conference on health promotion, Ottawa, 17–21 November 1986. In: Milestones in health promotion. Statements from global conferences. Geneva. (2009).

3. Kovess-Masfety, V, Husky, MM, Keyes, K, Hamilton, A, Pez, O, Bitfoi, A, et al. Comparing the prevalence of mental health problems in children 6-11 across Europe. *Soc Psychiatry Psychiatr Epidemiol.* (2016) 51:1093–103. doi: 10.1007/s00127-016-1253-0

4. OECD statistics. 2025. From data to action: Enhancing children's lives through better insights. Available online at: https://oecdstatistics.blog/2025/04/08/from-data-to-action-enhancing-childrens-lives-through-better-insights/. (Accessed September 22, 2025)

5. Viner, RM, Ozer, EM, Denny, S, Marmot, M, Resnick, M, Fatusi, A, et al. Adolescence and the social determinants of health. *Lancet* (London, England). (2012) 379:1641–52. doi: 10.1016/S0140-6736(12)60149-4

6. Langford, CP, Bonell, HE, Jones, HE, Pouliou, T, Murphy, SM, and Waters, E. The WHO health promoting school framework for improving the health and well-being of students and their academic achievement. *Cochrane Database Syst Rev.* (2014). 4:2–5. doi: 10.1002/14651858.CD008958.pub2

7. Pulimeno, M, Piscitelli, P, Colazzo, S, Colao, A, and Miani, A. School as ideal setting to promote health and wellbeing among young people. *Health Promot Perspect.* (2020) 10:316–24. doi: 10.34172/hpp.2020.50 (Accessed September 22, 2025)

8. Eurostat 2022 Secondary education statistics. Available online at: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Secondary_education_statistics

9. Dunhill, A. Children's Realities in Europe: Progress&Gaps - Eurochild 2024 flagship report on children in need across Europe (2024). Available online at: https://eurochild.org/resource/childrens-realities-in-europe-progress-gaps/

10. Bandura, A. Self-efficacy: the exercise of control In: Self-efficacy: The exercise of control. New York, NY, USA: W H Freeman/Times Books/ Henry Holt & Co (1997)

11. Masson, J, and Fenouillet, F. Relation entre sentiment d'efficacité personnelle et résultats scolaires à l'école primaire: Construction et validation d'une échelle. *Enfance (Paris).* (2013) 4:374–92. doi: 10.3917/enf1.134.0374

12. Sørensen, K. Review of health literacy and public health: a systematic review and integration of definitions and models, by Stephan van den Broucke, James Fullam, Gerardine Doyle, and al. BMC Public Health. (2012) 12:80. doi: 10.1186/1471-2458-12-80

13. Diener, E, and Lucas, RE. Personality and subjective well-being In: Well-being: The foundations of hedonic psychology. New York, NY, USA: Russell Sage Foundation (1999)

14. Inchley, J, Currie, D, Budisavljevic, S, Torsheim, T, Jástad, A, Cosma, A, et al. Spotlight on adolescent health and well-being. Findings from the 2017/2018 health behaviour in school-aged children (HBSC) survey in Europe and Canada. International report, volume 1. Key findings. (2020). Available online at: https://www.who.int/europe/publications/i/item/9789289055000. (Accessed September 22, 2025)

15. OECD/UNICEF. 2024. Education in the eastern Partnership: Findings from PISA. Paris: PISA, OECD Publishing. doi: 10.1787/d5d6f109-en

16. Masson, J. Review of promoting well-being within the health promoting schools framework: could life skills be a means rather than an end?, by Adeline Darlington-Bernard and Emily Darlington. *J Epidemiol Popul Health.* (2024) 72:202–748. doi: 10.1016/j.jeph.2024.02748

17. World Health Organization. 2003. 'Life skills approach to child and adolescent healthy human development | health and education resource Centre.' In Skills for health - skills-based health education including life skills: An important component of a child-friendly/health-promoting school. WHO INFORMATION SERIES ON SCHOOL HEALTH, Document 9. Available online at: https://healtheducationresources.unesco.org/library/documents/life-skills-approach-child-and-adolescent-healthy-human-development. (Accessed December 12, 2023)

18. Yoon, S, An, S, Noh, DH, Tuan, LT, and Lee, J. Effects of health education on adolescents' non-cognitive skills, life satisfaction and aspirations, and health-related quality of life: a cluster-randomized controlled trial in Vietnam. *PLoS One.* (2021) 16:e0259000. doi: 10.1371/journal.pone.0259000

19. Marmot, M, Friel, S, Bell, R, Houweling, TAJ, and Taylor, S. Closing the gap in a generation: health equity through action on the social determinants of health. *Lancet.* (2008) 372:1661–9. doi: 10.1016/S0140-6736(08)61690-6

20. Bartelink, N, van Assema, P, Vennegoor, G, and Bessems, K. Implementation of the health promoting school approach in Europe: a cross-sectional study among National Representatives. *J Sch Health.* (2024) 94:975–84. doi: 10.1111/josh.13499

21. Darlington, EJ, Violon, N, and Jourdan, D. Implementation of health promotion programmes in schools: an approach to understand the influence of contextual factors on the process? *BMC Public Health.* (2018) 18:1. doi: 10.1186/s12889-017-5011-3

22. Inchley, J, Muldoon, J, and Currie, C. Becoming a health promoting school: evaluating the process of effective implementation in Scotland. *Health Promot Int.* (2007) 22:65–71. doi: 10.1093/heapro/dal059

23. Patton, GC, Sawyer, SM, Santelli, JS, Ross, DA, Afifi, R, Allen, NB, et al. Our future: a lancet commission on adolescent health and wellbeing. *Lancet.* (2016) 387:2423–78. doi: 10.1016/S0140-6736(16)00579-1

24. Bagnall, CL, Jindal-Snape, D, Banwell, E, Panayiotou, M, Mason, C, and Qualter, P. Emotional wellbeing in the context of primary-secondary school transitions: a concept analysis paper. *Educ Psychol Rev.* (2025) 37:21. doi: 10.1007/s10648-025-09990-6

25. Benes, S, Boyd, KM, Cucina, I, and Alperin, HL. School-based health education research: charting the course for the future. *Res Q Exerc Sport.* (2021) 92:111–26. doi: 10.1080/02701367.2020.1712315

26. Mukamana, O, and Johri, M. What is known about school-based interventions for health promotion and their impact in developing countries? A scoping review of the literature. *Health Educ Res.* (2016) 31:587–602. doi: 10.1093/her/cyw040

27. Nasheeda, A, Abdullah, H, Krauss, S, and Ahmed, N. A narrative systematic review of life skills education: effectiveness, research gaps and priorities. *Int J Adolesc Youth.* (2018) 24:362–379. doi: 10.1080/02673843.2018.1479278

28. Olivo, M, Darlington-Bernard, A, Salque, C, Fraticelli, L, Ricard, E, Carrouel, F, et al. The Explo'Santé mixed methods protocol: an interventional research school health promotion project in France. *Arch Public Health.* (2025) 83:26. doi: 10.1186/s13690-024-01487-y

29. Darlington, Emily, and Masson, Julien 2020 *Promotion de la santé et réussite scolaire*. Available online at: https://www.dunod.com/sciences-humaines-and-sociales/promotion-sante-et-reussite-scolaire (Accessed July 11, 2025).

30. Ministère de l'Éducation 1998 'Bulletin Officiel de l'Éducation Nationale BO N°45 Du 3 Décembre 1998'. Available online at: https://www.education.gouv.fr/bo/1998/45/default.htm (Accessed December 9, 2025).

31. Légifrance 2013 'LOI N° 2013-595 Du 8 Juillet 2013 d'orientation et de Programmation Pour La Refondation de l'école de La République - Dossiers Législatifs'. Available online at: https://www.legifrance.gouv.fr/dossierlegislatif/JORFDOLE000026973437/ (Accessed December 9, 2025).

32. STROBE. 2024. 'Checklists'. STROBE. Available online at: https://www.strobe-statement.org/checklists/. (Accesses July 11, 2025)

33. Tessier, Damien. 2021. 'Echelles de mesure des compétences psychosociales'. Séminaire Santé Publique France, Online. Available online at: https://www.santepubliquefrance.fr/import/echelles-de-mesure-des-competences-psychosociales. (Accessed December 12, 2023)

34. Encinar, P-E. Review of *Compétences psychosociales et bien-être scolaire chez l'enfant: une validation française pilote*, by Damien Tessier and Rébecca Shankland. *Enfance (Paris).* (2017) 1:37–60. doi: 10.3917/enf1.171.0037

35. Simar, C. Review of Validation transculturelle d'une échelle de mesure des compétences sociales chez les élèves des 8 à 12 ans, by Julie Pironom, Damien Tessier, Christelle Nsambu, and Julien Masson. *Revue Education Santé Sociétés.* (2021) 1:125–139. doi: 10.17184/eac.3865

36. Schultz, D, Izard, CE, and Bear, G. Children's emotion processing: relations to emotionality and aggression. *Dev Psychopathol.* (2004) 16:371–87. doi: 10.1017/S0954579404044566

37. Weiss, MR, Bolter, ND, and Kipp, LE. Assessing impact of physical activity-based Youth development programs: validation of the life skills transfer survey (LSTS). *Res Q Exerc Sport.* (2014) 85:263–78. doi: 10.1080/02701367.2014.931558

38. Huebner, ES. Preliminary development and validation of a multidimensional life satisfaction scale for children. *Psychol Assess.* (1994) 6:149–58. doi: 10.1037/1040-3590.6.2.149

39. Rouquette, A. Review of health literacy throughout adolescence: invariance and validity study of three measurement scales in the general population, by Laurent Rigal, Julien Mancini, Francis Guillemin, et al. *Patient Educ Couns.* (2022) 105:996–1003. doi: 10.1016/j.pec.2021.07.044

40. Paakkari, O, Torppa, M, Kanas, L, and Paakkari, L. Subjective health literacy: development of a brief instrument for school-aged children. *Scand J Public Health.* (2016) 44:751–7. doi: 10.1177/1403494816669639

41. Masson, J, Darlington-Bernard, A, Vieux-Poule, S, and Darlington, E. Validation française de l'échelle de littératie en santé des élèves HLSAC (Health literacy for school-aged children). *Sciences Éduc Santé Publique.* (2021) 33:705–12. doi: 10.3917/pub.215.0705

42. Salque, C, Darlington-Bernard, A, Carrouel, F, and Darlington, E. Life skills development in schools: the Explo'Santé program's first-year impact. *J Educ Res.* (2025). 119:1–13. doi: 10.1080/00220671.2025.2595429

43. INSEE 2025 Comparateur de Territoires – Comparez Les Territoires de Votre Choix - Résultats Pour Les Communes, Départements, Régions, Intercommunalités... | Insee. Available online at: https://www.insee.fr/fr/statistiques/1405599geo=METRO-1 (Accessed August 29, 2023).

44. Salque, C, Darlington-Bernard, A, Olivo, M, Fraticelli, L, Ricard, E, Carrouel, F, et al. Cross-sectional study of the French Explo'Santé 4th grader cohort: a baseline for self-efficacy, life satisfaction, life skills and health literacy. *Glob Health Promot.* (2025) 32:60–70. doi: 10.1177/17579759251317512
45. Jaruseviciute, V, Silinskas, G, and Kiuru, N. Socioemotional functioning across the transition to lower secondary school: the role of temperament and relationships with mothers and teachers. *J Res Adolesc.* (2023) 33:1143–63. doi: 10.1111/jora.12866

46. Pedditzi, ML, Nonnis, M, and Fadda, R. Self-efficacy in life skills and satisfaction among adolescents in school transitions. *J Public Health Res.* (2023) 12:22799036231211420. doi: 10.1177/22799036231211420

47. Huttunen, I, Upadyaya, K, and Salmela-Aro, K. Longitudinal associations between adolescents' social-emotional skills, school engagement, and school burnout. *Learn Indiv Differ.* (2024) 115:102537. doi: 10.1016/j.lindif.2024.102537

48. Tercova, N, Muzik, M, Dedkova, L, and Smahel, D. The reciprocal relationship between parental eHealth literacy mediation and adolescents' eHealth literacy: three-wave longitudinal study. *J Med Internet Res.* (2025) 27:e67034. doi: 10.2196/67034

49. Else-Quest, NM, Hyde, JS, and Linn, MC. Cross-National Patterns of gender differences in mathematics: a Meta-analysis. *Psychol Bull.* (2010) 136:103–27. doi: 10.1037/a0018053

50. Chan, RCH. A social cognitive perspective on gender disparities in self-efficacy, interest, and aspirations in science, technology, engineering, and mathematics (STEM): the influence of cultural and gender norms. *Int J STEM Educ.* (2022) 9:37. doi: 10.1186/s40594-022-00352-0

51. Hyde, JS. Gender similarities and differences. *Annu Rev Psychol.* (2014) 65 Volume 65:373–98. doi: 10.1146/annurev-psych-010213-115057

52. Eriksson, K, and Strimling, P. Gender differences in competitiveness and fear of failure help explain why girls have lower life satisfaction than boys in gender equal countries. *Front Psychol.* (2023) 14:1131837. doi: 10.3389/fpsyg.2023.1131837

53. De Vriendt, T, Clays, E, Maes, L, De Bourdeaudhuij, I, Vicente-Rodriguez, G, Moreno, LA, et al. European adolescents' level of perceived stress and its relationship with body adiposity--the HELENA study. *Eur J Pub Health.* (2012) 22:519–24. doi: 10.1093/eurpub/ckr134

54. García-Moya, I, Paniagua, C, and Jiménez-Iglesias, A. Gender differences in adolescent school stress: a mixed-method study. *J Res Adolesc.* (2025) 35:e13057. doi: 10.1111/jora.13057

55. World Health Organization 2024 Rising school pressure and declining family support especially among girls, finds new WHO/Europe report. Available online at: https://www.who.int/europe/news/item/13-11-2024-rising-school-pressure-and-declining-family-support-especially-among-girls--finds-new-who-europe-report (Accessed September 23, 2025).

56. Fillol, A, Wallerich, L, Larose, M-P, Ferron, C, Rivadeneyra-Sicilia, A, Vandentorren, S, et al. The influence of educational determinants on children's health: a scoping review of reviews. *Public Health Rev.* (2024) 45:1606372. doi: 10.3389/phrs.2024.1606372

57. European Commission. Directorate General for Education, Youth, Sport and Culture. 2022. *Rapport de suivi de l'éducation et de la formation 2022: France*. Publications Office. Available online at: https://data.europa.eu/doi/10.2766/98979 (Accessed September 23, 2025).

58. Johnson, S, Laham, S, Blanc, S, and Bellanger, M. Cultivating partnerships to incorporate health promotion modules into primary school curricula: a case study in France. *Front Educ.* (2024) 9:1498753. doi: 10.3389/feduc.2024.1498753

59. Wu, Y-J, and Becker, M. Association between school contexts and the development of subjective well-being during adolescence: a context-sensitive longitudinal study of life satisfaction and school satisfaction. *J Youth Adolesc.* (2023) 52:1039–57. doi: 10.1007/s10964-022-01727-w

60. Hughes, JN, and Cao, Q. Trajectories of teacher-student warmth and conflict at the transition to middle school: effects on academic engagement and achievement. *J Sch Psychol.* (2018) 67:148–62. doi: 10.1016/j.jsp.2017.10.003

61. Bezzo, FB, Panico, L, and Solaz, A. Socio-economic gradients in pupils' self-efficacy: evidence, evolution and main drivers during the primary school years in France. *Longitud Life Course Stud.* (2024) 15:1–14. doi: 10.1332/17579597Y2024D000000028

62. Beatson, R, Quach, J, Canterford, L, Farrow, P, Bagnall, C, Hockey, P, et al. Improving primary to secondary school transitions: a systematic review of school-based interventions to prepare and support student social-emotional and educational outcomes. *Educ Res Rev.* (2023) 40:100553. doi: 10.1016/j.edurev.2023.100553

63. Engels, MC, Pakarinen, E, Lerkkanen, M-K, and Verschueren, K. Students' academic and emotional adjustment during the transition from primary to secondary school: a cross-lagged study. *J Sch Psychol.* (2019) 76:140–158. doi: 10.1016/j.jsp.2019.07.012

64. Wang, W, Xiao, J, Li, W, and Yao, J. How school climate affects the development of the social and emotional skills of underprivileged-background students—An empirical study based on the SSES2019 data. *Children.* (2022) 9:1812. doi: 10.3390/children9121812

65. Kontac, JC, Macrae, C, Caldwell, HAT, Feicht, B, Heath, S, Hancock Friesen, CL, et al. The process of student engagement in school health promotion: a scoping review. *BMC Public Health.* (2025) 25:1063. doi: 10.1186/s12889-025-22121-8

66. Darlington-Bernard, A. Review of *defining life skills in health promotion at school: a scoping review*, by Corélie Salque, Julien Masson, Emily Darlington, Graça S. Carvalho, and Florence Carrouel. *Front Public Health*. (2023) 11:1296609. doi: 10.3389/fpubh.2023.1296609

67. Fenouillet, F. Validation française de l'échelle multidimensionnelle de satisfaction de vie chez l'élève. *Canadian Journal of Behavioural Science.* (2014) 47:1–29. Available online at: https://hal.science/hal-01061826 (Accessed September 8, 2023).