From community diagnosis to policy dialogue: co-creating childhood obesity prevention strategies in rural and urban Portugal.

Introduction: Promoting healthy lifestyles from early childhood is central to balanced development and the prevention of health problems throughout life. The European HEALTH4EUKids project examines a participatory process of community diagnosis, co-creation into local policies for child health promotion and childhood obesity prevention in two Portuguese territories with distinct rural and urban profiles. Methods: A cross-sectional observational study was conducted within a mixed-methods action-research framework. The study provides an exploratory assessment of children's wellbeing indicators and contextual differences, without permitting causal inference. Participants included 202 primary-school pupils (mean age = 7.43 ± 1.14 years) and 54 community adults (mean age = 48.76 ± 11.51 years), alongside stakeholders from health, community, and local decision-making sectors. Data included a questionnaire adapted from the 2022 Health Behavior in School-aged Children (HBSC) protocol, KIDSCREEN-10, the Living Healthy Tool (LHT) which was translated and culturally adapted for the Portuguese context, satisfaction questionnaires and focus groups. LHT-student version was administered exclusively in Alter do Chão. Quantitative and qualitative data were analyzed using SPSS v.28.0 and thematic analysis supported by MAXQDA. Results: Descriptive analyses indicated that 57% of pupils reported irritability or bad mood and 46.7% reported nervousness, while quality of life and sleep were generally favorably rated. Regarding nutritional status, 66% had age-adjusted BMI within the reference range, whereas 36% reported not engaging in regular physical activity. Frequent screen use and exposure to violence during leisure time were also identified as concerns. Community LHT responses indicated differences between municipalities in perceptions of school meals, safety, and access to public services. Focus groups highlighted priorities concerning physical activity, school food environments, and coordination between schools, families, and the community. Conclusions: The findings indicate context-specific strengths and areas for further attention in child health and wellbeing. Quality of life, sleep patterns, and certain family health practices were generally favorable. Conversely, challenges were identified regarding physical activity, screen time, and psychological symptoms, as well as less favorable assessments of school meal quality, community safety, access to services, and opportunities for active leisure.