Service-learning (S-L) is a valuable resource to promote public health education and social engagement among students in health sciences, as essential parts in the curriculum of future healthcare professionals (1, 2). Cooperation and civic competencies are conveyed through this learning methodology, whose principles are based on critical reflection, mutual benefit, and experiential learning (3, 4), while the service improves the health of the communities (5, 6). This service is particularly useful for covering disregarded needs in specific collectives, that can benefit from health initiatives with no economic cost (7, 8). Among others, S-L programs focused on health education have demonstrated their usefulness when developed within the school community (4, 9).

Musculoskeletal disorders (MSKD) represent a public health problem, as leading cause of chronic pain and disability worldwide (10, 11). During the last decades, MSKD are affecting a growing number of people and occurring at younger age (12, 13), with prevalence data ranging from 20 to 40% when assessing chronic musculoskeletal and back pain among school-aged children (14). Furthermore, children reporting musculoskeletal pain are also more likely to suffer it during adolescence and young adulthood (15). Different factors appear to be related to the increasing prevalence in the early life stages, such as lower socioeconomic status (15), psychological distress (16), or a sedentary lifestyle (17), which is associated with obesity (18) and poor ergonomics (17).

Despite the burden of musculoskeletal conditions, health policies are not facing this problem satisfactorily (19, 20). The lack of awareness and investment in both research and preventive interventions is pointed. Whereas educational strategies conducted by physical therapists show to boost the effectiveness of rehabilitation in people with MSKD (21), these key interventions are not generally offered with preventive aims at the primary care level (19). Concretely, the school population is especially overlooked (22), and this scenario is even more disturbing since the diagnosis and management of pain, once it has become chronic, show uncertain efficacy in children (23).

Increasing knowledge in terms of body awareness (24, 25), healthy habits (22, 26), and self-management of pain or injuries (27, 28), is helpful to preventing the development of MSKD (28). Indeed, confidence in self-care strategies, achieved through increasing health literacy, is a meaningful resource for people presenting chronic musculoskeletal pain (19, 29). There is still no data from cohorts of children followed long-term after musculoskeletal health promotion programs (MSKHPP), which reinforces the dismissed needs in terms of prevention. However, it can be assumed that such training during the early stages of life can promote useful, lifelong learning for the primordial prevention of MSKD. Physical therapists are in an ideal position to address these aspects of education (29, 30), filling the current gaps in musculoskeletal health promotion among children and adolescents (12, 22).

Additionally, the benefits of health education interventions could be enhanced when conducted at school, driven by facilitatory aspects such as the peer context (31, 32). The training received by teachers, allowing them to implement this knowledge in the day-to-day school activities, as well as the fact that pupils and teachers learn together in a non-hierarchical relationship (33, 34), could also positively contribute. In addition, the cooperation values conveyed by S-L can promote motivation and learning in both student collectives (4, 35). However, despite these benefits can be hypothesized, the usefulness of S-L programs conducted for school-age children remains understudied. Finally, in addition to quantitative analysis to assess the interventions, qualitative approaches are important to enrich research on S-L programs, allowing to target specific aspects, and even capturing new beliefs, needs and barriers (4).

This study aimed to use quantitative and qualitative approaches to assess the learning and satisfaction of school students and teachers after participating in a MSKHPP conducted at school, as well as to assess fourth-year physical therapy students´ perceptions of their experiences in this S-L project.

This study examines the learning processes, experiences, and satisfaction of both school students and teachers within the school community, following their participation in a MSKHPP, which was carried out during two academic courses, reaching a total of 1,051 children and adolescents. The program was designed according to S-L principles and implemented by fourth-year physical therapy students, whose experiences were qualitatively explored.

For decades, peer education (46) and university learning through S-L projects (47) have been widely studied. This study uniquely combines both models by promoting reciprocal learning between two educational levels—school and university—while integrating teaching-based learning. Additionally, a third group, the schoolteachers, acted as learners and mediators, contributing to and benefiting from the teaching process. Together, these participants engaged in a collaborative effort that led to meaningful mutual learning.

The present findings provide preliminary evidence of the effectiveness of health promotion programs in the school community, particularly those that emphasize body awareness, prevention, healthy habits and self-management of MSKD. Other studies addressed health education within the school community and focused primarily on back posture (48), increasing physical activity (49, 50), improving nutritional habits (49), or reducing obesity (51, 52). However, this study takes a different approach by using a multimodal and targeted strategy specifically at the musculoskeletal system level. The development of both theoretical and practical interventions has been shown to be effective in facilitating the acquisition of new knowledge (48), and our results contribute to the need of growing the evidence in this area.

Significant improvements were observed in both schoolchildren’s and teachers’ knowledge related to the locomotor system, physical therapy, and the prevention of MSKD. A better understanding of musculoskeletal health is crucial for empowering individuals to make informed health decisions, a concept increasingly recognized as health literacy (HL) (53). According to Sorensen et al. (54), HL encompasses not only the necessary knowledge but also the motivation and skills required to maintain or improve one’s quality of life. The findings of the present study are consistent with the review and meta-analysis by García-Moreno et al. (55), who reported that physical therapy positively influences behavior and knowledge related to back care and the prevention of non-specific low back pain in children and adolescents. Regarding self-body awareness and posture, the results of this study are consistent with those of Minghelli et al. (56, 57), where an improvement in ergonomic knowledge was achieved through a back postural education program. However, these results were obtained through theoretical and practical tests, while the present results were gathered using a questionnaire.

This study also demonstrated the benefits of guided practical activities such as flexibility, strengthening, breathing, and self-treatment, which is in line with the work of Cardon et al. (58), suggesting that prevention of MSKD pain is more effective when active strategies are employed, compared to programs that focus solely on postural hygiene. Notably, few school-based interventions prioritize learning for the prevention of MSKD or offer opportunities for school students to practice self-treatment techniques as preventive measures, making our approach particularly valuable. Similarly, Mirskaya et al. (59) developed a specialized model for the prevention and correction of MSKD in school students, achieving a 50% reduction in prevalence among students in several Moscow schools. This model enhances the early detection of musculoskeletal pathologies in school-age children and supports ongoing prevention efforts within educational settings (60).

In addition, both school students and teachers expressed an increased interest in education on the prevention of MSKD. It is important to highlight that health promotion goes beyond simply encouraging children and adolescents to eat healthily and be physically active; it is embedded in a broader approach that relies on active engagement with the surrounding community (61, 62). The increased interest observed in both groups may be attributed to the engagement fostered by our study, which provided quick and available feedback and facilitated reflective practice through a combination of theoretical and practical teaching (63). This has also been accomplished through close collaboration between all school stakeholders—including teachers, school students, and community members—to create a transformative educational process, as highlighted in the study by David and Cooke (64).

School students reported a high level of satisfaction with the MSHPP, citing their increased knowledge of the human body, understanding of musculoskeletal disorders, and insights into prevention strategies as key contributors. For teachers, active participation in such programs was highlighted as the most significant aspect, supporting that continuous professional development and training are essential for them to effectively promote musculoskeletal health. These findings align with those of Rodrigo-Sanjoaquín et al., (62) who conducted a qualitative study on the challenges and opportunities in the implementation of Aragon’s Health-Promoting School network. Their research underscores the central role of teachers in school health promotion, pointing to their ideal position to design and implement tailored health programs (65). Similarly, the study by Hung et al. (66) emphasize the importance of providing teachers with education and training on health-related topics. Through the training, the teachers´ confidence in their ability to continue health education in the courses could be enhanced, optimizing the impact of the program in the long term.

As can be seen, the challenge of implementing training within school-based programs is engaging all relevant stakeholders. Durl et al. (67) demonstrated that integrating insights from both students and teachers enhances program effectiveness, particularly when a diverse group of stakeholders—including end users—is actively involved in key stages of co-creation (design, implementation, and evaluation). Our study aligns with the findings of this author, demonstrating a collaborative effort that fostered meaningful mutual learning. A scoping review identified several practical challenges can limit the effectiveness and reach of school-based interventions, including teacher training, academic priorities, limited resources, and staff workload. Additionally, it highlighted that evaluating these interventions is rarely included as a formal metric. However, systematically assessing intervention outcomes is crucial to understanding which interventions benefit specific populations. Incorporating rigorous evaluation informs decisions on intervention dissemination and future implementation strategies and ensures continuous assessment and refinement of interventions into practice (68).

This project was developed by physical therapy university students as part of their final degree project through a S-L methodology (69). Preparing the sessions, adapting to a school audience, improvising during the workshops, and guiding practical exercises required to deeply study the material in order to teach it effectively and address any questions that arose. This process fostered significant learning, both in knowledge and skills, through the mechanism of implicit learning. Learning by teaching, a method introduced in the 1980s and refined by Grzega and Schöner (70), enables students to achieve autonomous and deep learning. Participating students reflected on their learning experience, noting that it enhanced their skills as future health professionals. For physical therapists, effective communication with patients is essential, both during anamnesis and in establishing a strong therapeutic alliance (71, 72). Communicating health information to school children improved their communication skills as they had to adapt their message to an audience with different language skills and levels of knowledge. A similar study conducted in Mexico with engineering university students echoes these findings, emphasizing the benefits of learning through teaching (73). One student underscored the importance of going beyond written and purely cognitive learning to engage in real-world contexts. As noted in their reflections, this approach heightened their motivation toward such educational systems. Providing S-L experiences that include opportunities for reflection throughout education enhances university students’ understanding of social responsibility (74). Moreover, as future practitioners implementing S-L initiatives, physical therapy students must be prepared to operate within a rapidly evolving healthcare environment, which now demands greater community accountability.

Despite the promising results, policy and practical implications remain underexplored. School-based health promotion interventions, particularly those focused on musculoskeletal health, have the potential to be integrated into public health policies as a cost-effective strategy to reduce long-term MSKD-related burden. The inclusion of structured musculoskeletal health curricula in schools could help bring about sustainable behavioral changes that persist into adulthood and contribute to the prevention of chronic conditions such as low back pain (67). Future research should explore the feasibility of implementing these programs on a larger scale, ensuring collaboration between educational and healthcare public systems.

This study, designed to implement and assess a MSKHPP in schools, demonstrated its innovative nature by specifically targeting musculoskeletal disorders. A multimodal approach was developed, combining theoretical and practical methodologies to teach prevention and self-management of MSKD. However, it has certain limitations. First, the lack of family involvement, which could have enhanced the program’s effectiveness by reinforcing the learned behaviors at home. Evidence suggests that parental engagement plays a crucial role in maintaining health-promoting behaviors in children and adolescents (75). Additionally, the long-term impact of the intervention was not assessed, and further studies should incorporate objective testing methods and follow-up assessments to determine retention of knowledge and behavioral changes over time. Nevertheless, the extension of this program to two academic courses allowed it to reach a large population, supporting not only its usefulness in terms of MSKD prevention but also the sustainability of these interventions when conducted through S-L.

In conclusion, MSKHPP delivered by physical therapists in the school community, can contribute to learning useful resources for musculoskeletal pain prevention and self-management. In addition, health promotion initiatives developed using S-L could be a cost-free alternative to the current gaps in public health policies, while qualitatively improving the education of future healthcare professionals.