A scoping review of K–12 health education in Canada: understanding school stakeholders’ perceptions

ABSTRACT

A scoping review was conducted, analyzing peer-reviewed literature published between 1995 and 2022, focusing on school stakeholders' perceptions of K-12 health education (HE) in Canada. The results included 37 studies, with articles focused on the perceptions of students, in-service and pre-service teachers, parents, undergraduate students, and health partners/ educational professionals. Using reflexive thematic analysis, three main themes were identified: (a) HE is perceived as a valuable school subject; (b) teachers are not prepared to teach HE; and (c) HE courses are not meeting the needs of students. The outcomes of the review underscore the importance and value of HE as perceived by school stakeholders and highlight the necessity for heightened advocacy efforts to enhance HE at all school levels. The review emphasizes the need for broader consultation and research involving diverse school stakeholder groups in order to promote the advancement of HE in Canadian schools.

KEYWORDS:

• Health education
• sexual health education
• curriculum
• scoping review
• teacher education programs

Introduction

The delivery of school-based health education (HE) can serve as a foundation for students’ wholistic wellbeing and may have a direct influence on fostering positive health outcomes while preventing adverse ones (Auld et al., 2020; Pulimeno et al., 2020). The World Health Organization (WHO) has defined HE as ‘a combination of learning experiences designed to help individuals to improve their health by increasing their knowledge or influencing their attitudes’ (Kumar & Preetha, 2012, p. 6). This definition is supported by the national association Physical and Health Education Canada (PHE Canada). PHE Canada recently developed the Canadian Physical and Health Education Competencies (CPHEC; Davis et al., 2023) to provide provinces the curriculum competencies and outcomes necessary for quality school-based HE. The CPHEC describe HE as a wholistic course of study that empowers students to balance, connect, and maintain their emotional, physical, cultural, spiritual, social, and psychological wellbeing. HE, as proposed by Davis et al. (2023), places emphasis on enabling students to acquire the necessary skills, knowledge, and motivation to be healthy and aware, affirmed and connected, and active for their lifetime.

HE is critically important to the health of children and youth, and the continued wellbeing of future generations (Auld et al., 2020; Pulimeno et al., 2020). Auld et al. (2020) and Nutbeam et al. (2018) have argued that HE offers a means for improving health literacy – the ability of individuals to gain access to, understand, and use information to promote and maintain good health for themselves, their families, and their communities. The WHO (2008) suggests health literacy should be incorporated in all schools’ core curricula. Furthermore, schools offer children with diverse backgrounds the opportunity to develop health behaviours, ensuring that they receive equal support, attention, and opportunities (Davis et al., 2023). Coupled with HE affording all students access to information and resources, HE is the only school subject with learning opportunities on some critical topics, such as mental health support and stigma, sexual HE (SHE), social and emotional competencies, and topics associated with equity, diversity, and inclusion.

Despite its significance, HE has historically struggled to secure its position as a vital area of study in schools (Auld et al., 2020; Sinkinson & Burrows, 2011). Moreover, some have viewed HE as ‘contentious’ (Munro, 2003; Weaver et al., 2002), a ‘low-status’ subject (Sinkinson & Burrows, 2011), and/ or a ‘panacea that will transform the health of individual, community, and even nations’ (Leahy et al., 2016, p. 1). HE topics often spark debate, leading to a range of complex issues concerning the rights of students, parents, and governing bodies (Sinkinson & Burrows, 2011). SHE, for example, is a topic that is frequently discussed both within the education sector and the broader political arena (Rayside, 2014; Robinson et al., 2019). Other topics, such as mental health and gender identity, have also been considered controversial by some school stakeholders due to the perceived intrusion into the home and parental domain (Sinkinson & Burrows, 2011).

The implementation of quality and meaningful HE in K–12 schools remains an ongoing challenge (Auld et al., 2020; Lu & McLean, 2011; Robinson et al., 2023). Within Canada, there are no national or provincial guidelines mandating specific HE training for teachers (Vamos & Zhou, 2009). Consequently, HE is typically delivered by teachers who hold expertise in other subject areas or disciplines, rather than specialized training in HE (Birch et al., 2019). Insufficient formal training in HE leads to teacher frustration and a notable lack in confidence when navigating sensitive topics within the subject (Cohen et al., 2004, 2012; Robinson et al., 2019). Due to the often-narrow focus of school priorities (e.g. literacy and numeracy), along with curricula time devoted to other subjects (Robinson et al., 2023; Videto & Dake, 2019), there is a lack of coherent understanding of, and value towards, Canadian HE programming. Robinson et al. (2023), in their analysis of Canadian HE curricula, reported variations of instructional time allocations across provinces ranging from 2 to 8% of total instructional time, with limited senior secondary requirements. With such minimal instructional time, it is fair that some suggest that HE may have little to no impact on student health. In terms of structure, across Canadian provinces and territories, HE is offered both as an independent subject and as part of a combined health and physical education curriculum (i.e. British Columbia/Yukon, Manitoba, Ontario and Québec have combined physical education and HE). Notably, nearly all provinces and territories in Canada have distinct HE curricula, with two territories adopting the curricula of their neighboring provinces or territories (Robinson et al., 2023). Robinson et al. (2023) concluded their analysis of HE curricula in Canada by asserting the importance of ‘a coordinated, inclusive, and unified voice for HE’ (Robinson et al., 2023, p. 18) to establish it as a priority across the country. This includes students, teachers, postsecondary teacher educators, parents, health experts, cultural knowledge keepers, Indigenous Elders, as well as provincial and national partners (Robinson et al., 2023).

To accomplish this goal, it is imperative to gain an understanding of K–12 HE across Canada from the perspectives of school stakeholders. By attending to the voices of school stakeholders, we can identify more effective strategies and supports for those looking to create more positive HE for all involved. Seeking an understanding of the HE-related perceptions of multiple school stakeholders has become a commonplace occurrence for many who are engaged in curriculum development or reform efforts (Ingman et al., 2017), as well as educational policy advancement (Stosich & Bae, 2018). We can learn from school stakeholders, and we can apply that learning to current and future teaching and research related to HE. As such, the purpose of this scoping review was to synthesize the evidence gathered from empirical literature focused on school stakeholders’ perceptions of K–12 HE in Canada. Specifically, we aimed to: (a) canvass the existing literature in the field to determine the volume, nature, and characteristics of the research available; (b) summarize main findings from this area of research to identify action areas to build a stronger K–12 HE system; and (c) identify potential gaps in our understanding of school stakeholders’ perceptions of K–12 HE in Canada, to inform future directions and research. The primary objective of this review was to transform these findings into practical strategies that can have a positive impact on school-based HE.

Methods

Given the nature of the research objectives, we conducted a scoping review guided by the methodological framework by Arksey and O’Malley (2005). Scoping reviews aim to assess the breadth and extent of existing evidence or literature pertaining to a specific topic and they are conducted to summarize and share a range of research findings for policy makers, practitioners, and consumers who may not have the time or resources to complete the review themselves (Arksey & O’Malley, 2005). Given that the focus of the review includes this target audience, and the aims are focused on accessing available literature and identifying gaps for future research, this type of review is well-suited. Following Arksey and O’Malley’s staged framework, we adopted the following five-stage scoping review protocol: (1) identify the research question, typically broad in scope; (2) identify relevant studies through a comprehensive process; (3) select studies by establishing inclusion/ exclusion criteria based on familiarity with the literature; (4) chart the data, involving the sifting, charting, and sorting of information based on key issues and themes; and (5) collate, summarize, and report the results, encompassing both descriptive and numerical summaries of the data and a thematic analysis.

Identifying relevant studies

Following the recommendations offered by The Joanna Briggs Institute (JBI, 2015), two librarians (authors: Johnston and Frail) collaborated with the lead author (Sulz) to identify appropriate search terms. Johnston and Frail then created search strategies for, and conducted searches in, the following databases from database inception until August 12, 2022: Education Resources Information Center (ERIC) and Education Research Complete (both via EBSCOhost), Education Database and Canadian Business and Current Affairs (CBCA): Social Sciences Subset (both via ProQuest), and Scopus.

The search contained subject headings and free text search terms for four concepts: (a) stakeholder perceptions; (b) health curricula; (c) K–12 education; and (d) Canadian school systems. The search strategies were adapted for each database for optimal performance. (See details for the full search for ERIC in Appendix A.) All types of literature were included in the searches, and no language or methodological limits were applied to the searches, with the exception of excluding results for newswire feeds, magazines, and encyclopedias and reference works in CBCA: Social Sciences.

Study selection: inclusion and exclusion criteria

To be eligible for inclusion, the studies and documents must have included: (a) at least one topic related to health curricula; (b) the K–12 education context; (c) Canadian education systems; (d) a copyright date or publication date between 1995 and 2022 (the start date was chosen as earlier publications would be referring to obsolete curricula); and (e) peer-reviewed journals. An article was excluded if it: (a) did not include a topic related to health curricula; (b) focused on pre-schools or post-secondary education contexts; (c) included a school system outside of Canada; (d) had a publication date prior to 1995; (e) was not considered peer-reviewed research; and/ or (f) was written in a language other than English.

Articles identified during the search were imported into Covidence, a web-based platform used to facilitate screening and data extraction for scoping and systematic reviews. The review consisted of two levels: a review of the title and abstract and a review of the full-text. Articles were first screened by the lead author according to titles and abstracts to determine which studies addressed the research question. When an article was deemed to meet the eligibility criteria, it was downloaded and saved for a comprehensive review of the full text by two separate researchers. Two researchers then screened full text articles for consensus.

Interpretation, synthesis, and reporting

The information was charted using the database program Excel by one author and confirmed by a second author, using the following categories: (a) author, year, province; (b) journal; (c) study design and participants; (d) goal or purpose of the study; and (e) notable results. Arksey and O’Malley (2005) emphasize the importance of offering a descriptive numerical summary, advocating that researchers should delineate the features of incorporated studies. This includes detailing the overall number of studies included, types of study design, publication years, interventions’ types, characteristics of the study populations, and the countries where the studies were conducted. Upon review of the charted information, two additional groups were created: school stakeholder groups (e.g. student, parent) and HE topic studied (e.g. SHE, teacher preparation). The reporting of these insights emerged during the charting process with links to the goal and purpose of the study.

Following this, we performed a thematic analysis, categorizing our data into overarching themes. Our methodology aligned with Arksey and O’Malley’s (2005) step 5 of collating, summarizing, and reporting the results and Levac et al.’s (2010) suggestion to integrate a stage resembling qualitative data techniques, particularly employing thematic analysis. The presentation of our results included a combination of tables and descriptions corresponding to the identified themes. This approach established a clear link between our findings and the fulfillment of our research objectives (Daudt et al., 2013).

Results

Search outcome

A total of 2,861 articles were identified through the initial search. Covidence identified 257 duplicates, leaving 2,604 results for the title and abstract screening phase. In total, 131 papers were full-text reviewed (2,473 ineligible/ irrelevant) using the identified inclusion/ exclusion criteria. The full review of 131 papers was completed by the lead author (Sulz) and a second co-author (Robinson) resulting in the exclusion of 94 more articles. The final scoping review included 37 articles. The review process is summarized in Figure 1.

Figure 1. Literature Search Results

Characteristics of included studies

All included studies were published in peer-reviewed journals between 1998 and 2022. From the 37 studies, seven of the ten Canadian provinces were represented in the data: Ontario (n = 15); New Brunswick (n = 6); British Columbia (n = 6); Alberta (n = 5); Québec (n = 2), Nova Scotia (n = 1); and Newfoundland and Labrador (n = 1). The data did not include representation from any of the three Canadian territories. Summaries of the 37 studies for this research are found in Table 1 (supplementary materials).

Table 1. Perceptions of School Stakeholders on K–12 HE.

Author, Year (Province)	Journal	Study Design (D) & Participants (P)	Goal/ Purpose	Notable Results
Anderson & Thorsen, 1998 (ON)	Journal of Education for Teaching	D: quantitative (descriptive/ correlational) P: PSTs, elementary (n = 493)	To determine the nature and extent of preparation for HE, including structural characteristics (hours, classes) and students’ perception of their competence and comfort level teaching HE.	More than one third of respondents (35.3%) reported they received no pre-service instruction devoted specifically to HE. Half (50.5%) indicated their program included one to six hours devoted to HE. 71.2% indicated they did not teach any HE during practice teaching.
Begoray et al., 2009 (BC)	Global Health Promotion	D: general qualitative P: students, grade 10 (n = 33)	To examine the health component of the Planning 10 curriculum as it was experienced by students, and to examine how it contributes to students’ health literacy and how context influences HE.	Students reported experiencing repetitive course content, routinely delivered by teachers and passively received by students. The HE curriculum, and particularly its implementation, has had limited effect on health literacy (students’ abilities to access, understand, communicate, and evaluate health information).
Bialystok, 2018 (ON)	Educational Theory	D: conceptual/ theoretical P: NA	To provide an analysis of parental opposition to comprehensive SE that suggests their dissent should not be accommodated in the form of opt-outs.	Providing dissenting parents with opt-out options undermines a very urgent educational policy. This is due to the specific nature and aims of SE, especially its concern with mainstreaming sexual diversity and supporting the sexual autonomy of vulnerable students. It is suggested to find ways of honoring parents’ right to involvement in their children’s education while delivering a mandatory curriculum.
Bialystok, 2019 (ON)	Canadian Journal of Education	D: quantitative (descriptive/ correlational) P: ISTs, grades 1–12 (n = 117)	To establish teachers’ understanding of the revised SHE curriculum, their experience of the roll-out, and their values around the teaching of sexuality.	Teachers’ beliefs about the aims of the curriculum are closely aligned with the former Liberal government. Teachers expressed classically liberal orientations in their teaching, stressing the importance of promoting respect for diversity, equality, and healthy independent decision-making.
Byers et al., 2003a (NB)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: students, grades 6–8 (n = 745)	To examine student attitudes towards and experience with SHE at school and at home.	Students were in favour of SHE at school (93%), and the majority (69%) agreed that schools and parents should share this responsibility. Almost all students thought that SHE should start in middle school or sooner. They highlighted a need for more factual information and for practical skills associated with a variety of SH topics.
Byers et al., 2003b (NB)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: students, grades 9–12 (n = 1,663)	To assess high school students’ attitudes toward and experiences with SHE at school and at home.	92% of students were in favour of SHE at school. 77% agreed that schools and parents should share responsibility for SHE. Students highlighted a need for more factual information as well as practical skills related to a wide range of SH topics.
Byers et al., 2013 (NB)	Sex Education	D: quantitative (descriptive/ correlational) P: students, grades 6–8 (n = 478)	To examine factors associated with middle school students’ perceptions of the quality of SHE they received at school.	Boys and students in a lower grade and with less sexual experience rated the quality of their SHE more positively. Students who strongly agreed that their SHE matched their interests and covered sexual health topics adequately, reported higher quality SHE. Students who perceived their teacher as being more comfortable discussing SH topics also reported higher quality SHE.
Byers et al., 2017 (NB, ON, NS)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: undergraduate students (n = 296)	To gather information about SHE being provided in middle and high schools in three Canadian provinces.	Almost all participants reported receiving SHE in middle school. A quarter of participants reported not receiving SHE in high school. Participants rated the SHE they received in middle school as fair and in high school as good. The men tended to rate the SHE they received in middle school more positively than did the women. Participants reported that peers were a more important source of sexual health information than was SHE.
Causarano et al., 2010 (ON)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: youth, ages 13–18+ (n = 1,216)	To examine the SH topics respondents had received information about and the topics they did or did not want to learn more about.	Topics that are most often learned about (STI, HIV, birth control) and those less learned about (sexual pleasure, healthy relationships, communicating about sex) were both reflected in youths’ identification of topics they wanted to learn more about.
Cohen et al., 2004 (NB)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: ISTs, grades K–8 (n = 336)	To assess ISTs attitudes towards SHE, the importance they assign to SH topics, their knowledge about and comfort teaching SHE, and the grade they think SHE should be introduced.	93% of teachers supported school-based SHE. 65% had received no training to teach SHE. These findings underscore the need for in-service training to increase teachers’ knowledge about sexuality and their comfort teaching specific SH topics.
DiCenso et al., 2001 (ON)	Canadian Journal of Public Health	D: general qualitative P: students, grades 9–11 (n = 83)	To learn youths’ opinions about SH services and strategies to improve SHE delivery.	Students reported SE was often taught by teachers who felt uncomfortable discussing sexual issues. Students had limited knowledge on the availability of SH information and reported receiving information regarding SH from their peers.
Foster et al., 2011 (CA)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: students, grades 6–8 (n = 599)	To examine predictors of middle school students’ perceptions of the quality of the SHE they had received from their parents.	Results indicated that the relationships between youth's perceptions of the quality of SHE by parents were similar for boys and girls and for students in grade 6 and 7. The students did not give their parents high marks for providing quality SHE or encouraging questions about sexuality.
Grace, 2018 (AB)	Canadian Journal of Education	D: conceptual/ theoretical P: NA	To examine the degree to which legislation and educational policy enable comprehensive SHE, with particular attention to sexual and gender minority students.	Comprehensive SHE should be compulsory and age-appropriate, accommodating all students across sexual and gender differences. There is no legislation mandating comprehensive SHE or sexual and gender minority-inclusive comprehensive SHE as required learning for all students.
Gray et al., 2018 (QC)	Curriculum Studies in Health and Physical Education	D: general qualitative P: PSTs, K–12 (n = 16)	To explore how PSTs conceptualised health and the body, as well as how their understandings of health and the body influenced their perceptions of teaching ‘health’ in their respective PE contexts.	Students defined health holistically during the early stages of interviews. These students were starting to counter healthism discourse by perceiving health holistically and talking about health in alternative ways to the dominant ‘health = fit = slim’ equation.
Henderson et al., 2021 (ON)	Canadian Journal of Education	D: quantitative (descriptive/ correlational) P: ISTs, grades K–8 (n = 157)	To understand ON elementary teachers’ perceptions, attitudes, and practices with respect to financial literacy education.	Teachers overwhelmingly favour teaching financial literacy in elementary school. Almost half of respondents currently incorporate financial literacy into their classroom practice. With respect to barriers, respondents cited the lack of an appropriate curriculum and lack of support from schools and school boards.
Larkin et al., 2017 (ON)	Canadian Journal of Education	D: quantitative (descriptive/ correlational) P: youth, ages 13–18+ (n = 1,216)	To ascertain what youth want and need in terms of SHE.	At age 13, 24% of the youth had never received SE, although 5% of the 13-year-olds had engaged in vaginal or anal sex. There is a significant discrepancy between what youth are learning in SHE and what they want to know.
Laverty et al., 2021 (BC, ON, QC, AB)	Canadian Journal of Human Sexuality	D: general qualitative P: students, ages 12–19 (n = 66)	To understand the SHE experiences of students in CA and help determine the extent to which students feel informed and supported to develop and maintain their SH and participate in healthy sexual and/ or romantic relationships.	There is a need for youth perspectives when developing, implementing, and evaluating SHE and to help inform recommendations for where educational improvements are warranted. This insight could serve as a roadmap for SHE programing and curricula development.
Lokanc-Diluzio et al., 2007 (AB)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: ISTs, grades K–8 (n = 127)	To strengthen the capacity and confidence of ISTs to deliver SHE.	Pre – and post-surveys showed self-reported increases in knowledge, comfort, and perceived ability to present accurate information with regards to SHE.
Matheson et al., 2020 (ON)	Citizenship Social & Economics Education	D: qualitative (case study) P: ISTs, grades 9–12 (n = 12); students, grades 9–12 (n = 12)	To examine the experiences of high school students and teachers regarding personal financial curriculum and teaching at the secondary level; to identify the ways these experiences may have helped prepare students to become financially literate.	Current students and teachers perceived curriculum and teaching experiences as seriously lacking in effectively preparing them to be financially literate, and that a fundamental reorientation around transdisciplinary student-led learning was key to transforming such learning into a more meaningful and valuable educational experience.
McKay, 2004 (CA)	Canadian Journal of Human Sexuality	D: conceptual/ theoretical P: NA	To support the provision of high quality SHE in Canadian schools.	Canadian Guidelines for SHE provide a clear, easy to apply, evidence-based guide to the initiation, development, implementation, and evaluation of SHE in Canadian schools. Parents and students want schools to provide broadly-based SHE.
McKay & Barrett, 1999 (CA)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: BEd programs (n = 84)	To examine BEd elementary, secondary, and PHE programs to determine the extent to which PSTs receive SHE training.	Among all BEd programs surveyed, 53.7% reported that it was compulsory for all of their students to receive training in teaching skills to maintain/ enhance health. In contrast, 15.5% of BEd programs surveyed reported that all students received training in how to teach SHE as part of their compulsory course of study.
McKay & Bissell, 2009 (CA)	Canadian Journal of Human Sexuality	D: conceptual/ theoretical P: NA	To provide research-based answers to 16 common questions that parents, communities, educators, health and social administrators, and government may have about SHE in Canadian schools.	The Canadian guidelines for SHE provides a clear, easy-to-apply, evidence-based guide to the initiation, development, implementation, and evaluation of SHE in Canadian schools.
McKay et al., 1998 (ON)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: parents (n = 6,833)	To identify the percentage of parents in the community who wanted SHE to be taught in schools, what topics should be included, at what grade level(s).	95% of parents strongly agreed or agreed with the statement ‘SHE should be provided in schools.’ 82% were in favour of SHE that begins in primary grades and continues through senior grades.
McKay et al., 2014 (ON)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: parents (n = 1,002)	To examine the opinions and attitudes of ON parents regarding school-based SHE.	Parents (87%) strongly agreed or agreed that SHE should be provided in school and SHE should start by middle school (84%). Parents were in support of HE, with 94% of parents either agreeing (35%) or strongly agreeing (59%) that HE should be provided in school.
Meaney et al., 2009 (ON)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: undergraduate students (n = 161)	To investigate satisfaction with SHE in a sample of first-year university students recently graduated from ON high schools.	Participants gave very high importance ratings to more than half of 20 topics they considered ‘important to learn about in high school.’ Participants assessment of SHE did not differ based on type of school (i.e. public or catholic). Overall, participants were ‘generally satisfied’ with their SHE teachers and school-based SHE.
Ninomiya, 2010 (NL)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: ISTs, grades 7–9 (n = 31)	To identify the experiences, topic coverage, comfort levels, views, and training of teachers responsible for teaching SHE.	Researchers found a general absence of pre-service and in-service training, outdated curricular resources, under-coverage of topics associated with pleasure, satisfaction, and behaviour, and a lack of awareness of sexual diversity in the classroom (and responses to it) despite apparent acceptance of and comfort with the topic.
Noon & Arcus, 2002 (BC)	Canadian Home Economics Journal	D: general qualitative P: students, grade 10 (n = 14)	To explore the perceptions of students regarding their experiences in SHE.	Male and female students suggested the importance of including the emotional or personal aspects of sexuality in SHE. Female students suggested including information on male sexuality. Nearly all recalled multiple units being taught as repetitive.
Phillips & Martinez, 2010 (ON)	Canadian Journal of Public Health	D: general qualitative P: ISTs (n = 30); health partners (n = 14); young adults, ages 18–24 (n = 31)	To evaluate secondary schools’ ability to deliver relevant SRH and determine whether SRH education meets the standards of health promotion.	Methods used to educate SRH risk reduction was primarily through abstinence and use of condoms. ISTs motivated students to abstain from sexual activity and be sexually responsible by framing sex as an adult activity requiring a threshold maturity level, and by emphasizing the negative, risky consequences of sex. SRH education embodies many health promotion program ideals but schools need to improve the SRH promotion of students marginalized by sexual identities, race, and ethnicity.
Riecken et al., 2006 (BC)	Canadian Journal of Native Education	D: qualitative (action research) P: students, secondary (n = NA)	To move toward an in-depth, multifaceted understanding of the urgent and pressing health issues of contemporary Indigenous youth.	Participants rejected the Eurocentric deficit model of health and created a paradigm based in the holistic values of balance and respect as taught by their community and Elders. Participants felt empowered as emerging researchers and inspired to become messengers of health knowledge for their peers.
Russell-Mayhew et al., 2016 (AB)	Canadian School Counselling Review	D: general qualitative P: Administrators, ISTs, university educators, provincial organization (n = 6)	To understand educational professionals’ perceptions of health promotion, potential barriers to health promotion, and possible ways of overcoming barriers in school settings.	Participants expressed views that reflected dissonance between the importance of health and the perceived lack of ability to address it in schools. Participants shared concern that placing greater emphasis on health would detract from the chief goal of educating students. Teachers felt unprepared to promote health; they emphasized the need for greater training.
Rye et al., 2015 (ON)	Sex Education: Sexuality, Society and Learning	D: general qualitative P: undergraduate students (n = 11)	To investigate the relationship between high school SH curriculum satisfaction and the pursuit of further SHE.	Reasons for taking a university-level sexuality course stemmed mainly from not getting enough information in their high school SHE courses and/ or desiring a less skewed presentation of the material.
Vamos & Zhou, 2007 (BC)	American Journal of Health Education	D: quantitative (descriptive/ correlational) P: ISTs, grades K–12 (n = 166); PSTs, grades K–12 (n = 78)	To investigate the preparedness of health educators (e.g. related to knowledge, skills, preparedness, positive beliefs, satisfaction).	Positive relationships were found between PSTs’ knowledge, skill, preparedness, positive beliefs, and satisfaction in assisting them to teach HE. ISTs reported higher levels of knowledge, skill, and preparedness, and positive beliefs; they also had higher levels of satisfaction and more positive beliefs than PSTs.
Vamos & Zhou, 2009 (BC)	American Journal of Health Education	D: general qualitative P: ISTs, grades K–12 (n = 16); PSTs, grades K–12 (n = 14)	To explore HE teaching and assess needs among IST and PST teachers in a K–12 school system.	Seven themes were identified: effective and ineffective teaching strategies; barriers to teaching; comfortableness in teaching; self-perceived gaps in knowledge/ skills; adequacy of BC health curricula; knowledge of/ participation in school health initiatives; and role of school.
Walters & Laverty, 2022 (CA)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: youth, ages 16–25 (n = 1,507)	To explore SHE learning experiences for youth in CA and examine group differences based on self-reported gender and sexual identities.	The most commonly reported topics youth were exposed to were STIs (92%), physical anatomy and/ or puberty (89%), and pregnancy and birth control (79%). The results support the need for SH educators to integrate youth preferences into their teaching, particularly within school learning environments.
Weaver et al., 2002 (NB)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: parents (n≈4,200)	To examine parents’ attitudes and experiences related to SHE at school and at home.	Most parents (95%) felt SHE should be a shared responsibility (between school and home) and believed SHE should begin in elementary (65%) or middle school (32%). Most parents supported a broad range of SHE topics, including those often considered controversial.
Wood et al., 2021 (CA)	Canadian Journal of Human Sexuality	D: quantitative (descriptive/ correlational) P: parents (n≈2,000)	To examine parental support for the inclusion of SHE in schools, perceived quality of the SHE children received, assessed support for various SHE topics, and to determine if parental support varied across regions.	The majority of parents (85%) agreed that SHE should be taught in schools. Support was high across all regions in CA, ranging from 82% in ON to 91% in the Atlantic provinces.
Zain Al-Dien, 2010 (AB)	Journal of Muslim Minority Affairs	D: general qualitative P: students, ages/ grades not provided (n = 9)	To examine the perceptions of Muslim youth regarding SE in CA that is offered to them by Canadian schools, their parents, and the Islamic centres.	Findings from this research indicated that although SE programs offered by Canadian public schools were informative to Muslim youth, in participants’ perceptions they marginalized the experiences of those Muslim students that did not intend to engage in premarital sexual activity.

AB = Alberta; AIDS = acquired immune deficiency syndrome; BC = British Columbia; BEd = Bachelor of Education; CA = Canada; CSH = comprehensive school health; HE = HE; HIV = human immunodeficiency virus; HPE = health and physical education; ISTs = in-service teachers; NA = not available; NB = New Brunswick; NL = Newfoundland and Labrador; NS = Nova Scotia; ON = Ontario; PE = physical education; PSTs = pre-service teachers; QC = Quebec; SE = sexual education; SH = sexual health; SRH = sexual reproductive health; STI = sexually transmitted infection.

Description of the stakeholder groups

Six school stakeholder groups were the focus of the studies within this review: (a) students and young adults (kindergarten to 25 years old; n = 18); (b) in-service teachers (n = 13); (c) parents (n = 8); (d) health partners/ educational professionals (e.g. public health agencies, faculties of education, provincial organizations; n = 6); (e) pre-service teachers (i.e. Bachelor of Education [BEd] students; n = 4); and (f) undergraduate students (n = 3). Some of the studies within this review focused on the perspectives from one stakeholder group, while others sought the perspectives from multiple stakeholder groups. The four conceptual/ theoretical publications did not include research data but, instead, offered reasoned discussions and arguments related to different stakeholders.

Description of HE topics

Given the primary objective of this review was to understand the viewpoints of school stakeholders in relation to K–12 HE, it is important to consider the specific topics that studies focused on when seeking stakeholders’ perceptions. From the 37 studies, five HE topics were explored: (a) SHE (n = 26); (b) health/ health promotion/ health literacy (n = 5); (c) teacher preparation (n = 3); (d) financial literacy (n = 2); and (e) teacher experiences (n = 1). The detailed results of the topic studied by school stakeholder group are presented in Table 2.

Table 2. Topic studied by school stakeholder group.

School Stakeholder	Students & YA^b (n)	IST (n)	Parents (n)	HP/EP (n)	PST (n)	UG (n)
Topic^a
SHE (n = 26)	14	7	8	3	0	3
Health/ Health Promotion/ Health Literacy (n = 5)	3	2	0	2	1	0
Teacher Preparation (n = 3)	0	1	0	1	2	0
Financial Literacy (n = 2)	1	2	0	0	0	0
Teacher Experiences (n = 1)	0	1	0	0	1	0
Totals	18	13	8	6	4	3

Notes. EP = educational professionals; HP = health partners; IST = in-service teachers; PST = pre-service teachers; UG = undergraduate students; YA = young adults.

^a Studies were categorized into one topic; however, a few studies investigated the perspectives of more than one stakeholder group.

^a Walters and Laverty (2022) described participants as ‘youth’ age 16–25.

Description of study designs

The reviewed studies employed five different methods in terms of study design: (a) quantitative (descriptive/ correlational; n = 21); (b) general qualitative (n = 10); (c) conceptual/ theoretical manuscripts (n = 4); (d) qualitative case study (n = 1); and (e) qualitative action research (n = 1). The quantitative studies encompassed various stakeholder perspectives and primarily focused on the subject of SHE, with 19 out of the 21 studies addressing this topic. The general qualitative studies focused primarily on students’ perceptions (eight of the 10 studies). All four conceptual/ theoretical manuscripts centred around the topic of SHE. The single case study explored students’ and teachers’ perceptions related to financial literacy, while the sole action research study explored students’ perspectives on health in school settings.

Themes generated from included studies

Using reflexive thematic analysis, three themes were developed that speak to the perspectives of school stakeholders regarding K–12 HE and are presented below, referencing examples from the articles included in the review.

Theme 1: health education is perceived as a valuable school subject

The reviewed articles collectively demonstrate school stakeholders perceive HE as an essential school subject. While stakeholders express dissatisfaction with the quality of HE and their overall experiences with the subject (see Theme 3), they recognize the importance of its content and believe HE should be taught in schools. Students (Byers et al., 2003a, 2003b), teachers (Cohen et al., 2004), and parents (Weaver et al., 2002; Wood et al., 2021) were in favour of SHE at school and perceived the SHE topics in the curriculum as important. Studies examining parental attitudes related to SHE consistently revealed parental support for the inclusion of SHE, encompassing a wide range of topics, including those deemed ‘controversial’ (e.g. sexual orientation, birth control; McKay et al., 1998; Weaver et al., 2002; Wood et al., 2021). Parents expressed the need for SHE to commence in elementary or middle school (McKay et al., 2014; Weaver et al., 2002), before the onset of adolescence (McKay et al., 2014), and continue through high school (McKay et al., 1998, 2014; Weaver et al., 2002).

Although stakeholders support and value the teaching of SHE in schools, some studies reported students did not receive SHE throughout all grades (Byers et al., 2013, 2017). For example, Byers et al. (2017) reported that most students received HE in middle school grades but less so in high school grades. Notably, students, teachers, and parents acknowledged the shared responsibility of SHE, involving collaboration between schools and parents (Byers et al., 2003a, 2003b; Cohen et al., 2004; Weaver et al., 2002). Lastly, Henderson et al. (2021) highlighted in-service teachers’ perceptions of the importance of financial literacy in HE classroom instruction, citing numerous benefits to the student (e.g. learn to budget, learn the value of money). This theme highlights that while stakeholders’ express support for HE, specifically SHE and financial literacy, there are concerns about its consistent implementation across grades and the importance of school and parent collaboration.

Theme 2: teachers are not prepared to teach health education

Many of the studies highlighted the need for teacher training to ensure teachers are competent, confident, and comfortable teaching topics within HE. Studies reported that pre-service teacher preparation in HE is low and, in many instances, non-existent. This suggests that preparation in HE may not be a priority in pre-service teacher education programs in Canada (Anderson & Thorsen, 1998; McKay & Barrett, 1999; Vamos & Zhou, 2009). Studies assessing the needs of pre-service and in-service teachers described teachers’ uncomfortable feelings about teaching HE and self-perceived gaps of knowledge and skills (Vamos & Zhou, 2007, 2009). Cohen et al. (2004) reported in-service teachers felt only ‘somewhat’ knowledgeable to teach SHE and most teachers had received no training to teach SHE. This study and others (e.g. Grace, 2018; Henderson et al., 2021; Lokanc-Diluzio et al., 2007; Ninomiya, 2010; Russell-Mayhew et al., 2016) concluded that teacher training/ professional development in HE is an important and needed component in enhancing the knowledge, skills, and competence to teach HE.

Studies also reported that students perceived their teachers to be uncomfortable (DiCenso et al., 2001) and/ or unqualified and lacking motivation to teach HE (Begoray et al., 2009). Grace (2018) described SHE as ‘non-education’ as teachers tended to ‘steer away’ from issues in SHE related to sexual and gender minorities and called on faculties of education and school districts to offer courses and continued professional development to prepare teachers to teach SHE. However, Byers et al. (2003a, 2003b, 2013) found most students perceived their teachers as ‘pretty comfortable’ or ‘very comfortable’ with the topics covered in HE.

Theme 3: health education courses are not meeting the needs of students

Overall, the reviewed articles indicated that students’ needs were not being met in HE courses. When examining students’ perceptions of SHE, approximately a third of middle and high school students rated SHE as fair/ poor (Byers et al., 2003a, 2003b) or good (Byers et al., 2017). Similarly, parents rated the quality of SHE between fair and good (Wood et al., 2021). Several factors were identified as impacting the experiences of students within HE courses: (a) repetitive course content to previous grades (Begoray et al., 2009; Noon & Arcus, 2002); (b) limited time allocated to HE/ rushed curriculum (Noon & Arcus, 2002; Walters & Laverty, 2022); and (c) ineffective and unengaging teaching methods (e.g. videos, worksheets; Begoray et al., 2009; Byers et al., 2003a, 2017; Noon & Arcus, 2002). Students’ suggestions for HE to better meet their needs included extending the duration of course units to allow for more in-depth exploration, incorporating topics that are more relevant to their lives, sequencing content in a way that avoids repetition, offering opportunities for student voice and choice in learning activities, and portraying a more sex-positive approach to SHE (Begoray et al., 2009; Byers et al., 2003a; Larkin et al., 2017; Noon & Arcus, 2002; Phillips & Martinez, 2010). Furthermore, students have expressed the importance of including topics related to sexual orientation and sexual diversity (McKay et al., 2014; Meaney et al., 2009; Rye et al., 2015; Walters & Laverty, 2022). Similarly, undergraduate students reported being dissatisfied with their high school SHE courses and shared they did not learn enough personally relevant information in high school (Rye et al., 2015).

Religion and culture emerged as influential factors that negatively affected students’ experiences in HE. Undergraduate students expressed a preference to receive sexual health instruction from an unbiased source. This was particularly true for those students who attended religious high schools, who felt they received biased information in SHE courses (Rye et al., 2015). In a similar manner, Muslim youth were less inclined to express interest in learning about sexual health compared to students who identified as having no religion (Causarano et al., 2010), and they perceived that certain content in HE courses lacked sensitivity towards the religious and cultural difference of students (Zain Al-Dien, 2010). Moreover, within the context of religious and cultural diversity in Canada, parents emphasized the need to respect the diversity of moral beliefs in SHE within their school community (McKay et al., 1998, 2014).

Discussion

The abovementioned overview of school stakeholders and HE topics, as well as the related themes generated from the 37 articles, offer some possibilities for further contemplation and discussion. Certainly, two obvious possibilities here are the focus upon students (and teachers) as stakeholders and SHE being the most discussed issue within this stakeholder-related literature. In addition to these two topics deserving discussion, the literature also provides some important insight into school stakeholders’ views about the three themes detailed above. And while such stakeholders include many potential people, the literature here provides more insights into the views of students (and teachers) than any other groups. This student and teacher data has the potential to inform HE within similar Canadian (or Western) contexts. We can also offer some suggestions related to the relative shortage of some stakeholders’ perspectives. Accordingly, herein we offer a discussion of these interrelated and important topics/ issues.

Those tasked with curriculum development/ reform and/ or policy advancement might attend to this stakeholder ‘input.’ Amongst other insights, they would find that students and teachers place high value on HE and are wanting it to be offered in most-or-all years of schooling. Differences exist in the HE course requirements among Canada’s provinces and territories, notably with three (Saskatchewan, New Brunswick, Nova Scotia) having no HE requirements in senior high school (grades 10–12) (Robinson et al., 2023). Considering that the CPHEC incorporates competencies and outcomes for all grades, including senior high school, provincial/territorial ministry might consider integrating the national competencies during future HE curriculum revisions. This approach would help move towards the provision of quality HE to all students throughout their schooling years (Robinson et al., 2023). Students have also been able to explain what was missing from their instruction, just as teachers have been able to describe what was missing from their teacher training programs. Parental input is largely absent (save for SHE-related topics), and input from health partners/ educational professionals is relatively limited. So, we would suggest those with an interest in HE teaching and learning contemplate this existing stakeholder data. And researchers with this same interest ought to consider engaging with some of those school stakeholders whose insights are limited in this literature, namely parents and health partners/ educational professionals.

Contemporary Canadian HE curricula have multiple topics or units of instruction (Lu & McLean, 2011; Robinson et al., 2023). Yet, a gross majority of the literature reviewed here (i.e. 26 of 37) focused exclusively upon one topic: SHE. And all four conceptual/ theoretical papers focused solely upon SHE – with all authors advocating for students’ rights to access it without parental ‘meddling’ (e.g. by enabling parents to have their children ‘opt out’ of classes which focus upon SHE). That this topic generates more attention than all others combined is in some ways not altogether surprising. Indeed, SHE provides more opportunities for opposition than do any other HE topics – from both conservative populists and moral pluralists (Bialystok, 2018; Bialystok et al., 2020).

The almost singular focus upon SHE has come at the expense of similar research focusing upon other important HE topics. Other than financial literacy and the much more general health/ health promotion/ health literacy, no other topics have been a central focus in any of these 37 publications. The consequence here, of course, is that although we have plenty of stakeholder input related to SHE within HE (and some input into financial literacy within HE), we have no mention of any other ‘staple’ HE topics – such as personal health, career and life choices, safety and injury prevention, and substance misuse and prevention (Lu & McLean, 2011; Robinson et al., 2023). So, while those whose research interests focus upon SHE may continue with studies like those reviewed here, we suggest that HE researchers and pedagogues might broaden their view to invite and understand stakeholders’ perspectives related to the other 95% of HE curricula.

Notwithstanding the abovementioned contentiousness of SHE, amongst all stakeholder groups there was wholesale agreement about the importance and value of quality HE, particularly with respect to how HE contributes to students’ health literacy and school communities’ health promotion. Students and teachers have provided insight into the perceived value and importance of HE, as well as some ongoing issues with its curriculum (delivery). Yet, despite plenty of stakeholder support for quality HE (e.g. see Begoray et al., 2009; Grace, 2018; Laverty et al., 2021; McKay et al., 1998, 2014; Weaver et al., 2002), HE remains a marginalized subject in many school communities (Auld et al., 2020; Lu & McLean, 2011; Robinson et al., 2023). This body of stakeholder literature finds students and teachers as advocates for quality HE – while the subject faces challenges related to limited core course offerings, inadequate instructional time allocations, and the availability of few-if-any ‘qualified’ HE specialists (Auld et al., 2020; Robinson et al., 2023). We believe this stakeholder research offers support to those advocating for more core course offerings, instructional time, and HE specialists. It is difficult and careless, we believe, to ignore the views of students and teachers who suggest quality HE is important.

Although all stakeholders believed HE to be an especially important subject, many teachers felt under-prepared to effectively teach it (this finding was especially pronounced, unsurprisingly, for SHE). Research studies that made this point about ill-preparedness came from multiple stakeholders, including pre-service and in-service teachers themselves, as well as from pre-service teacher education program personnel (Anderson & Thorsen, 1998; McKay & Barrett, 1999; Vamos & Zhou, 2007). This presents an obvious cause for concern.

Across the nation, every province enjoys full autonomy with respect to teacher education (e.g. related to qualifications, licensure). So, teachers within each province do not have the same HE-related training (opportunities) as one another. That is, there is no ‘national standard’ of any sort. And so, it is difficult to fully understand teachers’ struggles teaching HE without first gaining a sense of the teacher education available or required in all of Canada’s teacher education programs. On this, there is limited available literature. In the few provinces which offer physical education and HE as one subject (i.e. British Columbia, Manitoba, Ontario, Québec), elementary and secondary specialization is commonplace (Hickson et al., 2012; Kilborn et al., 2016). This elementary and secondary specialization is also commonplace within all other provinces which offer physical education as a ‘stand-alone’ course. However, the same high standard is not the case within HE. So, that the teacher stakeholders shared that they felt ill-prepared to teach HE presents little surprise; there is good chance they had little formal teacher training in HE.

Most teacher education programs do not require pre-service elementary teachers to complete a HE course, and they generally do not offer HE as an elementary or secondary specialization. Though this is the case, there is a paucity of literature related to this. Indeed, since Marshall’s (1966) cross-Canada study found that only five of 143 (participating) teacher education programs allowed teachers to specialize in HE, the few similar studies have had narrow foci placed upon lone provinces or university programs (Anderson & Thorsen, 1998; Vamos & Zhou, 2007). Consequently, this is an area requiring immediate attention within the research community. A summary and review of HE across Canada would prove to be both informative and instrumental. That information would help us all connect some dots between teachers believing that HE is important while at the same time feeling unprepared to teach it themselves. We join others (like Veugelers & Schwartz, 2010) in calling for universities’ teacher education programs to require anyone who will be teaching HE to take some mandatory coursework in the disciplinary area.

Clearly, the observation that teachers themselves feel ill-prepared to teach HE partly explains this related finding that HE courses are not meeting the needs of their students. Undoubtedly, limited pre-service teacher coursework (or, more likely, no coursework) would have disquieting consequences on what was taught in HE and/ or on how it was taught. Students who found teachers relying upon ineffective and unengaging videos and worksheets (Byers et al., 2003a, 2017; Noon & Arcus, 2002) may have been finding themselves in classes taught by untrained HE teachers.

However, some concerns expressed by stakeholders placed the blame on things other than those teaching HE: the repetitive content (i.e. the curriculum) and limited time to learn and engage with HE content (Begoray et al., 2009; Noon & Arcus, 2002; Walters & Laverty, 2022). Attention might be placed on these two observations. First, those engaged in curriculum development and/ or reform and those engaged in curriculum studies and/ or inquiry might (re)consider existing HE curricula in light of these stakeholders’ concerns and complaints about repetitive content. It is possible that such (re)considerations might occur alongside Canada’s newly released (and first) national CPHEC (Davis et al., 2023). While the CPHEC offers an opportunity to address the aforementioned issues with HE, a challenge lies in the fact that CPHEC is not a mandatory national curriculum. Consequently, individual provinces and territories have the discretion to decide whether they engage with or consider this document in curriculum development and/ or reform. Also, attention must be placed upon the instructional time afforded to HE in all provinces. Certainly, teachers, administrators, government officials, and university researchers should see (or find) fault with limited instructional time for HE – and then do something about it.

Conclusion

A critical takeaway from this review is the consensus among stakeholders regarding the importance and value of quality HE. Collective agreement provides a promising foundation for the subject, but it is imperative to acknowledge the challenges that remain in fully realizing this vision, particularly in terms of teacher training and professional development, instructional time, and student experience. Ensuring that teachers are adequately equipped and confident in their ability to teach HE not only empowers them, but also holds the potential to better align their teaching with the educational needs of students within HE classrooms. We recommend that future research investigate teacher education programs and assess the level of preparation teachers currently receive concerning HE instruction. Furthermore, the studies in this review focused primarily on SHE, leaving a noticeable gap in our understanding of other crucial HE topics. To address the landscape of health education comprehensively, future research must expand its focus beyond SHE and encompass a broader spectrum of topics. Additionally, our exploration of school stakeholders’ perspectives should extend beyond those of students, in-service teachers, and parents. It is imperative that we also examine the viewpoints of key decision makers in the education community, including school administrators, district leaders, and government officials. Understanding their perceptions and how their views shape critical decisions, such as resource allocation, the perceived value attributed to HE, and the allocation of curriculum time for HE, stands as a pivotal step toward meaningful and quality HE.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The manuscript has not been previously published and is not currently under consideration elsewhere. This work was supported by the Social Sciences and Humanities Research Council of Canada under Grant [#890-2021-0036].

Notes on contributors

Lauren Sulz

Lauren Sulz is an associate professor in the Faculty of Education at the University of Alberta. She is a co-founder of the Healthy Schools Lab which aims to create a whole-school environment where student health is an essential foundation for schools’ core mission of learning. Her research includes comprehensive school health; physical and health literacy; school sport; whole-child education; and health and physical education pedagogy.

Daniel B. Robinson

Daniel B. Robinson is professor in physical education and sport pedagogy at St. Francis Xavier University. He is also Chair of the Department of Curriculum and Leadership and Coordinator of the PhD in Educational Studies Program. His current research focuses upon the following: culturally relevant pedagogy; inclusive and adapted physical education, physical activity, and sport; physical literacy; and school communities’ health promotion programming.

Hayley Morrison

Hayley Morrison is an Assistant Professor in the Faculty of Education at the University of Alberta. Her research areas include inclusive/adaptive physical education, health and physical education teacher education, and professional development to ensure educative and inclusive health and physical education experiences for all individuals.

Josh Read

Josh Read is a secondary school physical education and science teacher with a passion for student well-being. Josh completed his BEd in 2022 and worked in the non-for-profit sector at Physical and Health Education Canada before starting his career in teaching. Josh brings his academic and sporting background into his classroom by creating active learning environments that amplify student voice and choice.

Ashley Johnson

Ashley Johnson is a PhD Candidate in the Community-Engaged Health Promotion Research Lab within the School of Kinesiology and Health Studies at Queen’s University. Concurrently, she holds a position as a research assistant for the Healthy Schools Lab at the University of Alberta. Ashley's research is focused on understanding how a community health promotion partnership can be successful and sustainable in the Canadian context.

Lucinda Johnston

Lucinda Johnston is a Faculty Engagement Librarian at the University of Alberta, and supports research for the departments of Music, Drama, Linguistics, Philosophy and the Faculty of Education. She is the President of the Canadian Association for Music Libraries, Archives and Documentation Centres, and her research interests include library outreach, Indigenizing and decolonizing library instruction, music publishing, and sound as knowledge.

Kim Frail

Kim Frail is Head, Library Teaching and Learning at the University of Alberta. She has worked at UofA Library for two decades in a variety of roles, most recently as a subject librarian supporting the Faculty of Education. Her research interests include: the integration of library services in campus learning management systems and the impact of library teaching on academic performance and student retention.

Appendix A

Full Search conducted August 12, 2022 in Education Resources Information Center (ERIC) (EBSCOhost platform)

Table

	Search Terms	Results
S14	S6 AND S9 AND S12 AND S13	494
S13	Canad* OR ‘British Columbia*’ OR bc OR Alberta* OR Saskatchewan OR Manitoba* OR Yukon OR ‘Northwest Territories’ OR ‘North West Territories’ OR NWT OR Nunavut OR Ontario OR Quebec* OR ‘Nova Scotia*’ OR ‘Prince Edward Island’ OR Newfoundland OR Labrador OR ‘New Brunswick’	75,024
S12	S10 OR S11	57,870
S11	((Health OR Wellness OR alcohol OR smoking OR vaping OR drug* OR tobacco OR marijauna OR cannabis OR puberty OR sex* OR lifestyle* OR fitness OR food OR nutrition OR emotional OR financial OR media) N3 (curricul* OR education))	57,870
S10	((((DE ‘Comprehensive School Health Education’) OR DE ‘Alcohol Education’ OR DE ‘Drug Education’ OR DE ‘Family Life Education OR DE ‘Health Education’ OR (DE ‘Sex Education’))	4,492
S9	S7 OR S8	913,476
S8	K-5 OR K-6 OR K-7 OR K-8 OR K-9 OR K-12 OR 1–5 OR 6–9 OR 7–9 OR 8–12 OR 9–12 OR 10–12 OR kindergarten* OR elementary OR secondary OR primary OR intermediate OR highschool* OR ‘high school*’ OR ‘junior high’ OR ‘senior high’ OR ‘middle school’ OR private OR public OR catholic OR Islam* OR french OR francophone OR bilingual OR ‘first nations’ OR indigenous	893,453
S7	(DE ‘Schools’) OR (DE ‘Instructional Program Divisions’ OR DE ‘Grade 1’ OR DE ‘Grade 10’ OR DE ‘Grade 11’ OR DE ‘Grade 12’ OR DE ‘Grade 2’ OR DE ‘Grade 3’ OR DE ‘Grade 4’ OR DE ‘Grade 5’ OR DE ‘Grade 6’ OR DE ‘Grade 7’ OR DE ‘Grade 8’ OR DE ‘Grade 9’ OR DE ‘Intermediate Grades’ OR DE ‘Kindergarten’) OR (DE ‘Elementary Secondary Education’ OR DE ‘Elementary Education’ OR DE ‘Secondary Education’ OR DE ‘Adult Basic Education’ OR DE ‘Primary Education’) OR (DE ‘Curriculum’ OR DE ‘Elementary School Curriculum’ OR DE ‘Secondary School Curriculum’)	593,604
S6	S3 OR S4 OR S5	462,863
S5	(DE ‘Administrator Attitudes’ OR DE ‘Adolescent Attitudes’ OR DE ‘African American Attitudes’ OR DE ‘Caregiver Attitudes’ OR DE ‘Childrens Attitudes’ OR DE ‘Community Attitudes’ OR DE ‘Counselor Attitudes’ OR DE ‘Dropout Attitudes’ OR DE ‘Educational Attitudes’ OR DE ‘Employee Attitudes’ OR DE ‘Employer Attitudes’ OR DE ‘Family Attitudes’ OR DE ‘Majority Attitudes’ OR DE ‘Parent Attitudes’ OR DE ‘School Attitudes’ OR DE ‘Student Attitudes’ OR DE ‘Student Teacher Attitudes’ OR DE ‘Teacher Attitudes’) OR (DE ‘Father Attitudes’ OR DE ‘Mother Attitudes’ OR DE ‘Student Satisfaction’)	231,530
S4	(Stakeholder* OR teacher* OR educator* OR instructor* OR tutor* OR principal* OR vice-principal* OR superintendent* OR trustee* OR administrator* OR ‘district leader*’ OR ‘senior leader*’ OR (school N3 (psychologist* OR nurse* OR counselor*)) OR ‘success coach*’ OR elder* OR ‘knowledge keeper*’ OR ‘indigenous senator*’ OR assistant* OR aide* OR parent* OR guardian* OR care giver* OR caregiver* OR student* OR pupil* OR child* OR teen* OR adolescen* OR youth) N8 (perception* OR perceive* OR perspective* OR attitude* OR belief* OR opinion* OR satisfaction OR preference* OR experience* OR voice* OR narrative* OR expectation* OR impression* OR views OR story* OR stories OR insight* OR understanding)	447,206
S3	S1 AND S2	2,983
S2	((DE ‘Personal Narratives’) OR (DE ‘Attitudes’ OR DE ‘Beliefs’ OR DE ‘Opinions’ OR DE ‘Preferences’ OR DE ‘Program Attitudes’))	44,840
S1	((((((DE ‘Stakeholders’) OR (DE ‘Paraprofessional Personnel’ OR DE ‘School Personnel’ OR DE ‘Paraprofessional School Personnel’ OR DE ‘School Aides’)) OR (DE ‘Teachers’ OR DE ‘Instructor Coordinators’ OR DE ‘Tutors’)) OR (DE ‘Principals’ OR DE ‘School Cadres’ OR DE ‘School Nurses’ OR DE ‘Pupil Personnel Workers’ OR DE ‘School Counselors’ OR DE ‘School Psychologists’ OR DE ‘School Social Workers’)) OR (DE ‘Parents’ OR DE ‘Fathers’ OR DE ‘Grandparents’ OR DE ‘Grandparents Raising Grandchildren’ OR DE ‘Mothers’ OR DE ‘Unwed Mothers’)) OR (DE ‘Caregivers’ OR DE ‘Child Caregivers’)) OR (DE ‘Students’)	99,023