Health Education Research Advance Access originally published online on June 9, 2006
Health Education Research 2007 22(1):58-69; doi:10.1093/her/cyl043
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Focus points for school health promotion improvements in Dutch primary schools
1 Department of Youth Health Care, Maastricht Public Health Institute, Maastricht, 6202 NZ, the Netherlands
2 NIGZ steunpunt Gezonde School, Woerden, the Netherlands
3 Department of Health Promotion, Maastricht University, Maastricht, 6200 MD, the Netherlands
* Correspondence to: M. T. W. Leurs, ZonMw, PO Box 93245, 2509 AE The Hague, the Netherlands. E-mail: leurs{at}zonmw.nl
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Abstract |
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To enable improvements in school health promotion, this paper examines associations between the number of health-promotion issues addressed by primary school teachers in the Netherlands and factors thought to influence this behavior. The main factors studied are context characteristics and constructs of attitude, social influence, self-efficacy (SE) and perceived barriers. A total of 180 primary school teachers teaching 9- to 12-year olds (Grades 6, 7 and 8) participated in a cross-sectional survey. The results show that it is possible to differentiate between teachers addressing three or more health issues per year versus those who address fewer based on grade level (more health issues are addressed at higher grades), perceived disadvantages, SE and staff support. The latter seems to exert the greatest influence and may be one of the most promising focus points for improvements of school health promotion in the Netherlands.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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Overweight and obesity among children is rising rapidly in developed countries [1–3]. Smoking rates, binge drinking and the practice of unsafe sex among adolescents are additional reasons why we have to strengthen our investment in health promotion targeting youth in order to provide them with the best developmental opportunities toward healthy adulthood [4, 5].
Schools can play an important role in the promotion of children's physical and mental health [6–8]. As health promotion is a planned activity, an analysis of the current school situation and a needs assessment is necessary before a whole-school approach to health promotion can be designed [9–11]. These needs of a school are determined by the needs of its population: pupils, staff and—preferably—parents. The needs are based on health status and healthy behavior of the school population as well as the school climate and current school health policy and action taken. In schools, professional capacity is an important resource that is controlled by the school. This includes personal competence of teaching staff and motivational factors influencing them to do so. It implies an analysis of teachers' preferences for teaching health promotion, a topic that is mostly not addressed extensively, but is the goal of this paper. Moreover, effective health interventions may be developed, but if they do not take into account the motivational factors and barriers of school staff to implement these interventions, their impact is likely to be limited [10, 12]. Hence, it is important to investigate which characteristics are likely to exert the greatest influence on the performance of health promotion in class (whether mediated by individual perceptions or not) and which are the most open to change.
The goal of this study is therefore to analyze the decision-making process that leads a teacher to address health promotion at school. In primary schools, this ranges from education in healthy eating, dental care and physical exercise to the prevention of smoking and social skills training. In the Netherlands, three health-promotion issues are considered to be basic elements in school health promotion in primary schools: sports and physical exercise, social skills development (including the prevention of bullying) and personal care [13].
Insights into teacher decision making with regard to health promotion in the classroom is deduced from the current study via the motivational factors, attitude, social influence, ‘self-efficacy’ (SE) and perceived barriers, possibly all influencing the inclusion of health-promotion issues in schools [14–17].
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Methods |
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Sample
Data for the analyses reported here are from a survey conducted anonymously in the Maastricht region in the Netherlands, toward the end of the 2002–03 school year. Eligible for participation in the study were primary school teachers employed by one of the 84 schools for primary education in this region. This included four schools for special education. Teachers had to be teaching Grades 6, 7 and/or 8 (last 3 years of primary education).
Of the 352 primary school teachers approached, 180 (51.1%) completed and returned the survey. Inclusion criteria were teaching upper school classes for a minimum of 0.4 full time equivalent and having filled in at least 50% of the survey questions. Based upon these criteria, three surveys were excluded from further analyses. Respondents represented 78 of 84 eligible schools (92.9%). School size varied between 56 and 593 pupils (mean: 248.4, SD: 133.3).
Reasons cited for not participating in the survey were time constraints (particularly with the end-of-year quickly approaching), lack of experience with health education and lack of interest in the survey topic.
Procedure
A questionnaire was used focusing on the motivational factors of ‘teacher-based health promotion’, general health promotion needs-assessment, teaching support materials and knowledge regarding a new whole-school approach to health promotion in the region. As this article focuses on the motivational factors of behavior change regarding teacher-based health promotion, only the scales and items used to measure these factors will be outlined here.
As teachers tend to think about health in terms of topics and curricula [18], teacher-based health promotion was measured using a seven-point scale, assessing whether they had addressed one or more of the following health-promotion issues in the previous year: ‘sport and exercise’, ‘personal care’ (including hygiene), ‘healthy eating’, ‘substance abuse’ (smoking, alcohol and drugs), ‘sexuality and relations’, ‘mental health’ and ‘social skills’ (including bullying prevention). This was dichotomized into teachers reporting addressing a minimum of three health issues per annum, being at least one per term on average, and teachers who fail to reach the minimum set of three health issues according to their own report. Three is considered the minimum number of school health-promotion issues in the Netherlands [13].
‘Attitude’ toward teacher-based health promotion was measured using an attitude-scale of 14 items on a five-point scale. Cronbach's alpha of the attitude-scale was 0.61. Using principal component analysis (rotation method: Oblimin with Kaiser Normalization), an ‘advantage’ scale consisting of eight items (
= 0.82) and a ‘disadvantage’ scale of six items ( = 0.59) were extracted.
‘Social influence’ regarding teacher-based health promotion was measured using three scales: ‘modeling’, ‘social norm’ and ‘social support’, all reflecting ‘subjective social norm’ [19]. A five-point scale was used. Modeling was measured in relation to colleagues with one item (‘Colleagues address health education in class’). Perceived social norm was measured with nine items, starting with ‘The following persons/organizations find it important that I address health issues in class’ ( = 0.88). Principal components analysis of the social norm scale indicated three subscales of the social norm construct. The first scale of three items focused on the social norm of the ‘school staff’: school management, colleagues and the school-care coordinator ( = 0.85). The other scales included two items each. These can be referred to as the ‘client norm’: parents and pupils (Pearson = 0.66, P < 0.01); and the ‘external norm’: public health and welfare organizations, the inspector of education and the municipality ( = 0.82). Principal components analysis of the social support scale revealed the same subscales as with social norm. The first scale of three items focused on the social support of school staff ( = 0.87), with the latter two scales focusing on the client-norm (Pearson = 0.66, P < 0.01) and the external-norm ( = 0.86).
SE toward teacher-based health promotion was measured with seven items ( = 0.79). Based on principal components analysis two subscales were deducted. The first scale focused on ‘circumstances-related SE’ and includes five items ( = 0.82). The second scale focused on the so-called ‘educational routine-related SE’, consisting of two items (Pearson = 0.48).
The perception of ‘barriers’ toward classroom health promotion was measured with a yes/no question, followed by a list of possible barriers for those who perceived barriers. A sum score of perceived barriers was computed. This yielded a single barrier variable with integers as an outcome, ranging from 0 to a maximum of 14 barriers.
To increase response rates, the survey was recommended by the head of the youth health care department of the regional Public Health Institute Maastricht and by the coordinator of an organization responsible for cooperation between schools for regular and special education. This coordinator is a school principal of one of the special education schools in Maastricht. School physicians were asked to encourage school managers and eligible teachers to participate in the survey. Shortly after the survey deadline, teachers of schools without or with only one respondent received a reminder letter from the head of the youth health care department again stressing the importance of participation in the study.
Statistical analyses
Whole sample means and standard deviations were calculated for the study variables. This was followed by the calculation of average scores of the scales. For the context characteristics, correlations with behavior were calculated using Pearson correlation. For the motivation scales (attitudes, social influence and SE) and variables, t-tests were conducted distinguishing between teachers who addressed two or fewer health issues in the current year versus those who addressed three or more.
The relationship of the motivational factors attitude, social influence and SE with teacher-based health promotion was tested via logistic stepwise regression. In the logistic regression, variables were entered in two blocks. First the context characteristics were entered, followed by the motivational constructs (including barriers) in the second block. In this analysis ‘gender’ was treated as a nominal variable and ‘grade level’ as an ordinal variable.
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Results |
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Participation and context characteristics
Of the 180 respondents, 54.3% were female (average age = 38.6 years, SD = 11.7) and 45.7% male (average age = 46.1 years, SD = 10.3). As <25% of teachers in Dutch primary education are male, this gender group is overrepresented in this sample. The average age of respondents was 41.9 years (SD = 11.7), with a significant difference between the sexes (t = 4.59, df = 172.1, P < 0.001), comparable to the average ages of teaching staff in the Netherlands.
Respondents all taught at least one of the Grades 6, 7 or 8; 31.1% of the respondents taught a combination group of two or three grades. A slight majority of respondents (51.4%) worked at a school in an urban area; 48.6% worked in rural areas.
Health-promotion behavior
The number of health-promotion issues addressed by respondents ranged between 1 and 7 during the previous 12 months (mean: 4.03, SD: 1.51). Of the respondents, 46.2% addressed at least the three topics considered to be the basic elements of school health promotion in the Netherlands. In total, 19% of the respondents failed to address any of the three basic health topics in the previous year. Overall, 80.7% of teachers reported having addressed a minimum of any three health-promotion issues in the previous year. Figure 1 illustrates the popularity of the different health issues among upper primary school teachers.
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Of the context variables, the variables gender and grade level correlated significantly with the number of health issues addressed in the previous annum. Males reported on average 4.29 issues (SD: 1.49) and females reported 3.81 issues (SD: 1.50). Grades 6, 7 and 8 teachers reported, respectively, 3.29 (SD: 1.40), 3.98 (SD: 1.30) and 4.93 (SD: 1.24) issues addressed. No significant correlation was found between gender and grade level.
Attitudes
Two groups were compared on their attitudes toward teaching health promotion, comparing teachers addressing fewer than three health issues per year versus those who addressed three or more health issues. Table I shows that teachers who taught three or more health issues were significantly more positive than their colleagues about the fact that teaching health education would result in positive outcomes such as ‘personal enjoyment’, ‘personal satisfaction’ and a ‘positive commitment’ of the school toward pupil health. Furthermore, teachers who taught up to two health themes saw significantly more disadvantages, especially ‘regret of not being able to perform "regular" teaching tasks and going beyond perceived normal teacher responsibilities when addressing health themes in class’.
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Social influence
Of the main social influence constructs, only the modeling construct indicated a significant difference between teachers having addressed three or more health issues in the previous year versus those who did not as shown in Table II. Those who perceived more modeling by colleagues were more likely to have addressed three health issues or more. As part of the overall constructs regarding social norm and social support, the ‘staff social norm’ scale and the ‘staff social support’ scale revealed a significant difference between these groups. In both scales especially the social influence perceptions regarding ‘school administration’ and the ‘pupil-care coordinator’ can be held responsible, with ‘social influence of colleagues’ indicating a significant difference as part of the ‘social-support’ scale too. Perceived ‘social support by pupils’ indicated a significant difference between the two groups as well. The ‘pupil and parent social support’ scale indicated a trend (P < 0.1) toward significance. This means that when teachers perceive more support, particularly from pupils, for engaging in health promotion, they tend to be more likely to have addressed three health issues or more in the previous year, as opposed to those who did not perceive much support from their pupils.
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The Self-Efficacy
The SE scale indicated a significant difference between teachers who had addressed fewer than three health issues in the previous year versus those who addressed three or more issues. Table III shows that teachers who addressed three or more health issues are more likely to report a higher level of confidence in their own skills to address health issues in class than those who addressed fewer than three health issues. This can mainly be accounted for by the ‘circumstance-related SE’ scale. On average, teachers in the group having addressed three or more issues in the previous year had more confidence in their own skills than the teachers failing to address a minimum of three issues, that they were able to conduct health-promotion activities in class when they perceived the themes as being difficult. The ‘educational routine-related SE’ scale did not indicate a significant difference between the two groups. Although other scales and items do not reveal a significant difference between the groups, they are illustrative of a possible direction of influence.
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Barriers
Teachers who reported having addressed three or more health issues in the previous 12 months perceived 1.64 barriers on average (SD = 1.60). Teachers who reported having addressed fewer issues perceived 2.29 barriers on average (SD = 2.04). Analyses of variance showed a significant difference between these two groups (t = 2.95, P < 0.01). Taking a closer look at the individual barriers, Pearson correlations revealed negative relationships between the behavior variable and the barriers ‘lack of knowledge/information’ (Pearson correlation = –0.19, P < 0.01) and ‘lack of consensus’ within school regarding the importance of health promotion (Pearson correlation = –0.12, P = 0.01). This indicates that teachers are more likely to address a minimum of three health issues when they do not perceive a lack of knowledge or a lack of consensus with school regarding the importance of health promotion.
Overall, 80.4% of teachers reported that the ‘limited time available in class’ is an obstacle to engaging in school health promotion properly. ‘A lack of suitable materials’ was perceived as a barrier by 70.5% of all teachers. The third most often perceived barrier was ‘lack of time beyond the regular teaching schedule’ (43.8% of all teachers). Additionally, ‘lack of financial resources’, ‘lack of knowledge’ and ‘lack of proper insight into the overall health status of the pupils’ were perceived as barriers by 25.0, 20.5 and 17.9% of the respondents, respectively. Besides a lack of knowledge, none of these often-perceived barriers was significantly linked with the behavior barrier used in this study.
Correlations
Within the attitude construct, advantages were found to correlate significantly with parent/pupil norm (r = 0.47) and with external norm (r = 0.45), both from the social influence construct. Within the social influence construct, modeling correlated significantly with staff social norm (r = 0.53) and staff social support (r = 0.47). Staff social norm correlated significantly with parent/pupil norm (r = 0.55), with external norm (r = 0.59) and with staff social support (r = 0.52) as well. Additionally, the external norm was found to correlate significantly with parent/pupil norm (r = 0.55) and with external support (r = 0.51) also. Staff social support correlated significantly with parent/pupil support (r = 0.51) and with external support (r = 0.58). The latter correlated significantly with parent pupil support (r = 0.50) too. Table IV presents the correlations between all constructs and their significance.
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Logistic regression analyses
A sequential logistic regression analysis was performed to assess membership prediction of the group addressing three or more health issues versus the group addressing fewer issues, first on the basic demographic predictors (context variables) and then after the addition of attitude, social norm and SE predictors. To avoid multicollinearity as much as possible, only variables and subscales were entered in this logistic regression with a significant or near-significant t-value with regard to the behavior variable. Of the demographic variables, gender and grade level met this entry criterion. Of the motivational variables, advantages, disadvantages, modeling by colleagues, staff norm, staff support, pupil and parent support, circumstances-related SE and barriers met this criterion and were entered in the analysis.
When only demographic factors were taken into account, teaching three or more health issues was positively related with teaching in higher grades and indicated a tendency toward being male. When the motivational factors were included, the significant effect of grade level persisted. Perceiving disadvantages reduced the likelihood of addressing a minimum of three health issues. Staff support increased the likelihood of addressing a minimum of three health issues in the previous year. Nagelkerke's R2 for the two models was 0.23 and 0.43, respectively. The results of the regression analysis are presented in Table V.
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Discussion |
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This study analyzed the determinants of teachers' decisions for teaching health promotion. We found teachers addressing three or more health issues per year could be differentiated from those who addressed fewer based on gender, grade level, perceived disadvantages, circumstances related to SE and especially staff support. The importance of school staff, especially school administration, for school health promotion practice was demonstrated in earlier studies. Cullen et al. [20] found teachers more supportive of change when supported by the school principal. Additionally, an Australian study by St Leger [18] indicated that ‘resources’, ‘staff’ and the ‘curriculum’ were the most perceived enhancers of the health-promoting school concept among teachers. Our study added the importance of support by pupil-care coordinators. This is not necessarily someone who is part of the school administration. The importance of pupil-care coordinators is understandable since they deal with pupil care at a more individual level within Dutch schools.
The opinions of students and immediate colleagues were reported to be most influential in the decisions of Dutch teachers to provide an education program on organ donation and registration [21]. Earlier research already indicated that secondary school teachers in the Netherlands are more motivated by students' responses than by expected outcomes [22]. This confirms the finding that pupil support may be positively linked to the likelihood that teachers engage more in school health promotion. It fits with the so-called Dutch Polder model, characterized by attaining solutions through a process of dialogue and compromises. Following also the Ottawa Charter [23] advocating participation and empowerment, the influence of pupils may be another promising entry point for exploring school health promotion improvements.
In the St Leger study [18], ‘staff’ was named among the top three perceived inhibitors of the accomplishment of a health-promoting school. Unlike in the current study, this perception was not related to the actual input in school health promotion. We found the perceived barriers ‘a lack of knowledge’ and ‘a lack of consensus in schools with regard to the importance of health promotion’ significantly linked to addressing less than three health-promotion issues in the previous year or not. For both these barriers, a link with staff seems likely, as staff themselves are responsible for additional training and expertise development (do they welcome knowledge from outside the education sector?). This could also boast their confidence in their own skills regarding the handling of themes perceived as being difficult. In the end, the staff members themselves are responsible for the level of consensus reached regarding school health promotion within their school. Support organizations may influence the agenda of the school and the awareness regarding school health promotion, they are not the ones deciding what staff is actually doing [11, 24].
St Leger [25], followed by Apostolidou and Fontana [26], advocates including a larger focus on school health promotion in initial teacher training programs. This is a more long-term strategy, preferably to be lobbied for and facilitated by national health promotion bodies and the Ministry of Health. At the regional level, we advocate training of pupil-care coordinators and school administrators. Attitude and more importantly behavior change of anyone who ought to be involved in school health promotion, including these professionals specifically cannot be accomplished by educating knowledge only. Additionally, skills training, experiencing short-term successes and beneficial/pleasant collaborations between the education and health sectors are needed to enhance school health promotion at a local and regional level [7, 18, 27].
Limitations of this study are that it is based upon a voluntary teacher survey, with a self-report regarding the number of health issues addressed in class, only. The voluntary character of the survey enhances response rate bias. As it seems already that males are overrepresented in the survey sample, response rate bias is likely. With respect to the teacher self-report issue, that was found not a valid measure for school health promotion completeness by Resnicow et al. [28], it was not completeness we looked for. We looked for an indicator of effort put into classroom-based health promotion least likely to overestimate the input in classroom-based health promotion. By asking them per theme in what manner or with what materials they had addressed it, we tried to focus their memory and to limit socially desirable answers. With one of the outcomes of the study being the importance of support of school administration and other colleagues, the results ought to be complemented with the perceptions and actions of these professionals as well. Preferably, this should be based on structured interviews [28].
The survey includes one variable measured with one item (modeling) and three variables measured with two items (pupil and parent social norm and social support; and educational routine-related SE), which correlated sufficiently. In future research, more items should be employed for assessing these variables. Although the variables included in the survey were theory based [14–17], this does not exclude the possibility that also other variables exert a direct or indirect influence on the number of health issues addressed per annum.
Another limitation is the possibility that the link between grade level and the number of health issues addressed is caused by the availability of specific health-promotion programs only in certain grades. Most materials traced were aimed at Grades 7 and 8 [29]. On the other hand, some materials available to lower grades in the Netherlands are more comprehensive and intense [30]. This may result in less health themes addressed in lower grades compared with Grades 7 and 8 within the same time. It calls for future studies to develop more comprehensive measurement tools for classroom-based health promotion further reducing the risk of overestimating the actual input provided.
As male teachers taught relatively more often in higher grades, compared with their female colleagues, it is very plausible that the near-significant gender effect (P = 0.067) found in this study is caused by the grade effect. This assumption is strengthened by the likelihood that male teachers were over-represented in the sample: less than 25% of teachers in Dutch primary education is male currently whereas 46% of the teachers participating in this study is male. Specific regional data for the percentage of male/female teachers in Grades 6, 7 or 8 are not available. Therefore, based on these results, a gender effect on school health promotion cannot be claimed.
This study indicates that a reduction of perceived barriers regarding school health promotion, especially misconceptions regarding school-based health promotion, the promotion of school-based knowledge and participation of pupils, staff and parents in school health promotion may be promising entry points for improvements in school health promotion in primary education. This implicates the important how question for future research and the development of professional school health promotion: ‘How to make optimal use of these entry points in health promotion practice to improve school health promotion in primary schools?’.
For the promotion of school-based knowledge and raising whole-school participation, we advocate a more participatory method: the schoolBeat priority workshop [31]. In this workshop, homogeneous groups of students, parents and staff are confronted with different health-promotion priorities for their school and asked to select six priorities maximum. It is our experience that a lot of knowledge and perceptions are exchanged within the groups and between the groups leading to a sense of shared responsibility and the consensus looked for.
Overall, Intervention Mapping [32] provides a sound and comprehensive planning strategy to go ahead from here. This implies that professionals map their interventions—step by step—based on sound analyses of the situation, including professional capacity. The focus points yielded by this study are the starting points. As school health promotion is a shared responsibility of the health sector and the education sector [10, 24], we promote a collaborative action-research approach of health-promotion professionals and school staff working through the Intervention Mapping planning matrix together.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The authors thank the Youth Health Care Department of the Maastricht Public Health Institute for providing assistance to the research process. This research is part of the schoolBeat study, supported by the Netherlands Organization for Health Research and Development (ZonMW Healthy Living grant 4010.003).
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References |
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Received on July 14, 2005; accepted on April 19, 2006
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