Health Education Curriculum in Cyprus, Dissertation – Discussion Example

Abstract: The new Cypriot health curriculum offers the prospect of outstanding improvements in health education in Cyprus. The curriculum itself is based on the foundational ideas that health is, to no small extent, determined by physical and by socio-cultural environments. More than behavioural change, the curriculum seeks to promote individual empowerment. This is a significant departure from previous Cypriot health education practice, which emphasized personal prevention and behavioural change.

The role of Cypriot teachers in all of this will be of paramount importance. This study investigates the relationship between the three crucial variables of teacher attitudes about the curriculum, teacher understandings of the curriculum and the underlying philosophy behind it, and teacher sense of self-efficacy in actually teaching the curriculum. The relationship between teachers’ understandings of the philosophy of the curriculum and teacher attitudes about it is investigated and found to positive and significant, as is the relationship between teachers’ sense of self-efficacy in teaching the curriculum, and attitudes concerning it.

Discussion: First and foremost, the respondents scored well on the background measures of knowledge and competency: the fact that some 62.1% of the respondents indicated that they had read health promotion literature, while 47.1% had attended in-service workshops on health education. Moreover, only 25 (17.86%) indicated that they had not read the health promotion curriculum at all, while 60 (42.86%) indicated that they had read it carefully; 30 (21.43%) that they had read it very carefully, and 25 (17.86%) that they had read it very carefully and studied the webpage. These metrics are indeed good summary indicators of a willingness to learn about health promotion, which could lead to an improved understanding of the curriculum and an improved sense of efficacy in teaching it (Ioannou, Kouta, & Charalambous, 2012; Mitchell, Palmer, Booth, and Davies, 2000).

In this vein, the findings presented in table 3, concerning the teachers’ attitudes and beliefs about the new curriculum, seem to evince such a correlation: with every statement, the majority or at least the largest percentage of responses indicated a favourable attitude towards teaching students to be healthy. The statements in table 3 are concerned with whether and how the teachers will attempt to influence students. The topmost statement, “My main aim is to persuade students to change their health behaviour”, is a good example, the more since 57.1% of respondents stated that they agreed, and 17.9% stated that they strongly agreed (p. 5).

Teacher attitudes about health promotion curricula would seem to be correlated with a higher incidence of understanding the underlying philosophy and taking a legitimate interest in helping students to live healthily.

And this evidence was further reified by the descriptive statistics concerning the teachers’ attitudes and beliefs about the new curriculum, in table 4: on question after question, the vast majority of the teachers agreed, evincing not only a strong interest in the curriculum, but also a firm understanding of it and positive attitudes concerning it. All of this is well in accord with the findings of St. Leger (1998), that teachers’ attitudes concerning health promotion curricula tend to be correlated with, or linked to, how well they understand it. This was confirmed also by Mohammadi, Rowling, and Nutbeam (2010): teachers’ conceptions of the program, what they know about it, influence their attitudes, or how they feel about it.

On table 4, the three questions with the highest means all emphasized student awareness about health. This is, indeed, a good thing: the highest-ranking statement emphasizes the social and the personal nature of health, while the second-highest emphasizes the teachers’ willingness to engage the student in activities salutary to their awareness of the determinants of health, including “culture, society and economic status”. Taken together, the responses to these questions do indicate a quite high level of understanding of the curriculum.

But, understanding the curriculum, do the teachers then integrate into their lessons? Do they translate understanding, intention and attitude into action? The evidence indicated an answer in the affirmative. Indications of how well the teachers truly understood the curriculum and incorporated it into their lessons were revealing indeed. Comparing tables 4 and 5, it is indeed evident that the attitudes and understandings of the teachers were translated into measurable action and good outcomes. From encouraging the participants of parents and the community more generally to using the curriculum to prepare lessons that pertained to daily life, teachers did indeed take their intentions and understandings of the curriculum and translate them into tangible results.

Nonetheless, a striking feature of the statistics on table 5 is the degree to which the distribution of the percentages varies from question to question. For example, some questions exhibit a distribution that is well divided between the answers “rarely”, “sometimes”, and “very often”, though both “never” and “always” tend to be consistently outlying minorities. However, the percentages for other questions are far more unevenly divided, with the majority going to one column: usually “very often”, but sometimes “rarely”. This is indeed an interesting pattern, but both “sometimes” and “very often” were particularly popular responses.

Thus, this indicates a reasonable to quite exemplary level of teacher understanding of the curriculum. It may also indicate substantial variance in teaching strategies, with different teachers favouring different strategies, as well as some teaching strategies being more popular than others. Statements that concerned encouraging the students towards behaviour change and health, as well as daily life, etc., actually received a substantial number of favourable responses, and often did better than others.

Concerning now the descriptive statistics pertaining to the teachers’ understanding of the curriculum in table 6, these also indicate a very high level of understanding. This is of considerable importance, inasmuch as these items are concerned with some of the most foundational aspects of the curriculum’s philosophy and aims: the highest-ranked question, for example, is “I believe that health education will have a positive impact on the adoption of health-promoting behaviour among students”. What these items attest to is teachers’ positive attitudes concerning, and understanding of, the philosophy of the curriculum and its aims: what it intends to do, and how, and why.

From all of this it seems the more apparent that the essential conclusions of Tjomsland, Wold, and Iversen (2010) are confirmed herein: namely, that the intentions and desires of teachers exert a significant and very real impact on their actual actions. In the course of their own study, Tjomsland et al. ascertained overwhelming teacher motivations to make meaningful impacts on students’ social environments,  motivations that were indeed translated into actions towards this end—over the course of three years, no less. Thus, positive attitudes were translated into actions with staying power: the curriculum made a real difference in the long run, affecting the ways in which the teachers engaged with the subject matter.

In light of Tjomsland et al.’s (2010) findings, then, the highest-ranking responses in table 6 take on no small import: they are the expected cardinal drivers of teachers’ behaviour and actions in the course of teaching the new programme. The highest-ranking question (mean= 4.1214) states: “I believe that health education will have a positive impact on the adoption of health-promoting behaviour among students”. This is indeed of great importance for the insight that it gives into teachers’ understanding, perceived self-efficacy, and attitudes: the high responses to this statement indicate high teacher self-efficacy, positive attitudes toward the curriculum, and a true understanding of the veritable essence of the curriculum.

And the second statement is not unlike the first, in terms of the insights that it gives into teacher perceptions of efficacy, attitudes, intentions, and understanding of the health promotion curriculum philosophy. With a mean of 3.9714, that second statement is: “The new curriculum helps me to encourage students in believing that there are things in their daily life they can do in order to take care of their health”. This statement links understanding with attitude (‘curriculum helps me’), and the two to the outcome, namely encouraging the students. Moreover, it evinces a truly deep understanding of the foundational philosophy that undergirds the curriculum.

But in truth, not a one of these findings is surprising in light of the work by Leurs, Bessems, Schaalma and de Vries (2007). Their findings mesh well with the findings here presented: knowledge and attitude drive performance. Teachers with higher levels of knowledge about health promotion curriculums tend to have better attitudes about them, and this in turn leads them to teach more material, and to do so more effectively. Of course, a key aspect of the attitudes in question is also seen here: the teachers’ own belief that the teachings will be effective, and make a real difference in the students’ lives.

Of course, the findings of Telljohann, Everett, Durgin and Price (1996) are of considerable interest here, inasmuch as these authors found a positive and significant correlation between in-service training and teachers’ perceived self-efficacy. Their study provides attestation of the crucial link between teachers’ knowledge and understanding, and efforts to further promote it, and teachers’ own sense of self-efficacy in teaching the material. The relationship is certainly intuitive at some level: after all, efforts to promote teacher understanding should lead to a sense of improved self-efficacy on the part of the teachers. Here, it is especially of interest to revisit the background questions: “Have you read any literature on Health Promotion/Health Education?”; “Have you attended any in-services or workshops on Health Education or about the New Health Education Curriculum?”, and “How closely have you read the new Health Promotion Curriculum?” The answers to all three of these questions were largely favourable, indicating that quite a number of the teachers had taken it upon themselves to become familiarized with the new curriculum, and/or had attended in-service training and workshops. This speaks well toward the success of the program.

And in light of the findings with the background questions, the good understandings and intentions of the teachers are the more comprehensible, as well as the more encouraging in terms of the level of efficacy that might be anticipated from the implementation of the curriculum. Of course, attitude is no mean part of this, either: self-efficacy and attitude are integrally linked (Leurs et al., 2007; Telljohann et al., 1996). Efforts to promote teachers’ understanding of the curriculum and its philosophy, then, whether on the part of the schools or simply initiated by the teachers themselves, seem to promote a kind of virtuous cycle whereby attitudes and perceived sense of self-efficacy also improve.

Thus far, then, hypothesis H2 would appear to be confirmed, substantiated to no small measure: it does indeed appear to be the case that teachers’ understanding of the philosophy of the curriculum has a positive relationship with attitude toward it. The findings presented in Table 7 address teachers’ sense of efficacy in teaching the curriculum: the degree to which they believe themselves capable of teaching it effectively, reaching students, and maintaining order in the classroom. The responses indicate high perceived self-efficacy in teaching: for nearly all of the statements, the vast majority of the responses are concentrated in the “agree” or “strongly agree” categories.

The first statement, “I can control disruptive behaviour in the classroom”, is an interesting case in point. Here, 53.6% of the responses were in the “agree” column, and another 33.6% were in the “strongly agree” column. This indicates a great deal about the teachers’ perceptions of the locus of control (Tschannen-Moran, Hoy, & Hoy, 1998). As Tschannen-Moran et al. explained, there is good reason to believe that teachers with a confident perspective on the locus of control, that is to say, teachers who believe themselves capable of exerting substantial and significant influences on student behaviour and learning outcomes, have a much stronger sense of self-efficacy in teaching the curriculum.

In other words, such teachers believe themselves capable of teaching the curriculum and dealing with any student misbehaviour, such that they will be able to reach their students, even those who lack motivation and/or discipline owing to poor influences in their home and community environments (Tschannen-Moran et al., 1998). Subsequent statements provide still further attestation of this high sense of efficacy among the majority of the teachers: the teachers expressed confidence in their ability to motivate students with low interest, to help students to value learning, and to “get through to most difficult students”.

In fact, the responses to one statement appear to be of especial interest: “The hours in my class have little influence on students compared to the influence of their home environment”. Here, some 17.9% of the teachers expressed strong disagreement, followed by 39.3% who expressed disagreement, 25.7% who expressed uncertainty, and then 16.4% who expressed agreement and .7% who expressed strong agreement. How, then, to adequately describe this pattern? Does this truly indicate a significant attestation of many teachers’ sense of efficacy in teaching the program?

In fact, another way of describing self-efficacy may cast further insights upon this: a theory that casts self-efficacy in terms of beliefs (Tschannen-Moran et al., 1998). As Tschannen-Moran et al. explained, this conception of self-efficacy is that it is “a future-oriented belief about the level of competence a person expects he or she will display in a given situation” (pp. 207, 210). Thus, different situations may bring out different responses concerning perceived self-efficacy.

Moreover, another way of describing perceived self-efficacy is in terms of outcome expectancy: the individual’s perceptions of what the likely outcomes are of a given situation or process (Tschannen-Moran et al., 1998, p. 210). This conception may hold the missing key to make sense of the apparent anomaly in table 7: the teachers’ perceptions of outcome expectancies exert influence on their perceived self-efficacy. In this vein, it is surely worth noting the comparisons and contrasts between the responses to the aforementioned statement, and the one that follows: “The amount that a student can learn is primarily related to family background”. Here, the responses were: 7.9% strongly disagree; 32.1% disagree; 21.4% uncertain; 27.9% agree, and 10.7% strongly agree.

The responses to this second statement, then, were all over the map, and this is particularly interesting given that the statement compares substantially with the aforementioned one about the hours spent in class having little influence on students compared with their home environment. If classroom work and instruction has but a little influence, then this would seem to imply that perhaps the amount that a student can learn is, indeed, primarily related to family background, and vice-versa. In fact, at least some of the responses seem to suggest interdependence: the percentages for the “uncertain” response were similar for both questions, to be sure, and the “disagree” responses were only several percentage points apart.

All in all, this would seem to be a reflection of a certain amount of diversity of opinion within this sample population concerning the degree to which students are influenced by their home environments as opposed to the classroom. However, the true measure of the ramifications for efficacy is best taken with a careful consideration of the findings in table 8: the statement about the influence of the home environment being paramount scored the lowest, with a mean of 2.4286. The next lowest was the statement about family background being the main determinant of learning, with a mean of 3.0143. And, of no mean interest, the next-ranked statement was: “The influence of a student’s home experience can be overcome by good teaching”, with a mean of 3.5857.

Thus, it would appear that despite some notable differences of opinion, a great many teachers do see the home environment as the main determinant of students’ learning potential. However, the likely means of resolving the apparent discrepancy is the realization that this is not mutually exclusive with the idea that the influences of such an environment can be modulated, modified, and even overcome, at least to some degree. This is the likely explanation: many of the teachers believe that the home environment exerts a greater natural impact on a student’s ability to learn and what they learn, but with even higher frequency the teachers believe that these influences can be overcome, at least to a significant degree.

And the other, even more highly-ranked responses seem to provide attestation of the above: the teachers expressed high levels of confidence in their abilities to motivate students, teach them to value learning, redirect them in case of noise and disruption, and utilize varying assessments to take the measure of their students’ abilities. These are positive answers to efficacy questions (Tschannen-Moran et al., 1998). And this is important, because as Tschannen-Moran et al. explained, teachers’ beliefs in self-efficacy have been linked, unsurprisingly, to their perseverance. Put simply, the effort and patience that teachers put into the health curriculum teaching enterprise should be correlated with their beliefs in self-efficacy: their beliefs in their abilities to make a difference in their students’ lives.

The Cronbach’s Alpha coefficient scores for the reliability analysis provide a powerful measure of the degree to which the findings can be taken with confidence. Scores of 0.7-0.95 are reliable. Teachers’ attitudes and beliefs about the new curriculum had a preliminary Cronbach’s Alpha of 0.796, and a final Cronbach’s Alpha based on standardized items of 0.825. This is a high measure of reliability indeed. Secondly, teachers’ understandings of the new curriculum had a preliminary Cronbach’s Alpha of 0.864, and a final Cronbach’s Alpha of 0.873. Finally, teachers’ sense of efficacy had a preliminary Cronbach’s Alpha of 0.764, and a final Cronbach’s Alpha of 0.806. All of these indicate a great deal of reliability.

Turning now to the factor analysis, the Kaiser-Meyer-Olkin test and Barlett’s test of sphericity were used to test the suitability of the variables for factor analysis. The fact that the Kaiser-Meyer-Olkin (KMO) values were all greater than 0.700 indicates significant relationships between the factors, which are found to be suitable for the study. Teachers’ sense of efficacy, teachers’ attitudes and beliefs, and teachers’ understanding were all found to be significant, with means of 3.7845, 3.7429, and 3.6604, respectively.

But what, in truth, does this mean for the hypotheses? The answers presented in table 12 definitively demonstrate a linkage between teacher’s attitudes and beliefs and teachers’ understanding, through the Pearson Spearman’s rho correlation. Similarly, there is an integral linkage between teachers’ attitudes and beliefs, and teachers’ sense of efficacy. Put simply, this vindicates the hypotheses of this study, which will now be revisited in some detail and expounded upon.

Hypothesis H1 stated: “Primary teacher efficacy has a positive relationship with the teacher attitude toward the new Cypriot health promotion curriculum.” The null hypothesis, H0-1, stated: “Primary teacher efficacy has no significant relationship with the teacher attitude toward the new Cypriot health promotion curriculum.” The Pearson Spearman’s rho correlation effectively demonstrates that in fact, H1 is supported and H0-1 is not supported. Efficacy and attitude are, indeed, integrally linked.

Hypothesis H2 stated: “Primary teacher understanding of the philosophy of the curriculum has a positive relationship with the teachers’ attitude toward the new Cypriot health promotion curriculum.” The null hypothesis H0-2 stated: “Primary teacher understanding of the philosophy of the curriculum has no significant relationship with the teachers’ attitudes toward the new Cypriot health promotion curriculum.” Again, the Pearson-Spearman’s rho correlation supported H2 and did not support H0-2. Teachers’ understandings of the philosophy of the curriculum are, indeed, linked to their attitudes toward it: the better the understanding, the better the attitudes that the teachers hold. This may seem intuitive, but there was always the possibility that no relation between the two would be found.

The multiple linear regressions were able to account for some 40.1% of the variations in teachers’ attitudes and beliefs concerning the curriculum, and the ANOVA found a significant relationship. Teachers’ attitudes and beliefs are very clearly integrally linked to understandings of the curriculum’s underlying philosophy. As this research has gone to great lengths to demonstrate, however, this is nothing surprising: in fact, Rimm-Kaufman and Sawyer (2004) found precisely this. Their researches are of considerable interest to these findings, in every conceivable way. First and foremost, Rimm-Kaufman and Sawyer found a relationship between experience with the Responsive Classroom (RC) approach on the one hand, and “positive attitudes toward teaching, and priorities similar to RC exemplars” on the other (pp. 321, 330). Put simply, this study has essentially confirmed what Rimm-Kaufman and Sawyer found.

Secondly, however, Rimm-Kaufman and Sawyer (2004) found a linkage between greater experience with the approach and “higher feelings of self-efficacy… and priorities more similar to RC exemplars” (p. 330). This is essentially congruent with both hypotheses, though the emphasis is slightly different: experience, leading to higher self-efficacy and a greater internalization of the curriculum. This would seem to suggest that over time, Cypriot teachers who cultivate experience with the new approach will develop even greater levels of self-efficacy, and will continue to further internalize the curriculum and agree with its underlying philosophy. This is not a surprising finding: after all, it makes sense that with more experience, the teachers will become even more adept in teaching the curriculum, and also more enthusiastic about it.

The third finding is more coterminous with the hypotheses of this study: types of self-efficacy were interrelated and interlinked (Rimm-Kaufman & Sawyer, 2004). This study did not differentiate between different types of self-efficacy, but it is still of considerable interest to note this integral relation between the different types of self-efficacy. What this suggests is that teachers with self-efficacy will likely have more than one kind, to be sure a positive outcome for their ability to teach the curriculum effectively. The fourth finding is of very great interest: “teachers who were more similar to RC exemplars in discipline priorities reported more positive attitudes toward teaching” (p. 330). This is, again, what this study found with regard to hypothesis H2: understanding and internalization is linked to attitude. Similarly, the fifth finding was that “teachers who were more similar to RC exemplars in teaching practices were higher in two of the four types of self-efficacy” (p. 330). Again, this is in accord with the second hypothesis.

Moreover, the findings of Deschesnes, Trudeau, and Kébé (2009) are of great interest to both hypotheses, because they demonstrate the possibility that the integral linkage between knowledge, understanding and self-efficacy on the one hand, and attitude on the other, is a two-way street. Specifically, not only is it the case that self-efficacy and understanding can improve attitudes about a health promotion curriculum, but it would also appear to be the case that initial receptivity, positive attitudes towards the program, influence adoption, understanding, and self-efficacy in teaching it (p. 445).

To reiterate, the essential point here is that there would appear to be so integral a linkage between teachers’ self-efficacy and teachers’ attitudes, and between teachers’ understandings and teachers’ attitudes, that even the initial factor of a favourable attitude can lead to marked improvements in the other fields. Thus, the relationship between these three variables may be even denser and more interconnected than the findings here indicate. In particular, being able to anticipate the benefits of a health promotion curriculum would appear to be a significant factor favouring adoption and implementation.

And to be sure, these findings also indicate the need for a great deal of organizational support for the implementation of a health promotion curriculum. This was the essential conclusion of Viig and Wold (2005), who found that successful implementations took place in schools that provided organizational support or ‘anchoring’. In other words, successful adopters internalized the curriculum within the organization by drawing it into every level: not only teachers, but principals must also be on board.

This is considerably important, and it is highlighted by both hypotheses: understanding must permeate the entire organization for there to be good, positive attitudes among all actors. Moreover, self-efficacy to implement and teach the curriculum must be widespread throughout the organization, anchored within its wellsprings at all levels, in order to ensure good attitudes and good outcomes (Viig & Wold, 2005). Schools that do not do this are setting themselves up for the possibility of failure, defined specifically as sub-optimal outcomes: the ideal outcome is for the curriculum to be integrated successfully within the school, such that all teachers are supportive of it, understand it, and feel confident in their ability to teach it. Commitment, then, is everything (Viig & Wold, 2005).

In order to achieve those crucial levels of commitment, it is necessary for there to be a congruity of goals: all teachers and the school principal must share the same goals pertinent to the curriculum (Viig & Wold, 2005). Leadership is another important factor: what Viig and Wold found was that schools that had successfully implemented the program had good leadership, and this was commented upon by the teachers and other participants. And, to be sure, motivation is an integral component of attitude, one that may improve over time (Tjomsland et al., 2010). Motivation can sustain a school’s drive to implement the curriculum, and it can help to improve performance and other dimensions of attitude (Tjomsland et al., 2010).

The findings here presented also cast further light on the findings of Jourdan et al. (2010). What Jourdan et al. found was that perceptions of responsibility made very real and significant differences with regard to individual contributions. Specifically, the levels of participation in health education reported by different individuals at French middle schools were in turn correlated with their understanding of their part in the curriculum. For some respondents, their reported duties and responsibilities in the curriculum, their perceptions of their roles, were inseparable from their job descriptions, while others reported little or no participation, and correspondingly little or no responsibility.

This speaks to the two factors investigated by this study in conjunction with attitude: knowledge/understanding, and perceived self-efficacy. Jourdan et al. (2010) were clear: they found that teachers who had a sound understanding of the curriculum and the philosophy behind it appreciated its benefits. Another key finding, which also speaks to the results here, is that through practice the teachers learned how to increase their self-efficacy in teaching the program: they became better at working with it over time. Moreover, Jourdan et al. (2010) found that professional development is important as well: teachers need to be taught, in order to understand the material fully, and appreciate the philosophy behind it. This in turn drives their sense of self-efficacy, and both, of course, drive attitude.

Thus, if teachers understand the curriculum, they can be expected to understand the part that they have to play in it. In other words, they will understand their responsibility. This should also lead to improved attitudes: not only attitudes of wanting to help, but also attitudes that it is their responsibility to help, and they are glad to fulfil it. Moreover, if they have a high sense of self-efficacy, they can be expected to feel confident in their ability to carry out their responsibilities. This is indeed an important dimension of attitude, and one that, like attitude in general, is integrally linked to participants’ knowledge and understanding of the material and the underlying philosophy, as well as their perceived self-efficacy in carrying it out.

Conclusion: This study set out to ascertain the relationship between teachers’ understandings of the new health promotion curriculum and their attitudes towards it, as well as teachers’ perceived sense of self-efficacy and corresponding attitudes. Through extensive research, these findings confirm those already well established in the literature: the more that teachers understand the underlying philosophy behind a health promotion curriculum, the better their attitudes about it are inclined to be. Furthermore, the higher of a sense of self-efficacy that teachers have, the better their attitudes are likely to be.

The relationships between these factors are notable and significant: there can be no doubt but that teachers’ understandings and perceived self-efficacy are correlated with better attitudes. But the truly interesting aspects of these findings are the ways in which these essential linkages were found to be very deep and profound: teachers’ perceptions of their ability to actually influence their students were found to be significantly related with positive attitudes about the curriculum, as well as sound self-efficacy. What all of this suggests is that teachers benefit from being solidly grounded in the curriculum, thereby increasing attitudes and efficacy.

Teachers’ intentions and desires, in particular, are important components of their attitudes that are related to understanding and self-efficacy. If teachers hold the view that they can make a positive impact on their students, and further have an intention to do so, then the prospects are favourable. In order for teachers to achieve this, however, the most important thing is that they be supported and encouraged: not only taught the curriculum, but taught how to teach it.

References

Deschesnes, M., Trudeau, F., and Kébé, 2009. Factors influencing the adoption of a Health Promoting School approach in the province of Quebec, Canada. Health Education Research, 25(3), pp. 438-450.

Ioannou, S., Kouta, C., and Charalambous, N., 2012. Moving from health education to health promotion: Developing the health education curriculum in Cyprus. Health Education, 112(2), pp. 153-169.

Jourdan, D., et al., 2010. Factors influencing the contribution of staff to health education in schools. Health Education Research, 25(4), pp. 519-530.

Leurs, M.T., Bessems, K., Schaalma, H.P., and de Vries, H., 2006. Focus points for school health promotion improvements in Dutch primary schools. Health Education Research, 22(1), 69. 58-69.

Mitchell, J., Palmer, S., Booth, M., and Davies, G.P., 2000. A randomised trial of an intervention to develop health promoting schools in Australia: The south western Sydney study. Australian and New Zealand Journal of Public Health, 24(3), pp. 242-246.

Mohammadi, N.K., Rowling, L., and Nutbeam, D., 2010. Acknowledging educational perspectives on health promoting schools. Health Education, 110(4), pp. 240-251.

Rimm-Kaufman, S. E., & Sawyer, B. E. (2004). Primary-grade teachers’ self-efficacy beliefs, attitudes toward teaching, and discipline and teaching practice priorities in relation to the ‘responsive classroom’ approach. The Elementary School Journal, 104(4), pp. 321-341.

St. Leger, L., 1998. Australian teachers’ understandings of the health promoting school concept and the implications for the development of school health. Health Promotion International, 13(3), pp. 223-236.

Telljohan, S.K., Everett, S.A., Durgin, J., and Price, J.H., 1996. Effects of an inservice workshop on the health teaching self-efficacy of elementary school teachers. Journal of School Health, 66(7), pp. 261-265.

Tjomsland, H.E., Iversen, A.C., and Wold, B., 2009. The Norwegian Network of Health Promoting Schools: A three-year follow-up study of teacher motivation, participation and perceived outcomes. Scandinavian Journal of Educational Research, 53(1), pp. 89-102.

Tschannen-Moran, M., Hoy, A.W., and Hoy, W.K., 1998. Teacher efficacy: Its meaning and measure. Review of Educational Research, 68(2), pp. 202-248.

Viig, N.G., and Wold, B., 2007. Facilitating teachers’ participation in school-based health promotion—a qualitative study. Scandinavian Journal of Educational Research, 49(1), 109.83-109.