Investigating the Relationship Between Primary School Teacher’s Attitudes Towards Teaching Health Promotion, Dissertation – Literature Example

Introduction

Whether the new health education curriculum in Cyprus succeeds or fails depends, to no inconsiderable degree, on the teachers. After all, schools are important stakeholders in promoting health, and teachers are of seminal importance for successfully implementing any health promotion curriculum (Ioannou, Kouta, and Charalambous, 2012). This research will highlight the importance of three parameters: 1) The importance of teachers’ understanding of health promotion; 2) the importance of teachers’ feeling efficient in teaching health promotion, also known as self-efficacy or teacher efficacy, and 3) the importance of teachers’ attitudes towards health promotion. All three of these dimensions are essential for successful implementation of a health promotion curriculum.

A few introductory concepts are in order, chief among them the concept of the health promoting school (HPS), used throughout this work. As St. Leger (1998) explained, the concept of the health promoting school (HPS) is a powerful and popular approach to health education, one that emphasizes the importance of the school environment and its diverse aspects in determining students’ health opportunities. The HPS may vary from school to school and programme to programme, but the approach is fundamentally concerned with actions regarding “school health policies”, the physical and social environments, “community partnerships”, “personal health skills”, and “integrated health services” (St. Leger, 1998, p. 224). This basic approach will return throughout the literature, inasmuch as it is foundational to successful implementation of a health promotion curriculum.

The underlying philosophy of the new Cypriot health promotion curriculum was elaborated by Ioannou, Kouta, and Charalambous (2012), who highlighted the importance of teachers’ attitudes and efficacy. The new curriculum is designed to promote health in the context of the students’ sociocultural and physical environments, through collaboration, partnerships, and the creation of “supportive environments conducive to health” (p. 156). The curriculum’s three levels emphasize collaboration between students and “’significant others’” as agents of health, and this approach guides the three levels of the curriculum: “Investigating determinants of health,” “Practicing action competency skills for health” and “Promoting and achieving changes” (p. 158). The first level emphasizes social learning: working with their teachers, students will discover and discuss salient factors that determine health, such as eating habits. The second level emphasizes action competence: students learn to apply their knowledge to affect outcomes through their interactions with others. The third level emphasizes actions in a more systemic perspective, one that seeks to promote healthy environments in schools and the communities they serve (Ioannou, Kouta, and Charalambous, 2012). It is, all in all, a good summation of the HPS approach.

Concerning the field of health promotion itself, Hauge and Hem (2011) attested to its utilization of the insights of the disciplines of “psychology, sociology, epidemiology, and education” in particular (p. 79). A good example of the influence that the health promotion field is coming to enjoy is the Galway Consensus Conference Statement (GCCS), which identified the following eight essential domains for the discipline of health promotion: “(1) catalysing change, (2) leadership, (3) assessment, (4) planning, (5) implementation, (6) evaluation, (7) advocacy, and (8) partnerships” (p. 80). These are well and good, and, as will be seen, enjoy no small support in the literature. All of these domains are therefore of interest to the work.

Part I: The Significance of Teachers’ Understandings of the Health Promotion Philosophy

However, there are significant limitations to the GCCS, and these limitations reveal a great deal that is of interest for studying practitioner attitudes and beliefs with regard to health promotion (Hauge and Hem, 2011). The cardinal weakness of the GCCS is its narrow perspective, inasmuch as it defines health merely as the absence of disease. This is a limiting, negative model, and it is not difficult to see how such a belief could negatively impact a health educator’s performance: the narrow focus on the absence of disease misses the many important positive components of health, including not only a healthful regimen of nutrition and exercise, but also physical and social environments that are health-promoting (Hauge and Hem, 2011).

Health promotion, then, needs to employ a broader perspective and a more positive orientation with respect to health than the narrow, limited, absence-of-disease model. This readily suggests a question: how successful are health-promoting school (HPS) programmes in promoting such a broader perspective in teachers’ minds? Do HPS programmes succeed in expanding teachers’ awareness of the variant dimensions of health?

One attempt to answer this question was made by Mitchell, Palmer, Booth, and Davies (2000), who compared an intervention group of schools with a HPS programme with a control group of schools without such a programme. The intervention itself consisted of a HPS programme, a resource kit which emphasized the importance of the concept itself and encouraged schools to develop a health committee in order to assess relevant health needs, formulate a plan of action, implement it, and assess their progress. Pre-intervention, the control and intervention groups evinced no significant differences in terms of HPS awareness and comprehension. Before the intervention, most schools in both of the groups had student health committees; however, fewer than half of all the schools had formulated a strategy for student health needs and issues (Mitchell, Palmer, Booth, and Davies, 2000).

After the intervention, teachers and other staff at the schools in the intervention group evinced much higher rates of understanding of the HPS concept, as well as participation in workshops (Mitchell, Palmer, Booth, and Davies, 2000). After the intervention, 63% of intervention schools reported having sent “health-related reading material to parents”, compared with only 29% of control schools (pp. 244-245). Nonetheless, changes in overall health policy were scarce and inconsistent, even among the intervention schools (Mitchell, Palmer, Booth, and Davies, 2000). Clearly, it is not enough to simply implement a HPS programme: teachers must understand it, be motivated to participate, and believe in their own self-efficacy to teach it.

St. Leger (1998) also set out to answer the question, with a study examining Australian teachers’ understandings of health promotion. In the first phase, teachers were requested to take photographs of salient aspects of their own schools’ health promotion efforts, and to explain the significance of the photographs. St. Leger (1998) found that teachers understood health in terms of health-promoting activities and learning outcomes, from proper nutrition and exercise to health education. In the second phase, focus groups on school health were conducted with teachers. Here, St. Leger (1998) found that teachers’ approach to school health was categorical, by topic: the three most important that they identified were “physical activity, food and nutrition, and safety” (p. 227). Another finding from the focus groups was that HPS participation exercised a significant influence on teachers’ own understandings of health promotion (St. Leger, 1998). Moreover, teachers with a more ecumenical perspective of health promotion, a perspective that incorporated HPS elements, tended to be more appreciative of its benefits: improved understanding led to better attitudes about the program. Other findings of the study, from the third and fourth phases, are also significant: teachers saw their schools as health promoting environments, with emphasis on the important content areas of “physical activity, nutrition, safety, mental health and sun protection” (St. Leger, 1998, p. 228). They also expressed strong desires for better professional development in the area of health. Teachers were inconsistent in their appraisals of the significance of the physical environment for health, though a key part of this may be the amenable school environments they have had to work with. With regard to the social environment and its role for school health, the teachers expressed high valuations of its importance, but had difficulty with describing and defining it (St. Leger, 1998).

St. Leger’s findings were confirmed by Mohammadi, Rowling, and Nutbeam (2010): teachers’ understandings of the curriculum, the first parameter in this analysis, has a positive and significant relationship with their attitudes about the program. In a study of eighteen Sydney, Australia primary schools, the authors found that understandings of the HPS concept can vary widely between teachers in a given school: participants gave varying definitions of the concept, and many requested clarification, finding the concept too obscure by virtue of its generality. Descriptions given by participants included “’a holistic strategy’, ‘just a label’, ‘a program’, ‘students’ welfare’”, etc. (p. 243). Overall, the responses clustered into four categories: firstly, “HPS as a school that promotes health”; secondly, “HPS as a new holistic model for health promotion”; thirdly, “HPS as an external health project”, and fourthly, “HPS as a credit/label” (p. 243). And significantly, the conception that teachers had of HPS played a key role in determining their attitudes about it: for example, those who identified it as merely a label tended to aver that it was not beneficial in any way (Mohammadi, Rowling, and Nutbeam, 2010). By contrast, those who identified it as a profoundly new model were far more likely to aver that it was very beneficial for all concerned (Mohammadi, Rowling, and Nutbeam, 2010). Clearly, poor understanding leads to distorted attitudes about teaching health promotion, while good understanding leads to positive appraisals. What knowledge, then, is essential for teachers to attain in order to have improved attitudes about a health promotion programme? This is surely grounds for further analysis.

Still, one answer is suggested by Mogford, Gould, and Devoght (2010): health literacy, based on the social determinants of health (SDOH). These include such factors as “income, early life experiences, education, food security, employment, health care services, social cohesion, political empowerment and gender equity” (p. 5). Understanding the social determinants of health is of considerable importance to the cultivation of health literacy, defined in terms of the individual’s ability to make use of personal, cognitive, and social capacities to promote health. In this wise, knowledge is the seminal element: the individual must have knowledge of positive and healthful practices. This is true not only of students, but also of the teachers who teach them: teachers must have a great deal of awareness of the social determinants of health, and how to affect positive outcomes. This is particularly important for teaching students critical thinking about health, especially with regard to health inequities (Mogford, Gould, and Devoght, 2010).

Part II: The Importance of Teacher Attitudes About the Health Promotion Curriculum

Teachers’ attitudes, shaped by their knowledge, in turn drive outcomes: as Tjomsland, Wold, and Iversen (2010) found, what teachers intend and desire to do in turn impacts what they actually do. In other words, beliefs and motivation shape actions. In their study, Tjomsland, Wold, and Iversen (2010) found, at baseline, that 97% of teachers expressed a desire to positively affect students’ social environment, while the “development of cross-curricular teaching plans in health promotion” received the least interest (Tjomsland, Iversen, and Wold, 2010, p. 96). Three years later, the teachers were most involved with the promotion of a healthy social environment for the students, and least involved in the cross-curricular teaching plans. Attitudes and intentions shape outcomes: in fact, the authors found that intentions were the only significant factor in determining teacher participation. Moreover, teachers’ baseline expectations of the health promotion curriculum’s outcomes were significantly correlated with their perceptions of the programme’s efficacy at the follow-up, and this too related to participation (Tjomsland, Iversen, and Wold, 2010). In other words, attitudes, intentions, and expectations play a seminal role in determining teacher participation.

Knowledge and attitude, then, drive performance. As Leurs, Bessems, Schaalma, and de Vries (2007) found in a study of Dutch primary school teachers, respondents taught varying numbers of health promotion issues, ranging from 1 to 7. There was a significant difference between those teachers who taught three or more health issues and those who failed to teach at least three: the former group evinced more positive outcome expectancies, including “’personal enjoyment’, ‘personal satisfaction’ and a ‘positive commitment’ of the school toward pupil health” (p. 61). By comparison, teachers who taught no more than two health issues saw them in negative terms: in particular, such teachers were far more likely to see the teaching of health issues as competing with other teaching for class time. There was also a significant, and again predictable, difference in perceived self-efficacy: teachers with higher perceived self-efficacy taught more subjects (Leurs, Bessems, Schaalma, and de Vries, 2007). This is further compelling evidence that teachers’ attitudes, knowledge, and perceived self-efficacy exert a very significant effect on their health teaching behaviour.

Clearly, teachers with a better understanding of a health promotion curriculum of the HPS type are more likely to have a more positive attitude about it. In their study, Deschesnes, Trudeau, and Kébé (2010) highlighted the importance of educators’ attitudes about health promotion, and how these attitudes correlated with the adoption of Quebec’s Healthy Schools (HS) approach. HS is again similar to the HPS approach; the Canadian province of Quebec began implementing this approach in 2004, on a voluntary basis. The authors found that some control variables exerted an influence on HS adoption, specifically “school location and HS knowledge level” (p. 444). More specifically, participants with a better knowledge of HS had higher rates of HS adoption compared with their superficially-informed counterparts (Deschesnes, Trudeau, and Kébé, 2010).

What, then, of participation? How can one convince teachers to participate in a programme with more than the bare minimum of effort? As seen, the literature suggests that the answer is knowledge and attitude. But is this enough? Viig and Wold (2005) sought to ascertain salient factors that facilitate teachers’ participation in their schools’ health promotion curriculums, highlighting the organisational dynamics at work. As they explained, if a school is to be successful in implementing such a curriculum, the implementation must be “anchored” across all levels of the organisation (Viig and Wold, 2005). Another key factor is strong commitment: principals and school staff who are committed to a health promotion curriculum are essential for a successful implementation. In a study of twelve teachers from two Norwegian schools, a primary and a secondary school, the authors found that the HPS programme had successfully challenged the teachers’ patterns of thought: teachers reported more positive experiences, both for the students and for themselves. Greater energy and happier classrooms are some of the results reported, evincing a great deal of satisfaction with the programme (Viig and Wold, 2005).

The teachers identified a number of supporting factors that facilitated the successful adoption of the programme, the first being common goals (Viig and Wold, 2005). The teachers reported finding encouragement in the significant congruity of goals that obtained between the National Curriculum and the HPS programme. In particular, both have a key emphasis on promoting positive, healthy social environments. It is of interest to ascertain how teachers’ perceptions of desirable goals might be shaped by attitudes, experience, and perceptions of self-efficacy. Another key factor was planning: informants reported that the HPS programme had been successfully integrated into the planning process for their schools. With the HPS programme occupying an important and central role, it was much easier to sustain. Yet a third factor was leadership: the teachers identified good leadership as essential for HPS implementation. Informants emphasized the importance of the school administration, particularly the principal (Viig and Wold, 2005). One informant said of the school principal that: “’His positive attitude has also given him a lot of goodwill with the students’” (p. 97).

Moreover, an important dimension of attitude is motivation: positive attitudes take the form of motivation to engage with the material. Tjomsland, Iversen, and Wold (2010) analysed teacher motivation and participation in the HPS concept in the Norwegian context, with a total of nine elementary and junior high schools. Significantly, the authors found that attitudes improved through participation: teachers with neutral attitudes at baseline were about equally divided between those maintaining a neutral attitude and those with a positive attitude at the three year follow-up, while the number of teachers with negative attitudes about the programme declined from five to three (Tjomsland, Iversen, and Wold, 2010). Attitudes, then, can improve through practice. Moreover, Tjomsland, Iversen, and Wold (2010) found that these positive attitudes were correlated with a high level of knowledge, further evincing the relationship between good attitudes and a successful program. However, it is notable that in this context, teachers already displayed high rates of positive attitudes (Tjomsland, Iversen, and Wold, 2010).

But another dimension of attitude may actually shape motivation to engage in a programme: the attitude that an individual has about their role within a programme, with respect to organisational objectives. This dimension of attitude might be called simply perception, but it fundamentally concerns individuals’ sense of responsibility. It might be summed up as the individual’s answer to the question, ‘What is the objective of the organisation [school, in this case], and what is my part in it?’ Jourdan et al. (2010) studied the health education (HE) attitudes of staff at five French middle schools in the Auvergne region. The respondents included teachers, principals, counsellors, nurses, social workers, and maintenance staff. Respondents reported widely varying levels of participation in health education: a full 10% claimed they did not contribute in any way, while 24% stated that they made limited contributions, and 66% stated that they made significant contributions (Jourdan et al., 2010).

These contributions were contextualized and interpreted through the lens of perspective, perception, and sense of responsibility: for some, health education was inextricable from their duties as educators and role models (Jourdan et al., 2010). Nurses, social workers, and doctors were especially high in this group. For other respondents, involvement in health education was less a part of their jobs and more a part of their personal missions, defined in terms of their connections with students. Finally, another group saw their contributions to health education in terms of group work and interactions, in collective health education projects (Jourdan et al., 2010). With regards to the objectives of health education, the school staff saw their health education contributions as pertaining to health centred concerns, such as “nutrition, tobacco, alcohol, cannabis, STD, AIDS, etc.”, and citizenship-centred concerns, pertaining to the social environment (p. 526). These findings make it clear that beyond motivation, individuals have different attitudes about the importance of what they do, and what it means for them and for other stakeholders in the organisational environment, particularly the students in this case.

These studies establish some very important things. First of all, teachers with a better understanding of the HPS curriculum evinced a greater understanding of its benefits: in other words, they were more appreciative; their understanding of the philosophy behind it positively impacted their evaluation of it. Thus, the first parameter complements the second: improved understanding of the philosophy leads to improved attitudes. The second key finding is that the teachers learned by doing, or rather by teaching: as they worked with the program, their own understanding of what it was trying to accomplish increased. A third key finding is the need for more professional development: simply put, teachers need more help with mastering the material and understanding and applying the philosophy behind it.

Part III: The Importance of Teacher Self-Efficacy

But what of teacher efficacy? How does the second parameter in this analysis relate to the first and third? Here, the findings suggest, first of all, that attitude is everything: teachers with positive attitudes towards health promotion curriculums tend to have high perceptions of their own efficacy in teaching it. In their study, Tjomsland, Iversen, and Wold (2010) found that positive attitudes towards the health promotion curriculum had a significant effect on teachers’ perceptions of efficacy in teaching it. Moreover, many teachers reported positive effects of the curriculum in promoting health. The three key dimensions or channels that they identified for the promotion of health were: firstly, through the curriculum itself; secondly, in the students’ own social environment, and thirdly, through interactions between teachers and students (Tjomsland, Iversen, and Wold, 2010). In other words, teachers with positive attitudes evinced not only improved self-efficacy, but also a better understanding of the elements of the programme.

Further clarity on the importance of teacher efficacy and how to achieve it comes from the study by Buijs (2009), which highlighted the impact that in-service training and professional development can have on teachers’ effectiveness. Buijs identified four best practices for HPS implementation from Slovenia, a country that has excelled in the implementation of HPS: “in-service training for teachers in health promotion;” “having a school team in each school;” “systematic planning and evaluation of school tasks related to health”, and “working meetings with school leaders three times per school year” (p. 512). It is scarcely hard to see why these practices have proven effective: in-service training increases teachers’ efficacy in teaching the health promotion curriculum, which is likely to increase their sense of self-efficacy, though this is an inference from Buijs (2009). Perceptions of increased self-efficacy are also likely to positively affect teachers’ views of the curriculum.

Having teams and conducting planning is a sound strategy for successful implementation, one that will ensure greater participation and increased efficiency, while meetings provide opportunities for dialogue and feedback between school leaders and teachers. This is a key lesson for Cyprus. In fact, the influence of planning on teachers’ effectiveness in implementing a health promotion curriculum was highlighted by Adamson, McAleavy, Donegan, and Shevlin (2006), in their study of primary and post-primary schools in Northern Ireland. The authors compared schools with and without a formulated school policy, noting that in Northern Ireland formulated school policies are a significant investment of time and effort: schools in Northern Ireland must go through the process of gaining formal approval for a school policy from the school Board of Governors. What Adamson, McAleavy, Donegan, and Shevlin (2006) found was that teacher perceptions of health promotion in their schools were generally high, in both the post-primary and primary schools, with and without policies.

However, teachers from policy-holding schools evinced significant differences with their counterparts from the non-policy-holding schools (Adamson, McAleavy, Donegan, and Shevlin, 2006). Teachers from policy-holding schools showed greater understanding of practice, better definitions of health, better use of pedagogy to teach health, and better understandings of the determinants of health and how to approach health problems. They also showed significantly greater understandings of psychosocial factors, as well as improved understandings of their own roles as staff, and the role of parents (Adamson, McAleavy, Donegan, and Shevlin, 2006). Here, though, a key question is the conundrum of causality, the ‘chicken-and-egg’ question: did the drafting and implementation of policies produce the improved teacher outcomes, or did the schools that drafted and implemented policies do so because their teachers were already higher-performing with regard to health promotion efforts? Still, the study is of significance for this analysis, inasmuch as it demonstrates a correlation, at the very least, between effective planning and high performance in the context of an organizational culture.

In a study of teacher efficacy, Tschannen-Moran, Hoy, and Hoy (1998) identified a number of proposed influences on this construct. Firstly, one strand of thought holds that a key factor is locus of control: teachers who view students’ home environments as the overriding determinants of student motivation necessarily perceive their own efficacy as rather low; by comparison, teachers with a more optimistic view, that with enough perseverance they can motivate even the most obdurate and recalcitrant students, have a much higher sense of teacher efficacy. This dimension of efficacy is explicitly captured in the instrument used for this study: participants are asked two converse questions concerning the impact of students’ home environments. In much the same vein, teachers who take responsibility for students’ successes and failures are more likely to have a strong sense of teacher efficacy, while those who view students’ successes and failures as the responsibility of (usually) the students themselves or other factors have a much lower sense of teacher efficacy (Tschannen-Moran, Hoy, and Hoy, 1998).

A second, competing conceptual framework portrays self-efficacy in terms of personal beliefs, formulated by cognitive processes: “’beliefs in one’s capabilities to organize and execute the courses of action required to produce given attainments’” (Bandura, 1997, qtd. in Tschannen-Moran, Hoy, and Hoy, 1998, p. 207). Perceived self-efficacy is the seminal determinant of patterns of thought and feeling that affect individuals’ behavioural outcomes. Another kind of expectation, also delineated by this theoretical perspective, is outcome expectancy: the individual’s valuation of the likely outcomes of a particular action. The use of the now-famous Gibson and Dembo instrument has demonstrated a positive and significant correlation between teacher efficacy and teachers’ efforts and perseverance in the face of challenges. Moreover, this instrument has shown a significant and negative relation between teacher efficacy and tendency to criticize students for giving incorrect responses; it has also been positively linked with perseverance and patience with students in failure situations. Teacher efficacy can also be delineated into two domains: personal teaching efficacy, which pertains to a teacher’s perceptions of their own ability, and efficacy in light of external influences, or efficacy with regards to performance and results. Overall, teacher efficacy determines a great deal about teachers’ behaviour, including their efforts, the goals they formulate, and how much they will aspire to (Tschannen-Moran, Hoy, and Hoy, 1998). These dimensions are also captured on the instrument, with questions about teachers’ perceived self-efficacy in dealing with problem situations and motivating students.

Can in-service training make a difference with respect to teachers’ perceived self-efficacy? This is a crucial question for the success of the Cypriot curriculum. Telljohann, Everett, Durgin, and Price (1996) studied the impact of in-service training on the self-efficacy of teachers with regard to teaching a health promotion curriculum. The training consisted of participation in Project Healthy Kids, a curriculum which aims to promote health by teaching students to avoid dangerous or otherwise risky behaviours; the teachers also participated in a 30-hour workshop. The study was designed to measure self-efficacy in terms of “efficacy expectations; outcome expectations; and outcome value as well as health teaching time and effort” (p. 262). Teachers in the experimental group evinced significantly improved scores for efficacy expectation, outcome expectation, and outcome value, as well as hours spent teaching health education. The improvement for time and effort was not significant (Telljohann, Everett, Durgin, and Price, 1996).

The ramifications of this study are obvious: teachers’ perceived self-efficacy with regard to teaching a health promotion curriculum, as well as their attitudes about said curriculum, improve when they are enabled to gain a better understanding of the health promotion curriculum and its importance, defined in terms of its relevance to specific health challenges and core concepts. Again, better understanding drives better self-efficacy and better attitudes. Martin, McCaughtry, Hodges-Kulinna, and Cothran (2008) conducted a similar study, with a group of elementary physical education teachers from the U.S., emphasizing the importance of teacher thinking, learning, and development. The authors found that the teachers in the control group, who had participated in more professional development, evinced higher perceived self-efficacy to teach physical education. The intervention group was also more efficient in teaching the material, and had better scores in general educational efficacy. Although the improvements were largely moderate rather than dramatic, the study demonstrated that even a limited intervention, in this case a workshop lasting only one day, can exert a positive effect on teachers’ perceived self-efficacy and ability to teach the health promotion curriculum (Martin, McCaughtry, Hodges-Kulinna, and Cothran, 2008).

In their study, Deschesnes, Trudeau, and Kébé (2010), found a correlation between knowledge, attitudes, and perceived self-efficacy. As discussed earlier, they found that schools that voluntarily adopted Quebec’s Healthy Schools (HS) programme tended to have teachers who were more knowledgeable about it. Moreover, the authors found that perceived self-efficacy was higher among participants from HS-adopting schools than it was for participants from their non-HS-adopting counterparts (Deschesnes, Trudeau, and Kébé, 2010). A crucial point here is that this is not simply self-efficacy with respect to the program: teachers from schools with the programme evinced higher self-efficacy than those from schools without. Participants from HS-adopting schools also expressed more anticipated benefits of the programme, as well as the conviction that the effects would be observable.

A sense of teacher self-efficacy in general is seminal to effective teaching practices. A sense of self-efficacy can be a powerful buoyant force in a teacher’s mind, one that can reduce their likelihood of burnout, as discovered by Evers, Brouwers, and Tomic (2002). These authors examined the importance of teachers’ attitudes and beliefs about self-efficacy with regard to an innovative Dutch educational system, a study-home programme. Though the programme in question was not a health education programme, the study is still of interest for its examination of teacher attitudes and perceived self-efficacy, and the effects of these on performance. The teachers’ burnout levels were assessed by means of a 20-item instrument comprising three subscales: “(1) emotional exhaustion”; “(2) depersonalisation”, and “(3) personal accomplishment” (p. 232). Teachers’ perceived self-efficacy was also measured, with the use of three subscales that each embodied a particular capacity: firstly, the ability to utilize the principle of differentiation to guide students in groups; secondly, the ability to promote pupil participation in tasks, and thirdly, the ability to make use of “innovative educational practices” (p. 232). Finally, teacher attitudes about the innovative new curriculum were assessed (Evers, Brouwers, and Tomic, 2002).

Evers, Brouwers, and Tomic (2002) found significant and positive correlations between self-efficacy beliefs across all three domains of that instrument with two dimensions of burnout: depersonalisation and emotional exhaustion. Predictably, self-efficacy beliefs were also “significantly but negatively related to personal accomplishment”: teachers with high perceived self-efficacy also had a strong sense of personal accomplishment, a negative burnout score (p. 234). By contrast, teachers with more negative attitudes about the programme evinced much higher rates of depersonalisation and emotional exhaustion, and much lower rates of feelings of personal achievement. There was also a positive correlation between total number of working hours and emotional exhaustion, and a negative correlation between total number of working hours and perceived self-efficacy with regard to innovative techniques: in other words, overworked teachers felt emotionally exhausted and unable to keep up with innovative techniques. Overall, positive attitudes towards the programme, coupled with high perceived self-efficacy, were correlated with negative burnout scores (Evers, Brouwers, and Tomic, 2002).

From these results it is clear that confidence and leadership go a long way toward the successful adoption and implementation of a school health curriculum. With higher perceptions of self-efficacy, educators are more likely to welcome a health promotion curriculum. It is equally clear that receptivity to a health promotion curriculum influences a school’s likelihood of implementing such a programme: positive educator attitudes towards health promotion curriculums are, indeed, significantly correlated with adoption.

How, then, does teachers’ handling of health promotion curriculum materials impact student behaviour, and, another crucial question, how ought the curriculum to be implemented? Cushman (2008) noted the importance of a well-designed, cross-disciplinary program: when classroom teachers can tie in the health promotion curriculum with activities around the school that afford students and families better opportunities for participation, the results will be particularly effective. In other words, the curriculum itself is far more than an assemblage of teaching sessions in classrooms: teachers need to know how to foster collaboration and interactive participatory activities, and they need to have the positive attitudes, motivation, and sense of self-efficacy to do it. Another important aspect of a health promotion curriculum is a good social environment and ethos, one where teachers, parents and students are free to participate as actors in seeking practical and viable solutions for health issues (Cushman, 2008). The social element is foundational to any health promoting school, and teachers have an important role to play: if they are connected to the school, including their interactions with other teachers, school administrators, parents, and students, then they will be more effective in implementing a healthy school environment (Cushman, 2008).

Another, somewhat similar answer comes from Mogford, Gould, and Devoght (2010), who advocated an emphasis on students’ own endeavours to ascertain their own agency, and the means by which they should direct it (p. 9). This approach emphasizes flexibility and personal choice: there is no one right answer; rather, students should be encouraged to find the approach to health that works for them. These authors also emphasize the development of skills: students should be encouraged to develop their skills of researching, critical thinking, and understanding in order to confront the challenges and opportunities of health promotion (Mogford, Gould, and Devoght, 2010). For a teacher to teach such a curriculum requires teacher knowledge, a strong sense of self-efficacy, and a motivated attitude: in light of the requirements of such a curriculum, it is clear that these teacher capacities are prerequisites.

Deschesnes, Martin, and Hill (2003) examined the implementation of both HPS and a similar concept, the Comprehensive School Health Programme, in order to ascertain the factors necessary for successful implementations of these programmes. What both models have in common is a strong reliance on a comprehensive approach to health education and promotion, a systemic and ecumenical perspective that incorporates all dimensions of students’ health, including their own attitudes and behaviours as well as their physical and social environments. This is a significant departure from the traditional paradigm of health education, which relies more on classroom instruction (Deschesnes, Martin, and Hill, 2003).

Deschesnes, Martin, and Hill (2003) explained that these models can be successfully achieved through an approach based on negotiated planning and coordination, which is necessary due to the ecumenical and systemic nature of both programmes. Negotiation is an imperative in order to establish goals that are informed by the feedback of the participating teachers, particularly because HPS and CSHP are comprehensive and multi-faceted. At the same time, coordination is essential to ensure that the strategy is successfully and consistently implemented. The importance of teacher understanding is self-evident: teachers must come to an understanding of what they will be doing, and ho. At the same time, the authors suggest that it is not necessary for all teachers to have the same understanding of HPS concepts: different interpretations can enhance the efficacy of the programme through negotiation (Deschesnes, Martin, and Hill, 2003). Teacher self-efficacy and positive teacher attitudes are also greatly important for successful negotiation and coordinated implementation, for reasons that are largely self-evident: teachers who perceive their efficacy as poor will impede their own performance through lack of confidence, while teachers with uncooperative attitudes will hamstring the coordinated implementation of the programme. The implementation of these programmes depends on teachers who are sufficiently motivated and willing to make the effort to understand them, allowing them to feel confident about participating in teaching the material.

But another important dimension pertaining to the success of a health promotion is student attitudes. As Samdal, Nutbeam, Wold, and Kannas (1998) explained, this dimension is actually quite complementary to teacher knowledge, perceptions of self-efficacy, and attitudes: a key factor affecting student attitudes about school is school participation, and having positive relationships with teachers. Teachers play an important role in classroom life, after all: they are responsible for evaluating academic performance and managing the class. In this capacity, a key teacher duty is the establishment of discipline, preferably in a manner that does not unduly curtail students’ individuality. Social support from a teacher can make a significant difference in a student’s school experience (Samdal, Nutbeam, Wold, and Kannas, 1998).

Samdal, Nutbeam, Wold, and Kannas (1998) evaluated student perceptions of, and satisfaction with, the school climate. Their participants were 11-, 13-, and 15-year-olds from Finland, Latvia, Norway and Slovakia. They found a strong tendency towards decreasing rates of satisfaction with school amongst the older students, for the most part. And significantly, in all countries the most important factor that influenced students’ rates of satisfaction and dissatisfaction was student perceptions of justice and participation in the development of school policies. And in Latvia and Slovakia, the second most important factor was support from teachers, while in Finland teachers’ expectations constituted the second most important factor. In Norway, support from teachers was the third (Samdal, Nutbeam, Wold, and Kannas, 1998). The ramifications of these findings are readily applicable to teachers’ efforts to implement a health promotion curriculum: if teachers provide students with social support, manage the classroom with justice, and encourage student participation, they will obtain significantly higher rates of student motivation and engagement. And, as seen, teachers with high perceived self-efficacy, a good understanding of the material, and positive attitudes towards the material are more effective as teachers.

Conclusion

There is a profound relation between teachers’ understandings of the material of a health promotion curriculum, their sense of self-efficacy in teaching it, and their attitudes about doing so. As the literature here presented overwhelmingly demonstrates, teachers’ understandings of a health promotion curriculum are integrally linked to their sense of self-efficacy in teaching it, and both are typically associated with positive attitudes. Acquiring any one of these three elements seems to be a significant predictor of a ‘virtuous cycle’: thus, a teacher who participates in a workshop or other program of in-service training can readily acquire more knowledge about the content and philosophy of a health promotion curriculum, and this will tend to improve their sense of self-efficacy with regard to teaching it. With this deep understanding and sense of ability, the teacher will tend to have a good attitude towards teaching the program. Nor is it difficult to see the reason: teachers who are willing to learn about a new health promotion curriculum are likely to master it and find their positive attitudes reinforced. Such teachers will also tend to have positive outcome expectations: that is, they will believe that their actions will make an effective difference for the students. The evidence here presented demonstrates the importance of all three elements of this easily-initiated virtuous cycle.

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