The Norwegian Network of Health Promoting Schools: A Three‐Year Follow‐up Study of Teacher Motivation, Participation and Perceived Outcomes, Article Review Example

My aim is to gain a deeper understanding of the role played by teachers in taking health promotion curriculum from a developmental stage to a practical one that will instill children with the skills necessary to take a proactive role in their own personal health.  St. Leger’s 1998 article ‘Australian Teachers’ Understandings of the Health Promoting School Concept and the Implications for the Development of School Health’ and Tjomsland and colleagues’ 2009 article ‘The Norwegian Network of Health Promoting Schools: A Three-Year Follow-Up Study of Teacher Motivation, Participation, and Perceived Outcomes’ are related to the subject of health promotion within the educational system and provide substantial information about the successes and limitations of health promotion curriculum in the Australian and Norwegian school systems.  Although not specific to the Cypriot Health Promotion curriculum, both articles enlarge my overall understanding of the reasons why health promotion is a crucial addition to all school curricula, as well as illustrating many universal barriers to creating a comprehensive and sustainable school program that emphasizes healthy lifestyles and choices amongst students, parents, and educators.

Published in Health Promotion International, St. Leger’s article, ‘Australian Teachers’ Understandings of the Health Promoting School Concept and the Implications for the Development of School Health’, discusses a variety of movements within both the European, Australian, and American school systems which have sought to provide children with curriculum that employs a holistic approach that goes beyond mere education of the mind in order to help students develop healthy physical selves through health promotion programs (1998).  St. Leger (1998) acknowledges that successful health promotion programs are largely dependent on the ability of teachers to accept and understand the reasons for merging such campaigns into their general curricula.  While the author has found that a majority of teachers are concerned about the health of their students and are eager to provide their students with tools for better health, St. Leger (1998) found that many teachers are hindered in their efforts to implement such programs due to a lack of preparation and education.

Using international efforts in health promotion as a framework through which to explore the specific needs of educators when attempting to implement health promotion programs, the article focuses specifically on an Australian research study conducted in the early 1990s.  Interview and surveys of teachers demonstrated that a majority of respondents have difficulty looking at health promotion beyond its use within the classroom, and were often ignorant of the resources available to them and the manner in which family and community partnerships could be used to improve the programs’ likelihood of success (St. Leger, 1998).  While the overall enthusiasm and acceptance of the majority of the respondents when presented with the opportunity to discuss health promotion within their schools was a positive outcome of the study, illustrating that Australian primary school teachers are generally open to expanding their curriculum to include health promotion, St. Leger (1998) points out that their are a number of key areas that may act as roadblocks in future efforts to create a long-term health promotion program within Australian schools.  Among these is a lack of integration between schools and health services organizations/personnel, the challenge of motivating school administration to support curriculum changes in the area of health promotion, and the continued need for teachers’ continued professional development (St. Leger, 1998).  Many teachers surveyed in the study had difficulty expressing what a ‘health promotion school’ looked like to them, primarily because they had not been exposed to any successful examples of schools who had been able to integrate health promotion into the overall curriculum of their institutions (St. Leger, 1998).  While health promotion curriculum presents an opportunity for educators and administrators to create programs which will allow them to address the health concerns of both their students and society, St. Leger (1998) emphasizes that health promotion efforts “will only be successful if teachers can understand it, interpret it, and shape it to meet the needs of their school community” (p.234).

Research conducted by Tjomsland and colleagues (2009) and reported in their article ‘The Norwegian Network of Health Promoting Schools: A Three-Year Follow-Up Study of Teacher Motivation, Participation, and Perceived Outcomes’ touches on many of the same areas as St. Leger (1998), including the perceptions that teachers have towards health promotion programs and the manner in which their attitudes can help or hinder the success of such programs.  The article points out that teachers wield a great deal of power when it comes to influencing the behaviours of their students and can be viewed as a largely untapped resource for improving the health behaviours and attitudes of their students (Tjomsland et al., 2009).  As agents of change, teachers are uniquely positioned to take on a greater role within the classroom in order to engage in health promotion campaigns; similarly, such programs may have difficulty succeeding if teachers are disinterested, uninformed, or resistant to change (Tjomsland et al., 2009).

The health promoting school can be defined as an institution which takes a “multifaceted approach [in] combining health education in the classroom with a healthy school environment, school health policies, collaboration with parents, and community, and reoriented school services” (Tjomsland et al., 2009, p.89).  Thus, this article evaluates research which was conducted at ten Norwegian schools which were already participating in the European Network of Health Promoting Schools (ENHPS), an educational network which seeks to develop support and alliances throughout over 40 European countries regarding health promotion in schools.  Although the survey was conducted annually between 1994 and 1998, Tjomsland and colleagues (2009) chose to review data from 1994 and 1997 in order to determine whether teachers’ initial motivation regarding health promotion programs is sustainable over a period of three years.

The researchers examined how teachers’ attitudes towards health promotion may have changed  during the program, the role that their expectations, general attitude, and intentions played in their ability to participate in health promotion activities, and whether their expectations and intentions during the 1994 survey had been substantially altered when researchers re-interviewed them in 1997 (Tjomsland et al., 2009).  Their research indicated that, overall, those teachers who were most positive about their potential involvement in health promotion programs continued to demonstrate a positive attitude in the subsequent survey; indeed, Tjomsland and colleagues (2009) suggest that positivity and an openness to curricular change tends to be self-perpetuating.  The researchers also found that 80% of those surveyed reported during the three-year follow-up that health promotion curricula had been successfully developed, although not all of the respondents had been personally involved in the development of the program.  Tjomsland and colleagues (2009) attribute the statistically high number of positive reports at the follow-up point to the likelihood that “the more teachers invest in a  program, the more they want the program to succeed, and the more positive their reporting of outcomes will be” (p. 99).  Overall, the researchers suggest that health promotion programs are more likely to become a long-term and sustainable portion of the general curriculum when teachers themselves believe in the viability and effectiveness of such programs, thereby creating an environment in which teachers are motivated to participate and implement health promotion interventions within the classroom (Tjomsland et al., 2009).

Both the Australian and Norwegian research studies employed a methodology which used a combination of quantitative and qualitative methods to gather relevant data.  While the research conducted by Tjomsland and colleagues (2009) relied heavily on the use of questionnaires and the statistical analysis of information gathered by these questionnaires over time, the research conducted by St. Leger (1998) based many of its findings on in-person interviews and focus groups.  Thus, it could be said that although both studies used multiple methods in their research, the Norwegian study was more heavily invested in a quantitative approach while the Australian study took a more qualitative approach.

Specifically, St. Leger’s (1998) research began by taking a more generalized survey of Australian teachers’ understanding of school health, and then became more specific as the researchers focused on teachers’ own perceptions of how health promotion programs could be developed, implemented, and improved within their schools (St. Leger, 1998).  The methods used by researchers employed four distinct phases in which to gather and evaluate data.  Phase 1 involved teachers at three schools that claimed to be already using health promotion within their curriculum and asked these teachers to take photographs demonstrating how health promotion was being implemented within their institutions.  Researchers followed up with the teachers two weeks later through individual interviews in which they were asked to explain their photographs (St. Leger, 1998).  Phase II built upon the findings of the first phase and  used five focus groups to rank and discuss the photographs that were taken in Phase 1.  Phase III used the results of the first two phases along with health promotion literature to create, distribute, and evaluate a questionnaire which was sent to a broad range of teachers (St. Leger, 1998).  The fourth, and final, phase involved a focus group interview of eight teachers in order to determine whether their expectations of health promotion programs was in line with previous data collected (St. Leger, 1998).  St. Leger (1998) supports the methodology used in his research by writing that

the use of both qualitative and quantitative methods and the

shaping of one phase by the preceding one(s), provides

opportunities for triangulation of data and accuracy in

mapping and explaining teachers’ understandings of a concept,

framework, or phenomenon. (p.224)


This approach echoes, in a sense, the methods used by Tjomsland and colleagues (2009) despite the fact that the Norwegian study took a much more quantitative approach.  Nevertheless, the researchers used the follow-up component of their study as an opportunity to refine and redefine their researchers’ strategies while also seeking to determine what, if anything, had changed amongst respondents’ attitudes towards health promotion.  Although data was collected annually between the years of 1994 and 1998, Tjomsland and colleagues (2009) chose to review only two periods when conducting their current research.  Although 200 teachers originally participated in the study in 1994, Tjomsland and colleagues (2009) found that only 104 had responded to the questionnaires in both 1994 and 1997 when analyzing the longitudinal data.  The baseline for the study was the initial 1994 survey, which achieved a response rate of 96% as compared to the 75% response rate in 1997.  The questionnaire itself looked at four areas:  demographic variables, health and lifestyle, working conditions, and the respondents’ perception of the project and motivation to participate in the project; Tjomsland and colleagues (2009) note that for the purposes of this particular paper, the most important aspect of the study was concerned with the teachers’ expectations, attitudes, and participation in health promotion activities.

The methods and methodology employed in both studies appears to be justifiable, especially because the use of both qualitative and quantitative methods allowed for both the Australian and Norwegian studies to evaluate their subject matter using two distinct, yet complementary, approaches.  In the case of St. Leger’s (1998) study of Australian teachers, the author himself points out some of the difficulties that may be encountered when a study is primarily quantitative, and therefore somewhat subjective.  Among these is the danger that the interviewer may play a role in influencing the responses received from the subjects; however, St. Leger (1998) addresses this issue by stating that “the perceived disadvantages of reliability of data from subjects with different opinions and beliefs is outweighed by the potential of the interview to provide rich and illuminating data” (p.225).

Additionally, the methodology of this study was improved upon through the use of a “step-wise discovery approach” (St. Leger, 1998, p.225) which allowed each subsequent phase to determine the appropriate methodology to be employed throughout the research process, allowing for researchers to refine their questions and methods based on the findings in the initial phases.  As well, the researchers were rigorous in their collection of qualitative data, employing tape recorders to ensure the accuracy of respondents’ statements; St. Leger (1998) emphasizes that recording devices were used to further understand the teachers’ comments in regards to “a variety of stimuli, namely photographs, individual and group tasks, and reactions to assertions” (p.225).  While qualitative methods dominated in the first two phases of St. Leger’s research, the information that was gathered through questionnaires and focus groups enabled the study to use statistical tests to find patterns and correlations within the data, leading to findings which involved quantitative data assertions based upon the original questionnaires (St. Leger, 1998).

The methodology and methods of the Norwegian study are equally justifiable, and researchers have put a great deal of effort into cataloguing, analyzing, and discussing various aspects of their quantitative data collection methods.  In conducting statistical analysis, Tjomsland and colleagues (2009) used both descriptive analyses on the study variables while also conducting Independent Sample t-tests to determine whether gender played a role in the teachers’ responses to the questionnaire.  When taking into account differences between the 1994 baseline and during the follow-up in 1997, researchers used both Spearman’s Rank Order Correlation and the Chi-square along with stepwise regression analyses to further understand the relationship between independent and dependent variables (Tjomsland et al., 2009).  The researchers suggest that their study was both reliable and valid because the data analysis instrument itself was developed through a university research centre which also acts as a resource centre for health promoting schools (Tjomsland et al., 2009).  Additionally, qualitative methods were used to make sure that the questionnaire was relevant to the study and easily understood by participants through discussions between teachers, school health promotion experts, and research team members (Tjomsland et al., 2009).

The biggest strength of the Australian study was the level of detail which it provided when exploring the attitudes, opinions, and ideas which teachers had in regards to working within a health promotion framework in their schools.  The progressive format of St. Leger’s research allowed for an in-depth analysis of teachers’ understanding of health promotion concepts in four distinct areas:  the structure of health promoting schools; the personnel required to implement this framework;  the manner in which the health sector and the educational sector can work together; and the professional development and resources needed to support teachers as they implement health promotion curriculum (St. Leger, 1998).  The one-on-one attention provided by research staff towards teachers in conducting interviews also enabled for a greater level of depth than if the study’s methodology had remained limited to questionnaires.  Researchers were able to take into account body language and conversational pauses which illustrated hesitancy or confusion on the part of the participants; for example, in looking at the social environment of schools and the manner in which this environment can encourage or inhibit the creation of a sustainable health promotion curriculum, many respondents found this area difficult to articulate (St. Leger, 1998).  As St. Leger (1998) writes, “of all the six components of a health promoting school, it is the social environment which was the most difficult for teachers to describe and define.  Teachers couldn’t photograph it, but in their stories about the photographs, referred to it constantly” (p.231).  Thus, the interviews and focus groups were successful in accessing information that might not have been gathered through alternative methods, allowing respondents to create a narrative which best expressed their feelings, apprehensions, and ideas about working within a health promotion framework.

Ironically, one of the projects greatest strengths is also its greatest weakness:  although the relatively small sample size allowed for a greater level of intimacy between researchers and respondents, it also limited the discovery of whether the study’s findings are universal to teachers beyond the Melbourne area.  Unlike Tjomsland and colleagues’ study, St. Leger (1998) does not provide detailed information about his sample size or demographic breakdown, merely noting that the overall study involved between three to five schools in the metropolitan Melbourne area.  One of the other possible problems with this study is the manner in which teachers were chosen for involvement in the project:  in Phase 1, teachers were drawn from schools which were already addressing school health issues; in Phase 2, the five focus groups were chosen at random from primary schools in the eastern suburbs of Melbourne; in Phase 3, the schools themselves were chosen randomly, but “principals were invited to choose teachers involved in school health programs to complete the survey” (St. Leger, 1998, p.224).  It seems possible, then, that the teachers used in this study may be more likely than the average teacher to have an awareness of and interest in health promotion in schools, given that they were already involved, to some extent, in the development and implementation of such programs prior to St. Leger’s study.  It would be interesting to contrast their responses against those of teachers drawn from populations in which health promotion has not yet been addressed as an issue needing consideration within schools.

Tjomsland and colleagues (2009) comparative study of questionnaire results from Norwegian teachers in the base-line year of 1994 and the follow-up year of 1997 is most beneficial because it provides quantitative evidence regarding teachers’ ability to maintain a positive and proactive attitude that is dependent both on their initial motivation and the level of resources that are provided to them over time.  Indeed, the strength of this research lies in its comparative methodology and the manner in which quantifiable data was used to predict outcomes in the follow-up study, both of which provide an opportunity for future researchers to use Tjomsland and colleagues (2009) research as both a resource and a starting off point when expanding studies into other regions.  As well, the level of detail provided with the questionnaires themselves allows for this study to continue well beyond the five-year window that researchers used, inviting future researchers to revisit this population to determine whether the positive attitudes and high motivation levels of teachers remained a constant.  As with the St. Leger (1998) study, Tjomsland and colleagues (2009) note that the sample group studied may have been predisposed to having a more positive attitude towards health promotion programs because the schools from which they were drawn were already active in developing such curricula.  As Tjomsland and colleagues (2009) write, “membership in the [ENHPS] network was based on consensus in staff, and as such most teachers probably perceived social norms favouring participation in program activities” (p.99), a position which was compounded by the confidence that many teachers felt given that their institutions supported the development of health promotion activities.

The biggest weakness of the Norwegian study stems from the fact that data was gathered from teachers through self-reporting, a method which may be limited in its accuracy and objectivity (Tjomsland et al., 2009).  As the authors write when addressing the limitations of their study, “having been involved in the program, the teachers may be biased in reporting positive outcomes; for example, they think students’ school satisfaction has improved because of their own involvement in program activities” (p. 99).  This aspect of the study may have been improved by drawing from a more diverse spectrum of teachers, especially given the authors assertion that their inclusion criteria and response rates amongst teachers tended to overly favour permanent staff already invested in health promotion curricula, thus disregarding temporary and part-time teachers and those who work in schools that had a less defined or non-existent approach to health promotion.  While both the Norwegian and Australian studies were very thorough in their methods and sought to acknowledge the weaknesses that arose in terms of their methodology, future research may benefit from combining the methodologies of St. Leger (1998) and Tjomsland and colleagues (2009) by using both a detailed questionnaire format and in-person interviews and focus groups.  Specific to the Norwegian study, the research may have also been improved by generating survey questions which addressed the specific needs of individual teachers and institutions rather than taking a more general approach which limited the data gathered in terms of teachers’ individual experiences, concerns, and ideas.

The articles by St. Leger (1998) and Tjomsland and colleagues (2009) will greatly assist my own research project, especially in terms of how I develop my own methods and methodologies.  While I am aiming to utilize both quantitative and qualitative methods within my study of Cypriot teachers, I can now see the strengths and limitations of both methods.  Because I intend to deal with a much smaller sample size than was used in the Norwegian study, I can definitely see the benefit of employing a primarily qualitative method through the use of personal interviews, focus groups, and a step-stage approach which would allow me to build my research through a series of phases.  Tjomsland and colleagues (2009) note that the generalizability within their study sample was one of its largest weaknesses; obviously, my study will be developed so as to be specific to the needs and experiences of Cypriot teachers.  While there is likely a universality to teacher experiences in relation to health promotion, I will strive to discover whether there are elements which are unique to Cyprus.  Tjomsland and colleagues (2009) also note that the aims of educators may sometimes be at odds with those looking to implement a health promotion program.  This is an area which I would like to research further in order to determine whether Cypriot teachers believe that health promotion curriculum can be used to build strong relationships both within the institution itself and amongst external but related groups.  Tjomsland and colleagues (2009) suggest that teachers are inclined to participate in school development programs if they believe that the program will result in improved relations with other in their work environment” (p.100) including parents, community groups, and local health services.  If I opt to go with a questionnaire and interview methodology, I would like to include this as an area of exploration.  The research conducted by both Tjomsland and colleagues (2009) and St. Leger (1998) suggests that the simplest aspect of developing health promotion programs is to motivate teachers to participate; where it can get more difficult, they suggest, is in ensuring that this motivation is sustainable, something which is difficult to accomplish when teachers lack support within their institution or the larger community.

While St. Leger (1998) acknowledges that health promotion programs have the opportunity to greatly improve the school experiences and long-term health needs of students through the development of a student-teacher partnership, he states that it can only be successful if teachers are able to understand the basic concepts and philosophy so that they may integrate them into the classroom while also receiving support, resources, and professional development from administrators and the community over the long term.    By modelling my survey questions and approach after the Norwegian and Australian studies, I hope to build upon some of the lessons learned in those respective studies so that I may gain a greater understanding of the attitudes possessed by Cypriot primary school teachers toward incorporating health promotion into their curriculum, whether they feel that they are knowledgeable enough in this area to accomplish such a task, and how the philosophy that underlies the Cypriot Health Promotion curriculum may assist in broadening their understanding of the successful implementation of this program.  Tjomsland and colleagues (2009) emphasized that future projects of a similar nature may benefit from comprehensive and in-depth case studies of individual schools that take into account the specific experiences of teachers, students, and administrators, a conclusion which provides me with a possible direction for my own research so that I may contribute to the field through the collection of concrete data regarding health promotion curricula.

Reference List:

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, vol. 13, no. 3, pp. 223-235, viewed 11 Jan 2012,

Tjomsland, HE, Iverson, AC, & 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, vol. 53, no. 1, pp. 89-102,