HealthLit4Kids: Dilemmas associated with student health literacy development in the primary school setting

Abstract

Objective:

To ascertain teachers’ articulation and experiences of navigating dilemmas that inhibit and/or enable the fostering of health literacy in primary school settings.

Design:

Qualitative analysis of teachers’ written reflections on introducing health literacy into their school and classroom.

Setting:

Tasmania, Australia.

Method:

Eighty-four teachers in five primary schools participated in the HealthLit4Kids programme. Teacher reflections were collected at the conclusion of the first year of the programme and assessed using Windschitl’s Dilemmas to identify recurrent themes raised by the conceptual, pedagogic, cultural and political dilemmas teachers faced.

Results:

Key dilemmas faced by teachers concerned the development of a whole-of-school approach, student engagement and professional development.

Conclusion:

Internationally few health literacy programmes for primary schools exist. The theory developed from the themes identified in this study will inform future health literacy programme design and implementation strategies. Purposeful consideration of each theme will guide their success, scalability and sustainability. Future research on the role of constructivist teaching styles in health literacy development in the school setting is urgently required.

Keywords

Health literacy HealthLit4Kids primary schools professional development whole-school approach

Introduction

Health literacy (HL) is an important component of the Australian Curriculum Health and Physical Education (HPE). HPE is one of eight dedicated Learning Areas within the Australian Curriculum which sets out Achievement Standards and HPE content elaborations for students from Foundation through to Grade 10. According to the Australian Curriculum and Assessment Authority (ACARA, 2019), HPE is organised into two distinct content strands: ‘Personal, Social and Community Health’ and ‘Movement and Physical Activity’. Underpinning the content and design of HPE are five foundational propositions, described as ‘Key Ideas’, one of which is to ‘Develop health literacy’ (ACARA, 2019).

The explicit presence of a direction to teachers to cultivate HL is indicative both of its significance and role in contributing to HPE outcomes (Alfrey and Brown, 2013; Macdonald, 2013). Despite its inclusion in the curriculum framework, research (Bröder et al., 2017; Nash et al., 2020, in press; Paakkari et al., 2018; Paakkari and Okan, 2019) indicates that the teaching of HL can be challenging for teachers. To better understand the nature of these challenges, there is value in looking at enablers and inhibitors to achieving HL outcomes in classroom situations. Providing opportunity for teachers to share, reflect upon and articulate the ways in which they teach HL enables the identification of the challenges experienced.

This qualitative study reports from an analysis using Windschitl (2002) framework of dilemmas to consider the complexity of concerns among teachers delivering HL teaching in primary schools. Windschitl (2002) developed a framework that examines constructivist teaching from a phenomenological ‘constructivism in practice’ perspective. The framework considers the tensions that characterise ‘reform teaching in general and teaching for understanding in particular’ (p. 132) through four frames of reference which he called ‘dilemmas’ (Windschitl, 2002).

HL in the Australian curriculum

The Australian Curriculum HPE is one of the few curricula internationally to explicitly focus on fostering HL in students (Alfrey and Brown, 2013; McCuaig et al., 2012, 2014). As one of the five key ideas underpinning the development of the Australian Curriculum HPE, HL is defined as ‘an individual’s ability to gain access to, understand and use health information and services in ways that promote and maintain health and wellbeing’ (ACARA, 2019). The Australian Curriculum describes three aspects of HL (functional, interactive and critical) to be developed using a strengths-based approach (ACARA, 2019).

Despite these descriptions, existing knowledge concerning how teachers achieve HL outcomes with their students suggests that teachers require pedagogical guidance to deliver on these goals (Bröder et al., 2017; McCuaig et al., 2012, 2014; Nash et al., in press; Paakkari et al., 2018; Paakkari and Paakkari, 2012; Peralta et al., 2017; Peralta and Rowling, 2018). This points to the need for the provision of resources and professional learning to support teachers in their approach to achieving HL outcomes in the classroom.

The relationship between HL and health education is long established. Scott Simonds first described HL as a product of health education in 1974 (Simonds, 1974), and HL has been acknowledged as an important outcome of health promotion efforts (Kickbusch et al., 2006; Nutbeam and Kickbusch, 2000; Sørensen et al., 2012).

The importance of HL can be seen in the positive relationship between HL, health behaviours and health outcomes (DeWalt and Hink, 2009). HL exhibits a bi-directional relationship with educational attainment (Cummings and Obel-Omia, 2016) and low HL has been associated with poorer health (Mõttus et al., 2014). HL has been shown to help communities achieve health equity and greater social equity (Batterham et al., 2014; Paakkari and George, 2018). While education is posited as an important social determinant of health, HL has been recognised as a social determinant of health in its own right (Bröder et al., 2018) and schools play an important role when it comes to equipping our future generations with HL.

HL in schools

An individual’s HL and associated health attitudes and behaviours are dynamic constructions informed, influenced and created by multiple environmental and social factors (Nash et al., 2019; Stokols, 2000). Schools provide a nexus for these factors to interact (Kilgour et al., 2015; Langford et al., 2014, 2017; Paakkari and George, 2018; Ryan et al., 2012). While adolescence had previously been thought of as the most appropriate time to consider health topics and HL development, contemporary life-course research suggests adolescence may be too late, thus justifying a focus on HL in the primary school context (Borzekowski, 2009; Bröder and Carvalho, 2019). Specifically, primary schools provide a key setting in which to support children to develop HL skills at an impressionable age (Fernandez-Jimenez et al., 2019; Hill et al., 2020). Furthermore, health attitudes and behaviours formed during childhood greatly influence adult health patterns, with experts internationally stressing the critical role that schools play in helping students achieve HL (Bröder et al., 2017; Deal et al., 2010). Paakkari and Paakkari (2012) usefully outline the key components of HL and encourage teachers to focus on the kinds of learning conditions needed to develop HL in schools. Class teachers, having an in-depth appreciation of their learners’ worlds are particularly well placed to teach HL education within the school context.

Internationally, few HL programmes currently exist in primary schools (Bröder et al., 2017; Nash et al., in press; Peralta and Rowling, 2018). In addition, teachers have highlighted several obstacles for focusing on health in schools, including competing priorities for curriculum time, lack of professional learning resources, uneven and sometimes ad hoc support from health services, and significant gaps between policy and practice (Basch, 2011; Leger and Nutbeam, 2000; Marks, 2010; Peralta, 2012).

The nature of interaction between teachers and students within learning environments has direct implications for HL, and therefore warrants further exploration. Such exploration is critical for being able to articulate the specific support and resources teachers require to successfully deliver agentive health education learning experiences in school settings (Pill, 2006). Evidence suggests that the most appropriate learning tasks and pedagogies for developing HL assets (Nutbeam, 2008) also need to be understood better and prioritised (Peralta et al., 2017; Ryan et al., 2012). Supporting teachers in their navigation of factors that impact on HL development is essential for ensuring children have meaningful opportunities to become health literate during their time at school (Nash et al., 2018).

HealthLit4Kids – a school-based intervention for HL

Responding to the identified paucity of HL programmes (Bröder et al., 2017; Nash et al., in press; Peralta and Rowling, 2018) assisting primary school teachers to develop their students’ HL, HealthLit4Kids (Nash et al., 2018) was developed to raise awareness of, and improve, HL.¹ Consistent with the aims of the Australian Curriculum, HealthLit4Kids builds on both cognitive and social constructivist principles, and focuses on teachers, children and their communities. HealthLit4Kids was co-designed with school communities to respond to the growing burden of avoidable non-communicable diseases and other locally relevant health issues. Primary school teachers have reported lacking confidence in teaching health or accessing credible resources to inform their teaching (Deal et al., 2010; Nash et al., in press). Therefore, the HealthLit4Kids programme sought to build the capacity of teachers to support students with HL development early in their schooling and understand teachers’ perspectives about including aspects of health within the curriculum. With an explicit focus on HL development opportunities, the programme culminates in an expo in which the children demonstrate and share their learning through creative works or artefacts² with the whole-school community.

The Australian Curriculum for HPE is orientated towards engaging students in their own HL development through the scaffolded acquisition of skills, knowledge and understandings pertaining to health. To synergise with this constructivist orientation, HPE teachers and classroom teachers must actively engage in ongoing reflection pertaining to the pedagogical assumptions they bring to HPE in their classrooms (Fyall, 2017). Central to constructivist pedagogy is the need for teachers to create learning environments that allow for critical thinking, questioning and discussion within a power neutral classroom (Macdonald, 2013). That said, constructivist ways of teaching health education for ‘making meaning’ are contingent upon a teacher’s capacity to understand socially contextualised and constructed aspects of health in their classrooms (Fane et al., 2019). This examination of teachers’ experiences participating in HealthLit4Kids, an example of a school-based HL intervention programme, explains how this kind of programme can enable and inhibit concurrent HL outcomes for both students and teachers.

Methods

This study explores some of the challenges encountered by teachers who participated in the first year of the HealthLit4Kids programme, as captured in qualitative data comprising written reflections. These reflections were analysed using Windschitl’s (2002) constructivist teaching dilemmas framework, to identify recurrent themes raised by the conceptual, pedagogical, cultural and political dilemmas teachers (outlined in Figure 1) encountered while implementing the HealthLit4Kids programme in their respective school settings.

Figure 1.

Windschitl’s four dilemmas definitions and representative questions.

The four-part descriptive model outlined by Windschitl (2002) reflects a continuum from the personal and intellectual concerns (dilemmas) of the teacher to the structural and public concerns of the school and community. The constructivist dilemmas identified by the model provide a theoretical framework with which to examine teacher’s reflections on their experience of fostering HL development in their school and classroom.

In recognition of how procedures, expectations, organisation and knowledge are co-created and constructed in HPE classrooms (Harvey et al., 2020), this study adapted a question from Porath’s (2016) work to examine

What can we learn from teachers’ experiences of cultivating HL through the HealthLit4Kids programme when examining them through Windschitl’s constructivist dilemmas?

In articulating the prominent themes emergent from our analysis in the light of Windschitl’s four dilemmas, this study unpacks the ways in which constructivist approaches for cultivating HL can manifest for teachers and students in the HealthLit4Kids programme. By so doing, we illuminate the ways in which the HealthLit4Kids programme concurrently supports teachers to navigate specific teaching dilemmas associated with cultivating student HL development in an Australian primary school setting. The research design is summarised in Table 1.

Table 1.

Summary of research design.

Epistemology	Theoretical perspective	Approach	Theory	Methods	Participants
Interpretivist	Constructivist principles	Qualitative	Windschitl’s Dilemmas	Teacher written reflections	Teachers

Participants

Participants in this study included 84 teachers (70 women, 14 men) from five Tasmanian primary schools with different demographics (Table 2).

Table 2.

School demographics and participants.

School	Date of final workshop	Location	TSCA^a accredited	MWEW^b School	SEIFA^c,d Decile (within Australia)	Number of children	Number of teaching staff	Number of teachers responded
1	22 November 2017	Inner Regional	Yes	Yes	8	297	18	11
2	6 November 2018	Inner Regional	Yes	Yes	2	289	27	18
3	20 November 2018	Inner Regional	No	No	1	176	15	6
4	31 October 2018	Inner Regional	No	Yes	7	597	43	32
5	21 November 2018	Outer Regional	No	Yes	2	366	29	17
Total								84

SEIFA: Socio-Economic Indexes for Areas.

Tasmanian School Canteen Association (TSCA) accreditation indicates if schools are gold, silver or bronze based on canteen management and promotion of healthy eating.

Move Well Eat Well (MWEW) member schools can access healthy eating resources and support from the Department of Health and Human Services Tasmania.

SEIFA score is an indicator of the relative socio-economic advantage or disadvantage in an area on a scale with a mean of 1,000 and standard deviation of 100.

SEIFA decile is an indicator of the areas SEIFA distribution in 10 equal groups (where 1 is the lowest score and 10 is the highest).

Instrumentation

Teachers completed a written reflection in response to a series of guiding questions (Appendix 1). The questions encouraged teachers to reflect on and evaluate their teaching of the programme, both in individual classrooms and in the school ‘as a whole’. The evaluation included reflections on their own learning and the learning of their students.

Procedure

HealthLit4Kids includes three professional development workshops over 12 months. The data in this paper were collected at the final workshop conducted at the end of the first year of the programme in each school. This workshop focused on providing teachers with the opportunity to reflect on the first year of the programme, and identify strengths, highlights and areas for improvement for the second year. The study was approved by the Social Sciences, Human Research Ethics Committee of Tasmania (Approval number H16289, H17189).

Analysis

The teacher reflections were analysed in four steps. The first step involved an inductive content analysis conducted by one of the researchers (R.N.) to preliminarily code the data (Lincoln and Guba, 1985). A line-by-line analysis was undertaken, ‘separating [the data] along their boundaries and identifying them for subsequent analysis’ (Lincoln and Guba, 1985: 203). In a second step, data were categorised by taking related text segments and grouping them according to one of the four dilemmas. This process was conducted by two of the authors (R.N. and S.P.) (Lincoln and Guba, 1985). The initial categories developed by R.N. and S.P. were compared and re-evaluated by V.C. who undertook selective coding to further reduce the data initially assigned to each of the four dilemmas. R.N., S.P. and V.C. then undertook a final analysis to agree upon the assignment of themes within the dilemmas (Strauss and Corbin, 1990). To conclude the process, a meta-analysis across the four dilemmas was undertaken to develop the final themes.

It is important to acknowledge that R.N. co-facilitated workshops with the teachers in three of the five schools. V.C. and S.P. were not involved in project implementation in schools, and so were able to contribute greater independence to the assessment of themes and data.

Results

Analysis of teachers’ reflections led to the identification of three key themes spanning all four of Windschitl’s conceptual, pedagogical, cultural and political dilemmas of relevance to teachers’ participation in and enactment of the HealthLit4Kids programme:

First, a whole-of-school approach emerged as significant to how different classes and areas of the school contributed to developing an increased awareness and knowledge of health and well-being within the school community, enhancing learning opportunities within and between classes, using common HL language in lessons and conversations;

Second, student engagement deriving from the constructivist aligned, student-centred approach adopted by HealthLit4Kids revealed how students were able to see the importance of improving their HL, and how their engagement and excitement had a positive influence on the programme.

Third, teacher development centring on teachers’ articulations of and reflection on awareness of gaps in their own HL featured prominently, as did teachers’ articulations of how they developed their HL knowledge, personally, and in terms of integrating the teaching of this knowledge into other subject areas.

Examples of quotations from teachers relevant to these three themes across all four dilemmas are presented in Table 3 and discussed below.

Table 3.

Themes and example quotes identified across all four of Windschitl’s dilemmas.

	Conceptual	Pedagogical	Cultural	Political
Whole-school community	I have developed a greater understanding of the HealthLit4Kids project and the importance of health literacy in our school community and wider community. (Teacher 16)The change in the language in the student self-talk have been very evident in their changed behaviour and wiliness to take risks in the classroom. (Teacher 52)	Hearing and seeing the children throughout the whole school involved in the program has been a huge development for the school. Child took ownership at the expo and were proud of their learning and increased knowledge of healthy eating. We had great feedback from parents about the expo. (Teacher 2)The cross-school sharing of work in mental health, strategies to reach calmness and personal stories in mandalas were very useful. (Teacher 7)	Staff were enthusiastic and we have had a great response from students and parents and have seen obvious changes in the choices students and parents are making towards healthier choices. (Teacher 28)Helped establish a common language within our school, I am noticing ‘buzz’ words such as ‘sometimes’ and ‘always’ foods filtering through teacher and student language. (Teacher 47)	Motivating children was easy e.g., healthy lunch boxes and the value of exercise. Having teachers buy into it was initially slow but once involved, the momentum generated was contagious. We loved how engaged students were and their enthusiasm was infectious. (Teacher 42)With effort, a whole school focus it is possible to embed student learning across the school. The focus of ‘create a lunchbox’ was engaging and very worthwhile. (Teacher 34)
Student engagement	I have learnt that there are so many aspects of HealthLit that arise in the classroom. Offering kids realistic experiences was the best way for them to develop their health literacy and understanding of their choices. (Teacher 43)It has been really beneficial putting HL into practice and seeing students’ engagement and excitement for it. (Teacher 28)	The students were highly engaged and motivated at all times. The children have a greater understanding of health and well-being and it is a topic that we are continually focusing on. (Teacher 16)I have learnt the importance of incorporating health literacy across a broad range of curriculum areas and how it can be an underlying theme. Having the students engaged and interested in their learning was rewarding. (Teacher 21)	Rewarding: children were proud and excited about sharing healthy lunchboxes; seeing children explain their understanding; children proud at their healthy habits; whole school Expo – loved seeing the work of all classes. (Teacher 32)Most rewarding was the enjoyment the students got out of actually building their artefact. Students were eager to show off their learning. (Teacher 18)	Definite changes in children’s understanding of health and well-being – food choice is often not their choice but a matter of convenience for busy parents. (Teacher 19)I found the expo the most challenging, yet also the most rewarding part of Health Lit. It was wonderful celebrating the success of all the students across the school. (Teacher 61)
Teacher development	I didn’t realise how broad Health Lit 4 Kids was. In the end I selected bullying and resilience as my focus as it was very applicable to my year group. I was thrilled with the unit and my new-found awareness of health literacy. (Teacher 61)I have developed a greater understanding of health literacy and the health networks available to support my teaching of health literacy. (Teacher 5)	Having begun this program, I am now continuing into 4th term and plan on doing it for the whole year, next year. (Teacher 12)During the project I found it very easy to link our topic with multiple areas across the curriculum. This allowed students to engage with the tasks on many levels, bringing different experiences and prior learning to their work. (Teacher 23)	There are many ways to include HL topics in busy curriculum. Teachers and parents, I’ve spoken to have praised the ideas, importance of skills/knowledge at a young age, especially resilience. (Teacher 38)Students have more of an understanding of health issues and difficulties facing society. Obviously mental health is very much in the media and it is so much easier to talk to kids about it than I thought it would be. (Teacher 75)	The most challenging part has been that the time required to add this to our curriculum and contribute to the expo (even though it was a wonderful way to ‘spread the word’ through the wider school community). (Teacher 59)Challenges that are faced are time and the unknown of a new project. Not knowing the expectations of artefacts or showcase was a little unnerving but set us up well for next year. (Teacher 20)

HL: health literacy.

Discussion

While the teacher’s dilemmas appear to be compartmentalised into four discrete categories, in reality, the dilemmas are interrelated. The point where they intersect provides an opportunity for programme developers, teachers and policy makers to gain efficiencies and design programmes for greater success, sustainability and scalability.

Whole-of-school approach

Teacher’s reflections highlighted the programme’s efficacy as a whole-of-school approach to overcome the conceptual, pedagogical, cultural and political dilemmas teachers encounter when supporting their students to develop HL. This finding aligns with the recommendations of researchers (e.g. Langford et al., 2015; Nutbeam, 2000; Paakkari, 2015; Paakkari and Okan, 2019) who have advocated for a whole-school approach to the development of HL.

Despite this apparent consensus, reviews of HL programmes in primary schools (Bröder et al., 2017; Nash et al., in press; Ormshaw et al., 2013) have found that few primary school HL programmes incorporate a whole-of-school approach. The whole-of-school focus employed by HealthLit4Kids seems to have been a major contributor to the perceived success of the programme and increased awareness and the status of health and well-being in participating schools and their communities. Participants stated that ‘having the entire school focused on the project together increased participation with individual students and their families’ (Teacher 72) and ‘the most rewarding part [of the project] was working as a whole school and in collaboration with the wider community to provide a broad and engaging way to expose the concept of HL to students, staff and families’ (Teacher 39).

More specifically, this approach was seen as leading to positive changes, such as healthier lunchbox contents and increased awareness of preventive strategies to deal with mental health problems. In addition, the HealthLit4Kids expo and the artefacts supported shared learning opportunities within and across classes and grade levels, so students could learn from the artefacts produced by learners in different classes who had focused on different topics. Teacher 39 noted that students also ‘reflected on the learning and opportunities for health literacy within their community’. The synergies and momentum this learning created extended across the school and into the local community, resulting in substantial parent engagement (Nash et al., 2020).

Written teacher reflections highlighted common language being used to describe and understand HL in each school community. Conceptually and pedagogically, teachers recognised the importance of exposure and attainment of a shared health vocabulary as critical to developing each child’s HL. Children could be heard in the classroom and out in the playground conversing in this new-found health language. As Teacher 15 noted, ‘I have noticed when talking to children that they are able to tell me what “sometimes” and “always” foods are. They have begun to label foods as healthy and some strong ideas about sugar have formed. In addition, the artefacts provided an age-appropriate voice that led to conversations about health, which may not otherwise have been initiated. In the classroom with peers and at the expo with peers, teachers, family members and local community, the children’s artefacts allowed them to apply new-found HL competencies (Paakkari et al., 2018; Paakkari and Paakkari, 2012), and provided a visual cue or ‘talking point’ to stimulate new conversations utilising their new-found health vocabulary.

Student engagement

A constructivist classroom adopts a student-led approach to learning in which HL assets can be developed (Nutbeam, 2008), whereby children build upon their previous knowledge and understanding to construct meaning about health and well-being in relation to their own lives and experiences. This kind of approach led students to develop greater awareness of the importance of developing HL and seeing clear links between the content of the programme and health decisions they were making each day. Teacher 9 stated that through the programme students ‘start to see links and that health literacy is very broad and takes in so many decisions they make every day. They can see that the decisions they make impact on themselves and people around them daily’.

This linkage was amplified by each school choosing health topics that were responsive to the needs of local communities. The fact that students could see strong links between the programme and their everyday lives appeared to have a positive influence on their engagement, with teachers using terms such as ‘pride’, ‘excitement’ and ‘enthusiasm’ to describe the engagement of their students. For example, Teacher 10 reported that ‘student buy in was also great with huge enthusiasm and engagement’ and Teacher 1 stated ‘as a teacher, I have been excited by the enthusiasm of students’. These findings align with previous research (Boberova et al., 2017; Nash et al., 2020; Paakkari and Paakkari, 2012), which noted that students are more engaged if they can see the relevance of the content they are being taught and their perspectives are considered.

Interestingly, student engagement seemed positively influenced by the knowledge that their artefacts would be shared with their families and wider school community. Teachers indicated that students found that showcasing the artefacts provided a platform for them to advocate for the health of themselves and their family and friends. Teacher 32 stated that one of their most rewarding aspects of being involved in the programme was seeing ‘children becoming HealthLit4Kids heroes – advocating for their own health and others’, while Teacher 23 noted that ‘students were very excited about the HealthLit4Kids expo. It was really rewarding to see students engage positively with the task and show, and share, their developing understanding about healthy lunchboxes etc’. This finding is important as health behaviours established at a young age are known to persist into adulthood and provide protection against non-communicable diseases (Bruselius-Jensen et al., 2017; Deal et al., 2010).

Some students (known as ‘HealthLit4Kids heroes’) were involved in the school’s programme development, providing an additional opportunity to exercise citizenship, which is an important element of HL (Brey et al., 2008; Paakkari and Paakkari, 2012). Primary school students’ engagement in developing HL through a programme such as HealthLit4Kids can reverberate into their home as students’ new-found voices lead intergenerational change in the health behaviours of both themselves and their families (Bröder et al., 2018; Kostenius and Bergmark, 2016).

Teacher development

Primary school teachers are often expected to teach a broad range of subjects including health, which they may not feel confident about or adequately trained in (Boberova et al., 2017; Cruickshank et al., 2020; Deal et al., 2010). Teachers in this study described limited awareness of HL initially but noted personal and professional growth, demonstrated by increased confidence in both their own HL and their ability to integrate HL into other subject areas within their classroom. Teachers described their increasing knowledge and understanding of HL and how their increased confidence to teach HL resulted in better HL outcomes for their students. For example, Teacher 4 wrote

Through participating in the HealthLit4Kids project I now feel more confident that I personally have the resources/capabilities to find out any information required. I now feel as though I am in an important position to help my students become health literate.

Research (e.g. Aira et al., 2014; Formby et al., 2011) has emphasised the importance of good quality teacher training in health, yet few HL programmes internationally offer professional development to teachers (Bröder et al., 2017; Nash et al., in press). The self-reported improvement in HL-related knowledge, understanding and confidence of teachers in this study supports the prioritisation of this training.

Teachers in the study perceived time and organisation were major barriers to their development as HL educators and improving the HL of their students. Yet, they were quick to acknowledge that these barriers could be overcome by the familiarity of doing the programme for the second time, building on the positive momentum and excitement from the first occasion, and making it a focus for the whole school year. Numerous teachers made comments such as ‘[The] programme needs to be started at the beginning of the year so it can be an ongoing learning process’ (Teacher 31) and ‘I think HealthLit4Kids needs to be incorporated throughout the whole year’ (Teacher 54). These perceptions align with findings from previous research (McCuaig et al., 2012, 2014) which suggests that HL needs to be delivered across numerous units of work rather than as a short-term programme. A potential strategy for finding the time to fit HL into an already busy curriculum could be better integration into other learning areas. Participants were cognisant of the importance of doing so and indicated that a start had already been made. Teacher 83 said, ‘I have learned how we are able to integrate teaching health and wellbeing into our teaching practice’ and Teacher 20 commented, ‘it has been very worthwhile for our staff and students to be able to link HL across the curriculum and explore it through an inquiry lens’. Further professional development on constructivist teaching strategies and HL-specific content knowledge may help overcome these perceived barriers.

Limitations

Findings from this study should be interpreted in line with its limitations. First, data were collected at a single time point. Second, we relied on self-report and asked for recall making the data susceptible to social desirability and recall and reporting biases. Third, while teacher reflections provide some useful insights, deeper understanding of the intersections between HL, culture and language is needed. Employing additional methods such as follow-up interviews might provide additional insight into teachers’ understanding of these intersections.

Conclusion

Teacher reflections signalled three key themes that are capable of responding to all four dilemmas: (1) the use of a whole-of-school approach, (2) the promotion of student engagement and (3) support for teacher development. Teachers need both content and pedagogy expertise to introduce a HL perspective in their classroom. Programme designers, policy makers and teachers will achieve greatest efficiency by consideration of the three themes, given all three engage with the dilemmas that stop teachers from teaching in a constructivist way. This is important given how HL development is supported by both cognitive and social constructivist learning strategies. The theory developed from the themes informs HL programme design and implementation and provides guidance for future success, scalability and sustainability. Further research is required to understand the optimal conditions required to foster HL development in children and deepen our understanding of the role of culture and language in HL development in the school setting. Given increasing global recognition of the importance of developing HL assets early in the life-course, this research has local, national and international significance.

Footnotes

Appendix 1

Teachers were invited to complete a written reflection/survey which included the following questions:

Acknowledgements

We thank Kira Patterson, Casey Mainsbridge, Eliza Burke, Suzie Waddingham and Linda Murray for their help with workshop facilitation, data collection and proof reading.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article. The Tasmanian Community Fund, and the University of Tasmania (College of Arts, Law and Education Hothouse Funds and College of Arts, Law and Education Creativity, Culture & Society Research Development Fund) provided the funding that made this research possible.

ORCID iDs

Rose Nash

Shane Pill

Notes

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