The Efficacy of Comprehensive School Health Course in Changing Pre-Service Teachers’ Attitudes and Reactions Toward Weight-Related Teasing

Abstract

Teachers view overt expressions of weight stigma, such as weight-related teasing, as troublesome but are often ill-prepared to address instances of weight-related teasing when they arise in the classroom. Comprehensive school health is an emerging framework that aims to better prepare teachers to address issues of health and wellness in the classroom, including weight-related teasing. We examined the efficacy of a university course in comprehensive school health in changing pre-service teachers’ attitudes and perceptions of weight-related teasing. Pre-service teachers read a vignette and responded to 10 items about the vignette at both the beginning and end of the semester-long course. Items relating to pre-service teachers’ perception of, responsibility and obligation to address the weight-related teasing event showed significant, positive change from the beginning to end of the semester. These results suggest that exposure to developmentally sound methods of delivering health-related content can support adaptive educator reactions to weight-related teasing.

Keywords

bullying social and educational environment health and wellbeing preparatory programs education program and leadership elementary education/childhood comprehensive school health

Weight-related bullying is a common form of bullying experienced in childhood and early adolescence (Brixval et al., 2012). Children in large bodies experience nearly two times more risk of bullying than their smaller-bodied peers (Van Geel et al., 2014). As a result, teachers view weight-related bullying as among the most troublesome forms of bullying in schools (Bradshaw et al., 2013). Weight-related bullying is an outward expression of weight stigma with numerous health consequences for the children who experience it. These health consequences include low self-esteem, increased symptoms of depression, increased self-consciousness, and feeling of anger and unappreciation (Puhl & King, 2013).

Weight-related teasing, also an overt expression of weight stigma, is often a precursor to weight-related bullying and can be equally stigmatizing and damaging (van den Berg et al., 2008). Weight-related teasing is characterized by exclusion, name-calling, and the receipt of negative commentary about body size and shape (Libbey et al., 2008). Weight-related teasing by peers is extremely common, with 40% of 11- and 12-year-old students reporting being teased by classmates (McCormack et al., 2011). The detrimental effects of weight-related teasing on self-esteem, depressive symptoms, and body dissatisfaction occur at both the individual and school levels (Lampard et al., 2014).

Teachers are a critical stakeholder in elementary students’ social ecology (Bronfenbrenner, 1979). Often lacking formal training in health and wellness (Nocentini et al., 2019), teachers are ill-prepared to handle weight-related bullying and teasing. However, as leaders in the school community, educators are well-positioned to address this overt weight-related stigma if equipped with the necessary tools and knowledge. Further, the actions taken by educators have the potential to prevent future overt instances of weight stigma in the classroom (Puhl et al., 2016).

Comprehensive school health (CSH) is an emergent framework supporting the connection between the overall health and well-being of children and improved learning outcomes (Bassett-Gunter et al., 2016). Based on research findings that healthy children experience better learning outcomes (Bassett-Gunter et al., 2016), the CSH framework includes a focus on four components to support capacity for improving the well-being of all members of a school community (Joint Consortium for School Health [JCSH], 2020). These four components include: (1) a focus on the social and physical environment of the school community; (2) teaching and learning strategies and experiences related to well-being; (3) policies to support well-being in schools; and (4) partnerships and services with wellness-oriented community organizations (JCSH, 2020).

CSH is beginning to be applied in higher education settings to better equip pre-service elementary education teachers to deliver content related to health and wellness using developmentally appropriate and empirically informed methods, and to effectively manage issues that arise in the classroom, such as weight-related bullying and teasing (Russell-Mayhew et al., 2017). The current study examines the efficacy of a mandatory CSH course on changes to pre-service teachers’ attitudes and perceptions of weight-related teasing, in an effort to bolster prevention efforts in the classroom.

Method

All participants were enrolled in a mandatory six-week course on CSH at a Western Canadian university, with a focus of integrating health and wellness into the classroom. This course provided pre-service teachers with foundational theoretical knowledge of CSH and its applications to their future practice. The course included six plenary and lab sessions that allowed for introductions to general topics as well as opportunity for deeper learning, with a focus on case studies. Specifically, following an introduction to CSH (weeks 1–2), pre-service teachers received focused instruction on the utility of a weight-neutral approach to health (week 3), the promotion of healthy relationships (week 4), the promotion of positive mental health (week 5), and health promotion across cultures (week 6). For each of these focused topic areas, CSH served as the framework to support these aspects of health with individual elementary students, within classrooms, and within the broader school community. The plenary component of the course was taught by this paper’s final author (SRM), an expert in CSH, with smaller lab sections taught by instructors with training in education or CSH.

To highlight the weight neutral approach to health in week 3, pre-service teachers engaged with pedagogical experiences to: (1) improve their critical consumption of information related to weight in their daily lives; (2) engage in self-reflection on their relationship with their body; and (3) examine the experiences of elementary students with large bodies in schools. Pre-service teachers were provided the opportunity to connect this learning to strategies for engaging in teaching related to nutrition and physical education that is inclusive of all students, and for engaging with students who may experience overt expressions of weight stigma. An example case study included in the course is available on the Comprehensive School Health Hub (www.cshhub.com).

At the beginning and end of the course, pre-service teachers completed a battery of questionnaires intended to quantify the effect of the course on their understanding of health and wellness, ability to infuse the course material into their future classrooms and lesson plans, and their attitudes and perceptions of health-related issues. The current manuscript focuses specifically on changes in attitudes towards and perceptions of overt weight stigma, expressed through weight-related teasing.

Participants

One hundred twenty-one elementary pre-service teachers consented to participate; 35 of these participants failed to participate at time two (end of course) and were thus eliminated from the final sample. The final sample consisted of 86 pre-service teachers (72.1% female, 24.4% male, 3.5% non-binary), ranging in age from 21 to 50 (M = 28.25, SD = 6.95), in their final semester of their Bachelor of Education program. The sample was predominantly White or of European descent (76.7%), with the remainder of the sample self-reporting their race as South Asian (10.5%), East Asian (5.8%), Southeast Asian (4.7%), Filipino (4.7%), and African/Caribbean (2.3%; percent adds to more than 100 because participants could select more than one race). Only a small minority of participants (3.3%) had received formal training in CSH prior to enrolling in the course, and the vast majority of participants (81.4%) had received no training whatsoever in CSH.

Procedure

All participants provided written informed consent. Participation was an optional component of the course; 121 elementary pre-service teachers out of a possible 268 (45%) consented to participation. At both time points, the survey contained a vignette (adapted from Morrison & Pedersen, 2020) about an elementary-school aged youth named Sarah who experienced weight-related teasing from a peer named Janet and her friends on the playground. After reading the vignette, participants answered two screening questions to confirm their careful reading and comprehension of the story and were then asked a series of ten questions regarding their attitudes to and perceptions of the bullying at the individual teacher level. The 10 items appear in Table 1. Possible responses to each question ranged from one to seven, with higher scores reflective of more adaptive and health-promoting attitudes and perceptions. All procedures adhered to APA guidelines for research with human subjects and were approved by the university’s ethics board.

Table 1.

Response Items Administered at Pre-Test and Post-Test and Wilcoxon Signed Rank Test Values.

Item	Wilcoxon signed rank test value
If Sarah reported what happened on the playground to the school administration, how seriously do you think they would take it?	1.24
To what extent is Janet responsible for what happened during recess?	0.31
Should Janet be punished for what happened to Sarah?	0.22
+How upset do you think Sarah is by this event?	4.13***
+How likely do you think that what happened to Sarah will negatively affect her future friendships?	6.12***
Janet would not have behaved this way if she liked Sarah. How much do you agree?	1.11
+Janet did not mean to hurt Sarah, it was just harmless teasing	2.37*
Janet committed an act of bullying	0.15
+Would you as a teacher have a moral obligation to respond to this situation?	4.47***
+Would you as a teacher have a responsibility, based on school policy, to respond to this situation?	3.07*

item expected to change from pre- to post-test.

The vignette associated with these items appears below: Sarah is a grade 4 student in your class who struggles to make friends. At the end of the school day, after all the other students have left, Sarah hangs around and seems to want to talk. You inform her that you have some time if she needs to talk about anything, and Sarah immediately begins to tell you about an experience she had earlier today on the school grounds with Janet, another female grade 4 student of yours. Sarah says she is unsure what to do about this experience. Sarah informs you that Janet invited Sarah to play, with Janet and her friends, by the playground during recess. She continues to explain that when she got to the playground, Janet’s friends started to chant “Sarah’s a fatso!” and told her that they did not want to play with a “pig”. Janet seemed surprised, did not participate in the chanting, but also did not do anything to stop it. Sarah informs you that she ran away from Janet and her friends and hid in the bathroom until recess was over. As Sarah tells you the story she seems embarrassed about what happened, and she does not know what she should do.

Note. *p <.05. **p < .01. ***p < .001, n = 86.

Data Screening and Analytic Plan

First, we assessed whether any participants had answered the screening questions incorrectly. All participants answered these two questions correctly and were thus retained for analysis. Analyses were conducted using SPSS 26.0. Patterns of missing data were evaluated and found to be missing completely at random (Little’s χ² (142) = 138.22, p = .57). As a result, we chose to impute the missing data (missingness ranging from 0% to 4.8% across items) using Expectation Maximization. Our research question of the efficacy of the CSH course in changing pre-service teacher’s attitudes and perception towards weight-related teasing was next assessed using a series of Wilcoxon signed-rank tests for each of the items. The Wilcoxon signed-rank test allows for calculation of changes in ordinal data from pre-test to post-test and has been identified as the preferred method over paired samples t-tests for this type of data as it better controls for Type I error (Roberson et al., 1995). We hypothesized that learning about CSH from a weight-neutral approach would result in shifts in pre-service teachers’ attitudes and perceptions of instances of weight-related teasing. We hypothesized that perceptions of the administration’s policies about overt weight stigma and perceptions of the individuals expressing stigma would remain constant from pre-test to post-test, as neither are targeted in the course content.

Results

A series of Wilcoxon signed-rank tests were conducted to assess changes in ordinal data from pre-test to post-test on each of the potential pre-service teacher outcomes. Results and items are detailed in full in Table 1. Subsequent to course participation, pre-service teachers were more likely to acknowledge that Janet’s (the perpetrator’s) actions were more than harmless teasing (Z = 2.37, p < .05), recognize that Sarah (the teasing victim) would likely be affected and upset by the teasing (Z = 4.13, p < .001), acknowledge that the teasing might impact future relationships (Z = 6.12, p < .001), and were more likely to recognize their responsibility (Z = 3.07, p = .002) and moral obligation (Z = 4.47, p < .001) to respond to the situation upon becoming aware of it. No significant changes were found in anticipated responses from the school administration (Z = 1.24, p = .22), Janet’s perceived level of responsibility (Z = .31, p = .76), beliefs that Janet should be punished for her behavior (Z = .22, p = .83), the perception of this as an act of bullying (Z = .15, p = .86), or beliefs that Janet acted this way because she did not like Sarah (Z = 1.11, p = .27).

Discussion

Elementary pre-service teachers responded to a case study on weight-related teasing before and after a CSH course aimed at strengthening pre-service teachers’ health-related knowledge and attitudes and perceptions towards health-related issues including overt weight-based stigma. The current study examines the effect of the CSH course on attitudes and perceptions of overt weight-related stigma, expressed through weight-related teasing, among pre-service teachers. These results suggest that, by exposing pre-service educators to developmentally sound methods of delivering health-related content, their attitudes towards weight-related stigma became more adaptive and health-promoting. Our results supported our initial hypotheses. The items that produced a change in response from pre-test to post-test were items relating to pre-service teachers’ responsibility and obligation to respond to the teasing, and items relating to pre-service teachers’ perceptions of the teasing event. The items that did not change from pre-test to post-test related to the hypothetical school administration policies about bullying and the potential reasons why Janet chose to participate in the teasing. These items likely produced no significant change because neither of these areas is targeted by the CSH course.

It is difficult to pinpoint the active ingredient in the course that resulted in these changes to pre-service teacher attitudes, but we speculate that the weight-neutral approach to health and the practical case study approach were part of the success. The CSH course provided pre-service teachers with pedagogical experiences that invited them to reflect on their everyday lived experiences with weight and called for a close examination of the experiences of elementary students with large bodies from a weight-neutral approach that unlinks body weight and health. Weight-neutral approaches to health have been shown to reduce weight stigma in other settings (Pickett & Cunningham, 2017), and it appears a similar phenomenon may have occurred among our pre-service teacher sample. Likewise, prior research supports the efficacy of use of case studies in the university classroom (Herreid, 1994), and it is likely this course’s use of case studies, in addition to other pedagogical techniques, successfully reinforced the course’s weight-neutral messaging. In designing a CSH course aimed at strengthening pre-service teachers’ connection to the multi-dimensions of school community (social and physical environments, learning experiences, school policy, and community partnerships; JCSH, 2020), we may have better equipped teachers to handle instances of weight-related bullying and teasing in the classroom and also to better support the overall health and well-being of children, thereby leading to improved learning outcomes for elementary students (Bassett-Gunter et al., 2016).

Researchers have also identified a need for reducing weight-based bullying via anti-bullying policies in schools. In surveys of both parents (Puhl et al., 2015) and teachers (Puhl et al., 2016), weight-related bullying was identified as one of the most common forms of bullying and the majority of participants supported the inclusion of weight-related bullying in anti-bullying school policies. However, Puhl et al. (2015) note that, despite strong support, little action has been taken to augment anti-bullying policies to include weight. This research provides initial support for the idea that teaching CSH content provides future teachers with knowledge of the existence and importance of weight stigma that may translate into the inclusion of weight-related bullying in such school policies.

The current study is the first known analysis of changes in pre-service teachers’ attitudes and perceptions concerning overt weight-related stigma from the beginning to end of a CSH course. Given the prevalence and consequences of weight-related teasing, these findings are both important and relevant. However, the study design does come with some pertinent limitations. First, our two-time point design with no control group precludes investigation into whether specific aspects of the course, or whether the course in its entirety, contributed to the observed changes in attitudes and perceptions of weight-related teasing. Without a control group, we also cannot ascertain whether these findings occurred due to chance. A future, multi-time point design with a comparison group would allow for a more nuanced examination of the effects of course content on weight-related teasing and allow for identification of the information most important to include in future CSH courses. Our sample was also limited to pre-service teachers, which prevents us from generalizing our findings to in-service teachers. Future research should examine changes in in-service teachers upon receipt of similar CSH course content.

These limitations not-withstanding, the current work lays the groundwork for a unique solution for improving educators’ ability to manage overt weight-related stigma within the classroom. By exposing pre-service educators to developmentally sound methods of delivering health-related content, we saw a significant shift in their attitudes towards weight-related teasing over a brief six-week period. These findings suggest that such training may be of great importance for future teachers to be better equipped to handle instances of weight-related teasing in schools.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by funding from the Public Health Agency of Canada (1718-HQ-000788).

ORCID iDs

Jessica F. Saunders

Deinera Exner-Cortens

Author Biographies

Jessica F. Saunders is an assistant professor of Psychological Science at Georgia College & State University. Her research aims to optimize developmental outcomes by reducing eating disorder risk.

Sarah Nutter is an assistant professor of Counselling Psychology at the University of Victoria. Her primary area of research interest is weight stigma and she is especially interested in better understanding weight stigma and its harms in healthcare and education.

Isabel Brun is a doctoral candidate in the Counselling Psychology program at the University of Calgary. Her primary area of research interest is in preventing the intergenerational spread of body dissatisfaction.

Deinera Exner-Cortens is an assistant professor in the Faculty of Social Work, University of Calgary, and is jointly appointed to the Department of Psychiatry, Cumming School of Medicine, University of Calgary. Her research focuses on evaluating healthy relationships activities in school and community settings, and developing and evaluating implementation support tools for schoolbased mental health/healthy relationships service delivery. In her work, Dr. Exner-Cortens collaborates with a number of community and research partners both provincially and nationally.

Shelly Russell-Mayhew, R. Psych., is research professor of counselling psychology at the University of Calgary. Her research program centres around weight-related issues such as obesity, eating disorders, body image, and weight bias.

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