Abstract
A pilot training course on school health promotion in Austria focused on supporting teachers and school heads during the implementation of the health-promoting school (HPS) concept. The participants talked about their experiences during the implementation phase in focus groups held in a feedback seminar at the end of the training course. The focus groups were analyzed by using an inductive approach. A coding method for thematic analysis was applied. Compatibility of the training course with the school setting was examined and supporting and hindering structures and processes pertaining to the schools and the training course are described. The results can be displayed in a model showing connections between the themes. Internal and external collaboration structures were identified as central aspects in the implementation phase. Particularly collaboration within the faculty is shown to be of importance when implementing the HPS approach. Voluntary cooperation especially of teachers, which is often connected with work in their spare time, is another aspect influencing the sustainability and therefore also the compatibility of the training course with the school setting. For future designs of teacher training courses in health promotion, the aspects of collaboration, teamwork, and collective commitment have to be taken into consideration.
Keywords
Teachers have been identified as the fundamental change agents in the proliferation of school health promotion (Jourdan, Samdal, Diagne, & Carvalho, 2008; St. Leger, 2000). In light of this, professional development and support for teachers is needed to achieve effective implementation of the concept. The so-called health-promoting school (HPS) approach is grounded on the principles of the Ottawa Charter (World Health Organization, 1986), which follows the setting approach to health promotion with a holistic view of health.
The HPS approach is seldom implemented in its entirety and the focus has often remained on health education as a less comprehensive, more classroom-based approach with a focus on knowledge transfer rather than changing living conditions (Bond, Glover, Godfrey, Butler, & Patton, 2001; Denman, 1999). One of the possible barriers to the implementation of school-based interventions is inadequate provision of training for the intended implementers (Greenberg, Domitrovich, Graczyk, & Zins, 2004). Teacher training also often focuses more on knowledge transfer than changing the way teachers work and interact in general.
Therefore, a pilot training course on school health promotion in Austria, which aimed at supporting teachers and school heads during the implementation phase, was developed. The main research questions are if and how compatibility and connectivity with the school setting could be achieved. Focus group discussions with participants of the pilot were conducted to find possible answers.
Background/Literature Review
When reviewing the literature on the topic of teacher training in school health promotion and implementation of the concept, it becomes apparent that there is a lack of studies targeting educational activities for teachers and school heads to support the establishment of health promoting schools. Mostly, we found research on the implementation and support regarding specific programs (e.g., a program for drug prevention). There are also studies on teacher training for health education, which is, however, a less comprehensive approach than health promotion.
Following Jourdan et al. (2008), implementation depends on various factors: political factors (school system, political will), teachers’ beliefs and perceptions, and support given to the implementers themselves, such as teacher training.
For successful implementation, research has shown that the concept should be embedded in the school setting, not acting as an add-on or “just another project,” as this may lead to either no effective implementation whatsoever or a short-term project like intervention that has no long-term effects (see Inchley, Muldoon, & Currie, 2006). However, the question of how teacher training can aid a successful integration of school health promotion remains.
The Austrian Federal Ministry for Education, Arts and Culture, the Austrian Federal Ministry for Health and the Main Association of Austrian Social Security Institutions have initiated the project “Gesunde Schule,” meaning “Healthy School.” The main goal of this project was to develop a strategy for health promotion in schools. The main components are a paper on the strategy, quality standards for HPS, and recommendations for action. Two of the main recommended interventions are teacher training and the establishment of health management in schools.
The focus on teacher training resulted in the development of a pilot training course on health promotion in schools. This small-scale course followed theories of the HPS approach. The main strategy was to embed health promotion into a quality management and school development process. Not only teachers but also school heads were involved in the training course to appoint the latter as the leading sponsors of health promotion in their respective schools. From November 2008 to February 2009, 21 schools from all over Austria participated in the pilot phase, with at least one teacher and one school head per school.
The training course consisted of four phases: (a) an attendance phase at the beginning, in which the participants took part in a workshop, which provided them with basic information on health promotion in schools and was intended to enable them to start the health-promotion process in their schools; (b) a cooperative e-learning phase, centering on an Internet platform, to expand their knowledge on the topics of the training course; (c) an implementation phase, in which the participants were supported in their first attempts of implementation and received further information via the Internet platform; and (d) a feedback workshop that took place after four months of training to complete the course, in which not only the participating schools but also the developers of the training course got feedback from the participants on how to advance.
The schools had to achieve four milestones by the end of the implementation phase: (a) setting up a health team or coordinating team, (b) organizing a “health conference,” (c) a self-assessment on their status quo regarding health promotion, and (d) the development of goals and the planning of future measures.
Additionally, the schools were asked to document their actions with provided forms and tools. To support this phase financially, the participating schools received 3,000 euros from the initiators.
Methods/Strategies/ Intervention Applications
At the end of the pilot training course we performed focus groups following Anglo-American research methodology. Focus groups facilitate the collection of data on group norms and sometimes group consensus on an issue will be asserted (Kitzinger, 1994). Focus groups are also particularly suited to the study of attitudes and experiences (Kitzinger, 1995). Following Watts and Ebbutt (1987), we were aiming for a “fairly freewheeling discussion,” employing as little involvement from the facilitator as possible (Bender & Ewbank, 1994).
We conducted four loosely structured focus group discussions with the 37 participants of the feedback seminar, so that around nine people were present in each group. More teachers (representing project coordinators or project team members) than school heads attended the feedback seminar. That was why two focus groups comprised only teachers and two were mixed groups. Members of the evaluation team facilitated the focus groups following a rough topic guide. The discussions centered around the questions on how schools witnessed the implementation phase of the training course and how they would judge the fit of their internal structures to the aims of the training course. The focus groups lasted for about an hour each and were recorded, except for one because of the refusal of some participants. Verbatim transcripts were made of the three recorded focus groups. Because of the rather sensitive situation due to the Ministry for Education’s involvement in the training course, many participants were reluctant to talk about internal school affairs. Although confidentiality was assured, many did not want to introduce themselves on tape. That was why no attribution of speakers could be made in the transcripts, which certainly is a limitation of this study and has implications for the analysis.
We organized the data by using Atlas.ti software and conducted thematic analysis following Froschauer and Lueger (2003), while adapting it to the material. Froschauer and Lueger (2003) generally follow a data-driven inductive approach to analysis in the applied coding method for thematic analysis. We performed the analysis in different stages: (a) coding text passages by identifying themes, that is, establishing thematic categories; (b) identifying relevant characteristics of the themes, that is, producing relevant subcategories; (c) structuring, comparing, and linking the categories to produce a network of categories; and (d) interpreting the network of categories. Boyatzis (1998) also refers to organizing themes into a hierarchy as one approach to conceptually organized clusters in thematic analysis, meaning that some of the themes lead to or cause other themes. Therefore, we assembled the themes in a causal model showing connections between different categories. The network of categories evolved while focusing on the research question (see Figure 1). Because the overarching analysis revealed no major differences between the themes of the different focus groups, the categories can be seen as relevant to all three groups.
Network of Categories
Results
We distinguished between characteristics—structures and procedures—on the school level and on the level of the pilot training course as they were mentioned in the focus groups. On the school level, categories such as “size of the school,” “(lack of) previous knowledge and experiences” in the field of health promotion, “competing projects and demands,” “staff turnover,” “(lack of) motivation and commitment” to the approach, “(missing) resources and structures,” and “ways of decision making regarding the pilot training course” could be detected. Regarding conditions pertaining to the pilot training course, “the use of management tools in the school setting,” “the pace of implementation” set by the training course, “(lack of) clarity in concept and realization,” “too much paperwork,” “(lack of) exchange between schools,” and “the (lack of) support from higher authorities” were all relevant categories.
Characteristics on both the school level and the level of the pilot training course were found to have an (sometimes interrelated) influence on collaboration structures, as well as strategies of action in the project.
Collaboration structures in the project proved to be the central theme of the analysis:
It’s only possible with collaboration, good will—sometimes it works, sometimes it doesn’t. (FG 3, 86)
The participating school members often mentioned teamwork and collaboration issues. The term teamwork implied teams of various sizes: smaller core groups of approximately four people, larger teams with involvement of school doctors, school custodians, and/or community members and teams including almost every school member. There was the converse issue of “lone warriors,” referring to solitary activists for health promotion in their school.
The role of the school head was also an important theme in the focus groups: Some participants talked about the importance of involvement of the school head, whereas others stressed how indispensable the coordinating role of their school heads was when implementing health promotion. Because of a lack of collaboration experience or structures, it was necessary for some school heads to clearly appoint project coordinators or other members of the teams in front of the whole faculty.
We found parental involvement and cooperation with external service providers in the field of health promotion to be helpful for implementation of the concept as well.
Strategies of action in the project can be described with categories such as “adaptation of the concept of the training course” and “voluntary/involuntary cooperation.” The latter is also very often associated with work in the spare time of the teachers and a generally increased workload because of missing structures and resources, namely time, financial resources, and human resources.
Naturally, voluntary involvement of the teachers and other members of the staff is influenced by motivation and commitment. Motivation to participate willingly in all the project’s endeavors can depend on the school head’s commitment to the cause as well.
It is difficult to keep the collaboration, the activities going. In my opinion the matter seems to flatten out, if the school head is not pushing it as well. (FG 3, 37)
All those themes, first and foremost “collaboration structures” and “strategies of action in the project,” influenced the theme “compatibility/incompatibility between the training course and the school setting.” We defined that theme with the subdimensions of “(lacking) sustainability” including “(lack of) motivation/commitment” as well as “add-in/add-on” and “overstrain/pressure.” The subcategory “add-in/add-on” refers to the extent that school health promotion becomes integrated or institutionalized in the respective school:
And in my opinion, it is working out brilliantly. However, it is not like we’re imposing anything, it is growing inside the group and so many are willing to participate because it is somehow natural. (FG 3, 80)
In some schools, health promotion is portrayed as part of their school program and school development efforts, whereas others clearly indicate that they see health promotion in their school as a rather small project with only a few teachers involved. Again, the collective aspect is seen as essential for success:
It is crucial to see how much the team can carry it somehow, so that it becomes perceptible, tangible and a real attitude of the school. (FG 3, 112)
If health promotion is integrated into school life (add-in), sustainability of the intervention is naturally established. We defined sustainability according to the “WHO Health Promotion Glossary: New Terms” (Smith, Tang, & Nutbeam, 2006): A sustainable health promotion action can maintain its benefits beyond their initial stage of implementation and can continue to be delivered within the limits of finances, expertise, infrastructure, natural resources, and participation by stakeholders.
The compatibility between the training course and the school setting was not influenced by collaboration structures alone. According to the analysis, characteristics of school and/or training course also had a rather direct effect on the compatibility in some cases. Hindering factors for sustainability, for example, were (among others) missing resources and unpaid work in free time, often relating to inefficient team structures. If the whole school is not engaged in school health promotion and only a few teachers have to tackle the entire workload, the sustainability of the intervention is usually at risk.
There are very dedicated colleagues, but they are not working on one project, they are working on five. However, because they are reliable and working well, they get yet another project. And I know that they are the first to say: It’s enough. (FG 2, 195)
The demanded fast pace of implementation in the pilot training course posed a problem for many schools, especially those of larger size. According to the focus groups, they reacted by adapting the concept of the training course to their school needs to make it compatible. Some participants also recommended a modular organization for training courses targeting large schools.
The use of management tools as encouraged by the training course ultimately caused either compatibility or incompatibility. According to some participants of the focus groups, the management approach was helpful because it gave them structure. According to others, it was difficult to work with it because they lacked structures and resources to fulfill the course’s demands besides already existing duties:
And I think that this business term [project management] is not right for schools because the structures and resources are simply missing, because you are dependent on favors and voluntary cooperation and therefore you can hardly ask for something from the colleagues. And in the business world, it is obvious, there are different kinds of hierarchies and the tasks have to be fulfilled [. . .] People are paid for that. And here it is voluntary and that’s the problem with this in schools. If somebody doesn’t want to do it any longer, can’t do it any longer, because he is doing it in addition to his regular duties, the project will subside. (FG 3, 31)
Basically, this led to work in spare time, consequently problems with motivation/commitment, possible overstrain and a lack of sustainability:
[. . .] I have been working intensely in school health promotion for four years now. The coordinators should get time allocated for that. This is almost my limit. More is not possible. (FG 1, 32)
Discussion
The results clearly show that effective internal and external collaboration structures are crucial for compatibility between the pilot training course and the school setting, and thus for the development of the HPS approach. This is in concordance with Inchley et al. (2006), who also define collaboration and partnership working with external professionals as very important aspects for implementation.
One of the aims of the pilot training course was to encourage the participating schools to form health teams. Success in building such a team, as well as effectiveness and sustainability of such collaborations, was dependent on many factors. The most important ones seem to be previous experiences with team work and the pace of implementation in the training course. Additionally, missing structures and resources, especially in terms of human resources, can lead to problems with team work. As the concept of the training course includes a management approach to the implementation of school health promotion, it is also worthwhile to stress possible difficulties that can arise from that. To apply management tools, it is necessary to have some kind of existing cooperation structure and to be able to count on coordination within the team. Orpinas et al. (1996) also mentioned preexisting school organizational problems as impediments to implementation of a comprehensive violence prevention program.
Although the training course was only a pilot and an extended version with more time allocated for implementation has been planned from the beginning, it is still obvious that the pace of implementation is an important issue. Allowing participants of teacher education enough time to implement the HPS approach on site should be taken seriously. Schools that are not used to teacher collaboration or management procedures will especially need more time to successfully tackle the problems that can arise when trying to implement something new and innovative. Sawyer and Rimm-Kaufman (2007) also reported lack of time and lack of administrative priority as key barriers to collaboration.
Conclusion
As Han and Weiss (2005) stress in their research on teacher program implementation, teachers must perceive the program as complementing their teaching style. With comprehensive approaches to health promotion, it also has to complement their style of working in general.
As teachers are not generally used to working collaboratively, they often lack the skills to do so (Sawyer & Rimm-Kaufman, 2007). Therefore, training teachers to be able to collaborate should be a very important goal for teacher education. Maeroff (1993) also stresses the importance of instigating change through teamwork.
Professional learning communities (PLCs) come to mind when reviewing the results of the analysis. This concept originates from educational sciences. A PLC is usually described with five characteristics or features which operate together and are sometimes intertwined (Stoll, Bolam, McMahon, Wallace, & Thomas, 2006, pp. 226-227): shared values and vision, collective responsibility, reflective professional inquiry, collaboration, and promotion of group, as well as individual, learning. Evidence suggests that PLCs have a positive impact on school improvement (Stoll et al., 2006). The proliferation of PLCs is seen as preferable to traditional forms of professional development for teachers. In light of this, setting up and maintaining a PLC could be favorable for the implementation of school health promotion. One might even argue that the proliferation and institutionalization of the HPS approach is going to depend on the collaboration and innovative spirit of the professional community.
According to Bandura’s (2000) social cognitive theory, people’s shared beliefs in their collective efficacy influence how well they use their resources, how much effort they put in their group endeavor and how they deal with possible drawbacks. This concept can also be linked with results of the analysis and the conclusions we drew. Effective collaboration and collective motivation and commitment to school health promotion were influential for compatibility between the training course and the school setting.
Although the pilot training course has already embraced these approaches to a certain degree, more emphasis on teacher collaboration issues and prerequisites of teacher collaboration should be given for future conceptualizations. Further research should target teacher training on comprehensive school health promotion and not solely focus on health education interventions or programs aiming at a particular field.