Perspectives of spinal health within the school setting in a South African rural region: A qualitative study

2.1 Setting and design

This study was conducted in the Langeberg Municipal District of the Western Cape, South Africa, which has a total population of 99 609 [26], and 54 schools comprising combined (n = 4), intermediate (n = 5), primary (n = 41) and secondary (n = 4) schools. A descriptive qualitative case study design with an interpretative and phenomenological approach was used. In-depth Interviews (IDIs) and Focus Group Discussions (FGDs) were employed separately for each of the study participant groups (students, parents/guardians, teachers, and principals) during data collection. Ethical approval for this study was obtained from the Health Research Ethics Committee at Stellenbosch University (S16/10/187). Permission to conduct the study in the schools of the Langeberg Municipal District was obtained from the Western Cape Education Department. All participants gave signed informed consent before being interviewed or participating in a group discussion. In the case of learner participants, consent was obtained from the parents and assent from the students.

2.2 Selection criteria

The participating schools were selected based on geographic region, school type (primary, intermediate, secondary, and combined), and socio-economic status. The participants included principals, teachers, students, and parents or guardians.

Students were selected by the principal researcher to ensure inclusion of at least one group from each of the foundation (grades 1–3), intermediate (grades 4–6), senior (grades 7–9) and further education training (grades 10–12) phases.

The students were nominated by the class teacher after consultation with the principal researcher (RK) who advised the teacher in suggesting students with a range of potential variation factors, e.g. gender, age, race, and sports participation. Parents/guardians were selected by the researcher based on the educational phases of their children, to ensure involvement in all the phases. Principals had to have a minimum of 5 years’ experience as principal of the selected school for inclusion in the study to make certain that their knowledge was primarily related to the relevant school. These selection criteria (Table 1) ensured that a diversified set of study participants was selected.

All IDIs and FGDs were conducted by the principal researcher between March and June 2017. IDIs and FGDs were recorded using a digital voice recorder and then transcribed by the researcher. An interview schedule was used to guide questioning during the IDIs and FGDs. Depending on the literacy level of the participants, adapted terminology was used to simplify questions (Supplementary File 1).

The questions were developed from objectives set out prior to study commencement and converted to open-ended questions to avoid bias and to broaden the scope of information gathered. Questions were also translated into Afrikaans as 47 (87%) of the schools were Afrikaans (Supplementary File 2). The IDIs and FGDs were conducted in participants’ preferred language. A single participant indicated English as their home language and thus only one IDI was conducted in English. Questions were the same for both groups (IDIs and FGDs) and the phrase spinal health was defined to all participants as “taking care of your back”.

The duration of the sessions ranged from 30 to 60 minutes with only one group session lasting less than 30 minutes. The principal researcher took notes on the discussion schedule during the interview and discussion sessions. A summary of the discussion was made after each session ended and included the session’s characteristics, main themes, surprising information and new themes not emerging from previous sessions.

Transcripts were not returned to the participants for comments, but random transcripts were compared to their recordings by an independent researcher to ensure credibility of the data. Study results were returned to random participants for comments.

One repeat FGD was conducted with a group of secondary school students, within the same community of a group of primary school students, after inconsistent data about the influence of violence was obtained from the latter group. The researcher continued to conduct IDIs and FGDs until data saturation was reached.

2.4 Analytical methods

Data analysis was performed only from the transcripts to avoid researcher bias. Inductive reasoning was used to explore the phenomenon of spinal health in students and to subsequently narrow the scope of the study according to the objectives. Inductive reasoning was used given the limited qualitative research in the field and as no model or framework existed on which to base the study’s findings. Sub-themes were derived from emerging information within the main themes, and linking main themes were subsequently grouped into families. The Coding Tree (Supplementary File 3) depicts the codes used by the researcher. ATLAS.ti computer software was used for coding and data management. Data from the various participant groups (students, parents/guardians, principals, and teachers) were analyzed separately and then combined to form one comprehensive data set.

The principal researcher discussed and reflected on the themes and sub-themes with two co-researchers (QL and YB).

Transcripts were not translated and remained in their original language for analysis as the principal researcher is equally proficient in Afrikaans and English.

2.5 Trustworthiness

Credibility, transferability, confirmability, and dependability were considered to be relevant quality criteria and were therefore adhered to during the conduct and processes of this study. Credibility was ensured by adopting a semi-structured question format, where all participants were asked the same questions while allowing the researcher leeway to ask further explorative questions regarding topics raised. In addition, two data collection methods (IDIs and FGDs) were employed to cover individual shortcomings of each data collection method.

By using IDIs, the researcher obtained more detail from the participants, whereas the FGDs allowed participants to comment on each other’s thoughts, thus broadening the perspectives. The IDIs and FGDs ensured both narrow and broad investigation of the topics and instilled confidence in the study’s findings.

The transferability of the study’s results is arguable schools to other South African rural schools in the Western Cape province.

To ensure confirmability, the descriptions of the study’s methodology and results highlight the neutrality of the researcher regarding the findings. The study findings are based on the responses of the participants and do not stem from the personal motivations and potential bias of the researcher. Triangulation of data further reduces the effect of researcher bias on the study findings.

Dependability of the study findings was ensured by describing the research process and data analysis transparently. Both were also reviewed externally for consistency.

3.1 Demographic characteristics of study participants

This study involved 93 participants (66 women and 27 men) (Table 2). A total of nine IDIs and 11 FGDs were conducted. Participants identified themselves as white (32%), colored (57%) or black (11%). The participants spoke in their preferred language. Of the 93 participants, only one spoke English, another spoke a mixture of English and Afrikaans, while the remaining participants all spoke Afrikaans. Table 3 depicts the number of schools and enrolled students per town region.

4.1 Theme 1: Factors contributing negatively to spinal health

This theme describes factors identified by participants that may negatively impact spinal health in schools. The sub-themes that emerged from the data describe specific factors that may hinder students from taking good care of their spines.

The barriers associated with students’ spinal health were multifactorial, including low levels of physical activity, dangerous gameplay, sports risks, poor ergonomics, school bags, insufficient knowledge, and pregnancy risks. Proper school furniture and school bags were, for example, not adequately available and/or affordable; and decreased levels of physical activity led to injuries while doing sport or exercise.

4.2 Inactive lifestyle and spinal health

School teachers and principals indicated that the inactive lifestyles of students may negatively affect spinal health. They suggested that the frequent use of technology was a major contributor to physical inactivity. Incorrect sitting posture while using technology also had a negative impact on spinal health.

“They sit in front of the TV; they sit and play with a cell phone. I think that back health is in a very bad state in South Africa because of sitting so much and sitting incorrectly.” (Male, 62, primary school principal.)

Teachers were concerned about the effect of the extensive use of technology on the students’ musculoskeletal system and spinal health. They alluded to reduced physical strength and muscle tone as negative side-effects of using technology. Teachers believed that students’ poor postures when writing was due to inactivity underpinned by poor muscle tone in the trunk girdle.

“It worries me. It does worry me because of the inactivity of our children at school. And I see it not only in their spinal health particularly, but in their lack of physical strength that our children today have, compared to what we had when we were young.” (Female, 61, secondary school teacher.)

“Children don’t play and develop those muscles so they have low muscle tone in the trunk area and then they can’t sit and write properly.” (Female, 44, intermediate school teacher.)

Teachers were also concerned that many students suffering from the perceived musculoskeletal effects of technology overuse did not receive appropriate management. They suggested that parents may not be able to afford therapeutic or medical care.

“The vast majority of children that have problems don’t have the funds to receive therapy.” (Female, 42, primary school principal.)

4.3 Dangerous gameplay

Rough play was seen as the norm, with children ignoring warnings from their parents. Teachers expressed concern about the rough and sometimes aggressive nature in which students played games in schools. Parents added that their children did not heed warnings about how they played and reported that they responded in anger when children were injured while playing.

“Children from being, playing wild. You just told them then they run around doing it again. Go complain there where you got injured!” (Female, 34, primary school parent.)

Teachers saw rough play as bullying and attributed this behavior to what students were exposed to at home or maybe within their immediate communities. Physical contact games, such as wrestling, are perceived to be fun games and therefore students continued doing them.

“They play rough at school. They strike each other. They are wild. They wrestle and everything.” (Female, 54, primary school parent.)

“They wrestle. If something is fun then they (children) do it in any case.” (Female, 43, secondary school parent.)

“Children do what they see at home. They would kick and choke others, that’s not playing, they’re bullies.” (Female, 58, primary school principal.)

4.4 Sports-related risks

Students were expected to participate in sports matches without adequate physical preparation. In addition, the general inactivity of children contributed to an increased risk of spinal injury or pain when participating in sports.

“Children are unfit. Then you have to play all those matches.” (Male, 17, secondary school learner.)

Students were aware of the aggressive manner of play when participating in sports. One female student (quoted below) commented on the unnecessary physical contact when playing rugby, which may contribute towards an increased injury risk:

“They play hard, then they get tackled hard or when you are in the ruck and everyone dives at you.” (Female, 19, secondary school student.)

The lack of trained coaches and compliance with basic injury prevention strategies were also seen as problems that may have a negative impact on spinal health. Schools often lacked trained sports coaches, and teachers were expected to coach sports codes for which they had not had any training or experience. Parents attributed the injuries sustained by students to a lack of compliance with injury prevention strategies such as warm-ups.

“They don’t warm up right, it’s not good enough. You have to be warm, your muscles. That’s why he got injured.” (Male, 62, secondary school parent.)

“The coach isn’t always there, then you don’t feel like warming up.” (Male, 18, secondary school learner.)

“I have to coach shot-put; I look like I can do shot-put, but I never did. I can do something wrong. We don’t have outside coaches like the big schools.” (Female, 33, primary school teacher.)

Although students realized that under some circumstances, sports participation was not beneficial for them (for instance when they were ill), they would not stop participating. Parents believed that students wanted to “belong and be a part of something” which resulted in sport participation while injured, instead of recovering.

“No, it probably isn’t always good, but I’m not going to stop, I enjoy it.” (Male, 18, secondary school learner.)

4.5 Inadequate school furniture and prolonged sitting

Both the students and teachers indicated that students used furniture that was mismatched for their body height. The type of chair or desk and the anthropometric misfit between the body height of the students and the furniture were identified as noteworthy furniture considerations for spinal health.

Students and parents especially expressed concern about the quality of the school furniture and the impact it might have on spinal health. Additionally, classroom layout was mentioned as a consideration to improve the ergonomic practice in the classroom.

“These school desks are a lot of trouble to sit in, I can’t sit up straight, I slouch. And when I’m tired, I slouch more. I feel it when I play piano too.” (Female, 18, combined school learner.)

“There’s no back support, it (laboratory stool) is good for your abdominal muscles, but bad for your back.” (Female, 17, combined school learner.)

“The stool is high and the table not, then you have to write like this, you have to bend down to the table.” (Male, 19, secondary school learner.)

The school desks don’t comply with standards according to me. At parent’s evenings I try to get into those things and there’s no way, the bench is short, it doesn’t support your thigh. And there are children who are bigger than me at school.” (Male, 62, secondary school parent.)

“I judge desks for children. You don’t want them to sit in a desk that is too small.” (Female, 61, secondary school teacher.)

Similarly, students were concerned about the length of time they had to sit in classrooms. They reported that it influenced their spinal health because they employed awkward adaptive postures, and they associated this with musculoskeletal symptoms of the spine.

“My back gets sore if I sit for too long in one position.” (Female, 11, primary school learner.)

“Sometimes I move down to rest with my head on the desk behind me, just to relax, then my neck gets sore.” (Female, 18, secondary school learner.)

4.6 School bag-related risks

The importance of the type, weight and the way school bags were carried was emphasized by students, parents, teachers, and principals.

School bags were reported to be very heavy because students are required to carry many weighty textbooks in these bags. Teachers said that students carried all their textbooks daily due to being afraid of forgetting some books.

“The children’s bags are really heavy with all the textbooks they have to carry.” (Female, 32, primary school teacher.)

“The little ones when they start here in grade 4 with textbooks, it’s pretty difficult for them sometimes, they forget their things. So, lots are afraid, then they carry everything in their bag and that’s how they go to school every day.” (Female, 31, primary school teacher.)

Poor socio-economic status influenced the type of school bag used by students. Some students carried their books in plastic shopping bags, while many others used soft backpacks with little support for books or for the spines of the students. A lack of affordable school bags that can adequately support the weight of the books was highlighted by parents.

“Those backpacks they carry are soft and flimsy, they don’t protect the textbooks or the children’s backs, but they’re cheap. Remember the people in the district are poor. So, we can’t tell them what school bag they have to buy, we can advise them. And I tell the board every year they can’t when they want to make a rule about the school bags.” (Male, 60, combined school principal.)

The incorrect way in which students picked-up, pulled and carried their school bags was raised as a concern by teachers and affirmed by students. Parents were more worried about the way bags were picked up, as opposed to carrying the bags, as lifting requires a forward flexion and rotation of the spine which may result in injury. Principals were concerned about the manner in which students pulled wheeled school bags, stating that when the wheels caught on an obstacle, it caused sudden and excessive rotation of the spine.

“When they pick up their bags, I don’t know how you did it, but they stand in their desk then turn and bend to pick up the bag next to then. That’s the big problem with the heavy school bags.” (Male, 62, primary and secondary school parent.)

“When they pull those bags, the one with the wheels, those wheels are small, they pull the bag behind them with their backs turned slightly. Then the wheels catch, and it jerks them. That can’t be good for their back.” (Male, 62, primary school principal.)

Although teachers were alarmed about the way school bags were carried, students were of the opinion that carrying the school bag over one shoulder is more time efficient.

“It’s quicker. If I put my bag properly over both shoulders then by the time I’m done, they are in the next class already.” (Male, 18, combined school learner.)

“But I don’t worry how he puts it (school bag) on (his back).” (Female, 63, primary school grandparent.)

4.7 Curriculum deficiencies and teachers’ limited knowledge and time

Teachers were not properly equipped to encourage good spinal health in students when using the subject of Life Orientation. Teachers stated that they did not consider the spinal health of students in their teaching and related activities and that their time was very limited. They inadvertently contributed towards poorer spinal health and this pattern continued when they were promoted to management positions.

“You are in such a hurry to finish your work you don’t have enough time. Then you forget about these strategies like the stretching to help you.” (Female, 25, primary school teacher.)

“It’s not like you think of their back every time you do something. So perhaps we could be doing stuff that’s not good for their backs.” (Female, 29, intermediate school teacher.)

“The teachers aren’t taught about spinal health and what’s good for children and bad. Then they become principal and have to make decisions that influence children. I have an idea because I have a back problem and I’m aware of it.” (Male, 60, combined school principal.)

Principals believed that Life Orientation, the one subject that should address the wellbeing of students, was taught by teachers who had little training in spinal health and therefore spinal health education was neglected or not addressed at all.

“When you look at Life Orientation, the exercises are not specific to help with the back or sitting and such. Life Orientation should be the most important subject that prepares children for life after school. But that’s not how it is.” (Male, 60, combined school principal.)

4.8 Lack of awareness and limited time for spinal health promotion

Teachers and parents had limited time to educate children about spinal health due to work-related commitments. Teachers focused on curriculum delivery and did not have the capacity to deal with the implementation of spinal health strategies. Working parents spent limited time with their children and spinal health was a priority since the immediate consequences were often not deemed to be serious.

“Unless my child tells me he has pain, I won’t notice if something was wrong with his back.” (Female, 46, primary and secondary school parent.)

“But we have so much work to do, how are we supposed to have time to read a long document about spinal health and know how to implement it. And parents don’t even read a one-page letter that the school sends out.” (Female, 42, primary school teacher.)

“There are lots of those things that when we were young, that mommy and daddy taught you. But you can trace it back to absent parents and parents that work all the time. If you get home you just give the child orders until he goes to sleep and tomorrow morning you drop him off at school or day-care again. The time that parents truly spend with their children to emphasize and talk about these things, get less and less.” (Female, 42, primary school principal.)

4.9 Pregnancy-related spinal risks

Parents believed that pregnant teenagers were not sufficiently educated during their pregnancies. Many students expressed concern about pregnant girls who had to carry heavy school bags in addition to the added strain of their pregnancy. Students also said that pregnant girls complained about their backs but would not allow other students to assist them with their bags.

Students added that those few girls who allowed friends to assist them with their school bags to reduce their load, in turn increased the load carried by the friend assisting them.

“The girls struggle with their backs after giving birth, they don’t go to the clinic, they don’t know what to do, all those pre-natal class stuff. Many of them struggled with spinal problems after giving birth”. (Female, 46, secondary school parent)

“The pregnant girls are also a big problem because they also carry backpacks and they are pregnant. The back can’t carry both those weights.” (Male, 19, secondary school learner.)

“There’s this girl in my class that was pregnant this year, then I ask if I can’t carry her bag for her, but she doesn’t want to give her bag to me. Then she carries her bag, but she always complains her back is sore, but she doesn’t want to give me her bag.” (Female, 18, secondary school learner.)

“But if they give their bag to a friend then that person has to carry double.” (Male, 20, secondary school learner.)

4.10 Theme 2: Opportunities and strategies to improve spinal health in schools

This theme describes proposed opportunities and strategies that could improve the spinal health of students.

Participants reported on proposed strategies to address factors thought to contribute to poorer spinal health (Theme 1) and delivery modes that could be feasible within the local school context.

4.11 Strategies for reducing the weight of school bags

Teachers and students suggested changes in the school roster by reducing the number of daily subjects, which would reduce the number of books required per day. Students stated that they would prefer longer periods of one subject if it meant that they were able to carry fewer books.

“Less subjects on one day is better. Then you have to bring less books.” (Male, 11, primary school learner.)

Moreover, the type of prescribed books required consideration. Smaller A4 books fit well into school bags while bigger books may require larger heavier bags or disproportionate weight distribution.

“I prefer the A4 textbooks because I can pack my bag better. The A5 books are different widths and don’t fit next to one another properly, then the one side is heavier.” (Female, 17, combined school learner.)

Teachers suggested that students pack their textbooks according to the roster of the day, which would avoid the carrying of unnecessary books.

“Children must just pack their books according to their schedules, they are allowed to.” (Male, 25, intermediate school teacher.)

Students proposed using electronic devices as another way of reducing the weight of school bags.

Although not currently feasible in South Africa due to financial constraints, as indicated by some parents, the use of electronic devices instead of hard copy textbooks could present a solution to the problem of carrying heavy loads.

“A tablet will help with all the books that are in your bag.” (Male, 17, combined school student.)

“If parents can’t even afford to buy their children food, yes there are children that go to school hungry, then how could you expect them to buy a tablet?” (Female, 48, secondary school teacher and parent.)

Teachers additionally suggested the use of lockers to store textbooks securely, with the incentive that if students’ homework had been completed, the textbooks could be left at school.

“With lockers they can leave textbooks safely at school. They wouldn’t have to carry all the books all the time.” (Female, 23, secondary school teacher.)

4.12 Education about types of school bags

Students were eager to gain more knowledge about the different types of school bags and the correct methods of carrying the necessary loads. Students said that they wanted to know the appropriate type, load and carrying methods of school bags, as well as the associated advantages and disadvantages of each.

The different types of school bags that students said they wanted to learn about were bags with one and two shoulder straps, wheeled bags, and handheld bags.

“There are all these different school bags, some have one strap or two, or maybe wheels and those orthopedic ones. But what is the difference, why is one good and the other one bad?” (Female, 18, combined school learner.)

“The people don’t tell us how bad one strap or two straps are, they don’t tell us the disadvantages of one strap, and we carry it with two straps. So, we never know which way is the best way.” (Female, 17, combined school learner.)

On the other hand, principals and teachers said that they would like to see a more affordable and durable school bag design that would protect students’ backs as well as the textbooks. Parents said that students should be taught the correct way of picking up school bags, regardless of the type of bag.

“The suitcases must, there must be a happy medium between protection for the books and protection for the child.” (Male, 60, combined school principal.)

“It doesn’t matter what type of bag a child uses, if he doesn’t pick it up right, it won’t make a difference. They must pick them up properly, bend the knees, not the back, that sort of thing.” (Male, 62, primary and secondary school parent.)

4.13 Provision of lockers

Another feasible alternative for reducing the weight of school bags that teachers and students proposed was the use of school lockers. Teachers viewed this as a more effective way to reduce school bag loads because the students would not be required to carry all their textbooks every day. Some teachers said that they also allowed the students to leave their textbooks in the classroom if there was no homework for that subject or if they had finished their work in class.

“Some teachers will allow the children to leave textbooks in their class, but then the teacher becomes responsible for the book. I don’t do that; books get taken and then they complain if their book is gone.” (Male, 34, secondary school teacher.)

“I will let the children leave their textbooks in class if they have finished their homework. Because they don’t do it at home, this way at least they try.” (Female, 49, secondary school teacher.)

“I have a locker. It helps a lot because if you have to have all your homework books in your bag at the end of the day, then your bag is much heavier than it was between breaks.” (Female, 18, combined school learner.)

4.14 Strategies to improve participation in physical activity

The teachers felt that sport was very important for improving physical strength and that students should be encouraged to participate more.

Teachers said that younger children should be taught games that are safe to play, as well as why games such as wrestling were not safe.

“I think sports are very important for children to develop strong bodies.” (Female, 43, secondary school parent.)

Teachers reiterated that safe games should be encouraged and that students would otherwise continue to play potentially dangerous games.

“You must give children games that are safe for them to play. Otherwise they will carry on playing that way and wrestling with one another.” (Female, 58, intermediate school teacher.)

Parents and teachers suggested revision of the Life Orientation curriculum as the primary medium to promote physical activity and to include those who did not participate in sport. Teachers further mentioned that Life Orientation should be used as a medium to teach students specific exercises to help improve their posture. They added that knowledge of spinal health must be included in the curriculum.

“The knowledge must be part of life skills. We can bring it into healthy habits, all of us has that theme sometime during the year. And even as part of the physical education part of Life Orientation, I mean, there are all these activities they want us to do with the children, but they can also put some information there to also tell you why.” (Female, 53, primary school teacher.)

“I think if children were taught how to do abdominal exercises, to be more active, exercises to strengthen your body.” (Female, 42, primary and secondary school parent.)

The school principals reported that they encouraged students to participate in sports, and the younger students to play and run around during breaks.

“We encourage our children to participate in at least one sport per season, they don’t have to do all of them, but we have many sports.” (Male, 62, primary school principal.)

“Everyone participates in sports, all our children participate in sports –I mean, its Life Orientation, there are very few that don’t do it, but we give exercises twice a week for an hour.” (Female, 33, primary school teacher.)

4.15 Education for better posture and ergonomics

The participants indicated that students should be taught why, how, and what the consequences are of neglecting back care. Teachers and school principals reported that students should be taught back care strategies, with the focus on why it was important. Considering that spinal problems may manifest later in life, this suggestion for educational approaches is valid and participants also suggested that students should be aware of the longer-term sequelae.

“Why must I take care of my back? Why is this good and that bad?” (Male, 20, secondary school learner.)

“Why must I take care of my back, or what will happen if I don’t take care of my back?” (Female, 19, secondary school learner.)

“Posture related (education) and give them enough reasons why they have to do it. Not just tell them “Do it”. They have to know if I do this, that is the consequence and if I don’t do it, then the likelihood exists that I will develop a back problem.” (Male, 34, secondary school teacher.)

Teachers and students indicated that the education should provide detailed information on how to assume better postures. Strategies such as practical demonstrations could be useful in this regard.

“I don’t know how to take care of my back. They don’t tell us how or why. They will just tell you so sit up straight.” (Female, 14, intermediate school learner.)

“Everyone just always tells children to sit or stand up straight, but they might not know how to do that. You might have to teach them what those postures are.” (Male, 27, intermediate school teacher.)

It was suggested that relaxation techniques would greatly aid students, and that this strategy should be promoted in all schools, if taking breaks for performing stretches during class are not possible. Learners also felt that walking to classes for different subjects constituted a good break.

“Rest breaks where you just let them stand and stretch a bit, it improves their concentration. If teachers knew that, then they can’t have a problem with short breaks.” (Male, 62, primary school principal.)

“A rest break (in class). Just to relax your muscles.” (Male, 11, primary school learner.)

“When you walk from one class to another your back feels a bit better and then you can sit for a while again.” (Female, 11, primary school learner.)

4.16 Education modes and preferences to facilitate better spinal health

Teachers and parents suggested a variety of platforms that should be made available to educators (teachers and parents) to facilitate the promotion and implementation of good spinal health among students. Suggested strategies included: visual stimulants, interactive presentations, puppetry, and modern technology.

It was proposed that all students should be educated on all aspects of spinal health, but that different content delivery methods should be used for different age groups. Teachers and parents stated that they would not read through lengthy documents about spinal health. Parents preferred smaller group discussions where they could ask questions while teachers preferred short courses with practical demonstrations and pictures. Principals added that poster placements and positioning should be rotated to maximize exposure, as students stop noticing posters after a while if they remain in the same location.

“I think, like from time to time there are puppet shows that come to entertain and make children aware of things. Maybe something like that would be good, if something like that came to make children aware of their health.” (Female, 54, primary school parent.)

“I think something like a course, a short course, where they give you practical demonstrations of the different things.” (Female, 30, secondary school teacher.)

“Awareness programs and perhaps showing them. It’s like telling the smoker and showing the lungs. I’m not always sure but showing them what the outcomes could be.” (Female, 61, secondary school teacher.)

“Our children just want to look at pictures. Colorful, big and no words.” (Female, 42, primary school principal.)

“The children don’t want to listen. But when I do practical and they have to do things, they remember everything.” (Male, 54, secondary school teacher.)

The need for standardized education was seen as an important strategy to enhance spinal health. In a school setting, this would be important to prevent misunderstandings and conflicting messages.

“Everyone has to be educated. Because you can’t have one person saying one thing and then another person saying something else, then the child won’t know what’s right. Everyone must have the same knowledge.” (Female, 22, secondary school teacher.)

Students said that they wanted to know how things worked regarding the spine and felt that they would understand better as to why and how to take care of their spines if they had a basic knowledge of the functions of the spine.

“If we understand then we can do it better. If we know how the back works and how things go wrong then we can stop it from happening.” (Female, 11, primary school learner.)

Teachers and students proposed that spinal health education should be integrated into the formal curriculum. Students suggested that making activities enjoyable would capture the students’ attention.

“You can perform a drama piece that explains things to children, in Arts and Culture, the children can do the acting. These children like acting.” (Female, 17, secondary school learner.)

The use of media, such as television shows, was also mentioned. Similar to the “save water” campaigns, initiatives such as “save your spine” programs were deemed necessary. Participants added that spinal health should be promoted in such a way that taking care of your spine would be seen as being cool.

Parents and teachers strongly felt that spinal screening should be reintroduced into schools and managed similar to other formal preventative initiatives such as vaccination programs.

“We watch TV, like with the news they give warnings about electricity and water usage. They must make one for your back too, that will help.” (Female, 47, primary school parent.)

“Like when the children get their shots, vaccinations at the clinic, it’s a program, everyone has to do it. They can add the spinal health screening to those programs.” (Female, 46, secondary school parent.)

5.1 Limitations

There are several limitations to this study. The sampling frame imposed potential biases. Within the local school setting, the teachers are responsible for their respective classes and therefore researchers are compelled to liaise in order to include students in any research project. Although we have advised teachers on which factors to consider when selecting students, our approach has introduced potential selection bias. Another limitation is that the number of male participants could have skewed results to capture more female perspectives. Within the scope of this study, we could not conduct formal socio-economic assessment and therefore we are unsure how these factors influenced the perspectives of the participants.

The interviews were predominantly conducted in Afrikaans as this is the home language for this geographical region. The Afrikaans quotes were interpreted into English by the research team for institutional and publication requirements. During this process, the depth of the data could have been compromised.

The interviewer’s occupational experience and knowledge (that of a physiotherapist) may have influenced prompting and follow-up questions during the interview. In addition, her occupation could have influenced the responses from participants who may have wished to create a positive impression.

Finally, the findings cannot be generalized to all other rural settings throughout the nine provinces in South Africa due to the social and cultural diversity.