Training Teachers as Health Promoters

Abstract

In the context of the global changes that affect families and communities, including the current COVID-19 pandemic, today’s young people face new threats to their health and most of them lack adequate nutrition, healthcare services and education. As children and adolescents spend a significant amount of their time at school (or remotely connected with teachers, as occurred in these last months of health emergency), educators have the great opportunity to positively contribute to their global growth, fostering physical, mental and social wellbeing, which has also a significant impact on students’ academic achievements. Nowadays, training teachers as “health promoters” allows educational system to deal more effectively with health needs of the students, helping them in the prevention of risky behaviours (cigarette smoking, binge drinking, drug use etc). According to the recommendations provided by the World Health Organization and UNESCO, we highlight the need for pre-service and in-service teacher training on the major topics concerning young people health, as well as COVID-19 safety issues. Moreover, teachers should be trained on the most participatory and pro-active methodologies to effectively convey health-related contents in school setting, in order to trigger a personal interiorization of the knowledge acquired by the students, and to engage them in practical actions about healthy lifestyles (i.e. balanced nutrition and physical exercise, no smoking, no alcohol, no drugs). Teacher training on health topics enables educators to develop a new professional identity based on a health-centered vision, in the perspective of reducing social/health inequalities that still concern most disadvantaged children. Medical professionals and pedagogists could be appointed as available consultants respectively for training teachers on health contents and about the most effective didactic strategies useful for displaying educational interventions in school setting aimed at preventing unhealthy habits among young people. Health education should be included in scholastic curricula within scientific disciplines or treated as separate subject in extracurricular activities under direct responsibility of school staff.

1. Rationale: children and adolescents’ facing new health threats

Each year 1.1 million of teenagers (10-19 years old) die due to preventable causes, and a huge part of them – especially those belonging to the most vulnerable social groups – start adopting risky behaviours (tobacco smoking, alcohol or drug use, unprotected sex, inter-personal violence etc.), which can lead to illnesses, injuries and premature deaths (World Health Organization - WHO 2018; Bauman 2011; Currie et al. 2009; Walker et al. 2011; Evans et al. 2013). Substance abuse during adolescence, as well as the acquisition of unhealthy eating habits since childhood (high intake of saturated fats, transfatty acids, free sugars with junk foods) represent health topics of major concern. Intentional selfharm, including “deadly selfies” and extreme experiences, are the most frequent cause of death among young people aged 15-29 years in Europe, while about 135,000 adolescents remain victims of unintentional accidents that involve pedestrians, cyclists, cars, or motorcyclists (WHO 2018).

Heimlich manoeuvre, crossing streets and riding bikes are other important safety health issues to be addressed since early stages of life. Another impactful cause of accidental death is represented by drowning (up to 50,000 boys and girls dead per year) due to inadequate swimming skills or misperception of dangerous situations.

Concerning early pregnancies at global level, 44 births per 1000 belong to girls aged 15-19 (11% of overall births), and it is estimated that one girl out three (for a total of about 85 million young females) has experienced emotional, physical and/or sexual violence from husbands or partners. In less developed countries, infectious diseases, such as those preventable through vaccinations and free access to clean water and adequate hygiene (i.e. polio, measles, diarrhoea) still represent a big problem to be addressed. HIV-related deaths are decreasing worldwide with the exception of adolescents, who are largely affected from AIDS (2.1 million boys/girls in 2016, mainly concentrated in Africa) and often unaware of their condition, thus remaining usually untreated. Based on these epidemiological figures about infectious diseases worldwide, it is crucial providing young people with adequate information and knowledge in order to achieve the Sustainable Development Goal (SDG 3) set by the United Nations to eradicate AIDS, hepatitis, malaria, tuberculosis, and neglected tropical or water-borne diseases by the year 2030 (UNESCO 2015). Finally, half of the mental disorders resulting – at medium/long term – in depression, psychiatric conditions and suicide start by age 14, remaining largely undetected (WHO 2018).

Encouraging healthy habits since childhood is crucial for the prevention of risky behaviours and their harmful consequences in the future life and should be addressed by well-structured and multilevel programmes involving the entire society and all its stakeholders (Patton et al. 2016; Nutbeam 1997). Among those, schools - being the frontline educational institutions - can fulfil this critical and preventive task, giving the right information, providing support and a prompt feedback to students’ needs, thus working for reducing health inequalities (Bakker and Mackenbach 2003; Nutbeam 2000). We are willing to highlight the need for pre-service and in-service teacher training on the major topics regarding young people health and on the most motivational methods to effectively convey these contents in school setting (Peterson et al. 2001).

2. Training teachers to handle students’ socio-emotional and mental problems

In addition to physical health, an optimal emotional and social wellbeing enables individuals to cope with the challenges of life (WHO 2003; Sancassiani et al. 2015). The daily connection with children and adolescents gives schools, at least those who chose to display health educational interventions, the opportunity to impact students’ global health during the critical ages of childhood and adolescence (Breslow 1999). Taking care of students’ wellbeing has also undoubtable effects on their learning achievements, as documented in several studies (Zins et al. 2007; Gutman and Vorhaus 2012; West et al. 2004).

From primary to high school, teachers play a crucial role in the lives of young people, potentially able to spot early changes in behaviours that might represent signals of a mental discomfort (Russo and Boman 2007; Weare and Markham 2005). Unfortunately, the limited teacher education about health topics usually characterizes school systems, also in most developed countries (Fazel et al. 2014), and educators remain generally unprepared to deal with young people socio-emotional needs or mental problems, which can impair many aspects of students’ life such as self-confidence and resilience, peer interactions, relations with educators as well as cognitive outcomes (Banerjee et al. 2016; Andrews et al. 2014). Even when educators are conscious of emotional difficulties experienced by students, they are unsure how to effectively support them or manage pre-critical situations. In other cases, the teachers are not able at all to recognize on time the early signals and identify students who need help, leaving them at risk of developing more serious problems (Reinke et al. 2011).

As a result, reactive responses, stigmatization or regulatory approaches are generally used rather than whole school approaches focused on prevention.

In the context of good educational policies, a “health promoting school” could generate a safe and supportive environment where teachers and learners address together (and possibly try to solve) health issues related to real experiences suffered by students. In some cases, to stop emotional problems from worsening complications, it would be enough just letting students talk with somebody available for a non-judgementally listening and understanding about the situations that children or teenagers are living (Moynihan et al. 2015; Young, 2005; Langford et al. 2014; Inchley et al., 2007). On the other hand, it has been computed that over 10 million students worldwide aged 13–18 require specialized assistance due to mental health conditions such as depression, anxiety, attention-deficit hyperactivity disorder (ADHD), and bipolar syndrome. About fifty percent of all mental illnesses begin before 14 years old, and 75% of those become evident by age 24 (Haggerty et al. 1994).

For various economic or social reasons, many adolescents with mental problems don’t have access to professional help as early as possible. In this frame, well trained teachers might be able to identify mental illness at the onset and support students with the right tools (Ekornes et al. 2012). Mental problems impact dramatically students’ academic performance and their interactions with schoolmates, as half of young people who experience a mental illness drop out of school (Vitaro et al. 1999). At the same time, teachers’ inability to properly manage students with mental problems can make teachers themselves exhausted and burnt out, reducing their efficiency and sometimes causing early retirement. Responsibility for the mental health of the students should never be solely placed on teachers: a strong support system for educators is needed to reduce teachers turnover rate and to enhance their confidence dealing with these problematic situations (Ekornes 2017; AskellWilliams and Lawson 2013).

Of course, teachers cannot substitute health professionals (physicians, therapists, psychologists or family counsellors), but they should work together in order to better support the most vulnerable children and adolescents, establishing a continuous link between school and family environments. The key point is setting a whole-school approach, a caring and empathetic environment, where pupils feel safe to express their difficulties, without fear of being stigmatized (Michalos 2017). It is clear that teachers need to develop professional skills and knowledge on major young people health needs, as well as to acquire the best didactical practices, recognized as significantly effective in promoting students’ wellbeing (Askell-Williams and Lawson 2013).

Ideal training programs are those aimed at preparing teachers to act as first aiders, capable to reassure and give information, raise students’ self-confidence and refer those who need it to an appropriate professional support. Teachers equipped with the necessary knowledge, skills and tools might be able to detect in daily classroom routine pupils who experience a potentially critical issue and provide assistance without delay. This means responding to the adolescents socio-emotional difficulties before they result in a serious mental illness, in substance abuse or self-injuries (UNICEF 2002). In the contemporary social context, educators must be able to assess the risk of suicide, understand the early signs and risk factors of major mental illnesses, depressive syndromes and addictions.

3. How to train teachers as health promoters

Teachers perceive themselves as having the main responsibility for implementing health educational interventions at school, but they simultaneously face a general lack of training to adequately promote students’ physical, mental and social wellbeing (Jourdan 2016). Scientific evidence makes it clear that there is a strong need for school-based strategies in health education area in the frame of a “health promoting school approach”, where every experience and activity in the classroom is regarded as an opportunity to improve students’ global development. At the same time, it is challenging for the teachers to address health topics in everyday school routine without a specific training. Currently, teachers are not always sufficiently provided with additional pre-service or professional learning opportunities to assist them in developing student health (Byrne et al. 2015; Leger et al. 2007). Specific investments in strengthening the capabilities of teachers to implement health promotion in schools are still needed, as we are far away from reaching this goal.

The teachers training should be able to trigger cognitive and behavioral processes and provide educators with a wide range of methods and tools for organizing, managing and optimizing their teaching health-related practices in the classroom.

Twelve specific competences in health education (combining knowledge, attitudes and skills) have been identified on a small sample of researchers from nine EU countries, Canada and Australia – with expertise in this field – belonging to the Schools for Health in Europe (SHE) Network and the International School Health Network (ISHN), two big international organisations aimed at promoting school-based health education (Moynihan et al. 2015). Starting from a list of 36 items, the following twelve competences were selected by the experts involved by Moynihan and colleagues: knowledge health determinants; communication skills; ability of the teacher to act as a “researcher”; pedagogical health content knowledge; general content knowledge of health issues; fundamentals of general pedagogy; knowledge of health education/promotion theories and models; skills in planning, implementing and assessing whole-school health promoting initiatives; knowledge of health education curricula; knowledge of learners and their characteristics; ethical skills; willingness to engage in whole-school and community health promoting activities (Moynihan et al. 2015).

Pre-service teachers’ health education should last several years, while in-service training can be organised on regular basis (every year) for groups of teachers coming from the same or different schools (Moynihan and Mannix-McNamara 2014) and be placed at the heart of any teachers’ educational path. A successful teachers’ training program (both preservice and in-service) about health-related topics must not be limited to sporadic or fragmented information sessions that leave gaps in knowledge, but it should be implemented on a long-term period.

Aims, principles and the different parts of the training should be explained at the beginning of every session. Training sessions should be flexible, combine various formats parametrized on learners’ demands and institutional needs, targeted at development of required competences; at the same time, the intervention should give the opportunity to apply the new skills acquired, recognizing and developing personal interests and points of strength and able to motivate teachers in taking action.

The efficacy of training programs seems to increase when experiential workshops and interactive educational sessions with health professionals are used, having teachers directly involved in the participatory learning methods (Dewey 1986; Ahmed et al. 2006). Indeed, health contents should be re-constructed by the teachers in order to be successfully transferred to their students (Bandura 2001). Pre-training evaluations and post-training follow-up assessments could be performed (also in a subsequent operational phase, when trained teachers display their activities with students in the classroom) to monitor the outcomes of these specific teacher educational programs (Kutcher et al. 2013).

The socio-emotional competences (SEC) of the teachers are also important factors to be taken into account during pre-service training, as they are crucial for the development and maintenance of a supportive teacher-student relationships and an effective classroom management. A systematic review of twenty studies has demonstrated that teachers’ health education increases their selfefficacy to motivate students about health choices and to support children already suffering from unhealthy behaviours (Shepherd et al. 2016). Another review underlines the importance of teachers’ physical and mental wellness, required to nurture students and contribute at fully developing their potential (Pillay et al. 2005). The personal health attitudes and behaviours of teachers are crucial factors for successfully impacting their students in terms of both learning outcomes and wellbeing promotion (Yager 2011). In other words, teachers need to “feel safe” on the frontlines when they start a change process that involves day-to-day routine with students (Pickett et al. 2015).

Finally, a comprehensive teacher training health program should focus also on the educational use of technological tools and facilities, which can help to better address students with special educational needs and reduce health inequalities among vulnerable schoolchildren. Smartphone apps, audiovisual stories or educational games can increase students’ motivation to carry on with the acquisition of health-related contents and stimulating them to maintain the newly acquired correct lifestyles, improving students’ self-management at long term (Oomen-Early and Early 2015).

External experts (coming from University, Professional Associations or Healthcare Services) may provide effective training in teachers’ health education and remain available for ongoing consultation for students’ who need professional support that cannot be guaranteed by educators.

Teachers are recommended to involve all the school community members, cooperate and make networking with colleagues at global level (attending international seminars, webinars, meetings) to update their qualification programmes according to global standards (Hung et al., 2014; Flaschberger et al. 2012). Health education interventions are most effective if parents are involved: families can complement and reinforce at home what children learn at school. In this perspective, it is useful to ensure a constant consultation between parents and teachers and establishing consistency of approaches between them (Murray et al. 2013; IUHPE 2008).

However, every organization, including school system, has to cope with the low propensity of its staff to make full use of all the newly available training opportunities and to modify their educational practices by accepting to work with new methods (Byrne et al. 2018). Unwillingness could be due to the way in which teachers view their role and its social recognition, thus claiming for public awareness of the relevant position that educators have in the society (Charlton 1981).

4. Teacher training on active methodologies to convey health related contents

School is the ideal setting to provide basic health information and display related educational interventions (Hung et al. 2014). In this perspective, teachers should be adequately trained to increase young generations’ access to a functional, interactive and critical health literacy, and their ability to use it effectively in the real life. Pedagogic consultants could equip teachers with the pro-active didactic strategies - going beyond the simple transmission of information – needed to raise students’ motivation towards healthy habits and stimulate a personal re-construction of knowledge along with a critical thinking about harmful consequences of risky behaviours (Bandura, 2004),

Moreover, teachers should be trained on how to incorporate a wide range of motivational activities in the repertoire of their teaching skills as useful instruments for sharing health knowledge, values, and behaviours in a transversal and interdisciplinary way. Engaging children and adolescents in practical actions about healthy habits could trigger a deep and transformative learning, capable to enhance individual capacity to protect their own health lifelong (Dewey 1986; Mezirow 1997; Lengrand 1989; Rowe 2008; Michel et al. 2009).

In order to encourage young people to take more control of the learning process and environment, as well as to strengthen transversal life skills, a huge number of activities can be carried out in school daily practice: class discussions, small working groups, brainstorming, role play, tasks of reality, educational games and simulations, debates, audio and visual activities, case studies, storytelling, theatre, dance/music. These activities, along with promotional methodologies can enhance all the different talents and ways of learning of the students, and allow teachers to build up a friendly and supportive learning space, that encourages students to freely express their emotional difficulties without feeling “under judgement” (Payton et al., 2000). This kind of cooperative and non-competitive environment is also the most impactful way to cope with bullying behaviours and opponent or aggressive attitudes, strengthening students’ resilience and self-efficacy (Wilson and Lipsey, 2007; Seligman et al. 2009; Elias et al. 1994). In this frame, teachers act as facilitators who listen to the students’ health questions, and provides them with useful suggestions, opportunities and new perspectives within a democratic, participatory school community, rather than adopting reactive and regulatory approaches (Jennings and Greenberg. 2009).

5. Conclusions

Students’ health promotion represents an intrinsic ethical duty of scholastic institutions, calling for an adequate pre-service and in-service teachers’ training both on the main health issues related to young people and the most effective methods to deliver health knowledge in daily classroom activities.

Training teachers as “health promoters” represents a possible response to the new global challenges in the field of education and healthcare (Jourdan et al. 2008). Well-trained teachers with a new professional identity and a health-centered vision can make a difference in the prevention of harmful behaviours (tobacco smoking, alcohol and drug use, screenrelated or gambling addictions, betting online, consumption of junk food) among young people (WHO, Regional Office for Europe 2018; He et al., 2010; Goran et al. 1999). Medical professionals and pedagogists could be respectively appointed as consultants for training teachers on health contents and about the most effective didactic strategies for displaying educational interventions aimed at promoting students’ wellbeing in school setting. Health education should be included in scholastic curricula within scientific disciplines or treated as separate subject in extracurricular activities (Pearson et al. 2015; Kilgour et al. 2015; Paakkari and Paakkari 2012). Teachers should act as first aiders and promoters of young people global wellbeing, thus impacting not only students’ behaviours, but also their families and communities (Murray-Harvey and Slee 2007). The success of health educational interventions is directly related to the effectiveness of teachers’ training on the major health topics and on the pedagogical practices for working with students on these specific issues.