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Research Proposal on Health

An exploratory, mainly qualitative, research project amongst 10 year old children shows that children have a limited view of health. In their view, being healthy means to eat healthy (i.e. not nice) food, to have lots of fresh air and to do sports. Children at this age have a more limited concept than the adult’s view of health which is predominantly biomechanical and in which health simply means absence of disease. A survey of OFSTED-reports shows that most schools do not have a policy on health education. The paper recommends that the National Curriculum should be modified to allow health education to be wider than the biomechanical model and that health education should have its own entry in the National Curriculum.

Much work has already been carried out on the health beliefs of adults (Blaxter 1980, Seedhouse 1986), however little has been written about how children conceptualize health. There are many definitions of health, and like all social constructs are located within the culture, time and values held by the defining individuals. Until fairly recently it can be argued that within Western culture a bio-medical reductionist view of health holds sway. This view sees health as a product of a body that is not suffering from illness or disease, and so it is largely a negative view of health, i.e. health is something you have if you are not sick.

This view has been increasingly challenged since the definition advanced by the World Health Organization (WHO) in 1946: “Health is not merely the absence of disease and infirmity but complete physical, mental and social well-being”. Since then there have been many definitions of health advanced by both lay and professional individuals. Seedhouse (1986) provides a useful overview of the theories and their implications; however all these concepts of health have been advanced by adults.

Blaxter’s (1990) research shows that concepts of health differ by the class, gender and age of adults, however, little is known about how children view health and whether views are affected by class and gender.
Pridmore and Bendelow (1995) argue that research in this area has largely been carried out on adults rather than for children, and utilizes largely adult constructs of health and illness with little apparent attempt to identify how children relate to ideas.

This raises two important issues,
„The relevance and effectiveness of health education aimed at young children, and
„The need to use qualitative research methods to increase the understanding of the world in this area.

Quite a number of studies have been conducted in the past decades on the state of health of school children in Britain (e.g. Health Education Authority 1996, 1997), albeit that most attention focused on secondary schools. A number of these studies have resulted in proposals for innovations in the management of health care in schools (e.g. Hall 1991, 1996). However, little innovation in health education was implemented. No attention was paid to health promotion (in contrast to health education) in schools, let alone to well-being at home or spiritual or social well-being as part of a holistic concept of health. In fact, when we take a closer look at the National Curriculum for Primary Schools, what becomes apparent is the absence of health from the curriculum.

In 1988 the National Curriculum was introduced. With regard to health education this meant two things. (1) In the 1970’s and 1980’s many innovative actions and educational experiments were undertaken in secondary schools in the field of health promotion. The introduction of the National Curriculum halted most of these innovations. Budgets and staffing were limited and the introduction of the National Curriculum meant that schools were forced to cover all the decreed topics, leaving no opening for innovations. (2) Until the introduction of the National Curriculum, health promotion and health education were absent in the curriculum of most primary schools. For this type of education, the National Curriculum actually prescribed some health education, albeit limited and misdirected as we will point out below.

The OFSTED Handbook for “Guidance on the Inspection of Nursery & Primary Schools” (OFSTED 1995:75) states: “Schools should also provide health education, including education about drug misuse”. More specifically, it states (ibid.:81): “Health education should play a role in promoting the physical, social and mental well-being of pupils. Aspects of health education are found in subjects (for example, within the programmes of study for science) and in the daily routines of the school. Inspectors will need to establish: whether provision is planned, coherent, and appropriate to the ages and needs of pupils, and whether pupils have a sound knowledge and understanding of health issues, and an awareness of their ability to make choices relating to health.” This is what the inspectors are supposed to be looking for. But do they look for it? And should they expect to find it?

If we look more closely at the national curriculum, it becomes apparent that health education, let alone health promotion is virtually non-existent. There are only a few references to health in the national curriculum.

For Keystage 2, the national curriculum (Department for Education 1995) mentions ‘health’ only in the science lessons. Under the heading of “Humans as Organisms” it mentions the following topics that need to be covered (ibid.:45):
„(…) the importance of dental care”;
„(…) an adequate and varied diet is needed to keep healthy”;
„”the effect of exercise and rest on pulse rate”;
„[under the heading: Health] “that tobacco, alcohol and other drugs can have harmful effects”.
Similarly in the Attainment Targets for science (ibid.:53), it mentions that children should:
„(…) provide simple explanations for changes in living things, such as diet affecting the health of humans (…)”.
It also mentions under the heading Growth and Reproduction, the learning outcome (ibid.:45):
„”the main stages of the human life cycle”

However, this is not interpreted by the primary schools as a requirement to teach sex education, even though this may be considered part of health education. In fact the OFSTED Handbook (OFSTED 1995:75) states: “Governing bodies are required to have a policy on sex education – although not necessarily to provide it”. Our impression is that most schools only provide short lessons, segregated for girls and boys, on personal hygiene and that these lessons are given by the school nurse. In effect, they are separated from the normal curriculum.

It is obvious that the national school curriculum and many of the school educational implementation plans, stress two things: (a) a very limited ‘health knowledge’ as learning outcome; and (b) some biological/physiological functioning of the body. In fact, normal biological functioning and what may go wrong is stressed and ‘health’ as a positive concept is ignored. Health is considered to be absence of illness. Healthy behaviour is considered to be behaviour that will not cause or prevent biological malfunctioning. Health is not considered to be a positive concept in itself and thus, behavioural health, mental health, social health, happiness, etc. are not addressed. The National Curriculum only prescribes that a selected few topics of health education are incorporated in the teaching of the primary schools; health promotion as such is absent. Health promotion would include a more holistic notion of health (i.e. including social, mental, spiritual well-being) and geared towards making pupils aware of their health needs.

Looking at the OFSTED reports, it becomes obvious that even the prescribed type of health education has disappeared from the picture. A quick survey of 100 randomly selected OFSTED reports on primary schools in the North-West of England, shows that none mention health education. Apparently, health education, set out in accordance with the W.H.O. definition of health in the OFSTED Handbook and reduced to a few biomechanics in science lessons in the National Curriculum, is absent in practice or at least not visible enough to be noticed and reported by the school inspectors.

This prompts us with the following questions:
„h With what model of health are primary school pupils presented?
„h What is the child’s view of health?
In order to answer these questions we developed an exploratory study amongst year 5 pupils.

The research goals were:
(1) to acquire greater knowledge of the concepts of health amongst pre-adolescents;
(2) to investigate the relationship between the concepts of health and health behaviour amongst pre-adolescents;
(3) to study the impact of educational policies on the concepts of health;
(4) to make recommendations for health promotion among youngsters;
(5) to produce guidelines for revision of school curriculum plans.

The general aim of the study is to examine the models of health as perceived by school children and the way these influence their health behaviour and their health status. In order to study this relationship, four areas are assessed independently: the concept of health amongst 10-13 year old children (the main subject for study), the health education offered to these children (the major variable open for action), the health behaviour of these children, and the health status of these children (the assumed two major long term outcome variables).

The project has two phases: an exploratory study and a longitudinal study. The exploratory study of the research project has been finalized and most of the data of this study have now been analyzed. The aim of this phase was to obtain a first impression of the range of concepts of health held by school children and to hypothesize on the correlation between these concepts and certain background variables. For this reason we have opted, at this stage of the research, to employ a predominantly qualitative approach. Quantitative analysis may be required in follow-up exercises.

The research goals of the exploratory study, other than providing technical information for the longitudinal project, are:
(a) to acquire qualitative knowledge of the range of concepts of health amongst 10-year old children; (b) to obtain insight in the functioning of the National Curriculum at the school level; (c) to make recommendations for basic revision of the National Curriculum.

The exploratory study focused on children in year 5 of a primary school in the North-West of England. The study included a variety of research tools. Children were presented with questionnaires with open-ended and closed questions in order to obtain their self-image and their view of health. Most of the background variables, such as social-economic status, ethnicity, home situation, family background, were collected indirectly, either through the class teacher or with the aid of certain activities. All children kept a food diary for one week, so that we could assess their diet. They were asked to write short essays and make drawings on various topics. Measurements were taken of all children to obtain an assessment of their body-mass index and their physical stamina. The most important aspect of the data collection of this exploratory study was the use of focus group discussions, as this gave us the opportunity to discuss their view of health with the children. The focus group discussions were programmed towards the end of the field work, for the children to get to know the researcher and to create some rapport. The focus groups consisted of small groups of pupils. Finally, the school head and the class teacher were questioned on the health education provided to the pupils.

What we will present here are our impressions after the initial analysis of the research data. We will focus on the data from the focus group discussions and the draw-and-write exercises. A more full account of the analysis will be presented elsewhere.

When we listen to what children at this age say, one message is received loud and clear: health is related to food and sports. For instance, the children were asked how healthy they are and 18 out of 20 answered that their health ranged between 70% and 97% (highest possible score 100%; mean score: 80%). However when we asked why they consider to be that (un)healthy, all answers were centred on a common theme:
„I am healthy because I don’t eat too much rubbish
„I am healthy because I like doing most sports and like eating lots of fruit
„I am healthy because I play football
„Sometimes when I go to the shops I get some sweets, but most of the time I eat healthy things.
„I am healthy because I don’t smoke

It is not so much the absence of disease that dominates the child’s view, as it does in the adult’s view, but their type of behaviour. Exercise, eating healthy food and not smoking means that you are healthy; no exercise, eating sweets and smoking means being unhealthy.

In the focus group discussions the same image came forward. The question about their health is not interpreted as a question about their constitution, but considered a question about their behaviour. Did I not eat too many sweets? Did I eat fruit? Did I do enough sports? They do not assess their physical, social and mental well-being, nor just the presence or absence of illness, but they judge their own behaviour. Children at this age seem to be eager to conform to the standards that are set (according to their opinion) by important adults. Being healthy means behaving the way you should behave.

The children reacted in a similar fashion to the other data collecting instruments. When being asked to keep a food diary, i.e. to keep record of everything they ate or drank during one school week, the pupils considered this to be an opportunity to show how well behaved they were. We do not have the impression that many children ‘lied’ when entering data into their diary. They were aware that all information would be kept confidential and in fact we have the impression that almost everyone kept the diary meticulously. But what did happen was that some children changed their eating behaviour because of the diary. One anecdote is that one pupil started eating sunflower seeds and continued doing so for the whole week of the research, in order to show how healthy he was. Another anecdote is that one pupil was going to be absent during the research week and, being a vegetarian, thought she was going to miss out in showing how healthy she was and insisted on keeping a food diary anyhow.

Just like adults, children have their own model of health. They have created their own model of rationalizing which things are healthy, what behaviour is considered to be healthy and what a healthy body is. Like adults, children consider health to be a physical entity and mental health is usually not part of the model. The major difference between the child’s and the adult’s model of health is the differentiation between behaviour and health. Adults segregate behaviour and health in this sense that certain types of behaviour can lead to illness and that other types of behaviour can prevent ill health. In other words, according to adults health is considered to be absence of disease and the ill person could possibly be blamed for his/her ill health, though not necessarily so. In other words, the disease aetiology can be exogenous as well as endogenous. Children, on the other hand, consider health to be the same as behaviour. One is healthy if one behaves healthily; illness is failure to behave the way one should. As children behave to please adults, illness is considered to be not behaving the way adults tell you to. The adult’s message is focussed on do’s and don’ts in health and supports basically the more general notion that the individual is at fault when illness occurs. Stated differently, the child’s disease aetiology is only endogenous. The National Curriculum also stresses the do’s and don’ts as they focus on alcohol and drugs abuse and the need to eat healthy food; it does not take into consideration that there is such thing as mental and social well-being, happiness, feeling secure, etc.

During the focus group discussions, the children were asked to decide whether the topics of the drawings which they had made earlier, were considered to be healthy or unhealthy. The drawings they had made were on four themes: a type of food, an emotion, a person, an activity.

With food, the choice was easy for them: “All the nice things are unhealthy; all the awful things are healthy”, as some stated, or the ‘Cod Liver Oil Syndrome’ as we would label it. They had received the message that fat is unhealthy, so pizza was unhealthy “because it is made with olive oil”, even though this type of oil is not necessarily unhealthy according to the medical professionals. A drawing of a meal at McDonald’s was considered to be unhealthy, but no-one could explain why this was so. Most just said that that is what they were told or because “it is chips and all”. Many admitted that they liked the food at McDonald’s, though some denied this. One mentioned that this type of food is unbalanced, but could not explain this any further. Perhaps another example of the cod liver oil syndrome. A drawing of lots of fruits was classified as unhealthy, because “it is not good to eat too much of one thing”. “You have to eat small amounts of different things and not a lot of one thing”. “Eating one orange is healthy because it contains vitamins, but eating a lot of oranges is unhealthy”. However, the way the fruit is taken seems to be unimportant, as “Jam is healthy because it has fruit in it”.

All children had an initial reserve to classify emotions as either healthy or unhealthy. “How can a feeling be healthy or unhealthy” was a generally heard question. No answer was given to them, but they were requested to comply and classify the emotions they had chosen to draw as either healthy or unhealthy. It was surprising to hear what the reasons were for their classifications.

A number of drawings depicted the feeling “happy”. In all focus group discussions the children offered the same explanation as to why this emotion was healthy: “if you are happy, you will go outside and start doing sports and that makes you healthy”. Similarly, feeling depressed (“weighed down”) was considered to be unhealthy, because “if you feel depressed, you stop eating and you will die, so it is unhealthy”. A drawing of a person crying was also classified as unhealthy, because “if you cry you cannot eat, which is unhealthy”. The children simply refused to address the issue whether the emotion was healthy or not. Time and again the question about an emotion being healthy or unhealthy was answered using circumstantial details, which in turn would be linked to food, exercise and fresh air. A picture of “over the moon”, was once considered to be equal to “being happy”, which was classified as healthy because “if you are happy you eat a lot, so you won’t die”. Another time a similar drawing about “over the moon” was classified as unhealthy because the drawing showed someone in a space suit and if you were inside such suit “you do not get enough fresh air”. Never was the emotion itself discussed. Apparently, the children could not make the connection between emotions and health.

A third topic for the focus group discussions was the drawings of activities. Almost every activity was classified as healthy as the motto “exercise is healthy” was considered to be true to everyone. A drawing of a person doing a bungi jump, which we thought required further questioning, was still considered to be healthy, because “bungi jumping is done outside, so you get a lot of fresh air, so it is healthy”. A picture of motor racing was classified as unhealthy because “you get all these fumes that pollute the air you breathe”. Parachute jumping was similarly classified as healthy because of all the fresh air.

A fourth topic of the focus group discussions was the drawings of a person. Most children had made drawings of famous people. The Spice Girls ranked high amongst the girls. The persons were ranked healthy or unhealthy according to their behaviour, not according to their image. “Mel C is healthy because she does alot of exercise”. Prince Naseem is healthy because “he does a lot of sports”. Pavarotti is healthy because “singing is healthy”. Two children made a drawing of themselves: I am healthy because I eat healthy food an I do a lot of sport”. Again, here we see the same theme recurring: children do not assess health in its various aspects, but relate it to a limited set of health behaviour.

The children who took part in the research project all had internalized the adults view of health that health is physical and has biomechanical characteristics. The concept that health also comprises mental health and social well-being, is completely absent. Nevertheless, the children had a sophisticated and rational notion of health, be it that it all focussed on health behaviour. Health was considered to be equal to eating healthy foods (i.e. not the nice things); to doing lots of exercise; and to taking in fresh air. In contrast to adults’ view of health, the children’s disease aetiology was purely endogenous and lacked the notion of exogenesis. The children have strong ideas about friends and emotions, but do not link these to the concept of health. In contrast to adults, one can even state that children do recognize their own emotional needs, whereas (British) adults often even deny these.

It is in the pre-adolescence years that concepts of health are formed. The puberty years show, besides body changes also many behavioural changes, including many changes in health behaviour, with implications for long-term health. It is therefore important that health education is part and parcel of keystages 1 en 2. We recommend not only that health education is given a more prominent place in the national curriculum for primary schools than it is given now, but also advocate for a fundamental reappraisal of health education.

The national curriculum for primary schools places health education primarily as a subject within science lessons. We recommend that health education is given its own subject heading in the national curriculum. This will reflect the importance the subject has within the curriculum. Also it will demonstrate that health education is not just part of science and not just biomechanics, but a more holistic concept and that it includes mental and social well-being. By providing health education with its own subject heading, the message that health education is not just part of science but should be addressed within other subjects as well, will be more pronounced. Moreover, providing health education with its own entry in the National Curriculum creates a necessity for (a) the school to formulate a health education policy; and (b) the OFSTED inspectors to report on it. Stated differently, we would like the policy as set out in the OFSTED Handbook to be actually implemented and that this is reflected in the National Curriculum.

Furthermore we recommend that health education (including sex education in so far as appropriate for the age group) should be truly incorporated in the total curriculum of the school. This means that special talks about personal hygiene and, in some schools, also sex education, should no longer be given by the school nurse, but integrated in the overall curriculum and that the responsibility for the teaching should be with the class teacher. This relocation of responsibility to the school, will force the school to integrate health education into the normal curriculum. A second benefit of this relocation will be that, since the school nurse is no longer in charge, the topic of health becomes demedicalized.

A demedicalized curriculum should specifically address that mental health and social well-being are similarly aspects of health, just like biomechanical health. This means that health education needs to deal with of all aspects of health such as mental, social, physical, and emotional aspects. Besides the traditional topics, the following need to be included as well: relationships to friends, relationships to relatives and other adults, alternative family structures, body changes, demedicalized sex education, happiness and depression, care facilities available to children.

Education means that we must address the child’s model of reasoning in order to get the message across. Our research has shown that children have their own, albeit limited, model of health which is basically exogenous and biomechanical in character and focused on health behaviour. Therefore it is necessary that health education should move away from the message of do’s and don’ts; it should no longer place guilt on the person with ill health. Even though children should be told that we can do many things to stay healthy and that certain things may cause ill health, more emphasis should be placed on the child’s emotional and social well-being. The child should learn that it is important to be happy and to feel good in certain situations. It should learn that being able to communicate, to be part of a social group, is just as important as eating healthy foods.

An important conclusion from the research is that children consider health to be equal to a certain type of behaviour, namely the type of behaviour adults want children to portray. As children at primary schools still try to please the adults with their behaviour, they try be all means to portray “healthy” behaviour. However, as during adolescence children change their behaviour and mostly antithetically, their adult behaviour may not be aimed at a healthy lifestyle. Health education therefore should pay less attention to do’s and don’ts, but should teach children how to analyse their emotional, social and physical well-being. In other words, we would like to see that health education is not only expanded holistically, but that it changes in character: it should change from health education to health promotion. This will be give the pupils a sound foundation for the future health behaviour of their choice.


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