Back care education in elementary school: a pilot study investigating the complementary role of the class teacher
Introduction
Today back pain and disability secondary to back pain are serious concerns from the perspective of personal disability, lost work time and health care cost [1]. Since non-clinical studies also report high back pain prevalence in the growing child [2], [3], [4], [5], [6], [7], and since there are indications that adolescent back pain is an important risk factor for back pain as an adult [8], [9], [10], [11], many authors express the need for back care education in children [12], [13], [14], [15], [16]. The results of back care education programs in adults are questionable [17], [18], [19], [20], often attributed to difficulties in breaking wrong patterns of movement and establishing correct habits [21], [22], [23]. Advantages of back care education in elementary school systems are the possibility of giving prolonged feedback and the large percentage of the population that can be reached. Primary prevention programs have been part of the schools curriculum for years in areas such as dental hygiene, cardiovascular disease and teen pregnancy [22]. According to Johnson and Deshpande [24], schools hold enormous potential for helping students develop the knowledge and skill they need to be healthy. Although many authors express the need for early back care education, specific guidelines do not exist and literature on the role of different actors in back care education to children is sparse [22].
According to Grison [25], the physical education teacher is the best-positioned and trained person to observe the posture of pupils, and to elaborate a back care education and prevention action in collaboration with the school health services. However, in the Belgian elementary school system, physical education is mostly taught by the physical education teacher, who works with the pupils for only a limited number of hours. Therefore, the role of the class teacher may also be important, mainly for the application of back care principles during regular school hours [14].
According to Lightfoot and Bines [26], class teachers are in a good position to spot health problems but acknowledge a lack of expertise in health matters. In the literature, two different procedures were found to implement back care education: some preferred to instruct the class teachers, while others chose to implement the program through an external expert. The latter was most often a physical therapist, as reported in the studies of Vicas-Kunse [22], Sheldon [21], Robertson and Lee [27], Spence et al. [28] and Chometon et al. [29]. In these studies, the role of the class teacher was not elaborated. Program efficacy was shown with significant improvement in a practical and/or knowledge test.
Balagué et al. [14] preferred for economical and methodological reasons to instruct primary school teachers. Fifty-five teachers were instructed in the theories of the Swedish Back School in order to teach back education in their classes. A survey showed limited value of this type of intervention. Instituting back education in school through the teachers may present difficulties, such as convincing the teachers to add new material to an already full curriculum [14], [22] and the considerable training required to make the teachers feel confident to deliver this information [22]. In our previous studies [30], [31], the efficacy of an educational back care program, taught by a physical therapist in elementary school, was shown with the use of a practical test and a candid camera observation. The tested tasks related to taking care of the back in daily activities are referred to as back care principles. To optimize integration of the back care principles into the daily classroom routine, the teacher was asked to be present during all sessions and an information session was organized for the teachers and the parents. Study results proved that back care principles can be taught in elementary school. However, the comparison between a practical test and a candid camera evaluation showed that some back care principles had become a habit, while for the application of other principles, external stimuli would be necessary.
The latter study result and the above findings in the literature lead us to believe that the class teacher is perhaps not the best placed person to teach a back care education program but could be important in enhancing the implementation of back care principles and providing prolonged feedback. The instruction by an external person, with good expertise on the material, complemented by specific guidelines to the class teacher to implement the learned principles may be the most efficacious way to provide back care education. However, a class teacher may only play a complementary role when motivated. In a pilot study, we found that non-motivated teachers did not execute the instructed guidelines, to enhance implementation of the learned principles. This is in line with earlier findings in general health education, showing poor implementation of health education programs when the teacher was not receptive to the program [32].
In the present study, we aim to evaluate whether a back care education program, taught by a physical therapist, is more efficacious when a motivated class teacher is given specific guidelines to enhance the application of the learned back care principles during regular class hours.
We hypothesize that students who have followed a back care education program and whose teacher has been given extra guidelines will score better on a practical test, a candid camera evaluation and a knowledge test for back care principles in comparison with students who have followed a back care education program, but whose teacher has not been given extra guidelines.
We also expect to confirm our earlier findings that both intervention groups will do better on all outcome measures, compared to a control group.
Section snippets
Procedure
The back care education program was organized and sponsored by a health insurance company and the local authority. It was developed and carried out by a team of practitioners, independent of the testers. The program had been running since January 1999, in the fifth-grade of elementary school. Three groups of pupils were compared: the first group followed the back care education program and their teacher received extra guidelines for the application of the learned material (intervention plus
Practical test
The scores in the pre-test were found to be significantly higher in the intervention plus group than in the control and intervention group for handling a crate, picking up a pen, moving a crate and the sum score (P<0.01). For sitting posture, the baseline score was only significantly higher in the intervention plus group, compared to the intervention group (P<0.05). Other baseline scores did not differ significantly. The results of Mann–Whitney U-tests on the posttest–pretest gain scores are
Discussion
The specific aim of this study was to investigate whether a back care education program in elementary school, taught by an external expert, is more efficacious when the role of a motivated class teacher is more elaborated by giving extra guidelines. Testing consisted of a practical test in a pre- and 11 weeks post-design and additionally a candid camera evaluation and knowledge test, executed 11 weeks after the program. Three groups of fifth-grade elementary school pupils were compared: a group
Conclusion
From this pilot study, we learned that back care education, taught by an external expert, is more efficacious when a motivated class teacher is given specific guidelines to enhance the implementation of the learned principles.
Acknowledgements
The authors are grateful to Rudy Fosselle and Ilse Janda, PT, for their assistance in administering this project, to Dr. F. Staes, for helpful suggestions, and to all the principals, teachers and children collaborating in this study.
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