Factors facilitating and constraining the delivery of effective teacher training to promote health and well-being in schools: a survey of current practice and systematic review

Initial teacher training

Initial teacher training in England is currently predominantly provided by higher education institutions (HEIs) at undergraduate (e.g. Bachelor of Education, BEd) or postgraduate (e.g. Postgraduate Certificate in Education, PGCE) level. Some postgraduates choose school-centred initial teacher training (SCITT) courses, which provide a greater degree of practice-based learning, while allowing them to retain their student status. An alternative route is through employment-based initial teacher training (EBITT) whereby trainees are employed by schools and train through the Graduate Teacher Programme (GTP) or the Registered Teacher Programme (RTP). Teacher training is funded by the Teaching Agency (part of the DfE and formerly the Training and Development Agency, TDA), but additional health content may be funded from other agencies. Until September 2012, to qualify as a teacher all trainees had to meet QTS standards. 18 The standards specified 33 competencies that teachers need to attain, categorised as professional attributes, professional knowledge and understanding, and professional skills. Standard 21 related specifically to health and well-being, stating that teachers need to know about frameworks and policies around safeguarding and children and young people's health and wellbeing, and how to identify and support pupils' experiencing educational or personal difficulties, including when to refer to other professionals.

New teachers' standards were launched in September 2012, replacing the QTS. 19 Teacher training providers will need to ensure that their programmes are designed and delivered in such a way as to allow all trainees to meet these standards. Newly qualified teachers (NQTs) will also be assessed against the standards at the end of their induction period of employment. Unlike the QTS standards, the new standards do not make explicit reference to health, aside from mentioning the need to create a safe environment and to contribute to the wider life and ethos of the school. Health will be regarded as implicit throughout the standards, as exemplified in phrases such as ‘communicate effectively with parents with regard to pupils' achievements and wellbeing’ (p. 9) and ‘having regard for the need to safeguard pupils' wellbeing’ (p. 10).

A new framework for school inspection came into force in 2012. 20 Again, there is less explicit mention of health but the Office for Standards in Education, Children's Services and Skills (OFSTED) will be considering fundamental aspects such as the behaviour and safety of pupils at the school, including pupils' ability to assess and manage risk appropriately and to keep themselves safe; and the spiritual, moral, social and cultural development of pupils at the school.

The structure of ITT in England is likely to change in the future. In the Importance of Teaching14 the government states that it will reform ITT, to increase the proportion of time that trainees spend in the classroom, focusing on core teaching skills. It will also develop a national network of ‘teaching schools’, based on the model of teaching hospitals, to lead the training and professional development of teachers and head teachers, and increase the number of National and Local Leaders of Education – head teachers of excellent schools who commit to working to support other schools.

It is therefore a changing and challenging time for teacher training in England, and on the surface there appears to be a less explicit role for health and well-being within the framework for training and assessment. This raises questions about the extent to which teacher training providers will feel able to include issues relating to health within their curricula. However, it is also clear that, although less explicit, health and well-being delivered through PSHE education and the wider school ethos is understood to be fundamental to excellent education and improving pupil achievement. The move towards greater self-determination in schools will place more emphasis on teachers and other school staff having the appropriate knowledge and skills, and therefore understanding more about how teachers are currently being trained and how ITT providers are facing up to the future challenges is important. These recent changes to education and health policy are also likely to affect access to training and support around health for qualified teachers in terms of their professional development.

Continuing professional development

Qualified teachers develop their knowledge and skills as part of CPD. Within the context of health, CPD may address the provision of PSHE education or more specifically train teachers to deliver a specific health-promotion intervention (e.g. around a drugs and alcohol initiative, or a sexual health campaign). Training may also encapsulate broader school-wide health-promotion interventions (‘whole-school approaches’) involving others involved in schools with a responsibility for health (e.g. learning assistants, support staff, governors). A variety of people may train teachers around health issues, including Healthy Schools co-ordinators, health professionals (e.g. health-promotion practitioners, health advisers), youth workers, psychologists and educational professionals. Training can be provided in-service (i.e. organised by the school) or externally organised by the organisations responsible for developing specific interventions or teaching methods.

Initial teacher training

Since the mid-1980s, research in England and Wales has indicated that teacher education and training in health-related areas is poor and has mostly relied on in-service training, which teachers may or may not receive. 23 Progress on including knowledge and skills regarding health and well-being in the initial training and education of teachers entering the profession has been slow, both in England and elsewhere. 24 There are unanswered questions about the provision and quality of health promotion within ITT courses across England. Our previous survey research has shown that coverage of health and well-being in teacher training curricula is limited and variable in the South East of England region. 25 Using a questionnaire we surveyed 35 organisations offering ITT in 2007 (10 HEIs, 25 employment-based schemes). Fifteen (43%) organisations responded, representing 50% of the total number of trainees in the region (83% from HEIs and 17% from employment-based schemes). The results demonstrated the enormous variability of teacher training provision across the region and the lack of any consistent approach to educating student teachers about their potential roles in promoting children's health. Most organisations were found to be incorporating ECM supported by the NHSP and other external specialists, but to varying extents. Provision of information about the NHSP was also extremely variable, from nothing at all to inclusion in PSHE education or emotional health and well-being. Employment-based training organisations (i.e. EBITT providers) were more likely to have connections with the NHSP. Reasons for lack of inclusion of health issues included insufficient time in a busy curriculum and the extent to which placement schools were actively involved in the NHSP.

The extreme variability found in our survey in the amount of time allocated to health topics demonstrates a lack of consistency in interpretation of the requirements of training, leading to very little provision in many institutions compared with careful attention and innovative good practice in a few others. The survey was limited by the relatively low response rates, its timing (just before a holiday period), the length of the questionnaire (on reflection relatively lengthy) and its confinement to the South East of England. There remains, therefore, a need to assess the adequacy of provision of health initiatives within ITT curricula across England, with a sampling strategy that ensures representation from different types of providers (HEI based, employment based) and types of course (early years, primary, secondary). Such a survey will illuminate variations in practice, identify barriers and facilitators and generate recommendations for effective training and models of effective practice suitable for further evaluation.

More recently there has been further interest in researching ITT, for example considering student teachers' ways of experiencing health education as a school subject26 and guidance for teacher training for health education in France. 27

Continuing professional development and school-based health-promotion training

Questionnaire development

The questionnaire was devised between April and May 2011 and was designed to cover a range of issues in keeping with the aims of the study (e.g. how health and well-being is covered in ITT courses, in terms of who provides training, topics, methods and assessment, and any barriers and facilitators). The questionnaire was based on the one used in our previous survey of ITT providers in the South East of England,25 although it underwent extensive adaptation with the addition of a number of questions (e.g. asking respondents to describe how they think current policy changes in education will affect their courses). A range of question types was used including closed-ended questions, questions with pre-coded response categories, Likert scales and open-ended questions. The draft questionnaire underwent a number of revisions with input from all team members and the project's advisory group, who suggested minor changes. It was intended that the questionnaire would take around 10 minutes to complete and would be administered online via the internet using specialist survey software (SelectSurvey.net, version NETv4.068.002; Classapps, Kansas City, MO, USA).

Once internal revision was complete, the questionnaire was piloted in May 2011 with a sample of one HEI, one EBITT provider and one SCITT provider, randomly selected (using a random number generator in a spreadsheet) from each of the nine English regions (formerly known as the Government Offices for the Regions) (see following section for more detail on sampling). The purpose of piloting was to assess the effectiveness of the questionnaire itself in eliciting relevant information, as well as the process of recruiting, sampling and questionnaire administration. In the first wave of sampling the EBITT and SCITT providers were sent the questionnaire by e-mail, and the head of the education department of each HEI was contacted to introduce the study and to ask for the names and contact details of their course managers. In the second wave the course managers whom the HEI heads of department had named in their institution were sent the questionnaire by e-mail.

The response rate to the pilot was 37% (13/35 course managers surveyed). The data elicited from the questionnaires were variable in terms of the level of detail of the responses to the open-ended questions and the proportion of missing data. Following some minor revisions (e.g. removal of less relevant questions to shorten the questionnaire, some reordering of questions) we considered the questionnaire to be of suitable standard for full implementation. The final version is in Appendix 2.

Sampling

Sampling and recruitment of ITT providers began in May 2011 ready for a planned June survey launch. Our sampling frame was the 208 ITT providers in England listed on the TDA (now the Teaching Agency) website (as of May 2011). This included 74 HEIs, 57 SCITT providers and 77 EBITT providers. It was considered that surveying all providers would not be feasible in terms of time and resources (except for SCITT providers; see later in this section) and so a sampling approach was undertaken.

Initial teacher training courses vary in their duration from a 1-year PGCE to 3- or 4-year undergraduate degrees (BA/BSc with QTS or BEd). There are also variations in the level of education that they specialise in (e.g. primary, secondary, key stage 2/3) (Table 1).

School-centred initial teacher training programmes are designed and delivered by groups of neighbouring schools and colleges. SCITT courses lead to QTS, and some will also lead to a PGCE validated by a HEI. EBITT courses are run by consortia of schools, colleges and local authorities (although note that some universities also offer EBITT courses). On the GTP, graduates can attain QTS while training and working in a paid teaching role. The GTP normally takes between 3 months and 1 school year, working full-time, to complete. The RTP combines work-based teacher training and academic study, allowing non-graduates with some experience of higher education to complete their degree and qualify as a teacher at the same time. This course normally takes 2 years to complete. The Overseas Teacher Training Programme (OTTP) is for qualified teachers from overseas who wish to attain qualified teaching status in England. Courses can last up to 1 year. Key stage 2/3 courses cover children in the age range 8–11 years (key stage 2) and 11–14 years (key stage 3). Early years generally covers the 3–7 years age group.

The ITT providers in England were classified according to the nine English regions. Table 2 shows that the number of providers in each region varied from 14 (North East) to 36 (Eastern). We sampled ITT providers within each of the regions to ensure that all areas of England were represented, given that there may be geographical variations in teacher training practice in relation to health and well-being.

Our sampling strategy varied according to the type of provider in each region, as follows:

1. Random sample of 50% of each of the HEIs within each region. Our initial course mapping showed that the number and range of courses on offer varied considerably by HEI. For example, in the South East region of England, the University of Portsmouth offered (at that time) just two courses, both at postgraduate level. In contrast, Canterbury Christchurch University offered 10 courses covering undergraduate and postgraduate level. To obtain balance we took a random sample of 50% of HEIs classified as offering a ‘low’ number of courses and 50% of those classified as offering a ‘high’ number of courses (low and high to be determined by the average number of courses per provider in a region). We identified the number of courses offered by a HEI through a systematic mapping of each institution's website, with details logged in a spreadsheet database. A questionnaire was to be sent to each QTS-bearing course offered by the sampled HEIs, resulting in sampling of approximately 50–60% of available courses in each region.

2. A random sample of 50% of EBITT providers in each region. As EBITT providers generally offer fewer courses we did not classify them as high or low. (Note: HEI-run EBITT courses, such as the GTP, were sampled as above in 1.)

3. Survey of all SCITT providers. This was considered feasible as there are relatively fewer of them and they offer only a limited range of courses (e.g. one to two courses per SCITT provider).

Recruitment

Recruitment followed a similar approach to that described in the previous section for the pilot questionnaire. For HEIs we first e-mailed the head of the education department in each institution to introduce the project and to ask them to complete a short structured online proforma providing us with the name and contact details of the tutor of each of their ITT courses. This was primarily to ensure that we had accurate details of all courses, as the institutions' websites did not always appear to be up to date. It was also a courtesy so that the departmental head was aware that staff members were being surveyed, and it was anticipated that their support might potentially increase the response rate. A reminder e-mail was sent 2 weeks after the initial e-mail where a response had not been received. If a response was not received following the reminder we obtained the details that we required from the institution's website, supplemented when necessary with a telephone call to the department administrator to clarify which courses were offered and/or the contact details of the course managers.

When a response had been received from the relevant departmental head we e-mailed the course managers whose details had been provided, asking them to complete the online questionnaire. The e-mail briefly specified the purpose of the study and why they had been chosen, and provided a guarantee that their responses would remain confidential and anonymised in the dissemination of the project. Again, after 2 weeks, if no response had been received an e-mail reminder was sent. If no response was received following the reminder they were logged as a non-responder in our database.

We contacted the course managers directly in each randomly sampled EBITT provider and in each SCITT provider, again by e-mail, and asked them to complete an online questionnaire using the same process as that for the HEI course managers. They were contacted at the same time as the heads of department in the HEIs. In all cases consent to participate in the study was assumed by the response to the questionnaire.

To enhance response rates the course managers were offered a monetary incentive. All responders were entered into a prize draw to win an Amazon gift voucher. The first prize was a £50 voucher and the second a £30 voucher.

Ethical approval for the survey and the subsequent interviews (see Chapter 4) was provided by the University of Southampton Faculty of Medicine Ethics Committee (ethics approval number: SOMSEC080.10). Insurance for the study was provided by the University of Southampton, who acted as research sponsor.

Data analysis

Data were downloaded from the online questionnaire tool (SelectSurvey.net) directly into a spreadsheet. The quantitative questionnaire data were analysed using standard descriptive statistics (e.g. counts and percentages). The data were tabulated and for some questions transformed graphically in bar charts. The qualitative data elicited from the open-ended questions were analysed using a basic content analysis approach, with similar responses grouped together in summary categories.

Response rates

Table 3 shows the survey response rates stratified according to type of teacher training institution provider sampled and English region. The overall response rate was 34%. As the table shows, the percentage response rate varied by type of provider and by region. The regions with the highest percentage responses were Yorkshire and the Humber (56%), followed jointly by the North East (42%) and the South West (42%). No responses were received from any of the providers sampled in the West Midlands region. The highest rate of response was from the SCITT providers, followed by the HEI course managers and then the EBITT providers.

The respondents were asked if they would be willing to be contacted to take part in the follow-up interviews planned for this project (see Chapter 4). Of the 38 HEI respondents who answered this question, 19 (50%) agreed to be contacted; of the 16 SCITT respondents who answered this question, seven (44%) agreed to be contacted; and of the nine EBITT respondents who answered this question, four (44%) agreed to be contacted. The total number of survey respondents who agreed to be contacted was therefore 30.

Details of the respondents

Amongst the HEI respondents, when asked to describe their role, all reported that they managed, led or directed one or more teacher training courses. In some cases this was in addition to other duties such as senior management, assuring the quality of teaching across their institution, developing appropriate CPD and training for staff and conducting research. In some cases more than one person from each HEI sampled responded to the questionnaire. This was a result of the sampling strategy in which providers were sampled at random and all of their course managers were sent questionnaires. Of the SCITT and EBITT respondents, all described themselves as having responsibility for one or more teacher training courses. In addition, some of them also had responsibility for overall management of the organisation itself.

Respondents were asked to tick the ITT course(s) that they managed. Of the 43 HEI course managers who responded, 22 (51%) reported managing one course, 14 (33%) managed two courses, six (14%) managed three courses and one (2%) managed four courses. Between them they managed a total of 72 courses.

Figure 2 displays the number of HEI respondents who managed each type of course.

FIGURE 2.

Types of courses that respondents were responsible for managing: HEIs (n = 43 respondents).

The most commonly managed course was the PGCE (secondary closely followed by primary). At undergraduate level the most commonly managed course was the BA or BSc. Courses classified as ‘other’ included a Training Grant Only Programme and Assessment-Only Route to QTS.

Of the 21 SCITT respondents, 17 (81%) reported managing just one course, three (14%) managed two courses and one (5%) managed three courses. Between them they managed a total of 26 courses. Figure 3 shows the numbers of respondents who managed each type of course. The most common course was the primary course, followed jointly by the early years and secondary courses. One respondent mentioned managing a GTP course under ‘other’. In many cases the respondents mentioned that they managed courses that had PGCE status.

FIGURE 3.

Types of courses that respondents were responsible for managing: SCITTs (n = 21 respondents).

Of the 10 EBITT respondents, two (20%) reported managing one course, five (50%) managed two courses, one (10%) managed four courses and two (20%) managed eight courses. Between them they managed 32 courses. Respondents most commonly managed GTP courses, of which the secondary level was most common, followed by the primary level (Figure 4). They less commonly managed OTTP courses, and only one respondent reported managing a RTP course.

Respondents were asked to specify the numbers of students enrolled on their courses during the 2010–11 year. Table 4 provides the total numbers of students with means and ranges enrolled on courses by respondents in HEIs. In general, more students were enrolled on primary and secondary courses than on early years or key stage 2/3 courses. At postgraduate level, more students were enrolled on primary than on secondary PGCE courses. At undergraduate level, more students were enrolled on BA than on BEd courses, with BSc enrolees in a minority. In terms of employment-based training run by HEIs, students were reported as being enrolled on GTP courses only.

FIGURE 4.

Types of courses that respondents were responsible for managing: EBITTs (n = 10 respondents).

There was considerable variation in the numbers of students enrolled on certain courses. For example, amongst primary BA courses, the lowest number of enrolled students reported was 30, with the highest at 800. For primary and secondary PGCE courses, the lowest number was < 20 and the highest number was > 200.

Table 5 provides the total numbers of students with means and ranges enrolled on courses by respondents in EBITT providers. More students were enrolled on primary and secondary courses than on early years courses and there were none enrolled on key stage 2/3 courses, even though two of the respondents had reported that they had responsibility for courses at this level (see Figure 4). The GTP was the most commonly enrolled EBITT course, followed by the OTTP, although the number of enrolees on the latter was very low. The total number of GTP enrolees was lower at the primary level in the EBITT courses than it was for HEI primary-level GTP courses (see Table 4); however, at the secondary level the opposite was true.

Table 6 provides the total numbers of students with means and ranges enrolled on courses by respondents in SCITTs. The SCITT course with the largest total number of students was the primary-level course, followed by secondary and then early years courses.

Health and well-being topics covered

The respondents were asked to indicate which specific health and well-being topics were covered by their courses. This question was answered by 40 out of the 43 HEI respondents, 19 of 21 SCITT respondents and 9 out of 10 EBITT respondents. Table 7 reports the frequency with which topics were covered by the three types of ITT provider and the overall (ranked) totals. Coverage of topics appeared to be generally similar across the different providers. ECM and child protection were covered by all providers. Comments made in response to open-ended questions illuminated the perceived importance of topics such as ECM, with one respondent stating that it is a:

Strong theme running through all professional  . . .  modules.

HEI 5

There was also an indication of its changing status:

ECM permeates the programme and was an important assignment (now shifting with ECM no longer core government policy, but principles of ECM remain).

HEI 28

Other commonly covered topics (covered by at least 90% of providers) were SEAL/emotional health, antibullying and working with parents (e.g. seeking parental views on school health policies and initiatives). Some lifestyle-related topics such as healthy eating, SRE, drugs, alcohol and smoking received comparatively less attention. Topics were generally more often reported to have been covered during the college-based component of the course than during the school teaching placement, except for EBITT courses where topics were generally more often covered in the schools that the trainees were working in (data not shown). As discussed later in this report, course managers did not always have full knowledge of how health and well-being was covered in placement schools and so the frequency of topics covered in placement schools may be under-reported.

The topics that the respondents specified as ‘other’ were children's and young people's rights; mental and psychological health issues; care for children from vulnerable families; young carers; loss and bereavement; children and cancer; unmet attachment needs and therapeutic approaches; active global citizenship; equality, diversity and discrimination; restorative practice; and trainee health.

Ways in which health and well-being is covered in teacher training

The respondents were asked to ‘Please describe, as fully as possible, examples of how some of the health and well-being/PSHEE (personal, social, health and economic education) topics (as listed in questions 7/8) have been covered in your course’. (Note: the topics listed in questions 7/8 are those discussed in the previous section). In total, 34 of 43 HEI respondents (79%), 16 of 21 SCITT respondents (76%) and 7 of 10 EBITT respondents (70%) answered this question. The responses varied in terms of comprehensiveness, with some people summarising their activities in a few words and others providing more comprehensive accounts. In general, the level of detail provided was considered sufficient for meaningful data analysis.

Following examination of the data the responses were categorised into the following general themes: methods employed, people involved and context. Subthemes (and the frequency with which they were mentioned) were generated for each. The themes are now discussed in turn.

Table 8 provides a classification of the different methods that teacher training providers have used to teach health and well-being. In HEIs, health and well-being was covered generally through a wide range of methods such as lectures, seminars and tutor-led workshops. Some universities commit whole days within their courses to health issues or PSHE education. For example, in one university the students have a joint day-long conference with social work students exploring health (including mental health) and child protection. In several HEIs some health and well-being topics, such as SRE and drugs, are addressed in a lecture to the whole cohort. Topics may then be discussed in cross-curricular group workshops or in subject-specific areas. Some placement schools, which are linked to university courses, have their own professional studies programme, including school-based lectures and seminars.

Table 9 provides a classification of the different types of people who were mentioned as participating in teaching around health and well-being.

A variety of agents were mentioned, including people from local authorities, schools, charities and within ITT organisations themselves. In some cases the trainee teachers were actively encouraged to carry out the presentations on health topics themselves. For example, at one university the science and PE students organise a health day and there is a focus on the trainees as role models for health:

The aim is to prioritise the corporate responsibility for modelling healthy lifestyles and draw attention to key topics.

HEI 8

‘Micro-teaching’ was another method used in training whereby the student is filmed teaching and later evaluated. At one university (HEI 39) the students are encouraged to work in pairs to produce a lesson for their assessed presentation at the end of the cross-curricular module, which is often on health/PSHE education. On some courses there was an expectation that trainees will teach some PSHE education in their school placements, or through attachment to a tutor group in school, for example:

Teach the full curriculum at 90% contact for the final five weeks of the course, including all PSHCE [personal, social, health and citizenship education] in that part of the year.

SCITT 5

Classroom observation and practice was also mentioned as an important aspect of training.

Employment-based initial teacher training providers tended to use a variety of methods in their training. Several used experts in PSHE education from their own school or from other local schools. One respondent commented:

Our partnership has a core of outstanding and good schools which offer a full range of training to back up central sessions.

EBITT 10

One respondent mentioned that the training involved someone from a research background, taking an evidence-based approach:

A colleague who conducted research on SRE in schools leads session for trainees based on research findings and good practice.

HEI 34

Table 10 reports a classification of issues relating to the context in which health and well-being is addressed, specific to HEIs.

In some cases training around health issues was mentioned as being covered in science or PE courses. For example:

Primary science covers healthy eating and environment education.

HEI 7

Sex and drugs are part of a science module in the final year.

HEI 28

However, health was also covered in other areas of the curriculum such as the humanities. One respondent commented:

There are also elements explored in the science sessions e.g. global dimensions’ cross curricula session on science and DT [design technology] related to sustainability and environmental education. Some of these concepts are also explored through the humanities.

HEI 25

Some health topics were covered through broader professional themes in which students from all subject areas are involved. However, the integration of health into broader areas of the ITT curriculum mentioned by some respondents was not universal. One respondent cited evidence to suggest barriers to the infusion of health throughout their programme:

Having completed our own small scale research project on this topic this year, we have identified that beyond PE, geography and science our other training subject areas do not see how this aspect of education is their responsibility. They had little interest in engagement and did not see it as part of the learning package within their area.

HEI 11

Some of the HEI respondents discussed at what stage in their courses health and well-being is addressed. Health topics were covered at various stages of courses, from the first year and beyond. For example, in a BEd course:

In Year 1 an Introduction to PSHE and Citizenship which explores the coverage and what it incorporates and some of the debates around this area of education. We also look at circle time as one way of building relationships with young children. We explore well-being of themselves and children and consider the self-esteem cycles. In Year 2 we have covered a range of things and is usually covered by an outside provider e.g. RSPCA [Royal Society for the Prevention of Cruelty to Animals], SRE, DARE [Drug Abuse Resistance Education].

HEI 25

Assessment

The respondents were asked whether any of the health and well-being aspects of the course were assessed (in general and/or in relation to QTS). In total, 39 out of 43 HEI respondents (91%), 17 out of 21 SCITT respondents (81%) and 9 out of 10 EBITT respondents (90%) answered this question. The majority indicated that assessment was undertaken [overall 44/65 (68%), HEIs 25/39 (64%), SCITT 12/17 (71%) and EBITT 7/9 (78%)]. Those that indicated that assessment took place were then asked to specify which methods were used. Table 11 shows the frequency of use of different methods, overall and for the three types of teacher training providers.

The majority of teacher training providers specified using more than one method of assessment, with the modal class being use of two methods (range 1–5, data not shown). Teaching observation and submission of a portfolio of activities relating to health and well-being were commonly used methods of assessment, particularly so for SCITTs. Less common were methods such as presentations or assignments. Examinations were used by a minority of providers, and no respondents mentioned using questionnaires. In terms of methods listed as ‘other’, the most commonly reported method was the compilation of evidence to support attainment of QTS standards (n = 7, all HEIs). Evidence against the standards could be derived from school placement lesson plans or observational feedback and in some cases students were given the opportunity to select a health and well-being topic for an assignment, essay or their dissertation. Other methods of assessment included ‘professional dialogue’, ‘focused teaching evaluations and reflection’, ‘one-to-one assessments’, ‘tasks during placements assessed as part of their planning files’, ‘online bullying training assessed and certificated’ and ‘implicit through assessment of other aspects of the course’.

External support for teaching health and well-being

The respondents were asked whether they used any external organisations to provide information, resources or teaching to support the delivery of the health and well-being aspects of their courses. In total, 39 out of 43 HEI respondents (91%), 16 out of 21 SCITT respondents (76%) and 9 out of the 10 EBITT respondents (90%) answered this question. For all three types of provider the majority reported use of external organisations [31/39 (79%) HEIs, 10/16 (63%) SCITTs, 6/9 (67%) EBITTs]. Those that indicated that external organisations had been used were then asked to specify which types of organisation were used. Table 12 shows the frequency of use of different external organisations, overall and for the three types of teacher training providers.

The majority of respondents specified working with more than one external organisation. For HEIs the median number of external organisations was two (range 1–4, data not shown), for SCITTs the median was three organisations (range 1–4, data not shown) and for EBITTs the median was 2.5 (range 1–5, data not shown).

Local authorities were the most common external organisation that ITT providers worked with to support the health and well-being aspects of their course(s). The delivery of lectures, taught sessions, seminars and workshops by experts were mentioned. These included Healthy Schools co-ordinators, special needs advisors, 14–19 advisors, child protection officers and police liaison officers.

Local schools were also a commonly used external source of support for health and well-being, mentioned by around two-thirds of SCITTs and EBITTs and just over half of the HEIs. The school staff involved included PSHE education experts, PE teachers, senior or head teachers, a teacher specialising in cancer care and teachers with a responsibility for child protection.

Voluntary/charitable groups were used by just over one-third of ITT providers. Specific groups mentioned covered a wide range of health-related issues and included the Teenage Cancer Care Trust, Barnardos, the Red Cross, Rethink Mental Illness (mental health), Nelson's Journey (bereavement), Young Carers, Daisy Chain (autism) and the ABLE project (environmental education). The proportion of ITT providers who worked with health professionals was low overall, and more common for SCITTs. Specific types of health professional mentioned included a clinical psychologist, a speech and language therapist and a cognitive behaviour therapist. The SCITTs who responded did not have any input around health and well-being from a local university or college or youth organisation. The EBITTs made little use of local universities or colleges, sports organisations or youth services (only one used each one).

‘Others’ who support the health aspect of the curriculum in HEIs were the National Society for the Prevention of Cruelty to Children (NSPCC), trade union representatives, police officers responsible for child protection and Association of Teachers and Lecturers (ATL) (education union) consultants. ‘Others’ who were mentioned by SCITTs included child protection specialists (e.g. from the local authority) and ‘the five voices for effective teaching’, a voice development programme for trainees. The only ‘other’ mentioned by an EBITT was a community police officer.

Time spent on health and well-being in the curriculum

The respondents were asked to ‘Please estimate the approximate percentage of time spent, as a whole, covering health and well-being in your course’. In total, 37 of 43 HEI respondents (86%), 16 out of 21 SCITT respondents (76%) and 9 out of 10 EBITT respondents (90%) answered this question. Table 13 presents the percentage of time spent on health by type of provider.

The highest percentage of respondents indicated spending 5–9% of time on health and well-being, followed by 10–14% of time. A higher percentage of EBITTs reported spending < 5% of time on health and well-being, and several respondents from EBITTs felt that the health and well-being aspect was mostly the responsibility of the placement schools. The figures presented must be interpreted with some caution as some respondents commented that it was difficult to calculate as aspects of health are embedded throughout the course.

Importance of health and well-being in teacher training

The respondents were asked, ‘How important in your view is it to emphasise the health and well-being of pupils and staff/PSHE in the initial teacher training curriculum?’ In total, 37 out of 43 HEI respondents (86%), 16 of 21 SCITT respondents (76%) and 8 out of 10 EBITT respondents (80%) answered this question. Table 14 illustrates the degree to which respondents considered health and well-being important, by type of provider. For each type of provider, the majority considered health and well-being to be important or very important (although a relatively smaller majority of EBITTs), with only a minority considering it to be of some importance. No respondents indicated that it was not important, although, as acknowledged in Chapter 7 of this report, people who regard health as less important may have chosen not to complete the questionnaire.

Several respondents commented that the health and well-being aspects of the course are important. For example:

Health and well-being goes across all curriculum subjects. It is something we as tutors are passionate about.

HEI 19

We do a great deal on the pedagogy of these subject areas, how to deal with controversial issues, how to conduct circle time etc.

HEI 14

However, one respondent was open about the fact that she did not focus enough on health and well-being, but completion of our questionnaire had prompted her to re-evaluate her provision:

In reviewing the list of dimensions provided in this survey I feel that there are areas we have neglected to date and will endeavour to supplement our existing provision accordingly.

HEI 39

It was noted by some respondents that, despite the recognised importance of health, lack of funding and time pressures limited the extent to which it could be covered:

With additional resources (i.e. more time and money) we would focus more on this aspect of the course.

SCITT 8

Future changes to teacher training courses

The respondents were asked, ‘In what ways do you anticipate that the content, delivery or structure of your course is likely to change in the near future? (e.g. in response to changes in educational policy or funding?)’. In total, 30 out of 43 HEI respondents (70%), 13 out of 21 SCITT respondents (62%) and 6 out of 10 EBITT respondents (60%) answered this question. The responses given were examined and a number of key themes to emerge were noted. Subthemes were identified and the frequency with which they were mentioned was noted. Table 15 presents these themes, each of which is discussed in further detail below.

The respondents made a range of comments about the ways in which they anticipated that their courses were likely to change in the near future. Five course managers felt that there would be no significant changes to their courses, whereas seven were currently unsure or awaiting the outcomes of the National Curriculum review, information about funding or the new QTS standards. Eight course managers reported that adaptations would be made to their courses in response to these government changes, with six speculating that this might lead to a reduced focus on health and well-being if health was not so high profile in government policy or the QTS standards:

Unfortunately with the central Government’s focus on subject knowledge, we will probably have to spend less time on the health and well-being aspects of the course.

SCITT 8

Conversely, one provider felt that the government's emphasis on special educational needs (SEN), PE and classroom behaviour might raise the profile of health and well-being. Nine of the respondents stated that they would be maintaining or even increasing the health and well-being content of their courses, despite wider educational policy changes. This was often because they felt that it was important:

We will continue to pay attention to this area and give it the importance it deserves.

HEI 33

The respondents also stated other changes that they would be making to their courses, including to the content and methods of delivering PSHE education and health and well-being, and other more general changes:

[We will be] incorporating the elements of health and well-being into the programme much earlier next year in order to prioritise this element in the trainees view of their role as a professional.

HEI 11

One course manager reported that her course would be using external agencies less in the future, with the course staff providing more of the health and well-being sessions. Another said that they would continue to build on delivery from practitioners as evaluation of the course showed that this had the most impact.

Finally, two respondents expressed concerns about the impact of currently operating on ‘lean’ (EBITT 10) resources and anticipated fewer resources in the future:

Despite trends in educational policy and/or funding there is a sense that both expectations and demands to maintain existing high standards of practice will prevail. This will place undue stress on an already overburdened teaching team, who continue to delivery exemplary programmes with increasingly fewer resources.

HEI 39

Development of the interview schedule

The interview schedule was developed between October and November 2011. The interviews were intended to be semistructured in nature with a sequence of mostly open-ended questions with prompts and probes as required. The type of questions used in a research study should be cognisant with the aims and objectives of the study and should be logical, relevant and motivating. 38 As stated earlier, the aim of the interview phase of this project was to investigate in further detail approaches to addressing health and well-being by teacher training providers who had completed the initial questionnaire. It is for this reason that most of the questions used in this study were open-ended, to allow the interviewees to talk at length. The research team decided that the questions would focus on similar issues covered by the questionnaire, but that the questions would be designed to facilitate deeper discussion. In particular, questions would be included to identify and explore barriers to and facilitators of covering health and well-being, as the questionnaire survey did not contain specific questions relating to this. In addition, two questions were included to explore specific findings from the questionnaire survey. One was to assess the extent to which sex education, drugs, alcohol and tobacco were covered by courses and any reasons for lack of coverage relative to other topics (the survey findings suggested that these had received less attention). The second was to assess the extent to which teacher training providers involve health professionals in training teachers about health and well-being, and whether there were any particular barriers to their involvement (the survey findings suggested comparatively less involvement). Other additional questions covered the interviewees' professional background (a warm-up question, designed to explore whether their previous practice or research influenced their current work, specifically in relation to health) and also whether their courses addressed the health and well-being of teachers as well as pupils.

Piloting of the interview schedule took place during December 2011. Three pilot interviews were conducted with teacher training providers in the South East of England. Two of these were HEIs and one was a SCITT. One was a 4-year primary undergraduate course, one a 1-year secondary PGCE course and one a 1-year primary SCITT course. Sampling was partly purposive, to pilot the interview schedule on different types of teacher training providers. Sampling was also undertaken for convenience by selecting contacts of the research team in the local region for ease of access. The variation in terms of teacher training provider and type of course sampled was considered to be sufficiently representative of the intended sample for the main interview study. Furthermore, it was considered by the research team that three pilot interviews were sufficient to test the adequacy of the interview schedule, and as preparation for the interviewers in conducting the interviews.

The pilot interviews lasted for around 45 minutes and were judged by the research team to have been generally successful in terms of testing the comprehensibility of the questions and the suitability of the sequence of questions, and ensuring that the type of information disclosed was sufficient to meet the aims of the project. There was variability in terms of the degree to which health and well-being was covered in the courses of the providers sampled, from dedicated health awareness activities at the start of the course reported by one provider, to relatively minimal focus on health reported by another, and we found that the interview schedule was generally effective in yielding good responses from providers when there was both high and low provision of health training.

The interview schedule underwent a series of generally minor revisions, including suggested revisions from the advisory group, until it was finalised and implemented. Once in use, the interview schedule did not undergo any major changes. However, discussion between the interviewers during the course of the interview period about experiences to date provided the interviewers with a greater awareness of how the questions were being received, and of particular themes and issues that were emerging and in need of probing further in subsequent interviews (see below).

The final interview schedule is provided in Appendix 3.

Sampling and recruitment of interviewees

It was originally estimated that around 20–25 interviews would be a sufficient number for this project. As reported in Chapter 3 (see Response rates), a total of 30 out of 63 survey respondents (48%) who answered the question about whether they were willing to be contacted indicated that they would be. Therefore, the number of questionnaire respondents willing to be approached was sufficient to meet the target number of interviews.

To facilitate selection, key details of each of the 30 consenting survey respondents were tabulated for discussion among the research team (19 HEIs, seven SCITTs and four EBITTs). Details were tabulated for each type of provider including educational course level (i.e. primary/secondary), graduate course status (i.e. undergraduate/postgraduate), course type (e.g. BA, BEd, PGCE, GTP), number of students responsible for, subject specialism (e.g. maths, English) and geographical location (e.g. English region). A qualitative summary was also written based on the key findings of each respondent's questionnaire, including issues such as the degree of importance given to health and well-being (ascertained by responses to Likert-type scales plus qualitative comments describing their views on health in teacher training); the breadth of health topics covered (e.g. many topics covered compared with a relatively small number of topics); innovative examples of approaches to addressing health and well-being (e.g. specific activities such as seminars or workshops, and particular educational techniques or conceptual frameworks); and indications of how health and well-being might be covered as a result of future changes to educational policy and curriculum reorganisation (e.g. retaining or increasing focus on health compared with possibly less emphasis on health).

Once these details were tabulated, the research team discussed the key characteristics of the sample and selected a total of 22 respondents to contact to request an interview (with more to be selected if necessary). We purposively selected interviewees to ensure that the sample reflected the different types and levels of courses, subject specialisms, English regions and approaches to addressing health and well-being. Selection was also weighted according to type of provider consenting to be contacted, the majority being HEIs (and also because a large proportion of ITT provision in England is from HEIs).

We purposively selected course managers from courses using contrasting initiatives to obtain a range of views. We also sampled from the smaller number who appeared to be covering health less overall, or covering health through a narrower range of methods. We also sampled participants to ensure that there was a range of perceptions about the importance of health and well-being, using their responses to the question about its importance in our earlier questionnaire survey to do this (see Chapter 3, Importance of health and well-being in teacher training).

Once selected, a standard e-mail was composed and sent to each respondent from the project's dedicated e-mail account, with an attached participant information sheet providing brief details about the project and the nature and purpose of the interviews. The e-mail thanked them for completing the questionnaire and provided them with their original responses to the questionnaire as a reminder. In cases of non-response a follow-up telephone call was made within 2 weeks of the e-mail request. Only one person did not respond to any contact attempts. A second person declined the invitation to be interviewed, citing work pressure and lack of time. A further two people initially agreed to be interviewed, but subsequently it was not possible to arrange an interview because of their lack of availability.

During the course of the project the research team decided that, if necessary, interviewees could be recruited from other sources, in addition to those who had previously completed the questionnaire. This was a pragmatic decision to enable us to purposively interview teacher training providers who, it appeared, were using approaches to addressing health and well-being that were complementary to those in our existing sample. During the course of sampling and recruitment it was considered that the sample was adequate to reflect a range of approaches and that recruitment of additional teacher training providers would not likely be necessary. However, at the project's advisory group meeting in January 2012, it was noted that there had been no questionnaire responses from the West Midlands region, and therefore this would be the only region not represented in the interview sample. It was recommended that the project attempt to recruit an interviewee from a teacher training institution in this region, for completeness. Our sampling frame from the questionnaire survey showed that in the West Midlands region there were a total of 21 teacher training providers (nine HEIs, five SCITTs, seven EBITTs). We selected one provider (a HEI) from this region, chosen because it provided a range of courses (e.g. undergraduate/postgraduate, level of education) and the ethos and principles of the institution were in contrast to others in our sample (as ascertained from information provided on its website). We contacted three course managers from this institution and one consented to be interviewed.

In summary, a total of 25 people were contacted, of whom 19 were subsequently interviewed in a total of 18 separate interviews (Figure 5) (Note: one of the interviews was conducted jointly with two people from the same institution, at their request).

FIGURE 5.

Flow chart summarising sampling and recruitment of interviewees.

Conducting the interviews

The interviews were conducted by three of the authors (SD, KP and JS) over a 3-month period between January and March 2012. Before each interview the interviewer familiarised himself/herself with the interviewee's questionnaire responses and completed a standard pre-interview proforma containing general details about the interviewee's course(s) (e.g. subject areas) and ways in which health and well-being was covered (as disclosed in the questionnaire). The purpose of the proforma was to help the interviewer to tailor the interview (e.g. through use of specific probes) to the specific circumstances of each interviewee.

All interviews were recorded using a digital voice recorder. The intention was to conduct face-to-face interviews whenever feasible to facilitate rapport and in-depth discussion. Fifteen of the interviews were conducted face-to-face, with the remaining three conducted on the telephone (for reasons of convenience). The telephone interviews were of approximately the same duration as the face-to-face interviews (between 45 minutes and 1 hour) and the quality of discussion was judged to be comparable. All interview recordings were transcribed by a professional academic transcriber.

Data coding

A content analysis approach was used to analyse the data from the interviews. This was chosen as it is a standard and relatively straightforward technique used in the social sciences to categorise and explore qualitative data from interviews. 39,40 At its simplest, content analysis involves reading interview transcripts and recording the frequency with which key terms and issues are mentioned. 41 These can be grouped into response categories and the relevant dialogue coded according to each category. As coding progresses the categories can be amalgamated into broader themes, if appropriate. It was considered to be an appropriate method for the analysis of the type of data to be elicited in this stage of the research, and was in keeping with the inductive nature of the study as a whole.

There are a variety of different computer software programmes available to assist with the analysis of qualitative data. The software has made the process of data management and analysis more efficient, allowing researchers to store and organise data in a format that is easily retrievable, and which automates techniques that researchers used to do by hand. It is important to note, however, that these programmes cannot substitute for the considerable skill necessary to identify themes, explore associations and meanings and draw conclusions from the data. The researcher's analytical and intellectual input therefore remains as important as ever.

NVivo software (version 9; QSR International, Southport, UK) was used to code and analyse the data. This software was chosen as it is a specialist programme suitable for analysis of textual data and was considered adequate for the needs of this project. Once all of the interviews had been conducted, each finalised transcript was imported into NVivo ready for coding. Each interview transcript was coded in turn. Before the start of coding we set up a coding framework in NVivo based on the 12 main questions in the interview schedule (the full interview schedule is available in Appendix 3). A ‘node’ (i.e. a code) for each question was generated when the framework was set up in NVivo, with the aim of the researcher analysing the data to create second-order (or third-order if necessary) subnodes as response categories for each question. The specific nodes set up in NVivo that formed the analytical framework were interviewee background; significant changes to the course; how health and well-being are covered; time spent on and timing of health and well-being in the course; external agencies or external people; sex, relationships, drugs and smoking; funding for health and well-being; assessment of health and well-being; health and well-being of teachers and trainees; challenges and barriers to addressing health and well-being; facilitators to addressing health and well-being; and future changes to course. As part of the framework, a ‘free nodes’ node was also set up where data not directly related to any of the interview questions could be coded, such as any unexpected issues that emerged during the analysis. An example of a code that was created under ‘free nodes’ during the analysis was ‘conceptions of health and well-being’, which captured the interviewees' personal beliefs about the importance of health and well-being, how health and well-being relate to children and young people's education, and what these terms meant – an issue that we did not directly question interviewees about, but which most of the participants spontaneously mentioned during the interviews, and which is a key part of our findings reported below. As the researchers read through the transcript on the computer screen they highlighted passages of text (e.g. a sentence, or a paragraph) and coded them according to which of the interview questions they related to, creating new subnodes if necessary or adding to existing subnodes describing similar issues. For example, the node called ‘challenges and barriers to addressing health and well-being’ was created to categorise responses to the question, ‘What key challenges have you experienced in addressing health and well-being in the teacher training curriculum?’ Responses to this question were assigned to subnodes, with common responses assigned to the same subnode when applicable. Each of these subnodes was therefore classified as a specific barrier. The overall purpose of this exercise was to code each occurrence of a particular issue discussed during the interviews so that those issues could be easily retrieved from the database and the coded text analysed for meaning. The meaning units coded by the researchers were kept sufficiently large so that the context of the interviewees' points was not lost.

Coding of the initial interviews was carried out by the researcher who conducted each interview. Discussion between the interviewers took place after each had coded at least two interviews to ensure shared interpretation of the codes and intercoder reliability. At this point (i.e. at around the sixth coded interview transcript) the number of subnodes had grown to the point at which it was considered necessary to review the subnodes and merge similar or overlapping subnodes to avoid duplication and to keep the coding framework manageable. This was performed by one of the interviewers (KP) and acted as a quality assurance check for accuracy of coding. Following this revision to the coding framework the remaining interview transcripts were generally coded by this interviewer.

Once all 18 interviews had been coded, around 550 separate nodes had been created. A review of the nodes was undertaken by one researcher, to merge similar nodes and merge unnecessary subcodes into the higher-level nodes. Once this review was completed the number of nodes had been reduced to 420. The team then began to analyse the nodes in more detail by examining the passages of interview conversation that had been assigned to them, and noting any patterns in the data (e.g. we noted that, when interviewees had cited a lack of understanding and knowledge about health and well-being as a barrier, they sometimes mentioned this in relation to training provider staff and at other times mentioned it in relation to school placement staff and trainee teachers). From discussion within the team, the barriers to and facilitators of teacher training were considered to fall within the following spheres of influence on how health and well-being was covered in ITT:

• trainee teachers

• teacher training providers

• placement schools and the wider school community (e.g. where trainee teachers spend their placements)

• external agencies (e.g. local authorities, health services)

• local culture and geography (e.g. the socioeconomic and cultural profile of the locations where teachers are trained)

• wider educational culture (e.g. the perceived general culture within education in which providers, schools and trainees work)

• government policy (e.g. health, education).

It was considered that these spheres encapsulated the main influences on teacher training in relation to health and well-being. To illustrate the relationships between the different spheres we manually (outside of NVivo) constructed a model diagram with arrows showing the direction of influence (e.g. between government policy and teacher training providers, and between teacher training providers and placement schools). This was based on the interview data that we had analysed, but also on our background knowledge of health and education and on broader evidence (e.g. from research, theory and policy). The model was partly informed by the social–ecological model,42,43 which is a theory that explains how individuals' behaviours or social phenomena are influenced by reciprocally related individual and social factors, including intra-individual factors (e.g. attitudes), interpersonal factors (e.g. peers, social networks), the structure of the institutions and organisations in which individuals operate, the wider community (e.g. social norms) and, at the broadest level of the model, social structures, policies and systems (e.g. government policies). During data analysis we considered whether this model could form an explanatory framework for our findings as the barriers and facilitators identified seemed to relate to aspects of the model, but we decided finally that it was not a fully appropriate fit for our data. The social–ecological model therefore helped us to structure our thinking about the analysis and spheres of influence, but we created our own model to explain the findings as this allowed us to create a model that fitted the data better. The model we created became an explanatory framework for our interview findings and also shows the context of teacher training. A draft was discussed with the project's advisory group who made suggestions for minor revisions (the final model can be seen in Figure 7).

The barriers and facilitators that had already been coded were then assigned to each of the spheres of influence as appropriate in NVivo. This process also included some recoding of the barriers and facilitators themselves when necessary. After carrying out this process a total of 515 codes had been generated.

Generating analytical themes

Through the process of coding and analysis described above, a number of overarching themes began to emerge from the data. Two of the research team independently noted down the key themes that they had observed and met to discuss these (JS and KP). These two researchers agreed on the majority of the key themes, resulting in a list of around six. Over time this list of key themes was revised and increased, and then decreased again through discussion with other members of the research team. The reduced list contained six key themes considered to encapsulate the barriers and facilitators identified in the interviews. Once these themes had been defined and agreed by the research team, each of the barriers and facilitators was re-examined and one or more themes were assigned to each. This was done in a series of preliminary tables outside of NVivo, in which the barriers and facilitators were plotted in separate columns and the themes applicable to them were listed in adjacent columns, stratified by the spheres of influence described above (i.e. teacher training providers, placement schools, etc.). The purpose was to describe and discuss the barriers and facilitators operating within each of the six themes. The assignment of themes to the barriers and facilitators was carried out by one researcher and checked by a second for consistency. Minor amendments were made to the categorisation following discussion (mainly to assign additional themes to a barrier or facilitator, rather than reclassify barriers and facilitators altogether). Following this, in NVivo, the barriers and facilitators, labelled by the sphere of influence that they were located within, were then categorised according to the main theme to which they related and, in some cases, subthemes were inferred by comparing differences and similarities between the barriers and facilitators. These data are presented in our findings below and the themes themselves are described in Barriers to and facilitators of effective teacher training.

Characteristics of the study sample

The providers who were interviewed were spread across the country, with representation from every English government administrative region (Table 16). There were slightly more providers interviewed from the South East than from other regions, which may reflect a higher proportion of providers in the South East or perhaps that there may be more trainee teachers in this region. This is difficult to substantiate as the numbers of trainees on individual courses are not always clearly advertised on individual providers' websites, which were consulted before the survey and the interviews.

As stated earlier, the interviewees were sampled according to the type and level of courses that they managed so that they represented a range of courses catering for primary, secondary, early years and key stage 2/3, at undergraduate and postgraduate level, across HEIs, SCITTs and EBITTs. In the HEIs some of the interviewees managed more than one course (e.g. Programme Director for Primary Education) and some managed the whole portfolio of courses provided by their particular institution at undergraduate or postgraduate level (e.g. Head of the Undergraduate Programme) (Figure 6). Others managed one specific course (e.g. Programme Director for PGCE Key Stage 2/3) and had an input, for example as a lecturer, into other courses. SCITT and EBITT managers were responsible for managing postgraduate courses, which for some included courses at more than one level, such as secondary and 14–19 years (e.g. SCITT 15).

The providers of secondary, key stage 2/3 and further education courses generally offered a range of different subjects, some more limited than others, including mathematics, geography, science (physics, biology, chemistry), PE, English, modern foreign languages, religious education, design and technology, information and communications technology and music. Some of the interviewees were subject specialists in their current roles, such as a mathematics lecturer or PE specialist, and they frequently used their subject knowledge and expertise, for example in science or PSHE education, to contribute to the health and well-being content of their training courses.

FIGURE 6.

Role of course managers interviewed. GRTP, Graduate/Registered Teacher Programme.

The numbers of students on the courses varied between different institutions and types of organisation. The numbers of students on PGCE courses at SCITTs and EBITTs ranged from three students on an early years GTP course to 79 on a SCITT primary course. In HEIs the numbers of students on the undergraduate courses of those interviewed ranged from around 12 on a BEd in a particular subject to a total of around 800 on a 4-year course. The numbers on 1-year PGCE secondary courses ranged from about 120 to 140 students. On 1-year PGCE primary courses the numbers of students ranged from 60 to 190. On the PGCE 14–19 years course there were 33 students and on the PGCE key stage 2/3 course there were about 60 students. In general, the numbers of student places available in 2012 had been reduced from the time of our questionnaire survey in the previous year because of a reduction in government funding, particularly for training in the teaching of vocational courses in the 14–19 years age group. One course director mentioned that numbers would drop again considerably for vocational courses in the coming academic year.

Background of the study sample

All of the course leaders who were interviewed had teaching qualifications and teaching experience, many at a senior level. Five reported an academic research interest in the area of health and well-being, such as in outdoor play, how children in nursery education make meaning in science and the effect of well-being on children's resilience. A strong personal interest in health was mentioned by seven, as well as a holistic concept of health and well-being, for example through their interests in sport or in nutrition in adolescents, through their previous involvement in schools with the Healthy Schools award, through working with local authorities and children's centres or through their experience of working with parents and community groups. As one person commented:

My whole education background places children at the centre.

HEI 42, primary phase

Some of the course managers were trained in science or in PE and they noted that this has increased their interest in health and well-being. Others had worked with children with SEN or in deprived areas with refugees and asylum seekers, and one worked in the education department within a prison. Overall, seven of the course managers told us about health-related professional experience that they had had (including through their teaching role).

Some course managers had been working in education since their degree and had moved directly from senior roles in schools, which included pastoral responsibilities, to training teachers. Others had had gaps in their careers, to have families or to undertake voluntary work abroad. In some cases their work in schools included a large amount of health education, both with pupils and parents and with the wider school community. Some had worked as local authority advisors and school governors, giving them a broad understanding of how schools function. A few were relatively new to managing a teacher training course and had come to work in a university only within the last 10 years and could therefore draw on their recent experience of working in schools.

In summary, the interviewees came from teaching backgrounds and had progressed to teacher education. They varied in their background experience of health but, in total, 12 interviewees reported that they had either professional or personal experience or interests related to health and well-being.

Course managers' conceptions of health and well-being

In setting the scene for the interviews, the participants were informed that we had a broad definition of health and well-being and therefore anything that they felt was relevant to this theme could be discussed during the interview. Their comments illustrate that health underpinned many aspects of their courses and was often seen as fundamental to effective teaching and learning.

Many course managers mentioned the importance of holistic education, in which health and well-being permeates through the curriculum rather than being addressed in separate modules. They mentioned the importance of the ethos and values that are portrayed by their course which promote health and well-being, such as getting students to understand working across the curriculum, the benefits of different subject staff working together and the sense of health and well-being that this approach brings to staff, trainees and pupils in schools.

On some courses, health was interwoven into the ITT curriculum through a focus on particular themes throughout the course, including SEN, outdoor education and behaviour management – the exact underpinning theme varied from course to course. This did not necessarily mean that health and well-being was comprehensively addressed on these courses, but that there was a particular health-related strand that underpinned them:

We do not explicitly cover a lot of health and well-being in the classroom but it underpins a lot of what we do . . . We do a lot about inclusion and the inclusive classroom, and what an inclusive classroom looks like . . . get them to think about the diverse settings in which they work, which I think again is part of a child's well-being and happiness in school.

HEI 40, primary and secondary phases

As the above course manager explained, health and well-being is not always explicit in teacher training but it is related to issues such as inclusion and special needs. Similarly, in one interview in which two course managers were interviewed jointly, health and well-being was seen as fitting alongside behaviour management, classroom organisation and relationships in school. They highlighted the importance of encouraging their trainee teachers to think about their responsibilities as learners and to one another, and about their own student voice on their course, which would help them to use these approaches with pupils in school:

So it’s important that they have a deeper understanding of how children develop these behaviours, you know the appropriate ones, inappropriate and so on, rather than just being given a strategy if a child is the one child who’s rushing up and down the classroom or whatever, so that they also know about the different sorts of behavioural difficulties and syndromes related to that.

SCITT 19, primary phase

Several course managers acknowledged that subject knowledge is not the only important aspect of teacher training, but that awareness of child development and emotional well-being is also very important. One commented:

How can you run a teacher training programme without thinking about the development of adolescents, about the emotional upheaval, about the hormonal upheaval that’s going on in their lives?

EBITT 6, secondary phase

Conceptions of health and well-being also included awareness about pupils' social and economic backgrounds. One course manager described how a pupil's home environment can affect his or her learning, for example a pupil may be a carer of people within the family:

Class, deprivation, social class, all that sort of stuff, and it’s been my experience that actually a truly effective teacher who can inspire children, needs to take those things into account, and needs to know where their pupils are at, and work with that to improve that.

EBITT 6 secondary phase

The importance of topics such as drugs, alcohol, SRE, smoking, child protection and safety was discussed by several course managers. One commented on the importance of teachers helping pupils to develop health-related skills rather than just providing them with information:

The health and well-being of young people is all to do with more than just you know sex and relationship education, it’s about communication skills, listening skills, developing those skills, and social skills, and you can do that as a classroom teacher and you’ve got a part to play in that.

SCITT 15, secondary phase

Conceptions of health and well-being included teachers' as well as children's health. The fact that an emphasis on exam results can lead to teachers leading unhealthy lives was also mentioned. One organisation provided trainee teachers with the opportunity for self-study and the use of music and books, emphasising the message that part of children's health in your care is your own health:

If schools were more thoughtful and less pressured, given the amount of time that pupils spend in schools . . . we might have happier schools, happier teachers.

HEI 29, primary phase

Model of initial teacher training

From our analysis of the course managers' accounts and our existing knowledge of health and education, we created a model of ITT (shown in Figure 7) which shows the different organisations and people that can influence the delivery of training in health in ITT, and the relationships between them. The purpose of this model is to show the context of ITT and put the findings described in the subsequent sections into context. In particular, we found that the barriers to and facilitators of training in health mentioned by the course managers were each located within one or more of these spheres of influence, and this helps to highlight where changes can be made to promote more effective training in health.

The model shows that government policy (in education and health) partly influences the training provided in ITT and also what placement schools do around health. Our model shows this to be a top-down influence, as this was how course managers portrayed it. They felt that it had a major influence on the content of their courses. We have characterised the relationships between teacher training providers, placement schools and external agencies, as well as trainee teachers, as reciprocal, as the course managers' accounts suggested that these were sometimes two-way relationships. The role of the trainee teachers in our model should not be viewed as a passive one, as simply receivers of training. We found in our analysis that the course managers felt that trainee teachers could also impact on the health training that they received through, for example, the pre-existing knowledge that they brought to courses and their level of interest in and engagement with health issues. The model also shows that health training in ITT was located within the wider contexts of the local culture and geography of the areas in which providers, placement schools and agencies were based, and also the general perceived culture in education, and that these factors could also influence training in health or formed a backdrop to it. The following sections of this report will expand on the relationships between these people, organisations and contexts, and the impact that they have on the provision of health training.

In the following sections we present our findings from our analysis of the interviews with the course managers. We first describe how health and well-being was delivered on courses and then we consider the barriers to and facilitators of effective training in health in ITT in terms of the six analytical themes identified. We present all of the barriers and facilitators identified in the analysis in tables and have shown in the tables how each of the barriers and facilitators mapped onto the spheres of influence shown in the model of ITT in Figure 7.

FIGURE 7.

Model of the spheres of influence on health coverage in ITT and the relationships between them.

How health and well-being was covered on courses

We found that there was variability in how health and well-being was covered across courses, and also in the amount of time spent covering these topics. Furthermore, course managers were not always clear in the interviews about where health and well-being topics were located within their courses. This was partly because of the perceived wide-ranging nature of what constituted ‘health and well-being’, with a number stating that it came into many aspects of the course indirectly, such as in SEN and behaviour management. However, this was also because of some aspects of health training not being very explicit in some courses. For example, when asked how his course covered SRE, drugs and alcohol education and smoking prevention, one course manager said:

Very incidentally, if I’m very honest  . . .  I wonder whether we do that at all, but I think it’s more likely to come in the science session than it is in the PSHCE [personal, social, health and citizenship education]. The SEAL materials I think perhaps do wee bit of that, but then it’s more social emotional aspects of learning, and it’s, it’s again it’s only going to be incidentally.

HEI 5, primary phase

From the course managers' accounts we categorised the nature of how health and well-being topics were covered into the following groups – we found that our categories mapped directly onto those created by Arnold and Maio-Taddeo44 to describe teacher education in child protection in Australia, so we used the category names created by these authors:

• integrated/embedded approach – in which there was an underpinning health-related ethos or structure to the course and health topics were integrated into training across different areas of the course

• discrete approach – individual sessions or modules that explicitly covered a health topic or PSHE education

• incidental training – in which a health-related topic was covered incidentally or implicitly as part of another aspect of training, for example SEN, dance or PE, or when trainees chose a health-related topic for an assignment.

These categories are not mutually exclusive. For example, on some courses there were discrete sessions on some topics but other topics were covered more incidentally. The integrated and discrete approaches resulted in health training being much more explicit in the curriculum and contributed to a more coherent approach. There was also variability in terms of whether the trainee teachers across different types of courses (e.g. BEd, PGCE) and subjects within the same institution received similar health input. On some secondary-level courses, course managers said that science and PE trainee teachers were likely to receive more training in health issues because of the nature of their subjects.

Health topics were generally covered within the professional studies modules on courses (Table 17), and discrete sessions on PSHE education were commonly located within this. Specific health issues, such as drugs education and SRE, were sometimes covered as part of the PSHE education sessions, as stand-alone sessions, or were located within subject-specific modules, such as PE or science. All of the secondary phase course managers mentioned that some health topics were covered in professional studies, whereas only four of the seven primary phase course managers said the same. Conversely, more primary phase course managers (four) than secondary phase course managers (one) indicated that health topics were covered in many areas of the curriculum or that they made cross-curricular links.

Working with external agencies or external people

All of the course managers reported that they worked with people from external agencies to deliver some of the health-related content on their courses. In line with our questionnaire findings (see Chapter 3), they most commonly mentioned working with personnel from the local authority or local schools (Table 20). Local authority personnel were especially involved in delivering safeguarding and behaviour management training. The course managers mentioned a wider range of topics being covered by school personnel, including:

• emotional and behavioural disorders

• EAL

• vulnerable children

• behaviour management

• SEAL

• SEN

• pastoral care and PSHE education

• the role of the parent in children's learning

• pupil voice.

On two courses, support staff from schools (a parent support advisor and a teaching assistant) also delivered sessions. Furthermore, one HEI brought pupils from a secondary school in to help facilitate a session on pupil voice. Some course managers also involved theatre groups, charities and the police in delivering health-related content (typically safeguarding, SEN and equality and diversity), among other external people.

Few of the course managers mentioned involving people from external agencies in the delivery of training in health issues such as smoking prevention, healthy eating, physical activity, SRE or mental health issues. On the whole, provision from external agencies usually covered health topics more closely related to education and learning, such as those listed above provided by school personnel, rather than training in health promotion to live healthy lives. This perhaps reflects that this kind of expertise was more immediately available to ITT courses or reflects the sources of expertise that course staff knew about. Indeed, in line with our questionnaire findings, only six of the course managers we interviewed said that they involved health professionals in the course (e.g. nurses, counsellors, midwives, public health-promotion specialists).

As we found in the online questionnaire that few institutions worked with health professionals, we asked the course managers in the interviews what they felt the barriers to this might be. The barriers that course managers mentioned were:

• it was just not something that they had thought about doing, as they tended to think about education people when engaging external expertise and they felt that it was more appropriate for people with this background to deliver training in ITT

• difficulties making contacts and not knowing who to approach

• concern about a lack of understanding of ITT and education among people from external agencies

• reluctance from the health service to release staff because of the pressures that they were under

• difficulties finding mutually convenient times to work together.

Ten of the course managers said that working with people from other agencies or departments with health-related expertise had been a particularly successful part of the health training on their courses and they reported that the students liked it. They cited the following benefits of this for the trainee teachers:

• being exposed to a different perspective

• being exposed to a facilitator with ‘real-life’, direct experience

• knowledge for the future of other professionals' roles.

Timing of health in the course

In general, the course managers said that the timing of when health topics were introduced to trainee teachers depended on the trainees' needs and the topic, and that topics were spread throughout the course. Only one course manager said that the timing was incidental (i.e. not based on any specific reason) and another two said that the timing partly depended on timetabling and when contact time at the provider fell. In many cases, topics such as SEN, behaviour management and safeguarding were delivered in the first term, as the course managers felt that the trainees needed to know about these before going on their first school placement. In some institutions, topics such as PSHE education, citizenship and SEAL were also delivered early on in the course. At others, there had been a deliberate choice to introduce some health-related topics either in the middle of the course or later on, as the course managers felt that it was beneficial for the trainees to gain some experience in school before covering some issues:

We look at transfer and transition on their return in the New Year  . . .  [because they've] had some experience of seeing potential issues and seeing how children slip back and can actually contribute a bit more to those sessions.

HEI 40, primary and secondary phases

Funding of health and well-being

All of the course managers told us that they did not have any specific funding available to them at their institutions for health-related work. Some commented that they could make requests for funds to organise events or activities, with the case having to be made for these. Sometimes funds were available indirectly through other related areas (e.g. funding for SEN training) and sometimes one-off funding was available (e.g. through a funded research project).

In the absence of specific funding, 12 of the course managers said that some of the health-related activities on their courses were partly dependent on free support and the goodwill of others, such as personal contacts, in volunteering their time for minimal cost. Five of the course managers also commented that they had reciprocal relationships with external agencies, whereby the agency offered support on the course and the provider helped them in return, for example by giving them the opportunity to train and to influence their trainee teachers, to broaden the experience of the agency's staff or to advertise their services, or by providing support to the agency:

We’re quite fortunate in that because quite a lot of the close relationships we have with different agencies, a bit of give and take, so you know we support them with something, they support us with something as well.

HEI 25, primary phase

Assessment of health and well-being

Many of the courses did not specifically assess trainee teachers' learning around health and well-being. We characterised the nature of the assessment that took place into the following categories (note that, again, these categories were not mutually exclusive):

• assessment against the health-related standards in the current QTS standards

• direct assessment

• indirect/incidental assessment.

Ten of the course managers said that trainee teachers' learning in health was assessed against the health-related standards in the current QTS standards, and some told us that this was the only method of assessment that they used:

The teaching of PSHEE and elements of citizenship, form tutor roles and all of that kind of area form part of the required standards. Information advice and guidance and things like would come under the current QTS standards, which they’re required to all meet . . . so there’s no sort of necessarily written research-based academic evidence.

HEI 40, primary and secondary phases

Seven reported that their course included direct assessment of some aspects of health and well-being, for example as part of a discrete PSHE education module or on one or two specific health-related topics (e.g. transition and transfer, physical development). Eleven course managers mentioned that trainee teachers' learning in health was indirectly assessed. This was, for example, through assignments required for related subjects such as science or PE or through trainee teachers happening to choose a health-related topic as part of an assignment or research project.

The general lack of direct assessment seemed to be indicative of health and PSHE education sometimes being seen to be lower priority subjects than other aspects of the ITT curriculum. Indeed, the reasons given by some of the course managers for not carrying out direct assessment suggested so:

I suppose it’s because it’s an additional strand, it’s kind of we don’t, we don’t assess them specifically.

SCITT 15, secondary phase

Health and well-being of teachers and trainee teachers

Eight of the course managers acknowledged in the interviews that teacher training is demanding for trainee teachers and they stated that the health and well-being of their trainee teachers was a key concern for them. Five said that it was central to the ethos of their courses. Nearly all of the course managers felt that they addressed trainee teachers' health and well-being well on their course, with only one saying that they felt this could be improved. This was because they felt that they had effective pastoral systems in place, including good liaison with placement schools about trainee teachers' well-being. Six commented that they also got to know their trainee teachers well, and this helped them to ensure trainee teachers' well-being. In addition to the formal pastoral support system, other ways that interviewees stated that they dealt with trainee teachers' well-being on the courses included:

• encouraging trainees to support each other and share experiences (n = 5)

• good support services available at their institution which they signposted to trainee teachers (n = 7)

• encouraging a work–life balance (n = 3)

• health screening prior to the course (n = 2)

• raising awareness of union support and employment rights (n = 2)

• empowering students through the student liaison committee (n = 1)

• talking to trainee teachers about time management and stress (n = 3)

• giving trainees opportunities to slow down and take time out during training sessions, to help them understand the importance of this for themselves and pupils (n = 3).

Some of the course managers also mentioned specific initiatives that they had run to support the trainees' pastoral care. These included:

• paired placements (n = 1)

• mentoring support from previous trainees (n = 1)

• school mentor training to raise their awareness of trainee health and well-being (n = 3)

• supervision groups using a technique used in medicine to support GPs (n = 1).

However, few of the course managers mentioned that they held specific sessions on aspects of teachers' health such as mental health issues or aspects of living a healthy life (e.g. healthy eating and physical activity), although seven of the course managers mentioned that, in some of the training sessions about pupil health, they covered the topic as it related to both pupils' and the trainee teachers' health.

Barriers to and facilitators of effective teacher training

In the interviews, the course managers identified a number of barriers to and facilitators of the delivery of health training in ITT and we also inferred barriers and facilitators from their accounts. We categorised these into the themes shown in Figure 8, which encapsulate the main issues that we identified. The themes are now discussed in turn in terms of the barriers and facilitators relating to each.

FIGURE 8.

The analytical themes that emerged from the course managers' views on the barriers to and facilitators of the delivery of effective teacher training in health and well-being.

Literature searching

A highly sensitive search strategy was devised and tested on MEDLINE by an experienced information scientist. The strategy comprised a mixture of free-text words and controlled vocabulary terms (Medical Subject Headings). Once finalised, the MEDLINE strategy was then adapted for use on other available bibliographic databases (see Appendix 4 for the MEDLINE search strategy). The following databases were searched, with database platform and search dates in parentheses:

• MEDLINE (Ovid) (database inception to April 2011)

• MEDLINE In-Process & Other Non-Indexed Citations (Ovid) (May 2011)

• EMBASE (Ovid) (database inception to April 2011)

• The Cochrane Library [Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database] (May 2011)

• The Campbell Library (May 2011)

• C2-SPECTR (The Campbell Collaboration Social, Psychological, Educational, and Criminological Trials Register)

• Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO) (1982–May 2011)

• PsycINFO (EBSCO) (database inception to May 2011)

• Social Sciences Citation Index (Web of Knowledge) (1970–May 2011)

• Conference Proceedings Citation Index – Social Science & Humanities (CPCI-SSH) (Web of Knowledge) (1990–May 2011)

• Education Resources Information Center (ERIC) (ProQuest Dialog Datastar) (1986–May 2011)

• EPPI-Centre databases (TRoPHI/Evidence Library) (June 2011)

• British Education Index (ProQuest Dialog Datastar) (1975–May 2011)

• Australian Education Index (ProQuest Dialog Datastar) (1979–May 2011)

• International Bibliography of the Social Sciences (CSA) (May 2011)

• Sociological Abstracts (CSA) (May 2011).

No language restrictions were applied to the search.

The following websites were searched (in May 2012) for potentially relevant literature:

• Schools for Health in Europe (www.schoolsforhealth.eu/)

• Excellence Gateway (www.excellencegateway.org.uk/)

• Current Education & Children's Services Research (www.ceruk.ac.uk/)

• British Educational Research Association (www.bera.ac.uk/)

• National Institute for Health and Care Excellence (www.nice.org.uk/)

• NHS Evidence (www.evidence.nhs.uk/).

The reference lists of relevant systematic reviews identified by the search were checked for additional potentially relevant studies. All publications of studies included in the synthesis were checked for citations to potentially relevant studies that were not already identified through the sources mentioned above. All references (except those from the EPPI-Centre databases and from websites) were downloaded into a Reference Manager database (version 12; Thomson ResearchSoft, San Francisco, CA, USA) for storage and retrieval.

Inclusion screening

Development of the keywording tool

The keywording tool was devised specifically for use in this study, although it was based on similar keywording tools used in other systematic reviews in health. 45,47 It was designed to be able to characterise all aspects of the studies considered to be relevant to the aims and objectives of this investigation. A list of descriptive keywords to characterise studies meeting the first two rounds of inclusion screening was therefore generated. The keywords were grouped according to a number of specific aspects of the studies, including basic study details and country, health topic area, study design, level of education, teaching qualification status (e.g. pre-service, in-service), training content and format, training intensity and duration, types of teacher trainer, use of theory and types of processes and outcomes examined. The tool itself was built using Microsoft Excel 2010 software (Microsoft Corporation, Redmond, WA, USA).

A draft of the keywording tool was discussed by the project's advisory group, who suggested some additional keywords, which were subsequently added. The keywording tool was piloted by applying it to a random sample of 10 papers that had met the criteria in the two rounds of inclusion screening described above. The keywords were assigned to each study by one reviewer and checked by a second. The two reviewers discussed and resolved differences in keyword application, as well as the keywording instrument in general. Minor modifications were made to the instrument before it was implemented in full on the studies meeting the inclusion criteria.

Application of the keywording tool

To ensure inter-reviewer reliability, each reviewer carried out a pilot run of keywords on the same 10 studies used to pilot the keywording tool itself (see previous section). Any discrepancies with the keywords applied in the pilot exercise were discussed and resolved before the reviewer began keywording in full on the rest of the studies. Furthermore, to guide the reviewers many of the keywords were defined with explanatory notes to avoid any misinterpretation of meaning.

Each study report was read by a reviewer who then applied keywords from the keyword instrument based on the information given by the study authors. The first 30 papers were checked by a second researcher for accuracy, with all differences in judgement resolved through discussion. Once the level of agreement was considered satisfactory through discussion between the reviewers, the remaining studies were keyworded by one researcher and a random sample of 20% was checked by a second researcher. The level of agreement between researchers in the random sample (98%) was considered acceptable.

Analysis of the keywords

The Microsoft Excel spreadsheet housing the keywording instrument was designed to enable frequencies to be calculated for each keyword. Frequencies for each group of keywords were used as the basis for the data tables presented in the following section. The spreadsheet was also designed to allow subsets of studies with particular keyworded characteristics to be easily identified (e.g. studies keyworded as being about drugs and alcohol, which were classified as outcome evaluations, in which the teachers were taught skills for promoting health behaviour change). The purpose was to be able to generate various contrasting subsets of studies that could be examined in more detail for potential in-depth synthesis (e.g. ‘scenarios’ that were proposed in Inclusion criteria, Chapter 6).

Origin of study

Table 28 gives a breakdown of the origin of each publication, by country or region. The country with the largest proportion of publications was the USA (42%). A similar proportion of publications reported studies conducted in Africa, Australia and the UK (11–13%).

The African countries represented included South Africa, Nigeria, Tanzania, Kenya and Zimbabwe; the non-UK European countries represented included Italy, the Netherlands, Norway and Finland; and the Asian countries represented included China, India and Thailand. In two of the five publications in which a country was not explicitly stated it was inferred that the study was probably carried out in the USA.

Health topic areas covered

Publications were keyworded according to the main health topics addressed by the study. As Table 29 shows, the most commonly covered health topic areas were sexual and reproductive health (22%), drugs/alcohol (18%) and mental and emotional health (16%).

Other noteworthy topics were tobacco use prevention; studies addressing bullying, aggression and/or violence; child protection or safeguarding; physical activity; and youth development/life skills training. In total, 13% of the publications were classified as health education/promotion in general. These were papers that tended not to focus on a particular topic area but which addressed a range of health issues. Publications classed as PSHE education were only classified as such if there was explicit mention of that term, and publications classed as social development were those in which PSHE education was not mentioned but which could include elements similar to the social development aspect of PSHE education. Publications classified as ‘other’ included topics such as diabetes prevention and support to children experiencing cancer in their lives.

Study design

The papers were classified according to a study design typology, broadly defined as outcome evaluations, process evaluations and surveys. A total of 124 (73%) publications were classified as outcome evaluations, reporting the impact of teacher training on teachers, pupils or both (e.g. in terms of changes in health-related knowledge, attitudes). These tended to be evaluations of school-based health-promotion interventions delivered by teachers in which the training of the teachers was a particular focus of the study. Table 30 shows a typology of outcome evaluation study designs used. Just over half of the outcome evaluations were classed as controlled trials, of which 39 (31%) reported using random allocation of teachers and/or pupils to study groups.

A total of 36 (29%) publications were classified as single cohort before-and-after studies, in which outcomes were assessed in a group of teachers and/or pupils before and after teacher training had taken place, without any comparison to a group receiving an alternative form of training or not receiving any teacher training.

A total of 79 (46%) publications were classified as reporting a process evaluation. Some publications defined themselves as reporting a process evaluation whereas others did not provide an explicit definition of the study design, but we classified them as evaluating processes if it appeared that they empirically measured one or more process indicators (e.g. in terms of assessing how training was implemented and received by participants, see Table 44 for more information). Table 31 reports the data collection methods that the process evaluations used. Questionnaires were the most commonly used method, followed by interviews and observation. Methods classed as ‘other’ included teachers' written training responses and reflections (e.g. written in journals, in essays and on online discussion boards) and training attendance records.

A total of 49 (29%) publications were classified as reporting both an outcome evaluation and a process evaluation. These publications evaluated a range of outcomes and processes (see Outcomes and processes measured) and were representative of the sample of publications as a whole in terms of study characteristics.

Nineteen (11%) of the publications were classified as reporting a survey. A publication was classed as a survey rather than a process evaluation if it reported an evaluation of teacher training in general (e.g. a survey of a sample of training courses in an area) rather than in relation to a specific training programme (although surveys could report process indicators). Table 32 reports the survey data collection methods used.

Level of education

The publications were classified according to whether the teacher training was at the UK primary or the UK secondary educational level (or equivalent in other countries). Table 33 shows that slightly more publications reported training at the secondary than the primary level. Just over 20% of the studies featured both primary- and secondary-level training, and in 20% of publications it was not possible to classify level of education as it was unclear or not reported.

Study population

The publications were classified in terms of whether the recipients of the training were teachers only or a mixed population of teachers and others who work with children and young people. Table 34 shows that in the majority of publications (72%) only teachers received training. The remaining 28% of publications provided health training for teachers and people such as counsellors, school administrators and health-care professionals.

Characteristics of the training

Table 35 shows that the vast majority of publications (84%) reported training teachers classified as in-service (i.e. qualified). Only 18% of publications referred to ITT, although 2% of the studies included both in-service and pre-service teachers.

The publications were also classified in terms of the content of the health training. Table 36 shows the frequency with which publications reported different types of content. Provision of factual information was a key aspect of training, featured in 77% of publications. Skills development for promoting health was also included in a number of publications, classified most commonly as general skills development (39%), skills to identify health problems and/or how to refer children with health problems to specialist help (16%), pedagogical skills (e.g. strategies for teaching about health and how to develop pupils' understanding of health and well-being issues, 26%) and skills development for teaching behaviour change techniques (e.g. communication skills in relationships; assertiveness skills to resist peer pressure to smoke, drink, take drugs, etc., 6%). Just under one-third of publications (32%) were concerned with how teachers can manage and plan how to promote health and well-being. It was common for training to cover a range of aspects, for example providing factual information about a health issue and also developing health-related skills that teachers could apply in their practice.

A classification of the format of the teacher training is provided in Table 37. It was common for training to be multiformat using a combination of lectures, workshops, group work (e.g. discussions, or planning a lesson on health) and activities to practice skills (e.g. role play and modelling). A total of 32% of the studies provided support to teachers after initial training, including during the course of teacher delivery of a health intervention, and refresher training after a period of time. In total, 10% of studies included a period of school teaching practice as part of the training, in addition to other training formats such as discussion and group work. The publications classified as ‘other’ (38%) included a range of activities, most common of which was the provision of training manuals, materials and teaching resources. The ‘other’ category also included self-directed learning, tele- and videoconferencing, essays and assignments, feedback and coaching. In only one study classified as ‘other’ was this the only format used – all of the other studies classified as ‘other’ used multiple formats.

The publications were also classified according to how long the training lasted for, in terms of intensity and total duration. The intensity of the training was categorised in terms of total ‘contact time’ in days (Table 38). One-quarter of publications reported training lasting for 1 day or less. Some of these involved training that was spread out over a period of time but which, in terms of hours, added up to a day.

Just over one-third of the publications (35%) reported training lasting between 2 and 5 days. Training lasting longer than a total of 5 days was in the minority (9%). The classification of training intensity was limited by lack of reporting in 34% of the publications.

The total period of the training, in terms of the period of time that it was spread out over, is reported in Table 39. In one-third of the publications the training period was 7 days or less. The percentage of publications reporting longer training periods varied from 4% (training occurring for between 1 week and 4 weeks) to 10% (training occurring over a 7- to 12-month period). Again, the classification of training period was limited by lack of reporting in 40% of the publications.

Table 40 shows the range of providers of the teacher training in the publications mapped. Specialist trainers were reported by the highest percentage of studies (29%); these were classified as specialists in the health topics being addressed, for example specialist trainers in substance abuse prevention, or experts in child protection. In total, 16% of publications reported training delivered by education practitioners, including schoolteachers, college tutors and other people working in education. Health professionals (e.g. doctors, nurses, health advisors) were reported in only 10% of publications. Some training was delivered by more than one provider, for example practitioners in health, education or psychology working in partnership, or practitioners delivering training alongside computer and video training.

Table 41 shows that the majority of the publications did not report that the training was based on a theory or model (e.g. theory of education or health-related behaviour change). Only 18% of studies did make reference to theory, although given the complex and overlapping nature of theoretical models in this area we did not attempt to classify them.

Outcomes and processes measured

The publications were classified in terms of which outcome and process measures were reported.

A total of 133 (78%) studies reported the impact of training on the teachers themselves. [Note: this is in excess of the 124 (73%) publications classified as outcome evaluations in Study design – this is because nine studies classified as process evaluations reported impacts on teachers within the context of the process evaluation, for example how teachers considered their knowledge, skills, etc. had changed, without these necessarily being defined by the study as outcomes.]

A range of teacher outcomes was measured (Table 42), commonly including the rate of delivery of health promotion in schools by teachers (41%), changes in teachers' knowledge of health (37%), teachers' confidence or self-efficacy to address health in schools (32%), teachers' skills in addressing health (e.g. to promote healthy behaviours or to identify and assist pupils at risk of health problems) (25%) and attitudes towards promoting children's health (25%). Publications assessing teachers' values (22%) were classed as such if they reported teachers' views and beliefs around health and their role as teachers of health. Publications classed as ‘other’ (18%) included teachers' dissemination of health information to other teachers, teachers' perceptions of risk, teachers' own health-related behaviours and teachers' perceptions of their own health and well-being.

The impact of teacher training on pupils was less commonly evaluated [reported in 59 (35%) publications]. These tended to be controlled evaluations (many of which were randomised) of school-based health initiatives delivered by in-service (qualified) teachers, covering topics such as sexual and reproductive health and drugs/alcohol and tobacco use prevention. The training that teachers received in these studies included a range of activities to develop their knowledge and skills to deliver these health interventions. Table 43 shows the range of pupil outcomes measured, the most common being health-related behaviour (22%), knowledge of health issues (19%) and attitudes towards health (12%).

Table 44 reports a classification of the processes evaluated in the publications. The most commonly reported measure was the acceptability and adequacy of the training (41%). This measure included assessment of the views of the training recipients (and other study participants) on the content and format of the training (e.g. perceived usefulness of activities such as role play or didactic learning), whether it met their needs or expectations (e.g. in changing their knowledge, attitudes or abilities to address health issues in school) and whether the health topics covered conflicted with their personal beliefs and values (e.g. sensitive issues such as sexual and reproductive health).

Another common process measure was the implementation of the teacher training (38%). Publications were classified according to this measure if they reported an assessment of any aspect of the design or delivery of the training, such as its content or format (e.g. timing or location), exposure to training (e.g. number of people trained, how much of the available training participants received, which topics teachers received training on) and any reported barriers to or facilitators of teacher training (e.g. sufficiency of training length, ability to attend training). In total, 34% of the publications were classed as assessing teachers' general reflexivity of their health-promoting role and practice. This was defined as whether teachers reflected on what impact the training had, or was expected to have, on their teaching practice in relation to health and well-being. It could also include broader perspectives of teachers on their role in addressing health.

Inclusion criteria

As mentioned earlier in this report, the inclusion criteria for the synthesis were based on the results of the descriptive map. The results of the map were presented to the project's advisory group along with a number of different sets of studies with selected characteristics that the synthesis could potentially focus on. The sets of studies were presented as contrasting ‘scenarios’, including:

1. A set of studies focusing on a particular health area or combination of areas (e.g. some of the most prevalent topics from the mapping, such as sexual and reproductive health, mental health, drugs and alcohol) examining outcomes and processes (i.e. categorised as an outcome evaluation and a process evaluation). The rationale for this scenario was to investigate teacher training within the context of specific health areas, facilitating a detailed analysis of relevant issues. Also, restricting the analysis to studies that measure both outcomes and processes (as opposed to one or the other) could, in theory, provide a more informative investigation into factors associated with effectiveness (or lack of).

2. A set of studies focusing on a particular topic or combination of health areas and examining processes (i.e. including process evaluations but not outcome evaluations). The rationale was that process evaluations may provide more data on barriers to and facilitators of teacher training. The review could examine some of the processes categorised in the mapping exercise such as teachers' general reflexivity of their health-promoting role and practice in general, or the implementation of the teacher training programme and/or implementation by teachers of health promotion.

3. A set of studies focusing on teacher training that included an aspect of health-related skill development, examining outcomes and processes. One or more ‘types’ of skill could be examined (e.g. skills development to encourage health-related behaviour change; pedagogy of health; identifying children with health problems). Equipping teachers with health-related skills arguably is a key aspect of improving health and well-being, more so than just providing information or influencing norms and attitudes.

4. A set of studies examining pre-service teacher training. The studies would be diverse in terms of country, health issues, types of training provided and processes and outcomes, but they would all be conducted within the context of ITT. The advantage of this scenario was that it would mean the focus of the project as a whole would be on issues relating to ITT. Some of the themes arising from the interviews could be taken into account when analysing the literature, to identify commonalities and differences.

5. A set of studies conducted in the UK. As with scenario (4), the studies would be diverse in characteristics. The advantage of this scenario is that it would overcome the challenges of drawing generalisations from international studies in which values, culture and educational policy and systems vary considerably. Also in common with scenario (4), there could be greater linkage between themes identified from our interviews and the UK literature, such as issues relating to PSHE education. The project could therefore make specific recommendations relating to UK practice.

The advisory group discussed the merits and possible limitations of these scenarios with the project team. All of the scenarios were considered relevant. However, it was considered that a focus on studies of pre-service teachers was the highest priority as it provided continuity with the survey component of the project (i.e. it could inform/be informed by the survey), and was particularly relevant during a time of great change in policy and practice in ITT and education more broadly. There were 31 such study reports included in the descriptive mapping exercise. 25,26,44,57,61,63,67,70,81,83,85,88,92,94,116,117,142,148,156,174,179,189,191,192,195,199–202,206,213

It was noted by the research team that there was marked variability in the stated aims and research questions of these 31 publications, and that some appeared to be more focused on pre-service teachers than others. For example, some investigated a particular health topic or type of teacher training in pre-service teachers but with little or no rationale for studying this group as opposed to qualified teachers. These reports were therefore examined in more detail to ascertain the degree to which issues relating to pre-service teachers were investigated by the studies. The aim was to potentially exclude studies in which there was no explicit rationale for studying pre-service teachers or no exploration of issues pertinent to this group, so that the synthesis would be more focused. To be included a report had to meet at least one of the following three criteria:

1. Does the study provide a rationale for specifically studying pre-service teachers?

2. Does the aim/objective/purpose of the study make reference to studying pre-service teachers?

3. Do the results of the study specifically mention issues that affect/involve pre-service teachers (e.g. their attitudes towards their role as teachers in relation to health; their teaching practice)?

If the report met one or more of the above criteria the following criteria were also applied:

1. Is the training reported in sufficient detail?

2. Are the results reported in sufficient detail?

These criteria were applied to the reports by one reviewer and checked by a second. In summary, inclusion criteria for the synthesis were:

• publications (published from 1990 onwards) in the English language

• reporting (in adequate detail) evaluation research (of any design) into the processes and/or outcomes of teacher training in relation to the promotion of health and well-being

• training of pre-service (not yet qualified) teachers.

Data extraction

A standardised data extraction template was designed and piloted for use on studies included in this systematic review (see Appendix 7). It was designed to capture all of the data reported in study publications relevant to the aims of this investigation, and was partially based on the keywording instrument used in the descriptive map reported earlier (see Chapter 5, Development of the keywording tool). The template was split into subsections for basic study details (e.g. date, country, aims and objectives), health topics studied, details of study participants (e.g. sociodemographic characteristics, level of education taught), details of the teacher training (e.g. content, format, duration/intensity), processes and outcomes evaluated (when applicable), study methodological characteristics (e.g. study design, data collection instruments, data analysis methods), study results and reviewer's general comments on the study. Data were extracted by one reviewer and checked by a second.

Quality assessment

Methodological quality and risk of bias were assessed with published critical appraisal criteria (see Appendix 8). 37,47 Studies reporting outcomes were appraised using risk of bias criteria adapted from the Cochrane Collaboration's Effective Practice and Organisation of Care (EPOC) Group. 228 The EPOC Group has adapted the standard Cochrane risk of bias criteria for randomised controlled trials37 for use in evaluation studies that are non-experimental in design (i.e. without a control or comparison group). The methodological quality of process evaluation data was appraised with criteria devised and used in our previous systematic review of process evaluations of school-based behavioural interventions to prevent sexually transmitted infections in young people,229 based, in turn, on previous research assessing the methodological quality of process evaluations and qualitative research. 230–232 The criteria assess whether steps were taken to minimise bias and error in sampling, data collection procedures and data analysis. They also assess whether the findings are grounded in the data, and overall whether the findings presented are reliable and useful (to put this into context see Critical appraisal of process evaluation for the results of the quality assessment of process evaluations). Quality assessment criteria were applied by one reviewer and checked by a second, with any disagreements resolved through discussion and involvement of a third reviewer when necessary. Studies were not excluded from the synthesis on the basis of quality; however, methodological limitations (e.g. because of evaluation design) of particular studies are mentioned in the synthesis when relevant.

Synthesis methods

The results of the studies were analysed in a narrative synthesis, based on the data that had been systematically extracted from each study publication. Quantitative synthesis using meta-analysis was not possible because of the lack of studies using a controlled evaluation design. Because of the heterogeneous characteristics of the studies, particularly the methods used to report outcomes, summary tabulation of results was difficult. It is for this reason that the study outcomes (see Assessment of the effectiveness of training on teacher outcomes) are presented only textually.

A thematic analysis of the process evaluation data was conducted, similar to methodology described by Thomas and Harden. 233 One researcher (JS) read all of the results that had been extracted from the studies reporting processes and identified a list of five emerging themes which summarised the results. These themes were then discussed and agreed with other members of the project team. A second researcher (KP) also read the extracted results and then systematically coded the extracted data in a NVivo database. As part of this process she revised the five themes and identified a further three. A narrative account was then written summarising the results of the process evaluations for each theme, including barriers and facilitators that had been reported by, or inferred from, the studies. The first researcher then reviewed and agreed the final list of themes and cross-checked a sample of the coded study results against the narrative account for reliability of interpretation.

Characteristics of the included studies

Table 45 provides an overview of the key characteristics of the included studies. The level of reporting detail in the study publications varied, and in some cases the study characteristics were unclear. (Note: we requested and received further information from the authors of two of the studies25,142.) As the table shows, the studies varied in a number of respects, including the study population, the health topics addressed by the training, the content and length of the training and the study measures and designs.

In terms of country, the highest percentage of studies were conducted in the UK (n = 9,25,63,70,83,92,117,142,174,191 45%), followed by Australia (n = 7,44,94,189,195,200,201,213 35%). There was one study each from Finland,26,156 Zimbabwe81 and the USA,61 with one study not explicit about the country but it most likely being the USA. 148

Critical appraisal of the included studies

As stated earlier, the methodological quality of all of the included studies was appraised using standard criteria (see Appendix 8). The level of detail of study methods and findings reported in the publications varied considerably. In a number of cases detail was minimal, prohibiting a full appraisal of quality, although it is acknowledged that many academic journals impose word limits limiting the extent to which authors can describe methods.

The sample sizes of the studies varied considerably, from < 10 to around 1500 participants, with the majority including up to 100 participants (see Table 45). Some of these studies could be considered to be relatively small; however, to put the research into perspective, some authors pointed out that the status of their study was a ‘preliminary investigation’,201 a ‘pilot evaluation’,63 a ‘small-scale study’142 and ‘a case study methodological approach’. 70

Only two studies26,83,156 reported who had funded the research and it was therefore unclear in the majority of studies whether funding status represented a possible conflict of interests (e.g. whether the funder had a financial interest in the outcome of the research). In the majority of studies there was no explicit statement of whether informed consent was sought from the study participants.

Assessment of the effectiveness of training on teacher outcomes

Assessment of processes

During data extraction we classified the process evaluation findings according to the categories shown on the left-hand side of Figure 10. We then analysed these to identify overall themes within the findings. This resulted in a list of eight themes that encapsulated the findings of the process evaluations. Figure 10 shows the themes identified and which of the original data extraction categories most of the findings relating to each theme came from. We next discuss the process evaluation findings relating to each theme and the barriers to and facilitators of health training in ITT that can be inferred from these findings.

Acceptability of teacher training in relation to health

Eight studies61,81,83,92,94,195,201,213 reported findings on trainee teachers' and training providers' perceptions of the acceptability of the training in health that they had received or delivered. These studies reported on the perceived acceptability of the training overall61,81,83,92,201,213 (which included training in health education and promotion in general,213 sexual diversity,61 HIV infection/AIDS prevention,81 working with children who have experienced cancer in their lives,83 PSHE education92 and mental and emotional health201) and the resources used to support delivery. 94,195,213 The studies reported that, in the main, the training was seen to be acceptable and was well received by trainee teachers. 61,81,83,92,201,213 The authors of only one study, that by Athanases and Larrabee,61 reported that a minority of trainee teachers were resistant to the training. This study was conducted at a university in the USA and was published in 2003. It examined trainee teachers' responses to training about respecting sexual diversity and understanding and supporting lesbian and gay youth in schools, with the training delivered in part by a gay-identified guest speaker. The resistant trainee teachers had difficulty reconciling the topic with their religious beliefs, with one trainee teacher refusing to attend a class meeting with the guest speaker.

FIGURE 10.

How the process evaluation findings themes related to the original data extraction categories.

The findings of this study, along with those of Chifunyise and colleagues,81 who evaluated a HIV infection/AIDS prevention training programme in Zimbabwe, also highlighted that the creation of a non-threatening atmosphere was helpful for trainee teachers to discuss these sensitive diversity61 and sexual health81 topics.

Two94,195 of the three studies that reported on trainee teachers' and training providers' responses to resources and materials used as part of the training also suggested that these resources and materials were generally well received. Fenton94 stated that trainee teachers responded well to case studies that were included as part of child protection training, as these helped trainee teachers to explore different perspectives on child protection issues. Vincent and colleagues195 reported that 96% of the teacher educators in their study found it easy to use a multimedia resource package called Response Ability, which was distributed to pre-service education providers in Australia to support mental health training. Furthermore, 96% said that their trainee teachers were receptive to the material.

The other study that reported on trainee teachers' responses to resources and materials used as part of the training213 suggested that training delivered using online materials may not be effective in engaging the interest of all trainee teachers. Over the semester-long course about health issues relevant to trainee teachers, the majority of the trainee teachers (67%) engaged with these materials for fewer hours than they were guided to. Yager213 noted anecdotal evidence of ‘online overload’ and suggests that trainee teachers might be more likely to complete activities if they are provided in a hard-copy format.

Coverage of health and well-being

There was strong support for the inclusion of health and well-being in the ITT curriculum, with around 90% of the course managers surveyed in our study agreeing that it is important or very important (notwithstanding a potential sample bias in favour of health – see Strengths and limitations of this research). When interviewed some of the managers commented that they were passionate about health in education, and take it very seriously. Many showed a commitment to health despite policy shifts in favour of a focus on core education issues. There was also evidence of a holistic conception of health and well-being, with good health seen as important for effective learning. Although this is encouraging, the question arises whether the content of ITT courses reflects this enthusiasm. To some extent it does, with ECM and child protection included in courses by all of the managers in our survey, and topics such as social and emotional health, bullying and working with parents reported to be covered by at least 90% of the course managers. Furthermore, when asked how much time is spent covering health and well-being on their courses, 42% of the managers reported this to be between 5% and 9% of the time, and a further 26% estimated 10–14%. This could be considered generous given the numerous time constraints on the curriculum that some of the course managers who were interviewed mentioned exist (see Chapter 3).

An important overall finding of this research, however, is that coverage of health and well-being in ITT courses is variable, in terms of content, format and methods.

Variation in content

Although, as mentioned above, some health-related topics were covered universally, others – mainly lifestyle-related issues – were given comparatively less attention. Our survey found that smoking, alcohol, drugs and SRE were reported to be covered by only up to two-thirds of course managers. This seems surprising given the high profile of these topics in public health. Our descriptive map of the literature showed that sexual and reproductive health, drugs and alcohol were some of the most commonly addressed topics in evaluations of teacher training. During interviews we asked the course managers to comment further on coverage of these topics in their courses. In some cases there was detailed coverage through dedicated workshops and other events, whereas in other cases it was incidental. Some course managers acknowledged limited coverage and the need for improvement. The barriers to covering these topics did not appear to be different from barriers to covering health in general (e.g. lack of time in the curriculum – see What are the barriers to, and facilitators of, effective training and delivery?), although for SRE there was the suggestion of a lack of comfort in dealing with sensitive personal issues such as sex. Given that sexual health, drugs, alcohol and tobacco are public health priorities,16,237–240 it is important that these topics are covered adequately within any health training that trainee teachers receive.

Another prominent finding from both the survey and the systematic review is that trainee teachers' experiences of health issues while on school teaching placement are variable. Opportunities to discuss, observe or teach health-related issues, including PSHE education, varied according to how much of a priority the school itself gave to health or to practicalities such as timetabling of PSHE education in the school in relation to when the placement took place. Some course managers commented that they assumed that trainee teachers learned about particular health topics, such as SRE, while on placement and therefore these topics were given less exposure at college. There was also a perception that some trainee teachers' experiences of health on placement were better than others, depending on a school's commitment to health promotion. The likely increase in time that trainee teachers will spend training in schools as a result of ITT reforms14 (e.g. the introduction of teaching schools), and increased diversity in types of schools (e.g. free schools run by local groups and independent of local authorities), may compound the inconsistency in trainee teachers' experiences of health and well-being in ITT. With the decentralisation of the NHSP, which provided a national framework for health promotion in schools, it is uncertain how this will be addressed.

Variation in format and methods

Our survey also found variation in terms of where in the ITT curriculum health and well-being was covered. Health was not confined to traditional areas such as science or PE, but was also covered in broader areas such as professional studies, English and the humanities. Some ITT providers covered health issues across the curriculum and made cross-curricular links. Integrating health throughout the curriculum could be considered beneficial so that trainee teachers do not associate health as being confined within particular subject areas. One of the studies included in our systematic review critiqued the scientific emphasis on health in schools and aimed to encourage PGCE trainee teachers to recognise that their wider skills, developed through their main subject of English, could be applied in the teaching of PSHE education to enable pupils to grow emotionally and socially. 92 The authors reported that the trainees had a lack of overt awareness of how much PSHE education teaching could be planned for in English lessons, and suggested that they have a limited definition of PSHE education as being a scientific subject knowledge-based curriculum. To ensure adequate capacity for the teaching of health in schools it would appear to be useful to help trainee teachers to recognise how the skills that they develop in their subject specialisms can be applied in the teaching of PSHE education (and health more broadly). To be effective, training would need to encourage trainee teachers to recognise that health and well-being is part of their role as a teacher (see below). However, integration of health within the ITT curriculum might be more appropriate to broader issues that underpin many aspects of health, rather than specific health topics such as those discussed earlier (e.g. drugs, alcohol, SRE), which may need to be covered in discrete topic-focused sessions.

Our survey found a great deal of variation in the methods used to address health and well-being in the ITT courses. Some courses devoted whole-day sessions focusing on topics such as PSHE education, citizenship, equality and diversity, behaviour management and health in general. Workshops and interactive sessions were also common, as well as student-led presentations. It was common for multiple methods to be used, including various combinations of lectures, seminars, presentations, discussion groups, interactive workshops and electronic resources (e.g. virtual learning environment). Although health training was often provided by course managers and tutors themselves, external agencies were also very commonly used (e.g. representatives from local authorities and local schools), particularly to address specific health-related topics (e.g. emotional health, SEN, behaviour management). Engaging external expertise, including interprofessional working, was viewed by many of the course managers to have been a successful part of their delivery of health training. It was also reported by some course managers that trainees gained health experience through placements in non-educational settings such as social services, hospital schools, prisons and sports organisations. One course manager commented that this had been effective in raising trainee teachers' awareness of health issues. An implication of this is that inter-agency and interprofessional working could be encouraged where possible and the effectiveness of this could be subjected to further evaluation, including the effectiveness of alternative placements in health-related settings, which could be considered to be innovative practice.

Furthermore, few of the course managers we interviewed reported that they had worked with other departments at their institutions to deliver health training, although some raised this as a possibility in the interviews. It may be beneficial in the future to raise ITT providers' awareness of the possibilities for multidisciplinary working within their institutions – particularly HEIs, which may have more immediate access to a range of potential health inputs in their institutions than EBITTs or SCITTs – and encourage sharing of expertise within institutions (e.g. through existing networks or groups). The course managers whom we interviewed did not always know how to make contact with health professionals, and it could be argued that accessing this input from health-related departments at their institutions may be easier than making contact with external expertise. In common with the ITT courses surveyed, many of the studies included in the systematic review evaluated training that was multiformat and multimethod and delivered by a range of providers, reflecting the broad nature of health promotion in education.

Personal and organisational values, interests and background

A number of facilitators, as well as some barriers, were associated with the personal and organisational values, interests and background of those involved in ITT. As discussed above, there was much commitment and enthusiasm for health in ITT from the course managers, with a prevalent holistic conception of health in education. Accordingly, their personal and professional experience influenced the prominence of health in the content and format of courses, albeit within the constraints placed on ITT providers by recent educational policy shifts (see following section). For example, some had taught in schools in areas of social and economic deprivation and considered it important that trainees were aware of the needs of children from such areas. When teaching placements were in schools in deprived areas it was considered that this was beneficial to trainee teachers' development as they were more likely to encounter children with health issues than in schools in more affluent areas (where more emphasis might be placed on educational attainment rather than pastoral issues; this was seen as a potential barrier). Given the continuing commitment to tackling health inequalities it is important that all trainee teachers are aware of the health and educational needs of children from low socioeconomic status backgrounds. 16

The trainee teachers' own interests could be both a barrier and a facilitator. In some institutions in our survey trainee teachers were given the choice to pursue health-related topics through assignments or alternative placements (e.g. in sports organisations). However, it was noted that a minority of trainee teachers do not necessarily see health as being within their role as a teacher. The studies included in our systematic review that assessed teachers' roles and values generally found that trainee teachers became more aware and accepting of their health-promoting role over the course of their training. It would be useful for trainee teachers to be given the opportunity to explore their personal values and beliefs in relation to health, and to engage in critical reflection with tutors, mentors and each other. Opportunities could be provided to trainees motivated enough to want to pursue health issues further, for example through designing and organising events such as workshops or seminars, or taking placements with relevant organisations.

Competing priorities

A common theme in the data collected was that teacher training courses are constrained by competing priorities which act as a barrier to addressing health and well-being. However, pragmatic ways of overcoming these barriers were described.

One of the key issues discussed by the course managers was the changing policy landscape in education. There was a perception that recent developments such as the review of the National Curriculum, the revised teachers' standards and the withdrawal of ECM as a government policy signalled less overt support for health and well-being in education. The standards in particular no longer contain an explicit standard for promoting children's health, and there is more of an emphasis on developing teachers' subject knowledge, SEN and behaviour management. This conflicted with the commitment of many course managers to covering health within the ITT curriculum, and they felt that they were expected to give more attention to these priorities. However, some course managers commented that they intended to use these priority areas as ‘ways in’ to maintain a focus on health, such as considering health issues related to disability. The general way in which some policies have been written, such as the revised teacher standards, was considered by some to offer flexibility, giving them the opportunity to cover health issues. Although these pragmatic strategies are encouraging for addressing certain aspects of health, they may not offer scope for covering specific lifestyle-related issues discussed earlier, which, despite being health priorities, seem to receive comparatively less attention in ITT. As the survey and interviews were conducted during a period of policy change, and course managers were starting to revise their courses accordingly, it would be useful to conduct further research with ITT providers in the next few years to assess how successful they have been in terms of addressing health in a new policy era.

The difficulties of addressing health issues within a busy ITT curriculum was also a commonly mentioned issue, both by the course managers interviewed and in some of the studies in the systematic review. This was a particular issue in PGCE and GTP courses, which are run over relatively shorter time periods. Preparing trainee teachers to acquire subject and pedagogical skills necessarily took a priority over wider issues such as health. However, some providers found solutions to this such as encouraging trainees to self-study health topics.

Integration of health and education

We have already discussed the emerging policy shifts in which health and well-being appears to have a more implicit role in education, juxtaposed with the prevailing holistic conception of health in education from the course managers interviewed. The course managers in this study considered that integration of health and education was important as, for example, it fostered interprofessional and interdisciplinary working and was appreciated by trainee teachers. In particular, ECM was generally highly regarded by the course managers as a way of making essential links between education and health. The dissipation of ECM was lamented by some course managers, who expressed an intention to retain it as a theme underpinning their courses. However, as the new educational policy agenda takes hold, ITT providers may find it increasingly challenging to retain the principles and ethos of ECM and it would be useful to investigate how their courses adapt to the new agenda.

As touched on above, although trainee teachers generally came to accept and embrace their health-promoting role over the course of their training, a minority did not consider health to be part of their remit as a teacher. A move away from an explicit framework for the integration of health and education may exacerbate this view. Two of the process evaluations in our systematic review found that making training more personally relevant (e.g. encouraging trainees to discuss their personal experiences in relation to a health issue) was appreciated by the trainee teachers, and was more likely to encourage them to see health as more relevant to their practice. 61,94 This might be one practical method that ITT providers can incorporate into training to stimulate trainee teachers' interest in this area.

Another issue is that trainee teachers may not fully appreciate their potential health role because of a perceived lack of knowledge or confidence, particularly to address complex or sensitive areas. This raises the wider question of how extensive should the teacher's role be with regard to health, and at what point should he or she refer to more specialist professional input? Our systematic review found that training can improve trainee teachers' confidence in being able to identify children at risk of, or experiencing, health-related problems. However, trainee teachers recognised that there were limits to what they could realistically do to address problems and they felt reassured by the availability of specialist help to liaise with.

Our descriptive map identified a number of studies which evaluated the development of other skills that teachers can use to promote health, including health-related behaviour and lifestyle change skills. These studies have generally been conducted in schools in which teachers have been trained to implement a specific health-promotion intervention. Our previous systematic review of behavioural interventions to prevent sexually transmitted infections in young people in schools explored process evaluation findings about teachers' experiences of delivering skills-based sex education. 47 In a large UK randomised controlled trial (SHARE35) included in the review it was found that teachers did not engage with the theoretical basis of the programme that was fundamental to achieving health-related behaviour change. For example, they did not always facilitate role-play activities to model and practice skills required by the intervention. It was suggested that many teachers viewed such activities as too far removed from their teaching role, and some experienced discomfort in discussing personal and sensitive issues with pupils. Furthermore, in another study included in that review [the RIPPLE (Randomized Intervention of PuPil-Led sex Education) study241], peer-delivered sex education was more acceptable to pupils than teacher-delivered sex education. These findings suggest a potential limit to the teacher's role in relation to lifestyle areas such as sexual health. However, they may also signal the need for greater training and support for teachers to recognise the conceptual basis of health promotion, and to acquire the skills, confidence and values to enable pupils to develop healthy lifestyle skills. Further evidence synthesis, drawing on the studies included in the descriptive map, would be valuable to assess how applicable the findings from our previous systematic review are across other health lifestyle areas, and also to assess the effectiveness of teacher training programmes in relation to teachers' skills, confidence and values.

Access to expertise and knowledge

Course managers valued having knowledge of health issues, and some expressed that training for ITT provider staff on health issues would be beneficial. However, few mentioned receiving training and in a number of cases course managers drew on knowledge gained through their own personal and professional background, utilising their experience of teaching children from vulnerable backgrounds, for example, or using their contacts and networks to arrange external workers to provide training (sometimes for free or reduced rate). However, access to external agencies may become harder given recent budget cuts and pressure on services, as discussed below.

The interviews with course managers also revealed that trainee teachers could be uncomfortable about addressing certain health topics with pupils, particularly SRE. One of the process evaluations in the systematic review found that a minority of trainee teachers expressed resistance to discussing issues relating to homosexuality, although for personal or religious beliefs as opposed to embarrassment about the topic. Creating a non-threatening atmosphere was reported to facilitate discussion about sensitive issues such as diversity61 and sexual health. 81 This would be a prerequisite to increased coverage of such topics in ITT, which, as discussed earlier, is necessary.

How initial teacher training is organised

Barriers and facilitators were identified in relation to the way in which ITT courses were organised. As discussed earlier, trainee teachers' experience of addressing health on school teaching placements was variable, with some having more opportunities to engage with health issues than others. The course managers did not always have awareness of, or input into, what health issues were covered on placement. Again, this underlines the need for consistency in how health is addressed in ITT given the likely increase in school-based training in the future. 14 The course managers had mixed views on the appropriateness of a move to greater school-based training. Some thought that trainee teachers' experience of health would be fragmented because of the variability noted above in experience on placements. However, others felt that it would provide greater context as the teachers would have the opportunity to learn about pupils' health and well-being directly through practice, rather than indirectly through study. Both approaches have merits as well as drawbacks and it seems logical that a degree of balance between ‘theory’ and ‘practice’ should be aimed for. Research would be useful with trainee teachers themselves and school staff (e.g. mentors) to establish how health and well-being is covered within school-based training, and any barriers or facilitators experienced. The research could also include teaching schools and free schools, investigating trainee teachers' general experiences of these new initiatives and assessing any variations in health-related training across different types of school.

One of the key findings from our survey and interviews was that little or no specific funding was available for specific activities to cover health and well-being in ITT (notwithstanding, however, the fact that health was an integral theme underpinning routine aspects of some courses). Many of the initiatives described by course managers were supported by either existing course resources or, as we have mentioned above, through goodwill and reciprocal favours between ITT providers and external agencies. However, some ITT providers had experienced cuts to their core funding and were enrolling fewer trainees, which put pressure on budgets, resulting in some previously run health initiatives ceasing. Likewise, cuts to the budgets of some external agencies meant that they were in less of a position to work with ITT providers, at least without adequate remuneration, which, as said, was difficult.

Communication and relationships

Communication and relationships between ITT providers and others involved in teacher training were associated with a number of barriers and facilitators. ITT providers had good, often long-standing relationships with external organisations with a role in health and well-being. This was considered to facilitate effective training as providers were reassured of the quality of the training. There were mutual benefits, with providers sometimes offered the training for free, allowing the external organisations to gain experience of providing training to a trainee teacher audience.

Although communication between course managers and placement schools about coverage of health topics at respective institutions was lacking, communication between them about trainee teachers' own health and well-being was said to be more effective. Trainee teachers' health was considered to be important by a number of course managers, and was something they monitored through pastoral support and regular contact with trainees, although it was noted by one course manager that trainee teachers themselves did not always disclose issues that they were experiencing. Although trainee teachers' health is important in its own right, it could be argued that encouraging trainee teachers to be aware of their own health and well-being might increase their awareness of the importance of health more generally in schools, and in particular the needs of their pupils. This was the aim of one of the studies in our systematic review,213 which evaluated the use of behaviour change theory to improve trainee teachers' personal health behaviours and eventually prepare them for teaching about such health issues in schools. Only around half of the teachers agreed that the training had enhanced their own personal well-being, and found the issues covered to be personally relevant. The authors suggested that, with hindsight, the training should have made more specific links between the training topics and the teaching of health issues with pupils, as the trainee teachers did not yet understand the variety of demands of the teacher's role in the classroom and in the school community. This was echoed by other studies in the systematic review61,63,94 which suggested that training should be more relevant to trainee teachers' practice as teachers. ITT providers could therefore usefully explore more integrated forms of training in which teacher and pupil health are on an equal footing and viewed as mutually reinforcing.

Implications for practice

Below is a summary of the main implications for teacher educators arising from this research.

A broad holistic conception of health enabled course managers to integrate health-related issues throughout the ITT curriculum, rather than necessarily addressing health in isolation. Although this approach was seen to have advantages, it is important that education for specific health priority topics, such as sexual health, smoking, alcohol and drugs, is not overlooked in favour of a general approach to health.

To be successful health promoters, teachers need to see health promotion as part of their role. Evidence from this research suggests that trainee teachers gradually accept this role over time, and that training which emphasises how health is relevant to them personally (i.e. their own health) and professionally (e.g. addressing local health needs) is a facilitator. Further, trainee teachers recognise limits to their health-promoting role when referral of pupils to specialist support is appropriate. Teacher training should therefore encourage a realistic role for teachers, throughout the training period, to help establish their confidence, emphasising the benefits of good health for themselves as well as their pupils, and familiarising them with other practitioners (e.g. health professionals) who they can liaise with to provide specialist help when required.

Experiential learning, such as that gained during school teaching placements, was considered an important way for trainee teachers to develop knowledge, values and the confidence to address health. The planned increase in emphasis on school-based training in England will provide greater opportunities for trainees to address child health, which may be advantageous as it will be within context. However, a good level of support and feedback from tutors, mentors and, when relevant, external practitioners will be necessary to ensure effective teacher learning and development.

Our research found that creation of a non-threating atmosphere was important when addressing complex and sensitive health issues such as child protection, sexual and reproductive health and sexuality and diversity. Training should therefore aim to minimise any discomfort that may impede effective discussion of such issues (e.g. through establishing confidentiality, trust, respect for others' views).

Research recommendations

1. There is limited published research on the longer-term impact of ITT around health and well-being, particularly in the period when NQTs enter service. Evidence from our systematic review suggested that, although initial training was associated with improved knowledge and confidence, some teachers had continued concerns about their ability to address children's health needs. They valued the opportunity for experiential learning through practice with ongoing support from mentors and specialists, particularly when addressing complex or sensitive health-related issues. Further evaluation of the effectiveness of health-related training spanning ITT and the early career years is therefore required, using controlled designs when possible. Teacher and, when possible, pupil outcomes should be assessed, including health literacy, which has received little attention in the literature reviewed. All outcome assessment should ideally be accompanied by process evaluation to assess implementation, acceptability and adequacy, and other factors that may influence effectiveness.

2. Evaluation of ITT as recommended in (1) could also assess aspects of training that were found to be beneficial, such as inter-agency and interprofessional working to deliver health training; increasing the personal relevance of health issues to trainees themselves (to their own health, and pupils' health too); and creating a supportive and non-threatening atmosphere for discussion of sensitive topics and issues.

3. Given the likely increase in school-based ITT it would be useful to conduct research with mentors and tutors located in placement schools, and trainee teachers themselves, to ascertain barriers to and facilitators of covering health and well-being. It would be particularly important to explore potential variations in coverage between schools (particularly given provision in the new National Curriculum for schools to shape aspects of the curriculum according to local needs), and between different types of schools (e.g. free schools, academies, teaching schools). A relevant question would be how can schools maintain a balance between being sensitive to the needs of the local community (e.g. social, economic and cultural concerns) and keeping in mind national public health policy priorities. Research would be valuable to assess the feasibility and effectiveness of inter-agency and interdisciplinary collaboration, particularly given the reorganisation of education and health services (e.g. integration of public health within local authorities, establishment of Health and Wellbeing Boards).

4. Further evidence synthesis is needed to assess the effectiveness of health training for in-service teachers. Our descriptive map identified around 150 studies of in-service training, which have not been subjected to detailed synthesis. One or more of the scenarios proposed in Chapter 6 of this report (see Inclusion criteria) could be reviewed, including:

   • a topic-focused review, selecting studies of training around a health topic area or combination of areas (e.g. sexual and reproductive health, mental health, drugs and alcohol), focusing on outcomes of training, training processes or both

   • a pedagogical-focused review, selecting studies that evaluate how teachers can acquire the varied skills and competencies that a health promoter needs, such as teaching health-related behaviour and lifestyle change skills, or the ability to identify children experiencing, or at risk of experiencing, health problems

   • a geographical-focused review, selecting studies conducted in a particular country or region, with the aim of drawing out implications for practice and policy of specific interest to an area.

5. Follow-up research should be conducted with ITT providers over the next few years to assess the longer-term impact of government policy changes in education and health on the coverage of health and well-being in their courses. Many were in the process of revising their curricula in response to changes in teachers' standards, and exploring ways to retain a health ethos. It would be useful to further investigate how they have adapted their courses according to the new policy agenda and the barriers and facilitators experienced.

2.1.1 The importance of teachers as health promoters

The importance of teachers as promoters of health in schools has been acknowledged for some time. 1 However, pressure on busy curricula has meant that health and well-being has not always been covered in as much detail as desirable. Yet, teachers are playing an increasingly important role in the wider public health workforce. A number of Government policy strategies have underlined the importance of the school in children's health in recent years. For example, ‘Every Child Matters’ (2004)2 was a key policy for children's health, education and welfare, which stressed the importance of health and safety, and still underpins the current Qualified Teacher Status (QTS) standards for health. ‘The Children's Plan: Building Brighter Futures’ (2007)3 emphasised the pivotal role of schools in ensuring children are healthy and safe. It introduced the concept of Extended Services with its focus on improving access to school activities for disadvantaged children and young people to reduce attainment gaps. It also set a goal for all schools to work with the National Healthy Schools Programme (NHSP) by 2009.

Also in 2009 the NHSP began rolling out its Enhancement Model, a universal and a targeted approach to pupil well-being offering schools the challenge of meeting specific needs-led healthier behaviour outcomes. Since April 2011 the organisation of the NHSP has changed to being a schools-led initiative rather than one that is Government-led. The resources to support schools are now in the form of the ‘Healthy Schools Toolkit’ which is available to schools via the Department for Education website. 4

Effective health promotion with children and young people, particularly the early identification and prevention of health inequalities, was also a key aspect of the ‘Choosing Health’ strategy, launched in 2004. 5 The overall strategy was to develop and build capacity for health improvement at all levels of the system, and to better equip the wider workforce to promote health by ensuring basic skills and knowledge for more people. Furthermore, ‘Healthy Weight, Healthy Lives: a cross-government strategy for England’ (2008)6 stated that all schools should be healthy schools, and recognised the need for improvements in staff skills and capabilities.

The ‘Healthy Child Programme 5–19 years’, published by the Department for Health and the Department for Children, Schools and Families in 2009,7 set out the early intervention and prevention public health programme for children, young people and their families. It highlighted the need for schools to work together with parents, carers and health professionals and to have an understanding of how to promote health and well-being.

Importantly, the 2009 Macdonald Review of Personal, Social and Health Education (PSHE) recommended that it should be a statutory subject in the curriculum and that all ITT courses should include some focus on PSHE throughout the school life. 8 The Macdonald review also recommended that there should be in time, ‘a cohort of specialist PSHE education teachers’ (page 8). Since the recent change in government the Department for Education is currently conducting a review of the primary and secondary National Curriculum, which also includes an internal Government review of the non-statutory status of PSHE.

Since the election of the Coalition government in May 2010, the broad landscape and relationships both within and between health and education is changing. The Government published its White Paper ‘The Importance of Teaching’ in November 20109 which states:

We will recognise that schools have always had good pastoral systems and understand well the connections between pupils’ physical and mental health, their safety, and their educational achievement and that they are well placed to make sure additional support is offered to those who need it.

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The White Paper for public health, ‘Healthy Lives, Healthy People’, published in November 2010, set out the proposed substantial changes to the public health system in England over the next two years. 10 It is planned that joint commissioning of health services will be carried out by local authorities in conjunction with a new body, ‘Public Health England’, and the current Directors of Public Health will be employed within these organisations. The Commons Select Health Committee has held an inquiry into the proposed changes (though the results of the enquiry have not yet been reported). These proposed changes will no doubt have a major impact on the way that public health and health promotion activities are managed, and implications for the support for improvement of health education in schools.

2.1.2 Teacher training in the UK

Initial Teacher training in the UK is currently predominantly provided by Higher Education Institutions (HEIs) at under-graduate (e.g. Bachelor of Education) or post-graduate level (e.g. Post-Graduate Certificate in Education, PGCE). Some post-graduates choose school-centred ITT courses (SCITTs) which provide a greater degree of practice based learning, while retaining their student status. An alternative route is through employment-based ITT (EBITT) whereby trainees are employed by schools and train via the Graduate Teacher Programme (GTP) or the Registered Teacher Programme (RTP). Teacher training is funded by the Training and Development Agency for schools (TDA) (to become a new body called ‘The Teaching Agency’ from April 2012), but additional health content may be funded from other agencies.

This nature of teacher training is likely to change in the future. In the ‘Importance of Teaching’9 the Government states that it will:

• Reform initial teacher training, to increase the proportion of time trainees spend in the classroom, focusing on core teaching skills.

• Develop a national network of Teaching Schools on the model of teaching hospitals to lead the training and professional development of teachers and head teachers, and increase the number of National and Local Leaders of Education – head teachers of excellent schools who commit to working to support other schools.

Training is also provided to qualified teachers as part of continuing professional development (CPD). Within the context of health CPD may address the provision of PSHE, or more specifically train teachers to deliver a specific health promotion intervention (e.g. around a drugs and alcohol initiative, or a sexual health campaign). Training may also encapsulate broader school-wide health promotion interventions (‘whole-school approaches’). A variety of people may train teachers around health issues, including Healthy Schools Co-ordinators, health professionals (e.g. health promotion practitioners, health advisers), youth workers, psychologists, educational professionals, and educational professionals. Training is provided in-service (i.e. organised by the school), or externally organised by the organisations responsible for developing specific interventions or teaching methods.

It is unclear how current policy changes will ensure continued support for schools in actively promoting health and well-being. A key question is to what extent do teacher training courses adequately prepare teachers for this pivotal role?

2.2.1 Initial teacher training

Since the mid 1980s research in England and Wales has indicated that teacher education and training in health-related areas is poor, and has mostly relied on in-service training which teachers may or may not receive. 1 Progress on including knowledge and skills regarding health and well-being in the initial training and education of teachers entering the profession has been slow, both in England and elsewhere. 11 There are unanswered questions about the provision and quality of health promotion within ITT courses across England. Our previous survey research has shown that coverage of health and well-being in teacher training curricula is limited and variable in the South East of England region. 12 We surveyed, via questionnaire, 35 organisations offering ITT in 2007 (10 HEIs, 25 employment-based schemes). Fifteen (43%) organisations responded, representing 50% of the total number of trainees in the region (83% from HEIs, and 17% from employment-based schemes). The results demonstrated the enormous variability of teacher training provision across the region and the lack of any consistent approach to educating student teachers about their potential roles in promoting children's health. Most organisations were found to be incorporating Every Child Matters (ECM) supported by Healthy Schools and other external specialists, but to varying extents. Provision of information about the NHSP was also extremely variable, from nothing at all to inclusion in PSHE or emotional health and well-being. Employment-based schemes were more likely to have connections with the NHSP. Reasons for lack of inclusion of health issues included insufficient time in a busy curriculum, and the extent to which placement schools were actively involved in the NHSP.

The extreme variability in the amount of time allocated to health topics in our survey demonstrates a lack of consistency in interpretation of the requirements of training leading to very little provision in many institutions, versus careful attention and innovative good practice in a few others. The survey was limited by the relatively low response rates, its timing (just before holiday period), the length of the questionnaire (on reflection relatively lengthy) and its confinement to the SE of England. There remains, therefore, a need to assess the adequacy of provision of health initiatives within ITT curricula across England, with a sampling strategy that ensures representation from different types of providers (HEI based, employment-based) types of course (primary, secondary teaching). Such a survey will illuminate variations in practice, identify barriers and facilitators, and will generate recommendations for effective training, and models of effective practice suitable for further evaluation.

2.2.2 Continuing professional development, and intervention-specific training

There is a sizable evidence base on the effectiveness of school-based health promotion interventions worldwide. Stewart-Brown (2006)13 conducted a synthesis of systematic reviews of school-based health promotion interventions and health promoting schools (an update of the previous NIHR HTA funded systematic review published in 199914). Fifteen systematic reviews were included, between them comprising approximately 750 primary evaluations of school-based interventions on a variety of health issues (e.g. mental health, healthy eating, physical activity). There was little overlap between the reviews in terms of their constituent studies, suggesting that this figure has probably not been over-estimated by double counting and is therefore an accurate estimate of the size of the evidence.

2.2.3 The evidence base

Despite the volume of evidence for school-based health promotion interventions, little has been published, at least in terms of secondary research, on the effectiveness of training teachers to deliver such initiatives (either ITT or CPD), and of the barriers and facilitators to effective teacher training and their subsequent provision of health promotion. Scoping searching of electronic databases conducted for this protocol (e.g. Educational Resources Information Center (ERIC), Medline) and key websites (EPPI-Centre, National Foundation for Educational Research) did not identify any published systematic reviews of the evidence for the effectiveness of programmes to train teachers to promote health in schools. However, we did identify 18 potentially relevant primary studies (some of which were included in a broader published literature review of 26 studies investigating training of workers to implement adolescent prevention and positive youth development15).

The majority of these studies evaluated teacher training to deliver specific health promotion interventions. They covered a range of topic areas including sexual health,16–20 tobacco,21–24 drugs and alcohol,25–27 physical activity,28–30 injury prevention,31 and youth development/life skills training. 15;32 In terms of publication dates the studies spanned the last two decades with the most recent published in 200931, indicating that this remains a fertile area for research. The studies were conducted in a number of countries (e.g. Australia, Hong Kong, South Africa) though many were from the USA, with one notable example from the UK (see below). 17 A mixture of study designs were used, including process evaluations of teacher training as part of a randomised controlled trial (RCT) or other type of outcome evaluation of a school-based health promotion intervention, or process only evaluations of school-based interventions. At least three outcome evaluations compared the effectiveness of different types of teacher training (e.g. video instruction versus workshop training) on a range of teacher outcomes (e.g. implementation, morale, motivation, self-efficacy)21;25;26 and one of these also assessed changes in pupil outcomes (e.g. use of drugs, tobacco and alcohol). 25

In terms of theory, the interventions were based upon a range of well known theories of education, health and health-related behaviour change such as Social Learning Theory, Social Cognitive theory, and the Theory of Reasoned Action/Planned Behaviour, Diffusion of Innovations theory and the Social–Ecological Model. 15 Many of these theories predict the necessary mediators of effective health-related behaviour change. The training the teachers received was designed to equip them with the knowledge, motivation, confidence and skills, to facilitate, in turn, desirable improvements in mediators of pupils' behaviour, such as increasing their knowledge, their self-efficacy and their behavioural skills. For example Kealey et al. (2000),22 who evaluated the Hutchinson Smoking Prevention Project in the USA, conceptualized teacher training as a behaviour change process with a strong emphasis on teacher motivation to facilitate the intended behaviour (i.e. the teacher's effective implementation of the curriculum). Theories such as those mentioned above form part of the conceptual framework for this project (see Section 4.2.2.5).

All studies provided evaluation data on the implementation of the intervention, with varying detail given to the training received by teachers. One of the studies that provided detailed information on training was a Scottish trial of a sexual health education initiative called SHARE (Sexual Health Relationships Education). 17 An extensive process evaluation was carried out, comprising observation, questionnaires and interviews with teachers. The teachers reported that they valued and enjoyed the training very much and felt more confident to teach sex education, but a number of barriers to effective delivery of the curriculum emerged, including a lack of understanding by the teachers of the guiding theory of behaviour change and a lack of confidence to teach behaviour change skills (the key element of the intervention). This was echoed by other studies identified by our scoping searches such as Ward et al. (2006)29 who, in a process evaluation of a physical activity promotion programme for high school girls, reported that the teachers found it difficult to understand and implement behavioural skills concepts to encourage physical activity.

These findings, though perhaps not necessarily representative of the wider literature, suggest that additional training and support may be necessary to enable teachers to facilitate health-related behaviour change, an outcome that is considered as a key marker of effectiveness by many decision makers. 33 For example, they may require professional input from health educators to deliver skills-building exercises in the classroom which may be essential for encouraging healthy behaviours. This will have resource, and therefore, cost implications and it underlines the need for a full systematic review of the evidence to identify common over-arching barriers and facilitators to effective and efficient teacher training across a range of health topics. Recommendations would be made for health and education professionals, policy makers, and researchers to ensure teachers fulfil their potential in promoting health and well-being in schools, ensuring children adopt and maintain healthy lifestyles into adulthood.

3.1 Survey of teacher training providers

4.2 Systematic review of teacher training interventions

Our proposed systematic review will use rigorous methods to identify, appraise and synthesise relevant evidence, drawing on established processes and procedures in evidence synthesis,36–38 with particular consideration given to wider determinants of health and health inequalities. 39 Figure 1 provides an overview of the key stages of the review.

FIGURE 1.

Key stages of the systematic review.