Let’s Ask the Teachers: A Qualitative Analysis of Health Education in Schools and Its Effectiveness

Abstract

There is a need for action in health promotion for children and adolescents. Schools are assumed to be an appropriate place to enable students to behave healthily. Numerous interventions have been piloted in schools, but sustained implementation appears challenging. An alternative approach might be to ask teachers how they conduct health education and what they see as effective. Accordingly, we conducted an explorative study using semi-structured interviews with eleven teachers from secondary schools in Germany in 2019. The interviews focused on different aspects of health education: goals, methods and strategies, effectiveness, possible barriers, and ways to reduce them. We inductively identified six dimensions of effectiveness that teachers believe are relevant for effective health teaching in schools. Regarding methods and strategies, many were mentioned, but only a part was explicitly named as effective. Most of these strategies focus on improving students’ knowledge and skills, followed by strengthening health-promoting attitudes, but rarely promote long-term behavior change. Moreover, it became apparent that some aspects, such as goalsetting and developing action plans, received little attention in lessons, even though they are considered important for successful behavior change.

1. Introduction

Previous studies show a need for action in the field of health promotion and prevention for children and adolescents, e.g., for physical activity [1], nutrition [2], substance abuse [3], and mental health [4]. The Health Behavior in School-Aged Children (HBSC) study [2] referring to the area of Europe and North America, revealed that of adolescents aged 15, only 15% met the recommendations of the WHO of one hour of moderate to vigorous physical activity per day. In addition, half of them (53%) ate neither fruit nor vegetables on a daily basis, and 18% were overweight or obese. Furthermore, the 15-year-olds were asked about their current use (last 30 days) of addictive substances: 37% reported having drunk alcohol, and 15% having smoked cigarettes. In addition to somatic health problems, mental health problems are common among children and adolescents. Study results indicate that about one in three to four adolescents would meet the criteria for a mental disorder during their lifetime (according to the Diagnostic and Statistical Manual of Mental Disorders [5,6]). While most adolescents might be assumed to be healthy, their current health behaviors constitute a higher risk for later diseases, the permanent implementation of an unhealthy lifestyle in adulthood, and a lower quality of life [7,8]. Therefore, health promotion and prevention have to play a crucial role in childhood and adolescence.

Schools are assumed to be an appropriate place to enable children and adolescents to lead healthy lives and make health-supporting decisions [9]. Numerous interventions and programs have been developed and piloted in schools, but sustained implementation appears challenging [10,11,12]. Thus, these intervention programs by themselves do not reflect the reality of health education. To fill this gap, we pose the question of what health education looks like in regular school life today: What goals do teachers pursue in the classroom? Which methods and strategies do they currently use and consider effective? What barriers do they face and how do they try to overcome them? For this purpose, it is crucial to talk to the people doing the classes. Therefore, the present explorative study focuses on teachers and their personal teaching experiences. The expected benefit from the practitioner’s perspective is to get a sense of what is feasible and effective in the classroom so that praxis-related effectiveness criteria can be derived. On the one hand, this will be done inductively, and on the other hand, two theoretical constructs will be used as structuring aids. One is the KAP triad [13], often used as a survey structure [14]. It refers to knowledge (K), attitudes (A), and practices (P), which are considered essential outcome dimensions of different health promotion programs [15]. The other is Maslow’s pyramid of needs [16], which classifies the different needs of learners that might be addressed in health classes.

2. Theoretical Background

2.1. Theoretical Constructs Relevant for Health Education

According to the WHO, health is understood as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity“ [17] (p. 1). However, more recent definitions move away from the term “complete” and take into account that chronically ill and aging individuals can also feel healthy despite limitations [15,18]. Thus, health is more about actively and productively meeting life’s inevitable challenges [15]. Generalizing, McCartney et al. [18] suggest a definition of health to include the WHO multi-perspectivity (physical, mental, and social dimensions) as well as functional and experience-based components and to apply to the individual as well as to populations.

Health promotion serves to enable people to take control of and improve their health status [19]. For this purpose, health promotion uses both health education and health-related public policies. While the latter “provide the environmental supports that will encourage and enhance behavior change” [20] (p. 17), health education is defined as learning experiences that improve individuals’ health by “increasing knowledge, influencing motivation, and improving health literacy” [19] (p. 18). Thus, health literacy is considered to be an “observable outcome” of health education [19] (p. 7). To achieve this goal of health literacy, the WHO and UNESCO recommend in their global standards and indicators for health-promoting schools that the school curriculum should contribute to this “by advancing the knowledge, skills, attitudes, and behaviors of students and the school community” [21] (p. 22). A similar recommendation is made in the US-based Whole School, Whole Community, and Whole Child Conceptual Model from the US [22]. Concerning the health education component within this model, gaining knowledge, attitudes, and skills shall help students become health literate and engage in health-promoting behaviors [22]. This means that teachers should use methods and strategies in their teaching that support health-related KAP (i.e., knowledge, attitudes, and practices). It is assumed that these 3 components influence each other [13,23] and can, therefore, also reinforce each other. Thus, promoting KAP can be considered a basic element of health education and may also be interpreted as a sign of its effectiveness. Another way to influence the effectiveness of health interventions (e.g., attitude or behavior change) may be achieved by considering Maslow’s hierarchy of needs [16]. For if health behaviors satisfy more than one need, that is, not only the need for health, which is often less acute in adolescents, but also other more pressing needs (such as belonging and esteem), there may be multiple reasons to carry out the health-promoting behavior [23]. Thus, the KAP construct as well as Maslow’s hierarchy of needs appear useful as guiding principles for analyzing the diversity and effectiveness of health-related teaching measures.

2.2. State of Research in Designing Health Education

When planning educational interventions, actions like goalsetting, choosing adequate methods and strategies, and reflecting on their effectiveness are important components, as pointed out in the framework for health education intervention development [24]. Looking at the literature, a wide range of variations can be seen within these areas of analysis, which will be fragmentarily described below.

The goals of health programs as well as general health teaching either relate to preventing harmful behaviors or diseases [25], changing behavior [26], or reducing the harm caused by unhealthy behaviors [27]. In the latter case, interventions aim to ensure that students who still engage in unhealthy behaviors, such as using legal and illegal drugs, do so “in a less risky manner and experience less harm associated with use” [27] (p. 114). Examining teachers’ goals may also give initial insights into their teaching practices and interest in teaching health [28] because these aspects influence each other.

Interventions usually differ in the methods and strategies used. They are often multi-component interventions that combine different approaches. There are numerous potential health education strategies to use [29]. For example, they include teaching theory [30], practicing healthy behaviors [31], developing self-regulation skills [32], role-playing, or reflecting on case studies [25]. However, we still need to learn what methods and strategies teachers use in everyday health education.

Effectiveness and impact evaluation should play an essential role in all planned interventions and programs [15]. Based on such evaluation results, the WHO summarized eight crucial elements connected with effective life skills programs [33]. These comprise teaching generic life skills as well as specific prevention skills, whereby students are actively involved in the interventions and peers take over an important function (peer leadership). The intervention should take place at an appropriate developmental stage for the kids and should be long-term. In addition, there should be a close link to the curriculum in terms of content; the materials should be contemporary and easy to use; and teachers should be trained in delivering the interventions [33].

Current findings (next to practical experience) have also been the basis for the development of national education guidelines, such as the National Health Education Standards (NHES) of the US [34]. These standards (std.) range from comprehending functional (meaningful, applicable) health knowledge (std. 1) to developing certain skills in the areas of information procurement (std. 3), communication (std. 4), decision-making (std. 5), goalsetting (std. 6), and showing observable practices (std. 7). In addition, students should analyze external and internal factors influencing their health behavior (std. 2) and advocate for health behavior in order to support others in living a healthy life (std. 8).

Next to developing and scientifically determining the effectiveness of an intervention, dissemination and implementation of these programs in schools are also necessary but often challenging [35,36]. Even in schools where interventions have been initially piloted, they are only sometimes implemented sustainably [12]. For example, the Cochrane review of the World Health Organization’s Health-Promoting Schools (HPS) framework identified barriers to increasing students’ physical activity and healthy eating [37]. These included, e.g., the emphasis on academic subjects and/or a lack of institutional support [37]. This has been demonstrated in studies where students’ preparation for an academic exam or a general lack of time hindered teachers’ implementation of a health-related intervention [38,39,40]. Therefore, it is necessary to learn about teachers’ experiences with health education (including possible barriers and how to overcome them) so that health education can be implemented in a sustainable manner and lead to sustainable effects.

3. Research Questions

Given the difficulties of implementing health intervention programs sustainably in schools, the question arises as to what kind of health teaching is done by teachers and is thus considered feasible and effective by them. Therefore, we want to take a closer look at today’s teaching practices and focus on teachers’ experiences in their daily school lives. Associated with this are the following research questions:

• What goals do teachers pursue in health education?
• What methods and strategies do teachers use in health education?
• What obstacles do teachers face, and how do they deal with them?
• What contributes to higher perceived effectiveness?

4. Materials and Methods

4.1. Sample

In our study, eleven teachers (T1–T11) were interviewed. They represented three types of secondary schools in Germany with medium to high aspiration levels. Six teachers were male (54.5%), and five were female (45.5%). The teachers came from seven different schools, with six teaching at a comprehensive school (54.5%), three at a junior high school (27.3%), and two at a grammar school (18.2%). Their teaching experience ranged from 3.5 to 38 years (M = 13.55, SD = 9.37), and they taught at least one subject in biology (63.6%), physical education (36.4%), and home economics (9.1%; multiple selections possible). According to the respective core curricula [41,42,43], these are the subjects being predestined for health-related content and in which most health-related teaching takes place. (Note: There is no separate subject for health education in Germany). Despite the relatively small number of participants, the teachers nevertheless represented a comparatively broad spectrum of characteristics (in terms of gender, age, school type, and subject) of German teachers in the field of health education.

4.2. Interview

We used an interview guide to explore teachers’ perspectives and experiences in the field of health education. The semi-structured interview guide included the following sections related to the focus area of this paper: (0) teachers’ demographics; (1) their goals of health teaching; (2) methods and strategies used; (3) views on effectiveness; (4) barriers and ways to reduce them. The partial standardization of the interview guide, on the one hand, ensured that all teachers were asked the same guiding questions, but on the other hand, it allowed us to respond flexibly and individually to the teachers’ answers and thus to include specific in-depth questions.

The interview questions were similar to our research questions. For example, the teachers were asked about the goals: “What would you say are your goals in teaching health education?” Another aspect referred to methods and strategies considered to be effective: “Can you tell me about some of the activities that you have used in your health education classes that you think were particularly effective?” In terms of methods and strategies, the teachers were also explicitly asked about “practicing healthy behavior” with their students, “building habits”, and “making healthy behavior attractive”. We have emphasized these methods and strategies because we see them closely linked to the individual implementation of health-promoting behavior [44].

The interviews were conducted at the respective schools of the teachers. One interview lasted, on average, 33.59 min (SD = 10.12). The study was completed in 2019, before the COVID-19 pandemic started. Thus, there were no restrictions in the face-to-face classes.

4.3. Evaluation

The interviews (T1–T11) were recorded and transcribed. Then, a coding guideline was developed by applying qualitative content using the MAXQDA software [45]. As Schreier describes, the development of the coding framework often comprises deductive and inductive parts [46]. The root categories of our coding framework mainly correspond to the questions of the interview guide, and thus can be called to be developed ‘a priori’. For example, since one of the questions asked participants to name their goals in health education, the main category of goals was included in the coding frame. However, all subcategories and adaptations in the root categories (e.g., adding students’ current stage to KAP) were developed inductively by direct data analysis.

To examine the reliability of the coding framework, intercoder reliability was determined. Coder 1 provided the coding matrix and set the margins of the coding units within the interviews. A second person (Coder 2) recoded three interviews (T3, 7, 11), chosen due to their relative diversity and because they cover many different coding frame categories. Coder 2 coded the first interview, followed by a discussion about the coding differences to reach an agreement. This procedure was repeated for the other two interviews. Therefore, intercoder reliability increased from 62.1% to 90.1% after the discussions.

Our evaluation process can be divided into three steps. The first step was the qualitative analysis of the interviews. The results describe the coding framework with its root and subcategories (Figure 1), as well as suitable examples to illustrate the meaning and content of these categories. Moreover, relationships between different categories and subcategories were pointed out.

In the second step, the various subcategories of the coding framework needed to be structured and summarized on a theoretical basis. By this second analysis step, the results should be condensed in such a way that focal points and gaps become visible. In a previous publication, we created a conceptual concept map [23] to show the connections between different theories and constructs in the field of health behavior, including, e.g., the knowledge-attitude-practice survey structure (KAP) and Maslow’s pyramid of needs. These two constructs seemed appropriate to structure the subcategories: KAP for the goals and methods and strategies; Maslow’s pyramid of needs for the barriers and enablers of health-promoting behavior. The rationale for the assumed fit of subcategories and structuring aids is given in Section 4.4 and Section 4.5. However, for the barriers, the chosen structuring aid turned out to be inappropriate for content reasons. Therefore, in this case, the categories were inductively combined based on content proximity. The same was done for the countermeasures teachers mentioned to overcome health-related barriers. In this way, dimensions of effectiveness for health-related teaching could be developed.

In a third evaluation step, two different ways of determining the effectiveness of health-related instructional measures were combined. On the one hand, teachers had been asked which methods and strategies they considered effective. On the other hand, teachers had named countermeasures to barriers, which can as well be seen as ways to improve the effectiveness of health-related teaching. The effectiveness dimensions for these countermeasures were then used as a basis to assign those methods and strategies to them that teachers had named as effective. In this way, it should be checked whether the existing dimensions need to be supplemented by further dimensions. Based on this, a general pattern should emerge of which dimensions of effectiveness teachers believe to be important for successful health teaching.

4.4. Knowledge-Attitude-Practice (KAP) Survey Structure

As a structuring aid in the evaluation process, we used the knowledge-attitude-practice (KAP) survey structure [13,14], with its three components knowledge (K), attitudes (A), and practices (P). We considered this structuring tool to be appropriate as it relates to the aims and outcome variables of health education (see Section 2.1). With regard to the practice-oriented component, we would like to introduce an additional distinction: (i) practical knowledge, which is learning specific skills (S) and which we interpret to be closely connected with the knowledge domain (K) and (ii) behavior/practices in general (P) being shown in everyday life [23]. For example, we consider preparing a healthy breakfast at school just once or twice a year as learning a skill, but integrating a healthy breakfast into everyday life as a behavior. In this respect, we will not use the term KAP in the following, but rather the term K^/SAP, in which skills (S) are included as a kind of practical knowledge.

4.5. Maslows’ Pyramid of Needs

It can be assumed that decision motives for health-promoting behavior serve to fulfill various needs of an individual, which may be both in and out of the health domain. The importance of these different needs differs; thus, these needs can be arranged hierarchically, as in Maslow’s pyramid of needs [16]. Both barriers to healthy behaviors and enablers of such behaviors can be related to these levels of needs in that barriers may prevent the fulfillment of other, non-health-related needs, while enablers support the fulfillment of these other needs (next to the one of health) [23]. In this respect, it was planned for the 2nd evaluation step to structure both the barriers mentioned by the teachers and the enablers according to Maslow’s pyramid of needs and thus to establish hypotheses for their weighting. While for the enablers, such an assignment was feasible in terms of content, this was not possible for the barriers mentioned. In this respect, an inductive approach was chosen for structuring the barriers.

5. Results

First, an overview of the coding framework with its root categories and associated subcategories is given (Figure 1). These categories are described in more detail in the following chapters, which are arranged according to the four guiding questions concerning: 1st, the goals (Section 5.1), 2nd, the used method and strategies (Section 5.2), 3rd, the obstacles that may occur and what might help (Section 5.3), and 4th, the effectiveness of health-related teaching measures (Section 5.4).

The results of the first evaluation step, which refers to the coding scheme with its root and subcategories, are located in Section 5.1, Section 5.2 and Section 5.3. The results of the second evaluation step can be found in Section 5.2.9 and Section 5.3.3, and those of the third step in Section 5.4.2. Finally, Section 5.5 summarizes the results. With reference to the coding scheme, each root category is marked by a letter code, while each subcategory of a root category has an additional number associated with the letter code so that an unambiguous identification is possible. Those codes being printed in italics refer to categories considered effective. References to the teachers are given by the specification T and a number.

5.1. Results for Research Question 1: What Goals Do Teachers Pursue in Health Education?

5.1.1. Objectives (O)

The objectives (O) mentioned by teachers were summarized in seven subcategories (see Figure 1). The aim of increasing pupils’ knowledge of health-related topics (O1) was stated by almost every teacher (9 out of 11). Knowledge acquisition was assessed as a realistic goal (T3) and was equated to effectiveness in health education (T2). The importance of health-related knowledge for the pupils’ future was emphasized (e.g., T5). This goal also comprises teaching practical knowledge, i.e., health-related skills such as preparing meals (T9). Five teachers aimed to shift students’ attitudes towards health (O2) (T1, 4, 7, 8, 10). Teachers stated this goal as challenging to achieve and noticed that continuous and long-term efforts are necessary to be successful (e.g., T4). Changing students’ behavior (O3) was an objective of almost every teacher as well (8 out of 11) and effectiveness in health education seemed to be related to achieving this goal (e.g., T9). However, it was considered challenging to achieve this goal and to be successful with every pupil (e.g., T3).

Another objective broadly mentioned was body consciousness (O4) (9 out of 11). This includes prevention and health maintenance (e.g., T1), attentiveness (T5), responsibility for one’s body (e.g., T1) and also becoming familiar with it (e.g., T10). Five teachers aimed for health awareness (O5) so that health plays an essential role in students’ decisions and as a result, health should increase (e.g., T2). Although T2 also conceded that sustainable changes in attitude or practice may not yet be seen. In addition, it was assumed that through health awareness, skills and knowledge may transfer more easily from the classroom to the real world (e.g., T1). This corresponds with the teachers’ assumption that achieving health awareness is a sign of effectiveness (T1, 3). Moreover, some teachers (T3, 5, 11) refer to the information assessment (O6) and want their pupils to develop a critical and reflective attitude towards health-related information and instructions from the media, doctors, or their social environment. T5, for example, hopes that students will be reflective and not let their peers influence them to apply unhealthy behaviors (T5). T11 wants pupils to ask their doctors about medication and to be critical of campaigns by measles vaccination opponents, which was a highly debated topic at the time of the interviews in 2019.

An objective that does not directly focus on students is participation in competitions (O7). Two teachers stated that participation in competitions serves as a motivator to improve the school’s health education program (T3, 8). Furthermore, if successful, prize money enables the school to invest in health education. Indeed, several teachers identified a school-based program, equipment, and budget as requirements for successful health education (T1–13). Consequently, competitions appear as a means to improve these preconditions.

5.1.2. Verification of Goal Achievement (VG)

The teachers reported three clusters of strategies to gain at least partial insights into the effect of their interventions (for verification of goal achievement, VG). Tests (VG1) were mentioned as a possible means of indicating the students’ gains in knowledge or skills. Since increasing students’ knowledge is a common goal (cf. O1), tests are considered an appropriate tool to evaluate the effectiveness of teaching interventions (T9). Likewise, in physical education, performance tests seem to be helpful for measuring students’ abilities and comparing them with the results after an intervention (T10). In addition, T8 reports that some pupils are motivated by tests because they can feel like health experts (T8). However, it cannot be assumed that tests are suitable for behavior and attitude assessments. Moreover, grading could influence students’ answers, as they may tend to answer questions according to their teachers’ expectations. Therefore, tests could not offer reliable insights into students’ attitudes and behaviors (T9).

The most appropriate indicator of the effectiveness of teachers’ interventions seemed to be students’ reactions (VG2). Teachers described different strategies to check the achievement of goals by observing them. Firstly, teachers observed students’ activity levels and motivation during lessons (T7, 10). Second, they could sometimes see immediate changes in students’ behavior, such as how they carry backpacks (T3). Thirdly, extracurricular activities, e.g., parties or class trips, seemed like valuable opportunities to observe students’ eating behavior or detect other behavioral changes (T2). Thus, during these occasions, students gave a kind of passive feedback. However, students could also actively give feedback. They told teachers about their experiences with practices taught in class when they had implemented them at home. For example, they reported the preparation of a specific dish and whether they liked it or not (T9). T4 associated this way of receiving feedback with having a good relationship with the pupils (Ef2). Sometimes teachers interview their students in open conversations to learn more about their experiences with certain practices (T9). T10 also mentioned anonymous evaluations at the end of the school year to examine students’ opinions but admitted that these professional evaluations have rarely been done. Therefore, T10 thought that a standardized assessment could be helpful for teachers to investigate students’ feedback more closely.

Furthermore, teachers often expressed that they were limited (VG3) because they had little or no insight into students’ behavior outside the classroom. Their role as a teacher restrained their influence on students’ behavior in everyday life. For example, T1 stressed that they are teachers and not parents (T1) and do not have the authority to prohibit behaviors such as smoking (T1). Moreover, determining sustainability seemed complicated because teachers and pupils are in contact for a limited time (T4).

5.1.3. Teachers’ Perception of the Situation in Class

In order to have a basis for comparison for the goals stated by the teachers, the health related K^/SAP status of the young people, is described here. This status could be inductively derived from the interviews because teachers gave numerous examples of students’ knowledge and skills, attitudes, and practices regarding health (K^/SAP).

The examples of students’ K^/SAP status were additionally classified concerning their manifestation as health-positive, differentiated, or generally deficient (

Table 1. Frequency in percentage and absolute numbers with which teachers name examples of students’ current statuses in health-related K^/SAP.

	Examples Classified as
	Positive	Differentiated	Deficient
Knowledge and skills (K/SAP-K/S)	40.0% (6)	26.6% (4)	33.3% (5)
	“According to a healthy diet, they [the pupils] know, yes, I have to eat a lot of vegetables.” T3 03:22	“Well, easy example, topic of HIV and AIDS, you can tell them a thousand times and at the end, at least 10–15% still think that a mosquito transmits HIV.” T11 02:49	“We have a lot of chronically ill children who take something [medication] and have no idea what they actually take. They just take it.” T11 04:18
Attitudes (K/SAP-A)	30.0% (9)	16.7% (5)	53.3% (16)
	“They run a lap and even the less athletic, sort of tubby pupils enjoys it, running every now and again.” T3 44:43	“Some say ‘Ugh, I don’t like that’ and it takes a long time until they try it. Others try everything right away. That really depends on the child. It can’t be generalized.” T9 03:19	“[...] when I take my oats to school and they [the pupils] take a look at my meal and ask: ‘Yuck, what is that?’” T11 38:09
Practices (K/SAP-P)	14.6% (6)	19.6% (8)	65.9% (27)
	“It decreased a lot. [...] We are indeed almost smoke free.” T8 13:13	“[...] well, a third of the children arrives at school without breakfast.” T5 23:14	“Nonetheless, the children are overweight. They are not sufficiently physically active and so.” T2 24:36

). For example, statements describing students’ inadequate nutrition were assigned to K^/SAP-P and labeled as “deficient”. The classification “differentiated” includes statements where (1.) the deficit is attributed to only a certain number of pupils, (2.) the deficit is already present, but was corrected later (see K^/SAP-A example for differentiated in Table 1), or (3.) the students’ performance appears incomplete. The number of examples in these three manifestation categories is almost balanced for knowledge and skills. However, examples on attitudes and practices were mostly deficient. For instance, teachers perceived nutrition and exercise as insufficient.

5.2. Results for Research Question 2: What Methods & Strategies Do Teachers Use in Health Education?

The teachers mentioned several methods and strategies (MS) used in their health education classes. These methods and strategies, with specific examples and their perceived effectiveness will be described in the following, with the methods and strategies that share a specific focus being clustered:

• Focus on acquiring knowledge,
• Focus on advertising healthy behavior,
• Focus on the popularity of the lessons,
• Guidance and consultation,
• Encouraging health-promoting behavior in everyday school life,
• Temporal domain,
• Health education outside of regular lessons (ORL),
• General strategies associated with effectiveness.

5.2.1. Focus on Acquiring Knowledge (MS2, MS23, MS24, MS22)

The method of theory teaching (MS2) was widely mentioned in the interviews. The teachers referred to diseases (T4, 10, 11), nutrition (T1, 6), sex education (T4, 11), and the positive effects of endurance sports (T6). Theory teaching was considered beneficial because it was seen as a prerequisite for performing the activity, e.g., concerning physical activity and nutrition (T1). Additionally, becoming an expert on a particular topic motivated some students (T4), and a theory might enable students to understand the recommendations on healthy behavior (T1, 5, 11). It answered the why question, for example, “Why does it make sense to sit upright?” (T11) and “why are nutrients, respectively carbohydrates, so important?” (T1). Therefore, theory teaching could lead to insights influencing students’ behavior. Moreover, pupils who reject healthy behavior (cf. Ba2) could reflect their point of view through accurate information (T10). However, mentioned disadvantages of this method are, e.g., focusing on specific details could be too theoretical for students (T9). Moreover, pupils’ reading skills have decreased over the years (T9), and T10 observes a tendency for pupils to avoid texts. Consequently, much written information can lead to disinterest (T9, 10).

The strategy of practical learning (MS23) included different methods that required students to perform scientific measurements or experiments to improve their understanding of health. For example, students had to weigh their backpacks, take their pulse, or make a performance diagnostic, e.g., before and after a training plan (T1, 3, 4, 10, 11). The experiments tested ingredients, bacterial growth, or sleep deprivation (T2, 4, 5, 10). To learn more about the food the pupils eat, T2 made yogurt or sauerkraut with them. Furthermore, teachers noticed that students evaluated practical learning as effective, entertaining, and exciting (T2–5, 11). Nevertheless, practical learning relied on a relatively high amount of time and specific equipment.

The teachers also addressed common elements of composing lessons, such as visualization, interchange, and communication. Regarding visualization (MS24), the teachers mentioned various possibilities, e.g., pictures, films, models, or demonstrations. The visualizations may either be created by students (productive) or presented to them (receptive). Examples given included pictures of bacteria (T2), films on food processing (T2), models of contraceptives (T11) or the human spine (T11), which were used so that students could better grasp the given information. In addition, students were challenged to put information into a suitable visualization. Therefore, they had to create a PowerPoint presentation (T4, 8), actively use objects and simulations, e.g., to count the number of sugar cubes in a particular food or drink (T1, 6, 10), or to mimic the experience of being drunk (T3, 11). Teachers evaluated visualizations as important, because they contributed to better comprehension: “If someone tells me, ‘Okay. This bottle contains 300 g of sugar’, then it gets a lot easier to visualize it [the amount] with cubes of sugar.’” (T1 13:20). Additionally, especially films were mentioned as an effective means, as the students are “happy” about it and “actually, a bit [of the information] remains stuck with them” (T11 16:09). However, visualizations like showing movies required the necessary infrastructure (T7). Other common elements of lessons are interchange and communication (MS22). Students are expected to process health-related information, experiences, and perspectives through these measures. For this purpose, teachers implemented discussions in plenum and groups (T2–4, 11). T2 underlined the importance of discussions: “If the children only listen, it’s no use. One [the teacher] really has to allow discussions” (11:58). Further, working in groups or with a partner was common practice in lessons on health education (T2, 4, 7, 8, 10, 11).

5.2.2. Focus on Advertising Healthy Behaviors (MS14, MS7, MS8, MS4, MS15)

Five methods were clustered because of their focus on advertising healthy behavior. Externals (MS14) are considered experts in a particular field, like organizations and institutions informing about drugs (T3, 4), sex education (T11), or cyber mobbing (T4, 11). Also, health insurance companies (T3, 8), sports clubs (T3, 4, 8), doctors (T6), and a physical education college (T10), among others, were named for integrating externals in health education. Sometimes, externals were assumed to be better suited than teachers (T10, 11), e.g., for sexual orientation and identity: “[L]esbian, gay and trans. That is, in fact, a topic at our school. But I think it is really important that this is addressed by externals.” (T11 35:20). Other advantages of externals were that they might be younger, closer to students and consequently talk with them on a different level (T11). Moreover, they are more experienced and better equipped (T10). Schools could offer a broader program by cooperating with organizations like sports clubs. Additionally, accident prevention with experts like firefighters can be highly authentic (T10).

Authenticity also played a significant role in the strategy that teachers act as a role model (MS7). To teach health education persuasively, teachers should model a healthy lifestyle themselves, e.g., healthy eating (T3, 9, 10, 11), cycling to school (T10, 11), and not smoking (T10). The strategy was essential because parents may not act as role models (T3). Moreover, it emphasizes the importance of what teachers have taught (T1, 11). T11 described the effectiveness: “But I think that everything that is set as an example, is always going to be reproduced.” (T11 45:49). However, applying role model behavior creates pressure on teachers as it might interfere with their personal lives. For example: “I smoke a cigarette every now and then, but […] I never do that around students […] because I couldn’t justify that. I mean, why do I smoke as a teacher of biology? And it is important to me that nobody knows that. So that my authenticity stays intact.” (T1 21:11).

Another way to promote healthy behavior is to present it in an attractive way (MS8). Almost all teachers used this strategy, e.g., in the context of nutrition and physical activity. Pupils should experience that healthy food can be delicious (T2, 7, 11). Therefore, teachers prepared healthy food like spinach differently to make it taste better (T5, 7, 9) or made a healthier version of students’ favorite dishes like burgers (T5). This way, the prejudice that healthy food cannot be tasty (cf. Ba2) could be reduced, and attitudes towards certain foods could change. Moreover, nice food is more likely to be imitated at home (T9, 11). In addition, T8 observed that doing trendy sports makes physical activity more attractive.

The teachers discussed deterrence (MS4) controversially in the interviews. Most illustrate the consequences of undesirable behaviors such as alcohol (T3) and nicotine consumption (T5, 8), an unhealthy diet (T3), and driving while using mobile phones (T5, 10). Deterrence was related to visualization (MS24) as pictures or simulations illustrate the consequences (T8). On the one hand, this method is regarded as helpful (T3). Teachers aimed to achieve sensitivity to consequences (T6, 10) and thereby induce changes in practice. T5 explained “that they [the students] themselves do not want to end up like that“ (09:39) and consequently “rethink their own practices“ (09:51). T5 further hoped that deterrence would prove sustainable. In contrast, this method was also criticized. It was seen as “not so nice for a child“ to create fear (T1 17:58). As a result, T7 withdrew from deterrence, and others evaluated it as unsuccessful (T6, 11). T11 explicitly addressed the tendency to believe that one is the exception: “It doesn’t help them when I say ‘you will suffer from gout at the age of fifty’. They don’t know what it is, and one always thinks ‘I won’t get that.’” (T11 41:01).

Case studies (MS15) were another way of highlighting the possible negative consequences of unhealthy behaviors. Teachers either used theoretical cases (T3), invited guests (T8, 11), or encouraged classmates to talk about their experiences with health problems (T4, 8). However, inviting guests involves an organizational effort (T3). Topics mentioned in the case studies were drugs (T3), anorexia (T3), obesity (T11), organ transplants (T11), and accident prevention (T10). Case studies are suitable for discussing triggers for disorders, addictions, and recovery processes (T3, 11). Moreover, case studies promote empathy and reflection as students are impressed by these cases (T3, 5), they provide real-life experiences (T8), and they are associated with good retention (T11).

5.2.3. Focus on the Popularity of Teaching (MS17, MS19, MS20, MS25)

Addressing current topics (MS17) and debates were mentioned by some teachers (T3, 8, 11), e.g., discussions about measles vaccination (T3, 11). This strategy was seen as valuable because pupils are usually interested in current issues and are exposed to different opinions through the media, which may be more or less valid. Therefore, teaching facts about actual topics in school was considered important (T11). T8 described the motivational component: “things that originate not from afar, time-wise, but that are red-hot, and this motivates the most, right?” (T8 26:59). T8 also described the discussions about historical parallels (MS19) motivating students to healthy practices.

Shared laughter (MS20) was another strategy to engage students. For example, T3 explained that the simulation of being drunk (cf. MS23) was “funny“ and that it is essential not to take things too seriously, e.g., concerning sex education. Having fun together was associated with better retention: “And it goes along with big laughter [...]. It is important to have a little bit of fun because, if you think about it, what gets stuck? What do we remember of our school time? It is not a lot, but rather moments, and I try to create such moments.” (T11 15:22).

The last strategy assigned to “focus on the popularity of teaching” is increasing the lessons’ attractiveness (MS25). Teachers indicated students’ preferences and interests as important determinants for their lesson. On the one hand, different options and materials were presented so students could decide what they wanted to work on (T4, 10). Students demand the freedom to address issues that concern them (T4). Next to the topic, students’ preferences relating to methods were also considered. T3 avoided too theoretical approaches “because otherwise, students are bored” (06:14). T11 occasionally formed groups of pupils with homogeneous learning levels. On the other hand, teachers started with a topic and tried to arouse students’ interest through how they prepared the subject. As T11 stated, “it depends on the packaging” (05:07). Teachers could attractively present the topic: “To design an attractive introduction, so that the students really feel like dealing with a carrot. Yes. Well, and that it [the carrot] is maybe more likeable than coming in with a copy in black and white saying: ‘So, that’s a carrot, it contains this and that and that is why it is good.’” (T9 11:41). When pupils liked the lesson, teachers expected collaboration during the class (T4) and better retention (T2, 11). Generally, the enjoyment or fun students felt about a particular method seemed to be an essential criterion (T2, 3, 5).

5.2.4. Guidance and Consultation (MS3, MS6, MS12, MS11, MS13, MS18, MS26, MS5)

The cluster guidance and consultation comprises eight strategies that consider students’ individual situations to incorporate healthy practices into their lifestyles.

The strategy for creating relevance (MS3) followed students’ daily lives and emphasized the impact of their daily behavior on health. Regarding nutrition, teachers focused on foods that pupils like to eat (T3) and are familiar with (T1, 8, 10). In addition, opportunities to purchase healthy foods around the school were discussed (T3). Thus, focusing on students’ perspectives and relevance (T6, 8) was beneficial, as students were able to identify with the content and retain it better (T1, 3–5, 8, 10). Besides, health-promoting behaviors become more realistic and transferable to everyday life (T1, 7). However, a limitation was the curriculum, which limits flexibility (T10). In addition, more concrete materials, such as nutrition plans, would be beneficial in implementing relevance (T7).

The personal level strategy (MS6) referred to teachers’ and students’ experiences and habits. Teachers showed interest in students and their way of life (T3) by acknowledging healthy behaviors and observing their pupils outside of class (T3–5, 7, 11). Students’ experiences and opinions were shared during the course (T2, 3, 7, 8, 11). Sometimes one-on-one conversations were necessary when discussing sensitive topics (T7). Therefore, a good connection with the students was considered a precondition (Ef2). One-on-one talks were also effective in finding ways to change habits because they function as a form of coaching (T4, 7) and in understanding fears that impede the implementation of health-promoting behaviors (T1; Ba1). On the other hand, teachers’ accounts of their experiences and habits were rated as effective in promoting healthy lifestyles (T5, 8, 10, 11; MS7). T10 tried to “become tangible […] [by] sharing personal experiences” (25:29). Also, T10 stated that pupils are interested in their teacher’s lifestyle. Students were “thankful” (T10 26:14) when the teacher saw eye-to-eye with students and emphasized that “what we’re doing here now is important to me, too“ (T10 26:14). The personal-level strategy was seen as effective in changing pupils’ attitudes and mentoring students individually (T3, 7). However, teachers could not realize one-on-one talks with every student (T3). Nevertheless, T4, 5, 7, and 11 pointed out how motivating praise and recognition can be.

According to the personal level (MS6), teachers were also aware of the social network (MS12) to which students belonged. Parents and peers are social influences that seem relevant. Therefore, teachers tried to involve parents in their interventions and used students’ influence with each other. On the one hand, parents received information about health-related topics (T3, 5, 7, 8, 10), e.g., preparing a healthy breakfast for their children (T3). In addition, the parents were asked questions about their families’ habits, e.g., children’s Internet use (T8). On the other hand, teachers worked closely with parents to have a more significant impact on pupils. For example, teachers sought to talk with parents when a student needed further support (T3–5, 7), so that parents were involved in developing solutions. Moreover, parents were informed about the consequences and sanctions when students violate school rules, e.g., unhealthy foods such as chips and energy drinks were banned at some schools (T3). Teachers believed that it was “important“ (T4) and “useful“ (T6) to involve parents. T11 observed parental interest in promoting healthy lifestyles for their children, and T8 generally perceived parental support. T2 highlighted the influence of parents: “the children, first of all, follow the example of their parents“ (05:41). However, parents could also have a negative effect (T11). For example, if the parents are excessively overweight, educating their children about healthy eating may be difficult, and they may not serve as role models for their children (T11). T8 described how parents violate the smoking ban while waiting for their children outside the school and need to be reminded that smoking is not allowed there.

Another critical part of students’ social network were their peers, as students generally crave acceptance (T10). The negative influence older pupils have on younger ones when they engage in unhealthy habits was mentioned only once (T8). In contrast, teachers focused on the positive influence of students implementing health-promoting habits into their lifestyles (T3, 4, 6, 7, 10). They serve as role models (cf. MS7), can support peers, or mentor younger pupils. Teachers believed that advice and criticism are better received when given and modeled by classmates rather than teachers (T4, 7, 8).

Teachers also tried to develop students’ skills for self-reflection and self-regulation (MS11). Mainly, teachers tried to make their pupils aware of their deficits and reflect on their situations and attitudes, for example, by having them track their food for a day to identify their habits (T2). In addition, reflection on one’s relationship with food and body shape in the context of eating disorders was encouraged (T11). Students should also consider other habits, such as managing stress (T7) and consuming energy drinks (T10). Physical education activities could identify deficits in coordination and conditioning (T4, 7, 10, 11). Students could learn what they are capable of and what they are not. T4 explained teachers’ responsibilities: “And thus, many children learn about their deficits, and they should be supported in this case.” (T4 25:26). T10 recommended creating training plans and documenting improvements for fitness deficits, while T4 set specific goals with pupils. For example, apps could help to increase the students’ awareness of how much time they spend on their cell phones, which often encourages them to reduce this time, which is then, in turn, confirmed by the app (T7). T2 performed “silentiums” (quiet periods) to ground the students, and T7 provoked frustration to train mental strength and improve self-discipline (cf. Ba9). T7 explained the general concept of reflection: “The point is to make the student bring up his/her own thoughts, to reflect, to find a way out. [...] To indicate which price I pay for a high media consumption. So. Does that obstruct me in my goals? In the case of education or privately and so on.” (T7 19:44). T7 explicitly contrasted this approach with deterrence (MS4). Nevertheless, T7 is unsure about the amount of time that should be spent on reflection in physical education classes, as less time is available for physical activities.

In order to help students, incorporate healthy practices into their daily lives, teachers tried to support them in building habits (MS13). The interviewer addressed this strategy in each interview to see if and how it was being implemented. T3 and T7 described the idea of this strategy. Pupils should develop automatic healthy practices “not as work, as an obstacle, but like brushing their teeth in the morning, as part of their everyday life“ (T7 27:29). However, T3 was not able to give specific examples of how to build automatisms. T7 suggested always doing some physical exercises before showering. T8 explained that healthy eating habits become natural when students have lunch with a teacher and incorporate healthy eating into lessons or field trips (ORL2). T4 explained that support for building habits is especially relevant for physical education teachers as they strive to maintain an active lifestyle. However, some teachers were critical of the addressed method. For example, building habits is not feasible because it requires consistency (T6) and there may not be enough time (T10). In addition, teachers do not have enough influence on students’ behavior outside of school (T6). T3 raised the question of habit sustainability by comparing the beverages of fifth and eighth graders: Fifth-grade pupils chose water as a beverage, but “the question is, right? Do they maintain that or do they, like the older ones, […] would rather bring their tetra packs of ice tea along” (T3 26:10). T11 believed that students could develop habits in school, but that attitude and intrinsic motivation are crucial to building habits: “I believe one [a teacher] can initiate that and [...] everyone who is up to it, is going to proceed [with the practice], and indeed on their own, independently.” (T11 49:11).

Teachers also used the step-by-step strategy (MS18) or the formation of sub-goals. Rather than expecting each student to achieve an optimal outcome, they wanted their students to acquire at least the most critical information or focus on small improvements. As an example of knowledge about antibiotics, test results showed that many pupils appeared unable to reproduce an explanation for taking the antibiotics for as long as prescribed (T11). Then, it was sufficient that “if they know, keep taking them” (T11 16:56). According to practices, teachers focused on implementation and recognition of improvements (T7), although there was still room for optimization. For example, teachers suggested reducing the consumption of sweets rather than advising their students to avoid them altogether (T5, 9). In this way, they hoped their students would develop balanced eating habits and an awareness of the foods they consume.

During school hours, teachers assigned responsibilities (MS26) to their students. Students were involved in conducting events that enabled their classmates to acquire health-related knowledge or practice healthy behaviors. For example, classes could take turns preparing fruits to sell to their classmates (T3) or a student-run kiosk could help pupils actively apply their knowledge about healthy food (T2). At T4’s school, students were engaged in developing their school’s health program as an extracurricular activity (ORL3). They planned physical activities that can be done in classrooms (cf. MS21). In class, students were sometimes required to present health-related information to their classmates (T7, 10, 11; cf. MS22). Assigning responsibilities was rated useful because it awakens the need for agency and leads to better retention (T10).

Teachers often used the strategy of suggesting different options (MS5) to the students. These options should be applicable and adapted according to the situation, needs, and preferences (T1, 5, 7). T5 recommends straightforward ways to improve the students’ diets: “your brain needs food and energy, and that can be simply a banana” (T5 23:14). Other examples included suggesting alternatives to fast food (T3), riding a bike instead of taking transit (T11), and introducing different ways to increase physical activity that do not require special equipment (T7, 10). T7 explained: “I can show every adolescent a perspective to move, whether in a sports club or casual, like playing Frisbee in a park, that is somehow connected to physical activity” (T7 01:53). However, the effectiveness of suggesting different options was limited as teachers could only provide suggestions; the realization relied on students themselves (T6).

5.2.5. Encouraging Health-Promoting Behavior in Everyday Life (MS1, MS21, MS9, MS10)

All teachers mentioned practicing healthy behavior (MS1) related to nutrition or physical activities. For example, teachers planned a healthy breakfast with students sometimes (T1, 2, 4, 5). Beyond breakfast, healthy meals in general were prepared and consumed (T2, 5, 7, 10, 11). Some teachers even did groceries with their pupils (T1, 11). In addition, teachers also practiced packing and carrying a backpack (T1) and lifting heavy objects correctly on the back (T11). In physical education, endurance sports (T6, 10) and the correct execution of exercises were practiced (T10).

T5 explicitly described this method of practicing healthy behavior as effective. The teachers supported this method for several reasons. First, the experience motivates students (T3, 7, 9) and students could develop an idea of healthy meals in general (T4, 5). Furthermore, pupils may not have the opportunity to prepare meals at home, so it seems necessary to practice this at school (T5). Finally, practicing healthy behaviors allows students to step out of their comfort zone, which is an essential experience for overcoming barriers (T11). In particular, preparing healthy versions of fast food (T5) and trying healthy foods despite initial reluctance (T11) could help overcome the barriers of attraction to unhealthy food (Ba5) and rejection of healthy behaviors (Ba2).

However, restrictions on practicing healthy behavior were mentioned as well. This method cannot be applied to every area of health education. For example, teachers did not consider the practice a suitable tool for sex education, sub-areas of hygiene (e.g., menstruation products), and addiction prevention (T10). Moreover, time is a problem because practicing behaviors requires start-up time and repetition (T1, 3, 5, 7) and the school’s timetable is limited (T2, 10). In addition, teachers only accompany a class for a few years, so regular practice seems complicated (T2). Also, practicing is often limited to sports (T4). Nevertheless, extracurricular activities (ORL3) and events (ORL1/ ORL2) seem to be appropriate opportunities to practice healthy behavior more coherently (T4, 10).

Teachers also encouraged active breaks (MS21) during lessons. Movement is achieved either by interrupting classes to allow activity or by integrating training into the learning process. For example, teachers invited the students to leave the classroom to take a run outside (T1–4), interrupted lessons to do short movement exercises like stretching, or introduced methods to stand up and walk around the classroom (T4, 10, 11). This concept offered “possibilities to get to know things they can do, but also to move while learning” (T4 03:12). This does not require complicated exercises, and even teachers without experience in physical education can easily create opportunities for students to stand up during class (T4). The advantages of active breaks are positive effects on students’ concentration in all-day school (T2, 3, 10) and motivation to be physically active (T3, 4). The strategy of active breaks can be promoted due to the accessibility of the equipment, for example, if each classroom has a box containing materials that can be used for physical activities during lessons (T4).

By providing access (MS9), teachers create opportunities for students to be physically active or eat healthily. According to food, an essential factor is the school’s infrastructure. Kiosks, canteens, or students selling fruits, vegetables, and healthy or healthier foods at comparatively low prices (T3, 4, 8, 11) can lower the spending barrier (Ba6). As T4 pointed out, the foods students eat at school make up a significant portion of their diets, maybe leading to healthier eating. This approach also gives students access to healthy foods they might not yet be familiar with (T1). However, T2 was “skeptical” about the availability of healthy foods and argued that access to healthy foods does not equate to eating healthy foods. Therefore, students might not take the offer and reject healthy food (Ba2). T6 described another problem teachers might face: “There is no healthy food in the conventional sense in our canteen that can be bought. So, what should I do? Advising the students not to eat there?” (16:10).

Another way to incorporate healthy practices into the school day was through rituals (MS10; T1, 3, 8). Examples of rituals included clapping rhythms to improve body control and coordination (T3), eating walnuts in class before or after vacations (T1), and eating lunch together with younger students every day (T8). The effect of rituals is that students know and expect the actions (T1). Rituals are “very important in general“ (T1 25:13) and hopefully students will use these at home. However, introducing and establishing rituals requires time, which is mentioned as an obstacle (T3).

5.2.6. Temporal Domain (MS16, Ef1)

Two factors were included in the temporal domain. One of these referred to the strategy of sustainability and endurance (MS16). Ideally, all teachers should pay attention to children’s habits and food choices during school hours (T3, 8), as it is difficult to drive change individually (T4, 5). In addition, students should be relentlessly challenged and encouraged to maintain a healthy lifestyle (T3, 5). Teachers should not ignore students’ poor eating habits (T3–5) but instead try to talk to pupils. Health education should be ubiquitous in schools, and endurance was generally considered effective (T1, 4). It is necessary to “make more than one attempt to reach students, [because it] doesn’t always work on the first try for everyone“ (T5 03:21). Teachers argued that topics covered in previous courses should be repeated because “constant dripping wears away the stone“ (e.g., T7 29:48). For example, preparing a healthy breakfast once in fifth grade was not enough to make it a habit. Instead, a healthy breakfast should be organized repeatedly (T3). Similarly, interventions that extended over a longer period were helpful and more effective (T7, 10). For physical education, the concept of permanence and repetition seemed applicable because teachers can address health within the context of any sport (T7). Some aspects were considered problematic for the strategy of sustainability and endurance. While the repetition of critical content was effective, teachers also had to ensure that they covered all the different parts and areas of health education (T8). In addition, students should not be annoyed with health-related topics (T8). Finally, projects (ORL1) in the form of project days were critically evaluated because they did not provide continuity (T3).

The effectiveness of starting health education early (Ef1) was noted by two teachers (T1, 5). T5 stressed that it is necessary “to start early in order to have an effect later“ (T5 28:57).

5.2.7. Health Education Outside of Regular Lessons (ORL)

The category contains four clustered methods and strategies referring to health education in schools outside the classroom. Projects (ORL1) are an essential part of the school program and an appropriate opportunity to address health education outside regular classes (T3–8, 11). In addition, projects offer more flexibility in choosing topics. Students can focus on a topic they are interested in or identify with, e.g., the “Impact of computer games on the performance. That were the children who have a PlayStation at home and who might have noticed themselves that they spend too much time in front of it.” (T10 22:14). Another advantage is the more coherent time frame, which may cover when they take place on a day or over consecutive days (T10). For instance, T3 explained that the whole school spends one day working on projects that exclusively address health education. T10 suggested integrating project weeks into the school program and making them compulsory. Nevertheless, as with all methods, a project in itself is no guarantee of success. T6 referred to projects where the program or the responsible person did not meet student expectations or proved to be inefficient (cf. Ef6).

Like projects, class- and field trips (ORL2) were seen as appropriate occasions to provide health education. As teachers explained, health education is either a side benefit or the focus of the trip. For example, regardless of the trip’s theme, food might be organized and discussed with students, which provides an opportunity to address healthy eating (T3, 4, 8). Health education could also be the trip’s focus when physical activities are conducted (T3, 5, 10) or counseling centers for AIDS or addiction are visited (T4, 11). T8 explained the impact: “I do these trips with regard to exercising and health and […] there is attention paid to that. And this is how it becomes natural for them [the students].” (T8 34:52). Nonetheless, class- and field trips are time-consuming, as they require organization and usually take the time that schools would otherwise spend with regular lessons (T11).

Similarly, extracurricular activities (ORL3) were mentioned as a framework in which schools could easily implement health-related activities like physical exercise and preparing dishes (T3, 4; MS1). In some schools, a workgroup deals with health in particular (T3, 4). However, T3 explained that extracurricular activities were integrated into the school day of the younger but not of older students: “We are an all-day school and the structure is like this: students of the fifth class have [...] extracurricular activities [on one day of the week] that are partially physical exercising, there is an acrobatic group, a dance class, a football class, a class for preparing meals, where they pay attention to healthy food choices. Well, that is for class five and that is great [...]. But from the 8th grade onwards, there are lessons in the afternoons [...] and if one would have these workgroup activities for older students in the afternoons that would be really valuable and important.” (T3 21:29). A further occasion to expose pupils to health-related issues are stand-in classes (ORL4), which could be used as an opportunity to address and discuss nutrition with pupils (T6).

5.2.8. General Strategies Associated with Effectiveness (Ef)

Those (sub-)categories referring to effectiveness were either summarized in a special cluster (described here) as far as they were of a general nature, or they were assigned to other clusters of the root category methods and strategies if there was a content-related fit. In Figure 1 all these effectiveness-related categories are marked with an italic font. In the following, only those subcategories referring to general strategies for enhancing effectiveness are described, because the others were already introduced before (when dealing with the respective clusters they could be assigned to).

The first subcategory of this cluster on general effectiveness is early commencement (Ef1) of health education. Due to the time focus of this subcategory, it was also assigned to another, more specific cluster, which is the “temporal domain” where it was explained in detail. Another subcategory of general effectiveness is having a good relationship with students (Ef2). In the interviews, teachers mentioned the positive influence of this factor several times (T1, 4, 7). A certain level of familiarity between the teacher and the class was seen as essential for thriving health education, as sensitive topics such as physical appearance and intoxicants could be discussed (T4, 7). Action orientation (Ef3) was considered effective too (T4, 5, 10, 11), because it is associated with better topic retention (T11). In addition, experiences can motivate students and help them overcome barriers (T4, 5, 11). Teachers also considered interest (Ef4) and experiencing the aha effect (Ef5) important to making health education more effective. According to T2, interest (Ef4) may arise by teaching theory (MS2) and/or by visualizing content (MS24). Thus, in contrast to regarding pupils’ interest as a precondition, T2 and T11 think that teachers have the power to inspire interest. The experience of an aha effect (Ef5) was deemed effective by four teachers (T1, 3, 4, 5). It may, for example, be generated by surprising insights and experiences (MS2, MS23, MS4; T1, 3, 4) or by overcoming a barrier (Ba5; T5).

However, teachers also mentioned factors, circumstances, or interventions that they considered ineffective (Ef6). Ineffective methods were, for example, lecturing on its own in contrast to allowing questions (T2), exercises based on writing for younger pupils (T6), or reprimanding (T11). T11 and T7 experienced certain pupils who were persistently unable or unwilling to receive health-related knowledge or advice. A limited influence due to their position as teachers in contrast to being parents was perceived as hindering (T6). T6 further referred to interventions and projects that are conducted at their school that appear only to increase the school’s reputation but are not effective (T6).

5.2.9. Second Evaluation Step: Presence of the K^/SAP Structure in Health Education

The following part will refer to the K^/SAP structure [14] as a superordinate pattern to compare and assign our interview data to. This assignment seems reasonable because K^/SAP comprises important outcome variables for health education. The K^/SAP structure is used to classify the learning goals as well as the methods and strategies used by the teachers interviewed.

Teaching objectives, named by the teachers, directly reflect the K^/SAP structure (O1-O3) but also go beyond it. The latter becomes apparent in two ways: On the one hand, some learning objectives cannot be clearly assigned to one of these three categories (knowledge/skills—attitudes—practices) but fall in between. Thus, body consciousness (O4), general health awareness (O5), and critical information assessment (O6) contain both knowledge/skills as well as attitude components that are interwoven. On the other hand, participating in school competitions (O7) in the health field has a different focus, concentrating on course development and improving teaching quality in general rather than focusing on personal health development.

Methods and strategies used by the interviewed teachers in health classes were also assigned to the components of the K^/SAP structure. An overview of these assignments, as well as their corresponding justifications, is given in

Table A1. Assignment of the methods & strategies named by the teachers to the target categories of the K^/SAP structure (knowledge/skills, attitudes and practices) and determination of the frequency of the target categories (last line of the table), whereby multiple assignments of a method or strategy to different target categories were possible. The assignment was based on the descriptions of the subcategories in Section 5.2, which serve as justifications for the mapping. With respect to the attitudes, we distinguished two different facets: A¹, attitudes toward healthy behaviors, and A², emotional aspects that could influence attention and interest in lesson content, which in turn might affect students’ attitudes. The x-signs indicate the assignments to the categories K, S, A, and/ or P.

Methods & Strategies		K/SAP Structure
Focus on acquiring knowledge		K	S	A	P
Theory (MS2)	Theory teaching aims to expand students’ knowledge.	x
Practical learning (MS23)	Practical learning can increase students’ understanding of scientific measurements or experiments. Healthy skills can also be learned if these experiments are based on healthy behavior, like carrying backpacks.	x	x
Visualization (MS24)	Visualization focuses mainly on expanding students’ knowledge.	x
Interchange & communication (MS22)	Students can also learn from other people’s experiences through class discussions and exchanges.	x	x
Focus on advertising healthy behavior		K	S	A	P
Externals (MS14)	Externals can impact students’ knowledge beyond class instructions. If external persons report about their illnesses or experiences, this may also influence students’ emotions because they find it impressive (A1).	x		x
Teacher as a role model (MS7)	If teachers behave like role models (or not), students can change their perceived importance of the specific health behavior (A1); for example, riding a bike is fun.			x
Attractiveness of health behavior (MS8)	Increasing the attractiveness of healthy behavior, e.g., preparing healthy fast food, can likewise change the attitude towards healthy behavior (A1) and strengthen skills to prepare healthy food.		x	x
Deterrence (MS4)	Deterrence tries to influence attitudes (A1) through emotions but also can give facts about, e.g., the severity of an illness.	x		x
Case studies (MS15)	Case studies can impact students’ knowledge and influence students’ emotions because they may find it impressive (A1).	x		x
Focus on the popularity of the lessons		K	S	A	P
Current topics (MS17)	Selecting current topics can enhance students’ understanding and increase their interest (A2).	x		x
Parallels in history (MS19)	Topics with historical parallels can enhance students’ understanding.	x
Laughing together (MS20)	Sometimes teachers also rely on shared laughter in class, e.g., during teaching sex education, to increase students’ openness to the topic (A2).			x
Attractiveness of the lessons (MS25)	Raising the appeal of instruction, such as selecting topics that interest students, could also improve the class atmosphere and keep students’ attention (A2).			x
Guidance and consultation		K	S	A	P
Creating relevance (MS3)	Creating relevance for the lesson content could have an impact on students’ knowledge and attitudes (A1), e.g. if they realize that the topic also concerns them.	x		x
Personal level (MS6)	Personal references (e.g., by sharing personal experiences or giving personal feedback) can change students’ attitudes (A1) and knowledge.	x		x
Social network (MS12)	A person’s social network (e.g., parents, peers) is involved in health education, so that a change in practice and its acceptance (A1) is more realistic, provided that this social network supports the health-promoting intentions.			x	x
Self-reflection and regulation abilities (MS11)	Improving self-regulatory and self-reflection abilities refer to students’ skills.		x
Support for building habits (MS13)	Support for building healthy habits can help students learn new skills or even establish them as longer-lasting healthy behaviors.		x		x
Proceeding step by step (MS18)	Proceeding step by step refers to learning skills but also to acquiring knowledge. By this procedure the most important facts and action steps should be kept in mind.	x	x
Allocating responsibilities (MS26)	Allocating responsibilities to students, e.g. that they have to offer healthy activities to others, can help them acquire skills. If students do this over a longer period of time, healthy behaviors (habits) may also develop.		x		x
Introducing options (MS5)	When teachers suggest multiple options for students to engage in healthy behaviors, such as different sports, students can boost their knowledge (by knowing these options) and skills (by trying these options).	x	x
Encouraging health-promoting behavior in everyday school life		K	S	A	P
Practicing healthy behavior (MS1)	Practicing healthy behavior can lead students to try out healthy behavior (skills) and eventually transfer it to their daily lives (practice).		x		x
Active breaks (MS21)	Active breaks can get students to try out healthy behavior (skills) and eventually use it regularly (practice).		x		x
Providing access (MS9)	Proving access is a method of using the school’s conditions so students can learn and perform healthy behaviors more easily (skills), probably regularly (practice).		x		x
Rituals in school (MS10)	School rituals can get students to try out healthy behavior (skills) and eventually use it regularly (practice).		x		x
Health education outside of regular lessons (ORL)		K	S	A	P
Projects (ORL1)	Projects promote not only knowledge and skills, but may also affect longer-term health behaviors, provided they cover a longer time-period, e.g., a semester.	x	x		x
Class- and field-trips (ORL2)	Class and field trips can expand knowledge and train new skills. However, to elicit longer-lasting healthy behaviors, these activities are probably still too short in time.	x	x
Extracurricular activities (ORL3)	Extracurricular activities (taking place throughout the school semester) may increase knowledge, skills, and healthy behavior, as they occur regularly, such as basketball training after school.	x	x		x
Stand-in classes (ORL4)	Teachers with stand-in classes may use these extra lessons for health education.	x	x
General strategies associated with effectiveness (Ef)		K	S	A	P
Good relation with students (Ef2)	A good relationship with students affects their attitudes so that, e.g., students may be more open to talk about sensitive topics and/or themselves (A2).			x
Action-orientation (Ef3)	Focusing on action can increase skills if healthy behavior is attempted. Moreover, if active learning methods are used, they also aim to increase students’ knowledge.	x	x
Arousing interest (Ef4)	Arousing students’ interests can affect emotions (A2) or attitudes toward health (A1).			x
Aha effect (Ef5)	The aha effect focuses on increasing knowledge and tries to affect attitudes toward something surprising about health (A1).	x		x
Temporal domain		K	S	A	P
Sustainability and endurance (MS16)	Sustainability and endurance as well as early commencement referred to temporal aspects and were therefore not taken into account, since a focus on one or more special target categories of the K/SAP structure cannot be derived here.
Early commencement (Ef1)
Sum		19	17	14	9

. However, many methods and strategies cannot be assigned to just one target category (K, S, A, or P). Instead, they often contribute to more than one category simultaneously (see Table A1 and Figure 2).

Looking at the quantitative results of these assignments (thereby taking into account double counting), there is a clear ranking (Table A1). Most methods and strategies serve the goal of declarative knowledge transmission (K: 19 assignments). A relatively high number of methods also serve to teach procedural knowledge, i.e., skills (S: 17 assignments). The number of methods and strategies referring to attitude formation (including motivational aspects) is somewhat lower (A: 14 assignments), while the lowest number is found for methods and strategies that support the integration of a health-promoting behavior into everyday practice (P: 9 assignments).

Figure 2 visualizes in more detail whether a method or strategy addresses just one target category of the K^/SAP structure or more than one simultaneously. While there are some methods and strategies that separately influence knowledge or attitudes, this looks different for the target category of skills or practices. Thus, skill development is often accompanied by knowledge transfer (the combination of K & S applies to seven methods and strategies). Furthermore, the formation of (long-lasting) practices occurs almost entirely together with the promotion of skills (combination of P & S applies to eight methods and strategies, with two of them also referring to knowledge). It can be noted that attitudes are also frequently addressed together with knowledge transfer (combination of A & K applies to seven methods and strategies).

5.3. Results for Research Question 3: What Obstacles Do Teachers Face and How to Deal with Them?

5.3.1. Barriers (Ba)

Teachers named several barriers that prevent the implementation of healthy practices. Organizational barriers such as time and missing equipment were not the focus of the interview and are therefore not mentioned further here. Instead, we will refer to student-based barriers (Ba). Nine of them were addressed in the interviews, which can be divided into two groups: mental barriers and circumstances. Figure 3 shows student-related barriers (Ba) in relation to other factors that they affect or by which they have been affected.

Anxieties and inhibitions (Ba1) were mentioned as mental barriers (T1, 4). Students might refrain from asking essential questions in sex education due to embarrassment (T11). If students cannot perform on the same level as their classmates in physical education, a feeling of frustration and inferiority might be evoked (T4). Lastly, body shaming might prevent the pupils from applying necessary hygiene measures, like taking a shower after PE classes (T8). Dealing with these anxieties and inhibitions was regarded as “very strenuous, very laborious, but [...] very important” (T4 27:25). If the teachers were confronted with diagnosed mental illnesses, the situation for them became more complex (T11). T1 and T4 proposed to try to understand these anxieties and inhibitions and confer with parents, psychologists, or social workers (cf. MS12, MS14).

Another mental barrier was the lack of self-discipline (Ba9). T7 observed that students struggle to motivate themselves to carry out healthy practices. They missed the mental strength to “see things through” if they “do not feel like it” (T7 24:20). As T2 and T11 pointed out, this barrier is prevalent, and they could relate to that. In particular, T2 explained the gap between knowledge and behavior with this barrier: “One knows a lot, one could write a book about it, but one might be inconsequent.” (T2 03:51). Overcoming this lack of self-discipline was perceived as “rather very difficult through to impossible” (T7 25:35). T7 suggested analyzing “enhancers” for the “tendency of doing as one pleases” (by which is meant unhealthy behavior) in order to counteract these enhancers (T7 26:25). Furthermore, self-discipline had to be trained at an early stage (cf. Ef1; T7).

Pupils sometimes reject healthy practices (Ba2), for example, in the field of nutrition and an active lifestyle. Teachers observed that students did not aspire to eat healthy food but instead avoided or even rejected dishes regarded as healthy (T2, 5, 9, 11). T5, for instance, reported that students refused meals because of these meals “looking too healthy“ (T5 13:22). Additionally, diet was seen as a “very delicate topic because children want to distinguish themselves through the way they eat“ (T2 21:35), and therefore students might disapprove of healthy food. With increasing age, an active lifestyle might be rejected of as well: “And at some point, it gets unattractive to exercise. Well, the older they become, right? The less attractive it gets. Then, they don’t want to ride their bike anymore, they want to ride a moped.” (T11 45:05). Similarly, active breaks (MS21) might be perceived as “silly“ and the teachers should be aware of that (T7). Another factor that caused the refusal of healthy practices was prejudice in general (T10). Situations in which the rejection of healthy practices occurs were regarded as “difficult“ (T10 27:59). However, teachers still found ways to deal with them. For instance, teachers encouraged their pupils to try food they had rejected before, which might change their perception of healthy dishes (cf. MS8; T5, 9, 11).

Even if healthy food was not rejected, students might still neglect these food choices due to their competition with unhealthy food, which some students perceived as more attractive (Ba5; T3, 5, 9). For example, although vegetables were not generally disapproved of, they were not seen as being “as delicious as the kebab from around the corner, as the crisps that I can buy“ (T3 03:22). To encounter these tendencies, teachers prepared popular fast foods in a healthier version with the students at school (cf. MS1, MS8). Attractiveness did not only apply to unhealthy food but also to smoking. It is “not always cool to do just the healthy stuff. Smoking a cigarette once in a while and so on is, at that age, 16, 15 or so, of course they think it is cooler” (T8 11:38).

The following five barriers can be assigned to circumstances: Two different social environments (Ba3) were mentioned as potential barriers to a health-promoting lifestyle with the family on the one hand and the peers on the other (cf. MS12). T2 stated that parents have a tremendous impact on their children’s lifestyles. However, not all parents might be suitable role models for a healthy lifestyle (T3, 11), which underlines the importance of teachers exemplifying healthy behavior (cf. MS7). Some parents did not apply enough effort to support their children or implement a healthy lifestyle within their families (T3–6, 11). For example: “If the parents don’t take action [...], if the children are allowed to play computer games as long as they want and no exercising takes place, then it is nearly impossible for us to reach them.” (T4 05:42) or “When they play table tennis, some of them become really good at it. Then we said ‘why don’t you join a sports club?’. They don’t carry it out. The parents are unable to register their children there.” (T11 45:29). Peers are the other important part of the student’s social environment, as adolescents are very influential. Students displaying unhealthy habits could entice their fellow students into copying “cool” behavior (T2, 4, 8). “It is also an identification. If others do this, one wants to do it, too. One doesn’t want to be perceived as a health fanatic.” (T2 04:48). For teachers, it was not easy to encourage healthy practices in these cases: “Of course, it is really hard to ensure that other students say ‘That is not good’, instead they say ‘Oh, he has got crisps, I want crisps, too.’” (T4 05:58).

Established unhealthy habits (Ba4) were another barrier preventing the pupils from sustainably applying a healthy lifestyle and leading to the neglect of healthy practices or food. Changing these habits was difficult (T2–4, 11). However, clear rules in the school could help overcome unhealthy habits: “For example, during the lessons, students are only allowed to drink water. Then, the children can drink water or nothing. But not the lemonade they brought with them, and these are measures that I can influence to a certain extend.” (T4 29:22). Further measures included creating opportunities to leave the comfort zone, persuasion, and positive examples so students can experience a health-promoting lifestyle (cf. MS1, MS9; T2, 9, 11).

Additionally, physical barriers (Ba8) were mentioned (T4). Disabilities could be challenging for teachers, as they might not have the level of expertise to foster those students adequately. Then teachers had “to try to work as good as possible within these boundaries“ (T4 26:46). Moreover, teachers were sometimes confronted with pupils that were in impaired physical shape: “It gets difficult, if one [a student] is for example unable to walk for 2 km due to a lack of fitness, then it gets extremely difficult regarding the physical barrier, if it is not inclusion, but if it is just, yeah, a lack of fitness.” (T4 28:25).

Expenditure (Ba6) was another inhibitor of a health-promoting lifestyle. For example, “Of course, healthy food is more expensive than unhealthy food. For instance, crisps are cheaper than buying fruits or vegetables. Especially if you want to turn to organic food. I’m sure this is a huge barrier because we have families who don’t have much money, which makes it difficult for them to model this healthy lifestyle.” (T3 15:40). T3 described a project realized in school that provides access to fruits at comparatively low costs as a possible strategy to cope with that barrier (cf. ORL1, MS9).

Another named barrier was the unsuitability for everyday use (Ba7) of healthy practices. For instance, students spend most of their time in school and, therefore, have less time for physical activity outside school: “[I]n all-day school, the time for the pupils is limited. One shouldn’t neglect that. Nevertheless, I think it is very important that the students still have the opportunity to visit a sports club or the sports club come to school.” (T4 10:00). Thus, the importance of implementing health-promoting behaviors in everyday school life was highlighted (cf. MS9, ORL1, ORL3). Furthermore, preparing healthy dishes also required time, which was considered one reason for the success of fast food (T5).

5.3.2. Enablers (En)

Teachers mentioned six groups of enablers (En) that encourage pupils to make healthy lifestyle choices (see Figure 4). They argued that a healthy lifestyle is visible through an externally attractive appearance (En1; T5, 7). Therefore, students might be impressed: “[I]f you are healthy, you also exude that and that can be via skin, the hair, all kind of things, body form. If you avoid certain things, may it be smoking, you smell better and it is better for your teeth and everything else.” (T5 20:40). A healthy diet, physical activity, and not smoking are aspects of a healthy lifestyle that can improve or maintain attractiveness (T4, 5, 7) and therefore, healthy practices could themselves appear attractive (cf. MS8). In addition, T4 pointed out that “everyone wants to look attractive“ (T4 30:42), underscoring this enabler’s potential impact. However, teachers should be aware that some beauty ideals can be exaggerated and not achieved through healthy practices but through harmful ones (T4). In addition, implementing a healthy lifestyle could lead to recognition by classmates (En2) in the form of acceptance or positive feedback, which is important for students (T5, 7). Acceptance may depend on outward appearance (En1): “Well, in class five was a case like that, of a boy, who was kind of podgy and always felt excluded. He recently dropped weight and is, gets better along with his peers. Unfortunately, children have the tendency to form groups and exclude others on the basis of the outer appearance” (T5 10:49). Furthermore, good grades (En3) could be a solid motivation to internalize theoretical knowledge (cf. MS2) if tested in exams (T6, 8). The internal strive for self-realization (En4) might also encourage healthy practices. Pupils might aspire to be more successful in sports, exercise regularly, and apply a healthy diet. They are challenged and motivated by opportunities to perform (cf. ORL1): “There are of course many sports projects at school. Like sports competitions and cups, bicycle races and so on, where we try to give people a stage to perform. Thus, being extremely motivated” (T7 28:08). Consequently, students could be proud of their achievements and boost their self-confidence (T3, 7, 8, 11). A healthy lifestyle was associated with an increase in overall well-being (En5; T3). Drawing students’ attention to this by pointing out that “you notice that this is good for you” (T3 14:49) might encourage them to maintain or sustain health-promoting practices. T7 promotes the idea that physical activity reduces stress. Some pupils could be motivated to engage in healthy practices by the social component (En6; T7). In many disciplines, training takes place in a group and thus offers the opportunity to get to know other people. At school, students were encouraged to participate in healthy extracurricular activities (ORL3) to integrate socially (T4).

5.3.3. Second Evaluation Step: Strategies to Overcome Student-Based Barriers

Our study does not only identify barriers, but also different ways to counteract these barriers. These are, on the one hand, various methods and strategies mentioned by the teachers in the interviews (Figure 3) and, on the other hand, enablers (Figure 4) that provide young people with a timely benefit that can be health-related but does not have to be. These countermeasures to student-based barriers (referring to the methods and strategies named in Figure 3) can be inductively structured into 5 groups, which refer to a social, temporal, structural, practice- and benefit-related dimension. Figure 5 shows these 5 dimensions as well as the subcategories (based on the teachers’ statements) from which the dimensions were derived.

The social dimension refers, on the one hand, to direct support in implementing health-promoting behavior, e.g., in the form of a social network (MS12; as far as it shares the idea of a healthy lifestyle), and, on the other hand, to indirect support caused by creating proximity to reality and authenticity, e.g., through positive role models (given by the teachers, MS7) or through experience reports provided by externals (MS14). The temporal dimension refers to an early start in health education (Ef1) to form positive habits as early as possible. Even if the second time-related subcategory, sustainability and endurance (MS16), was not mentioned in this context (i.e., overcoming barriers), it also belongs to this dimension, particularly because it was seen as an effective strategy by the teachers. The structural dimension involves creating opportunities to access health-promoting services, for example, on the one hand by providing appropriate infrastructure and terms of use in the school (MS9) and, on the other hand, by using certain longer-lasting teaching methods such as projects (ORL1) and extracurricular activities (ORL3). The practice-related dimension addresses acquiring health-related skills (practicing healthy behavior/MS1). Finally, there is the benefit-related dimension. It comprises benefits that are associated with health-promoting behavior, although these benefits do not necessarily relate to health but also to other areas of personal goals. These additional benefits make health-promoting behavior attractive to students and, thus, may act as enablers.

These enablers mentioned by the teachers in the interviews (Figure 4) can be arranged according to their importance on the basis of Maslow’s pyramid of needs [16]. An increase in well-being (En5) can be assigned to the level of basal needs (level 1 or 2) if a person’s well-being is currently severely impaired (otherwise, this enabler would belong to a less important level of need). The need for belonging (level 3) is addressed by allowing social contacts (En6) while applying health-promoting behaviors. A person’s need for esteem (level 4) may be satisfied if a healthy lifestyle leads to a more attractive appearance (Ef1), as this may be associated with more recognition by others, e.g., by classmates (En2). Good grades may also result in recognition (e.g., by parents). However, long-lasting health-promoting behavior is unlikely to be realized through grades, since behavior outside of school is not included in the grading. Offering the possibility of self-realization (En4, e.g., in that the health-promoting behavior goes hand in hand with a special hobby, such as a certain sport) corresponds to level 5 of Maslow’s pyramid of needs and thus is important, but not as central as the previously mentioned level of needs.

5.4. Results for Research Question 4: What Contributes to Higher Perceived Effectiveness?

5.4.1. Different Types of Effectiveness Statements and Their Assignment to K^/SAP

Teachers’ statements on the effectiveness of their health lessons go in two different directions. Some refer to teaching as being effective when certain goals are met, while others indicate teaching methods and strategies they believe to be effective. Concerning the learning objectives, the achievement of the following 3 goals (out of 7) were rated as effective by the teachers: acquisition of health-related knowledge and skills (O1), development of general health awareness (O5), and change of practices/behavior towards more health (O3). This covers the whole spectrum of K^/SAP. However, we will not elaborate further on these goals here, as their achievement is just a sign of effectiveness, but they do not show the way to it as methods and strategies would.

When looking at the methods and strategies, 13 out of 35 were explicitly named by the teachers to be effective (see the green boxes in Figure 2), while 2 additional ones were discussed controversially, i.e., they were only partially classified as effective (see the half-green boxes in Figure 2). When assigning these effective methods and strategies to the areas of the K^/SAP structure, it becomes obvious that the aspect of practices, which means establishing (longer-lasting) healthy behavior, is only poorly covered and comprises just two strategies (see the bottom row in Figure 2 which contains only one green and one half-green box, alternatively see Figure 6). One of these strategies was a predefined one (MS1: practicing healthy behavior) that the teachers substantiated by naming examples and assessed as effective, while the second one (MS12: involving students’ social network in health education), was discussed controversially, with reference to both positive and negative examples.

5.4.2. Third Evaluation Step: Assigning Effective Methods & Strategies to Inductively Formed Effectiveness Dimensions

Those methods and strategies mentioned by teachers to overcome student-based barriers in implementing healthy practices had been inductively grouped into five dimensions (see Section 5.3.3 and Figure 5). We would like to title these content groups as effectiveness dimensions because they represent a way to increase the impact of health teaching. In addition, teachers directly labeled some methods and strategies used in health teaching as effective (green and half-green boxes in Figure 2). These methods and strategies were subsequently mapped to the effectiveness dimensions. In this way, it should be determined whether the existing dimensions are sufficient or still need to be expanded to include additional ones. Figure 6 shows that the methods and strategies named to be effective could be assigned to four of the five effectiveness dimensions (blue boxes). However, some methods and strategies do not fit these dimensions. Rather, they point to a separate domain (violet box) that includes both cognitive and affective aspects, with most of the methods and strategies addressing both simultaneously. This is the reason why both aspects were united in one new dimension.

The assignment of each method and strategy to the effectiveness dimensions was based on the teacher statements (see Section 5.2). This shall be described by an example referring to the subcategory MS6 (personal level, see Section 5.2.4), which had been assigned to the social dimension. Personal level means that students, but also teachers, report on personal experiences and thereby give other impulses, but they may also receive advice from the others. Especially one-on-one talks were seen as effective, emphasizing the social aspect and thus supporting the assignment to the social dimension.

5.5. Summary of Results

With reference to Section 5.3.3 and Section 5.4, the results on the effectiveness dimensions (Figure 5 and Figure 6) are summarized at this point. This leads to a total of six effectiveness dimensions (Figure 7), which were inductively derived from the teacher statements.

6. Discussion

The present study took another perspective than most research on health interventions and asked teachers how they conduct health education in their daily teaching and what they see as effective. Following the outline of the results section, the discussion is structured in the same way and addresses teachers’ goals in health education (Section 6.1.), methods and strategies used by them (Section 6.2), obstacles and how to overcome them (Section 6.3), the effectiveness of teaching measures (Section 6.4) and as a summary, the six effectiveness dimensions (Section 6.5). In addition, gaps that become visible are identified (Section 6.6). Finally, the study’s limitations are reported, and an outlook for future research is provided (Section 6.7).

6.1. Goals of Health Education

By assigning the goals to the three dimensions of the K^/SAP survey structure, it became clear that all three outcome levels (K^/S, A and P) were addressed by the teachers. In this context, knowledge transfer was important to many teachers, probably because it is a classic aspect that has always been central to teaching [37], even if it is of limited effectiveness in terms of behavior change [47]. The affective level was also mentioned by several teachers, because without a corresponding attitude and motivation, the acquired knowledge is generally not translated into action [13]. Several times, teachers also referred to goals that contain both cognitive and affective components, as is the case, for example, with conscious (i.e., cognitively supported) attitudes such as a general awareness of health. Behavior change is also mentioned by many teachers as a goal. However, the reported methods and strategies show that they support long-term behavioral change only to a limited extent (see Section 6.2).

6.2. Methods & Strategies in Health Education

Our study revealed various methods and strategies teachers use to design health lessons. However, it is already apparent that some content receives little attention in lessons, even though it is vital for successful behavior change. When allocating the methods and strategies to the K^/SAP structure, most strategies cannot be assigned to just one target category (see Figure 2). Instead, they often contribute to more than one category simultaneously. Nevertheless, a clear ranking emerged in terms of quantities (Table A1): Methods and strategies refer most often to knowledge (K), followed by skills (S), then attitudes (A), and finally healthy practices (P).

This descending order of frequency also corresponds to the difficulty with which changes at the various target levels (K, S, A, or P) can be achieved among students. Studies showed that changing knowledge is easier than changing attitude or practice [48]. Moreover, the order of frequency is inversely related to the number of pupils’ deficits concerning these different target levels (K, S, A, P) (Table 1). This reveals a contradiction: While teachers see the least deficit in students at the knowledge level, most of the methods used by teachers address knowledge. And likewise, while it is at the practice level that students have the greatest deficits, long-term behavior change (i.e., practice) is rarely targeted by methods and strategies used in the classroom. This finding indicates a need to strengthen teachers’ knowledge about methods and strategies that support students in integrating health-promoting behaviors into their daily lives, also in the longer term.

6.3. Obstacles in Health Education and How to Overcome Them

Several barriers (Figure 3) were seen by the teachers, which seem to hinder their pupils to implement health-promoting behavior. These barriers can be divided into two groups: mental barriers and barriers referring to students’ life circumstances. However, these two groups of barriers cannot be seen as completely detached from each other: For example, personal anxieties (mental barrier; Ba1) and the effect of one’s social environment (circumstances; Ba3) are closely related to each other. An example is given by adolescents in our study, who mention that some friends do not engage in sports because they are ashamed of their abilities, and thus the social environment harms students’ health behaviors.

Our study, however, does not only identify barriers but also different ways to counteract these barriers. These were, on the one hand, certain methods and strategies mentioned by the teachers in the interviews, and, on the other hand, enablers that provide the young people with a timely benefit that can be health-related but does not have to be. These countermeasures to student-based barriers could be structured into five subgroups, which refer to a social, temporal, structural, practice and benefit-related dimension and will be discussed in Section 6.5. Moreover, the enablers of the benefit-related dimension could be assigned to different levels of Maslow’s pyramid of needs [16]. These levels are ordered hierarchically, such that physiological needs (e.g., hunger) must first be satisfied before higher needs become relevant [16]. Therefore, one might expect that the enablers according tothe levels to which they were assigned would have different weights too. This means that the more basic the level of need an enabler addresses, the more effective it is.

6.4. Effectiveness in Health Education

The teachers revealed two different perspectives on effectiveness in health education. First, they equated effectiveness with achieving specific educational goals, second, teachers named general methods and strategies associated with effectiveness. When assigning these effective methods and strategies to the areas of the K^/SAP structure (see Figure 2), it became obvious that the aspect of practices, which means establishing (longer-lasting) healthy behavior, was only poorly covered. Thus, a similar problem emerged for the methods and strategies rated as effective as well as for all the methods and strategies mentioned. To overcome this problem and transform skills into everyday behaviors, it would be helpful to combine the strategy of practicing healthy behavior (MS1) with the time factor. The two subcategories of the temporal domain—early commencement (Ef1) and sustainability and endurance (MS16)—were both rated as effective by the teachers and hence might act as an important element for realizing the P-component of the K^/SAP structure. The importance of the temporal component, which emerged in our study, is also pointed out in other publications. On the one hand, the time dimension means that health education should start in early childhood since basic physical, cognitive, and emotional development processes occur [49], and habits can be built this way [50]. On the other hand, health interventions should be addressed repeatedly throughout school education to be effective in the long term [51,52]. However, time for such repetitions is often lacking at school; thus, practice might need to be shifted outside of school. For example, it could become long-term homework to integrate certain health-promoting measures into one’s everyday life and then to report in school at intervals on the extent to which these implementations have been feasible or not and whether the measures might need to be revised. For example, a study evaluated the effectiveness of a six-week “Healthy Homework” program to increase physical activity and healthy eating in children aged 9–11 years [53]. Healthy homework resulted in more steps per day, higher vegetable consumption, and less unhealthy food consumption than with children who did not have healthy homework [53]. Thus, mandatory health-related homework appears to be a useful approach to increasing the health behavior of children and adolescents.

6.5. Summary: The 6 Dimensions of Effectiveness

Bringing together two strands of analysis that both relate to effectiveness (methods and strategy rated as effective as well as proposed countermeasures to barriers) resulted in a total of six effectiveness dimensions. These dimensions can be classified as practice-oriented and experience-based for the most part, since they were inductively created on the basis of teachers’ statements about their teaching practices. (The only theory-based element is the reference to Maslow’s pyramid of needs). The dimensions of this effectiveness scheme can now be compared with other guidelines in order to highlight the extent to which there are consistencies and deviations. As an example, the eight WHO criteria for effective intervention programs [33] can be used. We refer to this older WHO source because it focuses on criteria for teaching (rather than setting) and thus is closer in content to our survey focus (namely, instructional design). Several of these WHO criteria are also reflected in our effectiveness dimensions. The WHO criteria that the use of health interventions should take place at appropriate times in the individual’s development, which also means starting early, and should run long term, belong to the temporal dimension. The acquisition of (generic and specific) skills and the active involvement of the students in the programs fit into our practice-related dimension. The peer leadership component corresponds to the social dimension. Aspects of a setting approach, however, were not included in the eight WHO criteria (to which we refer here ) but are present in more recent approaches, such as the Health-Promoting Schools approach from WHO and UNESCO [21]. Aspects of such a setting approach are also included in our structural dimension, which, however, represents only a limited area of our effectiveness scheme compared to the Health-promoting schools approach, where the setting dominates [21]. The cognitive-affective dimension, as it exists in our effectiveness scheme, does not occur in the WHO criteria in a similar way. However, the importance of the reference to the curriculum is emphasized there, which gives special significance to the content to be imparted. In our effectiveness dimension, however, the affective aspect is added to the cognitive one. The combination of both aspects seems reasonable, as it enables emotional learning and thus improves attention and retention of content [54]. The benefit-related dimension represents a special feature in the dimensional scheme in that it is both inductively and deductively based. The aim is to make the health-promoting behavior attractive, among other things, by means of possible additional benefits (which are on top of the health benefit). The hypothesis is that the coupling of several benefits increases the effectiveness of health teaching by making the health-promoting behavior more likely to occur [23]. An even more advanced hypothesis related to all six dimensions of effectiveness is that the more dimensions being addressed in health classes, the more effective the teaching intervention will be and the more likely a longer-term change in behavior toward health will be achieved.

6.6. Gaps in Health Education

Some gaps are noticeable when comparing the methods and strategies used by the teachers with the National Health Education Standards (NHES), a standardized and audited curriculum in the United States [34]. Choosing this reference for comparison seems sensible, since there is no corresponding set of rules for general health education in Germany.

Teachers in our study gave few examples of developing students’ abilities to set goals and develop action plans (NHES std. 6) [34]. These aspects were partially discussed in the subcategory self-reflection and self-regulation ability (MS11), but it was more about revealing deficits in health behavior through self-reflection. The aspect of strategically overcoming these deficits, i.e., learning realistic goal setting and developing effective, individual, and long-term training plans to achieve personal health goals, should be emphasized even more in the future. Moreover, students should also assess obstacles and use strategies that help them stick to their goals (e.g., track progress and set reminders) [34]. For instance, Schwarzer’s action and coping planning might be helpful here [55]. An exciting intervention focusing on everyday health behaviors combined the nutrition education class with psychological mediators of planning or self-efficacy, which make it easier to bridge the intention-behavior gap [55]. Adolescents were randomly assigned to control, planning, or self-efficacy conditions. For the planning condition, students had to formulate individual action and coping plans for the following seven days and start each day by recalling the plans. For the self-efficacy group, students were asked to start each day by recollecting mastery experiences they had earlier in their lives (e.g., feelings of success with a healthy food choice). Both interventions could increase healthy eating compared to regular teaching lessons in the control condition in the long-term (14-month follow-up) [55]. Thus, integrating psychological mediators into health education seems promising and should be more widely used. The NHES also exceeded teachers’ instructional practices in other ways. In our study, too little was stated about teachers trying to explain to students the influence of family, peers, social media, technology, and other determinants on health behaviors (NHES standard 2) [34]. Through influence analyses, however, students could learn how society affects their health behaviors [34]. Another strategy that is part of the NHES but was not mentioned in our study was learning interpersonal communication skills (NHES standard 4) [34]. This includes, e.g., being able to communicate needs and feelings and also being able to ask for help in health matters [34]. The gaps revealed by this comparison of methods and strategies named by the interviewed teachers with the NHES, could help in that filling them may increase effectiveness in health education.

6.7. Limitations and Future Research

The advantage of doing a qualitative analysis and getting in-depth insights into teachers’ experiences and views on health education can also be seen as a disadvantage as we deal with a small sample size. Due to the length and complexity of the interviews, taking a larger sample was not considered feasible. Moreover, the teachers interviewed may skew the data because only those who were available and motivated participated, making it an ad hoc sample [56]. In addition, due to the study’s exploratory nature, only descriptive and hypothetical statements can be made. Thus, hypotheses were generated with our research but have to be proven by subsequent quantitative studies.

For instance, further quantitative surveys could examine how many teachers use the methods and strategies named in the present study, how often they do so, and how effective these methods and strategies seem to them. For such quantitative studies, the categories of the coding framework could be used as a basis. Another shortcoming of our study is that it refers only to teachers’ statements concerning the effectiveness of methods and strategies used in health teaching but does not include students’ assessments. However, to appropriately assess the effectiveness of methods and strategies, students’ opinions also need to be collected (which might be done in a subsequent study). In general, more evidence of best instruction and implementation practices is needed to progress in this area [57]. Having this in mind, the present qualitative study can be a useful starting point for corresponding, subsequent quantitative surveys.

7. Conclusions

The qualitative results of our study reveal various methods and strategies teachers use to design health lessons. However, our findings indicate a need to strengthen those methods and strategies that support students in permanently integrating health-promoting behaviors into their daily lives. Promoting daily routines of healthy behavior could be enhanced by combining skill acquisition with a temporal factor (e.g., in the form of long-term homework related to daily practice of health-related skills). In addition, it became apparent in our study that some content receives little attention in lessons, even though it is important for successful behavior change (e.g., individual goal-setting skills see NHES). Focusing on psychological mechanisms (e.g., planning, self-efficacy) may be helpful, in this respect. Finally, six dimensions of effectiveness concerning school-based health teaching could be identified. We hypothesize that the more of these dimensions are considered when teaching, the more effective the teaching will be. In general, our qualitative results provide insights into the design principles of current health education but require quantitative confirmation in terms of frequency and importance. Nevertheless, the present study already allows some conclusions to improve the sustainable impact of health education and makes an important contribution to the research-practice gap from the practitioner’s perspective.

References