Knowledge and Perceptions About Back Education Among Elementary School Students, Teachers, and Parents in Belgium

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<ul><li><p>Research Papers </p><p>Knowledge and Perceptions About Back Education Among Elementary School Students, Teachers, and Parents in Belgium Greet Cardon, llse De Bourdeaudhuij, Dirk De Clercq </p><p>ABSTRACT: A back education program for Belgian elementary school children was evaluated using self-reported questionnaires before intervention and at three follow-up points during one year. Most children found the program interesting, important, and amus- ing. Intervention children (n = 347) showed better back care knowledge than control children (n = 359), and knowledge gained was retained over a period of one year. Back education did not result in increased fear-avoidance beliefs about physical activity, and intervention children reported more checking of their book bag weight than controls at all test moments. Self-reported behavior in rehtion posture-related and back care related segeficacy were affected only minimally by the pmgram, possibly due to pwr serf- judgment. Involvement. fear-avoidance belief, and back care knowledge of teachers and parents of the intervention children showed low correlation with the childrens perceptions and knowledge. Suficient promise exists to justib fitrther development and evaluation of early back education. (J Sch Health. 2002;72(3):100-106) </p><p>onsidering the social costs and disability secondary to C back pain, it is important to encourage back pain prevention programs, Prevention efforts are mainly directed at adults, but the results have been questioned,3 so several authors advocate implementation of back education in elementary schools. Other reasons for implementing early back education include the high back pain prevalence rates in children and adolescent^,'-'^ school-related risk factors of back pain such as book bag weight6. and prolonged ~itting,~ and predictive value of adolescent back pain on back pain as an Moreover, prevention h u g h the school system makes it possible to reach a large percentage of the population. </p><p>The need for early back education is expressed by many authors, but specific guidelines do not exist and little is known about effects of such a In the sparse literature on this topic, improved back care knowledge and practice of back care principles was found in elementary school children, shortly after completing a back education program.8 1Y-z2 Chometon et a12 found improved self- reported behavior in relation to back care up to two years following back education. Based on the theory of planned beha~io?~ knowledge, attitudes, self-efficacy, and social support can be considered important predictors for health behavior. However, literature on these factors in relation to back education in children is limited. Making use of a prac- tical test, efficacy of a back education program influenced use of back care principles up to one year after program completion.2- In this simultaneous study, determinants of the effects are examined, making use of questionnaires in extended samples. </p><p>In contrast to positive outcomes from early back educa- tion, Burtonz6 reported in a study on low back pain in chil- </p><p>Gnsl Cordon, PhD, (greet.cardon@.rug.ac.be); the De Bounhudh@, PhD, (ilse.debourdeaudhuij@rug.ac.be); and Dirk Dc Clercq, PhD, (dirk.declercq8rug.ac.be); Ghent University, Dept. of Movement and Sports Sciences, Watersportfaan 2, 9wo Ghent, Belgium. This articie was submitted March 2, 2001, and revised and accepted for publication October i, 2001. </p><p>dren and adolescents little evidence that giving ergonomic advice would be beneficial in adolescents with back pain, and it is arguable that such advice might be unduly alarmist. Conversely, Burton et alZ7 found in a study on adult back pain patients that back education resulted in improved fear-avoidance beliefs about physical activity. Fear-avoidance beliefs about physical activity may be involved at a very early point in the development of pain and associated activity problems in people with back pain.* However, no study could be located that evaluated the influence of back education in elementary school children on their fear-avoidance beliefs about physical activity. </p><p>This study investigated effects of a six-week back educa- tion program in children 9 to 11 years of age. Researchers hypothesized that knowledge, fear-avoidance beliefs, self- efficacy, and self-reported behavior in relation to back care are better in children who followed a back education program than in controls within one week after the program, three months after the program, and one year after the program. A previous studys and the literatures found that the teacher of the children may play an important role in efficacy of back education. According to the literature,M parents also play a vital role as primary influences on chil- drens health choices. However, no studies were found on involvement of parents in back education given to children. A second aim of this study was to evaluate commitment, social support, knowledge, and fear-avoidance beliefs of parents and teachers whose children or pupils followed back education, and to study the correlation for these vari- ables between the children and their teachers and parents. Researchers hypothesized that a positive correlation (&gt; 0.5) exists between children and their teachers and parents for the evaluated variables. </p><p>METHODS Child data were collected at school, during regular class </p><p>periods, under the supervision of an independent tester within one week before the start of the intervention (pretest); within one week after the intervention (posttest </p><p>100 Journal of School Health March 2002, Vol. 72, No. 3 </p></li><li><p>1); three months after the intervention (* 10 days) (posttest 2); and one year (A 1 month) after the intervention (posttest 3). At posttest 1, parent and teacher questionnaires were completed at home and collected at school. Data were obtained from April 1999 to December 2000. </p><p>Sample Respondents included fourth- and fifth-grade pupils </p><p>(Table 1) from Belgian public elementary schools with similar curricula, the intervention pupils parents and their class, and the physical education (PE) teacher, Classes (n = 16) of pupils (n = 347) were selected by simple randomiza- tion from all classes (n = 36), participating in the back education program between April and November 1999. Classes (n = 16) of controls (n = 359) were randomly selected from five comparable schools not participating in the program. Children younger than 9 or older than 12 years at pretest were excluded. </p><p>Because the parent and teacher questionnaires were linked directly to the program, they were only given to parents (one parent for each child, n = 347) and teachers (16 class teachers and 13 PE teachers) of intervention chil- dren. Three classes of the intervention group had no physi- cal education teacher because physical education classes were given by the class teacher. A limited sample (n = 198) of the intervention group, evaluated with a practical test in the scope of a different simultaneous study, was used to evaluate the correlation between self-reported and observed behavior after following back education. The pupil ques- tionnaire was considered part of the psychological, medical, and social counseling provided by the school for which parents signed a consent form. The study protocol was approved by the Ethics Committee of the Institution. </p><p>Intervention The back education program, also used in previous stud- </p><p>ies,ZI,29.31 was organized and sponsored by a health insurance company and the local government. The program was developed and carried out by a team of practitioners, inde- pendent of the testers. The long-term goal of the program was to attain good body mechanics and correct posture while performing various tasks based on good understand- ing of basic back care principles. Every six weeks, exclud- ing holidays, the program started in fourth- and fifth-grade classes of other schools. </p><p>The program, begun in January 1999, consisted of six sessions of 60 minutes at one-week intervals. It was taught by a physical therapist through guided discovery and active hands-on methods to one class group at a time (maximum </p><p>Table 1 Number, Gender, and Average Age </p><p>of Respondents in the Intenrention and Control Groups </p><p>Inbtwntlon Group Control Group </p><p>Number 347 359 </p><p>BoydGirls (%) 16511 82 (47.662.4) 236/123 (65.7134.3) </p><p>Avoraga Ago (SD) 10.0 years (* 0.6) 10.1 years (kO.7) </p><p>26 pupils). All games, movements, and exercises were based on childrens daily activities, like getting out of bed, brushing teeth, sitting at a table, and canying a book bag. Back care principles were translated, made easy to under- stand and attractive for the children, through use of cartoons, games, and lots of materials. Pupils were taught basic anatomy and pathology of the back and basic princi- ples of correct posture while standing, sitting, lying, lifting, carrying, pushing, and bending. </p><p>To optimize integration of back care principles into the daily classroom routine, the teacher was present during all sessions. The program was created making use of 10 guide- lines on how to make your discs happy: 1) always keep the natural curves of your back, 2) be active and join in sports, 3) place your book or homework on a ring binder or inclined desk, 4) when you relax lie down on your back with your legs raised, 5 ) bend your knees and not your back, 6) to lift, stand as close as possible to the object, 7) ask for help in lifting a heavy object, 8) carry an object as close as possible to your body, 9) carry your book bag on your back, and 10) your book bag should not weigh more than one-tenth of your body weight. </p><p>In every school, an information session was organized for parents and teachers, consisting of a two-hour lecture on back care principles with guidelines on how to enhance back care at home and in the classroom. Parents and teach- ers received a back care brochure. Every teacher received a manual with a thorough description of all lessons and extra exercises. </p><p>Instruments . Different questionnaires, based on a previous study and </p><p>the liter~~,9.I1.1920.32 were used for the children, parents, and teachers (Table 2). In a pilot study, 150 children, 20 parents, and 10 teachers not participating in this study, completed the questionnaire to identify unclear questions, which then were modified. Information about social support was obtained directly through the parents and teachers. Questions abut back pain prevalence and physi- cal activity also were included, but reporting of these results is beyond the scope of this study. </p><p>Data were analyzed using SPSS for Windows (9.0). To evaluate test-retest stability, 85 pupils not participating in this study, completed the questionnaire twice with a one- week interval. Stability estimates ranged from 0.42 to 0.82. The lowest estimate was found for self-reported posture while carrying a load. In cases where scales were used, Cronbachs Alpha reliability coefficients were established to check internal consistency of the items (Table 2). Independent-sample T tests were conducted to detect significant between-group differences. To study the correla- tion between observed and self-reported behavior and between scores of parents, teachers, and pupils, Pearsons correlations were determined. Statistical significance was set at P c 0.05. </p><p>RESULTS Pupil Questionnaire </p><p>A dropout of 8% (n = 56) was found from pretest to posttest 3 (interval 13-14 months), due to transfers to other schools or being absent on the day of the survey. Within one week after program completion, mean score for attitude toward the program among intervention children was </p><p>Journal of School Health March 2002, Vol. 72, No. 3 101 </p></li><li><p>14.3/15 (range 3-15, SD IS), with a maximum score in 72.1% of the children. At baseline no significant group differences were found except for a significantly higher score for self-reported book bag weight checking in the intervention group. </p><p>The intervention had a clear effect on general and specific back care knowledge at the three follow-up points. Improvement in general back care knowledge from pretest to posttest 3 was 33% in the intervention group and 12% in the control group. For knowledge more specifically related </p><p>to the program, the improvement was 21% in intervention children and 6% in controls. The intervention children demonstrated better fear-avoidance beliefs than comparison pupils at posttest 1 and 3. For self-efficacy, no statistical group differences were found, except for keeping good posture at posttest 1 and 2. For self-reported checking of book bag weight, intervention pupils scored higher than controls at baseline and at all posttests. Self-reported posture while taking off shoes was significantly higher in intervention pupils at posttest 2, while scores for lifting and </p><p>Table 2 Information on the Questionnaire for Pupils, Parents, and Teachers </p><p>Conmct Qurrtlonnaim for the Pupils </p><p># of ltems Sample Item Response Format a </p><p>When lifting a heavy box off the floor you should a) keep your feet as far apart as possible, b) do most of the work with your back, c) bend your knees, General back care </p><p>knowledge 12 d) keep the box on one side of the body Multiple choice </p><p>To carry a heavy load far away from your body 3-point scale (Yes, no or Specific knowledge 10 is healthy not sure) </p><p>5-point scale (definitely yes Fear-avoidance beliefs 5 When your back hurts, it is dangerous to swim to definitely no) </p><p>Attitude towards the program* 3 The back education program was interesting agree to I strongly disagree) </p><p>5-point scale (I strongly </p><p>How do you perceive checking your Self -efficacy 3 book bag weight? </p><p>4-point scale (very difficult to very easy) </p><p>5-point scale (definitely yes Self-reported behavior 4 Do you check the weight of your book bag? to definitely no) </p><p>Quectionnaim for the Parents Specific knowledge See pupils Fear-avoidance beliefs See pupils </p><p>Program commitment 5 Did you join the information session? 2-point scale (no-yes) </p><p>5-point scale (definitely yes Social support 3 Do you check your child's book bag weight? to definitely no) </p><p>5-point scale (definitely yes Do you think your child is able to keep good posture? to definitely no) Perceived behavior 2 </p><p>NA </p><p>NA </p><p>0.70" </p><p>0.71b </p><p>NA </p><p>NA </p><p>O.7Ob </p><p>NA </p><p>NA </p><p>NA </p><p>Questionnaire for the T m c k (class + Pf) Specific knowledge See pupils </p><p>Fear-avoidance beliefs See pupils Class: 0.82 PE: 0.70b </p><p>Program commitment 10 Do you think the manual is useable for your lessons? 2-point scale Qes-no) NA </p><p>': Reliability coefficients were calculated using baseline data. b: Reliability coefflcients were calculated using posttest 1 data (no pretest data available). NA = not applicable (not one-dimensional items) </p><p>only obtained from the intervention children at posttest 1 </p><p>102 Journal of School Health March 2002, Vol. 72, No. 3 </p></li><li><p>Table 3 Estimates and T-values of Between-Group </p><p>Dlfferences for Knowledge and Fear-Avoidance Beliefs in the Intervention and Control Groups </p><p>at Pretest, Posttest 1,2, and 3 </p><p>Inte...</p></li></ul>