Impact of a health promotion program on the health
of primary school principals
Rod Green
La Trobe University, Bundoora, Victoria, Australia
Susan Malcolm
La Trobe University, Bundoora, Victoria, Australia
Ken Greenwood
La Trobe University, Bundoora, Victoria, Australia
Gregory Murphy
La Trobe University, Bundoora, Victoria, Australia
Introduction
Over the recent past, there has been widespread concern internationally regarding the stress associated with the changing role of the principal in the public school system (Savery and Detiuk, 1986; Cooperet al., 1998; Tung and Koch, 1980). Further, this stress associated with the changing role and responsibilities of school principals has been implicated in some studies as a causative factor in work-related ill-health and disease. One survey of the health and fitness of principals in Victorian primary schools confirmed that, despite their relatively high socioeconomic status, they typically had poor exercise and nutrition habits and faced elevated risks of
cardiovascular disease (Greenet al., 2000). Improved employee health, morale and productivity have been cited as the major perceived benefits of health promotion programs in the workplace in Australia and internationally (Rearck Research, 1992; Department of Health & Human Services, 1992). There has been a wealth of literature reporting the benefits of such programs, but much of it suffers from methodological problems (Green, 1997; Shepard, 1992; Wanzel, 1994). It has been suggested that the postulated benefits, based largely on research from private-sector companies, may be generalizable to schools (Allegrante, 1998). Although some studies in US schools have suggested health and productivity benefits as a result of conducting school-based health promotion programs (Bjurstrom and Alexiou, 1978; Blairet al., 1986; Yanget al., 1988), others have not been as conclusive (Resnicowet al., 1998; Allegrante and Michela, 1990).
An additional reason for undertaking health promotion programs in schools is the suggestion that increasing the interest of teaching staff in their own health might
provide role models for pupils and encourage support for the implementation of broader health promotion programs within schools (Allegrante, 1998; Monaghettiet al., 1993).
One of the recommendations of the Victorian Government's Committee for the Review of Physical and Sport Education in Victorian Schools was ``that the importance of the fitness and wellbeing of principals and staff be recognised by the Department of Education'' (Monaghettiet al., 1993). Three years later the Victorian State Government's Department of Education (DoE) in
conjunction with VicHealth (The Victorian Health Promotion Foundation) initiated health promotion frameworks which were distributed to all schools in Victoria in 1996 (Directorate of School Education, 1996). This document provided a policy framework and accompanying resources which could be modified to suit individual schools. The framework proposed was based on a broad approach to organisational functioning whereby the link between organisational effectiveness and the health and wellbeing of employees is recognised and health and well-being programs are integrated into general school planning and management processes.
As outlined elsewhere (Greenet al., 2000), the Victorian Primary Principals
Association (VPPA) was concerned about the health of their members in a climate of increased workloads and responsibility associated with the introduction of self-governance programs for state schools. In an attempt to assist members in maintaining their health in the face of major
organisational change, the VPPA initiated a pilot health promotion program. This program was funded equally by the VPPA, the DoE, the health promotion provider (HBA Health Management) and the principals participating in the program. Initial health appraisals, the first stage of the program, took place in March 1996 (Greenet al., 2000), and post-tests were conducted in March 1997.
This study aimed to evaluate the impact of a health promotion program on the health and wellbeing of school principals. The current issue and full text archive of this journal is available at
http://www.emerald-library.com/ft The International Journal of
Educational Management 15/1 [2001] 31±38
#MCB University Press [ISSN 0951-354X]
Keywords
Health, Stress, Teachers, Schools
Abstract
The role of a school principal has changed dramatically in the last decade and there has been widespread concern regarding the impact of this change of role on principal health and wellbeing. Worksite health promotion programs have been used in many different settings to encourage employee health, but there is very little information on the effectiveness of such programs, particularly in improving principal health. This study evaluated the impact of a 12-month health promotion program on a group of 50 volunteer principals. Participants in the program reported improvements in their diet and exercise habits and this was reflected in improvements in blood pressure, cholesterol and body fat measures. These results indicate that worksite health promotion can play a significant role in improving the health and wellbeing of school principals.
Method
Research design
An intervention (INT) group was selected from all principals expressing interest in participating in the HP program. After stratifying all potential subjects on the basis of age, gender and school location
(metropolitan vs. country), the 50
intervention subjects were randomly selected to match the distribution of all VPPA members and hopefully all principal class employees. This method was adopted in an attempt to make the intervention group representative of the entire principal class in the DoE on the basis of the demographic information available.
The remaining principals who had expressed interest in participating were asked to participate as a control (CON) group. This group received no health appraisal as this was considered to be a significant part of the intervention for those participating in the HP program, but completed
questionnaires.
Subjects
All VPPA members were contacted and asked to give an expression of interest in
participating in a HP program conducted by an external provider which included a comprehensive health assessment at
significantly reduced cost. Fifty INT subjects were selected from 99 respondents as described above. Participation in the research program was obligatory for all participants in the HP program (Greenet al., 2000).
As indicated above, after the 50 INT subjects were selected, the principals not selected were requested to participate as CON subjects for the subsequent HP program. Twenty-nine of the remaining 49 principals (59 percent) agreed to participate as control subjects.
Although the INT group was selected to match the demographic characteristics of the entire population and the CON group were selected from the remainder of respondents, the groups did not differ on the basis of demographic characteristics (Table I). The two groups did not differ at pre-test on any behavioural or attitudinal data (Green and Small, 1997). Physical data could not be compared because they were not collected for the CON group.
Both the INT and CON groups better represent principals, rather than all principal class employees (which includes assistant principals) (Greenet al., 2000).
Three of the INT group and one of the CON group had retired at post-test, but still
completed the questionnaire. All subjects except one completed the post-test
questionnaire, and 43 of the 50 intervention subjects completed the post-test physical assessment representing retention rates of 99 percent and 86 percent respectively. Subjects not participating at post-test did not differ from the full INT group on the basis of demographic, health or health-related behaviour at pre-test (Green and Small, 1997).
All subjects completed an informed consent form and the project had approval from the La Trobe University Human Ethics Committee.
Health promotion program
The project was officially launched by the Director of the DoE and the President of the VPPA at a meeting in Melbourne. The general manager of HBA Health Management discussed the impact of lifestyle habits on disease and outlined the health screening program, and the primary author explained the research project. At the conclusion of the presentation, attendees were asked to sign an informed consent form for the research project. They were subsequently given pre-test questionnaires for the research project and booked dates for their health appraisal. Forty-nine of the 50 INT subjects attended the launch.
The program centred on a comprehensive health appraisal and counselling session conducted at the premises of the external provider of the program. The health appraisal included: a medical examination with medical history, rest and stress
electrocardiogram (ECG), physical measures (height, weight, strength, flexibility and body fat), fitness test (maximum oxygen
consumption), questionnaire-based nutrition assessment, psychological mood profile (Stress Arousal checklist) and blood and urine pathology. Results were presented during counselling sessions with the doctor and exercise physiologist and strategies for lifestyle modification were suggested. Subjects with particular health problems were referred to either a dietitian or psychologist for additional consultations as required.
Health screenings were initially all booked for March 1996, although a few were delayed due to unforeseen circumstances.
Approximately 14 weeks after attending for the health screening, all participants were contacted by mail. The letter contained a brief summary of their results and a reminder to see their doctor about any abnormal results. They were also invited to contact the program provider if they had any Rod Green, Susan Malcolm,
Ken Greenwood and Gregory Murphy
Impact of a health promotion program on the health of primary school principals
questions or concerns regarding their progress.
In August 1996 all INT subjects were invited to attend a presentation of the interim report on the project based on the initial screening results. The group results were presented by the Medical Director from HBA Health Management and an opportunity provided to ask questions. This was followed by a nutrition seminar presented by a dietitian, again with an opportunity to ask questions.
Questionnaires
Questionnaires were distributed to the INT group at the launch of the HP program and mailed to the CON group. All questionnaires were number-coded to ensure anonymity and returned via pre-paid reply envelopes.
The questionnaire has been described in detail elsewhere (Green, 1997), but, for comparative purposes, questions relating to health-related behaviour were drawn from those used in previous health surveys of the Australian population by the National Heart Foundation.
The NHF surveys use a two week recall of recreational exercise at three different levels of intensity (vigorous, less vigorous and walking). While there has been considerable debate over the intensity of exercise required for health benefits the total time spent in all three levels of activity was used as a measure of exercise participation in determining behavioural change in response to the HP program, that is comparison of pre- and post-test results.
The INT group were given the opportunity to describe the best features of the HP program and those features which could have been improved. This information was collected by the use of open-ended responses at the conclusion of the program. Up to three
best or worst features were coded for each subject.
Data analysis
Prior to the conduct of data analysis the distributions of all variables were examined to evaluate the normality of each
distribution. One variable (Arousal) which deviated significantly from a normal distribution was transformed and the transformed variable used in subsequent analyses.
The INT and CON groups were compared at pre-test using eithert-tests where variables were continuous in nature, or appropriate non-parametric tests (chi-square, Kruskal-Wallis) when categorical data were involved. Changes between the INT and CON groups over time were analysed using (for continuous data) a split-plot factorial design ANOVA with one repeated measure (pre-versus post-test). For non-parametric variables where there was no difference between groups over time, but there appeared to be a similar change for both groups, pre- and post-test data for both groups pooled were compared using tests for related samples (McNemar's test or Wilcoxon matched pairs signed ranks test).
The physical assessment data, available only for the INT group, were analysed using pairedt-tests.
To test the possibility that only employees with already healthy behaviours may be participating in HP program modules, pre-test comparisons of categorical data for those attending and not attending were conducted using the Kruskal-Wallis test for independent samples. To test the efficacy of the HP program modules variables representing changes between pre- and post-test were compared between those attending and not attending usingt-tests. Where there were no
Table I
Demographics of the intervention (INT) and and control (CON) groups (MSD, unless specified otherwise)
Variable INT (n= 50) CON (n= 29)
Gender (%) male 62 55
Age (years) 47.54.6 46.85.2
Age category (% under 44) 26 41
Age category (% over 49) 36 41
Seniority (% above Principal Class Level 2) 52 69
Duration employed (years) 27.75.4 27.26.4
Duration employed as principal (years) 6.55.8 6.44.7
Location at school (% rural) 28 28
Students enrolled at school (n= 47 andn= 28) 296145 338113
Salaried staff employed at school (n= 47 andn= 29) 19.98.9 20.37.4 Rod Green, Susan Malcolm,
Ken Greenwood and Gregory Murphy
Impact of a health promotion program on the health of primary school principals
differences between attendees and non-attendees for change, but there appeared to be a change for the groups pooled,
comparisons were made using the Wilcoxon matched pairs tests. Analysis of continuous data for those attending and not attending were conducted using two-way ANOVA as described previously.
Results
Table II contains information on the attendance at activities in the HP program. Subjects reported increased health-related knowledge after attending program activities. Of the six subjects who had individual consultations with the dietitian, one had five sessions, one had two sessions and the remainder had only one session. Of the three subjects who had individual consultations with the psychologist, one had two sessions, and the remainder had only one session.
There were no differences between attendees and non-attendees for the dietitian, psychologist and nutrition seminar on the basis of age, gender or seniority (Green and Small, 1997). The referral pattern from the initial counselling session to the dietitian and the psychologist was reflected in attendees. Although raw data are presented elsewhere (Green and Small, 1997), those who saw the dietitian at pre-test had higher cholesterol (t(48) = 2.6,p< 0.05), and those who saw the psychologist had lower arousal (t(48) = 2.2,p< 0.05) and higher stress levels (t(47) = 1.9,p= 0.06) at pre-test. Dietitian attendees showed greater reductions in cholesterol between pre- and post-test (Group by time interaction,F(1, 40) = 5.5,p< 0.05) than non-attendees and although the changes in raw data were substantial for both stress and arousal, low subject numbers precluded any statistically significant differences between psychologist attendees and non-attendees between pre- and post-test.
Attendees at the nutrition seminar had better diet patterns at pre-test than non-attendees (t(48) = 2.0,p= 0.05) and attendance
had no apparent effect on diet or health-related variables (Green and Small, 1997).
Open-ended responses by the INT group revealed general satisfaction with the program. There were 91 best features described by 44 subjects and 33 features for improvement by 27 subjects. The most common best features cited were the health assessment (25 percent of responses), the motivation to consider and/or change health stimulated by the program (23 percent) and increased general awareness of health (18 percent). The most commonly cited features for improvement were the need for more regular activities (30 percent), regional support groups (18 percent) and offering the program to all principals (15 percent).
Thirty-eight subjects reported behavioural change in response to the HP program at post-test (Table III). Both INT and CON groups increased the amount of time spent exercising, and the greater increase for the INT group approached significance (F(1, 76) = 3.3,p= 0.07, Table IV). Diet intentions improved for both groups as did the proportion of subjects reporting a modified diet. The greater improvement in diet intentions for the INT group approached significance (t(76) = 1.8,p= 0.07). There were no significant changes in reported alcohol consumption.
Physical and psychological variables for INT and CON groups at pre- and post-test are shown in Table V. There were no differences in stress and arousal between groups or over time (Table V). This was also true if retirees were excluded from the analysis.
Weight, body fat and waist-to-hip ratio decreased at post-test and the reduction in body mass index (t(42) = 1.7,p= 0.09) approached significance. HDL cholesterol increased and total cholesterol, cholesterol ratio, systolic and diastolic blood pressure decreased at post-test. Not surprisingly, cardiac risk score also decreased at post-test. In separate analyses not shown in the Table, group by time interactions indicated that weight (F(1, 41) = 14.8,p< 0.001), body fat (F(1, 41) = 16.3,p< 0.001) and body mass
Table II
Attendance at program activities by intervention group
Activity N(%)
Reported increased knowledge of health-related
activities (% of attendees)
Health appraisal and counselling 50 (100) 92
Dietitian consultation 6 (12) 80
Psychologist consultation 3 (6) 100
Nutrition seminar 22 (45) 96
Table III
Intervention subjects reporting behavioural change in response to HP program
Behavioural change N(%)
Increased physical activity 14 (29)
Improved diet 32 (65)
Better able to manage stress 9 (18)
Quit smoking 0
Modified in response to one or more activities
38 (78) Rod Green, Susan Malcolm,
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Impact of a health promotion program on the health of primary school principals
index (F(1, 41) = 9.4,p< 0.005) decreased for males, but increased for females. Changes in all other variables were consistent for both males and females.
Discussion
The present study was conducted with the aim of documenting the impact of a health promotion program on the health and well-being of a group of 50 volunteer school principals. The main study result was that
INT subjects reported improvements to diet and exercise patterns after 12 months and these were reflected in improvements in blood pressure, cholesterol and body fat measures. This resulted in a lowering of overall risk of cardiovascular disease.
Before discussing these results in detail, the strengths of the study need to be
recognised. First, the post-test retention rate for the questionnaire was exceptionally high (99 percent), with few similar rates having been reported previously for 12-month periods (Green and Small, 1997). This may
Table IV
Pre- and post-test health-related behaviours for intervention (INT) and control (CON) groups (MSD, unless stated otherwise
INT (n= 49) CON (n= 29)
Variable Pre-test Post-test Pre-test Post-test Differencea
Usual diet (% modified in some way) 18 53 17 38 Z (n= 78) = 4.2**
Healthier eating intentions (% preparation stage or better)b 63 88 72 79 Z (n = 78) = 2.5*
Time spent in recreational exercisec(mins/last two weeks) 278297 427365 348348 415371 T: F (1.76) = 10.0**
No recreational exercise (% none in last two weeks) 16 12 10 14
Alcohol consumptiond(% intermediate or greater risk) 6 6 0 0
Current smoke (%) 6 6 3 3
Notes: aFor continuous variables: T = time main effect. For categorical variables: Z for Wilcoxon test between pre- and post-test with groups pooled;bAs opposed to pre-contemplation or contemplation based on Prochaska's model of stages of change (Prochaskaet al.,1992);cTotal of vigorous exercise, less vigorous exercise and walking (National Heart Foundation of Australia, 1991);dHealth risk of alcohol consumption. Classified as none, low, intermediate, high or very high (National Heart Foundation of Australia, 1991) *p< 0.05; **p< 0.01
Table V
Pre- and post-test psychological and physical characteristics for intervention (INT) and control (CON) groups (MSD
INT (n= 50)a CON (n= 29)
Variable Pre-test Post-test Pre-test Post-test Differenceb
Stressc 7.55.1 6.35.4 8.45.3 8.65.2 ns
Arousalcd 8.13.4 8.93.0 7.83.4 7.63.9 ns
Systolic blood pressure (mm Hg) 13212 12513 N/A N/A t(42) = 4.1**
Diastolic blood pressure (mm Hg) 828 799 N/A N/A t(42) = 2.7*
Cholesterol (mmol/1) 5.750.97 5.340.92 N/A N/A t(42) = 3.9**
HDL Cholesterole(mmol/1) 1.120.39 1.200.31 N/A N/A t(42) = 2.1*
Cholesterol ratiof 5.671.97 4.721.34 t(42) = 4.3**
Weight (kg) 77.912.7 77.112.1 N/A N/A t(42) = 2.0***
Body mass indexg(kg/m2) 26.13.2 25.83.1 N/A N/A ns
Waist-to-hip ratioh 0.890.08 0.870.09 N/A N/A t(42) = 3.1**
Body fat (%)i 25.55.8 24.16.3 N/A N/A t(42) = 3.5**
Cardiac risk scorej 19.0
8.4 15.17.6 N/A N/A t(42) = 3.4**
Notes:an= 43 for all physical variables;bSignificance of difference between groups;cStress arousal checklist (SACL) typical scale (Mackayet al., 1978). Response to 30-scale items, resulting in a score from 0-12 for arousal and 0-18 for stress;dRaw data are presented in the Table, but analysis was conducted on transformed variable;eHigh density lipoprotein cholesterol. The fraction of cholesterol which serves a preventive role in terms of cardiovascular disease;fCholesterol ratio = cholesterol/HDL cholesterol. Higher results indicate increased risk of cardiovascular disease; g
BMI = (weight±1)/(height/100)2. Note: 1kg is deducted from the weight to allow for the weight of clothing (National Heart Foundation of Australia;hWHR = (waist girth/hip girth) in minimal clothing (Gore and Edwards, 1992);iBody fat (% of body weight). Calculated from skinfold thicknesses according to established formulae (Sloan and Weir, 1970);jCardiac risk score (arbitrary units). Calculated on the basis of know risk factors measured during the assessment. Risk classification: 0-8 = ``low''; 9-16 = ``average''; 17-23 = ``average''; 24-31 = ``above average''; >31 = ``high''; *p< 0.05; **p< 0.01; ***p= 0.05; ns = not significant
Rod Green, Susan Malcolm, Ken Greenwood and Gregory Murphy
Impact of a health promotion program on the health of primary school principals
reflect the highly motivated state of the group in terms of concern about their health. Two other factors reflected the motivation of this group in adopting healthier lifestyles. First, HBA Health Management reported greater enthusiasm in the VPPA group for additional consultation with the dietitian and
psychologist than was exhibited by other corporate groups. The second noteworthy factor was the high degree of enthusiasm shown by the subjects who were not
successful in being chosen for the INT group, with more than half volunteering to
participate in the CON group. A recruitment rate of 59 percent for a control group, with no intervention offered, is very high in worksite programs (Green and Small, 1997).
The retention rate for physical
assessments was also high (86 percent). There was no evidence to suggest any differences in demographics or pre-test physical health associated with this group which may have biased the outcomes of the study.
There were no differences between the INT and CON groups at pre-test. This reflects the identical recruitment patterns and the random selection of the INT group. The low number of assistant principals in both groups, despite their apparent representation in the VPPA membership (approximately 33 percent compared to 38 percent in the DoE principal class), appears to indicate a lack of interest in the program by this group. Assistant principals could be expected to be younger, although these data were not available, and are more likely to be female (47 percent compared to 34 percent for the entire principal class). Higher participation rates in health promotion programs are often reported for older employees (Green and Small, 1997).
The major limitation of the study was the self-selected status of all subjects. Although volunteers were randomly allocated to either the INT or CON groups, all had indicated their willingness to participate in the health promotion program. Thus results may not be generalisable to all school principals.
Participation in the HP program
Although assistant principals were less likely to participate in the project as a whole, participation in HP activities, other than the health assessment, was not related to age, gender or seniority (Green and Small, 1997). The higher pre-test cholesterol for dietitian consultation attendees probably reflected the referral process utilized during the health assessment, whereby those considered at high risk were referred for further
consultation by the attending doctor. Dietary change was reported by both groups,
although the increase in the number of attendees reporting dietary modification was greater than for non-attendees. Both
attendees and non-attendees decreased their cholesterol, blood pressure and BMI.
The low number of attendees for psychologist consultation hampered the statistical analysis of this part of the data. The higher stress and lower arousal levels for attendees at pre-test again probably reflect the referral process used in the health assessment. Arousal increased for both groups, but the suggestion of major changes in both stress and arousal for attendees in the raw data could not be supported statistically. Encouragingly, the results suggested by the raw data were enhanced if retirees were excluded from the analysis. That is, reductions in stress associated with retirement could not be held to be responsible for the results observed.
Subjects attending the nutrition seminar had better diets. Although dietary
improvement was reported for both attendees and non-attendees, the trend for greater improvements in diet intentions for
attendees may be indicative of a motivating effect of seminar attendance. In general, attendees at sessions other than the health assessment appear to have reported greater changes in health-related behaviours and health. Cholesterol, blood pressure, and probably BMI, again decreased for both attendees and non-attendees.
Changes in health and health-related behaviour
The overall reduction in the risk of cardiovascular disease evident in the INT group, due to reductions in cholesterol, blood pressure and body fat levels, was substantial. Despite similar changes in diet and exercise for both males and females, a greater weight loss was reported for males than females during the program (data not reported). This gender difference in weight loss associated with diet or exercise programs is consistent with previous reports (Ballor and Poehlman, 1995).
Although both groups showed
improvements in diet and exercise over the course of the program, the changes in diet intentions and the amount of time spent exercising were greater for the INT group.
There was a pattern of improved health-related behaviour in both the INT and the CON groups, although some benefits were more pronounced in the INT group. The latter finding suggests a program effect on such behaviour. There may be two possible explanations for CON group improvements. First, as indicated above, the CON group Rod Green, Susan Malcolm,
Ken Greenwood and Gregory Murphy
Impact of a health promotion program on the health of primary school principals
were probably highly motivated to improve their health and disappointed not to be selected in the INT group. Such conditions may induce compensatory rivalry, which tends to mask the effectiveness of the intervention because the CON group seeks their own intervention (Conradet al., 1991). Such an effect may have been enhanced by the reporting of the progress of the program back to the VPPA membership in the form of the interim report. Second, the results may reflect the increased awareness of health among principals as a whole. Factors inducing this may again relate to awareness of the program among VPPA members, but additionally to the MBF health survey which was also conducted over the program period (Greenet al., 2000). Although the
participation rate of CON group members in the MBF health survey was unknown, it was likely to be high given their interest in participating in the VPPA project. Compensatory rivalry and unintended outside influences on a control group are both threats to the internal validity of a program which tend to mask program effectiveness (Conradet al., 1991). However the positive changes associated with the program in inducing lifestyle changes amongst enthusiastic volunteers who contribute individually to the funding of the program is consistent with previous reports of the benefits of such a program amongst school staff (Yanget al., 1988).
It is also worth noting that the program in this study is unlike many other worksite HP programs, in that it was conducted entirely outside the workplace and the principals all returned to their own schools. As such it lacked a supportive local environment which is a feature of the more effective worksite HP programs (Worksafe Australia, 1995). As indicated earlier, two of the most common suggestions for improvement of the program were the need for more regular sessions and for regional support groups to assist in the encouragement and maintenance of behavioural change. This may be an important factor in maintaining ongoing effectiveness of the program or others similar to it.
Two studies involving HP programs in a school setting found that reduced staff absence was associated with participation (Bjurstrom and Alexiou, 1978; Blairet al., 1986). A non-significant trend for a reduction in absence for both CON and INT subjects in this study (Green, 1997) is consistent with those previous findings. Studies in non-school settings have found improved job performance associated with participation in a HP program (Penderet al., 1987; Bernacki
and Baun, 1984). Although there were no direct measures of job performance in this study, it is possible that the substantial health improvements associated with participation in this HP program may have improved the productivity of the
participants.
Conclusion
The introduction of the health promotion program appeared to be successful in improving the cardiovascular health and health-related behaviour of primary principals, although reductions in body fat levels were confined to males only. The apparent success of this program should be qualified by the self-selected status of the participants. Although no different in health status from their peers (Greenet al., 2000), the participants in this program had volunteered to participate in the program and contributed to the cost of the program. The similar changes observed in the health-related behaviour of the control group, although not as substantial as the
intervention group, support the suggestion that the benefits of this program may be related to the enthusiastic nature of the participants and therefore may not be expected to occur more generally across all school principals eligible to participate in such a program.
Although there have been benefits for both attendees and non-attendees at dietitian consultation and the nutrition seminar, the changes appear to be greater for the attendees. Benefits evident in raw data for attendees at the psychological counselling were unable to be substantiated statistically due to low subject numbers, but the possible benefits of health counselling should be further investigated in future studies of the impact of any health promotion programs organised for primary school principals.
Although employee productivity is very difficult to measure, future studies should also look at the possibility that
improvements in health and wellbeing associated with a HP program (as demonstrated in this study) may be associated with improved productivity of participants.
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