Daily physical education as part of holistic health promotion in Hungarian schools

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Annamária Somhegyi MD, PhD, Director for Prevention, National Center for Spinal Disorders, Budapest, Hungary; National coordinator for WHO Schools for Health in Europe (SHE) Network, nominated by the Ministry of Human Capacities, Budapest, Hungary

Summary

The objective of this article is to show how public health actors were able to achieve mandatory prescription and gradual implementation of daily physical education (DPE) for all schoolchildren in Hungary and how the implementation was helped by medical professionals and by some ambitious projects. It also shows that DPE is part of holistic health promotion (HHP) in schools, which is also a compulsory prescription for all educational institutions. Good intersectoral cooperation was of utmost importance. Now the challenge is to provide permanent, organised professional help from the public health institutions and actors — as teachers are in need for it. This article is written in the framework of EU-OSHA’s 2020-2022 campaign — Healthy Workplaces Lighten the Load (on musculoskeletal disorders) — to show how health promotion programmes can contribute to enhancing musculoskeletal health among children and young people (the future generation of workers).

A brief description of holistic health promotion

The plan for HHP in schools was born in 2003. Following parliamentary and governmental decisions, the Ministry of Health in consensus with other competent departments (Ministry of Education, Ministry of Children, Youth and Sport, Ministry of Finance) created the plan for HHP in schools, which — mainly because of a lack of political commitment from the education side — was not implemented until 2011.

In 2011 and 2012 the institutionalised implementation of HHP in Hungarian educational institutions became compulsory[1][2]. Since 2013 more projects from the health, education and sports sectors have given significant professional assistance and motivation to schools to further improve their daily work in health promotion.

Efficient intersectoral cooperation was running on the basis of the ‘giga-ministry’, the Ministry of Human Capacities, containing eight human sectors (health, education, sport, higher education, youth and family, social integration, culture, church and civil society). Several facilitating factors were provided by the international professional sites in the planning of HHP.

Holistic health promotion means a holistic, whole-school approach in which health promotion has to be part of the everyday life of the school. There are four main health-promoting tasks for schools to do in their daily work — with the participation of the whole school, the parents and the civil society[3]:

  1. healthy eating — potentially based on local food products;
  2. DPE fulfilling health promotion criteria and other forms of physical activity (on which this article is focusing);
  3. appropriate pedagogic methods (including the use of arts) to enhance mental health;
  4. improving children’s health literacy and health competencies.

Daily physical education as part of holistic health promotion

Physical inactivity has been identified as one of the leading risk factors for non-communicable diseases, which are by far the primary cause of death in the world, and their impact is steadily growing. Children are not immune to this burden, and effective interventions are urgently required. Several documents were already urging physical activity. The Global Strategy on Diet, Physical Activity and Health[4] states in § 49: ‘Schools are encouraged to provide students with daily physical education.’ Like several other documents[4][5][6][7][8][9][10] the Physical Activity Strategy for the World Health Organisation (WHO) European Region 2016-2025[11] highlights the need for at least 60 minutes of physical activity for children and young people and recommends that schools should provide ‘an appropriate number of regular physical education lessons, in line with the available scientific evidence’. ‘Nationwide implementation of quality physical education classes’ and ‘legislation’ is also recommended.

Methods of intersectoral cooperation

In accordance with several recommendations from WHO and with broad consensus from several medical societies in Hungary, DPE became an important goal of the National Public Health Program in 2001[12]. As the education sector was not convinced that schools would be able to organise DPE, in 2001 an intersectoral application was developed for schools (in cooperation with the Ministry of Health, Ministry of Education and Ministry of Sports). More than 700 schools applied and this convinced colleagues in the Ministry of Education that schools could organise DPE if they were given the necessary finance. Thereafter, DPE was included in the national education plan (2006), but it was not until 2010 when DPE became part of the government’s programme. The new National Education Act Nr 190 of 2011 prescribed compulsory DPE for all schools, and after a 4-year long gradual implementation all students have taken part in DPE since September 2015. The health-promoting criteria of DPE became part of the basic ruling documents for public education in 2012. Following a lot of work by the health sector since 2003, in 2012 HHP also became a compulsory prescription for all educational institutes.

Health-promoting criteria of daily physical education

To achieve the expected health gains of DPE it must fulfil some special health-promoting criteria that were laid down by several medical societies in 2012[13][14]:

  1. Every student must take part in DPE classes. Namely, the number of unexcused and excused absences must be reduced. On the one hand, this is the parents’ obligation and, on the other, this also applies to the doctor who, lacking in sports knowhow but wanting to be helpful and please, writes an excused note at the request of the student or parent. It is important that medical colleagues consider our current sedentary lifestyle that now requires a change in our thinking. For instance, a student with a musculoskeletal disorder who needs as much physical activity as possible should not be excused from PE classes (of course, it is the physician’s responsibility and right to decide otherwise in individual cases).
  2. Every PE class should contain enough exercise to properly strain the students’ cardiovascular and respiratory systems (indicated by flushing, perspiration, panting), and the classes should be planned so that the time the students spend waiting (i.e. not moving) to take their turn be reduced to as little as possible.
  3. Every PE class should contain gymnastics, including special posture correction exercises for every student for the development of a biomechanically correct posture[2], and exercises for developing good breathing techniques. The special posture correction exercises do not change with age and cannot be replaced with something else at any age; at most, they may be supplemented with playful or diversified exercises. The rules for protecting the spine and joints must be observed at all times.
  4. Special attention should be given to the age-related weight-bearing capacity of the spine and the joints while exercising.
  5. Relaxation exercises should also be part of every student’s daily PE class (the method used for children aged 1-4 years varies from the others).
  6. Awareness of our body and muscles during the special posture correction and relaxation exercises will intensify the effect of PE on the general well-being of our body and soul. It is important, therefore, that the PE teachers emphasise this awareness and encourage its verbal expression.
  7. The PE teachers should also impart their knowledge of the connection between physical activity and the healthy psyche and the development of the ability to learn.
  8. Dance classes could also be part of the DPE classes, if possible. Folk dancing for children in grades 1-4 and folk dancing and ballroom dancing for those in grades 5-12 should be preferred, as these have added value in encouraging healthy psychological development.
  9. It is important also to teach, as part of the DPE, sports that students would want to continue practising throughout their entire lives (i.e. lifestyle sports). The schools can help choose these sports according to their facilities and possibilities.
  10. Every PE class should include disciplined work, joyful playfulness and a sense of achievement for each student, even those with lower than average physical ability. In order to achieve this, such pedagogical and psychological methods should be followed that give each student activities suited to his or her capabilities, i.e. create work and play conditions that will allow each student to experience the sense of achievement and pleasure from a job well done.
  11. The PE teacher is in a singular position to make the students understand, through their own experiences, the effect that the activities of the class have on the healthy development of their system, body and soul. For this reason, in order for health skills to be effective and be internalised by students, it is important that it be taught as an integral part of the PE class. Personal hygiene, showering or other cleansing methods, and fluid replacement after physical activities are especially important topics to be included.
  12. When evaluating PE it should be done in such a way that encourages the student to take an active part. Each student should be evaluated according to his or her own capabilities and based on his or her own personal development.
  13. The quality of daily PE is best ensured if the PE class is taught by a PE teacher or a teacher especially trained in PE.
  14. It is important that the students become familiar with the history of Hungarian sports. Outstanding sports figures may motivate them when choosing a sport outside school.
  15. In Hungary, there is still much to be done on the part of the government in improving the physical conditions for DPE and in replacing missing items. Since improving conditions takes time and can only be accomplished gradually, many PE classrooms may, at the moment, not be set up adequately. In these situations, it depends upon the creativity of the teaching staff and the PE teachers to come up with acceptable solutions for DPE classes. Worse than the lack of a perfect location is the lack of daily physical exercise.

All of the above health-promoting criteria for DPE are contained in the national education rules. Now is the time for the public health sector to ensure that these criteria are met and are part of all schoolchildren’s daily lives.

Project to enhance the quality of daily physical education

To enhance the quality of DPE the government launched a huge project in 2013, which was realised through the Hungarian School Sport Federation (HSSF). The Federation produced seven very important methodological publications to help PE teachers to use new methods in accordance with the health-promoting criteria of DPE. All Hungarian schools (c. 3 800) were given these publications, and nearly 8 000 teachers took part in postgraduate courses to practise these new PE methods. HSSF created a new national measurement tool (NETFIT) for PE teachers to monitor the physical fitness of schoolchildren from 10 to 18 years. Online input of data and online analysis of results was made available to the public [15]. The devices for NETFIT were given to all Hungarian schools (more than 3 800 schools). The use of this measurement tool is compulsory according to Decree No 20/2012 of the Ministry for Human Capacities.

HSSF, together with the education, sports and health sectors (all in the Ministry for Human Capacities), produced a strategy of further measures and actions needed to enhance the quality of DPE. Professional supervision in education was ceased in Hungary in 1985. Now it has been reintroduced as monitoring and supervision, while the graduate and postgraduate education of PE teachers has also been revised — all of which are tools to enhance the quality of DPE.

Inside or outside gyms?

In Hungary there are not enough gyms for all school classes to have their DPE in them. At the beginning, it was often said that the prescription of DPE should have been postponed until enough gyms had been built. Actors in the health sector intensively stated the opposite opinion: children need not the gym daily, but physical activity. As part of the above project, all schools were given a special methodological publication, Alternative sport-games, in which HSSF introduced 87 types of interesting and enjoyable sports games to be played outside the gym. Today we know that we have won this communication game. Of course, we need to increase the number of gyms and the government is building new gyms and swimming pools and improving DPE equipment; nevertheless, the PE teacher’s creativity is also needed for DPE classes outside the gym.

Monitoring of daily physical education

The new national measuring tool, NETFIT, was developed by HSSF in cooperation with the Cooper Institute (United States) on a correct scientific basis and with protection of the spine. This is an appropriate tool for monitoring DPE. NETFIT is a yearly compulsory measurement to be carried out by PE teachers, for all 10- to 18-year-old schoolchildren. It has four profiles:

  • body composition
  • aerobic fitness
  • musculoskeletal fitness
  • flexibility.

In May 2015, NETFIT was measured for the first time (623 026 schoolchildren took part with 13 543 teachers); in May 2016 it was measured on 651 431 schoolchildren by 14 685 teachers, and the numbers were similar in the subsequent years. The main findings of the analysis after the first and second measurements are[15][16]:

  • 25.8 % of children were overweight and obese — and this was worse in 2016 than in 2015 (body mass index was calculated and bioimpedance was measured using the OMRON BF511).
  • The worst results were seen in:
    • progressive aerobic capacity endurance (PACER) test —only 61.8 % of the children were in the healthy zone
    • trunk lift test —only 51 % of the children were in the healthy zone.
  • An improvement in the results of the PACER test was detected in 2016: girls improved by 10 percentage points, especially those who had already taken part in DPE.

According to the latest measurements from May 2019 (measurements were ceased in 2020 because of COVID-19), the results of the PACER tests show further improvement, but despite this PE teachers have to work harder: the results of the PACER test are worsening with age, obesity is increasing slightly and in every year the results of the trunk lift test are the worst test of all the NETFIT tests[15].

Take-home messages

The key lessons learnt in the implementation of HHP in general, and more specifically in the implementation of the health-promoting DPE, may be helpful for other countries:

  • The highest level of political commitment is needed. In Hungary this was the commitment of the prime minister and of the leader of the education sector since 2010. The commitment of the health sector is naturally needed, and this has always been given since 2001.
  • Good cooperation between sectors is crucial. This cooperation was helped by the giga-ministry for human resources since 2010 (Ministry of Human Capacities).
  • Cooperation and mutual support between civil medical societies and PE teachers is key. The persistence of the civil medical societies in cooperating with the organisations representing PE teachers (since 1995) was also a very helpful element.
  • The supporting role played by some international organisations and networks was advantageous:
    • the lessons learnt from the European Network for Health Promoting Schools, now Schools for Health in Europe[17][18][19];
    • the work of the WHO European Region in the field of physical activity[11][20].

References

  1. 1. Somhegyi, A., 2018, ‘Furthering role of public health experts and institutions in holistic school health promotion’ (English abstract available), Népegészségügy 96:69-76. https://ogk.hu/~/media/Files/ogk/prevencio-tie-nepeu-segitese-nepegeszsegugy-2018-1.ashx
  2. 2.0 2.1 1. Information on the work for DPE, posture correction and HHP in schools: https://ogk.hu/en/medical-services/prevention/
  3. 1. Information on HHP in Hungarian schools: http://egeszseg.hu/holistic-health-promotion-in-hungarian-schools.html
  4. 4.0 4.1 1. WHO (World Health Organisation) 2004, Global strategy on diet, physical activity and health. Available at: http://www.who.int/dietphysicalactivity/goals/en/index.html
  5. 1. WHO, 2007, A guide for population-based approaches to increasing levels of physical activity. Implementation of the Global Strategy on Diet, Physical Activitiy and Health. Available at: http://www.who.int/dietphysicalactivity/PA-promotionguide-2007.pdf
  6. WHO, 2008, School policy framework. Implementation of the WHO Global Strategy on Diet, Physical Activity and Health. Available at: http://www.who.int/dietphysicalactivity/schools/en/index.html
  7. WHO, 2008, Action plan for the Global Strategy for the Prevention and Control of Non-communicable Diseases 2008-2013. Available at: http://www.who.int/nmh/publications/9789241597418/en/
  8. 1. European Commission, 2008, EU Physical activity guidelines. Recommended policy actions in support of health-enhancing physical activity. Available at: https://ec.europa.eu/assets/eac/sport/library/policy_documents/eu-physical-activity-guidelines-2008_en.pdf
  9. 1. WHO, 2010, ‘Global recommendations on physical activity for health’. Available at: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/index.html
  10. 1. European Commission, 2013, Physical education and sport at school in Europe. Eurydice report. Available at: https://eacea.ec.europa.eu/national-policies/eurydice/content/physical-education-and-sport-school-europe_en
  11. 11.0 11.1 1. WHO, 2015, Physical activity strategy for the WHO European Region 2016-2025. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/282961/65wd09e_PhysicalActivityStrategy_150474.pdf?ua=1
  12. 1. Ministry of Health, 2001, Healthy Nation Public Health Program 2001-2010, Budapest, 2001.
  13. 1. Somhegyi, A., 2014, ‘Health promoting criteria of daily physical education: present state of implementation’ (English abstract available), Népegészségügy 92:4-10. Available at: https://ogk.hu/~/media/Files/ogk/prevencio_nepegeszsegugy-2014_1.ashx
  14. 1. Somhegyi, A., Lazáry, Á., Feszthammer, A. et al., 2014, ‘Application of special exercises in physical education to develop, automatize and maintain the biomechanically correct posture’ (English abstract available), Népegészségügy 92:11-19. Available at: https://ogk.hu/~/media/Files/ogk/prevencio_biomech-tt-helyzete-nepegeszsegugy-2014_1.ashx
  15. 15.0 15.1 1. Hungarian School Sport Federation (HSSF) website: https://www.netfit.eu/public/pb_netfit.php
  16. Csányi, T., Finn K., Welk G. J. et al., 2015, ‘Overview of the Hungarian National Youth Fitness Study, Research Quarterly for Exercise and Sport 86(Suppl. 1):S3-S12.
  17. 1. Schools for Health (SHE) website: http://www.schools-for-health.eu/she-network
  18. Young, I., St Leger, L., Buijs, G., 2013, School health promotion: evidence for effective action, Background paper SHE Factsheet 2. Available at: https://www.schoolsforhealth.org/sites/default/files/editor/fact-sheets/she-factsheet2-background-paper-school-health-promotion-evidence.pdf
  19. Suldo, S. M., Gormley, M. J., Dupaul, G. J. et al., 2014, ‘The impact of school mental health on student and school-level academic outcomes: current status of the research and future directions’, School Mental Health 6:84-98. https://doi.org/10.1007/s12310-013-9116-2
  20. WHO Regional Office for Europe, 2014, Health 2020: education and early development. Synergy between sectors: fostering better education and health outcomes. Available at: http://www.euro.who.int/__data/assets/pdf_file/0004/257881/H2020-SectoralBrief-Education_11-09-Eng.pdf

Contributors

Palmer