Abstract

In Spain, Health Education is included in the Early Childhood Education curriculum, but teachers do not manage to develop it effectively. We intended to verify the opinion of the students of the Early Childhood Education Degree of the universities of Andalusia about their education and the relevance of this subject. The research was conducted on a population of 2,178 students, using the questionnaire as the main instrument. Its validation required measuring its internal consistency with Cronbach’s alpha coefficient and exploratory factor analysis. The students consider essential Child Health Education training (87.8%), and affirmed that the one they received in the official curricula had been weak. The subjects offered are mostly focused on the promotion of healthy lifestyles (61.5%) and prevention (38.5%). On the other hand, they consider first aid training very important. We propose the implementation of a complete and appropriate Health Education in the training of teachers.

Key words
School health; Education; Health education; Health promotion

Introduction

Health and Education

The World Health Organization (WHO) defined the concept of health as “a state of complete physical, mental and social well-being, and not merely absence of disease or infirmity”¹1 Constitución de la Organización Mundial de la Salud. Preámbulo. Conferencia Sanitaria Internacional; 1946; Nueva York, EEUU.. This concept is in the process of review and update. Indeed, several studies show that our physical, mental and social well-being is conditioned by environmental factors worth considering, and we cannot conceive a just society without all the people who are part of it living in healthy conditions and access knowledge that allows them to know which habits are healthier. Thus, the period of childhood is especially noteworthy, where all children have to enjoy the right they have to grow in healthy cities and socioeconomic environments²2 Sánchez I. VII Jornada: a la búsqueda de un nuevo concepto de salud. Revista sobre Salud Infantil y Medioambiente. [Artículo en internet] 2016 [citado 2017 Mar 28]; [cerca de 2 p.]. Disponible en: http://fundrogertorne.org/salud-infancia-medio-ambiente/2016/03/15/vii-jornada-a-la-busqueda-de-un-nuevo-concepto-de-salud/
http://fundrogertorne.org/salud-infancia... .

The health concept has a multidimensional and multicausal nature that transcends and overflows strictly medical competence³3 Alcántara G. La definición de salud de la Organización Mundial de la Salud y la interdisciplinariedad. Sapiens. Revista Universitaria de Investigación. [Artículo en internet] 2008 jun [citado 2017 Mar 28]; 9(1):[cerca de 14 p.] Disponible en: http://www.redalyc.org/pdf/410/41011135004.pdf
http://www.redalyc.org/pdf/410/410111350... , and becomes a cross-cutting axis that concerns the most various policies, including educational policies, overcoming the merely individual in favor of a social response that is the result of collective actions.

The Declaration of Jakarta⁴4 Declaración de Yakarta sobre la Promoción de la Salud en el Siglo XXI. Cuarta Conferencia Internacional sobre la Promoción de la Salud 1997; 21-25 jul., which already promoted the adoption of a multisector approach, indicates that the educational field is essential to foster health promotion, qualifying education as a prerequisite for health.

Health Education (EpS) training helps students maintain and improve their health, and is positively associated with healthy lifestyles⁵5 Kann L, Telljohann SK, Wooley SF. Health education: results from the school health policies and programs study. J School Health 2007; 8:408-434.. Likewise, schools that act from a global focus of a health-promoting school have been shown to improve their academic results⁶6 Dedaczynski K. State of research on the relationship between health and education: an empirical overview and implications for school health promotion. Zeits F Gesund 2012; 20(3):141-153. since they intervene in the socio-emotional factors that influence learning⁷7 Gobierno de Aragón. Actuaciones de Educación para la Salud en los centros educativos. Escuelas promotoras de Salud. Curso 2016-17. [Internet]. Zaragoza: Escuelas promotoras de salud; 2016 [citado 2017 Mar 28]. Disponible en: http://www.aragon.es/estaticos/GobiernoAragon/Departamentos/SanidadBienestarSocialFamilia/Sanidad/Profesionales/13_SaludPublica/19_Promocion_Salud/RAEPS/Actuaciones_EPS_curso_2016_17.pdf
http://www.aragon.es/estaticos/GobiernoA... .

The WHO claims health promotion in schools as a right of all children, arguing that one can learn the fundamental values of a healthy lifestyle⁸8 Organización Mundial de la Salud (OMS). Objetivo 13 de Salud 21: El marco político de salud para todos de la Región Europea de la OMS. Madrid: Ministerio de Sanidad y Consumo; 1999. from pre-school education.

The health system and the status of child health in Spain

The Spanish Constitution⁹9 España. Constitución Española. Boletín Oficial del Estado 1978; 29 dic. establishes the right to health protection and health care for all citizens (Article 43). Although the Spanish Ministry of Health, Social Services and Equality has the legislative power, each autonomous community can plan and organize its health services, respecting the essential competencies set by the central government. The health of the population is submitted to local corporations, and these collaborate in the management of public health services.

The Spanish National Health System (SNS) has been recently rated by the prestigious US financial software company Bloomberg as the third most efficient healthcare system in the world¹⁰10 Lisa D, Wei L. U.S. Health-Care System Ranks as One of the Least-Efficient. Bloomberg [periódico en internet] 2016 sep 29; [consultado 2016 Dic 3]. Disponible en: https://www.bloomberg.com/news/articles/2016-09-29/u-s-health-care-system-ranks-as-one-of-the-least-efficient
https://www.bloomberg.com/news/articles/... . This is characterized by its universal coverage – with certain contractual limitations – its public financing, free of charge – with certain co-payments – coexistence with the private sector, and powers transferred to the autonomous communities.

We find an entirely satisfactory panorama concerning the state of health in childhood. However, some data would improve considerably with adequate EpS. Specifically, we refer to 9.6% of the population aged 2-17 years with cases of obesity, and 18.3% of overweight. Also, 12.1% of children aged 5-14 years stated that they did not engage in any physical activity in their leisure time. Furthermore, half of the child population spends more time off than recommended in front of a screen (television, computer, or other electronic devices): 61.2% of children aged 2-4 years, more than 1 hour a day, and 52.3% aged 5-14 years, more than 2 hours a day, thus exceeding the maximum recommended time for each age group¹¹11 España. Ministerio de Sanidad, Servicios Sociales e Igualdad. Informe anual del Sistema Nacional de Salud 2015. [Internet]. España: Ministerio de Sanidad, Servicios Sociales e Igualdad; 2016. [citado 29 Mar 2017]. Disponible en: http://www.msssi.gob.es/estadEstudios/estadisticas/sisInfSanSNS/tablasEstadisticas/InfAnSNS.htm
http://www.msssi.gob.es/estadEstudios/es... .

Links between the education system and health in Spain

In Spain, the General Law of Health Nº 14/86 makes explicit that the Public Health Administrations¹²12 España. Ley 14/1986, de 25 de abril, General de Sanidad. Boletín Oficial del Estado 1986; 29 abr. will be oriented to the promotion of individual, family and social interest in health through adequate health education of the population (Article 6.2). Within the framework of primary care is the crucial role of the EpS. Among the specific activities of the SNS is Child Care, which includes health education and prevention of childhood accidents¹³13 España. Ministerio de Sanidad, Servicios Sociales e Igualdad. [Internet] Madrid: Gobierno de España. Sistema Nacional de Salud; [cerca de 2 p.]. [citado 29 Mar 2017]. Disponible en: https://www.msssi.gob.es/organizacion/sns/home.htm
https://www.msssi.gob.es/organizacion/sn... .

At the school level, the EpS is established for the first time expressly as a cross-cutting theme in all the curricular areas with the Law of General Regulation of the Educational System (LOGSE) (1990)¹⁴14 España. LOGSE. Ley Orgánica 1/1990, de 3 de octubre, de Ordenación General del Sistema Educativo. Boletín Oficial del Estado 1990, 4 oct. [citado 29 Mar 2017]. Disponible en: https://www.boe.es/diario_boe/txt.php?id=BOE-A-1990-24172
https://www.boe.es/diario_boe/txt.php?id... . This cross-cutting concept changes with the entry into force of the Education Regulation Law (2006), which indicates that students must receive full training, alluding to the promotion of health and healthy lifestyles in the curriculum¹⁵15 España. LOE. Ley Orgánica 2/2006, de 3 de mayo, de Educación. Boletín Oficial del Estado 2006; 3 may. [citado 29 Mar 2017]. Disponible en: https://www.boe.es/boe/dias/2006/05/04/pdfs/A17158-17207.pdf
https://www.boe.es/boe/dias/2006/05/04/p... (article 11).

Subsequently, the Organic Law for the improvement of educational quality (LOMCE) (2013)¹⁶16 LOMCE. Ley Orgánica 8/2013, de 9 de diciembre, para la mejora de la calidad educativa. Boletín Oficial del Estado 2013, 10 dic. Disponible en: https://www.boe.es/boe/dias/2013/12/10/pdfs/BOE-A-2013-12886.pdf
https://www.boe.es/boe/dias/2013/12/10/p... establishes that educational administrations will adopt measures so that physical activity and a balanced diet are part of child and youth behavior. The design, coordination and supervision of the measures adopted at the educational center must be assumed by the faculty with appropriate qualification or specialization in these areas (Additional provision Nº 4).

In the educational curriculum of the Spanish school system, the EpS is a theme that underpins Early Childhood Education (ECE) and Primary Education, where teachers become health promotion agents. However, the analyzed reality shows a decelerated development of health promotion in schools, with shy participation of the centers in the European Network of “Health Promoting Schools”¹⁷17 Davó MC, Gil-González D, Vives-Cases C, Álvarez-Dardet C, La Parra, D. Las investigaciones sobre promoción y Educación para la Salud en las etapas de infantil y primaria de la escuela española. Una revisión de los estudios publicados entre 1995-2005. Gac Sanit 2008; 22(1):58-64..

Thus, the suitability and need to incorporate the EpS in the Spanish school system is beyond doubt, especially for the promotion and development of healthy life habits in childhood and adolescence¹⁸18 Sanz-Arazuri E, Alonso RA, Valdemoros-San Emeterio MA, Ponce A. Validation of a questionnaire to know how kindergarten teachers develop health education through motor area. Revista Iberoamericana de Diagnóstico y Evaluación Psicológica 2013; 1(35):9-34..

Faculty health training

The EpS is not limited to specific actions and prevention, but includes all those learning actions designed to hold citizens accountable for their health and collective health. It is a health promotion instrument and, therefore, an essential function of health, social and education professionals¹⁹19 España. Ministerio de sanidad y consumo. Formación en promoción y educación para la salud. Informe del grupo de trabajo de promoción de la salud a la comisión de salud pública del consejo interterritorial del sistema nacional de salud. Madrid: Ministerio de Sanidad y Consumo; 2004..

One of the main obstacles in the integration of the EpS in the educational centers is the low level of faculty training²⁰20 González A. Promoción de la alimentación saludable en escolares desde la perspectiva comunitaria: aportaciones del ámbito familiar, educativo y enfermero [tesis]. Huelva: Universidad de Huelva; 2014.. Several studies have shown the need to improve faculty training in health²¹21 Gunay Y, Cavas B, Hamurcu H. Pre-service Teachers' Views on the Environmental Education, Human Brain and Genetics, Health and Sexual Education. Procedia - Social and Behavioral Sciences 2015; 167:141-151.

22 Paakkari L, Tynjälä P, Torppa M, Villberg J, Kannas L. The development and alignment of pedagogical conceptions of health education. Teaching and Teacher Education 2015; 49:11-21.

23 Cubero J, Calderón M, Costillo E, Ruiz C. La Educación para la Salud en el Espacio europeo de educación Superior. Publicaciones 2011; 41:51-63.

24 Alonso N, Campo M. Necesidad percibida de formación sanitaria de los profesores de Educación Primaria. Nuberos Científica 2014; 2(13):25-31.^-2525 Charro E. La Educación para la Salud en la formación del maestro de primaria. Un estudio con el método Delphi [tesis]. Valladolid: Universidad de Valladolid; 2016., identifying how this situation limits and even prevents the ideal development of protocols designed to safeguard the well-being of students¹⁸18 Sanz-Arazuri E, Alonso RA, Valdemoros-San Emeterio MA, Ponce A. Validation of a questionnaire to know how kindergarten teachers develop health education through motor area. Revista Iberoamericana de Diagnóstico y Evaluación Psicológica 2013; 1(35):9-34.^,2626 Rodríguez CR, Torres ML, Aguirre A. Conocimientos y actitudes del profesor ante el asma del alumno. An Esp Pediatr 2010; 72(6):413-419.. Professors should be knowledgeable of fundamental health aspects and the good use of the existing health services²⁷27 Oliva JM. Difficulties of secondary school teachers implicating in the reading, innovation and research in science education (I):The problem to begin with. Revista Eureka sobre enseñanza y divulgación de las ciencias 2011; 8(1). and should add specific EpS competences to their necessary teaching skills.

In Spain, although the weak and insufficient initial teacher training in this field has been evident for decades²⁸28 Rodrigo M. Concepciones de los futuros profesores de Primaria sobre la Educación para la Salud. Revista Interuniversitaria de Formación del Profesorado 1995; (24):173-180., the necessary measures have not been taken. This situation hinders the desired comprehensive education of the student²⁹29 Gavidia V. La Educación para la Salud en los Manuales Escolares Españoles. Rev Esp Salud Pública 2003; 77(2):275-285.. Therefore, it should not be surprising that teachers systematically entrust the health care of students to health professionals³⁰30 Gónzalez MD. La educación para la salud: "asignatura pendiente" para la escuela. XXI Revista de Educación 2008; 10:123-136.. Although teachers are aware of the relevance of the EpS in schools, they feel insecure about the way to develop it effectively, mostly due to the inadequate training received regarding this subject³¹31 González MD, Romero A. La Educación para la Salud en la escuela: investigando las dificultades desde el enfoque etnográfico. Investigación en la escuela 2007; (61):99-110.. This is so that, at times, they feel obliged to receive health training courses³²32 Femenias M, Salom M. El alumnado con enfermedades minoritarias y crónicas de 0 a 3 años: atención educativa y asistencial en la escuela infantil. Revista nacional e internacional de educación inclusiva 2014; 7(3):125-136. voluntarily.

At the beginning of our research, we asked ourselves two questions: what importance do future ECE teachers give to child health? Moreover, what training do they have in this field? In response to the problem raised, the general objective of this work is to identify the training received by senior students of the ECE Degree in Andalusia on child health holistically, so that the educational community becomes aware of the situation and adopt the necessary measures that favor their formation. Thus, we aim to improve the university education received in EpS by the future ECE teachers. To this end, we intend to identify what type of training they receive and their opinion about it.

Methods

Using an eminently quantitative methodology, our corpus of study consisted of senior students of the ECE Degree taught in all the Faculties of Educational Sciences of the public universities of Andalusia. Data provided by the competent bodies in each institution totaled 2,178 students in the senior course year (Almeria: 292, Cádiz: 186, Córdoba: 203, Granada: 658, Huelva: 126, Jaén: 232, Malaga: 231, Seville: 250).

With the assumption that subjects surveyed have received practically complete initial training, the population investigated has been circumscribed to the students who were in their senior year, that is, fourth; besides administering the questionnaires at the end of the second semester of the 2013-14 academic year.

The sample size was calculated with the formula for the estimation of finite proportions, with a population size of 2,178 people, a confidence level of 95%, Z equal to 1.96 and a precision of 5%. A sample of 327 students was found employing the following formula³³33 Albert MJ. La Investigación Educativa. Claves teóricas. Madrid: Mc Graw Hill; 2007.:

n = sample size, in this case 327 students; α= risk or level of significance;

Z_α= score corresponding to the selected risk, 0.05 (Z=1.96); p = proportion; q=1 – p; e = error margin.

The questionnaire was carried out ad hoc by authors of the paper for the development of this research. It was structured according to the following variables:

Assessment of factors that occur or may occur in childhood.

Relevance for ECE teachers to have basic notions of certain childhood medical/health aspects.

Training (curriculum or own account) acquired on certain childhood medical/health aspects.

Most essential aspects of their training as future ECE teachers.

We measured the reliability of the questionnaire by assessing its internal consistency through Cronbach’s alpha coefficient, based on the mean correlation between all the items of a test³⁴34 Padilla MT. Técnicas e instrumentos para el diagnóstico y la evaluación educativa. Madrid: Editorial CCS; 2002.. Thus, the result can range between zero and one, and the value close to one shows the relationship of the items³³33 Albert MJ. La Investigación Educativa. Claves teóricas. Madrid: Mc Graw Hill; 2007.; therefore, it provides a reliable measure of the subject studied. In our case, Cronbach’s alpha reaches a value of 0.85.

We used the exploratory factor analysis technique to validate the constructs of the designed questionnaire. We checked the correlations of each item to establish the group of indicators, then defining the construct as predicted by the theory and eliminating the variables that did not correlate with each other. Thus, we conducted a pilot test of this same course with a total of 60 senior ECE students from the Faculty of Educational Sciences of the University of Seville.

The questionnaires were administered in mid-2014, visiting the eight universities that are part of the study. The statistical program SPSS 18.0 was employed to analyze the collected data.

We have also resorted to the use of discourse analysis to examine the official curricula of all the graduation courses of the ECE Degree of public universities in Andalusia to grasp the initial training of the respondents and compare the results achieved.

Results

(Table 1 shows the assessment of the responding future ECE teachers about certain health-related factors that occur or may occur in the development of childhood. Healthy eating and body hygiene are among those that are considered most relevant. They are followed, by order of importance, physical activity, visual hygiene, and sleep disorders (Table 1).

We established three variables in order to find out to what extent they consider it essential for an ECE teacher to have basic notions about certain child health-related aspects: A. Promotion of healthy habits and lifestyles, B. Prevention, and C. Guidelines for immediate action in case of an accident.

Regarding the first section, the predominant option is “healthy eating”, and the least valued “oral health”. In block B, the “prevention of child abuse” is by far the option best valued by the subjects surveyed, while “immunization schedule” is the one that achieves the lowest percentage of response. Concerning section C, “first aid” and “choking or ingestion of foreign bodies” are the priority options; while the less prominent items are “sprains”, “burns”, “bites and stings” and “trauma” (Table 2).

When questioning about the acquired training, the respondents state that the main topics addressed in the curriculum of the ECE Degree are geared to the promotion of healthy habits and lifestyles, and the less addressed issues were about how to proceed in case of child accident. On the contrary, if we consider the courses taken by students on their account, we warn that the ones carried out the most are precisely those related to this type of incidents (“first aid”, “wounds and hemorrhages”, “burns”, “cardiorespiratory arrests”, and “choking”).

If we look at the aspects about which the respondents claim to lack training, the “correction of bad hygienic habits” stands out in the area of the promotion of healthy habits and lifestyles; in the case of prevention, the “immunization schedule information”; and in the guidelines for action in risk situations, “asthmatic crises” was the most significant training shortcoming (Table 3).

When asked to state the five child health aspects that they consider most important in the ECE teacher training, the most valued were: “first aid”, “prevention of child abuse”, “healthy eating”, “free games and child psychomotricity”, “prevention of learning difficulties related to organic disorders of development”. Some of the less chosen options were “sprains”, “oral health”, and “burns” (Table 4).

The vast majority of the surveyed population is in favor of the need to include the teaching of preventive medicine in the training of ECE teachers (87.8%). Only 1% of the sample considers that it should be the exclusive task of parents, and 3.3%, of medical professionals.

We carried out an analysis of the discourse of the curricula that underpin ECE degrees of the Andalusian public universities to complement the information obtained and know the initial formative supply of the surveyed subjects. We found a total of 26 subjects related in some way or another to children’s health (Table 5).

Of the universities studied, that of Granada is the one that incorporates more related subjects into their curricula, with a total of six, and the one that does so the least is Cadiz, which does not include any.

These subjects are related to children’s health and focused mostly (61.5%) on the promotion of healthy habits and lifestyles, and to a smaller extent (38.5%), on prevention. None of them specifically focused on immediate action guidelines in the face of any childhood accidents.

Most of the specialization areas (46.5%) that are responsible for its delivery are coordinated by Psychology departments. Smaller proportions are led by departments of Experimental Sciences (16.5%), Teaching of music, plastic and corporal expression (13.3%), Physical Education (10%) and, to a lesser extent, Teaching and school organization take center stage, Teaching of Science and Philosophy, Zoology, Botany, Ecology and Plant Physics, and Biology.

After analyzing the teaching projects of the EpS-related subjects available on the web page of the universities studied, we detected that, in certain subjects of the departments related to Psychology and Teaching, students are given a constructivist approach. Some of them even refer to it explicitly, either in their objectives (“Motricity in early childhood education” in Almeria, or “Early care in child development” in Granada); or in the methodology of the subject itself (as, for example, in “EpS and consumption” in Córdoba). However, university students barely hint at this constructivist approach in their answers.

Discussion and conclusions

Promotion of healthy lifestyles in childhood

The subjects surveyed estimate that healthy eating is one of the most critical aspects of children’s health and, in turn, a priority in the training of an ECE teacher.

However, some reports and studies³⁵35 Álvarez JC, Grima FG, Portella E, Torres N. Los problemas de salud infantil. Tendencias en los países desarrollados. Barcelona: Hospital Sant Joan de Déu; 2008.^,3636 Díaz Huertas JA, Vall Combelles O, Ruiz Díaz MA. Informe Técnico sobre problemas de salud y sociales de la infancia en España. Madrid: Ministerio de sanidad y consumo. Centro de publicaciones; 2006. show that, besides the already well-known issues of childhood obesity in Spain, other lesser-known problems begin to surface which, at their ongoing growing rate, will soon be very serious. Among others is mental health, due to the variety of disorders that are emerging and, especially, due to their speed of ascent³⁵35 Álvarez JC, Grima FG, Portella E, Torres N. Los problemas de salud infantil. Tendencias en los países desarrollados. Barcelona: Hospital Sant Joan de Déu; 2008..

Previously highlighting the benefits of the school establishment to expand an authentic and ideal EpS that can develop healthy attitudes, habits, and lifestyles³⁷37 Casero I. Educación para la Salud. Revista Enfoques Educativos 2008; 16:48-53., we agree with González²⁰20 González A. Promoción de la alimentación saludable en escolares desde la perspectiva comunitaria: aportaciones del ámbito familiar, educativo y enfermero [tesis]. Huelva: Universidad de Huelva; 2014., understanding childhood as one of the critical stages in the promotion of healthy lifestyles.

At the international level, since 2006, the WHO has been promoting a strategy in the field of EpS³⁸38 Organización Mundial de la Salud (OMS). Marco para el seguimiento y evaluación de la aplicación de la Estrategia Mundial sobre Régimen Alimentario, Actividad Física y Salud (DPAS). [Internet]. Ginebra: Ediciones de la OMS; 2006 [citado 2017 Mar 28]. Disponible en: http://www.who.int/dietphysicalactivity/Indicators%20paper-%20Spanish%20Version%20-%20July%202006%20-%20VC.pdf
http://www.who.int/dietphysicalactivity/... , whose main lines of action are improving food education and increasing physical activity in the population, which, as we have previously commented, is enshrined as one of the aspects to be improved in the area of child health in Spain.

As a result of the World Education Forum (Senegal, 2000), the WHO, UNESCO, UNICEF, and the World Bank are carrying out the Focusing Resources on Effective School Health initiative, which aims to raise awareness of the importance of implementing an effective school health, hygiene and nutrition program³⁹39 World Health Organization (WHO), United Nations Children's Fund (UNICEF), United Nations Educational, Scientific and Cultural Organization (UNESCO), World Bank. Focusing resources on effective school health: a fresh start to enhancing the quality and equity of education. [Internet]. Dakar: World Education Forum; 2000. [citado 2017 Mar 28]. Disponible en: https://www.unicef.org/lifeskills/files/FreshDocument.pdf
https://www.unicef.org/lifeskills/files/... .

Currently, the SHE Network, Schools for Health in Europe⁴⁰40 Schools for Health in Europe. [Internet]. Esbjerg Ø: University College Syddanmark [citado 2017 Mar 28]. She Network; [cerca de 2 pantallas]. Disponible en: http://www.schools-for-health.eu/she-network
http://www.schools-for-health.eu/she-net... , which gathers 45 countries, supports the development of health promotion in schools, highlighting the benefits of the “Promoting Health Schools”. The benefits of this type of schools in Spain have been shown⁷7 Gobierno de Aragón. Actuaciones de Educación para la Salud en los centros educativos. Escuelas promotoras de Salud. Curso 2016-17. [Internet]. Zaragoza: Escuelas promotoras de salud; 2016 [citado 2017 Mar 28]. Disponible en: http://www.aragon.es/estaticos/GobiernoAragon/Departamentos/SanidadBienestarSocialFamilia/Sanidad/Profesionales/13_SaludPublica/19_Promocion_Salud/RAEPS/Actuaciones_EPS_curso_2016_17.pdf
http://www.aragon.es/estaticos/GobiernoA... .

At the national level, we have seen that the LOMCE¹⁶16 LOMCE. Ley Orgánica 8/2013, de 9 de diciembre, para la mejora de la calidad educativa. Boletín Oficial del Estado 2013, 10 dic. Disponible en: https://www.boe.es/boe/dias/2013/12/10/pdfs/BOE-A-2013-12886.pdf
https://www.boe.es/boe/dias/2013/12/10/p... claims physical activity and balanced diet as healthy attitudes in childhood and youth, showing a keen interest in it in the teaching staff and their qualification. Teachers consecrate themselves as the most favorable resource to effectively achieve the health objectives demanded/required⁴¹41 Gutiérrez García JJ, Martínez Moreno F, organizadores. Plan de Educación para la Salud en la Escuela. Adenda 2016. Murcia: Consejería de Sanidad. Dirección General de Salud Pública y Adicciones; 2016.. However, we have been able to verify, and then we will see below that this qualification is not entirely satisfactory.

Inter-sectoral relationship

With our study, we have identified that certain aspects (among others, oral health, immunization schedule, and correction of hygienic habits) are considered by the respondents to be the responsibility of the parents, and a task foreign to the educational or health staff. Conversely, some studies advocate that this should be the work of teachers⁴²42 Jourdan D, Pommier J, Quidu F. A practices and representations of health education among primary school teachers. Scand J Public Health 2010; 38(1):86-94.. We believe that it is not a matter of delimiting territories so that each agent is in charge of these tasks. On the contrary, we emphasize the need to treat all the EpS-related aspects from a holistic viewpoint, where all the agents have a place.

Health and education professionals⁴³43 Rodrigo M, Ejeda JM, González MP, Mijancos MT. Concepciones sobre alimentación en estudiantes de magisterio y enfermería. Construcción del conocimiento pedagógico en cuestiones dietéticas. Teoría de la educación 2014; 26(1):187-209.

44 Whitehead D. The health promoting school: what role fur nursing? J Clin Nurs 2006; 15(3):264-271.^-4545 Biag M, Srivastava A, Landau M, Rodriguez E. Teachers' Perceptions of Full- and Part-Time Nurses at school. J Sch Nurs 2015; 31(3):183-195. and the family institution are critical agents of an ideal proliferation of healthy habits and lifestyles in childhood¹⁸18 Sanz-Arazuri E, Alonso RA, Valdemoros-San Emeterio MA, Ponce A. Validation of a questionnaire to know how kindergarten teachers develop health education through motor area. Revista Iberoamericana de Diagnóstico y Evaluación Psicológica 2013; 1(35):9-34.^,4646 Ridder MAM, Visscher TLS, Hirasing RA, Seidell JC, Renders CM. Dutch teachers and parents about overweight prevention in pre-vocational schools. Health Promot Int 2014; 29(1):15-25.^,4747 Sendall MC, Lidstone J, Fleming M, Domocol M. Nurses and Teachers: Partnerships for Green Health Promotion. J School Health 2013; 83(7):508-513..

Also, we agree on even more extensive collaboration with other fields of work. Several studies support the benefits resulting from contributive work in areas such as regional and local administrations⁴⁸48 Davo-Blanes MC, de la Hera MG, La Parra D. Health education in primary school: Alicante city (Spain) teachers' opinions. Gac Sanit 2016; 30(1):31-36., the media, scientific organizations, and other organizations linked to school health research and promotion⁴⁶46 Ridder MAM, Visscher TLS, Hirasing RA, Seidell JC, Renders CM. Dutch teachers and parents about overweight prevention in pre-vocational schools. Health Promot Int 2014; 29(1):15-25..

We do not advocate a mere juxtaposition of sectors, but rather the achievement of authentic intersectoral action, which requires a slow, negotiated process and constant dialogue⁴⁹49 Santos Silva C, Andrade Bodstein RC. A theoretical framework on intersectoral practice in School Health Promotion. Cien Saude Colet 2016; 21(6):1777-1788..

Beyond prevention. EpS is an integral state, and not one-off actions

Concerning the university training of future teachers, our research shows the existence of very high level of training in the prevention of learning difficulties related to organic disorders of development, free games, and child psychomotricity.

From our perspective, we report serious teacher training gaps in this area, since it is not enough to have proper training in prevention measures, as this is not the purpose of a real EpS, and is an obsolete approach that is limited to level health to an absence of disease.

Thus, some authors⁵⁰50 Jourdan D, Pironom J, Berger D, Carvalho G. Factors influencing teachers' views of health and health education: A study in 15 countries. Health Education Journal 2012; 72(6):660-672.^,5151 Nobiling BD, Lyde AR. From the school health education study to the national health education standards: concepts endure. The Journal of School Health 2015; 85(5):309-317. affirm that the purpose of the EpS in childhood should be to increase well-being and reduce health risks, marking as its primary objective the promotion of health based on the improved balance of physical, mental and social aspects related to healthy lifestyle habits.

Curricular restructuring

After analyzing the curricula discussed above, we highlight the need to include EpS in official degrees, an issue that is also evident in several recent studies at national⁴⁸48 Davo-Blanes MC, de la Hera MG, La Parra D. Health education in primary school: Alicante city (Spain) teachers' opinions. Gac Sanit 2016; 30(1):31-36. and international⁵²52 Jourdan D, Simar C, Deasy C, Carvalho GS, McNamara PM. School health promotion and teacher professional identity. Health Educ 2016; 116(2):106-122.

53 Byrne J, Shepherd J, Dewhirst S, Pickett K, Speller V, Roderick P, Grace M, Almond P. Preservice teacher training in health and well-being in England: the state of the nation. Europ J Teach Educ 2015; 38(2):217-233.^-5454 Persson L, Haraldsson K. Health promotion in Swedish schools: school manager's views. Health Promot Int 2017; 32(2):231-240. levels.

In this line, we advocate not only a change in the curricula of educational professionals but also in that of health professionals. We agree with several authors⁵³53 Byrne J, Shepherd J, Dewhirst S, Pickett K, Speller V, Roderick P, Grace M, Almond P. Preservice teacher training in health and well-being in England: the state of the nation. Europ J Teach Educ 2015; 38(2):217-233.^,5656 Tzenalis A, Sotiriadou C. Health promotion as multi-professional and multi-disciplinary work. International Journal of Caring Sciences [artículo en internet] 2010 [citado 2017 Ene 20]; 3(2): [cerca de 7 p.]. Disponible en: http://internationaljournalofcaringsciences.org/docs/Vol3_Issue2_01_Tzenalis.pdf
http://internationaljournalofcaringscien... ^,5757 Tavares MF, Rocha RM, Lobo CM, Petersen CB, Andrade M. Health promotion in professional education: challenges in Health and the need to achieve in other sectors. Cien Saude Colet 2016; 21(6):1799-1808 who claim the need for the aforementioned intersectoral and interprofessional collaboration to achieve adequate health promotion. We estimate that a typical minimum formation is required in order to achieve practical and real collaborative work.

In conclusion, and responding to the questions that marked the development of our research, we affirm, on the one hand, that teachers give not only prominent importance to child health, but also demand initial training in the subject since they lack it.

Thus, EpS promotion in the curricula of the ECE teaching is not granted the relevance it deserves. The achievement of the desired comprehensive education of the students of the faculties of Educational Sciences requires considering all the spheres underpinning the personality of the students, and among them is the EpS. For obvious reasons, this assertion takes on particular relevance if we refer to the ECE Degree, given the idiosyncrasy of the students who will be educated in the future. This training should prepare future teachers to teach constructivist teaching, where students are encouraged to build their knowledge from the interaction with their environment through an action-oriented teaching⁵⁵55 Tzenalis A, Sotiriadou C. Health promotion as multi-professional and multi-disciplinary work. International Journal of Caring Sciences [artículo en internet] 2010 [citado 2017 Ene 20]; 3(2):[cerca de 7 p.]. Disponible en: http://internationaljournalofcaringsciences.org/docs/Vol3_Issue2_01_Tzenalis.pdf
http://internationaljournalofcaringscien... .

The EpS must not suppose specific actions; it must pursue people’s actual state of happiness, a balanced physical and psychic plane, which allows human beings to have autonomy and well-being while integrating into their environment.

This need to promote the EpS in the school institution must be coupled with joint action with the family and health professionals so that it transcends prosperously in childhood education.

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