https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Knowledge and Practices of High School Teachers Regarding Healthy Life Style in Erbil City/Iraq ABSTRACT Background and Objective: Health promotion in a school setting involves educating the students and teachers about health-related matters that reflect on health in a more holis- tic way. Lifestyle includes behaviors such as food habits, sleeping and resting, physical ac- tivity and exercising, weight controlling, smoking and others. The purpose of this study is to assess the knowledge and practices of teachers about healthy lifestyles in the high school in Erbil city. Methods: A descriptive cross-sectional study was used. The data were collected from 3th December 2021 to 28th March 2022. A cluster random sampling technique was used to collect 400 teachers who attended High school in Erbil city. A valid questionnaire was used for data collection by face to face; it contained three parts of sociodemographic data, items of knowledge and practices. The validity and reliability were conducted for the tool and the value of Cronbach's Alpha was 0.826. Results: The teachers had good knowledge and practices about promoting healthy life- styles. There was a significant association between age, education level and experience with their knowledge and practices. There was no significant association between their knowledge and gender, marital status, or economic status, and no significant association between their practices and variables like gender, marital status and economic status. Conclusion: The outcome of the study revealed that most of the teachers had good knowledge and practices regarding healthy lifestyles in high school in Erbil city /Iraq, so they might be as a source of healthy life styles to the public. There was significant associa- tion between knowledge, practices and their age and education level, while there was no significant association between their knowledge, practices and gender and marital status. Keywords: Knowledge; Practices; High School; Teachers Healthy Life Style. Mohammed-Tahr Abdul-Jabbar; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region, Iraq. (Correspondence: mharki37@gmail.com) Kareem Fattah Aziz; Department of Nursing, College of Nursing, Hawler Medical University, Kurdistan Region, Iraq. 45 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 21/06/2022 Accepted: 21/08/2022 Published: 30/5/2023 mailto:mharki37@gmail.com?subject=mharki37@gmail.com%20 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Health-related matters instructed within the school have a remarkable effect on cre- ating the correct state of mind among schoolchildren and instructors Health care experts and community nurses have an es- sential part in making mindfulness con- cerning health promotion in school settings [1].Individuals' lifestyle choices, as well as their knowledge and attitudes toward adopting healthy behaviors, can be im- proved through health promotion educa- tion, especially when novel approaches are implemented. [2].Health promotion ad- vances and includes instructors with pio- neers within exercises from the school a sound. The health education method em- powering individuals to extend progress has characterized advancement. It passes a person in the middle. behavior towards a wide extent of social and natural interven- tions. [3].The term "lifestyle" may be a moderately common hypothesis that regu- larly is utilized to allude to individuals' complete run reflection of social values, states of mind and exercises [4]. Diseases and infections, which are now linked to the global mortalities are due to several threat- ening behaviors resulting from the inappro- priateness of individual and social life- styles, the most common of which are in- appropriate diet, low physical activity, smoking, and sedentary behavior. Control- ling risk factors in lifestyle and healthy hab- its such as poor diet, lack of physical activi- ty, smoking, alcohol intake, and drug use can nearly halve the number of people who die prematurely. [5]. The aim of the study is to identify teachers' knowledge and prac- tices regarding healthy lifestyles. This study is important because it is necessary to identify teachers' knowledge and practices regarding healthy lifestyles so they can teach their students and other staff in school regarding healthy behaviors and healthy lifestyles as a snowball system so that such knowledge and practices from them may be reached to other Kurdish populations. A descriptive cross-sectional quantitative study of 400 teachers in high schools in Erbil city was conducted from 3th Decem- ber 2021 to 28th March 2022. The inclusion criteria were that the researcher selected all participants, who had the desire to participate. The exclusion criteria were teachers who refused participate in the study. The samp- le size was calculated using the Epi Info program (issued by CDC) issue. These crite- ria were used for sample size calculation: Population 5751, confidant level is 95%, the prevalence of perception and satisfac- tion 50%, and margin error 5%. A cluster random sampling technique was used. The research obtained the permission from the Ethics Committee at Hawler Medical Uni- versity/College of Nursing in 7th October 2021 (number 119). In addition, the official approval was obtained from the General Directorate of Education in the center of Erbil city. The researcher constructed a questionnaire after an extensive review of relevant literature. The questionnaire in- cluded three parts. The first part contained socio-demographic information of teachers which included 7 items: age, gender, mari- tal status, address, education level, socio- economic status and years of experience. The second part consisted of 15 items which were related to the teachers' know- ledge of promoting a healthy lifestyle. The third part was consisted of 15 items which were related to the teacher's practices in promoting healthy lifestyles. The data we- re analyzed descriptively using frequency and percentage. 46 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. METHODS INTRODUCTION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Most of the participants live in the Urban which is about 97%. regarding the years of experience, it indicates that most of the participants have more than 10 years, which was about 89.2%, which indicates that high schools focuses on highly experi- enced teachers. Regarding the socio- economic status, the results indicates that most of the teachers are of the middle- class status, which is about 61.8%.Table 2 demonstrates that 36% of teachers ex- pressed a good level of knowledge about promoting healthy lifestyles while 35.5% of them expressed a fair level, and 28.5% of them expressed a poor level. Table 3 indi- cates that there was a significant associa- tion between the teachers' knowledge for promoting healthy lifestyles and variables of age, education level, address and years of experience in the study sample, where the significance value was less than the alpha value 0.05. The result was accepted the alternative hypothesis, which means that the variables are not independent, and reject the null hypothesis. Additional- ly, there was no significant association be- tween the knowledge and the variables of gender, marital status and socio-economic status in the study sample, where the sig- nificance value was more than the alpha value of 0.05. The result accepted the null hypothesis, which is that the variables are independent, and rejected the alternative hypothesis. (Significant: age P value=0.001, education level P value=0.002, address P value=˂ 0.001, years of experiences P val- ue=˂ 0.001; no significant: gender P val- ue=0.095, marital status P value=0.449, socio economic status=0.976).Table 4 demonstrates that 38% of teachers ex- pressed a good level of practice in pro- moting healthy lifestyles while 33.7% of them expressed a poor level and 28.3% of them expressed a fair level. The responses to the teachers' knowledge items included three answers (3 = Know, 2= Natural, and 1= Do not know). The cal- culation of overall teachers' knowledge (15 items) was categorized into three groups Poor knowledge (0-5), Fair knowledge (6-10), and Good knowledge (11-15). The responses to the teachers' practice items included three answers (3 = Done, 2= Sometimes done, and 1= Never done). The calculation of overall teachers' practice as follows (15 items) was catego- rized into three groups Poor practice (0-5), Fair practice (6-10), and Good practice (11 -15). A pilot study was conducted on 40 participants to determine the reliability of the questionnaire. It was carried out be- tween 1ts to 4th November 2021 for the test, and some participants were excluded from the study sample. The tool and time estimation for each participant to give full was obtained. The results were checked to determine reliability by calculating Cronbach's alpha (0.826) (SPSS, version 23). Table 1 shows that most of the teachers were 36-45 and 46 and above years old, as the number of teachers was within these two categories is 335 teach- ers, which is 83.7%, we infer from this per- centage that due to lack of appointments in the past ten years, the percentage of a large age within teachers is greater than the percentage of young. It is also noted that half of them were female which were 206 participants, which is 51.5%. This indi- cates that most of the teachers who teach in high schools are females. The majority of them are married which are 324 teach- ers 81%. Most 90.7% of teachers hold a bachelor degree, with a percentage of 90.7%. This indicates that the high schools are interested in recruiting individuals with bachelor degrees. 47 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 48 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 1: Socio-demographic characteristics of study sample Items Variables F (%) Age ≤ 25 7 (1.8) 26-35 58 (14.5) 36-45 200 (50) ≥ 46 135 (33.7) Total 400 (100) Gender Male 194 (48.5) Female 206 (51.5) Total 400 (100) Marital Status Married 324 (81) Single 61 (15.2) Divorced 6 (1.5) Widowed 9 (2.3) Total 400 (100) Education Level Diploma 21 (5.3) BSc. 363 (90.7) MSc. 15 (3.7) PhD 1 (0.3) Total 400 (100) Address Urban 388 (97) Suburban 5 (1.3) Rural 7 (1.7) Total 400 (100) Years of Experiences ≤ 5 21 (5.3) 6-10 22 (5.5) > 10 357 (89.2) Total 400 (100) Socio Economic Status Lower class 13 (3.3) Lower middle class 75 (18.7) Middle class 247 (61.8) Upper middle class 63 (15.7) Upper class 2 (0.5) Total 400 (100) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 49 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Overall teachers' knowledge of promoting healthy lifestyles Overall Knowledge F (%) Good 144 (36) Fair 142 (35.5) Poor 114 (28.5) Total 400 (100) Table 3: Relationship between socio-demographic characteristics of the study sample with their level of knowledge Variables Overall knowledge P- Value Do not know Neutral Know Total Age Under 25 1 2 4 7 ˂ 0.001 VHS 26-35 8 22 28 58 36-45 18 67 115 200 46 and above 17 46 72 135 Total 44 137 219 400 Gender Male 22 69 104 195 0.095 NS Female 23 68 115 206 Total 45 137 218 400 Marital Status Married 35 111 178 324 0.449 NS Single 7 22 32 61 Divorced 1 2 3 6 Widowed 1 3 5 9 Total 44 138 218 400 Education Level Diploma 4 6 11 21 0.002 HS BSc. 38 125 200 363 MSc. 2 6 7 15 PhD 0 0 1 1 Total 44 137 219 400 Address Urban 43 133 212 388 ˂ 0.001 VHS Suburban 0 2 3 5 Rural 1 2 4 7 Total 44 137 219 400 Years of Experiences Less than 5 years 4 6 11 21 ˂ 0.001 VHS 6-10 5 8 9 22 More than 10 years 36 123 198 357 Total 45 137 218 400 Socio Economic Status lower class 2 4 7 13 0.976 NS Total 45 137 218 400 lower middle class 10 26 39 75 Middle class 28 86 133 247 Upper middle class 5 20 39 64 Upper class 0 0 1 1 Total 45 136 219 400 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 50 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 5 shows that there was a significant association between the teachers' practic- es about promoting healthy lifestyles and- variables of age and years of experience in the study sample, where the significance value is less than the alpha value of 0.05. The result accepted the alternative hypothesis, which means that the variables are not independ- ent, and reject the null hypothesis. Additionally, there was no significant association between the teachers' practices and the variables of gender, marital status, education level, address and socio- economic status in the study sample, where the significance value was more than the alpha value of 0.05. The result accepted the hypothesis, which is that the variables are independent, and rejected the alternative hypothesis. (Significant: age P val- ue=0.001, years of experiences P value=˂ 0.001; no significant: gender P value=0.887, marital status P value=0.423, education level P value=0.055, ad- dress P value=0.356 socio economic status P val- ue=0.952). Table 4: Overall teacher's practices in promoting healthy lifestyles Overall Practices F % Good 152 38 Fair 113 28.3 Poor 135 33.7 Total 400 100 Table 5: Relationship between socio-demographic characteristics of the study sample with their level of practices Variables Overall Practices P- Value Never done Sometime done Done Total Age Under 25 1 3 3 7 ˂0.001 VHS 26-35 11 20 27 58 36-45 25 62 113 200 46 and above 21 43 72 136 Total 58 128 214 400 Gender Male 27 64 103 194 0.887 NS Female 30 64 113 207 Total 57 128 215 400 Marital Status Married 44 106 174 324 0.423 NS Single 12 18 31 61 Divorced 1 1 4 6 Widowed 1 3 6 10 Total 58 128 214 400 Education Level Diploma 3 8 10 21 0.055 NS BSc. 51 113 199 363 MSc. 2 7 6 15 PhD 0 1 0 1 Total 56 129 215 400 Address Urban 55 124 210 389 0.356 NS Suburban 1 1 3 5 Rural 1 3 3 7 Total 57 128 215 400 Years of Experi- ences Less than 5 years 3 8 10 21 ˂ 0.001 VHS 6-10 6 8 8 22 More than 10 years 47 113 197 357 Total 56 129 215 400 Socio Economic Status Lower class 2 4 7 13 0.952 NS Lower middle class 12 25 38 75 Middle class 37 78 132 247 Upper middle class 6 21 36 63 Upper class 0 1 1 2 Total 57 129 214 400 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article DISCUSSION 51 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Regarding the practices of teachers, most of them had good practices about healthy lifestyles to promote health and disease prevention this was a good indicator for teachers to educate their students and population to prevent the disease this find- ing was agreed with the study done by [6]. Regarding the teachers' knowledge for pro- moting healthy lifestyles, the degree of ac- ceptance was good, the results support that the teachers have good knowledge to promote healthy lifestyles in high schools in Erbil city. The outcome of the study indi- cated that teachers had good knowledge and practices about their healthy lifestyle in school this outcome was contraindicated or not accepted with a study done by [7] who revealed that the knowledge and practice of school teachers regarding healthy lifestyles was poor. The outcome of the study was focused on a healthy diet among teachers and staff it was not agreed with the study done by [7] who revealed that the teachers in this study had poor knowledge about healthy lifestyles and good diet education for students and staff in the school, therefore, it is necessary to increase their knowledge and practices [8]. In some items of our work, the author fo- cused on enhancing healthy lifestyles by assessing their knowledge and practices so these findings are accepted by the study done by [9] who reported that it is neces- sary to include a teacher in school, or uni- versity to train about healthy lifestyle and health promotion. According to the out- come of the study, there were some items of a healthy lifestyle that teachers did not respond properly or there were some poor responses, therefore, it is necessary to train teachers in secondary school regard- ing health promotion, disease prevention, and healthy life styles, these findings simi- lar with the study conducted by [10] who mentioned aspects of health promotion to be sources of such information for their students and staff in school [10]. The out- come of the study revealed that there was significant association between age, years of experiences and their knowledge and practices while no association between gender, economic and their knowledge and practices. This is because such varia- bles affect teachers to increase their knowledge and practices to promote health and healthy lifestyles this study similar to the study conducted by [11] re- garding their knowledge and practices ac- cording to their variables. After all, if teachers have knowledge and practices about health promotion and a healthy life- style it is the effect on students and other staff in school depends on a snowball pro- cess for distribution of the healthy knowledge to the public [11]. The findings indicated that teachers have adequate practices to promote healthy lifestyles this finding is similar to a study done by [12] who revealed that teachers have good practices for healthy lifestyles. The find- ings of the study indicated that the knowledge and practices of teachers were good for promoting lifestyles and healthy behavior, this finding is dissimilar by the study done by [13] who mentioned that the knowledge and practices of teachers were low for promoting health and life- styles. The study revealed that teachers had good knowledge and practices aspects of healthy eating and educating students so these findings were accepted by a study done by [14] who said that it is nec- essary to train more teachers on healthy foods as a healthy lifestyle to avoid them- selves and students from diseases and at the same time educating students and staff for that. The outcome of our study revealed that there was a normal distribu- tion of knowledge, practices, and healthy lifestyles so the majority of teachers have good responses about knowledge, https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 52 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [1] Campbell SH. Lactation: A Foundational Strategy for Health Promotion: A Founda- tional Strategy for Health Promotion. Jones & Bartlett Learning. Journal of Human Lac- tation. 2022;38(1):89-99. [2] Abdo NM, Mortada EM, El Seifi OS. Effect of knowledge about cardiovascular diseases on healthy lifestyle behavior among fresh- men of Zagazig University: An intervention study. The Open Public Health Journal. 2019 Jun 30;12(1):300-08. [3] Dowling J. Key Concepts of Lactation as Health Promotion. Lactation: A Foundation- al Strategy for Health Promotion: A Founda- tional Strategy for Health Promotion. 2021 Jan 25:19. [4] Pirzadeh A, Sharifirad G, Kamran A. Healthy lifestyle in teachers. Journal of education and health promotion. 2012;1. [5] Fesharaki M, Sahebalzamani M, Rahimi R. The effect of education on life style in Arda- bil primary over weight students in 2009. Iran Journal Diabetes Lipid Disord. 2010;9 (3):290-5. [6] Fergus S, Zimmerman MA. Adolescent resili- ence: A framework for Understanding Healthy Development in the Face of Risk. Annu. Rev. Public Health. 2005; 26:399-419. doi:10.1146/ annurev.publhealth.26.021304.144357. [7] Saadia AG. Knowledge and view of teacher regarding school health program in two localities Khartoum, Sudan 2019. Interna- tional Journal of Sciences Basic and Applied Research. 2019; 45:181-6. [8] Danielle Falkenbach1 Helen Freitas D'avila2 Elza Daniel de Mello3, Knowledge, Attitudes and Practices of Primary School Teachers on Nutrition and Food, International Journal of Nutrology. 2018;11:21–29. [9] Levchenko V, Levchenko A. Enhancing Healthy Lifestyle in Professional Teachers' Training Programs in Universities of Russia. Advances in Economics, Business and Man- agement Research. 2020;131:29-31. [10] Chavan GM, Chavan VM. Knowledge, atti- tude and practices of secondary school teachers regarding school health services in children. International Journal of Communi- ty Medicine and Public Health. 2018;5 (4):1541-46. practices, and lifestyles about promotion the health and life style this finding was similar with study done by [14] who indi- cated that teachers had good responding about healthy life styles and knowledge and practices toward promotion health [15]. The teachers had good knowledge and practices about promoting healthy life- styles in high schools. There was a signifi- cant association between age, education level, and experience and their knowledge and practices. There was no significant as- sociation between their knowledge and gender, marital status, or economic status, and no significant association between their practices and variables like (gender, marital status, and economic status). Based on the outcomes of the study, the following recommendations will be recom- mended to the policymakers in the Minis- try of Education and Ministry of Health to encourage teachers to participate in differ- ent activities about promoting a healthy lifestyle, health promotion and disease prevention, including school curriculum with such health programs so by this way the teachers will be a good source of knowledge and practices for students and staff and for the public. The authors would like to express their heartfelt gratitude to all the teachers at high school in Erbil city who participated in the study. The author reports no conflict of interests. Conclusion RECOMMENDATION AKNOWLEDGMENT CONFLICTS OF INTEREST REFERENCES https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.6 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 53 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. [11] Jillian Hill, Catherine E, Annizn De. Suraya Mohamad, Whadi ah parker, Nelia Steyn, Promoting healthy lifestyle behaviour through the Life-Orientation curriculum: Teachers' perceptions of the HealthKick in- tervention. South African Journal of Educa- tion. 2015;35(1). [12] Htun YM, Lwin KT, Oo NN, Soe K, Sein TT. Knowledge, attitude and reported practice of primary school teachers on specified school health activities in Danuphyu Township, Ayeyarwaddy Region, Myanmar. South East Asia Journal of Public Health. 2013;3(1):24-9. [13] Cheng NY, Wong MY. Knowledge and atti- tude of school teachers towards promoting healthy lifestyle to students. Journal scien- tific research health. 2015;7(01):11926. [14] Bezerra KF, Capuchinho LC, de Pinho L. Knowledge and approach to healthy eating by primary education teachers. Demetra: Food, Nutrition & Health. 2015;10(1):119- 32. [15] Pirzadeh A, Sharifirad G, Kamran A. Healthy lifestyle in teachers. Journal of education and health promotion. 2012; 1:46. https://creativecommons.org/licenses/by-nc-sa/4.0/