All published articles of this journal are available on ScienceDirect.
Developing a School-based Wellness Program to Prevent NCDs: A Mixed-Methods Study in Indonesian Elementary Schools
iD
Weni Kurdanti1
iD
Almira Sitasari1
iD
Siti Budi Utami1
iD
Indah Suci Widyahening2 , 3
iD
Authors Info & Affiliations
Abstract
Introduction
Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality worldwide. Schools are strategic settings for health promotion, and empowering teachers may contribute towards prevention of NCD . This study aimed to develop the School Wellness Program (SWeP) as a strategy to strengthen teacher capacity in health promotion.
Methods
A research and development design with mixed-method approaches was applied through five phases: needs assessment, baseline, intervention, endline, monitoring, and evaluation. The study involved 164 employees, 35 teachers, and 12 elementary schools in Klaten District, Central Java, Indonesia, in 2023. Data collection included assessment of schools’ needs regarding NCD prevention, pre- and post-tests of teacher knowledge, training interventions, monitoring, and program evaluation.
Results
Teachers’ knowledge increased significantly by 21.9±20.2 points (p <0.001). Teachers used applied standard operating procedures to measure students’ height (83.33%), weight (93.59%), blood pressure (76.22%), and blood sugar (95.45%). Risk factors identified included smoking (9.1%), low fruits and vegetables intake (70.7%), insufficient physical activity (56.1%), alcohol consumption (3%), and sleep-related problems (22.6%). Program sustainability was supported through collaboration with health professionals.
Discussion
The findings demonstrated that teacher empowerment can enhance early NCD risk detection and health promotion in schools. Integrating structured training and monitoring ensures program feasibility and aligns with global efforts to address NCDs in low-resource settings. However, longer-term evaluation is required to assess behavioural changes among students and community-wide impact.
Conclusion
Teacher-based wellness programs are effective for school-based NCD prevention and have potential for broader scalability when supported by health professionals.
1. INTRODUCTION
Non-communicable diseases (NCDs) remain a global health problem. The primary survey results in Indonesia showed that the prevalence of hypertension in individuals aged ≥ 18 years has increased from 25.8% in 2013 [1] to 34.1% in 2018 [2]. Likewise, the prevalence of diabetes mellitus in people aged ≥ 15 has risen from 6.9% in 2013 to 8.5% in 2018 [2]. In Klaten regency, Central Java, NCDs are silently crippling, with cases doubling in just three years. There were 6,136,532 new cases of NCDs in 2022 [3], compared to 3,074,607 cases in 2019 [4]. In addition, the prevalence of NCDs in Klaten exceeds the prevalence in Central Java [5], with particularly high prevalence of diabetes mellitus (2.39%), hypertension (34.16%), and stroke (52.33%). NCDs contribute to costing the country billions in healthcare, lost productivity, and tend to affect their offspring because of the inherited lifestyle [6]. In addition, NCDs can potentially cause economic losses of 0.003% to 0.004% of Indonesia's total gross domestic product [7].
Lifestyle choices such as unhealthy eating habits and physical inactivity are key contributors to NCDs [8, 9]. Some examples of unhealthy eating habits include emotional eating, eating late, snacking too much or eating mindlessly, poor meal planning, overconsuming processed food, larger portions, high-calorie drinks, and unbalanced meals [10]. In contrast, lack of exercise refers to insufficient physical activity or a sedentary lifestyle, where individuals fail to engage in regular moderate to vigorous physical activities that promote health and fitness. For example, sedentary jobs, screen time, motorized transportation, and modern conveniences like elevators, escalators, and household appliances have significantly reduced the need for physical exertion in daily tasks [11, 12].
Teachers play a crucial role in shaping health behaviors and preventing NCDs. They can educate students, promote healthy lifestyles through the curriculum, be a role model of healthy behaviours, identify at-risk students, create supportive learning environments, and shape students' lifestyles. Unlike health cadres or nurses who typically operate within community or clinical settings, teachers are uniquely positioned to influence children’s health behaviors on a daily and sustained basis within the school environment. Their direct, routine contact with students allows them to integrate health promotion into the learning process, observe early behavioral risk indicators, and act as consistent role models for healthy living [13].
Furthermore, teachers’ involvement in both curricular and extracurricular activities provides an unmatched platform for reinforcing preventive health messages. Their social capital within school communities also enables them to engage with parents and other stakeholders, thus amplifying the reach and sustainability of school-based wellness initiatives. Therefore, trainings on preventing NCDs for teachers is critical. The training will provide a foundation of deeper knowledge about NCD risk factors, screening, and effective prevention strategies [14, 15]. Evidence from earlier studies has shown that school health programs can positively influence health behaviors among students and staff [16]. Recent umbrella reviews also highlight the role of physical activity not only in preventing NCDs but also in mitigating mental health complications, thereby reinforcing the need for integrated approaches in school settings that addressess physical activity, diet, and sleep as interlinked health domains [17]. However, most existing research has focused on student-centered interventions, with limited attention given to the implementation of wellness programs targeted at school staff, especially in low- and middle-income settings like Indonesia.
This study addresses the research gap by exploring the implementation and effectiveness of a School Wellness Program (SWeP) targeting school personnel, particularly teachers, as agents of change in NCDs prevention. The rationale for this study arises from the urgent need to develop sustainable, school-based strategies for combating NCDs through preventive health promotion. Using the Theoretical Framework of Acceptability (TFA), the study assesses the perceived effectiveness, ethical alignment, implementation burden, and sustainability of the SWeP training program. To complement this, Social Cognitive Theory (Bandura) informed the assessment of individual-level behavioral change among teachers, while the Consolidated Framework for Implementation Research (CFIR) was applied to examine organizational-level facilitators and barriers for implementation. This study aimed to design, implement, and evaluate the SWeP training program in elementary schools in Klaten Regency to support the early detection and prevention of NCDs within school communities.
2. METHODS
2.1. Design
We conducted a multi-design research and development study, including quantitative and qualitative research. Quantitative research included: a) a quasi-experimental study to find out the influence of SWeP training on teachers’ knowledge, b) a one-shot case study to find out the effect of SWeP training on teachers’ skills, and c) a cross-sectional study to find out the risk of NCDs among program beneficiaries. In comparison, qualitative research uses a phenomenology design to determine teachers' acceptance of SWeP and program evaluations.
The research was carried out in 5 stages: 1) needs assessment, designing and developing training of SWeP; 2) baseline; 3) training intervention; 4) end line, and 5) monitoring and evaluation. Qualitative research was carried out during stages 1 and 5. Meanwhile, quantitative research was carried out during stages 2, 3, and 4 (pre-test, intervention, and post-test).
2.2. Settings
This research was applied in elementary schools in Klaten Regency, Central Java, during June-September 2023. For this selection, schools that had already implemented the Nutrition Goes to School program were considered. The NGTs programme is a school-based, multisectoral initiative that aims to improve students' academic performance and classroom engagement by promoting excellent nutrition, sanitation, and hygiene. As many as 39 districts in 20 provinces and 100,620 students in Indonesia received the NGTs program [18]. Specifically, in Klaten Regency, Central Java, there are 704 public elementary schools, but only 12 schools have received the NGTS program. The school was then recruited for SWeP intervention research. The consideration of teachers participating in SWeP training is to improve the quality of education through the prevention of NCDs, recognising the symptoms and signs of NCDs, and being skilled in assessing nutritional status both anthropometrically, vital signs, and biomedically. In this case, teachers have an essential role as educators, actors, motivators, and role models for optimal nutritional status, so enriching teachers' knowledge and skills in detecting dietary problems, including NCDs, is important. Another evidence-based national health survey in 2018 revealed that Klaten Regency has a high prevalence of NCDs. Based on these criteria, 12 elementary schools were eligible to participate in this research.
2.3. Participants
The number of participants in this research was different at each stage:
2.3.1. Stage 1-Need Assessment
Stage 1 aims to address the needs of school workers in preventing NCDs and design suitable training and training materials. Informants included school heads, primary health service programmers, and staff officers. Prior to data collection, participants were informed about the aims of the research, the researchers’ institutional affiliation, and their role in school-based health promotion. However, personal motivations and research interests were not explicitly disclosed to avoid biasing responses. We applied offline FGD for collecting the data with 14 participants. The duration of FGD is about 90-120 minutes.
2.3.2. Stages 2-4: Baseline, Intervention, and Endline
In stage 2, the baseline assesses the knowledge of the teacher; in stage 3, the intervention occurs through training for skill transfer, and in stage 4, the endline measures the knowledge and skills of the teacher after the training has been completed.
The study involved 36 participants appointed by 12 school principals to participate in a SWeP training, 3 people from each school. The inclusion criteria: teachers who are interested and commanded by the principal/head school to be participants in SWEP training. Hereinafter referred to as NCD teachers.
The program was developed from the Posyandu Book Guidance of NCDs [19] and was taught through 6-hour training practice using slide presentations, training modules, and anthropometric tools.
2.3.3. Stage 5: Monitoring and Evaluation
The monitoring and evaluation process aimed to identify NCD risk factors, including all school employees, both teachers, administrative, and non-administrative staff, as many as 164 employees from 12 schools. The exclusion criteria were incomplete data. Monitoring and evaluation were for identifying program acceptance, implementation obstacles, and program sustainability analysis. To complete information about the SWeP implementation experience, we conducted face-to-face in-depth interviews for 30-60 minutes with several officers and staff, as well as heads of schools.
The number of informants was limited until there was no new information to be obtained. All qualitative interviews and FGDs were conducted by the principal investigator and co-authors with extensive backgrounds in community nutrition and public health education. The researchers held a neutral stance and practiced reflexivity to minimize assumptions or biases during data collection.
No participants declined or withdrew from the study at any stage. All invited individuals gave informed consent and completed the required procedures.
2.4. Instrument
We applied many instruments regarding the type of research and outcome. Various instruments were used to collect both quantitative and qualitative data in the study. For the quantitative data, a quasi-experimental design was implemented to measure the impact of SWeP training on knowledge of participants, using structured questionnaires which were administered through a face-to-face interviews. A one-shot case study design was employed to assess the skills acquired from the SWeP training, with observations conducted to evaluate participants' performance. Additionally, a cross-sectional design was used to identify the prevalence of risk factors for NCDs, with data collected through structured questionnaires and face-to-face observations. For the qualitative data, an exploratory study was carried out to investigate the need for NCD prevention programs, desired program models, recruitment systems, and program sustainability, using focus group discussions (FGDs) and face-to-face interviews. Two evaluation studies were also conducted: the first examined the effectiveness of SWeP training, focusing on practical attitudes, ethics, innovation, opportunity costs, and self-efficacy, while the second evaluated the implementation of SWeP, identifying potential obstacles and analyzing the sustainability of the program, both using face-to-face interviews. We use an audiovisual recorder and field notes to increase data validity.
2.5. Analysis
Quantitative data analysis involved a multivariate t-test to assess the impact of SWeP training on teacher knowledge, a descriptive study of teacher compliance with operational standards, and prevalence analysis of NCDs and their risk factors. In contrast, qualitative data were analyzed manually without the aid of qualitative analysis software. The thematic evaluation using Theoretical Framework Analysis (TFA) includes NCD prevention programs, recruitment systems, program sustainability, and training. Thematic coding was conducted by two independent coders, and discrepancies in code interpretation were resolved through discussion to ensure reliability. The coding tree was structured into four major thematic domains: (1) perceived need for NCD prevention, (2) recruitment and training feasibility, (3) program acceptability and effectiveness, and (4) sustainability challenges. Subthemes emerged inductively within each domain. Transcripts or findings were not returned to participants for validation due to time constraints and resource limitations. However, the use of direct quotations and field notes helped to ensure accurate representation of views of the participants' .
3. RESULTS
The study findings revealed a strong alignment between the expressed needs of school stakeholders and the measured outcomes of the intervention. As shown in Table 1, focus group discussions (FGDs) revealed that schools lacked structured NCD prevention initiatives for teachers and staff and expressed a strong desire for teacher-led, school-integrated wellness programs. While Table 2 revealed that most of the participants were productive age groups, predominantly women with adequate teaching experience and academic qualifications. Their background as teachers puts them in a strategic position to integrate SWeP knowledge in teaching and learning activities, thus becoming a strong foundation for the effectiveness and sustainability of the program in elementary schools.
In addition, this qualitative insight was quantitatively confirmed by the relatively low pre-training knowledge score among teachers (x̄= 16.67, Table 3), which significantly increased post-intervention to x̄= 21.97, indicating a 31.8% improvement and large effect size (5.4; p < 0.05). Furthermore, teacher adherence to Standard Operating Procedures (SOPs) was generally high, exceeding 83% in key indicators such as height, weight, blood pressure, and blood glucose assessments (Table 4), suggesting effective technical skill uptake. The qualitative findings during the evaluation phase further reinforced the program’s perceived ethical appropriateness, feasibility, and sustainability (Table 5). Stakeholders emphasized the program's alignment with Klaten's local health vision, its low ethical burden, and its adaptability to school routines, despite limited operational resources. These findings demonstrate that the SWeP intervention was not only statistically effective but also contextually appropriate and socially acceptable within the school environment.
| Theme | Result | Quotation |
|---|---|---|
| The existence of NCDs prevention programs | Specifically none | “The school already has a School Health Unit, there are several health programs, but none for preventing NCDs”– (P1). “So far, the socialization of the School Health Unit and its officers is mostly from sport teachers, but not all schools have it. The obstacles is we have no health medical expertise.” – (P2). |
| Desired program model | Integration with School Health Unit programs, healthy schools, while the beneficiaries are teachers, employees, parents, and the entire surrounding community | “Agreeing with Mr. N, NCDs prevention programs can also include healthy schools and School Business Unit” – (P4). “…teachers of SWeP may be sports teachers or other teachers who are interested and have been trained previously” – (P6). “School can send their team or a teacher candidate to be trained. Later, we take it as inventory”– (P3)”. |
| Recruitment System | Voluntary or mandatory | “….Head School, please recruit candidates for SWeP Teachers, can be voluntary or mandatory …These teachers will be trained and supervised so they can run this program correctly, further NCDs can be prevented.” – (P7). |
| Sustainability program | Together with/teachers, schools, and local health officers. | “It is necessary to build a team, maintenance facilities, a time schedule, resource persons, and targets.” – (P2). “Therefore, the health office may give guidance, supervision and motivation routinely for the teachers, because it is strongly related to NCDs prevention that we have never received socialisation at all” - (P9). “In the future, we will ask for assistance from the health officer to foster, direct, supervise, and motivate so that the program can be maintained and sustained” – (P10). |
| Variable | Pre-test Score | p-value |
|---|---|---|
| Age (years old) | ||
| 20-39 | 56.24 | 0.345a |
| 40-59 | 54.28 | - |
| Sex | ||
| Male | 54.14 | 0.564a |
| Female | 56.38 | - |
| Work experience (years) | ||
| < 5 | 53.84 | 0.324a |
| ≥ 5 | 56.68 | - |
| Education level | ||
| Undergraduate | 54.24 | 0.244a |
| Master program | 56.28 | - |
| Role | ||
| Class teacher | 55.24 | 0.567b |
| Religious teachers | 52.12 | - |
| Sport teacher | 58.42 | - |
| Variable | Knowledge |
|---|---|
| Pre-test | 16.67 ± 3.05 |
| Post-test | 21.97 ± 3.41 |
| Delta | 5.3 |
| % Increase | 31.8% |
| Posttest-pretest | - |
| Size effect | 5.4* |
| 95% CI | 16.2 – 24.8 |
| Cons | 71.83 |
| QIC | 189.87 |
| Measurement | Result | Description | |
|---|---|---|---|
| Right (%) | Wrong (%) | ||
| Body weight | 83.33 | 16.67 | The teachers did not reset the number 0 on the body weight scale. |
| Body height | 93.09 | 6.91 | The teachers do not ask/ensure participants remove footwear, sandals, shoes, and other items that affect body weight. |
| Blood pressure | 86.22 | 13.78 | The teachers did not take measurements 2 times with a time gap of 1-2 minutes. The teachers did not re-measure the results of observation when the difference between the first and second results was more than 10 mm/Hg. |
| Blood glucose | 95.45 | 4.55 | The teachers did not dry the fingertips after being swabbed with 70% alcohol and rushed to insert the test strip, even though the insert strip test sign had not appeared |
| Effective attitude | In schools, NCDs can be avoided after a programme has been implemented. |
| Burden | It is possible to reach a consensus on the service time during working hours. The burden of operational expenditures cannot be alleviated in any way. |
| Ethic | Aligns with the vision and mission of “Klaten Sehat (Klaten City Health)” and does not contradict established ethical standards. |
| Coherence of innovation | Programs can be elaborated with other programs to achieve Klaten Sehat (Klaten City Health) |
| Opportunity cost | To improve the services program, they require cholesterol and uric acid tools, and coaching and supervising of Puskesmas, and also the mechanism of the referral system, and healthy Behaviour changes in the context of NCD promotion and prevention |
| Perception of effectivenes | Training is effective in determining the risk of NCDs, but it needs continuous motivation for healthy living behaviours to prevent it |
| Self-efficacy | Caders are self-confident, skilled, and have a good understanding, allowing them to serve clients. |
3.1. Need Assessment
According to the SWeP school needs analysis and need assessment findings, there haven't been any NCD prevention initiatives for staff members or instructors in schools. For this reason, NCD prevention efforts are required and should be further integrated with the School Health Unit. In detail, some of the items of information are unearthed, and the opinions of FGD informants are as follows (Table 1).
3.2. Base Line, Intervention and Endline
3.2.1. Subject Characteristics
The training participants were all prospective SWeP officers from 12 elementary schools, as many as 35 people, mostly aged 20-39 years, women, with working experience for ≥ 5 years, having graduate education, and their role as class teachers. As detailed in Table 2.
3.2.2. The Effectiveness of Training to Increase Teachers’ Knowledge and Accuracy of Measurement
The training significantly increased teachers’ knowledge by 5.3 points, or approximately 31.8%. This suggests that the training was not only effective in delivering content but also able to improve teachers’ cognitive understanding of NCD prevention. As detailed in Table 3.
To identify risk indicators it is essential to ensure that teachers follow the guidelines or assessment procedures . We found that there were still techniques of monitoring blood pressure, blood sugar, and blood glucose that did not adhere to standard operating procedures. As detailed in Table 4.
3.3.3. Monitoring and Program Evaluation
By implementing SWeP, risk factors for NCDs were being monitored. Up to 164 individuals from 12 schools signed up as participants at this point. The majority of participants (71.8%) were married, 71.3%) were female (71.3%), and 90.2% had graduated from college. The behavioral risk factors for NCDs include smoking habits (9.1%), reduced fruits and vegetables consumption (70.7%), lack of physical activity (56.1%), alcohol consumption (3%), and sleep and eating disorders (22.6%). The teacher also considers an individual's personal and familial medical background, which contributes for the development of NCD medicines. The participants thereby subject themselves and their families to the risk of contracting NCDs.
Evaluation and monitoring were carried out to determine the achievement, effectiveness, and efficiency of the program. By conducting continuous surveillance and evaluation, an initiative can decrease the probability of failure and successfully achieve its goals. The results of the SWeP implementation were ascertained through a comprehensive examination of the theoretical framework (Table 5).
4. DISCUSSION
In Central Java and across other regions in Indonesia, the growing prevalence of non-communicable diseases (NCDs) poses a significant threat to public health, contributing to increased disability-adjusted life years (DALYs) and premature mortality [20]. Adolescents and youth are particularly vulnerable, necessitating timely, school-based health promotion strategies [21]. The present study reinforces the relevance and timeliness of the SWeP, especially when teachers and staff are positioned as health promotion agents within their educational communities [22].
In this study, the SWeP training program revealed a statistically significant increase in teachers’ knowledge, with a 31.8% increase. These results suggest that structured training interventions can effectively enhance teachers’ capacity to serve as promotive and preventive actors in addressing NCDs [23, 24]. While qualitatively, informant reported improvements in self-efficacy, confidence, and awareness regarding the integration of healthy lifestyle practices into their professional roles. These findings are consistent with Bandura’s Social Cognitive Theory (SCT), which highlights knowledge acquisition and self-efficacy as primary determinants of behavior change and personal agency in health contexts [25, 26].
However, observational assessments of technical skills during practice sessions identified inconsistencies in procedural accuracy. For instance, 13.78% of teachers failed to repeat blood pressure measurements after an interval, and 6.91% neglected to ensure participants removed footwear when measuring height and weight. Lower adherence in height and weight procedures may be attributed to insufficient practice time during training, or the respondent did not want to bother taking off his shoes, especially lace-up shoes, because of the hassle. These findings suggest that while cognitive gains were made, technical proficiency has not yet been fully internalized. This gap aligns with Rogers’ Diffusion of Innovation Theory, emphasizing that adoption of innovation extends beyond awareness and requires reinforcement and contextual support for consistent application [27].
This study also found that teachers had a high affective attitude and strong ethical alignment with the program, indicating strong intrinsic motivation to participate. This finding aligns with the Theoretical Framework of Acceptability (TFA) that was employed to examine how the SWeP program was received by participants. However, time allocation challenges, particularly for physical activity integration and comprehensive anthropometric assessments, were noted as barriers. These constraints reflect a need to evaluate implementation burden and opportunity cost to ensure long-term sustainability [28].
Moreover, findings from the program’s monitoring and evaluation phase involving 164 individuals from 12 schools underscore the high burden of unmet health needs. Most of them had inadequate fruits and vegetables consumption, were physically inactive, and some participants reported irregular sleep and eating patterns. These data reflect substantial modifiable risk factors for NCDs that remain unaddressed among school staff. According to Health Belief Model Theory, an individual’s perception of disease severity and personal vulnerability influences behavior change [29]. Thus, enhancing risk perception and perceived benefits through education is critical for motivating lifestyle changes [30].
Physical inactivity among staff was often attributed to administrative burdens and scheduling constraints. The Consolidated Framework for Implementation Research (CFIR) [31] identified organizational barriers such as a lack of institutional support for physical activity during school hours. These findings echo the broader literature indicating that structural and environmental factors significantly influence health behaviors, as articulated in the Ecological Model of Health Behavior [32]. Sleep deprivation also emerged as a persistent concern, affecting metabolic, cardiovascular, and mental health outcomes [33-38]. This highlights the need for integrated approaches in school health programs that address diet, physical activity, and sleep as interconnected health domains.
Emerging technological innovations such as federated learning and IoT-based health monitoring systems offer promising avenues for sustaining school-based health promotion efforts while maintaining data privacy. These approaches may enhance continuous teacher training and real-time surveillance in future iterations of SWeP-like programs. Practically, this study underscores the importance of viewing teachers not just as knowledge transmitters but as role models and implementers of school-based health promotion. Embedding healthy behaviors into the school curriculum can yield wide-ranging benefits. Previous research stated that integrating health education into curricula has a positive impact on study outcomes, including reduced absenteeism, improved cognitive function, and strengthened student-teacher rapport [39-41]. Theoretically, this research also contributes to the field by integrating multiple frameworks, such as SCT (individual behavior), TFA (program acceptability), and CFIR (systemic context), offering a comprehensive model for evaluating and scaling health interventions in educational settings.
Lastly, teacher and school staff must adopt healthy lifestyles and integrate these practices into their teaching to effectively prevent NCDs. Beyond delivering knowledge, educators play a key role in promoting overall student and teacher well-being by incorporating healthy diet, exercise, and lifestyle habits into the curriculum. This holistic approach helps improve student and teacher progress, reduces absenteeism, boosts energy and concentration, enhances mental health, lowers stress, and strengthens teacher-student relationships [42, 14]. By encouraging early preventive actions, educators can also help reduce the long-term financial burden on the healthcare system, further emphasizing their vital role in fostering a healthier school environment and supporting public health [16, 22, 43, 44].
Moreover, future implementation of SWeP-like interventions could benefit from leveraging digital health innovations. Recent reviews, such as one on federated learning in smart healthcare, suggest that integrating Internet of Things (IoT)-based systems can support continuous teacher training, real-time health data monitoring, and secure data privacy management. These technological frameworks could enhance the sustainability and scalability of school-based health programs, especially in low-resource settings where in-person monitoring is limited.
Despite promising outcomes, several limitations warrant attention including: 1) the absence of randomization and a control group limits the causal inference and the ability to attribute knowledge gains solely to the SWeP intervention, 2) for observed skill acquisition, this study used a one-shot case study which does not allow for a pre-post comparison or determination of actual competency growth, 3) Geographic limitation, that the study was conducted solely in Klaten Regency, which may limit the generalizability of the findings, 4) short-term evaluation, and there is no longitudinal follow-up was conducted to assess sustained behavioral change or institutional adoption, 4) single observation point, that skill assessments were not repeated post-training, so limiting insights into longer-term technical competence, 5) This study including small sample size and the restriction to 12 schools in Klaten Regency limit the statistical power and generalizability of the findings.
This research implies strengthening technical training quality through direct practice and regular supervision by local health centers (Puskesmas), ensuring adequate health screening equipment, such as cholesterol and uric acid meters, and building a robust referral system, promoting intersectoral collaboration, integrating SWeP with national initiatives, and needs implementing longitudinal studies to assess sustained behavioral and institutional outcomes. Moreover, developing blended learning modules to enhance flexibility and self-paced teacher training, and scheduling physical activity for both teachers are important.
This study focuses on positioning teachers as health promoters, the SWeP may also help reduce stigma and increase trust in preventive health services, especially in rural or underserved communities. This represents a potential pathway for strengthening health literacy and intergenerational behavior change. In addition, when approached holistically, the SWeP model has the potential to become a replicable and scalable school-based NCD prevention intervention, particularly in resource-constrained settings across Indonesia. However, implementation of SWeP can vary in resource availability, institutional support, and health infrastructure across regions.
CONCLUSION
The School Wellness Program (SWeP) demonstrated promising outcomes in enhancing teachers’ knowledge and procedural adherence related to the prevention of non-communicable diseases (NCDs) in elementary school settings. The significant increase in knowledge and relatively high adherence to SOPs for basic health screening suggest that trained teachers can serve as credible health promotion agents in schools. However, the absence of a control group and the short-term nature of the intervention limit causal inference and long-term impact assessment. Despite these limitations, the program aligns with global health promotion priorities and highlights the feasibility of leveraging teacher capacity for early health risk detection in low-resource educational environments. Future implementation should consider integrating the SWeP into formal teacher development curricula and aligning it with existing school health policies. Regular coaching by health professionals, provision of essential screening tools, and support through cross-sectoral collaboration are crucial to ensure sustainability. A cost-effectiveness analysis and longitudinal follow-up are recommended to assess the broader impact on student health outcomes and institutional adoption. Moreover, future adaptation of the program can explore the use of digital health tools (e.g., mobile apps, federated learning platforms) to support continuous training, data monitoring, and scalability while preserving privacy and data integrity.
AUTHORS' CONTRIBUTIONS
The authors confirm contribution to the paper as follows: A.S.: Study conception and design; T.S., W.K., A.S., S.B.U.: Data collection; W.K., S.B.U., T.S.: Analysis and interpretation of results; T.S., I.S.W.: Draft manuscript. All authors reviewed the results and approved the final version of the manuscript.
LIST OF ABBREVIATIONS
| NCD | = Non-Communicable Diseases |
| SWeP | = School Wellness Program |
| SOPs | = Standard Operating Procedures |
| NGTs | = Nutrition Goes to School |
| FGD | = Focus Group Discussion |
| TFA | = Theoretical Framework of Acceptability |
| SCT | = Social Cognitive Theory |
| CFIR | = Consolidated Framework for Implementation Research |
| DALYs | = Disability-Adjusted Life Years |
| Puskesmas | = Pusat Kesehatan Masyarakat (Community Health Center) |
| POSBINDU | = Pos Pembinaan Terpadu (Integrated Development Post) |
| SEAMEO RECFON | = Southeast Asian Ministers of Education Organization – Regional Centre for Food and Nutrition |
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This research was approved by the Ethics Committee Poltekkes Kemenkes Yogyakarta No.DP.04.03/e-KEPK.2/404/2023 dated March 29th, 2023.
HUMAN AND ANIMAL RIGHTS
All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.
CONSENT FOR PUBLICATION
All participants provided written informed consent. No student or child health data were collected. Data privacy was safeguarded through anonymized coding, and abnormal findings (e.g., high blood pressure, blood glucose, cholesterol) were referred to the local referral health provider or Puskesmas.
AVAILABILITY OF DATA AND MATERIALS
The data can be accessed through the link https://docs.google.com/spreadsheets/d/1PUB1A-1BxGxKOjbQxD9nAut4exBHTcLs/edit?usp=sharing&ouid=111643021375817039050&rtpof=true&sd=true
FUNDING
South East Asian Ministers of Education Organization, Regional Centre for Food and Nutrition (SEAMEO RECFON).
ACKNOWLEDGEMENTS
We are very grateful to the Klaten District Education Office, Health Office, school principals, teachers, and all employees from 12 elementary schools who have participated in this research. We also thank the South East Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON) for funding the publication of this article.
