The point of departure is the understanding that health is closely linked to education as education is considered one of the most important determinants for public health (Gustafsson et al. 2010). Good health aids the learning process and a good learning environment in school also promotes health (Backman et al. 2012). According to the Swedish National Agency for Education (2010, 2018), schools are responsible for creating a safe environment. Further the agency stress that health promotion perspectives are integrated into the daily pedagogical work in preschool and school where teachers and school health staff are responsible for promoting health. According to section 25 in the Educational Act the focus of the Student Health Services (SHS) should be health promotion and disease prevention and students are entitled to three health dialogues during their education. It’s further stated that there must be access to staff with such skills that the students' need for special educational efforts can be met in order to support the students' development towards the educational goals. The Swedish national curriculum and the governmental guidelines for school health care staff articulate the need for collaborative nature of work exceeding professional boundaries (the Swedish National Agency for Education, 2011; the National Board of Health and Welfare, 2016). However, this is not easily realized. According to Skott (2018) it’s in the intersection of the SHS staff and the teaching staff where the basic challenge regarding student health work lies. International studies i.e. Colquhoun (2008) confirm the complexity of health promotion schools and the potential conflicts and tensions that might arise as demands on schools to handle societal challenges such as ill-health, inequality and social exclusion, are increasing. Additionally, he echo Skott (2018) about many interventions, policies and professions intersecting at the school arena. Accordingly, it´s importance to take this complexity within schools, and the schools embeddedness within different systems, into account in research and evaluations. According to the Swedish Association of Local Authorities and Regions (SKL 2018) to be able to give all students opportunities to develop to their fullest potential and enjoy school there is a need for a well-functioning SHS where close collaboration both within SHS and between teachers, principal and other staff is central to the school. Further, they argue that lack of cooperation can depend on lack of time and sometimes on different approaches and understanding of the causes of the difficulties students have.

In addition, there is a body of research on student voice arguing that students have much to tell us regarding school development and their participation foster engagement and create opportunities for school improvement (see for example Bergmark & Kostenius, 2018; Mitra, 2008; Cook-Sather, 2006). Participating research has the potential to empower people by giving voice and space in a democratic spirit (Ghaye et al. 2008). The process of increasing human beings control over their health can be enhanced when being heard and experience that their contributions are valued (Melander-Wikman et al., 2006).

Therefore, the aim of this study was to explore how the health dialogues as part of health promoting school development are experienced, understood and negotiated by different school actors – school nurses, teachers and students. The main research questions are:  How are different school actors experiencing, interpreting and mediating the educational act concerning health promotion in practice, i.e. in the health dialogue? How far are the school actors’ experiences, understandings and negotiations reflecting health promotion in practice?

The empirical focus of this paper is the health dialogues (Rising Holmström 2013). A total of 93 participants; 37 students from grade 4, 7 and year 1 in upper secondary school, 12 teachers and 44 school nurses wrote open letters continuing the following sentences; "Now I will tell you about my experiences of the health dialogues..." and, “To use the health dialogues to its fullest potential to promote schoolchildren’s health and learning, I think that…”. In the analysis of data we applied theories from the fields of education and health promotion, more specifically policy enactment in education and studies on health literacy. In the first phase of the analysis, to understand the complexity of health promotion policies and practice in the educational landscape, we followed the critical policy tradition where policies are understood as processes “as diversely and repeatedly contested and/or subject to ‘interpretation’ as it is enacted (rather than implemented) in original and creative ways within institutions and classrooms” (Braun, Ball, Maquire & Hoskins 2011, p 586 ). Teachers and school nurses are from this perspective understood as policy actors which are involved in creative processes of interpretation and translation of policy into practice (Ball, Maguire, Braun & Hoskins 2011). Our intentions were to gain an understanding of how the policies for health promotion are interpreted in the participants experiences of the health dialogues. We analysed the school actors’ interpretations and translations, in terms of their values, pre-existing knowledge, experiences and sense making of the assignment health promotion and the health dialogues in their professional roles. In the analysis we apply a contextual perspective as policy enactment is intimately shaped by school specific factors and resource differences are limiting, distorting or facilitating different responses to policy (Braun et al. 2011). In the second face of the analysis we used Nutbeam’s (2002) concept of health literacy consisting of three levels in order to understand in what way the school actors’ experiences, understandings and negotiations of the health dialogues reflect health promotion in practice. The first level, functional health literacy, reflects traditional health education goals of increased knowledge about health risks and how to use the health care system. The second level, interactive health literacy, reflects activities to develop personal skills in a supportive environment. The third level, critical health literacy, reflects cognitive, interpersonal and social skills to address the social, economic and environmental determinants of health (Nutbeam 2002).

The data illuminated the present state of experience and knowledge about how the health dialogues are experienced, understood and negotiated by different school actors. There were different interpretations of the health dialogues and of who is responsible, which indicates that the health dialogues cannot be conceptualized as a shared practice and neither the health promoting school as a shared and collective objective. While many school nurses wished to involve the teachers, the teachers often expressed lack of time and knowledge on the subject. Our analysis confirms that the teachers and school nurses interpretations and enactments of the policy are mediated by different institutionally determined factors (c.f Braun et al. 2011). The local organisation of the SHS, the priority of the health dialogues by the school leaders, and how the health dialogues are included into the systematic quality work, affects the actors´ interpretations and whether or not the health dialogues are acknowledged as a shared objective. All three levels of health literacy described by Nutbeam (2002) was found in the participants narrations. Experiences reflecting functional health literacy (level 1) with focus on information giving to improve knowledge about health risks was identified. Functional health literacy (level 2) was described in examples of activities directed towards improving personal capacity in a supportive environment. The narrations about how to use the health dialogues to its fullest potential to promote schoolchildren’s health and learning included examples reflecting critical health literacy (level 3). This research was conducted part of a larger project within the school using a participatory design with the experiences of the participants as the point of departure (Ghaye et al. 2008). The results are to be used in building a collaborative organization that includes both professionals and students, aimed at developing the health dialogues part of the school’s systematic development work.

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