Health promotion (HP) is linked to democratic and social values including equity and societal cohesion (Akerman et al., 2019). Health literacy, the critical and empowering component of HP, has been acknowledged as a health determinant across the life span (Carlsson, 2015; WHO, 2013). Schools are key arenas for HP (Paakkari & George, 2018). Apart from having positive implications for student wellbeing and academic performance, HP in schools can be operationalized to address some social issues such as the humanely problematic health divide (Braveman et al., 2011; Cerda et al., 2021; Mannix-McNamara & Simovska, 2015).  This study explores the articulation of school-based HP in Swedish education policies, in relation to democratic and social values (e.g., autonomy, empowerment, and equity). The study also investigates how far this articulation acknowledges health literacy as a core element in HP work.

School-based HP can be a contested domain where different agendas compete. For example, some health discourses may encroach on personal autonomy, while others may depoliticize health (Malmberg & Urbas, 2019; Paakkari & George, 2018; Petersen, 1996). HP work in schools has been repeatedly problematized from moral and social perspectives including inquiries into how far it adheres to democratic tenets and how well it fosters autonomy and empowerment (Danielsen et al., 2017; Jensen, 1997; Paakkari & George, 2018). It is informative to explore school-based HP from a sociological perspective to elucidate the links between ideologies, social values, and behaviors at the individual, group, and institutional levels.

Scholars have repeatedly highlighted the relations between policy discourses and health-related activities or outcomes in schools (e.g., Danielsen et al., 2017; Wolpert et al., 2015), suggesting that educational policy discourses co-shape the manner in which health issues are addressed in school contexts. Swedish schools incorporate HP in the legally mandated student health services governed by local student health plans at both the municipal and school levels. However, there is a national guide that outlines the general aims, responsibilities, and potential areas for action across the whole country (Swedish National board of Health and welfare and  Swedish National Agency for Education, 2017).

In this study, four education policies were analyzed, the national guide for student health services in Sweden and three municipal student health plans. The analysis was informed by Fairclough’s (1992) model of critical discourse analysis. The findings indicate that policy articulations in the analyzed documents exhibit an awareness of the democratic and social dimensions of HP. However, tensions were identified between different discourses deployed in the documents including ethical, public health, biomedical and governance discourses. For example, there was a tension between the biomedical and public health discourses, where the former frequently focused on risk factors and framed students as passive recipients of care, while the more socially oriented public health discourse acknowledged the meaningfulness of the social determinants of health and the value of student empowerment.

While the local policies mostly recapitulated the national guideline, they occasionally negotiated and recontextualized parts of the national discourse. This recontextualization was sometimes beneficial in the sense that it concretized key social values such as student participation. However, local discursive representations could also inadvertently undermine the democratic dimension of HP. For example, one municipal health plan used the floating term “norm-breaking behavior” which is potentially open to uncritical interpretations at the school level with possibly unfavorable implications for student autonomy as well as for equity.  The differences between the three municipal documents may be related to differential interpretations of the national document but can also represent a local adaptation to the sociodemographic context in which the policy is to be deployed. The policies acknowledged health literacy in spirit rather than semantics.

Data generation started by selecting relevant policy documents. Online searches by the authors (university librarians were consulted) were conducted to map out the field of potentially relevant documents for the study. These documents were then filtered to select the most pertinent ones for HP work in Swedish schools. The filtration process was informed by reading through said documents to get well acquainted with their content as well as consulting relevant professional experts who had worked in the field of school-based HP in schools, municipalities as well as in academia. Meetings were arranged with some key actors to further our understanding of which policy documents were considered relevant in practice in different schools (e.g., different parts of Sweden, private vs. municipal schools). Eventually, the national student health services guide (known in Swedish as “Vägledning för elevhälsa”) was selected as the primary document for analysis to explore how HP-related issues are articulated on a national level. The analysis also extended to include three municipal student health plans. The municipalities in question varied in terms of geographical location as well as in terms of their sociodemographic profiles. The municipal documents were included by way of exploring how the national discourse gets translated at the local level. The documents are all publicly available. Data sources amounted to a total of 252 pages. Data analysis was informed by Fairclough’s (1992) critical discourse analysis model which allows for exploring policies in terms of their linguistic structures and discursive practices while simultaneously accounting for the societal and institutional contexts in which they are formulated and enacted. The socially oriented model allows for exploring power struggles and potential discursive conflicts. Data analysis proceeded along four stages. The first stage was an iterative in-depth reading of the selected documents for data immersion and familiarization. The second was an open inductive coding that identified key discursive representations and tensions. During the third stage of analysis a more detailed linguistic scrutiny was applied to particular text blocks selected based on findings from the first two stages of analysis as well as on expert advice as recommended by Fairclough (1992). During the fourth phase of analysis, the findings from the different local documents were contrasted against each other as well as against the national document to explore the extent of (in)congruence between the different policy documents.

The findings indicate that the analyzed policies exhibit a fair level of awareness of social and democratic values involved in HP work. However, the interdiscursive tensions detected within the policies can have implications for the extent to which these values become observed in practice. The discerned tensions reflect ideological differences between various stakeholders particularly considering the shared authorship of the document (between the school and health boards) but could also be an indication of impending social change where stakeholders and policy makers are actively trying to adjust school practices to adapt to a rapidly mutable societal and global landscape. HP discourse is being renegotiated as it travels from the national to the local level. It is then important to consider how incongruent interpretations of the same national document in different municipalities may undermine the assumed equity in providing student health services across the country. Moreover, the implicit rather than explicit acknowledgment of health literacy may provide spaces for less critical policy enactments, thereby jeopardizing the empowering dimension of HP work. In light of our findings, we recommend that future education policies exercise more caution in deploying various discourses in their rhetoric. It is also important that HP discourses maintain a social and moral compass and that they are comparably committed to social and democratic values at various levels of action, e.g., national and municipal. This analysis has provided an opportunity for exploring discourse as a social force thus opening up venues for reflection about relations between policy discourses and various ideologies and social actions. However, we do acknowledge the importance of broadening our investigation to policy implementation in schools. We intend to pursue this in a subsequent study where we will explore how school professionals enact education policies in the course of their professional HP practices.

Akerman, M., Mercer, R., Franceschini, M. C., Peñaherrera, E., Rocha, D., Prado Alexandre Weiss, V., & Moysés, S. T. (2019). Curitiba Statement on Health Promotion and Equity: voices from people concerned with global inequities. Health Promotion International, 34(Supplement_1), i4-i10. https://doi.org/10.1093/heapro/daz009 Braveman, P. A., Kumanyika, S., Fielding, J., LaVeist, T., Borrell, L. N., Manderscheid, R., & Troutman, A. (2011). Health disparities and health equity: The issue is justice. American journal of public health (1971), 101(1), S149-S155. https://doi.org/10.2105/AJPH.2010.300062 Carlsson, M. (2015). Professional competencies within school health promotion — between standards and professional judgment. In V. Simovska & P. Mannix McNamara (Eds.), Schools for Health and Sustainability: Theory, Research and Practice (pp. 191-209). https://doi.org/10.1007/978-94-017-9171-7_9 Cerda, A. A., García, L. Y., & Cerda, A. J. (2021). The effect of physical activities and self-esteem on school performance: A probabilistic analysis. Cogent Education, 8(1). https://doi.org/10.1080/2331186X.2021.1936370 Danielsen, D., Bruselius-Jensen, M., & Laitsch, D. (2017). Reconceiving barriers for democratic health education in Danish schools: an analysis of institutional rationales. Asia-Pacific journal of health, sport and physical education, 8(1), 81-96. https://doi.org/10.1080/18377122.2016.1277546 Fairclough, N. (1992). Discourse and social change. Polity Press Jensen, B. B. (1997). A case of two paradigms within health education. Health education research, 12(4), 419-428. https://doi.org/10.1093/her/12.4.419 Malmberg, C., & Urbas, A. (2019). Health in school: stress, individual responsibility and democratic politics [Article]. Cultural Studies of Science Education, 14(4), 863-878. https://doi.org/10.1007/s11422-018-9882-0 Mannix-McNamara, P., & Simovska, V. (2015). Schools for Health and Sustainability: Insights from the Past, Present and for the Future. In V. Simovska & P. Mannix-McNamara (Eds.), Schools for health and sustainability. Theory, research and practice. (pp. 3-18). Springer. Paakkari, L., & George, S. (2018). Ethical underpinnings for the development of health literacy in schools: Ethical premises ('why'), orientations ('what') and tone ('how') [Review]. BMC Public Health, 18(1), Article 326. https://doi.org/10.1186/s12889-018-5224-0 Petersen, A. R. (1996). Risk and the regulated self: the discourse of health promotion as politics of uncertainty. Australian and New Zealand journal of sociology, 32(1), 44-57. https://doi.org/10.1177/144078339603200105 Swedish National board of Health and welfare and Swedish National Agency for Education. (2017). Vägledning för elevhälsa [Guide to Student Health Services]. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/vagledning/2016-11-4.pdf WHO. (2013). Health literacy: The solid facts. http://www.euro.who.int/__data/assets/pdf_file/0008/190655/e96854.pdf?ua=1 Wolpert, M., Humphrey, N., Deighton, J., Patalay, P., Fugard, A. J. B., Fonagy, P., Belsky, J., & Vostanis, P. (2015). Children, research, and public policy an evaluation of the implementation and impact of England's mandated school-based mental health initiative in elementary schools. School psychology review, 44(1), 117-138. https://doi.org/10.17105/SPR44-1.117-138