Social and democratic values in school-based health promotion: A critical policy analysis

Abstract

Schools are recognised as key arenas for health promotion (HP). The development of health literacy (HL) is one of the cornerstones of HP. HP is closely linked to democratic principles and social values. School-based HP may best be understood within the context of the socio-political spectrum in which it is embedded. This study explores how school-based HP is articulated in Swedish education policies, particularly in relation to democratic and social values, and whether that articulation acknowledges and fosters HL as a core element of HP work. Four education policies were analysed. The analysis was informed by Fairclough’s model of critical discourse analysis. The findings indicate that policy articulations exhibit an awareness of the democratic and social dimensions of HP. However, these dimensions may have been undermined by an occasional biomedical hegemony, coupled with a subtle deployment of governance discourse. The policies acknowledged HL in spirit rather than semantics and did not fully exploit teachers’ capacities as active agents in HP. Several interdiscursive tensions were observed that may have short as well as long-term social and democratic implications, particularly in terms of fostering student autonomy, empowerment and inclusion.

Keywords:

• health promotion
• health literacy
• democracy
• educational policy
• critical policy analysis

1. Introduction

Educational institutions need to consider and sometimes actively target issues linked to individual welfare and societal development (see Dewey, 1990). Health promotion (HP) is one of these issues. Physical and mental health problems have been linked to diminished academic achievement, limited school engagement and even discontinuation of education (Nasuuna et al., 2016; Riglin et al., 2014). On the other hand, engagement in health promoting activities has been associated with better school performance (Cerda et al., 2021).

Schools have been recognised as key arenas for HP, giving rise to the notion of school-based HP, which was deployed within numerous programmes and initiatives worldwide, such as the health promoting school in Europe and its American counterpart, the coordinated school health programme (Barnekow Rasmussen & Rivett, 2000; Mannix McNamara & Simovska, 2015; Whitman & Aldinger, 2009). Health promoting schools can cultivate competencies that not only advance health in the short run but also stimulate critical thinking to promote future health behaviours with long-term health and societal gains (Gostin, 2020; Iudici, 2015; Mannix McNamara & Simovska, 2015). Fostering critical health skills aligns perfectly with the educational mission or what St Leger (2001) refers to as the core business of school. In fact, it has been argued that health promoting schools can contribute to the fulfilment of some key educational outcomes including life long learning skills and specific cognate knowledge (St Leger & Nutbeam, 2000).

School-based HP is closely linked to democratic values. The international network, Schools for Health in Europe (SHE), which supports the development and implementation of health promoting schools,¹ explicitly identifies democracy as one of its core values (Buijs, 2009). This study sets out to explore how school-based HP is articulated in Swedish education policies, particularly in relation to democratic and social values.

The World Health Organization (WHO) defines HP as “the process of enabling people to increase control over, and to improve their health” (WHO, 1986 p.1). HP has been distinctly linked to democracy, social cohesion and equity (Akerman et al., 2019; Porto, 2019). In congruence with a progressive global orientation towards a biopsychosocial model of health,² HP is increasingly becoming a societal concern (Iudici, 2015; Petersen, 1996). HP, which lies squarely within the remit of public health action, is considered a socially oriented activity rather than a health service. Successful HP efforts call for integrated actions targeting health determinants and opening up opportunities for healthier lifestyles. According to Nutbeam et al. (2018, p. 4), a basic “foundation of modern health promotion” is the development of health literacy (HL).

HL refers to a set of skills whereby the acquisition, comprehension and appraisal of health information are employed to make informed health promoting choices (WHO, 2013). There have been calls for expanding the scope of HL to incorporate competencies at the group level, thus reinforcing the concept of health citizenship, where an individual is informed about health-related issues, not only in relation to self but also in relation to others (Paakkari & Okan, 2019; Paakkari et al., 2012). Moreover, it has been argued that modern societal developments³ should be accounted for in HL operationalisations, giving rise to what has been labelled electronic (digital) health literacy, a multifaceted competence incorporating health, media and computer literacies (Norman & Skinner, 2006). Paakkari (2015) considers HL development to be “the fundamental goal” of health promoting schools (p. 276).

It is relevant here to point out that Nutbeam (2000) distinguished between three levels of HL; functional, interactive and critical. Functional HL refers to the mere transmission of health related information. Interactive HL is oriented towards improving the ability to effectively act upon this information. Critical HL is concerned with the development of skills that facilitate health relevant social and political actions. Abel et al. (2022) stress that critical HL can promote agency on both the individual and collective levels thereby operating as a valuable resource for HP. Critical HL has been explicitly linked to democratic values particularly those of participation, empowerment and political action (Sykes & Wills, 2018; Sykes et al., 2013). However, Sykes and Wills (2018) argue that the political action dimension remains a contested arena in terms of conceptualization as well as implementation.

School-based HP faces many challenges, not least in terms of how much it fosters critical thinking skills and how far it adheres to democratic principles (Danielsen et al., 2017; Jensen, 1997; Paakkari, 2015). HP in schools cannot be isolated from the societal context in which it is embedded. There is an association between the socio-politico-economic spectrum and the allocation of and access to health resources (Islam, 2019). Moreover, links between policy discourses and various health-related activities or outcomes in schools have been reported (Danielsen et al., 2017; Wolpert et al., 2015), suggesting that policy rhetoric can influence how health issues are articulated and addressed in educational contexts.

Health discourses can contribute to shaping perceptions and beliefs, particularly in younger populations. For example, overemphasising the link between obesity and health behaviours may be linked to stigmatisation or undue self-deprecation (Bombak et al., 2021; Grimminger-Seidensticker et al., 2020). Health discourses, which are often ideology-laden, may have serious societal and moral ramifications, calling for careful consideration of how they are deployed in educational institutions (cf. Riska, 1982). There have been concerns that certain health discourses (particularly those informed by neoliberalism) may reduce individuals to enterprises and encroach on their autonomy (Petersen, 1996). On the other hand, there have been calls for toning down the overtly individual representation of some health issues in school curricula amid concerns regarding the ethical and democratic implications of depoliticising health (Malmberg & Urbas, 2019; Paakkari & George, 2018).

School-based HP is then embedded in a network of different ideologies, complex power relations and conceivably conflicting agendas (Leow, 2011; Wilkinson & Penney, 2021). Consequently, a comprehensive understanding of HP activities in schools calls for an exploration of how health issues are articulated in education policies and how such articulations may be seen within the context of the multifaceted school mission where ethical, legal, pedagogical and social dimensions should be simultaneously observed.

2. Empirical context and aim

Students in Swedish schools are legally entitled to student health services (SHS). The Swedish Education Act stresses that SHS should primarily be oriented towards HP and disease prevention (SFS Skollagen [The Swedish Education Act], 2010:800). SHS are expected to contribute to fostering a healthy school environment and upholding school values. The national SHS guide describes, inter alia, general aims, responsibilities, expectations and potential areas for action (Swedish National board of Health and welfare and Swedish National Agency for Education, 2017). However, school-based HP is operationalised at a decentralised level in Swedish municipalities and schools where local SHS plans are in action (The Swedish National agency for Education, n.d.).

This study aims to explore HP in the context of education policies. The research questions are:

• How is HP articulated in education policies and how is this articulation related to social and democratic values?

• How far do education policies, if at all, acknowledge and foster HL as a core element of HP?

3. Theoretical approach

Data analysis is informed by critical discourse analysis (CDA), which has been deemed useful in socially oriented educational research (Jorgensen & Phillips, 2002; Mullet, 2018). In CDA, discourse is impregnated with beliefs and values, oriented towards meaning making and may open up or close off particular choices or actions (Anderson & Holloway, 2020; Jorgensen & Phillips, 2002). CDA can be an informative theoretical lens in socially/democratically oriented research-especially that based on text analyses-as it not only acknowledges language as a form of social practice but also allows for the exploration of power struggles implicit in various discursive depictions (Janks, 1997). This study will draw on Fairclough’s analytical CDA model, which is, according to Jorgensen and Phillips (2002), “the most developed theory and method for research in communication, culture and society” (p. 60). The model involves three interrelated dimensions of analysis. The first⁴ is concerned with linguistic structure (e.g. vocabulary and grammar). The second involves understanding the discursive practices (i.e. processes of text production and interpretation), including intertextuality and interdiscursivity. Intertextuality represents a relationship between one text and other texts that are brought into it directly or indirectly. This bringing in is often imbued with certain assumptions or implications. Interdiscursivity occurs when text author(s) draw upon other styles and discourses, purposefully weaving them into their text, possibly to further or weaken some claim or argument (Fairclough, 1992, 2001, 2003). The third dimension is concerned with contextual issues, such as “the institutional and organizational circumstances of the discursive event and how that shapes the nature of the discursive practice” (Fairclough, 1992, p. 4).

Fairclough’s model allows for the exploration of potential conflicts or power struggles where the dominance of a particular order of discourse (the way various discourse styles are linked together) may lead to hegemony. Even in the absence of hegemony, power struggles between different actors can exist and may be evident in various discursive representations (Fairclough, 1992, 2001, 2003). This analysis is positioned within the structuralist realm as described by Anderson and Holloway (2020) thus seeking to unveil the messages and ideologies being perpetuated or legitimised by policy discourse.

4. Data corpus and analysis

Four policies were analysed. The primary document selected for analysis was the national SHS guide (Swedish National board of Health and welfare and Swedish National Agency for Education, 2017) which was used to explore how HP-related issues are articulated on a national level. Three municipal SHS plans were also included in the data corpus. The municipalities will be referred to as MK (an urban predominantly middle socioeconomic level municipality in western Sweden), EK (an urban predominantly high socioeconomic level municipality in eastern Sweden), and TK (a rural predominantly middle socioeconomic level municipality in southern Sweden). The three local documents were used to explore how national discursive practices are taken up at the local level as a proxy for social practice (textual enactment of national policy).⁵ The documents are all publicly available. Data sources amounted to a total of 252 pages.

Initially, an iterative reading stage was undertaken to allow immersion in and familiarisation with the data. This was followed by open inductive coding to identify key discursive representations and to explore potential tensions and power struggles. During the immersion and open coding stages, particular text blocks were identified as key parts of the data set and were then subjected to a more detailed linguistic analysis. This selective process is considered necessary in Fairclough’s approach due to the high level of detail involved in linguistic analysis and it is to be informed by a preliminary survey of the corpus as well as by expert advice (Fairclough, 1992).

5. Results

Data analysis yielded three key discursive representations and three discursive tensions. The discursive representations were (i) description of SHS work, (ii) the social dimension of SHS and (iii) the democratic dimension of SHS. The tensions were (i) health: an asset, a resource or an imperative, (ii) care provision vis-a-vis active participation, and (iii) risk linked to wellbeing or to performance (see Table 1 for an overview of the results).

Table 1. Overview of findings

(I) Discursive representations	Key categories
Description of SHS work	Scope of work Shared responsibility
The social dimension of SHS	Public health orientation
The democratic dimension of SHS	Autonomy and participation Equity and respect
(II) Discursive tensions	Discourses involved
Health: an asset, a resource or an imperative	Governance Legal	Ethical Public health Democratic
Care provision vis-a-vis active participation	Biomedical Legal	Democratic Public health
Risk linked to wellbeing or to performance	Accountability Governance	Democratic Public health Ethical

5.1. Discursive representations

5.1.1. Description of SHS work

SHS work was described in the policies in terms of its scope as well as the actors responsible for it.

5.1.1.1. Scope of work

The SHS guide distinguishes between three dimensions of SHS work: (i) HP work to maintain or strengthen wellbeing, (ii) preventive work focusing simultaneously on reducing the influence of risk factors and bolstering the effects of protection factors and (iii) remedial work concerned with problem management. As represented in the SHS guide, there seems to be some overlap between the action areas of HP work and preventive work, where both address protection factors. This discursive murkiness opens up spaces for potential misinterpretation and uncoordinated actions. In fact, the discursive representation of HP in the same document is not always consistent with this classification, where actions described in the course of HP work are sometimes directed towards risk factors or problematic issues (e.g., conflict management) making them either preventive or remedial (SHS guide, p. 88–89). The Swedish Education Act is repeatedly brought into the guide (222 times), stressing that all suggested measures are in accordance with it. This is a case of both intertextuality, where the Act as an official document is repeatedly cited, and interdiscursivity, where the biomedical and pedagogical discourses in the guide are blended with a legal one, perhaps by way of legitimisation.

At the local level, all three documents provide almost the same representation of SHS scope of work. However, the EK document exhibits a relatively more proactive discourse where it attempts to clear up the potential confusion between HP and preventive work by clarifying that the former is based on a salutogenic⁶ perspective while the latter is based on a pathogenic perspective.⁷ All three local documents acknowledge the SHS guide. However, they do not explicitly address all areas of action highlighted in it. For example, while the SHS guide repeatedly refers to the obligatory health dialogue (a scheduled dialogue between the school nurse and the student)⁸ as a resource for HP work as well as a potential tool for quality control, none of the three local documents refer to this dialogue. All three documents stress that they are guided by the Swedish Education Act. This may be seen as a reiteration of the national HP discourse (SHS guide) or as a legitimisation manoeuvre by means of which any potential local recontextualisation of the SHS guide is being preemptively sanctioned.

5.1.1.2. Shared responsibility

The SHS guide profusely addresses issues of responsibility. The word responsibility is mentioned 200 times in this 192-page document. This may be seen as an expression of an unwavering commitment or as a discursive thoroughness in outlining areas of action. It may also be related to the document status. SHS is a guideline, not a law. The authors may be deliberately stressing responsibility by way of ensuring a higher level of engagement at the local level. The repeated allusions to responsibility may serve as discursive nudges to intended readers (i.e. key actors at the municipal and school levels) to adhere closely to the guideline.

The SHS guide portrays HP as a joint responsibility where various actors are expected to contribute their respective competences, particularly within the student health team, a multidisciplinary forum in Swedish schools where students’ health-related problems are addressed.⁹ Responsibility is represented using two distinct but interrelated discourses: an organisational discourse concerned with responsibility assignment and an accountability discourse pertaining to how responsibility execution is to be monitored (e.g. quality control). However, the terrain of responsibilities sometimes seems obfuscated. The SHS exemplifies preventive work as;

In preventive work, SHS can help to map the school to identify risk areas, such as high smoking rates or high levels of stress, bullying or discrimination. (SHS guide, p. 89)

Here, the auxiliary verb “can” indicates possibility rather than commitment (as opposed to must), which might be due to the context being an example but may also be an indication (intentionally or otherwise) of trying to delimit the domain of SHS responsibility. The latter interpretation is given further weight by the subsequent verb “help”, implying that SHS would be supporting schools in dealing with these issues rather than assuming responsibility for them. Remarkably, no specific SHS actor is mentioned here, and the verb “help” has no object (who will be helped?), leaving the territory of responsibility rather ill-defined.

Although the SHS guide portrays school health as a joint responsibility, the actors whose job tasks are outlined, when the responsibility for this mission is described, are primarily care providers and school administrators but not teachers (SHS guide, p. 33–36). The omission of the teacher in this context may imply that the SHS guide is rather oriented towards problematic situations where care needs to be provided (by care providers) and coordinated (by administrators). It is also noteworthy that the guide’s foreword fails to be inclusive:

The guide is primarily aimed at staff in SHS, principals for current forms of activity, heads of operations for student health and care providers, school principals and decision-makers. (SHS guide, p. 2)

Considering that teachers (except special educators) are often not part of SHS, this formulation excludes most teachers from the intended readership of the document.

In the SHS guide, teachers’ competences are alternatingly marginalised, mobilised (seen as occasionally and conditionally useful resources) and glorified. The teacher’s role in HP is often downscaled (marginalised). Teachers are sometimes depicted as SHS resources (mobilised) who can provide information about conceivable areas of intervention (e.g. by reporting problematic behaviour) or instigate measures deemed appropriate by the SHS (e.g. special pedagogical contributions). However, a potential lack of competence is anticipated and SHS complementary measures are suggested as a course of action:

It can be difficult for the individual teacher to interpret the student’s behaviour, understand the reason for it or know how to act. In such a situation, student health can contribute its knowledge by giving teachers advice on attitudes and support. (SHS guide, p. 104)

Finally, the teacher is sporadically identified as a key person in students’ lives (glorified), particularly in the case of problematic students, such as those struggling with mental health issues, where the teacher is described as a “safety person” (SHS guide, p. 106).

At the local level, the notion of joint responsibility is also stressed by a mixture of organisational and accountability discourses. Remarkably, the EK document extends the responsibility spectrum to students (p. 7), exhibiting support for student autonomy and empowerment. Where the teacher is concerned, all three local documents mirror the discursive patterns in the SHS guide, whereby the teacher’s contribution, while rhetorically valuable, is not given its full due.

5.1.2. The social dimension of SHS

The SHS guide exhibits an awareness of the public health orientation of HP by acknowledging the social dimension of health and the value of health knowledge. Here, two types of discourse are deployed. First, a scientific discourse where references to published research are frequently used to ground this social awareness in evidence-based knowledge. Second, an action-oriented discourse citing relevant statistical findings at the national level (such as the percentage of students suffering from socially related health problems) is used to highlight the anticipated practical value of a socially oriented HP work. All local municipal documents make references to the social dimension of health, albeit in a distinctly less prolific fashion, possibly due to the rather concise nature of these documents.

Although HL is not explicitly mentioned in any of the documents, there are several references to promoting students’ health-related knowledge, which may be interpreted as an investment in HL. The SHS guide also highlights the importance of fostering a critical perspective (a core value in HL) in relation to health issues. Furthermore, the guide repeatedly refers to “salutogenesis,” an approach that supports and capitalises on HL skills (Antonovsky, 1996; Eriksson, 2017). In fact, HL is seen as inherently incorporated in the salutogenic approach which fosters abilities (individual/group) to overcome psychosocial stressors (Jensen et al., 2017).

All three local documents emphasise the value of developing student knowledge, albeit with different degrees of abstraction. For example, while the EK document merely points out that fostering knowledge can contribute to better health, the MK document explicitly links enhanced knowledge to autonomy and provides suggestions for knowledge-promoting approaches.¹⁰ The TK document highlights concrete examples of ongoing measures to foster students’ health-relevant knowledge.¹¹

The relationship between engagement in digital arenas and health is briefly hinted at in the SHS guide, which points out the increased challenges involved in safeguarding students’ mental health when the scope of student interaction has expanded into social media platforms, where inappropriate behaviours (e.g., bullying), which technically occur outside the school perimeter, may still be a school responsibility. At the local level, the MK document concretely reports that one of the ongoing preventive projects will be supplemented with a digital component and emphasises the importance of being up-to-date in terms of the tools used to foster student knowledge. The TK document only acknowledges the value of digital resources in relation to learning environments, while the EK document displays no particular interest in digital resources.

5.1.3. The democratic dimension of SHS

The policy documents exhibited a democratic orientation, as indicated by an apparent awareness of how HP is related to values of autonomy, participation and equity.

5.1.3.1. Autonomy and participation

The SHS guide repeatedly highlights the importance of fostering autonomy and empowering students. In the course of stressing the importance of student participation, four discourses were identified: (i) a legal discourse with references to Swedish laws such as the Education Act (2010:800) and the Work Environment Act (1977: 1160), (ii) a pedagogical discourse where student participation is seen as a key factor in improving the learning process, (iii) an ethical discourse where articles from the UN’s child convention are referred to and (iv) a scientific discourse where the importance of student participation is foregrounded in empirical findings (SHS guide, p. 111). However, the linguistic structures used in some of these instances are frequently peculiar in that they advocate for students’ active participation while simultaneously suggesting that participation is to be bestowed on presumably passive recipients. For example,

Students must be given influence over the education. They shall be continuously stimulated to take an active part in the work of further developing the education and be kept informed in matters concerning them. (SHS guide, p. 17)

Here, a passive voice dominates where students are to “be given” influence. By design or otherwise, the act of giving remains subjectless (i.e., it is not clear who will do the giving), thus obscuring the specific actor(s) responsible for it. It is, however, worth noting that the auxiliary verbs “must” and “shall” denote a commitment to empowering students and the adverb “continuously” strengthens such commitment and highlights that it is an ongoing process rather than a set of discrete actions. The seeming paradox between commitment and responsibility obfuscation may reflect a struggle between the rather modern social concern with democracy and empowerment and the more traditional and long-practiced conservative schooling, where students were passive recipients of educational and/or social goods. Another paradox in this excerpt is the seeming uncertainty in the conceptualisation of student influence. On the one hand, students are “to take an active part” in education development. On the other hand, students would be “kept informed in matters concerning them”. Education development is presumably a student concern, thus posing a conundrum where students would simultaneously be actively involved in developing education and passively informed about it.

On the local level, both MK and TK documents reflect the more passive representation of student influence being given and mention participation in a rather abstract sense. However, in the EK document, a more concrete understanding of participation is articulated:

Participation means being included in a context and comprises six aspects: belonging, accessibility, interaction, recognition, commitment, and autonomy. These aspects affect each other and can demonstrate what opportunities we create for children and students to become involved or not. It is crucial for children’s and students’ goal fulfilment that they have influence and responsibility over the education, in terms of content as well as work approach. (EK document, p. 7)

Here, participation is broken down into six interlinked aspects providing a well-defined blueprint for action. Using “we” signals that the municipality owns up to the responsibility for fostering participation. The pronoun also brings in a solicitous tone to the discourse, making it seem both caring and somewhat conversational. Moreover, the modality (It is), as well as the choice of the adjective “crucial” in the last sentence, exhibit a strong sense of commitment to the operationalisation of student participation rather than merely using it as rhetoric.

5.1.3.2. Equity and inclusion

The SHS guide stresses the importance of fostering equal opportunities, respecting interindividual differences and promoting inclusion. Equity is referred to as a core value, particularly in deference to the Swedish Education Act. The guide also acknowledges the link between health and equity and considers it an important domain for knowledge development.

According to the preparatory work for the Education Act, student health has an important role in teaching about gender equality, sex and cohabitation, tobacco, alcohol and other drugs, as well as other issues about lifestyle-related ill health. Student health has knowledge of determinants and risk factors and can thus draw attention to individuals in the risk zone and draw attention to negative conditions in the students’ everyday environment.

(SHS guide, p. 96)

Here, both intertextuality and interdiscursivity can be identified. The former is evident in explicitly mentioning the Education Act, according to which gender equality is an SHS concern. Interdiscursivity can be detected in mixing the biomedical discourse (seen in the focus on ill health and potential risks) with two other discourses: a legal discourse where the role of SHS is grounded in legal obligations and a public health discourse (socially oriented) where students’ lifestyles and everyday environments are domains of action.

On the local level, all documents acknowledge the value of equity and link it to inclusion. According to the EK document,

A definition of inclusion may be that all children and students should be given the same rights and access to equal education. Differences are seen as an asset which enriches the school environment. (EK document, p. 8)

Here, the document explicitly links inclusion to respecting and even capitalising on interindividual differences.

5.2. Discursive tensions

5.2.1. Health: an asset, a resource or an imperative

A tension was detected between ethical, public health and democratic discourses (where health is a valued asset in its own right) on the one side and accountability and legal discourses (where HP is a resource for institutional development and a fulfilment of a legal mandate) on the other. Across the data sources, the SHS mission is frequently referred to in relation to how it can advance learning rather than as an important undertaking in its own right possibly reflecting an institutional orientation towards the core school business, i.e., education. The goal of SHS is expressed as “to create as positive a learning situation as possible for the student” (SHS guide, p. 23). Curiously, there is no mention of health or wellbeing in this formulation.

It is noteworthy that while listing the expected outcomes of SHS work, learning oftentimes is mentioned before health, suggesting that education is prioritised over health or that school-based HP is important only insofar as it contributes to better conditions for learning. References are made, both in the national guide and in local documents, to the Swedish Education Act and how it highlights that SHS should contribute to learning. In this sense, both intertextuality and interdiscursivity are employed to legitimise the prioritisation of learning.

SHS should contribute to creating environments that promote student learning, development and health. (SHS guide, p. 28)

In this excerpt, the modal verb “should” denotes commitment and responsibility. Notably, the first target of this commitment is the student’s learning, not his/her health. Here, a governance discourse may be detected where a school’s primary mission (for which it is accountable) is education. While learning cannot be overlooked as a priority in school contexts, the general tone across the documents implies that HP is seen as catering to the achievement of learning goals rather than as an integral part of the learning process. This formulation constrains the conceptualisation of learning and implies that it is limited to achieving curricular goals (learning how to keep healthy can also be seen as a learning goal). It also effaces the ethical conceptualisation of health as a basic human right and a societal, hence educational, responsibility.

5.2.2. Care provision vis-a-vis active participation

Despite repeated references to the value of preventive measures and student voice in the SHS guide, active participatory prevention¹² seems to be repeatedly overshadowed by care provision, reflecting a tension between the proactive public health and democratic discourses oriented towards participation and empowerment and the somewhat reactive biomedical discourse (being supported by means of a legal discourse) oriented towards providing remedial services to rather passive recipients

The approach [to HP] is characterised by dialogue, participation and equality in the encounter with the individual. It aims to empower individuals to make independent decisions and to respect their values and experience of goals and meaning in life. (SHS guide, p. 22)

The vocabulary choice here (participation, equality, etc.) as well as the modality (“is characterised”, a factual statement) depict an orientation towards the student as an active participant in HP rather than a passive recipient of care and resonate with the student perspective repeatedly referred to in other parts of the guide. However, the approaches and examples highlighted in other parts of the SHS guide display an orientation towards care provision in response to particular problems (e.g. psychological counselling for troubled students or special support for poorly performing ones) rather than towards a universal fostering of skills that would support sound decision-making in health-related issues.

The problem solving orientation (by providing care) is evident across the data corpus where the importance and indeed the responsibility to report problematic issues (e.g., prolonged absences) is stressed and supported by a legal as well as a biomedical discourse (e.g., Education Act, Social Services Act and Patient Safety Act). The SHS guide clarifies that in certain situations (e.g., serious injury or the likelihood of one), school personnel are obliged to report to the Health and Care Inspectorate, signalling a legal and moral accountability of the educational establishment to health care authorities. Even licenced health care professionals on school premises can be reported if they are suspected of posing a danger to “patient safety” (SHS guide, p. 36). The latter linguistic formulation is interesting in that it operates to redesignate the identity of the student who has now been legally dubbed a (potential) patient, thus legitimising any prospective overriding of other working codes in the school (e.g., privacy regulations).

5.2.3. Risk linked to wellbeing or to performance

A tension between the democratic, public health and ethical discourses (that acknowledge diversity and foster inclusion) on the one side and the governance and accountability discourses (with a focus on discipline and performability) on the other was conspicuous in the TK document, which describes preventive work as follows:

The purpose of preventive measures is to deflect risk factors from the individual or reduce their influence, and simultaneously strengthen the protection factors … Known risk factors are school failures, norm-breaking behaviour (the earlier the debut, the greater the risk), lack of reading ability, deficiencies in parenting and disability (autism, language impairment, dyslexia, ADHD/ADD). (TK document, p. 5)

Here, the risk factors being identified seem to be more related to students’ performance (academic or behavioural) than to their health. Moreover, the nominalisation in “known risk factors are” implies that this is a universal truth. However, no scientific references are offered here, nor are there any explanations as to the origin of that knowledge and how it came to attain this matter-of-fact status. It is noteworthy here that the first two risk factors reflect a focus on school governance, whether academic (avoiding school failure) or behavioural (discouraging norm-breaking behaviour). The vocabulary choice in “norm-breaking” is also striking in that it stands in apparent contrast to the “norm-critical perspective” emphasised in the national document (SHS guide, p. 19). The SHS guide, while acknowledging the value of norms, explicitly states that they are sometimes “restrictive and discriminatory” and thus it seems rather peculiar that norm-breaking behaviour (with no further specifications) would be depicted as a “known” risk factor at the local level. “Norm-breaking” is a floating term that can be differentially interpreted by various readers. A possible interpretation at the local school level could be undisciplined students, which in turn can be used to suppress behaviours deemed undesirable by teachers or school administrations, potentially undermining the democratic and ethical discourses (in the SHS and even in the TK document) that emphasise the value of inclusion and student voice

6. Discussion

This study examined HP discourse in Swedish education policy and explored the extent to which this discourse acknowledged and fostered HL. Several discourses were detected in the policy documents, e.g., biomedical, legal and ethical. Sometimes, tensions between two or more discourses could be detected, possibly due to struggles between different ideologies. In the following section, these ideologies, along with the tensions they may have invoked, will be unpacked. The travel of policy discourse from the national to the local level will also be discussed.

6.1. Responsibility discourse

The analysis of the data corpus revealed an occasional ambiguity in responsibility designation. This may have emanated from the mixed ideologies standing behind the formulation of the original document (and, by extension, the local ones). Both the National Agency for Education and the National Board of Health and Welfare share the authorship of the SHS guide, with contributions from multiple actors (from different professional domains) in both organisations. This joint authorship may have simultaneously enriched and crippled the discourse. On the one hand, it may have allowed for a multi-perspective representation of HP work. On the other hand, subtle interprofessional tensions may have impacted the discursive representations of some areas of action, making them seem rather vague, possibly due to a combination of unresolved tensions and an unsophisticated discursive attempt at smoothing them out. Discrepancies (particularly interprofessional) in the conceptualisation and operationalisation of HP have been repeatedly reported in schools and may have cast their shadows on how responsibility is articulated in the policy documents (Guvå & Hylander, 2012; Kostenius & Lundqvist, 2021; Reuterswärd & Hylander, 2017).

The analysed documents also exhibited some inconsistencies in the representation of the teacher role, where the discourse vacillated between marginalisation, mobilisation and glorification. This fluctuation may have been brought about by ongoing ideological struggles in the school arena. The marginalisation of teachers may have its roots in the predominance of the biomedical discourse, where health care professionals’ knowledge gains validation and subsequent dominance over teacher knowledge by virtue of being “scientific and expert” (Lupton, 1997, p. 104). The mobilisation of teachers as resources, implicitly subject to SHS authority, can also be understood within the context of biomedical hegemony. However, a neoliberal ideology may also be at play, where the teacher is deemed an asset. It is presumably a practical and cost-effective strategy to have teachers, who already work in close proximity to the students, screen for potential problems and implement countermeasures as deemed appropriate by SHS. Finally, the glorification of teachers as safety persons in difficult situations may be fulfilling an institutional imperative whereby teachers, as key actors in the school context, must be duly acknowledged (see The Swedish National agency for Education, 2021).

The tendency to undervalue the teacher role in HP settings signals an organisational failure to exploit the full potential of teachers’ capacities as key school actors. In the long run, this may contribute to underinvestment in teachers’ skill development, thus setting off a vicious circle of depreciating teachers’ efficiency followed by (an understandable) scepticism that they can efficiently contribute to HP work (as seen in the results section) and invoking even further dismissal of their role as health promoters. This may be particularly problematic for students in Swedish schools, where HP work is often initiated by the teacher to whom students usually turn for help (Skolinspektionen, 2015).

Keeping in mind that teachers’ under-involvement has previously been highlighted as a shortage in HP work (Jourdan et al., 2008), an alternative discursive representation emphasising the teacher’s role in fostering knowledge and promoting skills (such as HL, so that problems can be averted rather than handled) might have been better suited to a health promoting mindset. Even where a lack of competence is feared, investment in teachers’ skill development may be a more efficient approach than dismissing their role in HP altogether. Previous literature has both recognised the teacher’s role as a health promoter and the need to consolidate that role by providing adequate support, including fostering interprofessional collaboration and developing teacher competence (Ekornes, 2015; Simovska et al., 2016; St Leger et al., 2007).

6.2. Focus on learning outcomes

An overt focus on and prioritisation of learning outcomes over health was observed in the data. This may be partially underpinned by a neoliberal philosophy. Neoliberalism tends to emphasise an investment-outcome reasoning and represents one type of governmentality where an entrepreneurial model becomes inculcated in the social sphere, making individual development an economic asset as well as a socio-political endeavour (cf. Foucault, 2008; Mincer, 1958; Sims & Hui, 2017). Prioritisation of learning, in a rather curricular sense, seems to resonate with human capital theory, which underscores the value of education in building up the workforce. The theory, which is deeply influenced by neoliberalism, has been instrumentally, if not uniformly, deployed in European educational discourses (Gillies, 2011).

Modern school systems seem to be occupied by performance assessments and measurable outcomes, a distinct feature of a neoliberal orientation (Suspitsyna, 2010). The policy documents analysed in this study, while not education policies in the strictest sense, were meant to be deployed in an educational context. This might be one reason they focus on learning, which is probably the institutionally perceived equivalent of achievement. However, it should be noted that a vigorous deployment of the accountability rationale in schools has been criticised for adversely affecting pedagogical practices and constraining students’ perceptions of health initiatives (Danielsen et al., 2017), and may thus be inconsistent with the proclaimed commitment to democratic and social values in HP work. Simovska et al. (2016) pointed out that schools overburdened with competing agendas may view HP as an auxiliary rather than a core school task.

The preoccupation with learning goals may also have a social welfare dimension (Shore, 2019). In Sweden, there has been a growing concern for students who fail to graduate high school, as they are likely to be socially marginalised, with potentially serious implications for their physical and mental health. This invoked a series of national measures that aimed to minimise the discontinuation of studies, including a focus on grades that affect eligibility for high school admission (SKL, 2018; SOU, 2018: 11). In this sense, a focus on learning goals may be seen as a health investment. However, the neoliberal influence cannot be completely dismissed. While the welfare and neoliberal discourses are seemingly at odds and are sometimes thought to yield different sets of beliefs (Fulge et al., 2016), Rich and Evans (2012) have pointed out that they sometimes co-exist.

6.3. Biomedical hegemony

A recurrent tendency to reduce SHS to care provision was observed in the analysed documents, thereby underestimating the health promotional dimension of these services. This may be due to a tension between the pedagogical, social, public health and democratic discourses on the one hand and the biomedical discourse on the other, where the latter is oriented towards treatment rather than prevention. This seeming biomedical hegemony may explain why the preventive dimension in SHS work was deemed underdeveloped in several Swedish schools (Skolinspektionen, 2015).

The biomedical model has been repeatedly criticised for its focus on disease rather than health, for perceiving the human as a dichotomy of body and mind as well as for its individualistic sensibilities (e.g. Engel, 1977; Haslam et al., 2019). A biopsychosocial model that adopts a holistic view of health (i.e. body and mind, individual and context) has been suggested as a promising approach in both research and practice (Borell-Carrió et al., 2004; Iudici, 2015). However, the progress of the biopsychosocial model may have been hampered by societal and professional tendencies to valourise and reinforce biomedical reasoning (Suls et al., 2010).

It has been argued that in order to fulfil their aims, public policy documents “in a complex world must simplify and stabilise certain features of the world they relate to” (Soreide, 2007 p.140). Health and education policymakers nowadays have to navigate an excessively complicated environment where student health is embedded in a maze of conflicting narratives. For example, emotional and social wellbeing, though linked to developmental goals, may be somewhat challenging to prioritise in modern schools where performative accountability is becoming an increasingly prevailing logic (Brown & Donnelly, 2020; Högberg et al., 2021). In the course of navigating such complexities, policymakers (behind the analysed documents) may have tried to “stabilise or simplify” at least some parts of the discourse by resorting to more chronologically and conventionally established models, in this case, the biomedical model.

While a biomedical discourse in health-related contexts is hardly surprising, its hegemony may have undesirable consequences for students, the school environment and society at large (cf. Andipatin et al., 2019; Bastos et al., 2013; Hamre et al., 2019). One such consequence is that HP, an essentially public health concern, becomes individual rather than group oriented (Keefe & Lane, 2018). According to Goldberg (2012), individualistic tendencies in HP work are inefficient and ethically questionable, in that they foster stigmatisation and enhance health inequalities. Hence, while individually oriented measures may occasionally be required, predominantly individual HP work is socially and ethically problematic. A biomedical hegemony may also compromise student autonomy where the student is seen as a target of action rather than an actor (cf. Ribeiro et al., 2021). A sense of autonomy has been linked to students’ sense of wellbeing (Celik, 2018), and may be an important factor in developing critical thinking skills and fostering self-esteem (de Araújo et al., 2018).

It should also be observed that a biomedically driven school practice would call for the identification and investigation of students before declaring them eligible for SHS intervention. Such a process implies that school action would be reactive rather than proactive. Help would likely be offered when students have already exhausted other compensatory mechanisms (social or emotional),¹³ thus foregoing the opportunity for early action and allowing for unnecessary suffering. This would be particularly hazardous among students struggling with mental health issues who may try to hide their conditions for as long as possible (see Kostenius & Lundqvist, 2021). Moreover, some students might feel the stigmatising burden of labelling (e.g., slow, troubled) and refrain from seeking help, making early problem detection even more difficult (cf. Iudici et al., 2021).

It is important to keep in mind that a labelling protocol, if not cautiously handled, may foster segregation practices, potentially eroding away at the equity and inclusion values that have long been a tenet of the Swedish education system (Hjörne, 2016). The labelling practice may also act as a discursive device whereby institutional or social shortcomings are inadvertently masked, thus underestimating the contextual and social dimensions of student problems (cf. Hjörne & Säljö, 2004; Malmberg & Urbas, 2019; Marmot, 2015). In this context, some students may be forced into what Iudici et al. (2021 p. 1031) refer to as a “biographical career” where possibilities are delimited by how the student is perceived and categorised.

It is also worth noting that this biomedical hegemony resonates with the governance discourse and neoliberal influence observed across the documents. Clarke et al. (2003) argued that biomedical reasoning can be operationalized as a form of governmentality. Krupar and Ehlers (2020) explicitly link the prevalence of biomedical logic to biopolitics and neoliberalism. They discuss the concept of “biocultures” where biomedical logic permeates various institutional and social discourses, and argue that “neoliberal logics and techniques of efficiency, economic utility, optimisation and moralising deservedness regulate and manage populations and individuals within biocultural spheres and thus organise biological and social existence” (p.445).

6.4. Health literacy

Although HL is not explicitly mentioned in any of the documents, there are several indicators that there is an awareness of the concept, in spirit, if not in terminology. While this absence of HL may be a semantic issue due to translation controversies (see Ringsberg et al., 2020), it is still problematic. To begin with, it may obscure the skill-fostering dimension of HP activities and contribute to the conceptualisation of SHS as being oriented towards problem solving. Furthermore, the absence of HL from education policies may have ramifications for goal setting as well as for performance evaluation. If HL (or a Swedish equivalent addressing the same concerns, e.g. critical thinking) is not an acknowledged construct, then a health-related initiative may be designed and later appraised, with no attention as to how it fostered (or not) active participatory knowledge. In other words, the students’ knowledge and skills will not be duly accounted for, neither in setting goals nor in evaluating outcomes (cf. Kintsch, 2009). Finally, the absence of HL (or a Swedish equivalent) from policy documents might make supranational collaborations or comparisons problematic or less informative. Sweden has several HP-oriented European partnerships, such as its partnership in the EU project IC-health and its membership in the SHE initiative (European commission, 2020; SHE Network, n.d.; Vilaça et al., 2019). HL is a construct that is increasingly being put forth in European discourses (e.g. Dadaczynski et al., 2020; McDaid, 2016). While Sweden has several school-based initiatives that are HL-oriented (e.g. Kostenius & Nyström, 2020; Schubring et al., 2021), these initiatives have to be sorted out from the massive set of activities included under the rubric of SHS, making a clear and constructive dialogue, let alone cross-country comparisons, rather difficult. It is also worth noting that the digital dimension of HL does not seem to feature in policy articulations, suggesting that Swedish school-based HP may not be keeping abreast of evolving student needs in an increasingly digitised society (cf. Müssener et al., 2020). This resonates with prior findings indicating that the full potential of digital resources in Swedish schools is yet to be exploited (Molin et al., 2018).

On the other hand, it should be noted that a recent update of the National Agency of Education web page explicitly refers to HL as an integral part of school work (The Swedish National agency for Education, 2021). The analysed SHS guide was the latest version available at the time of writing this text. It was revised, edited and reprinted less than a year after the prior version had been published (Swedish National board of Health and welfare and Swedish National Agency for Education, 2017). This may suggest that health work in Swedish schools is at a particularly mutable stage and that policymakers are trying to keep up with the exponential increase in relevant areas of knowledge as well as with a rapidly changing societal landscape (both nationally and globally). It is conceivable, then, that upcoming editions of the SHS guide may be more explicitly oriented towards HL.

However, it is worth observing that HL (particularly the critical dimension) remains a somewhat contested arena of knowledge and practice (Ringsberg et al., 2020; Sykes & Wills, 2018; Sykes et al., 2013). In this context, policymakers, should they decide to explicitly include the concept of HL in upcoming SHS guide editions, would probably be facing a rather arduous task in the sense that they would have to introduce a rather novel concept in the Swedish school context, formulate a semantically accurate definition of it and then outline a clear yet broad (so as to accommodate various contexts of implementation) strategy for fostering it.

6.5. Policy travel and recontextualisation

The analysed municipal documents mostly reiterated the national HP discourse and even reproduced the key discursive tensions identified in the SHS guide. However, the local documents sometimes engaged in subtle negotiations of national discourses whereby some notions were endorsed and sometimes developed (e.g. the joint responsibility for HP), while others were eschewed (e.g. the contribution of school health dialogues to HP). It has recently been pointed out that policies may be reframed as they travel across levels of execution (Lindegaard Nordin et al., 2019).

The policy reframing at the local level, though limited, sometimes served to reorganise and even corporealise parts of the original discourse. In this respect, the EK municipality stands out in terms of its democratic and action-oriented discourse. In this document, participation is deftly transformed from a concept to a procedure by breaking it down into six areas of action and explicitly assuming responsibility for fostering it. EK is also remarkable in that it extends the SHS responsibility domain to students, thus endorsing student participation as a core value. Student participation has been linked to an improved understanding of health as well as to enhanced student agency (Beattie et al., 2021), which in turn is linked to a better sense of ownership and engagement (cf. McClelland & Giles, 2016; Mifsud et al., 2019). The EK document also takes the initiative to clear up potential ambiguities in understanding HP work in contrast to prevention work (as put forth in the SHS guide), ergo demystifying the national discourse in this regard.

The aforementioned democratic and proactive undercurrents in the EK document may be, in part, a discursive appropriation to the context in which this policy is to be deployed. EK is a municipality with a higher-than-average socioeconomic level. Education, globally but particularly in Sweden, is increasingly becoming what Lidström et al. (2014) refer to as a “quasi-market” (p. 14). Policy regulations in Sweden have previously been linked to students’ school choices. Moreover, policy directives at the municipal level may make some municipalities more attractive than others for independent schools (Lidström et al., 2014). It is conceivable that policymakers would try to address issues anticipated to be of concern to target population(s). While citizens from all social classes can and do embrace democracy, Letsa and Wilfahrt (2018) argue that those from higher socioeconomic classes are more appreciative of the participatory (as opposed to the redistributive) dimension of democracy.

Other noteworthy representations at the local level include the democracy-oriented discourses in both the MK and TK documents. The MK document displays awareness of the link between knowledge and autonomy, thereby consolidating the democratic discourse in the SHS guide. The discursive representations in the TK document also build on and further concretise the national discourse by providing examples of ongoing health knowledge fostering initiatives. On the other hand, the references to norm-breaking behaviours in the TK document may have inadvertently undermined the democratic dimension of HP, where the floating term norm-breaking is open to various interpretations, some of which may be uncritical, thus risking conflation of individualistic or identity asserting behaviours with unacceptable ones (cf. Youdell, 2003). This, in turn, may lead to the marginalisation of “non-dominant forms of behaviour” (Brown & Donnelly, 2020, p. 16), thereby jeopardising equality values.

6.6. Discursive tensions … a potential way forward?

Although a certain biomedical hegemony has been observed in the analysed data, the frequent use of interdiscursivity brought into the texts a variety of other discourses (e.g. ethical, legal). The discursive tensions observed in the documents may best be understood in the context of the current societal scene. Swedish education, like other European education systems, is now quite strained with the need to reconcile different ideologies, value systems and even knowledge conceptualisations in a manner that can accommodate students’ needs and available school resources while simultaneously responding to societal demands and fulfilling accountability imperatives (Adolfsson, 2018; Capucha et al., 2016; Erlandson & Karlsson, 2021; Erlandson et al., 2020; Kinsella, 2020). Concurrently, the public health sector is struggling with its own challenges, including health inequalities, potentially risky lifestyles and declining school satisfaction among students (Inchley et al., 2020; The Swedish Public health agency, 2021). Over and above these issues, promoting health in a school setting faces a unique set of challenges, including time constraints as well as organisational or leadership issues (Kostenius & Lundqvist, 2021). In this context, addressing HP in an education policy may be fraught with tensions that would be mirrored in said policies’ discursive formulations.

However, it should be noted that these interdiscursive tensions may also imply a disposition for social change. According to Jorgensen and Phillips (2002, p. 139) “interdiscursivity is both a sign and a driving force of social and cultural change”. Both health and education are highly dynamic, multidimensional domains. School-based HP in contemporary societies faces a need to revise and modify actions such that they are context and time responsive in a rapidly changing societal and global landscape (cf. Ghalavand et al., 2020; Qushem et al., 2021; Wolf et al., 2015). It may be the case that the observed interdiscursive tensions were an instantiation of policymakers’ responses to the need to reconsider and perhaps rearticulate some previously established practices. Consequently, these apparent tensions may open up opportunities for challenging deep-seated assumptions, contesting traditional conceptualisations, reconstructing meanings and reshaping practices. Whether the latter would be for the better or the worse can hardly be a matter of certainty at this point.

6.7. Final reflections

This policy analysis of school-based HP has simultaneously addressed two domains that are of significant concern at both the national and global levels—health and education—and linked them to democratic and social values (United Nations, 2016). While the findings presented here are purely based on text analysis, it should be kept in mind that text analysis, in and of itself, can provide valuable contributions to our understandings of the social. Language is not neutral but rather a materialisation of ideologies (Fairclough, 2013). Popkewitz (2012, p. 179) points out that “language can be thought of as embodying structures or systems”. Discursive formulations can be quite influential insofar as they contribute to shaping identities and instigating inclusion or exclusion practices within social institutions (Barker, 2001; Liasidou, 2008). Discourses can be significant tools for shaping power relations and “decoding the power discourse requires a series of understandings about the nature of language as a verbal expression of social relations” Cookson (1994, p. 116). In this sense, we hope that this analysis contributes to a better understanding of how HP is represented in education policy and how this may be related to societal challenges, democratic principles and ideological struggles.

Another issue for reflection is the researchers’ role in meaning making. While researchers set out to analyse texts and explore the implicit messages in them, they must keep in mind that these unveiled messages are also a function of the researchers’ understandings and interpretations. Making claims about a text through another text brings in the analyst’s assumptions into the analysis and may risk what Fairclough (2003, p. 11) has described as “problematic attributions of intentions”. However, it would be useful to keep in mind that a published text renders itself open to various interpretations and that what this analysis offers may be one or some of those interpretations, but not necessarily all of them.

7. Conclusions and implications

In this article, the HP discourse in Swedish education policy was explored at the national as well as the local level. The findings indicate that education policies deploy several discourses in their formulation of school-based HP. The discursive representations across the data corpus imply that policy actors acknowledge the democratic and social dimensions of HP. However, these dimensions may have been somewhat undermined by an occasional biomedical hegemony, coupled with a subtle but frequent deployment of governance discourse. The policies seemed to acknowledge HL in spirit rather than semantics. Based on our findings, we argue that HP in Swedish schools would benefit from an explicit and clear acknowledgement of HL which would facilitate more transparent and efficient design, execution and evaluation of HP initiatives. Moreover, an emphasis on fostering critical HL would serve to consolidate the democratic orientation of school based HP.

The policies did not fully exploit teachers’ capacities as active agents in school HP. The interdiscursive tensions observed in this data corpus may suggest that HP in schools is at a particularly mutable stage, possibly in response to ongoing rapid changes in the educational and societal landscapes. In light of the current findings, future education policies may need to be more scrupulous in deploying biomedical or governance models in their discourse so as not to jeopardise the social and democratic dimensions of HP. While we acknowledge the rather complex terrain of knowledge domains, ideologies and values that the education sector needs to navigate while drafting various policies, we believe that HP in schools warrants a special kind of attention from policy makers considering the great potential it holds in terms of preparing younger generations to navigate a world that is becoming increasingly complex.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Hadil Elsayed

Hadil Elsayed is a doctoral student at the Department of Education, Communication and Learning, University of Gothenburg, Sweden with a prior doctoral degree in public health. Her research interests include health education, exploring health issues from a sociocultural perspective and the potential role of technology in health contexts.

Linda Bradley

Linda Bradley is an associate professor, at the Department of Education, Communication and Learning, University of Gothenburg, Sweden. Her interests are digital and mobile learning, design based informal and formal learning in the workplace, integration and migration studies.

Mona Lundin

Mona Lundin is a Professor of Education at the University of Gothenburg, Sweden. Her research interests concern what happens when digital technologies are put to use in professional contexts and hence, the consequences for professional competence and how work is carried out and coordinated in everyday work settings.

Markus Nivala

Markus Nivala is a senior lecturer at the Department of Education, Communication and Learning, University of Gothenburg, Sweden. His research interests include technology, learning and expertise development in different domains.

Notes

1. Sweden is a member State.

2. A biopsychosocial model of health acknowledges the multiplicity of physical, social and environmental factors that can influence health as opposed to the previously prevailing biomedical model that focused on the healing of diseases.

3. Such as the increased prevalence of cyber mis/disinformation as well as the increased influence of social media on self perceptions and health related behaviors.

4. The order here is arbitrary as the dimensions are interrelated.

5. Not to claim that social practice is limited to textual enactment.

6. Salutogenesis focuses on factors that support wellbeing and health. The term was introduced by Aaron Antonovsky in his 1979 book Health, Stress and Coping.

7. Pathogenesis focuses on disease and disability factors.

8. Legally, all students are entitled to individual health dialogues (hälsosamtal) with a school nurse at least once in preschool, twice in elementary school and once in high school where they can discuss various health issues.

9. Team participants generally include a school administrator, a psychologist, special needs teacher(s), a social worker and a school nurse.

10. For example, engaging in group exercises.

11. For example, the Depression in Swedish Adolescents (DISA) program.

12. Refers to an acknowledgement of the significance of student knowledge, teacher knowledge and agency in preventive work.

13. For example, students with mental health issues may be able to cover them up by increasingly using compensation mechanisms.