Health Promotion in Swedish Schools: Navigating Institutional, Social and Professional landscapes

Abstract

This thesis explores school health promotion (HP) as a set of policy discourses and professional practices embedded in the institutional context of the Swedish school. School settings provide a unique opportunity for HP early in life. HP, a legal and ethical responsibility in schools, fosters student well-being and is related to better social and academic functioning. HP practices cannot be seen in isolation from relevant social and institutional contexts. Socially, HP is connected to democratic values such as autonomy and empowerment. It is also interlinked with social variables (e.g., socioeconomic) and developments (e.g., changes in available information seeking tools or in the arrangement of health systems). Institutionally, HP practices can be affected by how they are regulated by policies and governance systems. In Sweden, school HP is regulated by national guidelines. However, the practice is locally governed where municipalities and schools formulate their own health plans. The practice faces several institutional challenges such as mainstreaming it in daily schoolwork and scaling up relevant professional competencies. This thesis addresses questions related to how HP is depicted in policy discourses and how professionals navigate the institutional landscape in the course of HP practice. The thesis also examines how health literacy, as the empowering dimension of HP, is addressed in policy discourses. Moreover, it explores how professional practices are adapted to relevant social developments and subsequently shifting student needs. The thesis addresses these interests via three distinct but interrelated studies. The empirical material consists of four policy documents and nineteen interviews with various school professionals. Study 1, a critical policy analysis, explores how HP is articulated in education policies and how far this articulation acknowledges health literacy as a component of school HP. The study draws on critical discourse analysis to examine how policy discourses function as a form of social practice that can facilitate some actions and constrain others. Studies 2 and 3 are based on data generated from in-depth interviews with school professionals who work with HP. In study 2, practice theory is used to explore how school professionals conceptualize their roles and responsibilities in relation to the increased use of social media among students and how this conceptualization is related to institutional affordances and constraints. Study 3 uses a combination of practice theory and an institutional logic perspective to investigate how school professionals navigate the institutional landscape in schools (policies, regulations, governance systems) in the course of their HP work. Overall, the results indicate that the institutional setup of school HP in Sweden is rather complex and involves multiple levels of governance thus creating substructures and subsystems. The policies informing the practice show a considerable awareness of the social and democratic dimensions of HP despite the existence of some policy ambiguities and inconsistencies. Policies do not semantically acknowledge health literacy but refer to competencies that support health literacy such as critical awareness. Policy discourses are negotiated and (re)contextualized as they travel across organizational levels which may have an impact on how HP is enacted in different settings. The results also indicate that school professionals exhibit a solid commitment to school HP and a willingness for relevant professional development. They also exhibit notable resourcefulness in relating to the institutional setup of HP. Although they use institutional regulations (policies and organizational systems) for structuring their work, they sometimes negotiate and (re)contextualize these regulations to produce what they deem as more situationally appropriate professional responses. The thesis draws attention to the links between HP practices and institutional development and provides some suggestions as to how institutional variables can be manipulated to sustain and improve the practice.