Health Promotion International, 2017;32:231–240
doi: 10.1093/heapro/dat073
Advance Access Publication Date: 11 October 2013
Article
Health promotion in Swedish schools: school
managers’ views
Louise Persson1* and Katarina Haraldsson1,2
1
Center for Research on Child and Adolescent Mental Health, Karlstad University, Karlstad SE-651 88,
Sweden and 2Department of Research and Development, Region Halland, Halmstad, Sweden
*Corresponding author. E-mail: [email protected]
Summary
Schools are recognized worldwide as settings for health promotion, and leadership has a bearing on
schools’ ability to be health promoting. School managers have a great influence on what is prioritized
in school, which in turn affects students’ school performance and health. There is lack of research into
school managers’ views on health promotion, and what they consider to be central to health promotion. The aim was therefore to examine school managers’ views about what health promotion in
schools include. An explorative design, qualitative content analysis, was performed. In-depth interviews were conducted with all 13 school managers of a middle-sized municipality in central Sweden.
The analysis had both manifest and latent content and three categories: ‘Organization and
Collaboration’, ‘Optimize the arena’ and ‘Strengthen the individual’, and 10 subcategories emerged.
The theme, ‘Opportunities for learning and a good life’, describes the latent content of these categories. Taking into account the views of school managers are important because these views help form
a more complete picture of how school managers work with health promotion and what is needed to
enhance health promotion to improve students’ opportunities for learning and a good life. The Ottawa
Charter for Health promotion is thereby transformed into practice.
Key words: schools; qualitative methods; public health
INTRODUCTION
Schools are recognized worldwide as settings for health
promotion (World Health Organization, 1986;
Mittelmark, 2007), and there is increased attention on
school as a health-promoting setting (Sansolios and
Egberg Mikkelsen, 2011). In school it is possible to
reach a large population over several years, and it is during the first years of life that most future health-related
lifestyles, behaviours, habits and attitudes are formed
(CSDH, 2008; Marmot, 2009). Outside of the home and
family context, children and young people spend most
of their time at school, which has an influence on their
health and well-being in general (James, 2010).
Research shows that poor school performance leads to
lower self-esteem, which in turn can lead to aggressive
forms of behavior. The association also goes in the other
direction; low self-esteem and externalized behavioral
problems increase the risk of a child performing poorer
in school. There is evidence that a vicious circle of poor
mental health and poor school performance follows the
child into adolescence (Currie et al., 2008; Gustafsson
et al., 2010). Because of the link between student health
and well-being, on the one hand, and schools meeting
their educational goals, on the other, health promotion
in school has become even more essential (Nutbeam,
2000; St Leger and Nutbeam, 2000a,b; Weare, 2010).
C The Author (2013). Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
V
232
School health promotion is encouraged in the target document ‘Health for All’, and highlights that by the year
2020 at least 95% of all young people in the European
region should have access to education in a healthpromoting school in order to learn how to make better
choices in life, become healthier and to better take an active part in the community and in society (World Health
Organization, 1999). Each country should encourage
this when developing laws and regulations related to
school (World Health Organization, 1997; Rowling and
Jefferys, 2000). Sweden has developed national public
health targets, partly building upon the ‘Health for all’
(World Health Organization, 1999), which emphasize
the importance of establishing good living conditions for
children and young people and prioritize the school setting (Sveriges Regering, 2007/08, p. 110). However,
health promotion in schools is extensive and can be interpreted in different ways (Lynagh et al., 1997;
Aggelton et al., 2010). There are well-known concepts,
criteria and guidelines for this purpose (Lee et al., 2007),
such as the Health-Promoting School concept (HPS)
(Nutbeam, 1987; World Health Organization 2000).
Swedish schools are obliged by the schools act to pay
heed to health promotion, including activities concerning physical, emotional and social behavior, as well as
the school climate (Sveriges Riksdag, 2010, p. 800). The
health promotion concept for schools also builds upon
these three aspects, and underlines the idea that ‘health’
involves school and community life as a whole (World
Health Organization, 2000). In Sweden there are no specific statutory concepts, criteria or guidelines for school
health promotion, except that the school manager needs
to ensure that the curriculum is developed in a healthpromoting way and determine the structure of health
promotion (Sveriges Riksdag, 2010, p. 800).
Historically, job descriptions for school managers in
Sweden have been vague, not helped any by unclearly
formulated laws and policy documents (Johansson and
Bredeson, 2011). Yet they play a crucial role in the operations of local schools, and must be familiar with a variety of issues in order to contribute to their organization
and development. It is therefore a growing awareness to
investigate the views of school managers, and especially
their importance for students’ well-being and perfor€
mance in schools (Arlestig
and Johansson, 2011). School
managers are also central to growth of health promotion
in schools, and schools need support from the manager
to succeed with health promotion (St Leger, 1998).
There is, nevertheless, limited research that focuses on
school managers’ views on health promotion in school
(Aggelton et al., 2010; Mohammadi et al., 2010). The
purpose of this study is to compensate for the lack of
L. Persson and K. Haraldsson
research with a more detailed picture of how school
managers work with health promotion. Such knowledge
can add important aspects for a more complete guide for
how to work with health promotion in schools and for
improving the health promotion work already going on
in schools. The aim of the study was therefore to explore
the school managers’ views about what health promotion in schools include.
METHOD
Design and setting
The study is of qualitative nature and has an explorative
design. Qualitative content analysis with an inductive
approach has been used (Hsieh and Shannon, 2005).
The study was conducted in all 13 school districts with
children aged 1–16, in a municipality with a population
of 100 000 in central Sweden. Each school district is
approximately equal in geographical size and number of
students, but differs when it comes to student retention
and socioeconomic status. Of the 13 school districts, 4
are country districts, and the rest are city districts. The
school districts have preschools and primary schools in
their area.
Informants and data collection
All 13 school managers consisting of both men and
women, in charge of one school district in the municipality participated in the study. The school managers
have the main administrative responsibility for the
schools in their district, including staff (for example
principals and teachers) as well as the students. All of
them also have a background as principal. The school
managers received an information letter about the study,
which was sent by e-mail and later followed up with an
informative telephone call. They were all positive to participate in the study and to take part in individual indepth interviews. The interviews started with an openended question: Can you tell me your view of what
health promotion in school includes? In order to clarify
and deepen the understanding of the school managers’
responses, questions followed about relations in school,
school climate, mental health promotion in school and
the role of the school manager and health promotion.
The interviews took place in undisturbed settings at
school and were audio-taped and took 1 h. All interviews were conducted by the first author, who is a public health researcher. A pilot interview was done and
another public health researcher, the second author, experienced in qualitative methods, attended in the first interviews to ensure that the interview guide functioned as
Health promotion in Swedish schools
intended. The interviews were later transcribed verbatim
by the first author.
Data analysis
The analysis consisted of both manifest and latent content (Graneheim and Lundman, 2004). First, the transcription of each interview was read through several
times to become familiar with the content. Secondly,
meaning-carrying units, which corresponded with the
aim of the study, were extracted. Thirdly, the meaningcarrying units were condensed and abstracted into
codes. To identify similarities and differences, the codes
were compared and then sorted into categories.
Comparisons were made with the context in each step of
the analysis to verify the empirical base of the data
(Graneheim and Lundman, 2004). A public health researcher experienced in the method participated in both
the research design and data analysis process. The first
two steps in the analysis were conducted separately by
both researchers and then compared and agreed on before the last step, which was done together in order to
increase the trustworthiness of the study.
Ethics
The study was reviewed by the Ethics Committee at
Karlstad University (code number: C2010/707), and no
objections were raised. All 13 school mangers received
both written and verbal information about the aim of
the study, the design, the voluntary nature of participation, their liberty to withdraw their participation at any
time and the confidential treatment of data.
RESULTS
The interviews show the school managers’ views of
what health promotion in schools include. Three categories emerged from the analysis: ‘Organization and collaboration’, ‘Optimize the arena’ and ‘Strengthen the
individual’. The latent content of these categories are described by the theme ‘Opportunities for learning and a
good life’ (Figure 1). The results demonstrate categories
that, both separately and together, emerged as important for health promotion and for enabling learning and
a good life.
233
Policy and leadership
Policy and leadership included the school’s legal duty to
work with health promotion, policies, plans, objectives
and surveys for health promotion, with regard to the
role of the school manager and school staff in health
promotion. The school managers were obliged by the
Swedish schools act to work with health promotion,
which should permeate the school curriculum and involve the whole school. They had set up policies, plans
and objectives for health promotion in order to meet the
overall goal of health promotion. Matters of particular
interest included healthy eating, outdoor teaching, students’ mental health, increased physical training, values
and equality, safety and security, students’ behavior, cooperation with parents and how to deal with problems
such as infringement of personal rights and bullying.
‘You cannot just go along and say that achieving
learning outcomes in mathematics is the most important
thing. You’ve got to have the fundamentals in life as a
child, like feeling safe and well. It is those things that allow a child to perform in each subject’ (no. 5).
Furthermore, as basis for these policies, plans and objectives, various types of surveys were conducted in the
schools, which are often in charge of the school health
care, to examine students’ well-being, or sense of comfort and safety within school. From these results, the
school managers could identify and prevent risk behaviors and unsafe places, and set up objectives for the
schools to follow. Furthermore, the role school manager
was much about being an organizer for health promotion, by clarifying objectives and work methods, and by
talking regularly with school staff about it. Being genuinely interested and arguing for its importance was described as crucial to success. ‘. . .You have to be pretty
confident in yourself as a manager and genuinely believe
that these sorts of issues are important, like how students are feeling and how you as a manager are going to
deal with that. That’s a big part of [helping students to]
perform’ (no. 2). The influence of school managers on
staff in working to promote student health emerged as
central in this context, giving inspiration to staff and
helping them to inspire each other. It was described as
vital that the school manager supported teachers in their
efforts to promote student health by encouraging and rewarding them through the salary system. Teachers’ roles
in health promotion had a lot to do with taking an interest in students’ well-being.
Organization and collaboration
The category organization and collaboration was described as central to health promotion in schools and
consisted of policy and leadership, partnerships and
competence.
Partnerships
Establishing partnerships with parents and the local
community emerged as essential for organization and
234
L. Persson and K. Haraldsson
Fig. 1:Categories that individually and together emerged as important in school health promotion to enable opportunities for learning and a good life.
collaboration in health promotion. The school managers
believed that forming partnerships with parents should
begin soon after the start of every new academic year.
Teachers were recognized as key persons when establishing partnerships with parents. Well-functioning partnerships with parents were important for their involvement
in students’ schoolwork and school activities overall,
and for quick resolutions to student issues. The school
managers gave examples of how to get parents involved
in school activities, for instance, by encouraging parents
to visit the school during a regular school day or by involving them in the parent council. Partnerships with
the local community such as sports clubs, local industry
and businesses and social services were perceived as important in demonstrating to students the connection between learning and real life. ‘I believe that the school
and the local community must be connected in some
way, I think that it is health promotion to be able recognize why you are doing something. . .’ (no. 1).
Partnerships with sports clubs gave students opportunities to develop interests in new sports. This was described as valuable for opening up immigrant girls’ first
contact with sport clubs. Partnerships with industry and
businesses, on the other hand, were significant in learning more about education options and careers in the future. Finally, partnerships with the local police and
social services were necessary in handling problems in
specific cases involving students.
Competence
The school managers described competence as an essential factor in organization and collaboration in health
promotion. Competence included the idea that the
school managers as well as school staff needed to be
competent role models, who were continually training
their leadership skills to progress and succeed with regular schoolwork and health promotion. It was also considered important to have access to a variety of tools to
prevent or handle problem situations, and to keep up to
date with new research in the field. ‘I really believe in
teachers, especially those who focus on improving
school quality and, for example, keep abreast of the latest research in the field and pass it on’ (no. 6). It further
emerged that it was important to pass on examples to
other teachers of successful leadership styles in order to
paint a picture for everyone involved of where the organization was headed as regards student health.
Optimize the arena
This category describes the importance of school as an
arena for health promotion. Student participation,
working climate and social networks in school were recognized as central in optimizing the arena in health
promotion.
Student participation
It emerged by the school managers that student participation in health promotion involved listening to other
students’ opinions concerning their schoolwork and
school activities, and the school environment overall, including opinions on the food in the canteen. ‘. . . last
year I spent a lot of time talking to older students. I’d
ask them: What would you like to see happen at school?
In what way? What would you rather see and what
should the school environment be like and so on? And,
we got a lot of good suggestions, and on the basis of
these we did quite a bit. For example, we set about making a brand new classroom and they had to be involved
in this, and finally we showed how it looked, so that
they also felt empowered’ (no. 10). Student representation on the school council as well as on the canteen and
school-environment councils was the most important
areas of student participation. On these councils students could express how they wanted the school environment to be, which food they wished to be served and
how to increase students’ well-being in general. The
school managers described how, on the basis of students’ comments they made decisions, addressed specific
topics and made changes. Student participation was considered as key to generating greater creativity and engagement among students in school as a whole.
Health promotion in Swedish schools
Working climate
The school managers highlighted the working climate as
central to optimizing the arena in health promotion. It
was important to create a work climate that improve
students’ feeling of security and desire to learn, and
helped them to strive for a climate free of competition,
where everyone got recognized for their abilities. It was
also important to organize different kinds of celebrations and joyful activities resembling life in general; to
have an open physical environment to eliminate precarious places and to have spaces where students could find
both a quiet and remote corner, as well as places where
they could socialize. ‘. . . It is important to have things in
school that are fun too, because it is through joy that
you learn’ (no. 8). The working climate was further described as including adults whose duties included social
activities with students, for example during breaks.
During break these adults socialize with students, take
note of and resolve conflicts and ensure that no student
is excluded from games. Furthermore, the school managers mentioned the importance of having a bullyingteam at the school to quickly solve such problems.
Having an appropriate language between adults and students also emerged as central for a pleasant working climate. The school managers pointed out that respecting
and caring for each other in school was essential. ‘It has
to do with respect for children. If you have respect for
children and take them seriously, the atmosphere at the
school will be good’ (no. 9). The school managers likewise emphasized that it was vital that students got an
outline of the school day, every morning by the teacher,
and had made it clear to them what was expected of
them and what they should accomplish during the day
to maintain optimal performance. Moreover, the managers acknowledged the need to keep themselves informed about the state of things if a good working
climate was to be maintained.
Social networks
Building social networks emerged to be essential for optimizing the arena and health promotion, mainly between students, but also between students and staff.
‘Relationship building is for me the key to all health promotion’ (no. 2). The school managers emphasized that
building social networks could be done in various ways:
by having student mentors in school, whose task it was
to create a good team spirit, by having special days with
companionship as a theme or by arranging meetings between students. Furthermore, social networks could be
formed through arranged discussion groups where students gather, talk and get to know each other; or by
235
occasionally building new classes: ‘Dissolving relationships and building new relationships in new groupings;
are important skills for a person to have. . . We see this
as a way to broaden the social safety net, and the more
people know you, the less likely you are to become a victim downtown late at night and so on. So, there is a certain amount of security in being involved in several
social networks...’ (no. 8).
Strengthen the individual
This category contains components that are significant
for strengthening the individual in health promotion
such as: confirmation, support, care and trust and learning about health.
Confirmation
Teachers, who see students for who they are, were described by the school managers as vital in health promotion ‘...You must see every student. That is the key!
Then, it is a delicate task, but the teachers who are adept, they do that!’ (no. 2). Teachers who confirmed students’ sense of themselves by showing respect to every
person and by talking and listening to the student during
the school day were important. The consensus was that
every student should be seen, heard and treated in a
pleasant way. ‘It is really important to see each child,
and to create a relationship with the child. This is something that we are recognizing more and more. . .’ (no. 3).
Support
To support the individual throughout his or her years at
school was described by the school managers as central
for strengthening the individual in health promotion.
Teachers played the most important role in supporting
the student, since they meet the person every day and
could quickly identify who was in need of help and support, either with their schoolwork or emotionally.
Hence, the school managers pointed out that all students
need individual support, not just individuals with learning problems or diagnosis. Teachers needed tools to support and assist each individual, if the student was to
achieve goals and succeed in school and to develop as a
person. ‘You should not feel limited because you think
that you cannot do better, dare more, or don’t have tools
to do so, we will help you. You should feel that you can
get where you want to get to’ (no. 5). It emerged that
teachers who worked together in teams and those who
cooperated with parents, as well as teachers with a background in special education and school healthcare staff
played an important role in quickly supporting individuals and in removing possible obstacles. Finally,
236
providing swift support was recurrently mentioned as
crucial by the school managers in order to ensure that
no student fell behind in his or her schoolwork, felt unwell or was expelled for any extended period.
Care and trust
Caring for the individual was described by the school
managers as valuable in strengthening the individual in
health promotion. Teachers played an important role in
caring for the individual by creating a trusting relationship with students, so that they can feel safe and secure,
helping them to perform optimally in their schoolwork.
‘Our results –the schools’ results– and the students’ results are dependent on them doing well. And on our
ability to create a trusting climate for them, which they
enjoy and which allow them to grow. If we fail in that,
we fail with our core mission – the learning process. It is
clearly very important that we spend a lot of time on
this, and take care of each student as much as possible’
(no. 13). The school managers emphasized that much effort is required to build trusting relationships between
teachers and students. It is about showing that you as a
teacher care about the student, so teachers’ individual
time with students was seen as essential. Private conversations were the most effective, and during that time the
teacher could get an overall picture of the student’s life,
and the student’s perspective on it. It was necessary for
the teacher and student to trust each other in order to
hold fruitful dialogs, and the feeling of mutual trust was
likewise strengthened through such conversations.
Learning about health
The school managers highlighted the fact that it was vital to strengthening the individual in health promotion
in order to give students solid competence in health
competence issues. Learning about health was seen as a
broad concept with the overall purpose to teach students
how to be concerned and respectful citizens, and to
show them the connection between health and performance in school. ‘It is important to understand quite
early the connection between how you feel and how you
perform and so on. But, taking responsibility for yourself is only something you do if you like who you are,
right?’ (no. 11). To teach students how to be good citizens was a priority. This included learning about human
rights, and the importance of voicing your opinion and
standing up for the welfare of others. What also
emerged was the importance of teaching students how
to keep and maintain good physical and mental health,
and how to behave well and communicate with others in
a pleasant way. Increasing students’ learning about
L. Persson and K. Haraldsson
health, could for instance, be done by generally talking
more about health, by having theme weeks on health, by
having discussions groups or group work on health, by
having healthcare staff inform students on how to adopt
a healthier lifestyle, by spending time outdoors and
learning more about nature or by serving ecological
food in the school canteen, and at the same time explaining why it is healthy.
DISCUSSION
Discussion of method
In qualitative content analysis, it is important to have
variation and diversity in the material (Graneheim and
Lundman, 2004; Hsieh and Shannon, 2005). This requirement was fulfilled since both men and women participated, and each participant represented a different
school district, with varying student retention rates and
socioeconomic status. Before each interview, the informant received both oral and written information about
the aim of the study and their ethical rights, which is important for the trustworthiness of the researcher. Given
the school managers’ different backgrounds and experience from their own school district, the research question could be looked at from several angles, important
factor in ensuring the credibility of the results. Inclusion
of citations in the presentation of the results facilitates
assessment of the study’s credibility and trustworthiness
is thereby enhanced, thus two researchers performed the
whole analysis process through discussion until consensus was reached (Graneheim and Lundman, 2004; Hsieh
and Shannon, 2005). Hence, a possible limitation could
be that there is more health promotion going on in the
school districts than expressed by the participants in this
study. However, the aim of the study was to get an overall picture of the views of the school managers regarding
what health promotion in school includes. Several examples of health promotion activities emerged from the interviews. Furthermore, the length of the interviews,
about 1 h, may have been insufficient. Albeit, the interviews were content rich and contained great variety.
Overall, the research process, including its design and
implementation has been described in detail and the
steps involved in the analysis have been carefully outlined (Graneheim and Lundman, 2004). Lastly, it is apposite to mention that the analysis was made by two
public health researchers and should therefore be understood from a public health perspective.
Discussion of result
School is an important setting for health promotion
(World Health Organization, 1986; Mittelmark, 2007).
Health promotion in Swedish schools
This study describes the views of school managers about
what their health promotion work include, and it concerned the following categories: organization and collaboration, optimize the arena and strengthening the
individual. These categories, taken separately and together, emerged as important for school health promotion as regards the enabling of learning and a good life.
They are in line with the salutogenic approach to health
promotion, which aims to enhance health and wellbeing in schools (Eriksson and Lindström, 2008).
Furthermore, within the salutogenic approach to public
health in the Ottawa Charter for health promotion, the
concept of ‘healthy learning’ has begun to gain ground
(Lindström and Eriksson, 2011). This supports the
theme of this study, because an individual needs to feel
well in order to learn. It is about creating an atmosphere
in school where students are comfortable, and can learn
and perform optimally. The results also show that the
school managers have a good understanding about what
a health-promoting school should be. Some of the results
address the criteria that need to be met in order to be an
HPS (World Health Organization, 2000; Lee et al.,
2007). Regarding ‘Organization and collaboration’, it
emerged that having a well-structured agenda for health
promotion in school was important for its success.
Similarly, functional partnerships with parents and the
local community were important for learning and a
good life. These are also important features of an HPS
(World Health Organization, 2000). Earlier research
shows that school managers can influence student results by clearly determining which strategies and actions
are relevant in an individual, organizational and policy
context (Leithwood et al., 2006). Furthermore, the
school managers expressed the view that having a
school-health policy was vital to the success of their
health promotion work. Research shows that a longterm, health-related school policy can have a positive
impact on students’ health (Julious et al., 2007).
Implementing an overall health-promoting policy for
schools, supported by school administration and management, as well as teaching, is vital for a healthy psychosocial environment and to being an HPS (World
Health Organization, 2000). Likewise, the school managers mentioned the role of teachers’ leadership style in
supporting, inspiring and increasing school staff’s willingness to work with health promotion. School managers and staff who share knowledge, observations and
thoughts with their colleagues the development of the
school’s organization as a whole, because nobody can
observe everything, know everything, nor develop their
thinking all on their own (Moos, 2011). The importance
of teachers’ leadership style in health promotion within
237
an organization is not mentioned in the World Health
Organization document concerning HPSs (World
Health Organization, 2000). It would be of value to examine teachers’ views on this and how they describe
their leadership role in health promotion. Furthermore,
working in partnership with parents was described as essential for students to feel engaged in their schoolwork
and in other activities at the school. The HPS concept
also touches on the benefit of parents taking part in their
children’s education (World Health Organization,
2000). Partnerships with the local community were considered by the school managers to be important in learning more about future education options and careers,
and necessary for the handling of problems in specific
cases involving students. It is health promoting for
schools to work in collaboration with parents and the
local community in order to enhance students’ health
and well-being (Stewart-Burgher et al., 1999; World
Health Organization, 2000; Aggelton et al., 2010;
Weare, 2010; Wills, 2010). Furthermore, it is possible to
make sustainable health changes, when taking a wholeschool approach, including parents and the local community (Wills, 2010), a point which is likewise underscored in the documents for the HPS (World Health
Organization, 2000). This helps the student to attain enhanced physical and mental health, as well as improved
social well-being (Wills, 2010). Competence was considered by the school managers as vital for organization
and collaboration in health promotion. This is in line
with research indicating that employees who undergo
continual training improve their own flexibility, capability and capacity to relate to students in an emotionally
healthy way (Weare, 2010). The education and training
of teachers and parents in health is thus important for
the HPS (World Health Organization, 2000).
Concerning ‘Optimize the arena’, it emerged that student participation was important for optimal health promotion work within schools, and that students want to
be listened to and involved in their schoolwork
(Haraldsson et al., 2010a). Asking for, and listening to,
students’ opinions concerning their schoolwork and
school as a whole was considered by the school managers to be important, as well as in accordance with the
Ottawa charter, the UN Convention on the Rights of the
Child and the concept of the HPS; which emphasizes the
participation of the target group (World Health
Organization, 1986; General Assembly, 1989; World
Health Organization 2000). Moreover, student participation has a positive bearing on schools, since both students and staff can learn from each other, and learn how
to work together (Kirby et al., 2003). Hence, schools
need to find learning strategies and teaching methods,
238
which will encourage reflection and personal awareness
(Naidoo and Wills, 2000). Here, the HPS concept could
better reflect the needs of students and assist them to
raise their concerns, by helping them to improve their
self-esteem and self-awareness, to be better in charge of
their own lives. Also, schools that take participation seriously have fewer expulsions and better attendance records (Hannam, 2003). Involvement by students in
school happenings was considered by the school managers to be important, along with the students’ ability to
have fun, and feel valued and respected. This is important for social and emotional development and for learning skills and students’ well-being (Butcher, 2010). The
school managers emphasized the importance of creating
a safe and friendly environment if students to like
school. Students who enjoy school have better selfesteem, lower levels of risk-taking behavior and higher
levels of self-rated health (Nutbeam et al., 1993 and
Samdal et al., 1998). Enjoyment of school allows positive relationships to flourish (James, 2010), and is one of
the greatest assets for change and creativity (Land and
Jarman, 1993). Similarly, the school manager’s pointed
to the building of social networks within the school as a
key part of optimizing the arena in health promotion.
Having a circle of supportive friends could moreover
help students manage stressful situations better
(Haraldsson et al., 2010a). This focus along with working in partnership with parents and the local community
was described by the school managers as important.
Partnership building contributes to long-term health and
well-being (Stewart-Burgher et al., 1999; World Health
Organization, 2000; Thomas et al., 2010). Enjoyment of
school, having friends and building new social networks
could be usefully studied further, and could afford to be
better highlighted in the concept of the HPS (World
Health Organization, 2000).
Concerning ‘Strengthening the individual’ was the
importance of warm and caring encounters that give students a sense of belonging, and a feeling of being accepted, valued, listened to and respected lifted. These
are vital prerequisites for the motivation to learn, for
good behavior and for good mental health (Haraldsson
et al., 2010b; Weare, 2010). Additionally, the feeling of
trust is in itself health promoting, and the key to being
able to cooperate properly with others (Jones and Barry,
2011). A climate of caring, respect and trust is also central to the HPS (World Health Organization, 2000). The
school managers stated the importance of supporting all
students, and not just those with special needs or diagnoses. This is interesting; as it is more common to focus
on strengthen those with poorer health in school
(Weare, 2010). Trying to strengthen health of everyone
L. Persson and K. Haraldsson
in school is in line with the salutogenic approach to
health (Eriksson and Lindström, 2008; Lindström and
Eriksson, 2011). The school managers considered that
role of teachers was crucial in this context, that is, to
confirm, support and care for the student. Lastly, they
described the importance of improving students’ understanding of health. It included teaching students how to
become democratic citizens, in line with ‘Health for all’
and the Swedish schools act (World Health
Organization, 1999; Sveriges Riksdag, 2010, p. 800).
Additionally, the school managers emphasized that
teaching students how to attain good physical, mental,
emotional and social health, and building up their social
and emotional skills, increases their motivation for
learning as well as, leading to more positive beliefs and a
greater sense of attachment to the school, which in turn
leads to better mental health, improved behavior and
greater academic achievements (Hawkins and Catalano,
1992; Eriksson and Lindström, 2008). The concept of
the HPS stresses the importance of health education in
school, but not so much what that include (World
Health Organization, 2000).
In sum this study shows that school managers have a
large impact on what is prioritized in health promotion.
The results also show that the school managers have a
good understanding of health promotion, as called for by
the concept of HPSs (World Health Organization, 2000).
With that it seems like the school managers are ready to
extend their health promotion work. It is however vital
that each school manager is particularly interested in these
issues and understands the value of them; and that he or
she organizes the school setting and the curriculum accordingly, taking a whole school approach for best results.
This study has added certain aspects for a more complete
picture concerning the views of school managers about
what health promotion in schools include. This knowledge
could function as a basis for schools when improving their
health promotion work. However, earlier research investigating the views of students, teachers and parents
(Torsheim and Wold, 2001; Haraldsson et al., 2010b;
Jourdan et al., 2010; Sansolios and Egberg Mikkelsen,
2011) differs from the views of the school managers in
this study. Besides, there is a need of further studies exploring the effects of the Health Promotion School concept
(Mukoma and Filsher, 2004). It is likewise vital that
school managers are responsive to all concerned when developing their health promotion approach.
CONCLUSION AND IMPLICATION
The study describes the views of school managers about
what health promotion in schools include, and three
Health promotion in Swedish schools
categories emerged: organization and collaboration, optimize the arena, and strengthen the individual. These
categories are important both separately and combined
for health promotion in schools in order to enable ‘opportunities for learning and a good life’ which emerged
as the latent content in this study. The results show that
the school managers have a good understanding of
health promotion, as called for by the concept of HPS.
With that it seems like the school managers are ready to
extend their health promotion work. It is however vital
that each school manager is particularly interested in
these issues and understands the value of them; and that
he or she organizes the schools and the curriculum accordingly, taking a whole school approach for best results. The study has given a more complete picture of
the views of school managers on what should be implemented in school as regards health promotion. This
knowledge can function as a basis for schools when developing their health promotion work. In order to get a
comprehensive picture and increase awareness of the importance of strengthening health promotion in schools,
today and in the future, it is vital to further explore
teacher and parent views of what health promotion in
school include. Research examining students’ opinions
about what concerns them are requested, and are moreover promoted by the UN convention on the Rights of
the Child.
FUNDING
The data collection was a part of a project founded by
the city of Karlstad, provided by foundation from the
Swedish National Institute of Public health.
REFERENCES
Aggelton, P., Dennison, C. and Warwick, I. (2010) Promoting
Health and Well-Being through Schools. Routledge, New
York.
€
Arlestig,
H. and Johansson, O. (2011) Research on principals in
Sweden. In Johansson, O. (ed.), Principals—A Research
Review 2000–2010, Chapter 5. Vetenskapsrådet [The Swedish Research Council], Stockholm, pp 76–111.
Butcher, J. (2010) Children and young people as partners in health
and well-being. In Aggelton, P., Dennison, C. and Warwick, I.
(eds), Promoting Health and Well-Being through Schools,
Chapter 9. Routledge, New York, pp 119–133.
CSDH. (2008) Closing the Gap in a Generation: Health Equity
through Action on the Social Determinants of Health. Final
Report of the Commission on Social Determinants of
Health. World Health Organization, Geneva.
Currie, C., Nic Gabhainn, S., Godeau, E., Roberts, C., Smith, R.
and Currie, D. (eds) (2008) Inequalities in Young People’s
239
Health: HBSC International Report From the 2005/2006
Survey. WHO, Regional Office for Europe, Copenhagen.
Eriksson, M. and Lindström, B. (2008) A salutogenic interpretation of the ottawa charter. Health Promotion International,
23, 190–199.
General Assembly. (1989) The United Nations Convention on the
Rights of the Child. Resolution 44/25 of November 1989.
Graneheim, U. H. and Lundman, B. (2004) Qualitative content
analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today,
24, 105–112.
Gustafsson, J. E., Allodi Westling, M., Alin Åkerman, B.,
Eriksson, C., Eriksson, L., Fischbein, S. et al. (2010) School,
Learning and Mental Health: A Systematic Review. Health
Committee. The Royal Swedish Academy of Science,
Stockholm.
Hannam, D. (2003) Participation and responsible action for all
students: the crucial ingredient for success. Teaching
Citizen, 5, 24–33.
Haraldsson, K., Lindgren, E-C., Hildingh, C. and Marklund, B.
(2010a) What makes the everyday life of swedish adolescent
girls less stressful: a qualitative analysis. Health Promotion
International, 25, 192–199.
Haraldsson, K., Lindgren, E-C., Mattson, B., Fridlund, B. and
Marklund, B. (2010b) Adolescent girls’ experiences of underlying social processes triggering stress in their everyday
life: a grounded theory study. Stress and Health, 27, 61–70.
Hawkins, J. D. and Catalano, R. (1992) Communities That Care:
Action for Drug Abuse Prevention. Jossey-Bass, San Fransicso.
Hsieh, H. -F. and Shannon, S. E. (2005) Three approaches to
qualitative content analysis. Qualitative Health Research,
15, 1277–1288.
James, C. (2010) The contribution of parents. In Aggelton, P.,
Dennison, C. and Warwick, I (eds), Promoting Health and
Well-Being through Schools, Chapter 10. Routledge, New
York, pp 134–146.
Johansson, O. and Bredeson, P. V. (2011) Future research perspectives on principals—what research is missing. In Johansson,
O. (ed.), Principals—A Research Review 2000–2010,
Chapter 4. The Swedish Research Council, Stockholm,
pp 61–74.
Jones, J. and Barry, M. M. (2011) Developing a scale to measure
trust in health promotion partnerships. Health Promotion
International, 26, 484–491.
Jourdan, D., McNamara, M. P., Simar, C., Geary, T. and
Pommier, J. (2010) Factors influencing the contribution of
staff to health education in schools. Health Education
Research, 25, 519–530.
Julious, S., Osman, L. and Jiwa, M. (2007) Increases in asthma
hospital admissions associated with the end of summer vacation for school age children with asthma in two cities from
England and Scotland. Public Health, 121, 482–484.
Kirby, P., Lanyon, C., Cronin, K. and Sinclair, R. (2003)
Building a Culture of Participation: Involving Children and
Young People in Policy, Service Planning, Delivery and
Evaluation. Handbook. DfES, London.
240
Land, G. and Jarman, B. (1993) Breaking Point and Beyond.
HarperBusiness, San Francisco.
Lee, A., St Leger, L., Cheng, F.F, Hong Kong Healthy Schools
Team. (2007) The status of health-promoting school in
Hong Kong and implications for further development.
Health Promotion International, 22, 316–326.
Leithwood, K., Day, C., Sammons, P., Harris, A. and Hopkins,
D. (2006) Successful School Leadership: What It Is and
How It Influences Pupil Learning. DfES, London.
Lindström, B. and Eriksson, M. (2011) From health education
to healthy learning: implementing salutogenesis in educational science. Scandinavian Journal of Public Health, 39,
85–92.
Lynagh, M., Schofield, M. J. and Sanson-Fisher, R. W. (1997)
School health promotion programs over the past decade: a
review of the smoking, alcohol and solar protection literature. Health Promotion International, 12, 43–60.
Marmot, M. (2009) Social determinants and adolescent health.
International Journal of Public Health, 54, 125–127.
Mittelmark, M. B. (2007) Setting an ethical agenda for health
promotion. Health Promotion International, 23, 78–85.
Mohammadi, N. K., Rowling, L. and Nutbeam, D. (2010)
Acknowledging educational perspectives on health promoting schools. Health Education, 110, 240–251.
Moos, L. (2011) Research on principals in Denmark. In
Johansson, O. (ed.), Research on School Leaders, Chapter 7.
Vetenskapsrådet [The Swedish Research Council],
Stockholm, pp 134–160.
Mukoma, W. and Filsher, A. J. (2004) Evaluations of health promoting schools: a review of nine studies. Health Promotion
International, 19, 357–368.
Naidoo, J. and Wills, J. (2000) Health Promotion Foundations
for Practice, 2nd edition. Baillière Tindall, New York.
Nutbeam, D. (1987) The health promoting school: organization
and policy development in welsh secondary schools. Health
Education, 46, 109–115.
Nutbeam, D. (2000) Health literacy as a public health goal: a
challenge for contemporary health education and communications strategies into the 21st century. Health Promotion
International, 15, 259–267.
Nutbeam, D., Smith, C., Moore, L. and Bauman, A. (1993)
Waring! Schools can damage your health: alienation from
school and its impact on health behaviour. Promotion and
Education, 2, 4–7.
Rowling, L. and Jefferys, V. (2000) Challenges in the development
and monitoring of health promoting schools. Health
Education, 100, 117–123.
Samdal, O., Nutbeam, D., Wold, B. and Kannas, L. (1998)
Achieving health and educational goals through schools: a
study of the importance of school climate and students’
L. Persson and K. Haraldsson
satisfaction with school. Health Education Research, 13,
383–397.
Sansolios, S. and Egberg Mikkelsen, B. (2011) Views of parents,
teachers and children on health promotion in kindergartenfirst results from formative focus groups and observations.
International Journal of Pediatric Obesity, 6, 28–32.
St Leger, L. (1998) Australian teachers’ understandings of the
health promoting school concept and the implications for
development of school health. Health Promotion
International, 13, 223–235.
St Leger, L. and Nutbeam, D. (2000a) Research in health promoting schools. Journal of School Health, 70, 257–259.
St Leger, L. and Nutbeam, D. (2000b) A model for mapping
linkages between health and education agencies to improve
school health. Journal of School Health, 70, 45–50.
Stewart-Burgher, M., Barnekow-Rasmussen, V. and Rivett, D.
(1999) The European Network of Health Promoting
Schools the Alliance of Education and Health. WHO
Regional Office for Europe, Copenhagen.
Sveriges Regering. (2007/08). En förnyad folkh€
alsopolitik.
Regeringens proposition [The Swedish Code of Statutes. A
New Public Health Policy. Government Bill], 110 pp.
Sveriges Riksdag. (2010) Skollagen [The Swedish Code of
Statutes. The Education Act], 800 pp.
Thomas, M., Rowe, F. and Harris, N. (2010) Understanding the
factors that characterise school-community partnerships.
Health Education, 6, 427–444.
Torsheim, T. and Wold, B. (2001) School-related stress, support,
and subjective health complaints among early adolescents: a
multilevel approach. Journal of Adolescent, 24, 701–713.
Weare, K. (2010) Promoting mental health through schools. In
Aggelton, P., Dennison, C. and Warwick, I (eds), Promoting
Health and Well-Being Through Schools, Chapter 3.
Routledge, New York, pp 24–41.
Wills, W. (2010) Tackling obesity: promoting physical
activity and healthy eating in schools. In Aggelton, P.,
Dennison, C. and Warwick, I (eds), Promoting Health and
Well-Being through Schools, Chapter 5. Routledge, New
York, pp 56–68.
World Health Organization. (1986) The Ottawa Charter for
Health Promotion. WHO Regional Office for Europe,
Copenhagen.
World Health Organization. (1997) Jakarta Declaration on
Leading Health Promotion into the 21st Century. World
Health Organization, Geneva.
World Health Organization. (1999) Health for all in the 21st
Century. WHO Regional Office for Europe, Copenhagen.
World Health Organization. (2000) Local Action—Creating
Health-Promoting Schools. WHO Regional Office for
Europe, Copenhagen.