Open letters about health dialogues reveal school staff and students' expectations of school health promotion leadership

Abstract

Purpose

This study explores to what extent health promotion policy in practice and leadership engagement is reflected in school actors' experiences of health dialogues (HDs) and their ideas about promoting health and learning in schools.

Design/methodology/approach

The 93 participants consisted of 44 school nurses, 37 students in grades 4, 7 or the first year of high school and 12 teachers, who shared their experiences with HDs by writing open letters.

Findings

The qualitative content analysis resulted in four themes: Putting health on the agenda, Finding a common goal, Walking side by side and Pointing out a healthy direction. The participants' expectations of school health promotion leadership are revealed in suggestions on how the HDs can fulfill both the educational assignment and promote student health.

Practical implications

Based on the findings, we argue that for successful school health promotion leaders need to acknowledge the field of tension where leadership has to take place, anchor health promotion policy and administer “a Sandwich approach” – a top-down and bottom-up leadership simultaneously that facilitates school-based health promotion.

Originality/value

When different school actors (school nurses, teachers and students) are given a voice, a collective picture of HDs can emerge and help develop health promotion practices.

Citation

Kostenius, C. and Lundqvist, C. (2022), "Open letters about health dialogues reveal school staff and students' expectations of school health promotion leadership", Health Education, Vol. 122 No. 3, pp. 318-334. https://doi.org/10.1108/HE-06-2020-0046

Introduction

There are strong links between student's health and academic achievements (Correa-Burrows et al., 2017; Dadaczynski et al., 2019). Therefore, school staff should be educated about the relationships between health and school performance (Busch et al., 2017) and how “school health promotion initiatives often target several levels (e.g. individual, professional, procedural and policy) simultaneously” (Rosas, 2017, p. 301).

The World Health Organization (WHO, 1946) has defined health as:

… a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity (p. 100). The Ottawa Charter on Health Promotion views health as a resource for everyday life, not the objective of living, and a positive concept emphasizing social and personal resources, as well as physical capacities (WHO, 1986, p. 1).

In 1997, the WHO's expert committee on comprehensive school health education argued that health-promoting school (HPS) initiatives would positively influence the health and education of future generations (WHO, 1997). Since then, practice and research have followed. Although definitions have varied over the years, a HPS “can be characterized as a school constantly strengthening its capacity as a healthy setting for living, learning and working” (WHO, 1998a, p. 1). Interventions proven to be effective have been identified and evaluated with methodological rigor, contributing factors that led to successes and considering country variations (WHO, 2017). Forums for in-depth knowledge sharing about becoming a HPS and how to design school health promotion have been established (SHE, 2020).

Additionally, there is a large body of research on HPSs. The work of Simovska and McNamara (2015) thoroughly develops the issue of sustainability in HPS. For example, Young (2015) argues that highly effective HPSs have common features, like a clear and focused vision, a safe and stimulating school environment, excellent leadership celebrating student and school successes and strong home–school relations. Also, in strengthening sustainable development in schools, students need to become critical about their attitudes and behaviors linked to health and sustainability (Deschesnes et al., 2014).

There are also arguments that school management and educational practices bring together research in areas such as school health, learning and teaching and, schools' effectiveness in achieving educational, health and social outcomes (Turunen et al., 2017). This complexity and need for collaboration across professional and institutional borders can be compared with the whole-school-approach described by multiple researchers (see, for example, Dassanayake et al., 2017; Kearney et al., 2016; Warne, 2013). However, schools tend to remain with a traditional topic-based approach instead of realizing an integrated whole-school-approach, which indicates a need for more support during implementation and cultural adjustments of health promotion activities (Adamowitsch, 2017; McIsaac et al., 2017).

School leaders in health-promoting schools

School leaders play a crucial role in health promotion efforts, and their collaboration with other stakeholders influences the successful realization of HPS (Langford et al., 2017). However, successful health promotion within a national educational system also requires political will and a partnership with mutual understanding between the education and health sectors to build trust and capacity (Kostenius et al., 2019; Young et al., 2013). Research has pointed to the critical importance of school leaders and their role in the successful implementation of HPS programs (Dadaczynski et al., 2020a; Viig et al., 2005). The role of school leaders is recognized as crucial for the school's development work (Hallinger, 2018), and principals have been conceptualized as gatekeepers of change (Fullan, 2001).

There have been lessons learned during the past decades from HPSs worldwide, where aspects, such as the crucial role of school leaders and their collaborative processes, including other stakeholders, are emphasized. For example, a Dutch HPS pilot intervention empowered an HPS coordinator to organize the program with partners from both inside and outside the school (Busch et al., 2015). Their findings show how this HPS intervention successfully changed student health behaviors, for example, by decreasing alcohol use, smoking, sedentary time and bullying behaviors. As a result, the students had significantly fewer psychosocial problems. These researchers suggest more strongly integrating health literacy, positive attitudes toward HPS and competencies in health promotion into the qualification and training of school leaders. However, school managers can have a good understanding of health promotion, but not act on their interests in health promotion (Persson and Haraldsson, 2013). School managers need not only to be interested in health promotion issues and understand their value, but to organize the school setting and curriculum accordingly, taking a whole-school approach for best results.

Combining health education in the classroom with the development of school policies, the school environment, life competencies and involving the whole school community makes for a complex undertaking (SHE, 2020). Colquhoun (2008) confirms the complexity of HPS and the conflicts and tensions that might arise for schools in handling societal challenges, such as ill-health, inequality and social exclusion. In this respect, school leaders can be described as positioned in a “field of tensions”, where multiple and sometimes conflicting assignments must be handled (Berg, 2003).

Influenced by Spillane (2005), we apply a working definition of the term leadership, which involves “...activities tied to the core work of the organization that is designed by organizational members to influence the motivation, knowledge, affect, and practices of other organizational members” (p. 384). This definition excludes relations that are not tied to the core work of the organization. In this article, we discuss two formal leader positions, principals and managers of student health services (SHS). In addition, in a Swedish context, the municipality school organizer refers both to the political leadership and to the head of the school organization.

Student voices and participatory processes in health-promoting schools

The principles of health promotion involve empowerment, participation, holism, intersectionality, equity, sustainability and multi-strategy support, and these have consequences for HPS implementations (WHO, 1997; 1998b). Regarding empowerment, Carlsson (2015) holds that involving students in the formulation of health problems and solutions, and transformative learning principles emphasizing critical reflection, thinking and action, can ensure that education is not reduced to a technical function in school health promotion. Bruun Jensen and Simovska (2005) argue for the involvement of students in learning and health promotion processes and explain that the participatory approach needs to influence all aspects of a democratic HPS. Students can inform school development, and their participation can foster engagement and create opportunities for school improvement (Peacock, 2006).

However, to successfully consider what students tell us regarding how best to improve schools, youth-adult partnerships are needed (Mitra, 2009). Similarly, Bragg (2007) suggests building a listening culture in school as relationships are key to promote health and learning in school; it is not about the school system itself, she argues. However, the school system needs to enable the process of increasing people's control of their health, which can be enhanced when they are heard and when they perceive that their contributions are valued (WHO, 1998b). Participatory practice can empower people by giving them a voice and space in a democratic spirit (Ghaye et al., 2008; Kostenius and Nyström, 2020).

Aim

This study explores to what extent health promotion policy in practice and leadership engagement is reflected in school actors' experiences of health dialogues (HDs) and their ideas about promoting health and learning in schools.

Theoretical starting point

Researchers within the field underline the complexity of HPS, as health education can involve the whole school community (SHE, 2020) and many interventions, policies and professions intersecting in the school arena, and that schools are often expected to handle societal challenges (Skott, 2018; Colquhoun 2008). Dadaczynski et al. (2019) call for an integrated multi-setting approach. Taking this into account, our theoretical starting point is policy enactment theory, which concerns policy actors' creative processes of interpretation, translation and negotiation. Consequently, “policies are understood as processes as it is enacted (rather than implemented) in original and creative ways within institutions and classrooms” (Braun et al., 2011, p. 586). This theoretical perspective is responsive to contextual dimensions – as, argued by Braun et al. (2011). We argue that this theoretical starting point helps us grasp the complexity and offer a wide perspective on HPSs.

Following our argumentation for participatory processes enhancing school actors' empowerment (Peacock, 2006; Ghaye et al., 2008), teachers, school nurses and students are all understood as policy actors involved in processes of interpretation and translation of policy into practice (Ball et al., 2012). Enacting policy is an act of positioning, as interpretations and sense-making of the policy depend on “where you stand” (Maguire et al., 2015). Therefore, we highlight how school actors enact the health promotion assignment and understand leadership engagement, as they position themselves with the roles and engagement they ascribe to school leaders.

Policy enactment studies have mainly focused on teachers and school leaders as policy actors. However, following Ball et al. (2012) and Tanner and Pérez Prieto (2014), we argue that students are also policy actors. Tanner and Pérez Prieto (2014) thus illustrate that both teachers and students contribute to the translation, use and maintenance of policy discourses, though unequally.

Methods

The chosen design was inspired by participatory research which has the potential to empower people involved, through democratic partaking and appreciating strengths and abilities (Ghaye et al., 2008). When people feel heard and valued they can become empowered to influence their own practice (Melander-Wikman et al., 2006). Participatory research is doing research with people in a given context, not doing research on people (Heron and Reason, 2001). By introducing the beginning of a sentence, we encouraged the participants to take part by thinking of a HD they participated in and asked them to share their ideas about promoting health and learning in school. The participating school actors' shared experiences enabled the exploration of health promotion policy in participatory process enhancing school actors' empowerment (Ghaye et al., 2008; Kostenius and Nyström, 2020).

Context and participants

In Sweden, where this study took place, several policies reflect a political interest in health promotion in schools. According to the Swedish law (SFS, 2010, p. 800), all students in preschool, grades 4, 7 and the first year of high school are entitled HDs with SHS staff. To allow students to develop to their fullest potential and enjoy school, there is a need for a well-functioning SHS with close collaboration among the SHS, teachers and school leaders (SKL, 2018). In Sweden, the school principal has the formal and overall responsibility for ensuring that the school focuses on achieving national goals. The Education Act (2010: 800) extends and clarifies the principal's responsibilities, authority and decision-making powers. It provides principals new instruments to continuously shape and develop their schools' organization and pedagogical activities (Swedish School Inspectorate, 2015). The pedagogical leadership is stated as a key concept and assignment for school principals (Johansson, 2011). Further, the principals are responsible for student health, ensuring good study conditions and student safety (SFS, 2010, p. 800).

This study was carried out in the most northern county in the Arctic region of Sweden (Norrbotten), including 14 municipalities ranging in size from approximately 2,700 to 78,000 inhabitants. Three schools in three municipalities in the region were contacted based on variations (one large, one medium and one small municipality) inviting students and teachers in the three schools (one primary, one middle and one high school) to participate. All 55 school nurses in the region were invited. The 93 participants included 44 school nurses, 37 students in grades 4, 7 or the first year of high school and 12 teachers from the same grades as the students. Due to the risk of identifying the municipality and the individual participants, we have refrained from collecting additional information.

Data collection and ethical considerations

The entire research project was focusing on health promotion school development in a broad sense, while this particular article focused specifically on leadership aspects. The participants were invited to write an open letter by continuing the following sentence; “To use the health dialogue to its fullest potential to promote student's health and learning, I think that…”. They were encouraged to think about one or many HDs and describe their experiences with holding, participating in or facilitating HDs. The open letters were distributed in both paper and digital forms so that participants from a large geographical area could take part. The first author visited the regional network for school nurses from the 14 most northern municipalities in Sweden on three different occasions and distributed the open letters. The first author and LN (see acknowledgments) visited the three schools in the three different municipalities, inviting students and teachers to participate in the study. The study was approved by the local ethics committee [2017/403–431].

Analysis

The data consisted of 93 open letters (handwritten or digital). The process of analyzing the open letters was inspired by Graneheim and Lundman's (2004) qualitative content analysis. The authors read all of the transcribed data multiple times to obtain an initial sense of the whole and discussed their individual understandings. Further they highlighted meaning units, where the authors aimed to individually identify the experiential structures found in the data and looked for differences, similarities and patterns. The underlying meanings were discussed while creating subthemes. Finally, the authors asked themselves the following questions; What are different school actors' thoughts about how HDs can be used to their fullest potential to promote student health and learning? To what extent do their reflections address leadership engagement? Based on this query four themes were created that describe what the text is talking about, referred to by Graneheim and Lundman (2004) as the latent content.

Findings

The qualitative content analysis resulted in four themes: Putting health on the agenda, Finding a common goal, Walking side by side and Pointing out a healthy direction. The school staff and students' expectations of school health promotion leadership are revealed in suggestions on how the HDs can fulfill both the educational assignment and promote student health.

Putting health on the agenda

The participants' thoughts about using the HD to its fullest potential make visible the expectations of leadership, including health promotion as a valuable aspect of educational responsibility. This, according to the participants is a prerequisite for putting health on the agenda.

The participants argued that the HD needs to be prioritized and viewed as something valuable, helping the students excel and helping the school staff fulfill their professional assignments. One school nurse wrote that the HDs “...need to be accepted as part of the student's learning; having the HDs is part of their learning”. The input and results coming from the HDs are, according to the participants, valuable information. One student wrote, “I think that the HDs can help the teachers and everybody to understand how we perceive things”. However, in order for the HDs to have full potential for promoting students' health and learning, the participants suggested a change in attitude. One teacher wrote, “My experience is that student HDs do good and are important. We need more staff, resources and opportunities to help students in a more comprehensive way.”

According to the participants, when school leaders view health as part of the educational responsibility, HDs are prioritized as a natural part of health promotion and disease prevention efforts. The leaders have the power to put health on the agenda and to get everyone involved, school staff, students and parents alike, which increases the chances for a common agreement that good health supports learning. The HD is an important tool in the health-promoting efforts in school, improving not only students' health and wellbeing but also increasing their school achievements. The participants stressed the role of the heads of schools and principals to put health on the agenda. One teacher who also was a principal wrote:

As a new principal, I did not get any information about the HDs and when these were to be held. The nurse came to me after she had completed the HDs to talk about (student's) ‘individual problems,' some which were known; however, new issues emerged. I was surprised and astonished at the width of the questions in the HD questionnaire and realized that the information the school receives from the HDs is very valuable!

One teacher wrote that the HDs:

should be held more often, preferably in every grade, in order for students to feel that we care about them and that there will be an annual follow-up. Only then will we notice possible improvements. It may be a good idea for many more adults who work with the students to become involved in HDs. Then several viewpoints could be gathered. After all, health is complex.

A student reflected on voicing students' needs and how the school practice can facilitate a health-promoting environment “We can give some tips ... about how to act during breaks and then you can hire staff to be involved during the breaks, people who are also calm and kind to the students”. All in all, to put health on the agenda in school, there's a need for a health-promoting direction. One school nurse wrote, “We need to raise questions and talk about how we can perform HDs so that these can be truly health-promoting and not just measuring height and weight and talking about problems”.

Finding a common goal

The participants' thoughts about using the HD to its fullest potential made clear that school leaders need to be engaged in making health promotion a common goal for all actors in the school, i.e. professionals, students and parents. The participants identified aspects such as sufficient time to hold the HD and prioritizing health promotion efforts as key to successfully using the opportunity. Additional time slots would, according to them, enable the school nurses to fully interact with each student. One school nurse wrote, “In order for the HDs to have full potential promoting the student's health and learning, I think we must have fewer students per school nurse. We need more time for each student”. She continued, “Documentation and using statistics take a lot of time. We need more time for each student, fewer students.” Although lack of time is an aspect in need of improvement, according to the participants, the way the time is spent (the quality of the encounter) is also important. In order to find a common goal, the students' suggestions on what is needed for a HD to be successful are valuable. Acknowledging the challenges with disease prevention and problem-solving strategies is key. One student wrote, “some are afraid to talk about mental illness because they are afraid of being judged in a bad way”.

The participants made suggestions on finding a common goal, and it was evident that understanding each other was permeating their experiences. The lack of information about the purpose of the HD was seen as a deficiency. One school nurse wrote:

It is important that the teachers and principals have an understanding of what we are doing during the HDs. Why do we do them? They are part of the health promotion efforts in school, and it (the school nurses assignment) is not just about measuring height and weight, checking eyesight and hearing.

The absence of a feeling of team effort made it difficult to be engaged. One teacher wrote, “I have no experience with them//...teachers should receive information about what can affect the student's learning and social situation in school”. Understanding each other, according to the participants, is easier within a school organization that promotes an all-inclusive environment, than everyone tending to their tasks without seeing their role in building the common good for everyone in the school. One school nurse stated:

I believe that a well-functioning student health service team at a school can work magic. However, to succeed, everyone in school must promote health, all staff from the school restaurant, the school janitors, the teachers etc.

Similarly, a teacher expressed: “We should gather teachers and student health professionals to form a summary of general development opportunities and strengths after the HDs.” However, health promotion is more complex than gathering all staff. A listening culture was described as a prerequisite for all actors to be seen and heard. One student expressed that “it is good to know that there is always someone to talk to.”

The participants also suggested bringing the results from the HD to the guardians. One teacher wrote, “It is also important to meet with parents, the student, and other school staff to discuss the student's situation and the efforts needed to help the student”. According to the participants finding a common goal also included the guardians' health promotion and disease prevention efforts to be successful. One school nurse wrote:

In my world, we have to be MUCH better at building good relationships with the parents beginning in preschool. We need to meet early on if problems arise. Without having parents with us, we are not going to succeed.

The students connect their health and wellbeing as well with the different contexts of both home and school and made suggestions for the HD to be a tool to help students confide in someone about their situation. One student wrote: “When you have had the HD, perhaps you'll find the need to talk to someone, if one feels bad, have a hard time at home or so. More students may start talking to each other about it and then feel better.”

Walking side by side

The participants believed that to use HD to its full potential involves leadership engagement that supports collaboration among all school staff, students and parents. The collaboration was described on different levels, including the individual student's level and crossing professional boundaries to work side by side. One teacher wrote, “It is important to bring in all actors to get a comprehensive picture of the student's situation”. A school nurse concluded, “Cooperation with teaching staff and school management needs to be improved. Student health is created together, not something that the student health professionals can fix on their own”. They elaborated about finding a common cause that agreed on the content of HPS development. They emphasized the importance of finding a common interest in HDs and clarifying staff responsibilities. One teacher wrote:

Routines for HDs should be planned in collaboration with the pedagogical staff, the student health staff, and the principal in a joint planning day in June. The important point is to address HDs and their “role” in the health promotion efforts at school.

Participants articulated the importance of seeing the potential of the HD among school staff and students alike in order for the HDs to be best used to promote health. One student wrote, “It gives teachers and other adults in the school world a chance to see how their students feel and be able to do something about it. If students are very tired, the (adults) can fix the school days and lessons based on that!”.

HD questionnaires are used as a point of departure for the HDs between the school nurses and the students. They also provide a way to collect and save information about students' self-reported health in a database. The participants described an HD database as an opportunity to enhance health promotion efforts in school. According to the participants, using the results from the HD questionnaires was not only a task for the health professionals but also the teaching staff, municipality officials and the local politicians. A school nurse wrote:

Give feedback about the health questionnaire to school staff and parents. It is important to bring the teachers into the work. Student health starts in the classroom. The results must be disseminated at all levels from the student and up to the officials in the municipality and the politicians.

The participants pointed out the importance of communicating results from the HD questionnaire with the students. This could bring awareness to the students themselves about the results and how they can relate to these. They indicated several possible ways to involve the students in analyzing the HD questionnaire results on individual, group and school levels. One school nurse wrote, “I think we could benefit from using the questions about food ... and ask what the student thinks about the results and what might improve the result rather than pointing to where they wrote the ‘wrong’ answer”. Further, unleashing the power of positive change was articulated by the participants due to making the HD a part of the school organization. When able to successfully walk side by side, the professional collaboration within the school organization could enable positive change on the individual student's level. One student wrote, “It was a wake-up call for me, I got to see what my diet and sleep look like on paper. I have started to eat breakfast and sleep better now, on my own”.

Pointing out a healthy direction

Although we asked the participants to share their ideas about using the HDs to their fullest potential to promote student's health and learning in school, we received several negative narratives presenting an array of challenges. The participants described school leaders who were not considering HDs as an important part of the school's mission, which is reflected in decisions regarding which professionals were hired and which issues were on the school agenda. One school nurse wrote:

At some schools, the management and the teaching staff show little or no interest in hearing about the results. They do not see the potential of working with the results. It can even become a problem for some teachers when the students are pulled away from the classroom for their HDs.

A teacher wrote:

The saddest thing is that sometimes the HDs do not help. Either you do not receive the help or resources you would need. There is either no staff or money/materials/possibilities to help. Then I, who am a teacher, become frustrated and get the feeling that we only sit in meetings, but nothing happens. That is a waste of time.

The participants also pointed out a power imbalance in the school as an organization. One student wrote, “children should be able to decide”. However, parallel with their descriptions of the lack of sufficient leadership engagement, they elaborated on the need for school leaders to indicate a healthy direction.

Discussion

The qualitative content analysis resulted in four themes: Putting health on the agenda, Finding a common goal, Walking side by side and Pointing out a healthy direction. These themes illuminate a large variation of school actors' experiences of HDs and their ideas about using the HD to its fullest potential to promote student's health and learning. The findings give a broad picture of the school nurses', teachers' and students' experiences, and descriptions of contexts reflecting health promotion policy in practice and leadership engagement (in terms of principals and SHS managers engagement), or lack thereof. Similarly, Carlsson and Simovka (2012) found that the interplay between different approaches when implementing HPS projects and contextual factors substantially influence the scope of the outcomes. Regardless of the extent to which the participants felt that they had promoted health and learning in school in general, and developed the HDs in particular, we identified a consensus on what is desirable, which will be addressed in the following discussion.

Leadership in a field of tensions – a possible way forward

According to the findings, there seems to be a field of tension where leadership has to take place. First of all is this important to acknowledge. Given that school leaders are of critical importance to their entire school, this professional group should be placed more firmly in the focus of school health education and health promotion (Dadaczynski et al., 2020b). The health-promoting organization that the professionals described involved administrative leadership building structures, budgeting and directing resources. However, just as important was the pedagogical leadership described as capable of creating consensus and common goals shared by both teachers and SHS staff. Thus, the findings illustrate a principal's leadership concerns about creating both structures and cultures. Previous studies show that principals enter a field of tensions where the ambiguous structure of the school organization together with the different cultures in school and healthcare challenge their preconditions for successful leadership (Törnsén, 2014; Höög, 2014).

The findings provide a picture of great variations. On the one hand, professionals voice a collective responsibility for health and learning, and on the other hand, professionals do not collaborate to accomplish their assignments. To handle this, different staff situations present leadership challenges for principals. Törnsén (2014) described tensions between different perspectives that the principal must deal with in his/her leadership. This tension is based on different views of the starting point for the work of the SHS staff, a professional perspective or a school assignment perspective.

In order to manage an HPS on an individual, group and organizational level, collaboration with managers and leaders of SHS is crucial. Developing a collaborative culture enables dialogue about role perception and mission perception so that the strengths with the professional perspective can be supplemented with an assignment perspective in line with the school's governing documents (Törnsén, 2014). Based on the findings, school actors appreciate the leadership that enables collaboration and builds bridges of communication and understanding. In other words, they desire school leaders who point out a common healthy direction involving actors at all school levels: student and professional, group and organization. This calls for simultaneously administering a top-down and bottom-up leadership – a Sandwich approach – facilitating school-based health promotion. This echoes Rowling's (2009) and Warne's (2013) description of a whole-school approach. According to the findings, such an approach requires leaders at different levels within the school organization to collaborate and take responsibility for defining a healthy direction.

Health promotion policy needs to be anchored

Based on the findings, we argue that health promotion policy needs to be anchored with all students and professionals at the school and municipal levels with support in the local and national political agenda in order for actors to successfully practice health promotion policy. Collaboration with the guardians is also highlighted in the findings.

One of the possibilities that surfaced in the findings illustrates how HDs are a natural part of health promotion and disease prevention efforts. School leaders and teachers are familiar with the purpose and results of the HD questionnaires and, consequently, with how this is handled as a shared responsibility among school professionals. The findings show how HDs can be used as tools for reactive interventions identifying students with problems to help them. Additionally, the health-promoting benefits of HDs were described by participants throughout the entire school organization, at the individual, group, and institutional levels. The participants experienced different levels, from individual to organizational, as interwoven and spoke for the need to view the HDs as being beneficial not only for individual students but also for the entire school environment. The findings are in line with Gugglberger and Dür (2011), who argue that schools need support from their environment in terms of building resources and institutionalizing health promotion into their core and management processes.

The findings illuminate challenges and a lack of principals and SHS managers leading the development of HD to contribute to the school's educational assignment. There also seems to be a discrepancy between the high expectations of the School Health Services (SHS) staff and the assignments that SHS has under current government regulations. National reports from Swedish schools further reveal the widespread view that one of the most challenging aspects is how to develop health promotion and disease prevention efforts (Swedish School Inspectorate, 2018). According to the Swedish School Inspectorate, several school organizations are deficient in SHS, with great variations among schools. Also, the agency states that variations are seen not only among schools but also between occupational groups, and the extent to which SHS staff are involved in realizing educational goals. This means that the principal's prerequisites for organizing and conducting efficient SHS are limited.

When problematizing the findings further, one alarming consequence of inadequate school organization and indistinct leadership engagement regarding health promotion is that reactive interventions targeting individual students are easier to achieve. Therefore, reactive interventions on the individual level can be prioritized at the expense of promotional efforts at the group and school levels. Such an individualized perspective can also mean that social problems in school and societal challenges can be conceptualized as a student's problems (Säljö and Hj örne, 2013). In a school context with insufficient structural readiness to correctly address the results from the HD questionnaire and detected problems at the school or organization level, there might be a tendency to individualize students' ill-health (cf. Törnsén 2014). In the worst-case scenario, this can lead to an unjustified preponderance for treatment and medicalization (Mind, 2018). On a societal or municipal level, the organizational inability to address the causes of individual ill-health might result in complex problems relating to life conditions being downplayed on a political agenda (Beck and Beck-Gernsheim, 2002).

Based on the findings, for HDs to effectively inform health education practices and to enable school actors to successfully practice health promotion policies, such policy needs to be anchored, not only at the school level but also at the municipal level with support in the local and national political agenda. Therefore, we argue, in line with the Schools for Health in Europe (SHE, 2020) and Dassanayake et al. (2017), that the whole school approach to health promotion is extremely important. Also, the findings indicate that another layer of structural anchoring at the municipal level is needed, since these variations exist at the local settings.

Administering “a Sandwich approach”

Based on the findings, we suggest administering a top-down and bottom-up leadership simultaneously – a Sandwich approach – facilitating school-based health promotion. To anchor health promotion policy with all students and professionals at the school and municipal levels with support in the local and national political agenda calls for an approach involving all concerned. Further, the findings draw attention to the localized nature of policy enactment and how local organizational conditions and leadership engagements produce different policy responses and responsibilities in local practices. Braun et al. (2011) argued that schools with distinct sets of professional outlooks and attitudes “make certain policy responses more or less possible” (p. 591). Consequently, as the findings highlight, certain school organizational structures foster distinct professional roles and responsibilities, resulting in specific local and individual strategies. As a result, school actors position themselves by taking on either an active or passive role regarding their responsibilities for HD. In such a process, they also ascribe the school leaders' roles and responsibilities.

The issue of shared or non-shared responsibility and the mission's high or low priority and legitimacy remain ambiguous. For example, a lack of cooperation between the staff of different professions revealed a feeling of separation between the teaching assignment and the assignment of health promotion. This indicates that the health promotion assignment in general and specifically regarding the HDs cannot be conceptualized as a shared responsibility and a collective objective. From the students' perspectives, there are expectations where health promotion is a shared responsibility, and this is a prerequisite for putting health on the agenda.

The findings confirm that the teachers' and school nurses' interpretations and enactments of the policy are mediated by different institutionally determining factors, in line with Braun et al. (2011). One evident explanation of why HDs, in many cases, failed to be conceptualized as a shared responsibility is related to the institutional conditions, as the school leaders did not view the HDs as part of the entire school's mission. Important aspects seem to be: the local organization of the SHS, the organizational space to involve teachers in the process, the priority of the HDs among the school leaders and how HDs are included in the systematic quality. Accordingly, to reinforce the schools' capacity to absorb a healthy school approach, supportive organizational conditions are needed, including the principal's leadership and integrative management that enable integrating the HS action plan within the school's operations (cf. Deschesnes et al., 2014). Similarly, Viig et al. (2005) argue that several conditions at the organizational level facilitate teachers' participation in school-based health promotion. These conditions are common goals, supportive leadership, sufficient and available resources, competence and cooperation inside the school and within the local community. Broadly anchoring the policy and making the health-promoting assignment a shared practice and a collective objective might also reduce the vulnerability that can arise in schools with a large turnover of principals (Swedish School Inspectorate, 2019).

School actors are given a voice

The findings speak to co-creation beyond age and profession. As suggested by the participants, when different school actors (school nurses, teachers and students) are given a voice, a collective picture of HDs can emerge and help develop health promotion practices. We concur with previous research on school development, arguing for a participatory process enhancing school actors' empowerment (Ghaye et al., 2008; Kostenius and Nyström, 2020).

Further, based on the findings we argue in line with Peacock (2006), it is evident that positive school development is enabled by a participant approach, including ethics, trust and cooperation, which requires that everyone in the organization is allowed to make their voices heard. In the case of Sweden, the health-promoting assignment is in line with the key paragraphs in the Swedish School Law (SFS, 2010:800) and curricula, which state that the democratic principles of being able to influence, take responsibility for and be involved in their education should cover all students.

According to the findings, there are some useful examples of good practices from which to learn. However, in some cases, the conditions in the school or municipality are not sufficient to do so. Support is needed to pursue equal health, following Haglund and Tillgren's (2009) reminder that the main focus of practicing health promotion is social justice. Therefore, the findings can be used to fuel the argument for building regional or national collaborative support structures for municipalities that need to develop HDs for the school's systematic development work. Following Nutbeam's (2000) and Kickbusch's (2012) line of reasoning, as health education is directed toward improving health literacy, the role of regional support structures should focus on enabling empowerment and lifting best practices for shared learning. This will simultaneously increase health literacy at an individual, organizational and societal level: a synergy for social justice and health equity.

Limitations and future research

Although the open letters were not written by school leaders we argue that school nurses, students and teachers' expectations of school health promotion leadership provides a noteworthy contribution to research in this area. Further, to address trustworthiness in qualitative research, the concepts credibility, confirmability, dependability and transferability have been used to discuss possible shortcomings (cf. Graneheim and Lundman, 2004; Polit and Beck, 2004). Quotes from the students were fewer than those from professionals, which can be viewed as a credibility issue. Although the authors tried to balance the quotes between professionals and students, the two professional groups' perspectives seem to emerge more clearly. However, when choosing participants with various experiences, ages and genders, as was the case in our study, shedding light on the research question from a variety of aspects increases likewise increasing the credibility (Graneheim and Lundman, 2004). To avoid bias and one-sided interpretation, the two authors and two colleagues with different personal experiences and professional backgrounds (middle school teacher, school leader, sociologist and health educator) analyzed the qualitative data to enhance confirmability. Bringing different actors together, as we have in this study, might present challenges with the transferability of findings. The two professional groups have many years of formal school education, including academic studies, while the students have between 4 and 10 years of education from primary and secondary education. We turned to Warne et al. (2020), who argue that including students and those who are part of the social setting, thus school staff, widen the understanding of the studied phenomenon. We also noted that the 93 open letters varied in length from five sentences (the shortest) to one full page (the longest). The letters from the students were generally shorter than those written by the participating teachers and school nurses. This might raise doubts as to whether the students' voices were heard.

Nevertheless, echoing Peacock (2006), we hold that positive school development is enabled by a participant approach and requires that everyone in the organization is allowed to make their voices heard. When analyzing and writing the results section, we made an effort to balance the quotes from all actors. Further research, including actors of different ages and backgrounds, is needed. Also, the findings of qualitative studies are not generalizable in the same way as quantitative results are. However, following Graneheim and Lundman (2004), we tried to strengthen the transferability by giving an as detailed as possible description of the context of the research by presenting participants, data collection, data analysis and quotations. Also, as dependability is about to what extent the findings are consistent and could be repeated (Guba and Lincoln, 1994), the research process was thoroughly described. Overall, the limitations presented above need to be kept in mind when the findings are interpreted.

Conclusions and practical applications

Summing up, the findings reveal school staff and students' expectations of school health promotion leadership. Regardless of the extent to which the participants felt that they had promoted health and learning in school and developed the HDs, we identified a consensus on what is desirable in connection to health promotion leadership. Based on the findings, we argue that for successful school health promotion leaders need to:

• 1. Acknowledge the field of tension where leadership has to take place. A possible way forward is focusing leadership based on a high degree of collaboration among all professionals in school, students and their caretakers.

• 2. Anchor health promotion policy. Health promotion need to be anchored with all students and professionals at the school and municipal level, an assignment for principals as well as school organizers, with support from the local and national political agenda.

• 3. Administer “a Sandwich approach.” A practical application of the findings is to administer a top-down and bottom-up leadership simultaneously that facilitates school-based health promotion.

Although this study did not examine the sustainability of HPS development in connection to political agendas, we noted a clear link between the two, which can be an interesting topic for future research. Also, as the findings show that organizational structures supporting the health promoting assignment vary greatly among schools, we suggest further research on this topic.