Health Promotion International, Vol. 15, No. 3, 185-195,
September 2000
© Oxford University Press 2000
Policy content and context for health promotion in Swedish schools. An analysis of municipal school plans
Karolinska Institutet, Norrbackahuset, Department of Public Health Sciences, Division of Social Medicine, 171 76 Stockholm, Sweden
Address for correspondence: M.-L. Taylor, Karolinska Institutet, Norrbackahuset, Department of Public Health Science, Division of Social Medicine, 171 76 Stockholm, Sweden
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In international literature policy documents are considered as major strategic tools for health promotion in schools. In Sweden, since 1991, local municipalities are obliged to produce a politically approved school plan for compulsory schools, grades 1–9, i.e. policy instruments which should indicate the aims and objectives, the moral and political values of the municipality. The aim of this study was to describe the content of school plans, focusing on health and environment in 1994 in 62 municipalities in four counties in Sweden, using content analysis. The study was implemented as a total investigation of the 62 municipalities based on the principles of purposeful sampling procedures in order to provide selections of informative cases for in-depth studies. The content analysis was conducted in four steps. Twelve themes were identified in the school plans, representing different issues on health and environment in the first step. Secondly, quotations illustrate and provide a broader meaning of themes. Third, similarities and differences between the counties and municipalities are summarized. Finally, the strategic components of the HELPSAM model (The HEaLth Promotion Strategy Analysis Model) are presented in relation to the 12 themes. As policy documents the school plans seem to be valid instruments to promote the intentions of the municipality concerning health promotion. A supportive environment for health relates to the physical and social aspects of our surroundings, and these aspects are prominent as themes of the school plans. The major part of the municipalities has focused on environmental issues, well in advance of the desired development of a local Agenda 21. The finding points out a rapid diffusion of environmental questions in the Swedish society, at least in the counties of concern.
Key words: health promotion; HELPSAM model; policy instruments; school; supportive environment
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In the international discussions on the development of health-promoting schools, the support of policies is considered a key prerequisite (Nutbeam et al., 1987
; Rescnikov et al., 1993; Jamison, 1993). Health promotion initiatives should involve the collaboration of agencies from relevant sectors of the society, whereof the school system is one. Policy as strategy for health promotion includes a variety of complementary measures, e.g. legislation and regulations on both a national and local level, financial measures, as well as administrative and organizational changes. Policy is also considered by the World Health Organization (WHO) as one of seven key strategies of the development of supporting environments for health (WHO, 1986, 1988).
To develop policies for health promotion activities is one of the most important strategies in creating supportive environments for health (Haglund et al., 1996). In both international and Swedish literature, policy documents for health promotion in schools are mentioned as strategic instruments. In spite of this, there are to our knowledge few international studies on policy instruments for the school system (Vikström, 1996). Nakamura and Smallwood [(Nakamura and Smallwood, 1980), p. 31] define policy as follows.
A policy can be thought of as a set of instructions from policy makers to policy implementers that spell out both goals and the means for achieving those goals.
According to Rist (Rist, 1994), the policy process has three stages, policy formulation, policy implementation and policy accountability. In this study of school plans we will focus on the first stage, the policy formulation. Premfors (Premfors, 1989) has suggested that policy documents can be either politically or societally oriented. The object of the policy analysis is to contribute to problem solutions and formulate recommendations through a process perspective (Premfors, 1989). On the other hand, Munico (Munico, 1995) claims that the policy process is made up of a number of parts: planning, decision, implementation, evaluation, feedback and possible reappraisal. She means that decisions should be built on sensible judgements of alternative ways for reaching certain goals. Policy documents are the instruments of control for the state that take the form of regulations, economic control or information (Vedung, 1996, 1998). The school plans are a combination of these three elements. The main focus for the school plans should, according to Vedung (Vedung, 1996, 1998), be instruments of control for the local schools.
During the 1990s, information as a public policy instrument, in Sweden, has been more prominent for government-directed attempts at influencing people, including the school system, through transfer of knowledge, communication of reasoned argument and moral persuasion in order to achieve a policy result (Vedung, 1998). In a school environment, characterized by organizational changes, policies are particularly important. At the national level, Sweden's parliament and government regulate principles and guidelines. In Sweden, policy instruments at the municipal level, the school plans, are based on national goals, and the moral and political values of the society. The school plans are in turn supposed to guide local schools in formulating their local work plans. The Swedish school system has drastically changed during the last few years. Policies for local schools were previously issued by the national government. Since January 1991, local municipalities (284 in all) are obliged to produce a politically approved school plan. On 15 December 1993, the Swedish government approved a new curriculum for compulsory schools (Curriculum, 1994), to be implemented by the academic year 1995/1996. Thus, in Sweden, policy documents regarding the school exist on three levels. The national goals, decided by the parliament, include the School Act, the curriculum, subject areas and time schedules for the mandatory school for grades 1–9. At the municipal level, local politicians, including goals and activities for schools of the municipality, decide upon a local school plan. The school plan guides the local school in developing its own work plan (Vikström, 1996). In a broader sense, the school plan works as a contract between local politicians and the board of local schools on the activities in schools, and secondarily between politicians, headmasters and teachers. It is also a foundation for discussions between politicians, administrators and parents, and an instrument of control of planning and budgetary processes of the administrative organization of the schools. It also forms the basis for priorities and savings as well as organizational changes. Also, it is important for internal as well as external evaluation, control and follow-up, and finally as a foundation for community involvement of the activities in schools. Thus, the process of policy formulation and implementation has in Sweden been strongly decentralized. At a national level, also, a new National Agency for Education (Skolverket) has been established with a mandate including supervising and monitoring responsibilities. The first local school plans written between 1991 and 1992 mainly followed the goals and guidelines given in the previous national curriculum from 1980 (Curriculum, 1980).
At the Ottawa Conference for Health Promotion in 1986, five areas were identified concerning health promotion, building a healthy public policy, creating supportive environments, developing personal skills, strengthening community actions, and reorienting health services (WHO, 1986). At the Sundsvall Conference in 1991, with the theme of creating supportive environments for health, a health promotion analysis model was developed, the HELPSAM model (The HEaLth Promotion Strategy Analysis Model) (Haglund et al., 1996). The HELPSAM model includes seven strategies for creating supportive environments for health, and one of the key concepts is policy development (Table 1). This was our fundamental basis for prior knowledge guiding our analysis in this study.
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Because policy is considered a key strategy for health promotion in schools, the aim of this study was to describe and analyse the content of school plans focusing on health and environment using the HELPSAM model in 62 municipalities of four county council areas in Sweden.
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MATERIALS AND METHODS |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In 1994, Sweden was divided into 24 counties, from which we selected four for this study, after the principles of purposeful sampling (Patton, 1990
). The four counties were chosen with regard to the extensive public health work carried out there over a number of years. All in all, there are 284 local municipalities in Sweden of which 62 are included in this study. Among the 62 municipalities, 58 school plans were collected in the autumn of 1994. The four municipalities that did not send in their school plans argued that they were either rewriting the school plan or that it was not yet in use. The four counties represent different geographical areas of Sweden, Västernorrland county (seven municipalities) in the north with a population of 260 285, Skaraborg county (17 municipalities) in the west with a population of 279 901, Kristianstad county (13 municipalities) in the south with a population of 294 505, and Stockholm county (25 municipalities) in the east of Sweden and with a population of 1 708 225. In total the sample represents almost one-third (27%) of the pupils of Sweden, in the compulsory school system, grades 1–9.
The method used for analysing the text in the school plans is qualitative and quantitative content analysis. Holsti defines content analysis as a method to make conclusions in an objective and systematic way in order to identify the specific character of a message (Holsti, 1969). It is a process that extracts information from a text and makes it clear, through themes/keywords which are relevant to the research question (Rosengren, 1981). The analysis presented here aimed more specifically at clarifying health and environmental policy issues in the school plans.
This analysis was implemented in four steps. In the first step an analysis based on quotations concerning health and environment in the school plans was made, on the basis of a prior knowledge from the authors. One of the authors (M.L.T.) has coded the material. The relevance of the themes in relation to the total content of the material has then been discussed with the co-authors. These quotations were compiled to 12 different major themes. In the second step quotations are presented in order to give a broader description of the content and the variation of themes. The third step presents differences between the counties and also which themes the municipalities have prioritized. Finally, in the fourth step the HELPSAM model and its strategies for health promotion were used as a framework to provide a more in-depth understanding of the themes.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The results are presented from the four steps in the analysis. First, the 12 themes categorized from the analysis of the text are presented (Table 2
). Second, quotations to illustrate the themes are provided. Third, similarities and differences between the counties and municipalities are summarized (Table 3). Finally, the strategic components of the HELPSAM model are presented in relation to the 12 themes.
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Themes
(A) Schools with health and environment profiles
Several of the municipal school plans suggest that local schools should develop special profiles. That can be considered as an expression for ‘reorienting organizations’, which is one of the strategic components in the HELPSAM model of health promotion. The most common profiles are music, sports, or a specific educational profile, e.g. Montessori schools. There are 10 schools with an environmental profile and not one has a health profile (Table 3
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(B) Outdoor environment
In health promotion, the concept of supportive environment for health relates to the physical and social dimensions of the environment for creating favourable conditions for health. In the analysis of themes on environment three major dimensions were seen, the outdoor environment (theme B), the indoor environment (theme C), and the psychosocial environment (theme D).
The following quotations illustrate some environmentally related educational issues in the school plans from the different counties.
Schools have an important task to give children and young people knowledge and skills in order for them to be able to take responsibility for and also be able to influence conditions for a safe outdoor environment (Kristianstad county).
Respect for the outdoor environment in our community is a fundamental norm which the school is responsible for imparting to the pupils (Västernorrland county).
Schools lay the foundation for outdoor environmental awareness in the future (Skaraborg county).
Schools should contribute towards creating an ecologically sustainable society (Stockholm county).
Most of the municipalities have policies concerning comprehensive outdoor environmental education, expressed in terms of increasing respect for and knowledge about nature and the outdoor environment. This is also reflected in the plans with emphasis on ecology and a global perspective. One municipality of Skaraborg has chosen the academic year of 1994–1995 as ‘the year of the school yard’ to encourage schools and pupils to promote improved playgrounds/recess areas.
(C) Indoor environment
The physical/indoor environment is here described from a perspective of working environment, but also as a requirement for creating a stimulating school climate.
A well-functioning working environment creates possibilities for development (Stockholm county).
Pupils and school staff must have an indoor and psychosocial environment so that a positive working climate can develop (Kristianstad county).
The classrooms should be a stimulating working environment for pupils and teachers. The indoor environment should stimulate development work, co-operation and a comprehensive view of the children (Västernorrland county).
The majority of the municipalities identify conditions in classrooms and school working facilities as being poor. Municipalities mention lack of economic resources for carrying out necessary repairs, which some have attempted to address by establishing a 3–5 year plan for improvement of the indoor environment. In Kristianstad county, one of the municipalities mention that according to the Work Environment Act (Gullberg et al., 1994), the work environment and the indoor environment are the responsibility of the employer. One of the municipalities in Skaraborg county has singled out the school working environment as a priority during 1992–1994.
(D) Psychosocial environment
The psychosocial environment is an important component in a good school climate as well as in the working environment. The following quotations refer to that.
The schools must develop a safe environment. The indoor and psychosocial environment must improve constantly (Stockholm county).
The well-being, involvement and performance of pupils and staff are crucial for the outcome (Skaraborg county).
All school staff groups should work together with pupils and parents to create a positive psychosocial school environment (Västernorrland county).
The school plans state that it is important that pupils and the school staff can develop their psychosocial environment according to their ability so that everybody can feel safe and secure in school. Several municipalities underline that the psychosocial environment is a prerequisite for well-being, good collaboration between school staff/teachers and parents, good academic results, as well as good health.
(E)–(G) Health services, ADT (alcohol–drugs–tobacco), sex education and personal relationship issues
In the HELPSAM model, ‘reorienting organizations’ is described as one of the seven strategies for health promotion. Themes (E)–(G) represent this strategy. In the international discussions, reorienting health services is one of the key strategies for creating a supporting environment for health. This also holds true for caring and health services in the school.
This is expressed in quotations as follows.
Health services in the schools concern everything that supports the pupils' intellectual, physical, emotional and social development, deals with adverse conditions and supports pupils who are having problems (Theme E, Skaraborg county).
Activities targeted at teenagers should also be seen as socially preventive measures for reaching risk groups among young people, and thereby working against drug abuse, racism, bullying, violence etc. (Themes E and G, Västernorrland county).
The preventive work against drug abuse should be carried out in co-operation with the parents (Theme F, Stockholm county).
The health service and the youth clinic in the schools should assist in the education on sex and relationship issues (Theme F, Stockholm county).
The themes of the health issues (themes E–G) relate to pupils' health and its support from the health and social services, management of drug policies, and policies of relationship and sex education. There are large differences in terms of policy for these themes between the counties presented in more detail below. In the school plans of all four counties, health services are considered as health care (medical examination, im-munizations, etc.) and psychosocial care (school nurse, psychologist, social workers). In Västernorrland county, the municipalities consider the school health services to be very important for pupils well-being. Two school plans suggest the use of culture, drama and dance in the preventive work towards ADT. In Kristianstad county, several school plans pinpoint the organizational structure of the school health services, suggesting either an organization of its own, or creating new alliances contracting external health service organizations. Of the municipalities mentioning ADT, seven point at work towards attitudinal change and negative peer pressure. Also, three of the municipalities pinpoint sex education and relationship issues as being important within the schools' health service health education strategies. In Skaraborg county, the school plans underline the importance of staff in the school health service being active in school health promotion activities. Some of the municipalities recommend health teams to be established including a psychologist, a school nurse and a social worker. In order to work successfully with ADT, it has to start at an early age of the pupils. In addition, the school plans pinpoint alliances building with external resources in fulfilling these efforts. None of the municipalities in Skaraborg county mentions sex education and relationship issues in their school plans. In Stockholm county, half of the municipalities' school plans emphasize that preventive work in the health services should be prioritized. The abuse of ADT should be followed up individually by the school health services in close co-operation with parents. Sex education and relationship issues are mentioned in three of the municipalities with the recommendation that schools should have youth clinics for the older pupils.
(H) Violence, bullying, racism
How the local schools deal with violence, bullying and racism is an important indicator of the school climate. How to create favourable conditions with a good climate in the school setting is in the HELPSAM model named ‘enabling’. This is quoted in the school plans.
When pupils from different social, cultural and ethnic backgrounds are together, conditions exist for creating understanding and for getting used to working and living together with people of different ethnic groups and nationalities. This supports equality and counteracts racism and segregation (Stockholm county).
Conflicts should be resolved without violence (Västernorrland county).
The issue is about strengthening the self-confidence of the pupils. In particular, the school is responsible for taking care of the pupils, who need extra support (Västernorrland county).
In Västernorrland county, some of the school plans state that the school is the place where children from different backgrounds get to know each other, learn to understand each other and get along, solve conflicts, and develop knowledge and values together. Kristianstad county's municipalities emphasize that the schools should work with issues around peace, human rights, war and violence, and also that the schools should have programmes dealing with bullying, violence and truancy. In Stockholm county, some of the school plans refer to the Stockholm area as a large, densely-populated urban area with attending social problems in some municipalities, e.g. housing segregation, unemployment, language problems among immigrants and alienation among young people.
(I) Nutrition/school lunch
This theme is also included in the HELPSAM model under the strategy of ‘enabling’. The goals and guidelines for nutrition are presented in a similar way in quite a few of the school plans.
The school lunch should provide one-third of the daily intake of nutritionally appropriate food, and should also be eaten in a nice environment to promote good habits (all four counties).
Adults in the dining room guarantee a calm environment, and it is suggested that teachers and staff have lunch with the pupils (Stockholm county).
Common for the four counties are statements that the environment of the school lunch facilities should be nice and relaxed, and in addition the school lunches should be eaten at the same time every day.
(K)–(M) Pupil–family–society co-operation
‘Alliances building’ is a key strategy in creating a supportive environment for health, and the above themes on collaboration between the school and families and other parts of the surrounding society are different examples of this strategy.
In the school plans the following are quoted.
Pupils should when realistic be encouraged to be active in the planning of different activities, evaluation, environment work, etc. (Theme K, Kristianstad county).
It is important that the parents co-operate towards a good psychosocial environment in the school (Theme L, Skaraborg county).
The parents are a very important resource in the environmental work in the schools (Theme L, Västernorrland county).
Good contacts are needed with the social workers, staff in the youth recreation centres and the police (Theme M, Stockholm county).
Several municipal school plans from all four counties state that developing ‘alliances’ is especially important when considering the schools' work environment.
In Västernorrland and Kristianstad counties, a couple of municipalities mention the possibility of pupils' involvement in the planning and delivery of school lunches. In the majority of school plans the parents are considered as a valuable resource in the work with the physical as well as psychosocial environment. In Stockholm county, a couple of municipalities' school plans state that the pupils have ‘an unique insight’ into the school environment that should be used in the environmental education.
An overview on how the different themes for health and environment are reported in the municipal school plans in the four counties is shown in Table 3.
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In a literature review it was found that research about school plans as policy instruments is a neglected area (Vikström, 1996
). By law, since 1 January 1991, every municipality in Sweden has to produce a politically approved school plan. This is the result of a change in the Swedish public policy process including the school system towards information as the major instrument of government, even if regulations and economic control play a role (Vedung, 1998). The school plan has to follow the national goals for the school and also be revised every third year. The municipalities are free to choose priorities according to the needs of the community. In the process of change in the society where goal-related issues are becoming more important, the school plans as policy documents can indicate the will of the politicians. The analysis of the school plans can give valuable information about what is going on the political agenda. This is important for influencing the political decision about health promotion issues. It is also important to follow up the national goals in the political process in the municipalities.
This study is implemented as a near complete sample of municipalities (58 out of 62) in four counties based on the principles of purposeful sampling procedures suggested by Patton (Patton, 1990), in order to provide selections of informative cases for in-depth studies. The Stockholm county covers, e.g. more than one-fifth of the Swedish population. The selected counties also represent different regions of Sweden: north, south, east and west. In this study, the coverage rate is very high and this leaves us with a rather fair description of the Swedish society.
In this study, a content analysis in four steps has been conducted, identifying patterns categorized in themes. Some themes categorized are traditional descriptions of physical and psychological environments, supported by a new Work Environment Act (Gullberg et al., 1994). Others are descriptions of activities for psychosocial care of pupils and school health service, while other themes due to our prior knowledge describe strategies for creating a supportive environment for health as, e.g. collaboration, building alliances and participation (Haglund et al., 1996).
Different municipalities prioritize different themes. Sometimes there are plans of action supported by special descriptions of the municipal local needs. Specific educational profiles of some schools could be seen in the school plans, e.g. environmental schools, Montessori schools, etc. Relating to the strategies of the HELPSAM model, this is an example of reorienting organizations (Haglund et al., 1996).
In all the school plans, the environment, expressed as outdoor–indoor–psychosocial environments, which the municipalities prioritize is the psychosocial environment. All three aspects of environment are important dimensions for creating supportive environments for health.
Environmental awareness has increased in Sweden since the Rio Conference in 1992 (Månsson, 1994). It is obvious that the municipal school plans studied concentrate more on the environment than on health issues. When these local school plans were established, the curriculum LGR-80 was still the main guideline for the Swedish school system. In 1994, a new curriculum, LPO-94 was decided upon, but the schools had been familiar with it already since the early 1990s. The discussions of the new curriculum during these years have probably influenced the majority of the school plans and explain why so many focus on environmental themes.
The Swedish government has recommended (Månsson, 1994) that before the end of 1996 municipalities should have started working on a municipal Local Agenda 21. That was also one of the most important conclusions at the UN Conference on the Environment in Rio de Janeiro in 1992. At this conference it was pointed out that central/national decisions are important, but that no long-term changes will be achieved unless the local level are made part of the decision-making. ‘Think globally, act locally’. To be able to involve people in the municipalities, information and knowledge are important. The compulsory school, grades 1–9, reaches all children and youth, and is an important arena for providing information and knowledge about the Local Agenda 21. The major part of the municipalities has focused on environmental issues, well in advance of the desired development of a local Agenda 21. The finding points out a rapid diffusion of environmental questions in the Swedish society, at least in the counties of concern. The schools play an important role in changing attitudes that in a long-term perspective can serve the society and the individual.
The school health services are considered to be very important for the pupils' well-being. Its staff are even seen as key actors for health promotion activities in schools. Involvement in health education regarding sex education and relationship issues is considered important for health service personnel. There are, however, findings concerning geographical differences on sex education and relationships. In one of the counties (Skaraborg) this is not considered in the school plans. Another issue is the pinpointing of building new alliances suggesting either a new health services organization of its own, or contracting external services (Kristianstad), whilst other municipalities suggest teams within the existing school organization dealing with the above tasks.
In an evaluation of the school health services in 77 municipalities (25%) in Sweden, performed by the National Agency for Education in 1993, it was shown that the pupils valued the psychosocial services more than health examinations (Skolverket, 1994). A well-functioning school health service is an important component in creating a supportive environment in the school.
Relatively few school plans contained policies about ADT education. One reason might be that ADT and sex education and relationship issues are themes that the schools have worked with for a long time. It is, however, still important to have guidelines for these areas, because if ADT and sex education and relationship issues are not mentioned in the school plans these questions are made invisible. This might be one of the explanations why tobacco smoking among youth has increased during the past few years.
In both the School Act, and the national curricula LGR-80 and LPR-94 internationalization is emphasized. It is, e.g. emphasized that the school has a commitment to teach pupils to understand and show solidarity with other countries, people and cultures. Because of the existing refugee policies in Sweden, there are refugee children in the schools in almost every municipality. Respect, understanding for other cultures and human rights are some issues discussed in the School Act. This is interpreted in the local school plans as part of the psychosocial environment also related to violence, bullying and racism.
In this study, the municipalities have an almost standard way of writing about the school lunch. This is probably a result of the free school lunches offered to the pupils in Swedish compulsory schools. At the same time according to a study by Sjögren and Wesslén (Sjögren and Wesslén, 1994), 25% of the municipalities in Sweden do not have goals for school lunches. This might be an effect of the municipalities cutting resources allocated to school lunches (Sjögren and Wesslén, 1994). In the municipalities' school plans both psychosocial and physical environments were considered important in the facilities where school lunches were served.
A number of examples of the considered importance of ‘alliances building’ are provided in the school plans under the themes of pupil– family–society co-operation. Here quotations also support the empowering strategy through encouraging both the pupils and their parents to be active and participate in school activities and in the process of changing the environment. This is in line with a review by Gillies on effectiveness of alliances and partnerships for health promotion (Gillies, 1998), where she states: ‘the greater the level of local community involvement in setting agendas for action and in the practice of health promotion, the larger the impact’.
In a report on attitudes towards school published by the National Agency for Education (Skolverket, 1995) based on surveys of parents, pupils and teachers, the outcome of school activities should be emphasized from a societal perspective, less teaching in the classroom, more contact outside the school, e.g. field studies, study visits in different areas. These findings are close to the strategies for creating supportive environments for health as, e.g. building alliances, expressed in many of the school plans studied.
The Health Promotion Strategy Analysis Model (HELPSAM model) and its seven key strategies for health promotion has guided us in the analysis of the school plans to obtain a more in-depth understanding of some of the key strategies to create supportive environments for health. Policies as expressed in the school plans have been presented under the 12 themes. During the last decade at least three important national laws and regulations have had an impact on local schools and influenced local school plans. First, the national curricula in 1994, supported by a law to provide new school plans from the municipalities every third year. Second, a new work environment law also includes the pupils of Swedish schools, as well as teachers and other personnel groups. Third, the Swedish government has recommended (‘White paper’) that all municipalities should develop a Local Agenda 21, also including the school system.
Several examples are provided on reorienting organizations, both the local schools as such with special profile schools focusing on environment, but also suggested changes of the organizations within schools, e.g. the health services organization and having a more pronounced responsibility for health promotion. In several of the school plans advocacy for improved health could also be found. This is most pronounced in some of the school plans from the Stockholm area stressing the importance of the development of school activities that respond to the special needs of pupils in urban areas. Alliances building is underlined in several school plans in relation to the work with ADT, sex education and relationships in school. These alliances could be with parents, NGOs, or other public organizations, e.g. youth clinics. The enabling strategy of the school is maybe the most expressed one in the school plans. There are three major dimensions presented on the environment, the outdoor, indoor and psychosocial environment. Especially the psychosocial environment and its importance for creating a good school climate as a prerequisite for prevention of violence, bullying and racism could be seen in the school plans. Finally, the empowering strategy has been presented in quotations under the themes of pupil–family– society co-operation, e.g.
Pupils should when realistic be encouraged to be active in the planning of different activities, evaluation, environment work, etc.
Policy development in all sectors of society is of importance for health promotion work. In many countries there are national goals. Certain areas in health promotion have been prioritized nationally and then followed up locally (Nutbeam et al., 1993). Studies implemented in the USA and England point out that if policy plans in schools are to have an effect, it is important to have broadly-based programs in the community at the same time (Reid et al., 1995; Gillies, 1998). According to Young and Williams, policy plans are needed on the local political level in order to promote effective health promotion in schools (Young and Williams, 1989). Gillies in her review found in addition that the existence and implementation of policies for health promotion activities were crucial to sustainability (Gillies, 1998). The resources of the local society are also significant for the outcome of health promotion. The municipality gives priority to health promotion in accordance with the resources and needs of the local community.
Our study has thus focused on the policy formulation stage of the policy process at local municipal level (Rist, 1994). Because national laws guide local politicians in their development of the school plans in their municipalities, this results in similarities as indicated in our results. In other cases, policy makers on a municipal level are not faced with a given problem. Instead they have to identify and formulate their problem based on a needs assessment approach which can be found facing the differences presented between the school plans. The policy implementation stage will be at the local schools and transformed into programmes of their working plans.
As policy documents, the school plans seem to be a valid instrument to promote the intentions of the municipality concerning health promotion. A supportive environment for health relates to the physical and social aspects of our surroundings. The majority of the municipalities has focused on environmental issues, well in advance of the desired development of a local Agenda 21. The finding points out a rapid diffusion of environmental issues in Swedish society, at least in the counties of concern.
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REFERENCES |
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TOPSUMMARYINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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