Making sense of health in PE: conceptions of health among Swedish physical education teachers

Abstract

Purpose

Over the last couple of decades, health has become a central part of the subject content in physical education (PE) curricula in many countries. As a result, issues of health have been foregrounded much more clearly in the teaching of PE. The aim of this study was to explore how Swedish PE teachers make sense of health in relation to their teaching practices. This was done through investigating conceptions and theories about health in the teachers' descriptions of their teaching practices.

Design/methodology/approach

The data analyzed in this paper were collected through focus group and individual interviews with PE teachers in the grades 7–9 within compulsory schools in Sweden. The data were analyzed using thematic analysis.

Findings

Four dominant themes were identified in the data: 1) Health as a healthy attitude, 2) Health as a functional ability, 3) Health as fitness, 4) Health as mental wellbeing. There is a clear impact from healthism and obesity discourses on the teachers' accounts of health, but there is also an impact from holistic views and approaches to health. The authors contend that teachers should be explicit in what they mean by health in relation to what they teach, how they teach and why they teach health in a certain way.

Originality/value

The knowledge produced by this study is crucial since teachers' assumptions regarding health affect the subject content (what), the pedagogies (how), as well as the reasons (why) they teach health and therefore what students learn regarding health.

Citation

Korp, P., Quennerstedt, M., Barker, D. and Johansson, A. (2023), "Making sense of health in PE: conceptions of health among Swedish physical education teachers", Health Education, Vol. 123 No. 2, pp. 79-92. https://doi.org/10.1108/HE-11-2022-0086

Introduction

In many countries, schools have an overall goal to protect and support children's and young people's health development (Fitzpatrick and Tinning, 2014). In Sweden, this assignment is summarized by the Swedish National Agency for Education (2019, p. 24) as “stimulating children and young people to develop an understanding of and knowledge about their own health and well-being”, and further to “design the activities based on a care for children's and young people's health and well-being”. In this overall school assignment, the school subject physical education (PE) plays an important part. Since 1994, health has also been included in the subject's designation (i.e. physical education and health) in Sweden, as it has in, for example, Australia (McCuaig et al., 2013). Over the last couple of decades, health has also become a central part of the subject content in PE curricula in many countries (see, e.g. Lynch and Soukup, 2016; Mong and Standal, 2019). As a consequence, issues of health have since been foregrounded much more clearly in the teaching of PE (Larsson and Redelius, 2008; Schenker, 2018).

The increased focus on health has often resulted from a perceived threat of an obesity epidemic, as well as a general shift towards a “holistic” discourse in PE during the 1980s and 1990s (Lynch and Soukup, 2016; Quennerstedt et al., 2010). The discourse advocates a broader, more holistic health concept, and PE is constituted as a potential critical and constructive tool for reflecting on and learning from experiences of different physical activities (e.g. Quennerstedt, 2019). In Sweden, this discourse is, according to a review by the National Agency for Education (2019), reflected in policies and documents that govern the school's various strategies for promoting students' health, including PE. References to “the expanded health concept, wellbeing, salutogenic approach and sense of coherence” are plentiful in these documents (National Agency for Education, 2019, p. 12). Despite this push for a more holistic view of health in educational policy, and the strong emphasis that has been placed on health as a concept, little is known about how PE teachers make sense of health in relation to their teaching practices. This knowledge is crucial since teachers' assumptions regarding health affect the subject content (what), the pedagogies (how), as well as the reasons (why) they teach health and as a consequence what students learn regarding health (Quennerstedt, 2019).

In a recent systematic review of literature, Mong and Standal (2019) investigate how health is taught in PE and find that teachers using different health perspectives also emphasize different ways of teaching health in PE. Their analysis distinguishes “alternative perspectives” of health, including both critical and so-called salutogenic perspectives, from a “biomedical perspective”. While the latter emphasizes the importance of diet and physical activity for health, critical and salutogenic perspectives share a critical view of a biomedical understanding of health in PE based on a healthism ideology and reducing health to a matter of promoting physical activity and preventing obesity (Mong and Standal, 2019).

Similar to Mong and Standal (2019), in a study exploring how PE teachers use discursive resources related to body weight and obesity to create professional identities, Barker et al. (2021a) found different perspectives of health and on PE. While the participating teachers' identities contained elements that were fundamentally unsympathetic to overweight individuals, they were also more inclusive, sensitive and critical with regard to questions of body size, weight and health than current PE literature on obesity has suggested (Barker et al., 2021a). These findings are surprising considering that PE has been presented as an important cure for the “obesity epidemic” (e.g. Davidson, 2007; Bennet and Burns, 2020). The teachers consequently presented not only pathogenic obesity discourses but also sensitive and caring ones. This finding sparked our interest for investigating more closely how PE teachers make sense of health. There are important insights for PE teaching and PE teacher education to be gained from examining how the concept of health is interpreted and understood within the discipline. We also contend that PE teachers need a (more) systematic and analytical understanding of how health can be theorized in different ways, not least to be able to relate more critically to different discourses about body, weight and health in order to teach health in more holistic and non-reductionist ways. This is especially important since research highlights the complex and multidimensional character of the concept of health and also its moral and ideological qualities (e.g. Williams, 2003, p. 46). Any notion of health or notions of a “healthy lifestyle” involves value judgements and is fundamentally ideological as it refers to a specific notion of what it means to be healthy (Korp, 2008, p. 25). We believe this will have crucial consequences for what teachers teach and how or why a certain content or activity is chosen with regards to health.

The aim of this article is thus to explore how Swedish PE teachers make sense of health in relation to their teaching practices. This is done through investigating conceptions and theories about health in the teachers' descriptions of their teaching practices. The research questions guiding the investigation are as follows: 1) what concepts and theories of health are expressed in PE teachers’ accounts of health? and 2) what values and norms regarding health are implicit in PE teachers’ accounts of health?

Exploring PE teachers' beliefs, representations and ambivalence regarding health

There has over the years been several studies exploring how people in general understand and conceptualize health in everyday life (e.g. Herzlich, 1973; Blaxter, 1990; Flick et al., 2002; Aim et al., 2020). This research is based on an effort to explore what illness and health means to people and what social significance health has in their personal or professional lives. Perhaps the most influential work in this area is Claudine Hezlich's study from 1973 (Herzlich, 1973), which has inspired several subsequent studies (e.g. Jovchelovitch and Gervais, 1999; Downey and Chang, 2013; Aim et al., 2020). This strand of research has demonstrated how people's conceptions of health are complex. For example, people at times understand health as absence of disease, as a resource, as an equilibrium, or as an inner balance (Ohlin Lauritzen, 1997, p. 437). Thus, health is not just a matter of the body and physical health, but also of mental experiences and states. People also understand health as part of social life. According to Blaxter (1990), an important aspect of health is being able to fulfil social roles and duties. Studies have also shown that people's beliefs, or social representations of health vary with social position (e.g. d’Houtaud and Field, 1984), ethnicity (Jovchelovitch and Gervais, 1999), age (Williams, 1990), gender (Aim et al., 2020), sexuality (Adams et. al., 2013), and profession (Flick et al., 2002). In their review of research on people's everyday understandings of health, Flick et al. (2002, p. 585) found four recurring categories: 1) being free of problems and complaints; 2) functionality; 3) a condition for flexibility and adaptation; 4) well-being and (mental) balance. According to these findings people's everyday understanding of health is often holistic and more than just a matter the absence of disease.

Another, more recent strand of research in this area in education is focused on how prevalent discourses of body weight and health affect people's conceptions of health (e.g. Powell, 2016; Wright et. al., 2006; Wright et. al., 2018; Vander Schee, 2009). Drawing on poststructural theories, a number of studies examine how such discourses affect PE teachers’ and pre-service PE teachers’ professional as well as personal understanding of health (e.g. Burrows and McCormack, 2012; Garrett and Wrench, 2012; Varea and Underwood, 2016; Welch and Wright, 2011; Gray et al., 2018). Garrett and Wrench (2012), for example, found that pre-service teachers used both healthism and biomedical discourses when describing being healthy as a matter of taking personal responsibility for eating the “right” food and participating in the “right” amount of exercise, thus focussing on physical aspects of health over social, emotional and cognitive aspects. In Varea and Underwood's (2016) investigation, pre-service PE teachers expressed anti-fat bias by considering fatness as an indicator of health through BMI, body size and weight. Other studies claim that PE teachers become crusaders against fatness within these discourses (Pringle and Pringle, 2012), and that teachers try to fulfil these expectations of being healthy role models by being fit and slim (González-Calvo et al., 2019; Webb and Quennerstedt, 2010).

However, there are also clear signs of ambivalence in how healthism and obesity discourses are met in PE. Welch and Wright (2011) found that pre-service PE teachers took different positions in relation to dominant discourses that reduce health to a matter of body size and weight. On the one hand the pre-service teachers in this study agreed with discourse that “associates good health with diligent dietary and exercise practices; and sees a healthy weight or ‘fit’ appearance as within an individual's reach” (Welch and Wright, 2011, p. 208). On the other hand, they presented a counter-discourse in which they dismissed and challenged the connection between body size or shape with health, spoke about health as other than physical, and emphasized the problematic nature of health being indicated by appearance (Welch and Wright, 2011, p. 204). The teachers also vacillated to an extent, challenging the concept of health as solely a matter of body size, shape and weight, but also emphasizing the importance of the physical body for health.

This ambivalence is also visible in a study of preservice teachers by Gray et. al. (2018). They found that the students deconstructed dominant healthism and obesity discourses, but did not necessarily articulate critical practice as a result. Instead, they constructed counter discourses in which health was defined holistically, for example in terms of aspects of mental wellbeing such as “being happy” and “having a good mindset”, but also as having a functional body and positive social relations (Gray et al., 2018, p. 30). When talking about ideal bodies, the students maintained that bodies can be any shape and size, but still referred to size and weight when defining the ideal body (Gray et. al., 2018, p. 32). In a similar way Burrows and McCormack (2012) claim that the teachers in their study both related to obesity health discourses, and at the same time described their diverse role as physical educators, which included caring. Burrows and McCormack (2012, p. 729) proposed that teachers' views of teaching PE are “intimately linked to their lived histories of ‘health’, their understandings of their own and others' bodies and their personal convictions about what constitutes a ‘good’ and/or ‘healthy’ life”.

Ambivalent and contradictory positions in relation to discourses of health and obesity are also reflected by the PE teachers in our previous work (Barker et al., 2021a, b). Our research suggests that PE teachers tend to see health as involving mainly physical properties. Body size and weight are thus often regarded as indicators of health. As a consequence, to be healthy is to be slim and fit, while being unhealthy is clearly associated with fatness understood within a biomedical understanding of health. Teachers also commonly regard health as a matter of individual responsibility, i.e. to have the character or will power to do the “right” thing and make “healthy” choices. Teachers also express holistic perspectives of health, but tend to subject these perspectives to a pathogenetic notion of health.

Theoretical and methodological considerations

Theoretically, there are differences in how people's conceptions of health have been researched. Studies of people's everyday experiences of health and illness commonly rely on the concept of “lay beliefs” (or “theories”) about health (e.g. Herzlich, 1973; Blaxter, 1984; Cornwell, 1984; Williams, 1990), but there are also studies using social representation theory (e.g. Flick et al., 2002; Aim et al., 2020). For the purpose of this study, we will work with social representation theory described by Flick (1998) and Flick et al. (2002), which emphasizes that human representations of health are socially shared. However, we are also sensitive to the criticism of social representation theory regarding how social representations are produced (e.g. McKinlay and Potter, 1987; Potter and Edwards, 1999). Therefore, we will also use insights from Billig (1993) and Radley and Billig (1996) on the argumentative and discursive aspects of how conceptions of health are produced.

Social representations are defined by Flick (1998, p. 641) as “how a social group (or system, society or culture) conceptualizes a material or symbolic object - the socially shared core of this conceptualization”. According to Flick et al. (2002, p. 583), people hold everyday ideas of what health is, how to deal with it, and what it depends on. These ideas are constructed and transformed in everyday interactions, being influenced by concepts of health found in research, everyday knowledge, media and public discourse. Professional groups, sharing educational background and professional socialization, further tend to produce common social representations that have implications for how they understand and deal with different problems within their professional lives (Flick et al., 2002, p. 583).

Billig (1993) however, claims that social representations need to be understood as a matter of people's participation in “the thinking society”. He argues for extending social representation theory to deal with “the essentially argumentative aspects of thinking”. Based on Wetherell and Potter's (1988, pp. 168–169) argument that discourse is a social practice, Radley and Billig (1996) claim that the representations people make of health must be seen as accounts produced in specific situations. This means that people's accounts derive their meaning from the rhetorical situation in which they are produced. Investigating perceptions of health thus means examining an activity of “accounting” in terms of giving explanations and justifications for specific thoughts or actions, and thus, articulating a position within a wider social discourse (Radley and Billig, 1996, p. 228).

In line with Flick (1998) and Billig (1993), we consider the different conceptions and theories about health in teachers' descriptions as constructed. These constructions occur in an interview situation and in relation to available health discourses, but also as representations of philosophies and theories that the teachers through their teacher education and professional socialization have learnt to act upon in their everyday teaching. This entails that, unlike most research on people's everyday perceptions of health we do not explore personal experiences of illness or health, but the professional “everyday theories” that teachers use to meet the curricular requirements for teaching PE and health.

Methods

The interview material used as data in this paper were generated within a larger project exploring discourses of body, health and weight among PE teachers (see Barker et al., 2021a, b; Quennerstedt et al., 2021). Data were produced in Sweden in fall, 2018 and spring, 2019.

Participants

The study involved PE teachers of grades 7–9 within compulsory schools in Sweden. To be included in the study, teachers needed to have a teacher's degree in PE and professional experience as a PE teacher of at least one year. In total, there were 24 participants (11 women and 13 men), aged 27 to 61, with professional experience as a PE teacher of between one and 30 years. Most participants (20) had more than three years of experience as PE teachers. All except one worked in an urban or suburban school.

The data

In total we conducted 12 interviews, which were held at either the participants' schools or at the university coordinating the project. Two focus group interviews with five participants, four focus group interviews with two participants, and six individual interviews were conducted. Interview format was determined by practical factors—focus groups were the researchers' preferred format but finding times that suited multiple participants was not always possible.

The interviews lasted on average 65 min and the focus group interviews were slightly longer. Health was one of several areas covered. The main foci of the interviews related to what it means to be a good student in PE, if there is a normal body in PE, if there is a healthy body in PE, and meanings of health. We also asked about how the teachers work with overweight students in PE lessons and if they had focused on bodies as a subject area in their teaching. Follow up questions allowed for elaborations on specific topics. Sometimes these elaborations were initiated by the teachers, sometimes by the interviewer.

Because of the different interview methods, the data we have collected are different in character. In the focus groups, group interactions took place that highlighted the participants' ways of thinking, as well as different group norms and cultural values. In the individual interviews, participants reflected on the questions we had alone. Still, it is our impression that the individual interviews were perceived as safe and comfortable by the participants and that they developed into relatively open discussions that produced a data comparable to that generated by the focus group interviews.

Data analysis

We conducted a thematic analysis following the six phases described by Braun and Clarke (2006). The interviews were recorded and transcribed verbatim. Led by the first author, the analysis started with iterative readings of the transcripts. In this stage initial ideas were noted. We then coded theoretically relevant aspects of the data across the whole data set focussing both on concepts and arguments explicitly reflecting socially shared representations of health, as for example references to the WHO definition of health, and concepts and arguments reflecting personal or less conventional ideas. When initial codes were generated, we reiteratively organized the data into meaningful themes. When constructing the themes we looked for representations of health that articulated a professional understanding based in education and experience (Flick et al., 2002). We also looked for explanations for different approaches to health and justifications for different ways of approaching health in the teaching practice (Radley and Billig, 1996). The themes reflected both explicit and implicit aspects of the teacher's accounts of health. This produced a mapping of the data in unrefined codes and themes. The themes were then tested against coded extracts and the data set as a whole and checked for patterns, variability and consistency. In the final stage, compelling extracts were chosen to illustrate the themes and the overall analysis. The writing of the results concluded the analysis.

Results

Four dominant themes of how the teachers make sense of health in relation to their teaching practices were identified: 1) health as a healthy attitude; 2) health as fitness; 3) health as functional ability; and 4) health as wellbeing. The themes are distinct conceptualizations of health, but at the same time are also closely related in different ways to their teaching practice. Different aspects of the themes were often articulated in the same interview and often also by the same teacher.

Health as a healthy attitude

The theme health as a healthy attitude entails a recurring assumption that health is a matter of how each person individually approaches health. This is often with regard to how students relate to PE, but also to health in general. Within the theme, health becomes an unattainable goal to strive for where improvement can be achieved through a positive approach, a willingness to take on challenges, and individual “grit”, particularly in relation to physical activity and PE.

One teacher maintained that a healthy attitude is self-reinforcing and thus creates health, stating that; “A healthy body, it is a product of a healthy attitude” (Interview 3). Another teacher further developed how attitude creates a healthy body.

Yes, a healthy body is probably one that, if we talk from a student perspective, it is probably one that manages to come here, has a reasonably lively and happy mood as I said before. [they] have slept well, have eaten, are also perhaps properly dressed for sports and have the right clothing and do not come in jeans perhaps. And also, at the same time [a healthy student] shows interest that “I don’t know this, but I want to learn”. (Interview 7)

However, the healthy attitude was seldom described so explicitly. More often, it was expressed as an underlying condition in the many occasions when health was articulated as something you need to strive for that requires a will to develop and get better. This includes being active, taking on challenges and constantly trying to improve.

First of all, you have to think about whether you can ever achieve health. I would claim that you cannot. I would claim that health is something you strive for, but you never achieve. And then it will be a little easier, I think. And if you have a body that strives for health, it is a body that is sometimes active, that gets enough sleep, that does not expose itself to too many diseases and toxins and things like that. […] A healthy body […] is a body that is trying to improve. (Interview 6)

Rather than an end, or a means for other ends, health, within the theme, is unattainable. The logic in this argument is that a healthy attitude (a will to improve) produces an active body that produces health in terms of constant improvements. Since improvement is always possible, one can never reach a permanent or final state of health. Health consequently both consists of, and is created by, activity and effort.

Health as a healthy attitude also entails a positive and embracing approach to life in general, which by having a healthy attitude means being positive, committed and willing. There are a number of normative conceptualizations of the healthy attitude in teachers' statements in terms of being; reasonable, positive, engaged, committed, willing, and responsible. A willingness to engage and take on challenges are also important aspects of a healthy attitude. Closely related is the use of the concept “grit”, which signals a tougher attitude towards these challenges in the sense of having strong will and perseverance.

Health as fitness

Health as fitness is a dominant theme in all interviews. Within the theme there are clear connections to body weight and form, and performance on fitness tests is constituted as an indicator of good or poor health. Fitness becomes fitting into physical ability norms, and not being fit equals not being healthy. References to physical capacities and skills as indicators of health are plentiful, and being fit is an attribute that most of the teachers consider important in PE. Fitness is also high on the teachers' lists of health determinants.

There are several examples of teachers expressing frustration over the decreasing levels of fitness and increasing levels of overweight among their students and concern about the effects this will have.

Teacher 1: But I also think that if you are overweight, you could say it's okay. You’re strong. You’re in good condition. But it depends on how being overweight affects health. If there are diseases because you are overweight, it’s definitely not good. And we have to say that it’s unacceptable. There’ll be diabetes and other heart problems.

Teacher 2: And cardiovascular disease, yeah.

Teacher 1: And that's a lot. So, it's not good. If we think about health, about health … it is not … if you are overweight … if obesity affects health, it is absolutely not good, I think. (Interview 9)

Teacher 1 in this excerpt is a bit frustrated about his colleagues. In this focus group there was an engaged discussion about whether a clearly overweight body (described by one of the teachers) could be healthy. By elaborating a physical ability argument, the group seemed to come to the conclusion that an overweight body can be healthy, or at least that it doesn't have to be unhealthy. The teacher in the excerpt thought they moved too far in this direction and wanted to assert the importance of fitness as a health indicator. The importance of fitness was also evident in the recurring emphasis on various fitness tests and how poor results in these tests indicated poor health.

So, I think it's problematic when you do not manage a Harvard step test of 30 cm. Then it can feel that … Then I am a little worried about the student's health and also … Then it’ll be difficult to … Then I need to check complex mobility first 10 minutes of the lessons because he will not last through the whole lesson because the student does not have the physical capacity. (Interview 5)

Although most of the teachers presented complex and multifaceted accounts of health, fitness was a decisive demarcation of health or not health for many of them. A person cannot, according to many of the teachers, be healthy if they're not fit. Often this assumption is implicit in formulations which, by attempting to reduce its significance, confirm it; “You do not have to be completely fit” (Interview 3), health is “not just a matter of what the scale says” (Interview 4), and “your health is not completely dependent on the body you have” (Interview 6).

Health as functional ability

This theme is about health as being able to do things and to have an everyday functional ability. Here, health is relational in the sense that the functional abilities are related to personal needs and desires. These needs can be social or psychological, connected to family or friends, or how the abilities enable people to do the things they want to do in life. It is a holistic concept of health in relation to PE. The theme can be illustrated in this excerpt where the participants in the focus group discuss what it is to be healthy.

P2: But if you isolate the body, can you see if there is a healthy body, or less healthy? Is it about coping with a certain load?

P1: Yeah, you mean if you just look at the body or if you see how it moves?

P2: Yeah, if you see how it moves, yeah. There is health somewhere, in mobility. Don’t you think? A healthy body can move …

[…]

P1: Take on the challenges you face in everyday life. That you have the energy for it. That you have the ability to participate. That is, you are not limited by what you want to do. (Interview 9)

This discussion ends in agreement that health is about having a body that gives you the energy to take on challenges in life and enables you to do things you want to do in life. Health is thus understood as something relational, a matter of how bodily abilities relate to needs. However there are also examples of articulations of a wider understanding of functional abilities.

And then I spontaneously think that a healthy body is a body that has enough resources to cope with all the demands of everyday life … And also has the strength and energy to concentrate on lessons … I think here too, we talk about health as something social, these social capacities also have to be able to function in different contexts, to be able to handle such situations …

(Interview 4)

This extract illustrates a more holistic view of health that many teachers expressed. There are also articulations of determinants of wider functional ability. Apart from fitness related examples, there are also examples of determinants involving fundamental psychological and social needs such as the need to; feel healthy, feel good physically and mentally, have a family and someone who listens to you, have friends, and live a life that you enjoy. These are accounts that were based in teachers' experiences of meeting students who do not have such needs fulfilled.

Health as wellbeing

While attitude, functionality and fitness dominated the teachers' accounts of health, there were also recurring references to psychosocial and mental aspects of health and wellbeing. The theme health as wellbeing involves a holistic notion of health embracing physical, mental as well as psycho-social aspects of wellbeing. The focus in the theme is on mental wellbeing, but with a close connection between mental and physical health. Reflecting the well-known definition of the WHO, several teachers proposed a more holistic health as three dimensional including physical, psychological and social aspects of wellbeing.

That you have balance in life and in yourself. That you get to know yourself. That you know what health is. Social health, mental health, physical health. And social health, it can be having friends and moving, yes, between them. Not just maybe having a friend, but several. Family. Mental health, having mental well-being, being able to relax. Stress management. (Interview 11)

Notions of “balance in life” and “knowing yourself” in the quote above illustrates the way mental wellbeing is constituted within the theme. Often referred to as “the inside”, mental aspects of health were also described as a state of being comfortable and satisfied with oneself, but also in terms of feeling safe and not being afraid. These kinds of discussions were often directly related to the experience of seeing many students who are uncomfortable with, and sometimes worried about, PE. Fear, stress and mental barriers are examples of challenges to the students' mental wellbeing. Several teachers also talked about the interconnection between mental and physical health in terms of wellbeing.

You should feel well. Be happy with yourself. Eat, yes. But you should enjoy yourself. If you have any problems, ask the teachers for help. Don't diet as a teenager. Because I have also come across that, already. I haven't worked for many years at all, but have already come across 13-year-olds who are dieting. They diet on powder. Because they have somehow been told by someone else that “You are fat. You need to lose weight”. (Interview 3)

Bodily dissatisfaction and anxiety as threats to wellbeing was also an aspect of the theme. This was frequently in relation to bodily issues in general, but more so with regard to thinness and anorectic tendencies among students than fitness and obesity.

Discussion

Our study of how Swedish PE teachers make sense of health in relation to their teaching practices have revealed four distinct but interrelated themes: 1) health as a healthy attitude; 2) health as fitness; 3); health as functional ability; and 4) health as wellbeing. The themes represent different conceptions and theories about health in the teachers' descriptions of their teaching practices with important consequences for what teachers teach, and how or why a certain content or activity is chosen with regards to health.

The themes identified in the study reveal an understanding of health that largely replicates aspects that have been found in previous research. Two of the four general “lay” definitions found by Flick et al. (2002) some twenty years ago are represented in our data (“functionality” and “well-being and mental balance”), and health as fitness is well represented in a number of studies of how PE teachers view health (e.g. Welch and Wright, 2011; Gray et al., 2018). However, the theme health as a healthy attitude is not as common in the literature as a specific aspect of health in studies of everyday understandings of health.

In terms of theories, the teachers present different systems of thought about what health is and how it is determined. The idea of health as a healthy attitude is an example of such a system that defines health as a primarily mental phenomenon. A critical question for this “theory” is how the healthy attitude itself is produced, whether it is an inner motivational factor determined by behavioural beliefs and perceived norms as described in social psychological models of health behaviour change (e.g. Montano and Kasprzyk, 2008), or if a healthy attitude is to be understood as a matter of access to “health relevant cultural capital” emphasizing structural conditions for health (Abel, 2006, p. 67). In our study it sometimes appeared as if a healthy attitude is something that students choose to have, and sometimes as determined independent of the students' willpower.

The use of “grit” further suggests an understanding of the healthy attitude as determined by the individuals' perseverance and an expectation that one's efforts will pay off (Morton and Paul, 2019). The “theorizing” expressed in this theme also includes the idea that overweight and obese students can reshape their bodies and overcome health problems through a healthy attitude which, just as in the studies by Welch and Wright (2011) and Garrett and Wrench (2012), signals a strong impact of healthism and obesity discourses, where individual responsibility is at the forefront.

The theme health as fitness relates to a biomedical concept and theory of health by which health ultimately is an absence of disease (Quennerstedt, 2019). According to this approach strategies to improve health should aim at producing risk-reducing “healthy” lifestyles (Bandeira et. al., 2022). This is a pathogenic approach that focuses on physical activity and fitness as a means of preventing disease and illness. This approach also connects to discourses about healthism as it focuses on whether or not the individual has a healthy lifestyle that generates acceptable fitness and strength (Gray et al., 2018). However, there are examples where fitness is also related to functionality in a wider sense, and to arguments based in more salutogenic orientations (McCuaig et al., 2013; Mittelmark and Bauer, 2016), thus defining fitness as a resource for health. At the same time, the theme as such is based on accounts that problematize lack of fitness as a threat to students' physical health status. It is in this context that overweight and obesity are most clearly expressed as health problems and obesity discourses come to the surface. There are aspects within the theme that can be interpreted as stigmatizing for overweight and/or non athletic students, similar to the anti-fat bias among health and PE teachers found by Varea and Underwood (2016).

A more complex system of thought regarding health is, however, found within the theme health as a functional ability. In this case health is determined by the interplay of individual desires and needs and the resources available to satisfy these needs. Although the socio-culturally determined nature of individual wishes and needs were seldom discussed, this kind of theorizing opens up for more holistic views of health, relating to well established theories of health (e.g. Antonovsky, 1987; Nordenfeldt, 2007), that could be productive for PE teaching.

The theme health as wellbeing captures a wide range of accounts that relate to the general idea of wellbeing as a matter of balance between physical, mental and social aspects in life (Hagget, 2016). The way wellbeing is articulated also reflects ideas from positive psychology (Lomas, 2016). The theme presents an understanding of health as subjective and holistic and includes social relations and feelings of belonging and self-esteem. This theme also includes accounts that link physical and mental aspects of health and, like the pre-service teachers in the study by Gray et. al. (2018), involves a critique against the dominant focus on physical health that exists in our society. The core ideas of wellbeing are however, not elaborated upon within the theme and the holistic reasoning by the teachers stops at references to the WHO's definition of health from 1946 as a matter of physical, mental and social aspects of wellbeing (WHO, 2020).

Concluding remarks – teaching health in physical education

In this article, we have explored how Swedish PE teachers make sense of health in relation to their teaching practices focussing on the conceptions and theories about health. We identified four distinct themes that capture fundamental aspects of how the teachers in different ways theorize health within their profession as teachers. The themes relate to prevailing discourses in society as well as to specific discourses within PE. There is a clear impact from healthism and obesity discourses on the teachers' accounts, but interestingly there is also a clear impact from holistic views and approaches to health.

While interviews does not provide the full story about how the teachers actually teach, research suggests that the way PE teachers theorize health have significant consequences for what they teach, as well as how and why a certain content or activity is chosen with regards to health (Quennerstedt, 2019). In our study, we can see that the conceptualization of health as a healthy attitude and as fitness dominates when the teachers talk about and give examples of how they teach. At the same time, holistic conceptualizations of health as well-being and as functional ability occurred clearly during the interviews. However, in contrast to the theories of health as a healthy attitude and as fitness, the holistic theories were not as evident in the teacher's stories and examples of how they teach. These theories of health, even if they clearly align with the Swedish national curriculum, seemed more “theoretical” to the teachers and came up rather as a result of them trying to define health than from illustrations they provided of their teaching practices. Hence, we believe that it would be desirable that PE teachers develop a deeper understanding of how health can be understood and theorized in a consistent and analytical way, as well as the consequences of different theories for teaching methods.

Theories and practice of health as functional ability as well as health as well-being carry a potential for PE as a subject to move beyond health as being fit and having the right attitude. We see them as a road to a possible embracement of more holistic approaches and a reframing of what PE is and could be. This implies a better understanding of the practical consequences of different theories of health. Thus, our contention is that one key would be for the PE teacher education to address the practical consequences of these theories for PE teaching in terms of what to teach, how to teach and why to teach health more holistically.