School Health Program: challenges and possibilities for health promotion from the perspective of healthy eating

The School Health Program (PSE) elects health promotion as a guideline for developing health actions at school. The aim is to identify and analyze the program’s strengths, opportunities, weaknesses, and threats to implement health-promoting actions that promote healthy eating habits. This review, of qualitative approach, comprises 29 articles of evaluation of the program published between 2015 and 2021. By the SWOT matrix, the analysis grouped the results into Strengths, Opportunities, Weaknesses, and Threats. Among the strengths, the proximity of the health and education sectors and the integration between the school, health unit, and family stood out; as opportunities, the possibility of intersectoral planning for health promotion was observed. The weaknesses refer to the intersectoral disarticulation, the lack of training, and the predominance of biomedical actions. The threats found demonstrate the centralization of power in health and the schoolchildren’s approach to the health service without a broader understanding of health promotion, providing opportunities for medicalization. It is concluded that it is possible to develop intersectoral educational actions to promote healthy eating in basic services involving schoolchildren and their families. This practice should be prioritized in public agendas in order to enable its daily practice in services.


Introduction
Excess weight, characterized by the Body Mass Index above the normal range 1 , presents itself as an important public health problem in much of the western world, including Brazil 2 , which, in 2020, recorded a prevalence of 57, 5% and 21.5% of overweight and obesity respectively, for adults 3 .For adolescents and children, data from the 2020 Food and Nutrition Surveillance System revealed that 31.9% of adolescents and 31.7% of children between 5 and 10 years old were overweight and that, of these, 11.96% and 25.8%, were obese 4 .Data from the 2019 National Health Survey (PNS) showed that, for adolescents between 15 and 17 years old, overweight prevailed in 19.4%; and, of these, 6.7% were obese 5 .
In recent decades, Brazil has been the scene of social transformations that have led to changes in its health and food consumption pattern.Data from the Family Budget Survey (POF) 2017-2018, when analyzing the last 15 years, showed that the availability of in natura or minimally processed foods and processed culinary ingredients in Brazilian households has lost ground to processed and, mainly, ultra-processed food.During this period, ultra-processed foods rose from 12.6% to 18.4% of the total calories available at home 6 .In this aspect -and in view of the increase in health care demands, mainly related to the diseases that accompany Chronic Noncommunicable Diseases (NCDs) -, public policies were instituted in different countries with the intention of prioritizing Health Promotion (HP) to fight obesity, through healthy eating practices and lifestyles for the population 2 .
National and international studies have confirmed the association between consumption of ultra-processed foods and obesity, hypertension, dyslipidemia, metabolic syndrome, among other chronic diseases 7,8 .Considering that the consumption of these foods has been increasing in Brazil and in the world, it is necessary governmental measures that prioritize the health of the population 2 , with actions that promote healthy lifestyles, respecting food as a social right guaranteed in the Brazilian Federal Constitution, in the aspect that the adoption of healthy eating habits should be encouraged by public policies.Health and food are interconnected, with food being essential for health; and an adequate state of health is necessary for the best use of the food consumed 9 .
In this context, in 2007, the Ministry of Health (MS) and the Ministry of Education (MEC) created the School HealthProgram (PSE), as an intersectoral and interdisciplinary strategy to articulate education and health policies aimed at children and adolescents, in order to promote comprehensive health care for students in the public school system, based on the involvement of Primary Health Care teams, basic education and the school community 10 .
The legislation that guides the organization of the PSE provides for actions aimed at HP, which program is structured in three components: assessment of health conditions; HP and disease prevention and; training 11, 12 .In 2017, the program's guiding document reinforced the need for healthpromoting actions, continuous and permanent training, to strengthen the relationship between the areas 13 .
In this sense, the program is a possibility for the development of HP actions at school, including the Promotion of Healthy Eating (PAS), anchored in the guidelines of the National School Feeding Program (PNAE) 14 , which guides the use of adequate and healthy food, as well as Food and Nutrition Education (EAN) for school children, reinforcing the theme of food and nutrition and the development of healthy living practices.In 2018, the MEC established that the curricula of Early Childhood Education, Elementary School and High School, in addition to having a common national base as a structuring axis, could include, at the discretion of the education systems, transversal themes, which would have a complementary character to the fulfillment of the curriculum; in this movement, EAN became one of the transversal themes to be worked on in the school curriculum 15 .In addition, since 2006, the Interministerial Ordinance No. 1,010 [known as the School Canteens Law] established guidelines for PAS in Kindergarten, Elementary and Middle Schools in public and private networks 16 .
The understanding that the school is an important space for the development of health-promoting actions is not new; already in 1977, the report of the IV International Conference of HP pointed out this potential 17 .Currently, these actions are guided by the PSE guidelines: decentralization and respect for federative autonomy; integration and articulation of public education and health networks; territoriality; interdisciplinarity and intersectoriality; completeness; care over time; social control; and ongoing monitoring and evaluation 13 .
Among the health actions foreseen in the PSE, to be developed by the public basic education network and primary care health teams, the implementation of the action 'Promotion of healthy eating and prevention of childhood obesity' 13 was pointed out as a necessity, considering that excess weight is already a public health problem among schoolchildren.
In this way, understanding both the strengths and weaknesses involved in the process of implementing HP actions in the PSE, from the perspective of PAS for the prevention of childhood obesity, justifies the present research, which can expand the understanding of public policies, in order to articulate strategies to consolidate strengths and minimize or reverse weaknesses, allowing the professionals involved, as well as the school, students and their families, a practice that respects the reality, culture and space that these people occupy in the society.
In this context, this study aimed to identify and analyze strengths, opportunities, weaknesses and threats to the program, to implement HP actions that promote healthy eating habits.

Material and methods
This is a bibliographic research with a qualitative approach, divided into two stages.The first, aimed at selecting the publications that would be included in the study, was developed through a narrative review of the literature carried out in the SciELO, Virtual Health Library (VHL) (LILACS, and MEDLINE) databases, with the keywords: PSE, saúde na escola, saúde escolar, Programa Saúde na Escola and promoção de alimentação saudável na escola.We found 63 texts related to the PSE, of which 29 were selected (9 from SciELO, 13 from VHL/LILACS/MEDLINE and 7 located in literature reviews), as they met the inclusion criteria: being original articles; published between 2015 and 2021; relating to PSE (including food and nutrition actions); relevant to the theme and objective of the study (table 1).The remaining 34 texts found, after reading, were not selected because they included the exclusion criteria: theses and dissertations; review articles; and studies that evaluated the specific action of other areas in the PSE (physiotherapy, speech therapy, dentistry).students report activities related to health care and difficult access, however, health promotion and disease prevention activities were not mentioned.They recognize the actions as a benefit, for which they show their gratitude, without the necessary protagonism to produce their own health.
To analyze the school Health program in the health district of one of the Brazilian capitals from the perspective of intersectionality in school health promotion actions.Qualitative.
The integration between health and education takes place with punctual and fragmented actions, but little by little articulated proposals that are committed to intersectionality and health promotion emerge, with the need for monitoring and evaluation of the program in the context of health promotion.
To compare the implementation of the saúde na Escola program in municipal and state elementary schools in five municipalities in the state of paraná, Brazil.Qualitative.
In municipal schools, actions direct nutritional habits for a healthy life, improving the quality of life of students and their families.Intersectoriality was a contributing factor in caring for students' demands and health promotion activities.This issue is not addressed in state schools, with distance and lack of understanding between the health and education sectors, harming the quality of the actions carried out.Both allege lack of teacher training.
Understand, from a phenomenological perspective, the meaning of the actions of the school Health program for primary Health care teams.porto Alegre, Rs.Qualitative.
The coordinators recognize the potential of the work on prevention and health promotion carried out by the psE, with a challenge for working in networks, due to the great demand generated by the program.The school does not feel included in the actions, with distance from the families and little resolution of the clinical demands of the students.

Referencias
Objective, study site and methodological approach main features of interest Baggio MA, et al., 2018 28 .
To understand the implementation of the school Health program in the city of cascavel, paraná, based on the nurses' report. Qualitative.
The program presents weaknesses in the training of professionals, in the structure of schools, human and material resources, and incipient intersectoral interaction.The psE actions are based on health assessments of students.
Evaluate the implementation and execution of the psE in the Municipality of Belo Horizonte, Minas Gerais, the mechanisms that favor intersectoral action and the managers' perception of intersectionality.Qualiquantitative.
Difficulty in building intersectoral work in the fields of management and development of psE actions.little sharing of responsibilities between sectors, little scope in the development of health promotion and its determinants.centrality of power in the higher levels of management, needing to give priority to training and continuing education processes that include the current discussion on intersectionality, with the participation of students and the community to ensure the sustainability of actions.To analyze the intersectoral action developed between the health and education sectors in the process of implementing the Health at school program in a municipality in the metropolitan region of Northeast Brazil.Qualitative.
In the implementation of the program, health leadership was noted, with education playing a peripheral role.The activities have a biomedical approach, carried out through lectures.However, the program strengthened the relationship between the two sectors, but the intersectoral articulation in the political-management process and in practices showed weaknesses and limitations.
To analyze the context of health promotion with adolescents in the health and education interface, focusing on psE actions.Fortaleza, cE.Qualitative.
The organization of spontaneous demand causes disharmony in scheduled appointments and health actions at school.The professionals' lack of knowledge about the psE and the lack of planning of actions confirm the disarticulation of the education and health sectors, although they signal possibilities of this intersectoral practice.
Build and validate the logical model of the school Health program.Rio de Janeiro -RJ.Qualitative.
Intersectionality presents itself as a challenge to be overcome by the program, having as strategies and recommendations: local meetings, with periodicity, in their respective areas, and a unique information system for the program, which allows its use in a timely manner by the departments involved.
To analyze the social function of the psE based on a bibliographic and documentary study, based on the historical materialist method.Documentary research.
The psE, as an educational assistance program, plays a mitigating role in the face of social manifestations, conservative, integrates neoliberal policies, however, it does not disqualify it as important initiatives in the scope of the democratic struggle for rights.
To know and analyze the process of intersectionality in the psE in a municipality in the metropolitan region of pernambuco.Olinda, pE.Qualitative.
The operation of an intersectoral policy in an environment with actors that have previously assembled sectoral agendas and with no space for their execution, makes it difficult to reconcile the institutional times of the sectors, preventing the sustainability of actions.
There is a shortage of training and continuing education, in addition to the lack of protocols that guide the development of intersectoral actions.However, the psE allowed health professionals to perceive their social role as educators and enabled adolescents to have greater contact with the health team.
To evaluate the actions developed by the Family Health strategy teams and their impact on improving the quality of life of adolescents in sobral.sobral, cE.quantiqualitative.
In the evaluation of the components, the study identified relevant values of component I, regarding the presence of students with health alterations.component II, on the other hand, presented satisfactory numbers in health promotion and disease prevention actions, which proved the reach of these actions developed by the municipal teams with the adolescent public.The psE is little recognized among educators.
To understand the perception of nurses from the Family Health strategy on the psE.Jequié, BA.Qualitative.
The psE is understood as an intersectoral policy focused on the health of children in the public school system, showing the limited knowledge of professionals about the program.The work overload in the EsF, the problems related to municipal management and the lack of partnership with the parents, are presented as weaknesses.However, they recognize their capacity for integrality in health.To assess the presence of the Domains of core competencies in Health promotion in the discourses on the practices carried out by actors who implement the psE as well as in the regulations that guide this program in the Federal District (DF).Qualitative.
limitations were identified to develop practices in a broader perspective of health promotion, with the need to broaden the understanding of these domains and the theme, with specific training for managers and health and education workers, with educational methodologies of a participatory and multidisciplinary character, through continuing education.
To analyze the entrance of health in the school space through psE actions, classify them as pedagogical practices and, from there, verify if they align with the perspective of health promotion.Duque de caxias and Nova Iguaçu, RJ.Qualitative.
In the municipalities, the school community does not participate in the planning of actions, and the participation of FHs professionals took place through feedback of information from the actions carried out.Intersectionality was characterized with social assistance, sport and leisure, among others.Health actions in schools change school dynamics and health professionals may not be prepared to interact with students outside of health services.The psE supports critical reflection on administrative limitations in the execution and effectiveness of intersectoral policies.
Understand the intersectoral relationships from the perception of managers and professionals in the health and education sectors, in the implementation of the psE, in two regions of the DF: Gama and candangolândia.Qualitative.
The program enhances intersectoral articulation, presents communication challenges and in the distribution of power between sectors in all spheres.Intersectoral Working Groups are important in supporting intersectoral work.It was noticed that the psE is not a priority for health and education, with a disconnection between formal adherence and activities carried out.
Understand the implementation of intersectoral actions foreseen in the Bolsa Família, Family Health and school Health programs, in Manguinhos, north area of the city of Rio de Janeiro, Brazil.Qualitative.
Importance of the psE for the transformation of the organizational culture of the state.
Managers and professionals at the 'front' recognize the importance of intra and intersectionality, pointing to the need to create an exclusive sector for the development of the program's actions and consider internal articulation positive, when it occurs.Despite intersectionality and territorialization being dimensions valued in the normative plan of the program, isolated, overlapping and discontinuous actions were frequent.
check the development of activities to promote adequate and healthy food in the school environment, from the perspective of the psE.pernambuco.Qualitative.
Nutrition education such as the psE is little recognized.The professional related to excessive attributions, precarious working conditions [physical, material and human resources] and lack of planning and execution of psE actions.The program is strategic in health promotion and prevention, it needs continuous actions, reinforced by the importance of the nutritionist in primary care for actions to promote healthy eating.
Understand the perception that teachers have of a school health program and its relationship with health education actions developed at school.Barbalha, cE.Qualitative.
Teachers perceived the psE as assistentialist, without integration between teachers and health professionals, for which adolescents show no interest.The educational actions in the school were perceived as clinical evaluations that were not integrated with the actions already developed in the school.
Identify the inconsistencies of the psE from its conception of health promotion, having as a counterpoint the understanding of the WHO on the subject.Documentary research.
Health promotion actions are curative and of assistance nature, being confused with prevention.However, health promotion does not seem to be adopted as the core of the psE.
There is a predominance of the conservative concept, which focuses on behavioral change without taking into account social determinants.To know the public policies that promote adolescent health at school proposed and developed under the responsibility of education and health managers in the city of Recife, pE.Qualitative.
The psE promotes comprehensive health care and enables reflection on administrative limitations for intersectoral practices.professional training for the care of adolescents, and the practice of intersectoriality in the daily life of professionals in the health care network of the municipality, are necessary, however, responsibility for actions should not be centered on workers.
source: self elaborated.The second stage of the research was based on the use of the Strengths, Weakness, Opportunities, and Threats Matrix (SWOT) as a tool for selection, systematization and analysis of data and information about the PSE, contained in the 29 selected articles.
The SWOT Matrix is a tool widely used in the field of administration, having been adapted and used in planning, management and evaluation studies, both in the analysis of policies and the territorial-based health situation and in intersectoral research in health 47-50 .
The use of the SWOT Matrix allows a quick didactic visualization of the analyzed scenario, providing the analysis of positive and negative elements, both internal (Strengths and Weaknesses of the object studied) and external (Opportunities and Threats that, even if not part, may influence the performance of the object studied).The SWOT Matrix integrates management analysis for policy formulation and decision-making, as it groups strengths and weaknesses, allowing the evaluation of programs and interventions in their internal and external contexts (table 2) 51 .

External elements
Opportunities When the strengths of the program meet positive conjunctures of achievement, they express the potential at stake.positive conjunctures of achievement can reveal still weak points of the program, which can be read as a challenge to overcome Threats Adverse situations can compromise the performance, including the strengths of the program, constituting alerts to be considered When adverse circumstances meet with program weaknesses, they express the conditioning and restrictions on the ability to respond.
For the elaboration of the SWOT Matrix, the strengths and weaknesses were listed and organized according to the highest frequency in which they were reported in the articles.
In the case of strengths, the strengths highlighted in the articles were considered, which are intrinsic to the program and which were well evaluated; the opportunities refer to the suggestions that the authors presented in their discussions; the group of weaknesses included the internal problems detected by the researchers in the actions identified, which make it difficult or even prevent the realization of the PSE as provided for in the legislation; and as threats, the external factors pointed out that serve as a warning for the failure of the program.
For a better understanding of the identified factors, some concepts were necessary, as follows:

Results and discussion
The articles that make up this review come from research carried out in several Brazilian states, parts of the Northeast, South, Southeast and Center-West regions, in addition to studies related to the PSE legislation and secondary data from the MS, including all Brazilian states (table 3).
The SWOT Matrix exposes the application of categories organized based on the frequency in which the information was presented in the articles under study, grouped into internal factors by the Strengths and Weakness Groups; and external factors by the Opportunities and Threats Groups.

Analysis of factors internal to the PSE STRENGTHS GROUP
Strengths refer to factors intrinsic to the PSE, representing the strengths to be maintained, providing an overview of how these actions are implemented in the program.In the review presented here, strengths were less expressive (n = 5) compared to weaknesses (n = 13), showing that there are challenges for the implementation of the program.
Despite the insufficient intersectoriality, presented as the main factor in the fragilities quadrant, studies show that the PSE brought the school and the health unit 20,31, 35 together with the family 20,28 , favoring dialogue between the actors 33 .When implemented, the intersectoral approach signaled a contributing factor 26,32 , allowing planned actions between the different sectors 20,26,41 and, within each sector (intrasectoral) 20,40,41 , enabling comprehensive care and expanding the perception of the problems of the schoolchildren 20,26, 36 .
A research carried out with managers evaluated the PSE as the only policy for comprehensive care for students, through the establishment of intersectoral actions for the care of adolescents in the school environment 46 , with the potential capacity to positively interfere in the lives of these students 29 , redirecting them towards integrality in health 37 , with actions directed to their realities 26 .Furthermore, according to Barbieri and Noma 34 , it was presented as an important initiative within the scope of the democratic struggle for rights.
The approximation of primary care with the school made it possible to identify problems that were not previously perceived by the health sector, in addition to expanding the student's contact with professionals and health services, and these, with their social role of educator 35 .Students recognize the importance of health professionals 18,24 , especially to identify their health problem 18,36 and refer them for clinical consultation 24,36 .
On the other hand, professionals working in the PSE recognize its potential for healthpromoting actions 20,27,39,42, 43 .Studies indicated that actions related to 'health promotion and disease prevention' were the most agreed upon, with emphasis on actions about 'promotion of food security and healthy eating' 21,22,26,36, 42 .
There is a vast literature that brings intersectoriality as essential for the actions of the PSE, which is not just an approximation of the areas, but the inclusion of professionals in the planning of actions, as well as the entire school community, so that they recognize the need and the importance of these actions.
According to analysis in the Integrated Monitoring, Execution and Control System (SIMEC), the anthropometric assessment record and food safety and healthy eating actions presented the highest frequencies among the actions recommended by the PSE 45 .Furthermore, the monitoring report of the last completed PSE cycle (2019/2020 cycle) showed that the collective activity on the topic of healthy eating and obesity prevention was the second most performed action (18.19% of the total) among the actions of the PSE 52 .

WEAKNESS GROUP
The identification of weaknesses contained in the program is an essential task for it to be adjusted towards greater efficiency.Studies have shown an expressive presence of these factors -in which the disarticulation between the health and education sectors is the most relevant -which actions compromise intersectoriality and integrality, still insufficient 18,25-33,35,42,43, 46 .The lack of protocols for the development of intersectoral actions was identified, which sectoral agendas are prepared in advance 35 , with disconnection and distance between services 26,38,40, 43 .In addition, there was a lack of planning of actions 32,37 , with little involvement of schools 18,27,36, 43 and families in the program, and students in decisions 27,37,39,42 .Intersectoriality must support the planning of managers, so that it can be implemented in practice, as well as all subjects of the school community must be involved in the scheduling so that they recognize, value and engage with school health.
The lack of professional training to work in the PSE was one of the main problems reported 21,22,26,28,29,35,37-39,45,46 , being pointed out as the least agreed actions by the municipalities 21, 45 .The studies identified that the professionals involved in the development of the program do not have a proper understanding of the PSE 32,36,37 and of the HP 19,38, 44 , suggesting that they did not have training in pedagogical practices 39 and, still, there are different perceptions among managers in the three spheres of government 40 .However, Cavalcanti, Lucena and Lucena 44 , when verifying the inconsistencies of the PSE, from their conception of HP, did not concretely identify that it is adopted as the guiding concept of the program itself.The training of the professionals involved on the subject is essential for the realization of these actions, considering that, to a large extent, with the exception of the nutritionist, the other professionals did not have the content of Food And Nutrition Security (FNS) in their training, which makes it difficult to carry out these actions.
The few actions named as HP 19,29,38,41 are presented as assistance, curative, of a technical nature 21,25,28,39,41,43, 44 .In addition, they follow a preventivist model, centered on fragmented and individualized actions 21, 38 , offered in the form of lectures with a biomedical approach 31 , focusing on behavioral change without taking into account social determinations 29, 44 .
Furthermore, students seek and recognize the presence of health in the school in care actions 18,19,24,43 , in addition to understanding them as a benefit, and not as a right 24 .Through these actions, there is a considerable number of schoolchildren with some change in their health 22,36 , however, with little resolution of the diagnosed clinical demands 27 .The diseasecentered educational approach is not in line with the HP, which should guide the actions of the PSE.
Health professionals, on the other hand, reported the excess of attributions in their units 37, 46 and the great demand generated by the PSE 27,30,42 , which, added to the lack of human, material and structural resources 28,30,42 , reinforces the fragility of the program.In addition, studies indicate that there is centrality of power 29, 39 , with a predominance of the health sector 31,40,41, 44 , in which school work occupies a peripheral space 31 .Furthermore, flaws in the monitoring system of the actions developed and evaluation were also found 25, 45 .

Analysis of factors external to the PSE OPPORTUNITIES GROUP
The opportunities presented here were reported by the authors, referring to the actions that are possible to be carried out from the program, but which have not yet been fully implemented in the routine of the services.The authors suggest that the PSE provides opportunities for the union of different sectors, the exchange of experiences and knowledge 23,39 , which social function of the school (forming citizens) can be shared by the family and other services, such as health 19,24,36,38 , strengthening bonds, building care networks 27, 29 , thus enabling an institutional strategic planning for intersectoriality.Furthermore, the PSE enhances intrasectoral actions, expanding the understanding of intersectoral management, and, with that, the transformation of the organizational culture of the State 40, 41 .
Through inter-ministerial programs such as the PSE, institutions find space to organize actions for the HP, in a planned way, with better communication and dialogue 21,22,28,39,40 , providing opportunities for working together 23,39 .Considering that the reorganization of agendas, especially in the areas of health and education, is necessary to achieve intersectoriality 29, 44 , this partnership contributes to the process of permanent education of managers and workers, to transform the hegemonic health care model 38 (reported in the weaknesses quadrant), in a work directed to the community 19 , minimizing the vulnerabilities of the students 43 , aiming at the empowerment of the school community 22 .In this context, each actor has the possibility to act according to their reality, their social, cultural, economic determinants, enabling the school community to work together, sharing competences and skills 19 , following the principle that "listening to voices can be a good starting point" 24(2897) .

THREATS GROUPS
Threats were considered to be factors that, even external, when present, could jeopardize the implementation of program guidelines.The weakness related to the centralization of power in the health area 29,31,39- 41 is highlighted, in which education is perceived as having a peripheral role 31 , not feeling valued 27 .It is known that the PSE is an inter-ministerial policy, it is a strategy for the integration and permanent articulation between education and health policies and actions, with the participation of the school community, involving the family and basic education health teams, under the coordination of an Intersectoral Commission on Education and Health at School (CIESE), organized in an Intersectoral Working Group (GTI) 10, 13 .However, the PSE Commitment Term together with the agreed actions, the monitoring and reports made are available in a disintegrated way, in which each area has its responsibilities, with the sharing and dissemination of information at the discretion of each municipality, which, most of the time, it is not shared between sectors, or even accessible to the public -and most importantly: the financial incentives for the cost of the actions are transferred from fund to fund through and at the expense of the MS, according to the number of students enrolled 13 .In this structuring format, education occupies a passive position starting from the legislation, which may explain this weakness reported by teachers, inducing a secondary and peripheral participation, compromising intersectionality.
The easy access of students to health professionals and services, if, on the one hand, it can be a strength, for Brambilla, Kleba, Dal Magro 20 , on the other hand, the simple approach without due reflection and co-responsibility of professionals can strengthen the medicalization of health by expanding students' access to professionals, reinforcing the biomedical and curative model 21,24,28,31 , without a proper understanding of HP, intersectoriality and comprehensive care.Considering that the studies show that the actions in the PSE follow a biomedical model, centered on the disease, it is suggested that the actions carried out will reproduce this model, already outdated, not promoting health, a field in which healthy eating is inserted.Added to this is the fact that students recognize health actions at school as clinical, punctual, fragmented care 21,24,25,28,44 ; as a benefit, and not as a right, showing that the principles of social rights, such as health and food, may not be properly addressed in this program.
The high demand for work generated by the program was reported by health professionals, associated with the lack of resources for the agreed actions, which led one of the studies to suggest the creation of an exclusive sector to develop PSE actions.In this view, it is necessary to reflect on the program guidelines that bring decentralization and respect for federative autonomy; integration and articulation of public education and health networks; territoriality; interdisciplinarity and intersectionality; integrality; care over time; social control; and permanent monitoring and evaluation 13 , which do not support this division of labor, as they do not meet the intersectoral policies that act on social, cultural, political, economic determinants, among others, showing themselves as a setback and a threat to the principles of HP.

Final considerations
The use of the SWOT Matrix in the evaluation of the PSE made it possible to visualize the strengths and weaknesses of the program, listing elements that can contribute to the analysis of its development for professionals and managers of health and education, in order to problematize obstacles that limit the full development of the program, aiming at HP and healthy eating, proving to be an important tool for use in the evaluation of public policies.
Studies have shown that, when intersectionality takes place, it invites the sectors to reflect, to dialogue, making a difference in carrying out actions and in the involvement of the entire school community, providing opportunities for educational actions that meet the PAS, as strategies used for healthy eating practices and appropriate to the biological, social and cultural conditions of individuals and communities.In this context, and based on the strengths and opportunities found in the studies, it can be said that it is possible to develop educational actions that promote healthy eating for children and adolescents in the school environment, in order to involve the school, the family, the health service and other areas that may be necessary, but mainly the student at all stages of the process, from planning to the execution of actions.
Childhood obesity presents itself as an important public health problem, and its prevention is among the actions to be developed by the PSE.In addition, educational actions that promote healthy eating are included in the PNAE and the National Common Curricular Base (BNCC), among other initiatives.
The main weakness in the PSE refers to the intersectoral disarticulation, proving to be the main problem faced by health and education professionals, justifying disjointed practices that can make it difficult to promote health and healthy eating actions.However, it is important to consider that the PSE includes training as one of the three structuring components of the program from 2011, which until then was included in the actions of permanent education in health, with less visibility, since it was not among the structuring components.Thus, further studies are needed to better identify the effects of training over time.
In line with the PSE legislation, the GTI, composed of the actors that make up the program, obligatorily health and education, does not seem to occupy a prominent place  for the actors, since only one study reported the difficulties of the GTI in monitoring the actions in the municipalities, which could stand out as an important instrument for intersectoral work, still dormant.Intersectoral government programs enable debate, as well as access to public services, however, they are incapable of solving social, economic and political problems, which present themselves as a struggle of forceson the one hand, the health of the population; on the other hand, the commercial interests of the disease industry -, which balance point presents itself as the greatest challenge, for which structural regulatory, fiscal and legislative actions are fundamental, as it is in the case of childhood obesity.

Collaborators
DallaCosta MC (0000-0003-0769-5290)* contributed to the design, acquisition, analysis and interpretation, as well as the writing and final approval of the version to be published.Rodrigues RM (0000-0002-7047-037X)* contributed to the writing of the work and critical review of the content and final approval of the version to be published.Schütz G (0000-0002-1980-8558)* contributed to the design, writing and final approval of the version to be published.Conterno S (0000-0003-2493-8071)* contributed to the critical review of the content and final approval of the version to be published.s

Health
Promotion: A set of strategies and ways of producing health, at the individual and collective level, characterized by intrasectoral and intersectoral articulation and cooperation and by the formation of the Health Care Network, seeking to articulate with the other social protection networks, with broad participation and broad social control; [...] Promotion of Adequate and Healthy Food: A set of strategies that provide individuals and communities with food practices appropriate to their biological and sociocultural aspects, as well as the sustainable use of the environment; [...] Intersectoriality: Process of articulating knowledge, potentialities and experiences of subjects, groups and sectors in the construction of shared interventions, establishing bonds, co-responsibilities and co-management for common goals; [...] Intrasectorality: Permanent exercise of defragmenting the actions and services offered by a sector, aiming at the construction and articulation of cooperative and problem-solving networks; [...] Integrality: Interventions based on the recognition of the complexity, potential and uniqueness of individuals, groups and collectives, building articulated and integral work and care processes 2 .

Table 1 .
Characterization of the studies regarding the objective, place where it was carried out, methodological approach and main features of To identify the facilities and difficulties in the implementation of the psE in a municipality in the northeast of Brazil.Natal, RN.QuantitativeThe most frequent facilities were intersectoral articulation (38.1%) and professional satisfaction (24.8%) in carrying out psE activities.The difficulties were: scarcity of material and financial resources (50.5%), lack of intersectoral articulation (26.7%) and excess of activities in the work process (17.1%).

Table 3 .
Strengths, opportunities, weaknesses and threats in the School Health Program . centralization of power in the health area; 2. schoolchildren's access to health services without a proper understanding of health promotion can reinforce the medicalization of health; 3. Deficient intersectionality and integrality of care reinforces the biomedical model; 4. creation of an exclusive sector to develop psE actions, due to problems in spontaneous demand; 5. students seek health care and clinical actions to the detriment of health-promoting actions; 6. students recognize health actions at school as a benefit and not as a right.
1source: self elaborated based on literature review.